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Born C, Schwarz R, Böttcher TP, Hein A, Krcmar H. The role of information systems in emergency department decision-making-a literature review. J Am Med Inform Assoc 2024:ocae096. [PMID: 38781289 DOI: 10.1093/jamia/ocae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED. MATERIALS AND METHODS We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes. RESULTS Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes. DISCUSSION Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation. CONCLUSION We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.
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Affiliation(s)
- Cornelius Born
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Romy Schwarz
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Timo Phillip Böttcher
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
| | - Andreas Hein
- Institute of Information Systems and Digital Business, University of St. Gallen, 9000 St. Gallen, Switzerland
| | - Helmut Krcmar
- School of Computation, Information and Technology, Technical University of Munich, 85748 Garching bei München, Germany
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Jennings LK, Lander L, Lawdahl T, McClure EA, Moreland A, McCauley JL, Haynes L, Matheson T, Jones R, Robey TE, Kawasaki S, Moschella P, Raheemullah A, Miller S, Gregovich G, Waltman D, Brady KT, Barth KS. Characterization of peer support services for substance use disorders in 11 US emergency departments in 2020: findings from a NIDA clinical trials network site selection process. Addict Sci Clin Pract 2024; 19:26. [PMID: 38589934 PMCID: PMC11003047 DOI: 10.1186/s13722-024-00453-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 03/18/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Emergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs. METHODS A survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) evaluating PSS effectiveness, Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis. RESULTS A total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided "general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding. CONCLUSIONS The majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.
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Affiliation(s)
- Lindsey K Jennings
- Department of Emergency Medicine, Medical University of South Carolina, 169 Ashley Avenue, MSC 300, Charleston, SC, 29425, USA.
| | - Laura Lander
- Department of Behavioral Medicine & Psychiatry, West Virginia University, Morgantown, WV, USA
| | - Tricia Lawdahl
- Faces and Voices of Recovery (FAVOR) Upstate, Greenville, SC, USA
| | - Erin A McClure
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Angela Moreland
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Louise Haynes
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Timothy Matheson
- Center On Substance Use and Health, San Francisco Department of Public Health, San Francisco, CA, USA
| | | | - Thomas E Robey
- Providence Regional Medical Center Everett, Washington State University, Everett, WA, USA
| | - Sarah Kawasaki
- Departments of Psychiatry and Internal Medicine, Penn State Health, Hershey, PA, USA
| | - Phillip Moschella
- Department of Emergency Medicine, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Amer Raheemullah
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Suzette Miller
- Mercy Health - St. Elizabeth Youngstown Hospital, Youngstown, OH, USA
| | - Gina Gregovich
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Deborah Waltman
- Deaconess Hospital, MultiCare Health System, Spokane, WA, USA
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly S Barth
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Westafer LM, Beck SA, Simon C, Potee B, Soares WE, Schoenfeld EM. Barriers and Facilitators to Harm Reduction for Opioid Use Disorder: A Qualitative Study of People With Lived Experience. Ann Emerg Med 2024; 83:340-350. [PMID: 38180403 PMCID: PMC10960719 DOI: 10.1016/j.annemergmed.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/09/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024]
Abstract
STUDY OBJECTIVE Although an increasing number of emergency departments (ED) offer opioid agonist treatment, naloxone, and other harm reduction measures, little is known about patient perspectives on harm reduction practices delivered in the ED. The objective of this study was to identify patient-focused barriers and facilitators to harm reduction strategies in the ED. METHODS We conducted semistructured interviews with a convenience sample of individuals in Massachusetts diagnosed with opioid use disorder. We developed an interview guide, and interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. After initial interviews and coding, we triangulated the results among a focus group of 4 individuals with lived experience. RESULTS We interviewed 25 participants with opioid use disorder, 6 recruited from 1 ED and 19 recruited from opioid agonist treatment clinics. Key themes included accessibility of harm reduction supplies, lack of self-care resulting from withdrawal and hopelessness, the impact of stigma on the likelihood of using harm reduction practices, habit and knowledge, as well as the need for user-centered harm reduction interventions. CONCLUSION In this study, people with lived experience discussed the characteristics and need for user-centered harm reduction strategies in the ED that centered on reducing stigma, treatment of withdrawal, and availability of harm reduction materials.
