In this community engagement feasibility review, we evaluate the infrastructure warranted to implement bystander CPR and bleeding control skills training to diverse social organizations in an urban region over an 9-month period. Further, we review the necessary variables to sustain such an effort, for both the health system as well as the partnering communities. The intervention, brought forth with partnering communities through community health workers or other community brokers, for this community engagement feasibility study is the execution of teaching CPR skills and bleeding-control skills to various social networks in an urban region. The intervention focused on a changeable behavior, specifically on community members’ abilities to execute life-saving interventions. The goal is to meet the intended behavior outcome under ideal circumstances, which are training of the aforementioned skills in respective community settings over a 120-min teaching session. Over an 9-month period, we were able to implement CPR training at 5 communities reaching 136 community members. These trainings were implemented in regions that have the highest homicide rates (mean of 0.86 ± 0.14 homicides per 1,000 persons; Maryland as a state averages 0.12). Implementation of CPR and bleeding control training in diverse community settings in an urban region was feasible and cost-efficient over a 9-month period. Further, utilizing community liaisons, such as community health workers, was critical to its success.

OBJECTIVES: To identify the most frequently prescribed medications, the location where prescriptions were filled, and whether a voucher was utilized among patients enrolled in a charitable care program within an academic medical center. STUDY DESIGN: This was a retrospective cohort study analyzing electronic health record and pharmacy dispensing information at a medical center's outpatient pharmacies. METHODS: Patients included in this analysis were enrolled in a charitable care program and had at least 1 ambulatory encounter in a primary care clinic from March 1, 2019, to June 30, 2021. The study identified frequently prescribed medications, prescription payment methods, the overall cost of prescriptions if available, and the percentage of patients who filled their prescription at a medical center's outpatient pharmacies vs external outpatient pharmacies. Descriptive statistics were used to describe the results. RESULTS: This study included 511 patients, 87% of whom were Spanish speaking. A total of 8453 prescriptions were identified, and more than half of the prescriptions were sent to external outpatient pharmacies. The most common medications prescribed were for cardiovascular disease, diabetes, and pain treatment. Forty-seven percent of all prescriptions were sent to the medical center's outpatient pharmacies. The medical center's charitable care program covered the costs of 44% of the prescriptions sent to internal pharmacies, assisting 148 unique patients and incurring a cost of $111,052 for the medical center. CONCLUSIONS: Overall, this study was able to characterize patient demographics, historical costs related to charitable care coverage, and the utilization of health care services among this population. This information can be used to support the development and implementation of a charitable medication formulary, with the aims of improving quality of care for this population and reducing medical center costs

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INTRODUCTION:Buprenorphine is used to treat opioid use disorder (OUD). However, therapy is often disrupted during acute pain episodes, and re-initiation is often deferred due to intolerable interruption in opioid analgesics. This case report describes a unique strategy for inducing buprenorphine without stopping opioid analgesics. CASE:One patient with OUD and acute pain was initiated on buprenorphine using intravenous microdosing without precipitated withdrawal or pain exacerbation. Full agonist opioids were successfully weaned after discharge and the patient was linked with a community-based treatment program. CONCLUSION:This case describes use of intravenous buprenorphine to treat OUD and acute pain without adverse consequences.

Objective To assess the association between provider type (primary care provider [PCP] or perioperative provider) and excessive preoperative testing. Study Design Cross-sectional study. Setting Academic medical center. Methods Electronic medical records of adult patients who obtained an outpatient preoperative assessment and underwent surgery in the Department of Otolaryngology-Head and Neck Surgery during the first 2 weeks of January 2019 (n = 94) were reviewed. Patients receiving preoperative tests beyond those recommended by the guidelines were deemed to have had excessive testing. Descriptive statistics were used to characterize the study population. Simple and multivariate logistic regression were used to analyze the association between the outcome and the predictor variables. Results Overall, 44.7% of preoperative evaluations had excessive testing. Patients who had their preoperative evaluation performed by a perioperative provider had 89% lower odds of having excessive preoperative testing compared to those evaluated by a PCP (odds ratio = 0.11, 95% confidence interval: [0.03, 0.37], P < .001). Female sex, younger age, and higher risk of major adverse cardiac events were associated with greater odds of excessive testing. Conclusion Excessive preoperative testing is more commonly performed by PCPs compared to perioperative providers. These results give preliminary evidence in support of a potential shift in the clinical responsibility of preoperative evaluation from PCPs to perioperative providers in order to reduce excessive testing and promote high-value health care. The next steps include validating these findings, identifying reasons for differential guideline concordance, and intervening accordingly.

