Faculty Bibliography

BACKGROUND: Buprenorphine can be used for the treatment of opioid dependence in primary care settings. National guidelines recommend directly observed initial dosing followed by multiple in-clinic visits during the induction week. We offered buprenorphine treatment at a public hospital primary care clinic using a home, unobserved induction protocol. METHODS: Participants were opioid-dependent adults eligible for office-based buprenorphine treatment. The initial physician visit included assessment, education, induction telephone support instructions, an illustrated home induction pamphlet, and a 1-week buprenorphine/naloxone prescription. Patients initiated dosing off-site at a later time. Follow-up with urine toxicology testing occurred at day 7 and thereafter at varying intervals. Primary outcomes were treatment status at week 1 and induction-related events: severe precipitated withdrawal, other buprenorphine-prompted withdrawal symptoms, prolonged unrelieved withdrawal, and serious adverse events (SAEs). RESULTS: Patients (N = 103) were predominantly heroin users (68%), but also prescription opioid misusers (18%) and methadone maintenance patients (14%). At the end of week 1, 73% were retained, 17% provided induction data but did not return to the clinic, and 11% were lost to follow-up with no induction data available. No cases of severe precipitated withdrawal and no SAEs were observed. Five cases (5%) of mild-to-moderate buprenorphine-prompted withdrawal and eight cases of prolonged unrelieved withdrawal symptoms (8% overall, 21% of methadone-to-buprenorphine inductions) were reported. Buprenorphine-prompted withdrawal and prolonged unrelieved withdrawal symptoms were not associated with treatment status at week 1. CONCLUSIONS: Home buprenorphine induction was feasible and appeared safe. Induction complications occurred at expected rates and were not associated with short-term treatment drop-out

Research Objective: For a subset of fee-for-service Medicaid patients with frequent hospital admissions, contact with the health care system remains acute and episodic at high cost to Medicaid, while less costly outpatient primary and preventive care services are underutilized. Previous work validated the accuracy of a predictive case-finding algorithm to identify complex Medicaid patients at risk for future high costs who might benefit from more intensive services, and identified remediable risk factors such as substance use, homelessness, and lack of social support associated with frequent hospital admissions. We aimed to pilot an intervention for a limited number of high-cost patients to address unmet health and social needs in both the hospital and community, to improve care while reducing hospital admissions and associated costs in this population. Our intention was to expand the program based on pilot success. Study Design: Community and hospital-based care management intervention with process and implementation evaluation, and pre-post cost analysis. Eligible patients were offered intervention enrollment during an admission to an urban public hospital. Patients underwent in-depth psychosocial interviews by study social workers to identify immediate and long-term needs such as housing, primary care, transportation to and advocacy during appointments, medication management, entitlements enrollment, improved connections to psychiatric and substance use treatment, and home visits. Patients who met criteria for chronic homelessness were evaluated in-hospital by a community-housing partner who initiated housing applications based on a housing first model. Pre-paid cell phones were provided to patients when needed to maintain close contact with study staff for reminder calls and crisis management. Study staff worked closely with inpatient providers to facilitate appropriate discharge planning and follow-up. Population Studied: Consecutive English-speaking Medicaid fee-for-service patients aged 18-64 identified as high-cost and high-risk for readmission in the following 12 months by a validated predictive case-finding algorithm. Principal Findings: Over the past year, 19 patients have enrolled. 100% are male. 17/19 were chronic substance users at enrollment. 5/19 were lost to follow-up. Of the remaining patients, 8 met criteria for chronic homelessness that would facilitate expedited placement into permanent housing. Of these 8, 2 were placed in nursing homes and 2 died. The remaining 4 chronically homeless patients are now in transitional or permanent housing. Hospitalizations and ED visits have decreased, while establishment of an outpatient medical home has increased. Comparing the 9-12 months after the intervention to the 12 months before intervention revealed a decrease in average monthly inpatient Medicaid costs per patient ranging from $1205-$2881. This resulted in an average annual inpatient cost reduction from $14,464 to $34,568.52. Prior research indicates without intervention, Medicaid costs for these patients in the following 12 months will increase. Conclusion: A pilot intervention to improve care for medically, socially complex high-cost Medicaid patients shows savings to Medicaid and decreased hospitalizations and ED visits by addressing issues that are challenging for the traditional health care system to manage. Implications for Policy, Delivery or Practice: Our model will be expanded to serve a greater number of patients across additional hospitals to determine if the success of our pilot can be replicated, and will include a more detailed cost analysis. Funding Source(s): The United Hospital Fund

