Faculty Bibliography

Aims: ED-based SBIRT for alcohol and drug use has the potential to impact public health greatly. Time and resource constraints limit implementation. Targeted intervention may be more efficient and practical. We hypothesized that we could use chief complaints to identify patients at highest risk of positive drug or alcohol use assessments. Methods: Using baseline data from NIDA CTN0047: SMARTED, free text chief complaints of 14,972 subjects from six sites were coded using a tested algorithm (Thompson, 2006). Multiple team members manually reviewed and further collapsed the chief complaint categorization to ensure agreement. We excluded subjects having missing data or complaints related to substance use and chief complaints stated by <15 subjects. Positive screens were defined as AUDIT-C > 4 for men and >3 for women (alcohol) and DAST > 2 (drugs). We ranked-ordered the chief complaints by their sensitivity and positive predictive value to (1) minimize the number of chief complaints and (2) assess the fewest number of ED patients. Our goal was to identify 75% of ED patients having positive assessments using these strategies. Results: The screening assessments were positive in 5805/14,561 (39.9%) for alcohol and 2454/14,494 (16.9%) for drugs. We collapsed the free-text chief complaints into 50 usable categories. To identify 75% of all ED patients having positive assessments using the first strategy would require including 19 chief complaints for alcohol screening and 20 chief complaints for drug screening. Adapting the second strategy, we would need to screen at least 71% and 68% of all ED patients for alcohol and drugs respectively to identify 75% of those having positive assessments. Conclusions: Based on this large, multicenter study, chief complaints provide little assistance in targeting SBIRT for alcohol or drug use in the ED

IMPORTANCE: Medical treatment settings such as emergency departments (EDs) present important opportunities to address problematic substance use. Currently, EDs do not typically intervene beyond acute medical stabilization. OBJECTIVE: To contrast the effects of a brief intervention with telephone boosters (BI-B) with those of screening, assessment, and referral to treatment (SAR) and minimal screening only (MSO) among drug-using ED patients. DESIGN, SETTING, AND PARTICIPANTS: Between October 2010 and February 2012, 1285 adult ED patients from 6 US academic hospitals, who scored 3 or greater on the 10-item Drug Abuse Screening Test (indicating moderate to severe problems related to drug use) and who were currently using drugs, were randomized to MSO (n = 431), SAR (n = 427), or BI-B (n = 427). Follow-up assessments were conducted at 3, 6, and 12 months by blinded interviewers. INTERVENTIONS: Following screening, MSO participants received only an informational pamphlet. The SAR participants received assessment plus referral to addiction treatment if indicated, and the BI-B participants received assessment and referral as in SAR, plus a manual-guided counseling session based on motivational interviewing principles and up to 2 "booster" sessions by telephone during the month following the ED visit. MAIN OUTCOMES AND MEASURES: Outcomes evaluated at follow-up visits included self-reported days using the patient-defined primary problem drug, days using any drug, days of heavy drinking, and drug use based on analysis of hair samples. The primary outcome was self-reported days of use of the patient-defined primary problem drug during the 30-day period preceding the 3-month follow-up. RESULTS: Follow-up rates were 89%, 86%, and 81% at 3, 6, and 12 months, respectively. For the primary outcome, estimated differences in number of days of use (95% CI) were as follows: MSO vs BI-B, 0.72 (-0.80 to 2.24), P (adjusted) = .57; SAR vs BI-B, 0.70 (-0.83 to 2.23), P (adjusted) = .57; SAR vs MSO, -0.02 (-1.53 to 1.50), P (adjusted) = .98. There were no significant differences between groups in self-reported days using the primary drug, days using any drug, or heavy drinking days at 3, 6, or 12 months. At the 3-month follow-up, participants in the SAR group had a higher rate of hair samples positive for their primary drug of abuse (265 of 280 [95%]) than did participants in the MSO group (253 of 287 [88%]) or the BI-B group (244 of 275 [89%]). Hair analysis differences between groups at other time points were not significant. CONCLUSIONS AND RELEVANCE: In this sample of drug users seeking emergency medical treatment, a relatively robust brief intervention did not improve substance use outcomes. More work is needed to determine how drug use disorders may be addressed effectively in the ED. TRIAL REGISTRATION: clinicaltrials.gov Identifier:NCT01207791.

