Deborah Rinehart

Patients with methamphetamine use disorder (MaUD) face social, financial, and systemic barriers to accessing evidence-based addiction treatment. We designed a care navigation intervention to better engage patients with MaUD in treatment after an acute care encounter. This intervention was modeled after linkage-to-care strategies for infectious diseases and emphasized rapport building, trauma-informed care, and practical assistance in overcoming barriers to treatment. We also added elements of contingency management given its treatment efficacy with MaUD. We describe the development of the care navigation model, characteristics and care needs of subjects receiving the intervention, and intervention engagement outcomes. Among 94 patients who received this intervention as part of a randomized controlled trial, 64% were considered engaged with at least 2 or more visits with the care navigator Patients had substantial barriers to care—85% of patients were not stably housed, 83% were unemployed, and 46% lacked access to a phone—and the most common domains of need were accessing addiction treatment, housing resources, or communication needs such as a phone or interpreter services. This intervention poses a model for connecting patients with MaUD to treatment after acute care encounters.

Objective: This qualitative study aimed to understand facilitators and barriers to implementation of interventions to improve guideline-concordant antibiotic duration prescribing for pediatric acute otitis media (AOM). Design: Clinicians and clinic administrators participated in semi-structured qualitative interviews, and parents of children 2 years of age or older with a recent diagnosis of AOM participated in focus groups. The Practical Robust Implementation and Sustainability Model (PRISM) guided the study. Interviews were analyzed using the Rapid Assessment Process. Setting: Denver Health and Hospital Authority (Denver, CO) led the study. Recruitment occurred at Vanderbilt University Medical Center (Nashville, TN) and Washington University in St. Louis Medical Center (St. Louis, MO). Participants: Purposeful sampling was used to recruit clinicians and administrators for qualitative interviews. Convenience sampling was used to recruit parents for focus groups. Results: Thirty-one participants (15 clinicians, 4 administrators, and 12 parents) engaged in interviews and focus groups. Factors influencing antibiotic prescribing included patient history, years of practice, familiarity with the patient, concerns with patient medication adherence, and practice type. Clinicians endorsed electronic health record modifications and clinician prescribing feedback as methods to improve patient care and reduce the durations of prescribed antibiotics. Suggestions for intervention optimization and education needs were also obtained. Conclusions: Findings suggest that clinicians and administrators support reducing prescribed antibiotic durations for AOM and are receptive to the proposed interventions. More education is needed to increase parent awareness about antibiotic stewardship and AOM treatment options. Clinical trials identifier: RELAX: Reducing Length of Antibiotics for Children with Ear Infections (RELAX), NCT05608993, https://clinicaltrials.gov/study/NCT05608993.

Objectives: Methamphetamine addiction is a serious and difficult-to-treat disorder. Existing treatment options are limited, and patient perspectives on effective strategies are lacking. Emergency departments (EDs) may be a critical entry point for individuals with methamphetamine use disorder (MUD) to be identified and linked to treatment. We aimed to understand patients’ perspectives regarding their methamphetamine use and related ED experiences and how to improve linkage to substance treatment. Methods: Between July and November 2022, semistructured qualitative interviews were conducted with adult patients with MUD in an urban safety-net healthcare setting in Denver, Colorado. Interviews were recorded, summarized, and analyzed using the Rapid Assessment Process. Results: During the interviews, 18 patients shared their experiences. Participants described feeling stigmatized and experiencing a lack of communication from ED staff during their visit. Additionally, participants shared the perception that ED staff often did not take their health concerns seriously once substance use was identified. Participants were uncertain about overdose risk and felt that their psychiatric symptoms complicated treatment. Referrals to treatment were lacking, and participants supported a care navigation intervention that incorporates elements of contingency management. Participants also shared the importance of ED staff recognizing their social needs and being empathetic, trauma-informed, and flexible to meet patients where they are regardless of their readiness to seek treatment. Conclusions: Treatment options and entry points for individuals with MUD are currently limited. The patient perspectives described here are helpful in developing services to support, engage, and link individuals to MUD services after discharge from ED services.

