Unintended consequences of methadone regulation for opioid use disorder treatment among hospitalized patients

BACKGROUND

In the United States, there are no federal restrictions on the use of methadone to manage opioid withdrawal symptoms when patients are hospitalized with a medical or surgical condition other than addiction. In contrast, in an outpatient setting, methadone for opioid use disorder (OUD) is highly regulated by federal and state governments and can only be dispensed from an opioid treatment program (OTP). Discrepancies in regulatory requirements across these settings may lead to barriers in care for patients with OUD.

OBJECTIVE

Identify how methadone regulation impacts the care of patients with OUD during hospitalization, care transitions, and in the OTP setting.

METHODS

We completed 26 interviews with clinicians and social workers working on hospital-based addiction consultation services across the United States. Study findings are the result of a secondary content analysis of interviews to identifying the word "methadone" and construct themes resulting from the data.

RESULTS

We identified three major themes related to "methadone" for OUD treatment, all of which impacted patient care: (1) limited OTP hours leads to tenuous or delayed hospital discharges; (2) inadequate information-sharing between hospitals and OTPs leads to delays in care; and (3) methadone regulations create treatment barriers for the most vulnerable patients.

CONCLUSION

Strict methadone regulations have resulted in unintended consequences for patients with OUD in the hospital setting, during care transitions, and in the OTP setting. Recent and ongoing federal efforts to reform methadone provision may improve some of the reported challenges, but significant hurdles remain in providing safe, equitable care to hospitalized patients with OUD.

Physician views of artificial intelligence in otolaryngology and rhinology: A mixed methods study

Objective

The study aimed to investigate otolaryngologists' knowledge, trust, acceptance, and concerns with clinical applications of artificial intelligence (AI).

Methods

This study used mixed methods with survey and semistructured interviews. Survey was e-mailed to American Rhinologic Society members, of which a volunteer sample of 86 members responded. Nineteen otolaryngologists were purposefully recruited and interviewed until thematic saturation was achieved.

Results

Seventy-six respondents (10% response rate) completed the majority of the survey: 49% worked in academic settings and 43% completed residency 10 or fewer years ago. Of 19 interviewees, 58% worked in academic settings, and 47% completed residency 10 or fewer years ago. Familiarity: Only 8% of survey respondents reported having AI training in residency, although 72% had familiarity with general AI concepts; 0 interviewees had personal experience with AI in clinical settings. Expected uses: Of the surveyed otolaryngologists, 82% would use an AI-based clinical decision aid and 74% were comfortable with AI proposing treatment recommendations. However, only 44% of participants would trust AI to identify malignancy and 53% to interpret radiographic images. Interviewees trusted AI for simple tasks, such as labeling septal deviation, more than complex ones, such as identifying tumors. Factors influencing AI adoption: 89% of survey participants would use AI if it improved patient satisfaction, 78% would be willing to use AI if experts and studies validated the technologies, and 73% would only use AI if it increased efficiency. Sixty-one percent of survey respondents expected AI incorporation into clinical practice within 5 years. Interviewees emphasized that AI adoption depends on its similarity to their clinical judgment and to expert opinion. Concerns included nuanced or complex cases, poor design or accuracy, and the personal nature of physician-patient relationships.

Conclusion

Few physicians have experience with AI technologies but expect rapid adoption in the clinic, highlighting the urgent need for clinical education and research. Otolaryngologists are most receptive to AI "augmenting" physician expertise and administrative capacity, with respect for physician autonomy and maintaining relationships with patients.

Level of Evidence

Level VI, descriptive or qualitative study.

Clinical Inertia Among Outpatients With Heart Failure: Application of Treatment Nonintensification Taxonomy to EPIC-HF Trial

BACKGROUND

The contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear.

OBJECTIVES

This study examined reasons for GDMT nonintensification and characterized clinical inertia.

METHODS

In this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase.

RESULTS

Among 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification.

CONCLUSIONS

In this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse.

Otolaryngologist perceptions of AI-based sinus CT interpretation

BACKGROUND

Overcoming non-standardization, vagueness, and subjectivity in sinus CT radiology reports is an ongoing need, particularly in keeping with data-driven healthcare initiatives. Our aim was to explore otolaryngologists' perceptions of quantitative objective disease measures as enabled by AI-based analysis, and determine preferences for sinus CT interpretation.

METHODS

A multi-methods design was used. We administered a survey to American Rhinologic Society members and conducted semi-structured interviews with a purposeful sample of otolaryngologists and rhinologists from varying backgrounds, practice settings and locations during 2020-2021. Interview topics included sinus CT reports, familiarity with AI-based analysis, and potential requisites for its future implementation. Interviews were then coded for content analysis. Differences in survey responses were calculated using Chi-squared test.

RESULTS

120 of 955 surveys were returned, and 19 otolaryngologists (8 rhinologists) were interviewed. Survey data revealed more trust in conventional radiologist reports, but that AI-based reports would be more systematic and comprehensive. Interviews expanded on these results. Interviewees believed that conventional sinus CT reports had limited utility due to inconsistent content. However, they described relying on them for reporting incidental extra-sinus findings. Reporting could be improved with standardization and more detailed anatomical analysis. Interviewees expressed interest in AI-derived analysis given potential for standardization, although they desired evidence of accuracy and reproducibility to gain trust in AI-based reports.

CONCLUSIONS

Sinus CT interpretation has shortcomings in its current state. Standardization and objectivity could be aided with deep learning-enabled quantitative analysis, although clinicians desire thorough validation to gain trust in the technology prior to its implementation.

