Linkage to Primary Care for Persons First Receiving Injectable Naltrexone During Inpatient Opioid Detoxification

HIGHLIGHTS

• XR-NTX begun during opioid detoxification can be continued in primary care settings.
• 55% of XR-NTX recipients link to primary care for continued treatment.
• We found no predictors of XR-NTX continuation in primary care.

INTRODUCTION:

Opioid use disorders commonly require ongoing medication-assisted treatment to reduce relapse following discharge from inpatient detoxification programs. Naltrexone, an opioid antagonist, is an increasingly popular treatment option in its once-monthly injectable form (XR-NTX). The aim of this study was to examine the follow-up rates of persons who received an initial injection during inpatient detoxification and scheduled for receipt of a first outpatient injection in the primary care setting.

METHODS:

We reviewed the electronic health records of 62 consecutive opioid dependent adults who received an initial injection of XR-NTX during extended inpatient detoxification at Stanley Street Treatment and Resources (SSTAR) in Fall River, Massachusetts, from March 2013 to August 2015, and were referred to the adjacent SSTAR primary care health center for their second injection 1month later. Demographic information, drug use and opioid treatment history, and aftercare planning were assessed.

RESULTS:

Participants averaged 32.4 (±7.8) years of age, 90.3% were non-Latino Caucasian, 35.5% were homeless, 21.3% reported a drug overdose in the last year, and 53.2% had been in detoxification within the last year. Of the 62 participants referred to primary care, 34 (54.8%) followed up to receive their second XR-NTX injection. Twenty of these persons received at least a third XR-NTX injection. No demographic, treatment history, substance use behaviors, or aftercare plan variables were associated with receipt of a second injection (p<.20).

CONCLUSION:

Predicting, and therefore improving, XR-NTX continuation during the transition from inpatient detoxification to primary care may be difficult in this population.

Purchase full article at:   http://goo.gl/mEBWGY

By:  Stein MD1, Risi MM2, Bailey GL3, Anderson BJ2.

• 1General Medicine Research Unit, Butler Hospital, Providence, RI, 02906; Warren Alpert Medical School of Brown University, Providence, RI, 02912. Electronic address: michael_stein@brown.edu.
• 2General Medicine Research Unit, Butler Hospital, Providence, RI, 02906.
• 3Warren Alpert Medical School of Brown University, Providence, RI, 02912; Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts, 02720. 
• J Subst Abuse Treat. 2016 May;64:44-6. doi: 10.1016/j.jsat.2016.01.007. Epub 2016 Feb 23.

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Project ECHO: A New Model for Educating Primary Care Providers About Treatment of Substance Use Disorders

BACKGROUND:

Project ECHO trains and mentors primary care providers (PCPs) in the care of patients with complex conditions. ECHO is a distance education model that connects specialists with numerous PCPs via simultaneous video link for the purpose of facilitating case-based learning. We describe a teleECHO clinic based at the University of New Mexico Health Sciences Center that is focused on treatment of substance use disorders (SUDs) and behavioral health disorders.

METHODS:

Since 2005, specialists in treatment of SUDs and behavioral health disorders at Project ECHO have offered a weekly 2-hour Integrated Addictions and Psychiatry (IAP) TeleECHO Clinic focused on supporting PCP evaluation and treatment of SUDs and behavioral health disorders. We tabulate the number of teleECHO clinic sessions, participants, and CME/CEU credits provided annually. This teleECHO clinic has also been used to recruit physicians to participate in DATA-2000 buprenorphine waiver trainings. Using a database of the practice location of physicians who received the buprenorphine waiver since 2002, we calculate the number of waivered physicians per capita in US states. We evaluate the increase in waivered physicians practicing in underserved areas in NM compared to the rest of the US.

RESULTS:

Since 2008, approximately 950 patient cases have been presented during the teleECHO clinic, and more than 9000 hours of CME/CEU have been awarded. Opioids are the substances discussed most commonly (31%), followed by Alcohol (21%) and Cannabis (12%). New Mexico is near the top among US states in DATA-2000 buprenorphine waivered physicians per capita, and has had much more rapid growth in waivered physicians practicing in traditionally-underserved areas compared with the rest of the US since the initiation of the teleECHO clinic focused on SUDs in 2005.

