Audrey Sarah Cohen

Background: Referral documentation is a critical component of care coordination, yet inconsistencies and incomplete information can hinder communication and delay access to specialty care. Objective: This scoping review examines digital health interventions to improve referral documentation across healthcare settings, organized according to the Donabedian model of structure, process, and outcomes. Methods: A scoping review of PubMed, EMBASE, and Web of Science identified original studies published between 2020 and 2025 evaluating informatics-based interventions for referral documentation. Sixteen studies met the inclusion criteria and were analyzed using the Donabedian model. Results: Electronic referral systems, standardized documentation tools, and artificial intelligence approaches were associated with documentation completeness, efficiency, and referral tracking, particularly when aligned with clinical workflows and organizational structures. Conclusion: Digital health interventions may improve referral documentation quality. Applying the Donabedian model underscores the importance of aligning organizational structures, documentation processes, and outcome measures to optimize referral performance across healthcare settings.

Background/Objectives: School-age athletes occupy a paradoxical position in the adolescent opioid crisis, combining health-oriented activity with elevated risk of sports-related injury and prescription opioid exposure. In response to the opioid epidemic, states enacted opioid prescribing limit laws (OPLLs) beginning in 2016–2017, yet whether these supply-side policies reached high-risk youth subgroups remains unclear. This study evaluated national temporal trends in prescription opioid misuse among U.S. high school students during the period of OPLL implementation and examined differences across athletic participation, concussion history, sex, grade, race/ethnicity, and substance-use profiles. Methods: Using four biennial waves of the Youth Risk Behavior Surveillance System with a consistent prescription pain-medicine measure (2017, 2019, 2021, and 2023; total N = 44,501), we conducted survey-weighted multivariable logistic regression models producing adjusted odds ratios (aORs) for lifetime prescription opioid misuse, controlling for survey year, sports participation, sex, grade, race/ethnicity, alcohol use, and other illicit drug use. Interaction and stratified models examined differences associated with sports participation, concussion history, demographic characteristics, and substance use. Results: Weighted prescription opioid misuse declined from 13.9% in 2017 to 12.0% in 2023, with a significant unadjusted linear decline per two-year survey wave (OR = 0.936; 95% CI: 0.879–0.997; p = 0.040). This overall trend was attenuated after adjustment (aOR = 0.967; 95% CI: 0.914–1.024; p = 0.248). Temporal patterns differed significantly across race/ethnicity, sex, grade, and selected substance-use groups. White and male students demonstrated significant adjusted linear declines, whereas Hispanic/Latino and female students remained flat. Black/African American students showed significant year-to-year variation, with elevated adjusted odds in 2019 and 2021 relative to 2017. Concussion history was independently associated with misuse among athletes (aOR = 1.645; 95% CI: 1.417–1.909; p < 0.001), with significant associations observed among White, Asian, Black/African American, and Hispanic/Latino athletes. The pooled concussion-by-race/ethnicity interaction, however, was not significant (p = 0.295). Conclusions: Although prescription opioid misuse declined descriptively between 2017 and 2023, adjusted analyses did not identify a significant overall national temporal change. Since subgroup patterns diverged, prevention planning and surveillance should be disaggregated by race/ethnicity and sex rather than guided by national totals, and groups whose misuse did not decline may require strategies extending beyond clinical prescribing controls.

IntroductionBuprenorphine is an effective, evidence-based treatment for opioid use disorder (OUD), yet fewer than 20% of individuals with OUD receive it. Limited pharmacy-level availability—as low as 37% with wide geographic variation—remains a major barrier to identifying dispensing pharmacies at the point of care. These gaps are especially consequential during high-risk clinical moments, such as after withdrawal, overdose, or hospital discharge, when timely initiation or continuation of buprenorphine is critical. Despite having one of the highest opioid-related mortality rates in Texas, Harris County’s pharmacy-level buprenorphine availability and geographic distribution have not been characterized. This study aimed to (1) map buprenorphine-stocking pharmacies in Harris County to support timely identification of treatment access points, and (2) examine whether neighborhood sociodemographic characteristics were associated with pharmacy-level availability.MethodsWe conducted a cross-sectional assessment Harris County pharmacies from February to September 2025. Pharmacy locations were geocoded and linked to zip-code tabulation area (ZCTA)–level sociodemographic characteristics and the Social Vulnerability Index (SVI). Mixed-effects logistic regression estimated associations between neighborhood characteristics and pharmacy-level buprenorphine availability, with a random intercept for pharmacy chain to account for organizational clustering. Spatial autocorrelation was evaluated using Global Moran’s I.ResultsAmong 378 pharmacies, 164 (43.4%) reported buprenorphine in stock. Unadjusted spatial analyses demonstrated statistically significant but weak clustering (Moran’s I = 0.02, p = 0.04), which was no longer present after adjustment for ZCTA-level characteristics. Pharmacy chain membership accounted for 27% of the variation in availability. Higher neighborhood social vulnerability was associated with lower odds of buprenorphine availability (adjusted OR = 0.37; 95% CI 0.16–0.86).ConclusionFewer than half of pharmacies in Harris County stocked buprenorphine, with lower availability in more socially vulnerable neighborhoods. Chain-level clustering accounted for substantial variation, indicating that organizational decisions largely determine access. Clearer, enforceable policy standards are needed to ensure consistent and equitable pharmacy-level availability of buprenorphine.

