Esther K. Choo

As recreational cannabis legalization expands in the United States, concerns about cannabis-impaired driving and traffic injury risk have increased. Although cannabis impairs driving performance, less is known about how sex-specific behavioral and psychosocial contexts shape pathways to motor vehicle collisions (MVCs), particularly in legalized settings. We examined sex differences in cannabis and alcohol use, driving behaviors, mental health context, and crash-related outcomes among injured drivers. We conducted a secondary analysis of a multicenter cross-sectional study of 813 adults presenting to emergency departments in Denver, Portland, and Sacramento within 8 h of an MVC. Recent cannabis and alcohol use were identified using self-report and biological testing. Sex-specific differences in substance use, driving behaviors, mental health indicators, and clinical outcomes were evaluated using descriptive statistics. Recent cannabis use did not differ significantly between males and females (9% vs. 6%, p = 0.21), whereas alcohol use was higher among males (17% vs. 9%, p = 0.005). Male drivers more frequently engaged in high-risk driving behaviors, including higher reported speeds, use of open vehicles, and vehicle rollovers, and were more often admitted to the hospital (58% vs. 43%). Female drivers more commonly reported cannabis use for anxiety and a higher burden of posttraumatic stress symptoms (24% vs. 17%). Injury severity scores were similar between sexes. Similar prevalence of cannabis use among injured drivers concealed distinct sex-specific pathways to MVC risk. Among men, alcohol co-use and high-risk driving behaviors represented established mechanisms of crash severity and health-care utilization. Among women, cannabis use more often occurred within a mental health context, suggesting different pathways linking substance use to traffic injury risk. Traffic injury prevention strategies in legalized cannabis environments should incorporate sex- and gender-responsive approaches, including targeted interventions addressing polysubstance use and hazardous driving behaviors, and integration of mental health considerations into impaired-driving prevention.

Background: Oregon introduced a state policy, HB 3090, on October 6, 2017, which increased requirements on emergency departments (EDs) to improve transitions to outpatient mental health care. The objective of this study was to examine the policy's impact among low‐income adolescent patients who face severe barriers to follow‐up.Methods: This was a retrospective cohort study of visits by Medicaid enrollees ages 14–18 presenting to any Oregon ED for a mental health concern between January 1, 2016, and December 31, 2019. We calculated standardized mean differences and used interrupted time series models to evaluate the association of HB 3090 with 14‐day mental health follow‐up, in‐ED services, and inpatient admissions, adjusting for gender, race/ethnicity, primary language, and calendar months.Results: Among 26,071 adolescent mental health–related ED visits, we found an estimated increase of 3.63 percentage points (pp; 95% confidence interval [CI] 0.27 to 6.99) in the adjusted probability of a 14‐day outpatient mental health claim postpolicy. However, this effect was attenuated over time, with a slope change of −0.25 pp (95% CI −0.5 to 0) for each month thereafter. The probability of receiving mental health services in the ED or inpatient admission did not change in association with the policy.Conclusions: There was a small increase in short‐term outpatient mental health visits after the policy, but the association weakened over time, and other key outcomes did not change. Putting pressure on EDs to perform better in this area is likely to be a minimally effective strategy without accompanying strengthening of mental health resources.

Introduction: This study aimed to understand health care providers’ experiences implementing the Oregon Back Pain Policy (OBPP) over time. The Medicaid OBPP expanded coverage of evidence-based nonpharmacological therapy (NPT) for back pain and restricted access to opioid therapy and interventional approaches. Methods: The study included six online, asynchronous focus groups with providers in February 2020 (Time 1) and August 2022 (Time 2). Analysis was conducted with a longitudinal, recurrent cross-sectional approach. Analysis occurred in three stages: (1) An immersion/crystallization approach was used to analyze Time 1 focus group data, (2) reflexive thematic analysis was used to analyze Time 2 data, and (3) longitudinal analysis was used to integrate the findings across time points. Results: At Time 1, 48 clinicians and 44 NPT providers participated in the study. Time 2 included 63 clinicians and 59 NPT providers. The longitudinal analysis of the focus group data resulted in four themes: (1) general awareness of the policy, (2) providers support the policy and perceive a benefit to their patients, (3) barriers to NPT accessibility, and (4) barriers to referring patients to NPT. Conclusion: The goal of the OBPP was to improve back pain care for Oregon Medicaid members by increasing access to evidence-based NPT and decreasing reliance on opioid medications. This study revealed that, although clinicians and NPT providers supported the policy, they faced persistent implementation challenges related to referrals, prior authorizations, coverage limitations, low reimbursement rates, and a reduced workforce for NPT providers. In some cases, implementation barriers were removed during the COVID-19 pandemic, but other challenges were more prominent during the pandemic.