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Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | | | - Caty Simon
- National Survivors Union, Greensboro, NC; Whose Corner Is It Anyway, Holyoke, MA
| | | | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA; Department for Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
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Treitler P, Crystal S, Cantor J, Chakravarty S, Kline A, Morton C, Powell KG, Borys S, Cooperman NA. Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose. JAMA Netw Open 2024; 7:e243614. [PMID: 38526490 PMCID: PMC10964115 DOI: 10.1001/jamanetworkopen.2024.3614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/30/2024] [Indexed: 03/26/2024] Open
Abstract
Importance Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking. Objective To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization. Design, Setting, and Participants This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023. Exposure Hospital OORP implementation. Main Outcomes and Measures The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access. Results A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities. Conclusions and Relevance In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.
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Affiliation(s)
- Peter Treitler
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Boston University School of Social Work, Boston, Massachusetts
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Joel Cantor
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Sujoy Chakravarty
- Department of Health Sciences, Rutgers University, Camden, New Jersey
| | - Anna Kline
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
| | - Cory Morton
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- Center for Prevention Science, Rutgers University, New Brunswick, New Jersey
- Northeast and Caribbean Prevention Technology Transfer Center, Rutgers University, New Brunswick, New Jersey
| | - Kristen Gilmore Powell
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- Center for Prevention Science, Rutgers University, New Brunswick, New Jersey
- Northeast and Caribbean Prevention Technology Transfer Center, Rutgers University, New Brunswick, New Jersey
| | - Suzanne Borys
- Division of Mental Health and Addiction Services, New Jersey Department of Human Services, Trenton
| | - Nina A. Cooperman
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
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Lin CH, Siao SF, Lin PY, Shelley M, Chi YC, Lee YH. Understanding Healthcare Providers' Care for Patients with Medications Treating Opioid Use Disorder in the Emergency Department: A Scoping Review. Subst Use Misuse 2024; 59:622-637. [PMID: 38115559 DOI: 10.1080/10826084.2023.2294964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND There is limited research exploring the changing clinical practices among healthcare providers (HPs) care for patients with Emergency Department (ED)-initiated Medication for Opioid Use Disorder (MOUD). METHODS This scoping review followed the methodological framework of Arksey and O'Malley to map relevant evidence and synthesize the findings. We searched PubMed, EMBASE, CINAHL, Web of Science, and Scopus for related studies from inception through October 12, 2022. Following the application of inclusion and exclusion criteria, 16 studies were included. Subsequently, they were charted and analyzed thematically based on ecological systems theory. RESULTS The main determinants in the four ecological systems were generated as follows: (1) microsystem: willingness and attitude, professional competence, readiness, and preference; (2) mesosystem: ED clinical practices, departmental factors; (3) exosystem: multidisciplinary approaches, discharge planning, and (4) macrosystem: stigma, health insurance, policy. The findings have implications for HPs and researchers, as insufficient adoption, implementation, and retention of MOUD in the ED affect clinical practices. CONCLUSIONS Across the four ecological systems, ED-initiated MOUD is shaped by multifaceted determinants. The microsystem underscores pivotal patient-HP trust dynamics, while the mesosystem emphasizes interdepartmental synergies. Exosystemically, resource allocation and standardized training remain paramount. The macrosystem reveals profound effects of stigma, insurance disparities, and evolving policies on treatment access and efficacy. Addressing these interconnected barriers is crucial for optimizing patient outcomes in the context of MOUD.
