Highlights • A frequently implemented telemedicine services is in rural emergency rooms. • This systematic review of tele-emergency studies found support for many measures. • Support was shown for ...clinical processes, outcomes, throughput, and disposition. • Rigor of the studies was limited and needs additional support. • Tele-emergency has considerable potential to address specialist access issues.
Veterans with opioid use disorder have an increased risk of suicide and overdose compared with the general population. Buprenorphine, a U.S. Food and Drug Administration–approved medication to treat ...opioid use disorder, has shown benefits, including decreased risk of illicit drug use and overdose. This study assesses the mortality outcomes with buprenorphine pharmacotherapy among Veterans up to 5 years from treatment initiation.
This was a retrospective cohort study of Veterans receiving buprenorphine (2008–2017) across any Veterans Health Administration facility. Buprenorphine pharmacotherapy was evaluated as a time-varying covariate. The primary outcome was death up to 5 years from treatment initiation by suicide and overdose combined; secondary outcomes included suicide, overdose, opioid-specific overdose, and all-cause death. Secondary analyses included evaluating the risk of mortality in recent discontinuation and effect modification by select characteristics. All analyses were conducted in 2020.
Veterans who were not receiving buprenorphine were 4.33 (adjusted hazard ratio; 95% CI=3.60, 5.21) times more likely to die by suicide/overdose than those receiving buprenorphine pharmacotherapy on any given day, with similar protective associations with treatment across secondary outcomes. The risk of suicide/overdose was highest 8–14 days from treatment discontinuation (adjusted hazard ratio=6.54, 95% CI=4.32, 9.91) than in currently receiving buprenorphine pharmacotherapy. There was no evidence of effect modification by the selected covariates.
Mortality risk was greater among Veterans who were not receiving buprenorphine pharmacotherapy than among those who were. Providers should consider whether buprenorphine pharmacotherapy, either intermittent or continuous, may provide health benefits for their patients and prevent mortality.
Aims
To examine how the process of change prescribed in Kotter's change model applies in implementing team huddles, and to assess the impact of the execution of early change phases on change success ...in later phases.
Background
Kotter's model can help to guide hospital leaders to implement change and potentially to improve success rates. However, the model is under studied, particularly in health care.
Methods
We followed eight hospitals implementing team huddles for 2 years, interviewing the change teams quarterly to inquire about implementation progress. We assessed how the hospitals performed in the three overarching phases of the Kotter model, and examined whether performance in the initial phase influenced subsequent performance.
Results
In half of the hospitals, change processes were congruent with Kotter's model, where performance in the initial phase influenced their success in subsequent phases. In other hospitals, change processes were incongruent with the model, and their success depended on implementation scope and the strategies employed.
Conclusions
We found mixed support for the Kotter model. It better fits implementation that aims to spread to multiple hospital units. When the scope is limited, changes can be successful even when steps are skipped.
Implications for Nursing Management
Kotter's model can be a useful guide for nurse managers implementing changes.
Objective
Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or ...engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment.
Methods
A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.
Results
Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65).
Conclusions
As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.
The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) funded the Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) to serve the dual ...purpose of providing telehealth services in rural emergency departments (teleED) and systematically collecting data to inform the telehealth evidence base. This provided a unique opportunity to examine trends across multiple teleED networks and examine heterogeneity in processes and outcomes.
Six health systems received funding from HRSA under the EB TNGP to implement teleED services and they did so to 65 hospitals (91% rural) in 11 states. Three of the grantees provided teleED services to a general patient population while the remaining three grantees provided teleED services to specialized patient populations (i.e., stroke, behavioral health, critically ill children). Over a 26-month period (November 1, 2015 -December 31, 2017), each grantee submitted patient-level data for all their teleED encounters on a uniform set of measures to the data coordinating center. The six grantees reported a total of 4,324 teleED visits and 99.86% were technically successful. The teleED patients were predominantly adult, White, not Latinx, and covered by Medicare or private insurance. Across grantees, 7% of teleED patients needed resuscitation services, 58% were rated as emergent, and 30% were rated as urgent. Across grantees, 44.2% of teleED patients were transferred to another inpatient facility, 26.0% had a routine discharge, and 24.5% were admitted to the local inpatient facility. For the three grantees who served a general patient population, the most frequent presenting complaints for which teleED was activated were chest pain (25.7%), injury or trauma (17.1%), stroke symptoms (9.9%), mental/behavioral health (9.8%), and cardiac arrest (9.5%). The teleED consultation began before the local clinician exam in 37.8% of patients for the grantees who served a general patient population, but in only 1.9% of patients for the grantees who provided specialized services.
Grantees used teleED services for a representative rural population with urgent or emergent symptoms largely resulting in transfer to a distant hospital or inpatient admission locally. TeleED was often available as the first point of contact before a local provider examination. This finding points to the important role of teleED in improving access for rural ED patients.
Abstract Objectives We undertake a systematic review to examine the methods used by researchers in developing cost-of-illness (COI) studies. This review aims to categorize the approaches that the ...published literature uses in terms of perspective, scope, components of care analyzed in the literature, data sets, and valuation approaches used for direct cost. It draws conclusions regarding the adequacy of current COI research methods and makes recommendations on improving them. Methods The online bibliographic information service HealthSTAR (which incorporates MEDLINE) was used to search for COI studies in the research literature published during the period from 2000 to 2004. The search strategy used the term “cost of illness” as a MeSH (medical subject heading) term. Results The HealthSTAR literature search identified references to 650 articles. Review of abstracts resulted in the identification of 170 of these for a more detailed review. This process identified 52 articles that met all criteria of COI studies. We identified 218 components of care analyzed across the 52 articles. Private-insurance or employer-claims data sets comprised the largest source of utilization and cost information among the studies. Conclusion Analyzing cost of illness presents useful opportunities for communicating with the public and policymakers on the relative importance of specific diseases and injuries. Our research, however, indicates that COI studies employ varied approaches and many articles have methodological limitations. Without well-accepted standards to guide researchers in their execution of these studies, policymakers and the general public must be wary of the methods used in their calculation and subsequent results.
Home health care has a significant role in the care of Medicare beneficiaries. Certificate of Need (CON) laws for home health agencies limit their number in affected states. This study’s objective ...was to evaluate the association of CON laws with the availability and service utilization of urban and rural home health agencies in CON states and non-CON states using the generalized estimating equations (GEE) method. The results from this study indicated that CON states have fewer home health agencies for their Medicare population than non-CON states, regardless of urbanicity or rurality. Home health agencies in CON states also have less service utilization in terms of care episodes and visits per patient. This study provides an understanding of the effects of CON laws on Medicare beneficiaries' home health access and experiences.
Solution-processable electronic devices are highly desirable due to their low cost and compatibility with flexible substrates. However, they are often challenging to fabricate due to the hydrophobic ...nature of the surfaces of the constituent layers. Here, we use a protein solution to modify the surface properties and to improve the wettability of the fluoropolymer dielectric Cytop. The engineered hydrophilic surface is successfully incorporated in bottom-gate solution-deposited organic field-effect transistors (OFETs) and hybrid organic–inorganic trihalide perovskite field-effect transistors (HTP-FETs) fabricated on flexible substrates. Our analysis of the density of trapping states at the semiconductor–dielectric interface suggests that the increase in the trap density as a result of the chemical treatment is minimal. As a result, the devices exhibit good charge carrier mobilities, near-zero threshold voltages, and low electrical hysteresis.
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