Background A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. Objective To examine the effect of the policy on prescribing, health outcomes, and health service utilization. Design Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy’s association with selected outcomes using interrupted time series models. Subjects Adult Medicaid patients with back pain enrolled between 2014 and 2018. Intervention The Oregon Medicaid back pain policy. Main Measures Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. Key Results The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (− 2.68 percentage points [95% CI − 3.14, − 2.23] level, − 1.01 pp [95% CI − 1.1, − 0.92] slope), days of short-acting opioid use (− 0.4 days [95% CI − 0.53, − 0.26] slope), receipt of more than 7 days of short-acting opioids (− 2.36 pp [95% CI − 2.76, − 1.95] level, − 0.91 pp [95% CI − 1, − 0.83] slope), chronic opioid use (− 1.27 pp [95% CI − 1.59, − 0.94] level, − 0.46 [95% CI − 0.53, − 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. Conclusions A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

On June 24, 2022, the US Supreme Court in Dobbs v Jackson Women's Health Organization reversed a 50-year precedent, a constitutional right to an abortion, and returned this decisions to each state.1 Following the Dobbs decision, more than 24 states have some form of an abortion ban, although 11 of these bans face court challenges.2 As a result of these abortion bans, emergency medicine (EM) physicians are encountering new and increasingly complex clinical challenges.First, many of the state abortion bans leave EM physicians vulnerable to criminal liability.3 Some states criminalize aiding or assisting in the provision of an abortion. Even when there is an exception for medical care to save the life of the mother, the laws may not delineate what is a life-threatening emergency, although some specifically exclude mental health considerations.4 Conditions that seem unequivocal from a medical perspective, such as an ectopic pregnancy,5 for which the standard of care is to end the pregnancy, are not clearly protected from prosecution. Laws often leave room for interpretation or create specifications that can delay definitive treatment and cause harmful consequences. For example, many laws leave open whether methotrexate can be used to induce abortion for ectopic pregnancy if there is still a fetal heartbeat.6 With this ambiguity, EM physicians in states with bans may find themselves caught between risking criminal charges, on the one hand, or clinical negligence, on the other.7Moreover, the EM ethos of “anyone, anything, anytime”8 is threatened by legal challenges to the Emergency Medical Treatment and Labor Act (EMTALA), which requires emergency departments (EDs) to provide stabilizing treatment to patients under their care. Following the Dobbs decision, the US Department of Health and Human Services (HHS) issued explicit guidance that “if a physician believes that a pregnant patient presenting at an ED, including certain labor and delivery departments, is experiencing an emergency medical condition as defined by EMTALA, and that abortion is the stabilizing treatment necessary to resolve that condition, the physician must provide that treatment.”9 EMTALA, per HHS, should preempt any state law. However, courts have differed on whether it does.7,10,11The state-to-state variability in abortion access means starker differences in choices for incoming residents. Geographic location is consistently a leading driver of rank list decisions.12 Considering that residents tend to stay and practice where they trained,13 applicants may rightfully feel the need to ensure that a potential training site has long-term potential for their lives; access to a full range of reproductive services may be an important component of these decisions for residency applicants, their partners, and other loved ones.Information on the extent to which states' positions on reproductive health services informs choice of training location is emerging. In one recent online survey, nearly 90% of medical student respondents indicated they would not apply to residency in a state where there was an early or late ban on abortion or where there could be legal consequences for providing abortion care.14 Greater than 90% said they would preferentially apply for residency in states where access to abortion was preserved.14 The Association of American Medical Colleges' Match data from the most recent application cycle suggests that such intentions are being realized.15 This year the number of unique applicants to abortion restricted states appears to have declined disproportionately in states with abortion bans, and while unique applicants to obstetrics and gynecology decreased overall, the decrease was highest in states with complete bans (-10.5%) and lowest (-5.3%) in states without restrictions. If these patterns persist, shifts in where trainees apply, interview, rank, and practice will worsen the number and size of reproductive care deserts and exacerbate health inequities.EM trainees may be concerned about the completeness of their education in abortion-restricted states. Abortion restrictions are likely to impact the context of care in myriad ways, including the routineness of pregnancy testing, discussions after an incidental finding of pregnancy (eg, obtained during trauma evaluation or prior to cross-sectional imaging), as well as management of patients who are having spontaneous abortions or seeking care for complications after medical or procedural abortions. Abortion restrictions can compromise clinical care and patient-physician relationships. For example, a history of a previous abortion may be relevant to patient care, but patients may not wish to divulge such histories in states where there are legal consequences for doing so.Programs in all states that wish to attract diverse, competitive candidates need to consider how they will address the concerns of prospective applicants. Saying nothing may be the worst course of action: it may amplify the perception that discussing abortion care is off limits and will be neglected during training, even when relevant. As they are able, program leaders may wish to address the impact of reproductive health care restrictions directly during the inquiry and interview process, acknowledge any limitations on practice or training, and consider discussing with applicants accommodations (eg, elective away rotations) or curricular adaptations under consideration to make up for training gaps.One of the appeals of EM is its practice breadth and autonomy (ie, the ability to jump in and do what is necessary for sick and unstable patients). Post-Dobbs, it is important for programs to vouch they are preserving the essence of EM practice, even as laws attempt to encroach on evidence-based, high-quality care. This is particularly necessary in a time when students' interest in entering EM is plummeting.16The Accreditation Council for Graduate Medical Education (ACGME)...

Objectives The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. Design, setting and participants This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. Outcomes and analysis We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. Results We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. Conclusions Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

[This corrects the article DOI: 10.2196/20469.].