Opioid overdose, an urgent public health (PH) crisis, can be countered through harm reduction strategies such as community education and naloxone distribution. Embedding opioid education and naloxone distribution (OEND) into a graduate PH practicum allowed students to experience firsthand the impact of expanding community access to life-saving interventions. This report evaluated an OEND practicum within a Master of Public Health program using Kolb’s experiential learning cycle as an organizing structure. A quantitative evaluation was conducted, examining the feasibility of program enrollment and volunteer participation over multiple semesters, and the ability of practicum students to recruit, schedule, and complete OEND events. Quantitative analysis of pre-post surveys collected during student-led OEND events were collected and assessed and opportunities for structured student reflection were tallied. Practicum students applied harm reduction concepts to practice and reflected on the challenges and successes of this initiative. Participants in the OEND events demonstrated improvements in knowledge, attitudes, and self-efficacy for recognizing and responding to opioid overdoses, while opportunities for structured reflection among practicum students expanded over time. This evaluation adds to the literature by illustrating how harm reduction education can be integrated into graduate training through experiential learning, reporting benefits for both student development and community awareness and preparedness to address opioid overdose. Additional implications include utilizing the experiential learning cycle to strengthen future PH practicums that develop OEND events in diverse community settings or other harm reduction initiatives.

Background: Financial sustainability remains a central challenge for U.S. hospitals as rising operating costs, shifting federal reimbursement, and policy uncertainty intensify economic pressures. This study estimates the prevalence and recent changes in financial distress among U.S. short-term acute care hospitals. Methods: We conducted a national longitudinal analysis of all U.S. short-term acute care hospitals from 2021 to 2023 using financial and operational data from Medicare cost reports linked with community-level data from the American Community Survey. Financial distress was measured using the Altman Z-score, with severe distress defined as Z ≤ 1.8. Logistic regression models were used to identify organizational, operational, and market characteristics associated with distress. Results: The proportion of hospitals classified as severely financially distressed increased from 18.6% in 2021 to 22.0% in 2023. Operating margins and returns on assets declined significantly over the study period, while mean Z-scores showed a modest but non-significant downward trend. In adjusted models, urban hospitals had higher odds of distress (OR 1.27, 95% CI 1.15–1.40, p < 0.001), as did hospitals with longer average lengths of stay (OR 1.07 per day, 95% CI 1.04–1.09, p < 0.001) and higher debt-to-equity ratios (OR 1.05 per unit, 95% CI 1.05–1.06, p < 0.001). Higher occupancy rates were protective (OR 0.31, 95% CI 0.25–0.40, p < 0.001). Larger market population was also associated with increased distress risk (OR 1.61, 95% CI 1.21–2.14, p = 0.001), while other market characteristics were not significant. Conclusions: Financial distress remains widespread and appears to be increasing among U.S. acute care hospitals. Operational efficiency, capital structure, and local market scale are key drivers of financial vulnerability, highlighting the need for targeted strategies to strengthen hospital resilience and preserve access to essential acute care services.

Criminal justice system (CJS) involvement is common among individuals with opioid use disorder (OUD), yet limited research examines retention in medications for OUD (MOUD) within community settings. This study assessed whether CJS involvement predicted retention on buprenorphine/naloxone and explored related demographic and clinical factors. A retrospective cohort included adults (n = 367) enrolled in a low-barrier outpatient MOUD program in Texas (January 2022–April 2024). CJS involvement was identified from program records. Retention was measured as the number of continuous days with buprenorphine/naloxone prescriptions. Analyses used univariate tests, logistic regression, and nonparametric kernel regression. Nearly one-quarter (24.8%) were CJS-involved. Retention at 180 days was similar between CJS and non-CJS groups (38%). CJS participants initiated substance use earlier and reported higher heroin and injection drug use. Behavioral health sessions were associated with both CJS involvement (OR = 1.10, p ≤ 0.001) and longer retention (β = 10.81 days/session, p = 0.001). With comprehensive, low-barrier services, individuals involved with CJS achieved MOUD retention comparable to their peers. Early behavioral health engagement was a strong predictor of retention, suggesting a key intervention point to enhance outcomes and advance equity for justice-involved populations.