CONCLUSION:

The ECHO model provides an opportunity to promote expansion of access to treatment for opioid use disorder and other SUDs, particularly in underserved areas.

Purchase full article at:   http://goo.gl/J61gO7

By:  Komaromy M1, Duhigg D1, Metcalf A2, Carlson C1, Kalishman S1, Hayes L3, Burke T1, Thornton K1, Arora S1.

• 1 ECHO Institute, University of New Mexico Health Sciences Center, University of New Mexico , Albuquerque , NM , USA.
• 2 Truman Clinic, University Hospital , Albuquerque , NM , USA.
• 3 El Centro Family Health Center , Espanola , NM , USA.
• Subst Abus. 2016 Feb 5:0. 

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Low-Intensity Case Management Increases Contact with Primary Care in Recently Released Prisoners

BACKGROUND:

The world prison population is large and growing. Poor health outcomes after release from prison are common, but few programmes to improve health outcomes for ex-prisoners have been rigorously evaluated. The aim of this study was to evaluate the impact of individualised case management on contact with health services during the first 6 months post-release.

METHODS:

Single-blinded, randomised, controlled trial. Baseline assessment with N=1325 adult prisoners in Queensland, Australia, within 6 weeks of expected release; follow-up interviews 1, 3 and 6 months post-release. The intervention consisted of provision of a personalised booklet ('Passport') at the time of release, plus up to four brief telephone contacts in the first 4 weeks post-release.

RESULTS:

Of 1179 eligible participants, 1003 (85%) completed ≥1 follow-up interview. In intention-to-treat analyses, 53% of the intervention group and 41% of the control group reported contacting a general practitioner (GP) at 1 month post-release (difference=12%, 95% CI 5% to 19%). Similar effects were observed for GP contact at 3 months (difference=9%, 95% CI 2% to 16%) and 6 months (difference=8%, 95% CI 1% to 15%), and for mental health (MH) service contact at 6 months post release (difference=8%, 95% CI 3% to 14%).

CONCLUSIONS:

Individualised case management in the month after release from prison increases usage of primary care and MH services in adult ex-prisoners for at least 6 months post-release. Given the poor health profile of ex-prisoners, there remains an urgent need to develop and rigorously evaluate interventions to increase health service contact in this profoundly marginalised population.

Below:  Percentage of intervention group participants contacting a general practitioner (GP) at 1 month post release, according to number of intervention telephone calls completed

Purchase full article at:   http://goo.gl/qiTkti

By:  Kinner SA1, Alati R2, Longo M3, Spittal MJ4, Boyle FM2, Williams GM2, Lennox NG5.

• 1Griffith Criminology Institute & Menzies Health Institute Queensland, Griffith University, Brisbane, Australia Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-UQ, The University of Queensland, Brisbane, Australia.
• 2School of Public Health, University of Queensland, Brisbane, Australia.
• 3Drug and Alcohol Services South Australia, Adelaide, Australia.
• 4Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia.
• 5Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-UQ, The University of Queensland, Brisbane, Australia. 
• J Epidemiol Community Health. 2016 Jan 19. pii: jech-2015-206565. doi: 10.1136/jech-2015-206565. 

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Stakeholders' Recommendations to Improve Patient-centered "LGBTQ" Primary Care in Rural and Multicultural Practices

PURPOSE:

Individuals among gender/sexual minorities share experiences of stigma and discrimination, yet have distinctive health care needs influenced by ethnic/racial minority and rural realities.

METHODS:

We collected qualitative data from lesbian/gay/bisexual/transgender (LGBT) and queer persons across the largely rural, multicultural state of New Mexico, particularly those from understudied ethnic groups, regarding factors facilitating or impeding patient-centered primary care. The themes identified formed the basis for a statewide summit on LGBT health care guidelines and strategies for decreasing treatment gaps.

RESULTS:

Three to 15 individuals, ages 18 to 75 years, volunteered for 1 of 4 town hall dialogues (n = 32), and 175 people took part in the summit. Participants acknowledged health care gaps pertinent to LGBT youth, elders, American Indians, and Latinos/Latinas, expressing specific concern for rural residents.