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Affiliation(s)
- Chia-Hung Lin
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Fen Siao
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Ying Lin
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mack Shelley
- Department of Political Science, Department of Statistics, Iowa State University, Ames, IA, USA
| | - Yu-Chi Chi
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Han Lee
- Department of Health Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, FL, USA
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van der Laag PJ, Dorhout BG, Heeren AA, Veenhof C, Barten DJJA, Schoonhoven L. Identification and development of implementation strategies: the important role of codesign. FRONTIERS IN HEALTH SERVICES 2024; 4:1305955. [PMID: 38385048 PMCID: PMC10879593 DOI: 10.3389/frhs.2024.1305955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/12/2024] [Indexed: 02/23/2024]
Abstract
Background To date, implementation strategies reported in the literature are commonly poorly described and take the implementation context insufficiently into account. To unravel the black box of implementation strategy development, insight is needed into effective theory-based and practical-informed strategies. The current study aims to describe the stepwise development of a practical-informed and theory-based implementation strategy bundle to implement ProMuscle, a nutrition and exercise intervention for community-dwelling older adults, in multiple settings in primary care. Methods The first four steps of Implementation Mapping were adopted to develop appropriate implementation strategies. First, previously identified barriers to implementation were categorized into the constructs of the Consolidated Framework for Implementation Research (CFIR). Second, the CFIR-ERIC matching tool linked barriers to existing implementation strategies. Behavioral change strategies were added from the literature where necessary. Third, evidence for implementation strategies was sought. Fourth, in codesign with involved healthcare professionals and implementation experts, implementation strategies were operationalized to practical implementation activities following the guidance provided by Proctor et al. These practical implementation activities were processed into an implementation toolbox, which can be tailored to a specific context and presents prioritized implementation activities in a chronological order. Results A previous study identified and categorized a total of 654 barriers for the implementation of a combined lifestyle intervention within the CFIR framework. Subsequently, the barriers were linked to 40 strategies. Due to the fact that many strategies impacted multiple barriers, seven overarching themes emerged based on the strategies: assessing the context, network internally, network externally, costs, knowledge, champions, and patient needs and resources. Codesign sessions with professionals and implementation experts resulted in the development of supported and tangible implementation activities for the final 20 strategies. The implementation activities were processed into a web-based implementation toolbox, which allows healthcare professionals to tailor the implementation activities to their specific context and guides healthcare professionals to prioritize implementation activities chronologically during their implementation. Conclusion A theory-based approach in combination with codesign sessions with stakeholders is a usable Implementation Strategy Mapping Method for developing a practical implementation strategy bundle to implement ProMuscle across multiple settings in primary care. The next step involves evaluating the developed implementation strategies, including the implementation toolbox, to assess their impact on the implementation and adoption of ProMuscle.
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Affiliation(s)
- Patricia J. van der Laag
- Julius Center for Health Sciences and Primary Care, Nursing Science, University Medical Center Utrecht, University Utrecht, Utrecht, Netherlands
| | - Berber G. Dorhout
- Research Group Innovation of Human Movement Care, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, Netherlands
- Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, Netherlands
| | - Aaron A. Heeren
- Research Group Innovation of Human Movement Care, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, Netherlands
| | - Cindy Veenhof
- Research Group Innovation of Human Movement Care, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, Netherlands
| | - Di-Janne J. A. Barten
- Research Group Innovation of Human Movement Care, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Lisette Schoonhoven
- Julius Center for Health Sciences and Primary Care, Nursing Science, University Medical Center Utrecht, University Utrecht, Utrecht, Netherlands
- Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