INTRODUCTION: The Patient Assessment of Chronic Illness Care (PACIC) survey is a patient-centered instrument for evaluating the quality and patient-centeredness of chronic illness care received according to the Chronic Care Model paradigm. This study validates the Spanish translation of the PACIC in an urban, Spanish-speaking population. METHODS: One hundred Spanish-speaking patients with diabetes completed the translated PACIC and sociodemographic and cultural questionnaires. Test-retest reliability was assessed in a subset of 20 patients who completed the questionnaire 2 to 4 months later. Internal consistency was evaluated with Cronbach alpha. PACIC score and subscale associations with sociodemographic characteristics were examined. RESULTS: Test-retest reliability for the overall translated PACIC scale was 0.77. Scores were not associated with patient sociodemographic characteristics, including age, country of birth, years living in the United States, or education level (P >.05). CONCLUSION: The Spanish translation of the PACIC survey demonstrated high reliability, internal consistency, and test-retest reliability. Scores showed no association with sociodemographic or cultural characteristics. The Spanish version can reliably be used to assess care delivered according to the Chronic Care Model in a heterogeneous Spanish-speaking population

The importance of the public hospital system to medical education is often absent from the debate about its value. Best known as a core provider of services to the underserved, the safety net hospital system also plays a critical role in the education of future physicians. Particular strengths include its ability to imbue physicians in training with core professional values, to reveal through the enormous range of clinical experience provided many of the social forces shaping health, and to foster interest in and commitment to advancing population health. Faculty teaching in the public hospital system has unusual opportunities to reveal to learners the broader meanings of their diverse and rich experiences. Now, as an alarming array of pressures bearing down on the safety net system threaten its stability, the potential negative impact on medical education, were it to shrink or be forced to change its essential mission, must be considered. As advocates of the safety net system marshal forces to rationalize its funding and support, its tremendous contribution to the training of physicians and other health care professionals must be clearly set forth to ensure that support for the public hospital system's health is appropriately broad based

INTRODUCTION/AIMS: We designed an interactive web module to improve medical student competence in screening and interventions for hazardous drinking. We assessed its impact on performance with a standardized patient (SP) vs. traditional lecture. SETTING: First year medical school curriculum. PROGRAM DESCRIPTION: The web module included pre/posttests, Flash(c), and text didactics. It centered on videos of two alcohol cases, each contrasting a novice with an experienced physician interviewer. The learner free-text critiqued each clip then reviewed expert analysis. PROGRAM EVALUATION: First year medical students conveniently assigned to voluntarily complete a web module (N = 82) or lecture (N = 81) were rated by a SP in a later alcohol case. Participation trended higher (82% vs. 72%, p < .07) among web students, with an additional 4 lecture-assigned students crossing to the web module. The web group had higher mean scores on scales of individual components of brief intervention (assessment and decisional balance) and a brief intervention composite score (1-13 pt.; 9 vs. 7.8, p < .02) and self-reported as better prepared for the SP case. CONCLUSIONS: A web module for alcohol use interview skills reached a greater proportion of voluntary learners and was associated with equivalent overall performance scores and higher brief intervention skills scores on a standardized patient encounter

BACKGROUND: Active drug use is often associated with poor adherence, but few studies have determined psychosocial correlates of adherence in injection drug users (IDUs). METHODS: Of 1161 Intervention for Seropositive Injectors-Research and Evaluation study enrollees, 636 were taking antiretrovirals. We assessed self-reported adherence to self-reported antiretroviral regimens and medication errors, which we defined as daily doses that were inconsistent with standard or alternative antiretroviral prescriptions. RESULTS: Most subjects (75%, n=477) self-reported good (>or=90%) adherence, which was strongly associated with an undetectable viral load. Good adherence was independently associated with being a high school graduate, not sharing injection equipment, fewer depressive symptoms, positive attitudes toward antiretrovirals, higher self-efficacy for taking antiretrovirals as prescribed, and greater sense of responsibility to protect others from HIV. Medication errors were made by 54% (n=346) and were strongly associated with a detectable viral load and fewer CD4 cells. Errors were independently associated with nonwhite race and with depressive symptoms, poorer self-efficacy for safer drug use, and worse attitudes toward HIV medications. CONCLUSIONS: Modifiable factors associated with poor adherence, including depressive symptoms and poor self-efficacy, should be targeted for intervention. Because medication errors are prevalent and associated with a detectable viral load and fewer CD4 cells, interventions should include particular efforts to identify medication taking inconsistent with antiretroviral prescriptions