BACKGROUND:Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs). OBJECTIVE:To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted. DESIGN, SETTINGS, AND PARTICIPANTS:A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD. EXPOSURE:OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD. KEY RESULTS:The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD. CONCLUSIONS:This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

The arts and aesthetic experiences have fostered and enhanced relationships between diverse, distinct groups in an effort to build comradery, trust, and engagement. In regards to collaborations between health systems and communities, taking into account strategies to build such relationships is vital in an effort to assure a bidirectional collaboration that implements public health insight and resources effectively. There are many factors warranting consideration when building effective community engagement for health promotion between healthcare systems and local community organizations and residents. Such factors include, but are not limited to, homophily, transitivity, structural holes, and maintaining weak ties. In this brief review, we will explore how the arts can be utilized to broker relationships for healthcare systems implementing community engagement with partnering, diverse social networks. Specifically, we will explore the role of the arts and aesthetic experience to create homophily, foster transitivity and balance, enhance collaboration and build meaningful connections between healthcare systems and social networks to more effectively address health concerns for all involved.

Purpose To describe one strategy for dispensing of methadone at emergency department (ED) and hospital discharge implemented within 2 urban academic medical centers. Summary Expanding access to medications for opioid use disorder (OUD) is a national priority. ED visits and hospitalizations offer an opportunity to initiate or continue these lifesaving medications, including methadone and buprenorphine. However, federal regulations governing methadone treatment and significant gaps in treatment availability have made continuing methadone upon ED or hospital discharge challenging. To address this issue, the Drug Enforcement Administration (DEA) granted an exception allowing hospitals, clinics, and EDs to dispense a 72-hour supply of methadone while continued treatment is arranged. Though this exception addresses a critical unmet need, guidance for operationalizing this service is limited. To facilitate expanded patient access to methadone on ED or hospital discharge at 2 Baltimore hospitals, key stakeholders within the parent health system were identified, and a workgroup was formed. Processes were established for requesting, approving, preparing, and dispensing the methadone supply using an electronic health record order set. Multidisciplinary educational materials were created to support end users of the workflow. In the first 3 months of implementation, 42 requests were entered, of which 36 were approved, resulting in 79 dispensed methadone doses. Conclusion This project demonstrates feasibility of methadone dispensing at hospital and ED discharge. Further work is needed to evaluate impact on patient outcomes, such as hospital and ED utilization, length of stay, linkage to treatment, and retention in treatment.

INTRODUCTION In clinical practice, sublingual (SL) buprenorphine-naloxone is prescribed as once daily or split daily dosing for the management of opioid use disorder (OUD). Evidence is lacking that assesses how split daily buprenorphine-naloxone affects OUD outcomes. This study aims to evaluate how the dosing frequency of SL buprenorphine-naloxone impacts therapy effectiveness when treating patients with OUD. METHODS This retrospective analysis included adult outpatients prescribed treatment with SL buprenorphine-naloxone for OUD between July 1, 2016, and March 1, 2020. The study excluded patients with sickle cell disease, recent methadone treatment, or pregnancy. We characterized study groups by dosing frequency, either once daily or split dosing. The study compared retention in treatment, medication adherence, adherence to treatment program, and hospital encounters between groups. RESULTS The study screened eight-hundred and seven patients, and included 250 patients newly prescribed SL buprenorphine-naloxone. Fifty-seven patients (22.8 %) were prescribed once daily dosing and 193 patients (77.2 %) were prescribed split daily dosing. The study found no significant differences noted in 12-month rates of treatment retention (52.6 % vs. 45.6 %, p = .35). These outcomes remained similar when assessed at three and six months. Within a year of buprenorphine-naloxone initiation, the study found no differences in the percentage of patients with hospitalizations (26.3 % vs. 38.3 %, p = .10), median number of hospitalizations (2 vs. 2), or proportion of days covered by a prescription ≥80 % (93.3 % vs. 92.0 %, p = .82). CONCLUSIONS In this study, patients receiving once daily buprenorphine-naloxone had similar treatment outcomes to patients receiving split dosing. Further controlled studies are necessary to evaluate which patients are more likely to benefit from split dosing.

Abstract Sexual and reproductive healthcare standards for adolescents and young adults with sickle cell disease (SCD) are not established. A total of 50 young adults entering adult SCD care completed a Family Planning Survey assessing sexual and reproductive health needs from March 2019 to July 2020. Clinical data were abstracted from respondents’ electronic medical records. Linear and logistic regression was applied to explore associations between clinical characteristics and survey results. Few respondents (8%) wished to be pregnant in the coming year, and 46% answered yes to at least one of four needs assessment questions. Those who were not employed full time were more likely to endorse needing help with getting sickle cell trait testing for a partner (ORadj = 9.59, p‐value = 0.05). Contraceptive use was associated with having an obstetrician–gynecologist (OR = 6.8, p‐value = 0.01). Young adults with SCD entering adult care have diverse reproductive health needs, highlighting opportunities to provide multidisciplinary, SCD‐specific reproductive healthcare.