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Stewart RE, Christian HP, Cardamone NC, Abrams C, Drob C, Mandell DS, Metzger D, Lowenstein M. Mobile service delivery in response to the opioid epidemic in Philadelphia. Addict Sci Clin Pract 2023; 18:71. [PMID: 38031174 PMCID: PMC10687974 DOI: 10.1186/s13722-023-00427-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND The harms of opioid use disorder (OUD) and HIV infection disproportionately impact marginalized populations, especially people experiencing homelessness and people who inject drugs (PWID). Mobile OUD service delivery models are emerging to increase access and reduce barriers to OUD care. While there is growing interest in these models, there is limited research about the services they provide, how they operate, and what barriers they face. We characterize the capacity, barriers, and sustainment of mobile OUD care services in a large city with a high incidence of OUD and HIV. METHODS From May to August 2022, we conducted semi-structured interviews with leadership from all seven mobile OUD care units (MOCU) providing a medication for OUD or other substance use disorder services in Philadelphia. We surveyed leaders about their unit's services, staffing, operating location, funding sources, and linkages to care. Leaders were asked to describe their clinical approach, treatment process, and the barriers and facilitators to their operations. Interview recordings were coded using rapid qualitative analysis. RESULTS MOCUs are run by small, multidisciplinary teams, typically composed of a clinician, one or two case managers, and a peer recovery specialist or outreach worker. MOCUs provide a range of services, including medications for OUD, wound care, medical services, case management, and screening for infectious diseases. No units provide methadone, but all units provide naloxone, six write prescriptions for buprenorphine, and one unit dispenses buprenorphine. The most frequently reported barriers include practical challenges of working on a MOCU (e.g. lack of space, safety), lack of community support, and patients with substantial medical and psychosocial needs. Interviewees reported concerns about funding and specifically as it relates to providing their staff with adequate pay. The most frequently reported facilitators include positive relationships with the community, collaboration with other entities (e.g. local nonprofits, the police department, universities), and having non-clinical staff (e.g. outreach workers, peer recovery specialists) on the unit. CONCLUSIONS MOCUs provide life-saving services and engage marginalized individuals with OUD. These findings highlight the challenges and complexities of caring for PWID and demonstrate a need to strengthen collaborations between MOCU providers and the treatment system. Policymakers should consider programmatic funding for permanent mobile OUD care services.
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Affiliation(s)
- Rebecca E Stewart
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Hanna P Christian
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Caroline Drob
- The Health Federation of Philadelphia, Philadelphia, PA, USA
| | - David S Mandell
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David Metzger
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Margaret Lowenstein
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Lowenstein M, Perrone J, McFadden R, Xiong RA, Meisel ZF, O'Donnell N, Abdel-Rahman D, Moon J, Mitra N, Delgado MK. Impact of Universal Screening and Automated Clinical Decision Support for the Treatment of Opioid Use Disorder in Emergency Departments: A Difference-in-Differences Analysis. Ann Emerg Med 2023; 82:131-144. [PMID: 37318434 PMCID: PMC11019868 DOI: 10.1016/j.annemergmed.2023.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 06/16/2023]
Abstract
STUDY OBJECTIVE Emergency department (ED)-initiated buprenorphine improves outcomes in patients with opioid use disorder; however, adoption varies widely. To reduce variability, we implemented a nurse-driven triage screening question in the electronic health record to identify patients with opioid use disorder, followed by targeted electronic health record prompts to measure withdrawal and guide next steps in management, including initiation of treatment. Our objective was to assess the impact of screening implementation in 3 urban, academic EDs. METHODS We conducted a quasiexperimental study of opioid use disorder-related ED visits using electronic health record data from January 2020 to June 2022. The triage protocol was implemented in 3 EDs between March and July 2021, and 2 other EDs in the health system served as controls. We evaluated changes in treatment measures over time and used a difference-in-differences analysis to compare outcomes in the 3 intervention EDs with those in the 2 controls. RESULTS There were 2,462 visits in the intervention hospitals (1,258 in the preperiod and 1,204 in the postperiod) and 731 in the control hospitals (459 in the preperiod and 272 in the postperiod). Patient characteristics within the intervention and control EDs were similar across the time periods. Compared with the control hospitals, the triage protocol was associated with a 17% greater increase in withdrawal assessment, using the Clinical Opioid Withdrawal Scale (COWS) (95% CI 7 to 27). Buprenorphine prescriptions at discharge also increased by 5% (95% CI 0% to 10%), and naloxone prescriptions increased by 12% points (95% CI 1% to 22%) in the intervention EDs relative to controls. CONCLUSION An ED triage screening and treatment protocol led to increased assessment and treatment of opioid use disorder. Protocols designed to make screening and treatment the default practice have promise in increasing the implementation of evidence-based treatment ED opioid use disorder care.