BACKGROUND: There is a lack of effective behavioral interventions for HIV-positive injection drug users (IDUs). We sought to evaluate the efficacy of an intervention to reduce sexual and injection transmission risk behaviors and to increase utilization of medical care and adherence to HIV medications among this population. METHODS: HIV-positive IDUs (n=966) recruited in 4 US cities were randomly assigned to a 10-session peer mentoring intervention or to an 8-session video discussion intervention (control condition). Participants completed audio computer-assisted self-interviews and had their blood drawn to measure CD4 cell count and viral load at baseline and at 3-month (no blood), 6-month, and 12-month follow-ups. RESULTS: Overall retention rates for randomized participants were 87%, 83%, and 85% at 3, 6, and 12 months, respectively. Participants in both conditions reported significant reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence, and there were no significant differences between conditions. CONCLUSIONS: Both interventions led to decreases in risk behaviors but no changes in medical outcomes. The characteristics of the trial that may have contributed to these results are examined, and directions for future research are identified

OBJECTIVE: To identify modifiable factors associated with health care utilization by HIV-negative seropositive injection drug users (IDUs). METHODS: We analyzed longitudinal data from 966 participants in a randomized controlled trial of a behavioral intervention designed to address medical care, adherence, and risk reduction. The outcomes of this study were usual place for care (clinic vs. emergency room) and frequency of primary care visits. RESULTS: Results of multiple logistic regression analysis showed that increase in 'importance of HIV care scale' score (odds ratio [OR]=2.99; P<0.001), empowerment (OR=3.53; P<0.001), utilization of case management (OR=3.07; P=0.007), and having a stable residence (OR=2.63; P=0.008) were significantly associated with participants being 'clinic users.' Increase in importance of HIV care scale score (OR=5.65; P=0.01) increased empowerment (OR=2.42; P=0.005), taking greater control of one's health (OR=2.17; P=0.001), having health insurance (OR=2.58; P=0.003), utilization of case management (OR=3.14; P=0.027), and CD4 count>or=200 cells/mm (OR=2.09; P=0.007) were significantly associated with reporting 2 or more primary HIV care visits in the past 6 months. CONCLUSIONS: Future interventions for this population may be strengthened by addressing the importance of HIV primary care; empowering participants with respect to the health care system; and promoting linkages to case management, health insurance, and local housing programs

Active injection drug users (IDUs) are at high risk of unsuccessful highly active antiretroviral therapy (HAART). We sought to identify baseline factors differentiating IDUs' treatment success versus treatment failure over time among those taking HAART. Interventions for Seropositive Injectors-Research and Evaluation (INSPIRE) study participants were assessed at baseline and at 6- and 12-month follow-ups. Multinominal regression determined baseline predictors of achieving or maintaining viral suppression relative to maintaining detectable viral loads over 12 months. Of 199 participants who were retained and remained on HAART, 133 (67%) had viral load change patterns included in the analysis. At follow-up, 66% maintained detectable viral loads and 15% achieved and 19% maintained viral suppression. Results indicated that those having informal care (instrumental or emotional support) were 4.6 times more likely to achieve or maintain viral suppression relative to experiencing treatment failure. Those who maintained viral suppression were 3.5 times less likely to live alone or to report social discomfort in taking HAART. Study results underscore the importance of microsocial factors of social network support, social isolation, and social stigma for successful HAART outcomes among IDUs. The findings suggest that adherence interventions for IDUs should promote existing informal HIV caregiving, living with supportive others, and positive medication-taking norms among social networks