CONCLUSIONS:

This preliminary research emphasizes the need to improve primary care practices that treat rural and ethnic-minority LGBT people and offers patient-driven recommendations to enhance care delivery while clinic-level transformations are implemented.

...Summit participants pointedly appealed for “realistic action steps” that could lead to “immediate improvements” for LGBTQ patient-centered care:

• Create a safe, welcoming environment
• Post LGBTQ-positive visual representations, for example, images of people/families of differing gender/sexual, cultural, ethnic/racial backgrounds, in lobbies/examination rooms
• Use culturally appropriate, culturally specific terms on intake forms; that is, recognize that some patients may prefer local terminologies such as Native American use of “Two-Spirit,” patient preference for “queer” over “lesbian,” “gay” or “bisexual,” and/or use of “they” as a preferred gender pronoun by people across the sexual/gender minority spectrum
• Include gender/sexual difference in displayed antidiscrimination policies

Develop culturally competent medical staff

• Invite local LGBTQ community members/leaders to clinic meetings to discuss the experiences/treatment needs of LGBTQ patients
• Encourage respectful, direct, open-ended questions using culturally relevant terminology in provider–patient interactions regarding identity, sexual history, and risk factors
• Use local university/community-based safe zone training¹⁵ centered on how to be an LGBTQ ally while enhancing understanding of anti-LGBTQ stigma/phobias and microaggressions for all providers and staff to encourage patient feelings of security

Update medical training

• Deploy technologies in rural settings, for example, video/Web conferencing for consulting LGBTQ specialists
• Acquire information on LGBTQ-specific health, for example, hormone therapies and associated risks for transgender patients, gender-sensitive cancer screenings
• Participate in research to improve LGBTQ health care

Full article at:   http://goo.gl/ujDiCq

By:  Kano M1, Silva-Bañuelos AR2, Sturm R2, Willging CE2.

• 1From the Department of Family and Community Medicine, University of New Mexico, Albuquerque (MK); the University of New Mexico LGBTQ Resource Center (http://lgbtqrc.unm.edu/), Albuquerque (ARS-B); the New Mexico Community AIDS Partnership, Santa Fe (RS); and the Pacific Institute for Research and Evaluation, Behavioral Health Research Center of the Southwest, Albuquerque, NM (CEW). mkano@salud.unm.edu.
• 2From the Department of Family and Community Medicine, University of New Mexico, Albuquerque (MK); the University of New Mexico LGBTQ Resource Center, Albuquerque (ARS-B); the New Mexico Community AIDS Partnership, Santa Fe (RS); and the Pacific Institute for Research and Evaluation, Behavioral Health Research Center of the Southwest, Albuquerque, NM (CEW). 

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Satisfaction of HIV Patients with Task-Shifted Primary Care Service vs Routine Hospital Service in Northern Thailand

Introduction:

Shifting the task of HIV care to primary care providers is an important strategy to sustain expanding access to antiretroviral therapy (ART) in high HIV burden countries like Thailand. In a pilot project, the task of following up ART-receiving patients was shifted from a physician-led HIV clinic team based at district level community hospital, to a nurse-led primary healthcare team of seven primary care centers, based at sub-district level in a district of Chiang Mai in northern Thailand. This study aimed to evaluate the task-shifted ART service in a patient-centered approach.

Methodology:

Patients’ satisfaction level was assessed cross-sectionally in a sample of 198 patients, which included 66 people living with HIV (PLHIV) receiving task-shifted ART service and matched controls in a ratio of 1:2. HIV immunological outcome was compared in a retrospective cohort of a year follow-up. Transculturally translated patient satisfaction questionnaire short form (PSQ-18) was used. Multivariate analysis of variance compared seven domains of patients’ satisfaction levels.

Results:

Community hospital patients expressed significantly higher levels of satisfaction with the technical quality, communication, and time spent by the service provider, whereas the task-shifted model patients experienced significantly better accessibility and convenience of the service. At the one-year follow up, CD4 counts of the two groups were not significantly different.