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Affiliation(s)
- Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Rachel McFadden
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Ruiying Aria Xiong
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
| | - Zachary F Meisel
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nicole O'Donnell
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Dina Abdel-Rahman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
| | - Jeffrey Moon
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mucio Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
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Thakrar AP, Faude S, Perrone J, Milone MC, Lowenstein M, Snider CK, Spadaro A, Delgado MK, Nelson LS, Kilaru AS. Association of Urine Fentanyl Concentration With Severity of Opioid Withdrawal Among Patients Presenting to the Emergency Department. J Addict Med 2023; 17:447-453. [PMID: 37579106 PMCID: PMC10440418 DOI: 10.1097/adm.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND AND AIMS Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal. DESIGN This is a retrospective cross-sectional study. SETTING This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021. PARTICIPANTS This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing. MEASUREMENTS The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40-399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures. FINDINGS For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9-4.8) compared with 5.5 (5.1-6.0) among those with medium and 7.7 (6.8-8.7) among those with low fentanyl concentrations. CONCLUSIONS Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.
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Affiliation(s)
- Ashish P. Thakrar
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- National Clinician Scholars Program, University of Pennsylvania
| | - Sophia Faude
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Emergency Medicine, Grossman School of Medicine, New York University Langone Health
| | - Jeanmarie Perrone
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Michael C. Milone
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Pathology and Laboratory Medicine, University of Pennsylvania
| | - Margaret Lowenstein
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Christopher K. Snider
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Anthony Spadaro
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - M. Kit Delgado
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Lewis S. Nelson
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Emergency Medicine, Rutgers New Jersey Medical School
| | - Austin S. Kilaru
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
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10
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French R, Holliday Davis M, Aronowitz SV, Crowe M, Abrams M, Edwards G, Lowenstein M. "I wouldn't need Narcan for myself, but I can have it for somebody else:" perceptions of harm reduction among hospitalized patients with OUD. Addict Sci Clin Pract 2023; 18:41. [PMID: 37355639 PMCID: PMC10290347 DOI: 10.1186/s13722-023-00395-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/05/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Extant literature is limited on adoption of evidence-based harm reduction strategies in hospitals. We explored patient perceptions of incorporating harm reduction supplies and education in hospital care with patients with opioid use disorder (OUD). METHODS Qualitative descriptive study of hospitalized patients with OUD in Philadelphia, PA using semi-structured interviews conducted between April and August of 2022. RESULTS Three major themes emerged from 21 interviews with hospitalized patients with OUD: (1) Applicability and Acceptability of Harm Reduction Practices for Oneself; (2) Applicability and Acceptability of Harm Reduction Practices for Others; (3) Perceptions of Harm Reduction Conversations. Most participants were familiar with harm reduction but varied in their perceptions of its relevance for their lives. We noted differences in how participants viewed the applicability and acceptably of harm reduction practices that they perceived as intended to help others (e.g., naloxone) versus intended to help themselves (e.g., syringes). Most participants reported that meaningful conversations about drug use did not happen with their care team but that these conversations would have been acceptable if they were conducted in a way consistent with their individual substance use goals. CONCLUSIONS Patients' interest and perceived acceptability of harm reduction services during hospitalization varied by individual patient factors and the perceived user of specific interventions. Given their positive potential, harm reduction practices should be incorporated in hospitals, but this must be done in a way that is acceptable to patients. Our findings reveal ways to integrate concepts from a harm reduction approach within a traditional medical model. More work is needed to understand the impact of such integration.
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Affiliation(s)
- Rachel French
- National Clinician Scholars Program, University of Pennsylvania, 13th Floor Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute for Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA, 19104, USA.
| | - M Holliday Davis
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Shoshana V Aronowitz
- Leonard Davis Institute for Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA, 19104, USA
- School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA, 19104, USA
| | - Molly Crowe
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Matthew Abrams
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Grace Edwards
- College of Arts and Sciences, University of Pennsylvania, 249 S 36th St, Philadelphia, PA, 19104, USA
| | - Margaret Lowenstein
- Leonard Davis Institute for Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Research Director, Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA
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11
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Church B, Clark R, Mohn W, Potee R, Friedmann P, Soares WE. Methadone Induction for a Patient With Precipitated Withdrawal in the Emergency Department: A Case Report. J Addict Med 2023; 17:367-370. [PMID: 37267195 PMCID: PMC10248191 DOI: 10.1097/adm.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In the era of illicit fentanyl, reports on difficulties with buprenorphine inductions for patients with opioid use disorder are emerging. Methadone is the only other approved medication treatment with efficacy similar to buprenorphine but without risks of precipitated withdrawal. Unfortunately, outpatient methadone inductions can take days to weeks to complete, due in part to regulations that limit administration to opioid treatment programs. We describe a patient with opioid use disorder who presented to the emergency department in precipitated withdrawal who completed a same-day methadone induction with next-day dosing at an opioid treatment program as part of an emergency department methadone protocol. As opioid-related deaths rise, emergency department-initiated methadone is feasible for patients with opioid use disorder.