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

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.

Identifying factors that contribute to burnout and resilience among hospital-based addiction medicine providers: A qualitative study

INTRODUCTION

Inpatient Addiction Consultation Services (ACS) fill an important need by connecting hospitalized patients with substance use disorders with resources for treatment; however, providers of these services may be at risk for burnout. In this qualitative study, we aimed to identify factors associated with burnout and, conversely, resilience among multidisciplinary providers working on ACS.

METHODS

We completed 26 semi-structured interviews with clinicians working on ACS, including physicians, social workers, and advanced practice providers. Twelve institutions across the country were represented. The study recruited participants via email solicitation to ACS directors and then via snowball sampling. We used an inductive, grounded theory approach to analyze data.

RESULTS

Providers described factors contributing to burnout and strategies for promoting resilience, and three main themes arose: (1) Systemic barriers contributed to provider burnout, (2) Engaging in meaningful work increased resilience, and (3) Team dynamics influenced perceptions of burnout and resilience.

CONCLUSION

Our results suggest that hospital-based addiction medicine work is intrinsically rewarding for many providers and that engaging with other addiction providers to debrief challenging encounters or engage in advocacy work can be protective against burnout. However, administrative and systemic factors are frequent sources of frustration for providers of ACS. Structured debriefings may help to mitigate burnout. Furthermore, training to enhance providers' ability to engage effectively in advocacy work within and between hospital systems has the potential to promote resilience and protect against burnout among ACS providers.

Trust and activation in defining patient-clinician interactions for chronic disease management

OBJECTIVE

Patient-clinician relationship quality and patient activation can both improve patient health outcomes, but prior work has primarily examined these factors independently. We examine how these two factors shape patient behavior in the setting of ambulatory heart failure care, where serial intensification of multiple medications is central to chronic care delivery.

METHODS

We used content analysis to analyze 22 in-depth patient interviews and 32 audio-recorded clinic visits collected for the EPIC-HF Trial. This was a secondary analysis providing qualitative depth to the parent RCT.

RESULTS

We identified a typology of patient activation and patient-clinician relationship quality, with four types: Supported, Skeptical, Deferential, and Unempowered. Types were sensitive to time and context; a given patient might occupy multiple types throughout the course of a single clinic visit. The effects of patient-activation and the patient-clinician relationship appeared to be bidirectional, with each influencing the other.

CONCLUSION

Patient-clinician relationship quality and patient activation are dominant in shaping clinical interactions and disease management. This interaction is dynamic, and patients may change types depending on time, place, or context.

PRACTICE IMPLICATIONS

These findings suggest that both patient activation and high relationship quality work together to create a supportive environment for chronic care, where intermittent skepticism, deference or empowerment may be useful at particular times or in certain situations.

Talking About Things: A Patient Cue for Sensitive Healthcare Problems and Effective Physician Responses

In routine healthcare consultations, patients often use prefaces containing the word "thing", including "the thing is", "there's this thing" or "one more thing". Although "thing" is an all-encompassing term that is used in myriad ways, in this article we show that thing-prefaces perform a specific job. This study uses Conversation Analysis to analyze 90 video-recorded primary care consultations with 14 primary care physicians in the United States. Patients' thing-prefaces mark the upcoming talk as a disclosure of sensitive information that may reflect negatively on the patient, physician or service (e.g., medication nonadherence, refill was not sent to pharmacy). Patients pursue explicit resolution of these problems (e.g., personalized recommendation, lab work, referral) despite these problems being downplayed and treated as delicate. Because patients may "talk around" these sensitive issues, thing-prefaces can be an important cue for physicians that patients are seeking resolution for a sensitive healthcare problem.

An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010-12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.

"Many miles to go …": a systematic review of the implementation of patient decision support interventions into routine clinical practice

BACKGROUND

Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings.

METHODS

An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment.

RESULTS

After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption.

CONCLUSIONS

It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a 'referral model' consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the 'barriers' and 'facilitators' approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

Barriers and facilitators to routine distribution of patient decision support interventions: a preliminary study in community-based primary care settings

BACKGROUND

A growing body of literature documents the value of decision support interventions (DESIs) in facilitating patient participation in preference sensitive decision making, but little is known about their implementation in routine care.

OBJECTIVE

This study explored barriers and facilitators to prescribing DESIs in primary care.

SETTING AND PARTICIPANTS

Four community-based primary care practices across Los Angeles County serving diverse low and middle income populations participated.

DESIGN

The first phase focused on implementing DESI prescribing into routine care. Weekly academic detailing visits served to identify barriers to DESI prescribing, generate ethnographic field notes and record DESI prescriptions. The second phase explored the impact of a financial incentive on DESI prescribing. At the project's conclusion, each physician completed an in-depth interview.

RESULTS

The four practices prescribed an average of 6.5 DESIs a month (range 3.6-9.2) during Phase I. The financial incentive increased DESI prescribing by 71% to 11.1 per month (range 3.5-21.4). The estimated percentages of patients who viewed the DESI were 37.9 and 43.9% during Phases I and II, respectively. Qualitative data suggest that physician buy-in with the project goal was crucial to DESI distribution success. Competing demands and time pressures were persistent barriers. The effects of the financial incentive were mixed.

CONCLUSIONS

This study confirmed the importance of physician engagement when implementing DESIs and found mixed effects for providing financial incentives. The relatively low rate of DESI viewing suggests further research on increasing patient uptake of these interventions in routine practice is necessary.