BACKGROUND: Patients with altered level of consciousness secondary to alcohol use disorders (AUDs) often undergo imaging in the emergency department (ED), although the frequency and yield of this practice over time are unknown. STUDY OBJECTIVES: We describe the use of imaging, the associated ionizing radiation exposure, cumulative costs, and identified acute and chronic injuries and abnormalities among frequent users of the ED with AUDs. METHODS: This is a retrospective case series of individuals identified through an administrative database having 10 or more annual ED visits in 2 consecutive years who were prospectively followed for a third year. International Classification of Diseases, 9(th) Revision, Clinical Modification and Current Procedural Terminology codes were used to select individuals with alcohol-related diagnoses, track imaging procedures, and calculate cost. Diagnoses, imaging results, and radiation exposure per computed tomography (CT) study were abstracted from the medical record. RESULTS: Fifty-one individuals met inclusion criteria and had a total of 1648 imaging studies over the 3-year period. Subjects had a median of 5 (interquartile range [IQR] 2-10) CT scans, 20 (IQR 10-33) radiographs, 28.3 mSv (IQR 8.97-61.71) ionizing radiation, 0.2% (IQR 0.07-0.4) attributable risk of cancer, and $2979 (IQR 1560-5440) in charges using a national rate. The incidence of acute fracture or intracranial head injury was 55%, and 39% of the cohort had a history of moderate or severe traumatic brain injury. CONCLUSION: The remarkable use of imaging and occurrence of injury among these highly vulnerable and frequently encountered individuals compels further study to refine clinical practices through the development of evidence-based, effective interventions.

We introduced case management and homeless outreach to chronically homeless, alcohol-dependent, frequent emergency department (ED) visitors using existing resources. We assessed the difference in differences of ED visits 6 months pre- and postintervention using a prospective, nonequivalent control group trial. Secondary outcomes included changes in hospitalizations and housing. The differences in differences between intervention and prospective patients and retrospective controls were -12.1 (95% CI = -22.1, -2.0) and -12.8 (95% CI = -26.1, 0.6) for ED visits and -8.5 (95% CI = -22.8, 5.8) and -19.0 (95% CI = -34.3, -3.6) for inpatient days, respectively. Eighteen participants accepted shelter; no controls were housed. Through intervention, ED use decreased and housing was achieved.

NEEDS AND OBJECTIVES: Despite an increasing need for physicians trained in Internal Medicine (IM), the number of medical students entering residencies in IM has declined. Misconceptions about careers in IM, pay differentials between disciplines, student debt and work hours are thought to contribute to this decline. We developed an "IM Speed Dating Event" to increase first year medical student's awareness of the breadth and richness of IM training and careers. SETTING AND PARTICIPANTS: Faculty members from each Division within the Department of Medicine at our institution were asked to participate to emphasize the diversity of careers paths after IM training. Medical Students were recruited via email, flyers and word-of-mouth. Over 3 years of the event (2009-2011), 51 medical students participated (14-19/year). DESCRIPTION: This "speed dating" event was structured so that students rotated, in timed, five-minute blocks, speaking to a total of 10 faculty. Faculty members were organized to optimize diversity of disciplines to which students were exposed. Students asked questions about faculty members' career and training paths, current roles/responsibilities, work life, and work/life balance. The event was very informal, easy to set up and organize, and the speed dating format encouraged friendly, compelling and direct, but brief, discussions. EVALUATION: All 51 participants (n=18 in 2009, 19 in 2010, and 14 in 2011), completed a pre-event anonymous assessment of their attitudes toward and understanding of IM residency and career pathways and practices as well as their specialty and career intentions. After the event, 47 completed an evaluation of the "Speed Dating" event including listing 3 things they learned and the degree to which the event led them to become more interested in exploring IM. Pre-event assessment results suggest that medical students are quite unsure about IM careers (e.g., 45% reported being not sure whether faculty within IM Departments have all done IM residencies and 58% rep!

Background: The ED is a point of frequent contact for medically vulnerable, chronically homeless patients with alcohol use disorders, or chronic public inebriates (CPI). Despite this population's exposure to health and social agencies, its outcomes suffer due, in part, to lack of stable housing and fragmented, 'treat and street' medical care. Objectives: NYU School of Medicine and the Bellevue Hospital Center ED partnered with the Department of Homeless Services (DHS) to implement a multifaceted pilot initiative. This integration of services is hypothesized to improve access to housing and comprehensive medical care resulting in reduced costly ED and inpatient admissions, and homelessness. Engaging the ED as a point of intervention, a cohort of CPIs received needs assessments, enhanced care management, and coordination with DHS outreach. Methods: CPIs were identified primarily through an administrative database search and chart reviews. At the time of this 10-month analysis, 20 of the 56 patients who met inclusion criteria were enrolled. Enrolled (Figure presented) patients had a minimum of 20 ED visits in a 24-month period with at least one visit within 5 months of the pilot commencement in January 2011 and met the DHS standard for chronic homelessness. Preference was given to those with greater visit frequency, co-morbidities, or staff referral. The intervention for enrolled patients included the ongoing implementation of individualized multidisciplinary action plans, case management, and coordination with the housing outreach team upon discharge. Results: Eighteen of the 20 enrolled patients were placed in housing. After first housing placement (mean length, 4.7 months), monthly ED and inpatient use declined 48% and 40%, respectively. ED and inpatient use by the nonenrolled remained stable throughout the study period. Prior to intervention, hospital use had increased over time for the enrolled patients (Figures 1,2). Conclusion: ED-based collaboration amongst medical and social services for a small cohort of CPIs resulted in housing placements and reduced ED and inpatient visits. While promising, the results of this interim pilot data are limited by the non-random sampling method, power, duration, and singular location. Further study is needed to determine the intervention's effect on public health expenditures and patient outcomes