Conclusion:

Future research and training programs should aim to improve the technical quality and communication skills of nurse-led ART service teams to shift the task of HIV care and sustain expansion of ART access in primary care settings.

Full article at:   http://goo.gl/qf9p9O

By:  Myo Nyein Aung, Saiyud Moolphate, Tsutomu Kitajima, Yaowaluk Siriwarothai, Piyaporn Takamtha, Chitima Katanyoo　, Hiroshi Okamura, Malcom Field, Osamu Noyama, Pongsak Wannakrairot, Virat Klinbuayaem

Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

doi:10.3855/jidc.7661

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Leveraging HIV Platforms to Work Toward Comprehensive Primary Care in Rural Malawi: The Integrated Chronic Care Clinic

This case study describes an integrated chronic care clinic that utilizes a robust HIV program as a platform for NCD screening and treatment. 

A unique model, the integrated chronic care clinic provides longitudinal care for patients with an array of chronic diseases including HIV and common NCDs, allowing for a single visit for all of a patient's conditions. Set in Malawi's remote Neno District, this clinic structure aims to

1. increase access to care for NCD patients, 
2. maximize efficiency given the severe human resource shortages, and 
3. replicate strong HIV outcomes for patients with other chronic conditions. 

The goal is to increase the number of health facilities in Neno capable of fully delivering Malawi's Essential Health Package, the set of cost-effective interventions endorsed by Malawi MOH to reduce burden of disease and leading causes of death. While implementation is ongoing and processes are evolving, this model of healthcare delivery has already improved the accessibility of NCD care by allowing patients to have all of their chronic conditions treated on the same day at their nearest health facility, notably without additional investment of human and financial resources. 

Currently, 6781 patients on antiretroviral therapy and 721 patients with NCDs are benefitting, including 379 with hypertension, 187 with asthma, 144 with epilepsy, and 76 with diabetes. Among the NCD patient population, 15.1% are HIV-positive. Success hinged largely on several factors, including clear leadership and staff ownership of their specific duties, and a well-defined and uniform patient flow process. Furthermore, deliberate and regular conversations about challenges allowed for constant iteration and improvement of processes. 

Moving forward, several tasks remain. We are refining the data management process to further consolidate medical records, along with integrating our tracking processes for clients who miss appointments. Additionally, we are exploring opportunities for further integration, including family planning. 

A follow-up patient satisfaction survey is planned for the coming months to track the impact of the clinic's redesign. Given limited human and financial resources, innovative solutions are required to address the growing burden of chronic disease in Malawi. 

We have found that an integrated, patient-centered approach maximizes efficiency and reduces barriers to care for the hardest to reach patients.

Below:  Decentralization of the ART clinic, 2013

Below:  Patient flow in IC3

Full article at:   http://goo.gl/M3f4eC

By:   Wroe EB1, Kalanga N2, Mailosi B3, Mwalwanda S4, Kachimanga C5, Nyangulu K6, Dunbar E7, Kerr L8, Nazimera L9, Dullie L10.

• 1Brigham & Women's Hospital, Division of Global Health Equity, Boston, MA, USA; Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: ewroe@pih.org.
• 2Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: nkalanga@gmail.com.
• 3Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: brghtmls@gmail.com.
• 4Malawi Ministry of Health, Neno, Malawi. Electronic address: starmwalwanda@gmail.com.
• 5Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: chembekachimanga@yahoo.co.uk.
• 6Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: ksnyangulu@gmail.com.
• 7Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: edunbar@pih.org.
• 8Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: lkerr@pih.org.
• 9Malawi Ministry of Health, Neno, Malawi. Electronic address: lnazimera@gmail.com.
• 10Abwenzi Pa Za Umoyo, Neno, Malawi. Electronic address: ldullie@pih.org. 