Criminal justice system (CJS) involvement is common among individuals with opioid use disorder (OUD), yet limited research examines retention in medications for OUD (MOUD) within community settings. This study assessed whether CJS involvement predicted retention on buprenorphine/naloxone and explored related demographic and clinical factors. A retrospective cohort included adults (n = 367) enrolled in a low-barrier outpatient MOUD program in Texas (January 2022–April 2024). CJS involvement was identified from program records. Retention was measured as continuous days with buprenorphine/naloxone prescriptions. Analyses used univariate tests, logistic regression, and nonparametric kernel regression. Nearly one-quarter (24.8%) were CJS-involved. Retention at 180 days was similar between CJS and non-CJS groups (38%). CJS participants initiated substance use earlier and reported higher heroin and injection drug use. Behavioral health sessions predicted both CJS involvement (OR = 1.10, p ≤ 0.001) and longer retention (β = 10.81 days/session, p = 0.001). With comprehensive, low-barrier services, CJS-involved individuals achieved MOUD retention comparable to peers. Early behavioral health engagement was a strong predictor of retention, suggesting a key intervention point to enhance outcomes and advance equity for justice-involved populations.

Background: Substance use disorders (SUD) are associated with metabolic dysregulation and nutritional deficiencies. Studies show that incorporating nutrition interventions into treatment may improve physical and psychological health. This study sought to explore dietary and consumer behavior in individuals currently using substances. Methods: Data from the 2013 – 2018 National Health and Nutrition Examination Survey were used for this cross-sectional study. Individuals 18 – 69 who were currently using marijuana, cocaine, heroin, methamphetamines, or injected unprescribed drugs were compared with individuals not using substances. Dietary and consumer behavior, including alcohol consumption was assessed. Analyses were performed using Stata I/C version 15. Results: An unweighted sample of 12 943 adults was analyzed. A weighted proportion of 14.2% reported using substances in the prior 30 days. Individuals currently using substances reported more commercially prepared meals compared to individuals not using substances ( P -value ≤.001), increased food insecurity ( P ≤ .001), and increased alcohol intake ( P ≤ .001). Multivariable logistic regression showed that both food insecurity and alcohol intake were independently and significantly linked to substance use. Conclusion: Nutrition interventions for those using substances or in early recovery should incorporate education on practical food preparation within the social constraints of the individual, including higher rates of food insecurity.

Background: Effective blood pressure (BP) management is essential for several disease states, including secondary stroke prevention. Remote BP monitoring used in combination with an electronic data capture (EDC) system offers potential for improved BP control for patients. While such systems currently exist, there are many patient-, provider-, and system-specific challenges these systems currently do not address. In addition, such systems are rarely described transparently and comprehensively in the literature with enough detail to be reproduced by other clinicians. Objective: This study aims to describe the development and design of a web-based EDC system tailored for remote BP monitoring and management to overcome common patient-, provider-, and system-specific challenges. Methods: The EDC system was developed for use in the Video-based Intervention to Reduce Treatment and Outcome Disparities in Adults living with Stroke (VIRTUAL) and transient ischemic attack clinical trial, a randomized study involving adult stroke survivors receiving care for secondary stroke prevention. The EDC system supports remote monitoring using a BP monitor, which was specifically and methodically chosen for its suitability to the population. The EDC system integrates the data from the remote monitors into a web-based application, facilitating real-time monitoring for health care team intervention. The system includes a BP dashboard displaying time-series data, visual alerts, and email notifications for out-of-range readings. Proxy measures assessed system effectiveness in addressing patient-, provider-, and system-specific needs. Results: Seventeen BP monitors were evaluated, and the BlipcareBlip BP800 was selected based on its cellular connectivity, ergonomic design, and application programming interface compatibility. The EDC system successfully linked patient data to the dashboard, enabling real-time visualization of BP trends and provider alerts. A total of 97% (184/190) of participants in the intervention arm engaged in BP monitoring, averaging 1.2 readings per day. Clinicians actively used the system, with mean monthly logins ranging from 19 to 44 per provider. Alerts were triggered for 69% ( of participants, primarily for systolic BP abnormalities. Data transmission delays were minimal, with a median time of 1.4 minutes from data collection to dashboard entry. Outlier alerts were efficiently processed, with an average notification time of 17.9 hours. The system demonstrated high functionality in addressing patient-, provider-, and system-specific needs, supporting effective BP monitoring and intervention delivery. Conclusions: The VIRTUAL EDC system facilitates remote monitoring of BP in stroke survivors, offering a model for similar systems in clinical trials. Clinicians can analyze, track, and interpret monitored data in near real-time, remotely, which may enhance BP management approaches, particularly in communities with limited access to care. This approach has the potential to improve hypertension management for patients and clinicians when standard data transparency is insufficient, standard monitor features are incompatible with the user, or when integrating a commercial dashboard may threaten electronic health record security.