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Affiliation(s)
- Benjamin Church
- From the University of Massachusetts Chan Medical School-Baystate, Springfield, MA (BC, RC, PF, WES); Baystate Medical Center, Springfield, MA (WM); Behavioral Health Network, Springfield, MA (RP); Department of Emergency Medicine, Baystate Medical Center, Springfield, MA (WES)
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12
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Simpson MJ, Ritger C, Hoppe JA, Holland WC, Morris MA, Nath B, Melnick ER, Tietbohl C. Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study. Implement Sci Commun 2023; 4:41. [PMID: 37081581 PMCID: PMC10117277 DOI: 10.1186/s43058-023-00421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/22/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations. METHODS We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns. RESULTS Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine. CONCLUSION The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.
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Affiliation(s)
- Matthew J Simpson
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box F496, Aurora, CO, 80045, USA.
| | - Carly Ritger
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box B215, Aurora, CO, 80045, USA
| | - Wesley C Holland
- Yale University School of Medicine, 333 Cedar St., New Haven, CT, 06510, USA
| | - Megan A Morris
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Caroline Tietbohl
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
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13
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D’Onofrio G, Edelman EJ, Hawk KF, Chawarski MC, Pantalon MV, Owens PH, Martel SH, Rothman R, Saheed M, Schwartz RP, Cowan E, Richardson L, Salsitz E, Lyons MS, Freiermuth C, Wilder C, Whiteside L, Tsui JI, Klein JW, Coupet E, O’Connor PG, Matthews AG, Murphy SM, Huntley K, Fiellin DA. Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder. JAMA Netw Open 2023; 6:e235439. [PMID: 37017967 PMCID: PMC10077107 DOI: 10.1001/jamanetworkopen.2023.5439] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/05/2023] [Indexed: 04/06/2023] Open
Abstract
Importance Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused. Objective To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy. Design, Setting, and Participants This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022. Exposure A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback. Main Outcomes and Measures The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed. Results A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits). Conclusions and Relevance In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine. Trial Registration ClinicalTrials.gov Identifier: NCT03023930.
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Affiliation(s)
- Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn F. Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marek C. Chawarski
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Michael V. Pantalon
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patricia H. Owens
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Shara H. Martel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Richard Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lynne Richardson
- Institute for Health Equity Research, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Edwin Salsitz
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Caroline Freiermuth
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christine Wilder
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio
| | - Lauren Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - Judith I. Tsui
- Department of Medicine, University of Washington, Seattle
| | - Jared W. Klein
- Department of Medicine, University of Washington, Seattle
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patrick G. O’Connor
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - David A. Fiellin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
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14
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Spadaro A, Faude S, Perrone J, Thakrar AP, Lowenstein M, Delgado MK, Kilaru AS. Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series. J Am Coll Emerg Physicians Open 2023; 4:e12880. [PMID: 36704210 PMCID: PMC9871399 DOI: 10.1002/emp2.12880] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW. Methods This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument. Results A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self-directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine. Conclusions Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.
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Affiliation(s)
- Anthony Spadaro
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sophia Faude
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Emergency MedicineGrossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Jeanmarie Perrone
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ashish P. Thakrar
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- National Clinician Scholars ProgramUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Margaret Lowenstein
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of General Internal MedicineDepartment of Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - M. Kit Delgado
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Austin S. Kilaru
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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15
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Harris RA, Campbell K, Calderbank T, Dooley P, Aspero H, Maginnis J, O’Donnell N, Coviello D, French R, Bao Y, Mandell DS, Bogner HR, Lowenstein M. Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100641. [PMID: 35785613 PMCID: PMC9933784 DOI: 10.1016/j.hjdsi.2022.100641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022]
Abstract
Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program's core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.