LGBT youth experience disproportionate rates of mental health diagnoses, including depression and anxiety. Using qualitative interviews of LGBT youth (n = 14) and primary care providers (n = 12), we sought to identify whether mental health discussions with a primary care provider were perceived as overall beneficial. Most LGBT youth felt comfortable being asked about depression, anxiety, or other mental health conditions by their primary care provider. All felt it appropriate to provide this information by survey or tablet. However, youth participants’ comfort depended on feeling connected with and accepted by their provider. Those that did feel comfortable, perceived a benefit when these conversations did happen. Providers unanimously described wanting to address mental health needs in LGBT youth, either in terms of societal advancement, or clinic-based changes. Both LGBT youth and primary care providers appeared to want more mental health discussions during visits. However, more connectedness may be needed to improve willingness to engage in care; and providers may require specific support to successfully fill this need.

Background: Smoking is the leading preventable cause of illness and premature death worldwide. Most tobacco users desire to quit, but few are successful. Guidelines recommend varenicline as an initial treatment recommendation to support smoking cessation. Objectives: Determine whether historic warnings preclude the use of varenicline as an initial treatment recommendation in patients with and without certain comorbidities. Appendix 1 shows the questions asked in the survey. Methods: This study was conducted in 2 parts. Part 1 of this study was a provider survey. Part 2 was a multicenter, retrospective chart review. Survey respondents were primary care providers (PCPs) or internal medicine residents within a large health system. Patients included in the chart review had a PCP appointment between January 1, 2017, and December 31, 2020, and a diagnosis of tobacco dependence or tobacco cessation therapy prescription. Results: In total, 352 providers were included in survey distribution and 56 responses were received, resulting in a response rate of 16%. Most providers (77%) indicated that they would be likely to use varenicline as an initial treatment recommendation in a patient with no comorbidities. Providers indicated they would be unlikely to use varenicline in a patient with certain mental health comorbidities (43%, 43%, and 55% for patients with bipolar disorder, schizophrenia, or history of suicide attempts, respectively, with 25%, 30%, and 27% having no opinion for each group). In addition, chart review yielded data for 25,128 patients. Notably, patients with schizophrenia were found to have an odds ratio of 0.55 (95% confidence interval [CI] 0.39-0.77) to receive varenicline at any point in therapy, and patients with diabetes had an odds ratio of 2.66 (95% CI 2.22-3.19) to receive no treatment. Conclusions: Historic warnings for neuropsychiatric events with varenicline may still preclude usage in patients with serious psychiatric comorbidities such as schizophrenia. In addition, patients with diabetes were less likely to receive any form of tobacco cessation therapy. (c) 2023 American Pharmacists Association (R). Published by Elsevier Inc. All rights reserved.

Background: Hospitalization can be a critical time to stabilize chronically ill patients across levels that transcend medical and social determinants of health. The use of the biopsychosocial model can be instrumental in understanding both medically and psychosocially complex patient cases. An acute inpatient hospitalization provides an opportunity to mediate both intrinsic and extrinsic risk factors for both substance use disorder and suicide risk in the context of achieving medical stabilization and crisis mobilization. Case Presentation: Inpatient care of a 22-year-old African American female patient who was chronically ill involved tapping into existing resources within the larger academic hospital inclusive of both adult and pediatric expertise. This patient's care and treatment was multidisciplinary and involved a range of consults that further expanded both the depth and breadth of care and optimized stability from both medical and psychosocial standpoints. In fact, this patient's hospitalization presented a window of opportunity to facilitate a time of transition in chronic disease management and mobilize resources as part of securing wraparound care for her within a one-week timespan. Her care involved the integration of pediatrics (hematology, adolescent medicine), adult medicine (hematology, addiction medicine), and psychiatry. In addition to treating acute symptomology, underlying sources of pain stemming from her opioid use disorder were also alleviated. Furthermore, her care embodied the interface of chronic illness with opioid use, as her reported pain crises were determined to be motivated by intrinsic factors (e.g. poor coping skills from cumulative stressors) supporting her opioid use disorder. Conclusions: The biopsychosocial treatment approach taken for this patient also clearly delineated that physiological and mental health domains are interrelated aspects of chronic pain in chronic illness. Furthermore, this case also emphasized that chronically ill patients are at elevated risk of developing substance use disorders. This case study lends itself nicely to elucidating parity in physiological and mental health domains as crucial elements in promoting health and safety in patient care.