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Talking About Naloxone in a Primary Care or Pain Management Setting

Via:  http://www.csam-asam.org/

Exploring Lesbian, Gay, Bisexual & Queer (LGBQ) People’s Experiences with Disclosure of Sexual Identity to Primary Care Physicians

Background

It has been demonstrated that health disparities between lesbian, gay, bisexual and queer (LGBQ) populations and the general population can be improved by disclosure of sexual identity to a health care provider (HCP). However, heteronormative assumptions (that is, assumptions based on a heterosexual identity and experience) may negatively affect communication between patients and HCPs more than has been recognized. The aim of this study was to understand LGBQ patients’ perceptions of their experiences related to disclosure of sexual identity to their primary care provider (PCP).

Methods

One-on-one semi-structured telephone interviews were conducted, audio-recorded, and transcribed. Participants were self-identified LGBQ adults with experiences of health care by PCPs within the previous five years recruited in Toronto, Canada. A qualitative descriptive analysis was performed using iterative coding and comparing and grouping data into themes.

Results

Findings revealed that disclosure of sexual identity to PCPs was related to three main themes: 1) disclosure of sexual identity by LGBQ patients to a PCP was seen to be as challenging as coming out to others; 2) a solid therapeutic relationship can mitigate the difficulty in disclosure of sexual identity; and, 3) purposeful recognition by PCPs of their personal heteronormative value system is key to establishing a strong therapeutic relationship.

Conclusion

Improving physicians’ recognition of their own heteronormative value system and addressing structural heterosexual hegemony will help to make health care settings more inclusive. This will allow LGBQ patients to feel better understood, willing to disclose, subsequently improving their care and health outcomes.

Full article at:   http://goo.gl/s3JWfn

By:   Marcus Law, Anila Mathai, Paula Veinot, Fiona Webster, and Maria Mylopoulos

Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s College Circle, Room 3157, Toronto, ON M5S 1A8 Canada

Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON M5G 1V7 Canada

The Wilson Centre, 200 Elizabeth Street, 1ES-565, Toronto, ON M5G 2C4 Canada

Marcus Law, Phone: +416-978-4543, Email: ac.otnorotu@wal.sucram.

 

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Does General Practice Deliver Safe Primary Care to People Living with HIV? A Case-Notes Review

Safe care in general practice for people living with HIV requires early diagnosis of undetected infection and safe co-prescribing with antiretroviral therapy (ART).

To evaluate safe co-prescribing in general practice patients who are taking ART, and to describe missed diagnostic opportunities for undiagnosed HIV infection in primary care.

Retrospective case-notes review in general practices within NHS City and Hackney Primary Care Trust (PCT), London, UK.

All general practices in NHS City and Hackney PCT were invited to participate. Patients known to be HIV positive were identified using Read Codes. Each practice undertook retrospective case-notes reviews on specialist correspondence, coding of ART, prescribing of common contraindicated drug pairings, and missed opportunities for HIV diagnosis.

In total, 31/44 (70.5%) practices participated, and 1022 people living with HIV were identified. Practices had received HIV clinic letters for 698 of those 1022 (68.3%) patients in the previous 12 months. Of the 787 patients known to be prescribed ART, only 413 (52.5%) had correct drug codes recorded; 32/787 (4.1%) were receiving specified contraindicated drug pairings. In total, 89 patients were eligible for their case-notes to undergo a retrospective review of occurrences that took place pre-diagnosis. In the 2 years preceding diagnosis, these 89 had attended 716 face-to-face GP consultations, of which 123 (17.2%) were for indicator conditions. Fifty-one of these patients (57.3%) presented at least once with an indicator condition (interquartile range 1-3; median 2).

In a large-scale evaluation of GP records of people living with HIV, gaps in ART recording and co-prescribing were identified, and evidence demonstrated missed opportunities for diagnosis within general practice. Specialists and generalists must communicate better to enhance safe prescribing and reduce delayed diagnosis.

Via:  http://goo.gl/hyM4hl Purchase full article at: http://goo.gl/9fUq4f

By: Wellesley R1, Whittle A2, Figueroa J2, Anderson J3, Castles R4, Boomla K1, Griffiths C1, Leber W1.

• 1Centre for Primary Care and Public Health, Queen Mary University of London, London.
• 2NHS City and Hackney PCT, London.
• 3Centre for the Study of Sexual Health and HIV;
• 4Jonathan Mann Centre, Homerton University Hospital NHS Foundation Trust, London. 

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