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Affiliation(s)
- Rebecca Arden Harris
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Kristen Campbell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Tara Calderbank
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Patrick Dooley
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Heather Aspero
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jessica Maginnis
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Nicole O’Donnell
- Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Coviello
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rachel French
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104, USA,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, 10065, USA
| | - David S. Mandell
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hillary R. Bogner
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Margaret Lowenstein
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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16
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Lowenstein M, Sangha HK, Spadaro A, Perrone J, Delgado MK, Agarwal AK. Patient perspectives on naloxone receipt in the emergency department: a qualitative exploration. Harm Reduct J 2022; 19:97. [PMID: 36028882 PMCID: PMC9412772 DOI: 10.1186/s12954-022-00677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 08/15/2022] [Indexed: 12/03/2022] Open
Abstract
Background Emergency departments (EDs) are important venues for the distribution of naloxone to patients at high risk of opioid overdose, but less is known about patient perceptions on naloxone or best practices for patient education and communication. Our aim was to conduct an in-depth exploration of knowledge and attitudes toward ED naloxone distribution among patients who received a naloxone prescription. Methods We conducted semi-structured telephone interviews with 25 adult participants seen and discharged from three urban, academic EDs in Philadelphia, PA, with a naloxone prescription between November 2020 and February 2021. Interviews focused on awareness of naloxone as well as attitudes and experiences receiving naloxone in the ED. We used thematic content analysis to identify key themes reflecting patient attitudes and experiences.
Results Of the 25 participants, 72% had previously witnessed an overdose and 48% had personally experienced a non-fatal overdose. Nineteen participants (76%) self-disclosed a history of substance use or overdose, and one reported receiving an opioid prescription during their ED visit and no history of substance use. In interviews, we identified wide variability in participant levels of knowledge about overdose risk, the role of naloxone in reducing risk, and naloxone access. A subset of participants was highly engaged with community harm reduction resources and well versed in naloxone access and use. A second subset was familiar with naloxone, but largely obtained it through healthcare settings such as the ED, while a final group was largely unfamiliar with naloxone. While most participants expressed positive attitudes about receiving naloxone from the ED, the quality of discussions with ED providers was variable, with some participants not even aware they were receiving a naloxone prescription until discharge.
Conclusions Naloxone prescribing in the ED was acceptable and valued by most participants, but there are missed opportunities for communication and education. These findings underscore the critical role that EDs play in mitigating risks for patients who are not engaged with other healthcare or community health providers and can inform future work about the effective implementation of harm reduction strategies in ED settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12954-022-00677-7.
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Affiliation(s)
- Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, 122 Blockley Hall, 421 Guardian Drive, Philadelphia, PA, 19104, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. .,Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA.
| | - Hareena K Sangha
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony Spadaro
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanmarie Perrone
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA.,Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anish K Agarwal
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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17
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Melnick ER, Nath B, Dziura JD, Casey MF, Jeffery MM, Paek H, Soares WE, Hoppe JA, Rajeevan H, Li F, Skains RM, Walter LA, Patel MD, Chari SV, Platts-Mills TF, Hess EP, D'Onofrio G. User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial. BMJ 2022; 377:e069271. [PMID: 35760423 PMCID: PMC9231533 DOI: 10.1136/bmj-2021-069271] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN Pragmatic cluster randomized controlled trial (EMBED). SETTING 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION ClinicalTrials.gov NCT03658642.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Martin F Casey
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Molly M Jeffery
- Department of Emergency Medicine and Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Hyung Paek
- Yale School of Public Health, New Haven, CT, USA
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School, Springfield, MA, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | | | - Fangyong Li
- Yale School of Public Health, New Haven, CT, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
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18
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Samuels EA, Martin AF. Beyond the Waiver: Multilevel Interventions Needed to Expand Buprenorphine Treatment. JAMA Netw Open 2022; 5:e2212425. [PMID: 35552731 DOI: 10.1001/jamanetworkopen.2022.12425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Elizabeth A Samuels
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alister F Martin
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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