Aim: Preventing unnecessarily long durations of antibiotic therapy is a key opportunity to reduce antibiotic overuse in children 2 years of age and older with acute otitis media (AOM). Pragmatic interventions to reduce durations of therapy that can be effectively scaled and sustained are urgently needed. This study aims to fill this gap by evaluating the effectiveness and implementation outcomes of two low-cost interventions of differing intensities to increase guideline-concordant antibiotic durations in children with AOM. Methods: The higher intensity intervention will consist of clinician education regarding guideline-recommended short durations of antibiotic therapy; electronic health record (EHR) prescription field changes to promote prescribing of recommended short durations; and individualized clinician audit and feedback on adherence to recommended short durations of therapy in comparison to peers, while the lower intensity intervention will consist only of clinician education and EHR changes. We will explore the differences in implementation effectiveness by patient population served, clinician type, clinical setting and organization as well as intervention type. The fidelity, feasibility, acceptability and perceived appropriateness of the interventions among different clinician types, patient populations, clinical settings and intervention type will be compared. We will also conduct formative qualitative interviews with clinicians and administrators and focus groups with parents of patients to further inform the interventions and study. The formative evaluation will take place over 1.5 years, the interventions will be implemented over 2 years and evaluation of the interventions will take place over 1.5 years. Discussion: The results of this study will provide a framework for other healthcare systems to address the widespread problem of excessive durations of therapy for AOM and inform national antibiotic stewardship policy development. Clinical Trial Registration : NCT05608993 ( ClinicalTrials.gov )

Background: Chlamydia trachomatis and Neisseria gonorrhea are the most reported sexually transmitted infections in the United States. Testing rates remain suboptimal and may be subject to implicit bias. We evaluated the effectiveness of an opt-out chlamydia and gonorrhea testing program for adolescents and young adults in improving testing rates and promoting equity. Methods: An opt-out testing program that standardized testing to once annually for 14 to 24-year-old patients was implemented across 28 federally qualified health centers spanning 4 specialties. A quasi-experimental design using interrupted time series analyses evaluated testing and infection rates between baseline, intervention, and pandemic-associated test shortage periods. Reduction in testing inequities based on sex, race, ethnicity, insurance, and language preference were also examined. Results: A total of 57 452 encounters during the baseline, 17 320 during the intervention, and 26 993 during the test supply shortage periods were included. Testing increased from 66.8% to 81.0% (14.2% absolute increase) between baseline and intervention periods. Pediatric clinics demonstrated the largest improvement compared to other settings (absolute increase 30.9%). We found significant reductions in testing inequities for language preference ( P < .001), and un-insured and public insured individuals ( P < .001). More cases of chlamydia and gonorrhea were detected in the intervention period (chlamydia-29.7; gonorrhea-7.4 per 1000 patients) than in the baseline period (chlamydia-20.7; gonorrhea-4.4 per 1000 patients; P < .001). Conclusions: An opt-out approach increased testing, reduced inequities between some groups and detected more infections than a risk-based approach. Opt-out testing should be considered as an approach to increase detection of chlamydia and gonorrhea and promote equity.

Objective: Studies have consistently found high rates of unintended pregnancy among women with substance use disorder. While research efforts have begun to focus on understanding needs and providing family planning services for women in treatment, few studies have included men. This has resulted in a gap in the literature regarding men’s reproductive health experiences and family planning desires. Methodology: Between December 2019 and February 2020, we conducted semistructured qualitative interviews with adult men receiving medications for opioid use disorder at a safety-net healthcare system in Denver, Colorado. Interviews were recorded and analyzed using the Rapid Assessment Process. Results: Fifteen men participated in an interview. Overall, men described feeling excluded from family planning education and services as well as from decision making with their partners. Participants desired knowledge and resources related to contraceptive methods, partner communication, and parenting. Additional themes included loss of autonomy around pregnancy decisions, the importance of fatherhood, and the importance of addressing family planning during recovery. Participants expressed interest in a family planning intervention but indicated that engaging men on this topic may be challenging. Conclusions: Our findings suggest that men in treatment desire education and involvement in family planning. Participants endorsed access to a subject expert within the treatment environment, but engagement strategies that underscore topic relevance to men will be critical. Initiating a conversation involving education and service navigation in the treatment setting may be a promising strategy for engaging men in recovery in family planning and improving men’s access to needed services and resources.