Abstract In maintained, bi-directional medical-community collaborations, partnering social organizations may request teachings for health skills from their respective health system in an immediate moment-in-time due to certain contextual factors that demand it. One such health skill is cardiopulmonary resuscitation (CPR), a valuable competency that may allow a community member to save the life of their peer, and which is often requested due to personal experiences by members in the respective social network. Similarly, communities, especially those affected by violence, have sought out hemorrhage control skills training which can help to control life-threatening bleeding. In this community engagement feasibility review, we evaluate the infrastructure warranted to implement bystander CPR and bleeding control skills training to diverse social organizations in an urban region over a 9-month period. Further, we review the necessary variables to sustain such an effort, for both the health system as well as the partnering communities.

Background: This study aims to characterize patients with patient-directed discharge (PDD) and substance use disorders (SUD) and to summarize involvement of an Addiction Consult Service (ACS) in encounters resulting in PDD in an urban academic medical center. Methods: This single-center, retrospective, pre-and post-implementation study included patient encounters for hospitalized adults with at least one documented SUD and a PDD. The pre-and post-implementation periods were defined as July 2018–June 2019 and July 2020–June 2022, respectively. The primary outcome was a comparison of PDD rates between cohorts. Secondary outcomes were hospital length of stay (LOS) and 30-day read-mission rates. In the post-implementation cohort, ordering of and completion of an ACS consult and time to order and time to completion of the consult were assessed. For the subgroup with OUD, severity of withdrawal symptoms, utilization of methadone and/or buprenorphine in the first 24 h of admission, and rate of buprenorphine discharge prescribing were described. Differences in categorical variables between cohorts were analyzed using Chi-square or Fisher’s exact test and continuous variables were analyzed using the Student T -test or the Wilcoxon Rank Sum, as appropriate. Results: A total of 346 encounters (pre n = 101 and post n = 245) comprised of 252 unique patients were included. Patients were median 41 years old (IQR 33–54), 65.9% male, and 49.1% white. OUD (57.5%) was the most common SUD diagnosis among encounters and 40.8% were associated with more

Abstract In maintained, bi-directional medical-community collaborations, partnering social organizations may request teachings for health skills from their respective health system in an immediate moment-in-time due to certain contextual factors that demand it. One such health skill is cardiopulmonary resuscitation (CPR), a valuable competency that may allow a community member to save the life of their peer, and which is often requested due to personal experiences by members in the respective social network. Similarly, communities, especially those affected by violence, have sought out hemorrhage control skills training which can help to control life-threatening bleeding. In this community engagement feasibility review, we evaluate the infrastructure warranted to implement bystander CPR and bleeding control skills training to diverse social organizations in an urban region over a 9-month period. Further, we review the necessary variables to sustain such an effort, for both the health system as well as the partnering communities.

People released from prison are at risk of adverse health outcomes in the weeks after release. This article describes cases that illustrate the complexity of caring for this population. It is important to address medical and psychological needs as well as factors that contribute to social determinants of health.

BACKGROUND:Buprenorphine is a life-saving treatment for opioid use disorder (OUD). Low-dose initiation (LDI) is an emerging buprenorphine initiation strategy that circumvents barriers associated with standard initiation. This study aims to describe tolerability and completion of LDI using intravenous (IV) buprenorphine and to define dosing protocols in a cohort of patients hospitalized in an urban academic hospital. METHODS:Data was collected via retrospective chart review for IV buprenorphine LDI cases initiated between September 1, 2020 and February 28, 2021. Cases were excluded if diagnostic criteria for OUD was not met, Clinical Opiate Withdrawal Scale (COWS) scores were not recorded, or sublingual (SL) buprenorphine was given within 24 h before IV buprenorphine. Completion of LDI and COWS data were assessed for all cases. Cases were categorized based on adherence to a dosing strategy and LDI indication, including OUD and acute pain, non-prescribed fentanyl exposure, and transition from methadone. RESULTS:Seventy-two cases were identified, and thirteen cases were excluded, leaving 59 cases in the population. Of these cases, 72.9% (43/59) tolerated LDI, and 91.5% (54/59) completed buprenorphine initiation. Forty-four (44/59, 75%) cases were adherent. Median duration of LDI within the adherent group was 23.7 h (IQR 22.8-27.0), 37.1 h (IQR 36.2-40.9), and 48.8 h (IQR 47.0-52.4) for the "rapid," "moderate," and "slow" dosing strategies, respectively. CONCLUSIONS:IV buprenorphine LDI was tolerated and completed in a majority of patients. Dosing protocols allowed for rapid transition to sublingual buprenorphine. Acute pain or recent methadone or fentanyl exposure may inform IV LDI dosing strategy selection.