Buprenorphine is increasingly used to treat pain in patients with sickle cell disease but optimal timing and approach for transitioning patients from full agonist opioids to buprenorphine is unknown. We present the case of a 22-year-old woman with sickle cell disease and acute on chronic pain who transitioned from high-dose oxycodone to buprenorphine/naloxone during a hospital stay for vaso-occlusive episode. Utilizing a microdosing approach to minimize pain and withdrawal, buprenorphine/naloxone was gradually uptitrated while she received full agonist opioids. During the transition, she experienced some withdrawal in the setting of swallowed buprenorphine/naloxone tablets, which were intended to be dosed sublingually. Nevertheless, the transition was tolerable to the patient and her pain and function significantly improved with buprenorphine treatment. This case also highlights the challenges and unique considerations that arise when providing care for the hospitalized patient who is also incarcerated.

Background

Alcohol dependence results in multiple hospital readmissions, but no discharge planning protocol has been studied to improve outcomes. The inpatient setting is a frequently missed opportunity to discuss treatment of alcohol dependence and initiate medication-assisted treatment, which is effective yet rarely utilized.

Aim

Our aim was to implement and evaluate a discharge planning protocol for patients admitted with alcohol dependence.

Setting

The study took place at the San Francisco General Hospital (SFGH), a university-affiliated, large urban county hospital.

Participants

Learner participants included Internal Medicine residents at the University of California, San Francisco (UCSF) who staff the teaching service at SFGH. Patient participants included inpatients with alcohol dependence admitted to the Internal Medicine teaching service.

Program description

We developed and implemented a discharge planning protocol for patients admitted with alcohol dependence that included eligibility assessment and initiation of medication-assisted treatment.

Program evaluation

Rates of medication-assisted treatment increased from 0% to 64% (p value < 0.001). All-cause 30-day readmission rates to SFGH decreased from 23.4% to 8.2% (p value = 0.042). All-cause emergency department visits to SFGH within 30 days of discharge decreased from 18.8% to 6.1% (p value = 0.056).

Discussion

Through implementation of a discharge planning protocol by Internal Medicine residents for patients admitted with alcohol dependence, there was a statistically significant increase in medication-assisted treatment and a statistically significant decrease in both 30-day readmission rates and emergency department visits.

BACKGROUND: The prevalence of telehealth video use across the United States is uneven, with low uptake in safety-net health care delivery systems, which care for patient populations who face barriers to using digital technologies. OBJECTIVE: This study aimed to increase video visit use in an urban safety-net delivery system. We piloted a telehealth ambassador program, in which volunteers offered technical support to patients with access to digital technologies to convert primary care visits already scheduled as telehealth audio-only visits to telehealth video visits. METHODS: We used a descriptive approach to assess the feasibility, efficacy, and acceptability of the pilot telehealth ambassador program. Feasibility was quantified by the percentage of eligible patients who answered calls from telehealth ambassadors. Program efficacy was measured in two ways: (1) the percentage of patients with access to digital technology who interacted with the navigators and were successfully prepared for a telehealth video visit, and (2) the percentage of prepared patients who completed their scheduled video visits. Program acceptability was ascertained by a structured telephone survey. RESULTS: Telehealth ambassadors attempted to contact 776 eligible patients; 43.6% (338/776) were reached by phone, among whom 44.4% (150/338) were provided digital support between March and May 2021. The mean call duration was 8.8 (range 0-35) minutes. Overall, 67.3% (101/150) of patients who received support successfully completed a telehealth video visit with their provider. Among the 188 patients who were contacted but declined video visit digital support, 61% (114/188) provided a reason for their decline; 42% (48/114) did not see added value beyond a telehealth audio-only visit, 20% (23/114) had insufficient internet access, and 27% (31/114) declined learning about a new technology. The acceptability of the telehealth ambassador program was generally favorable, although some patients preferred having in-real-time technology support on the day of their telehealth video visit. CONCLUSIONS: This high-touch program reached approximately one-half of eligible patients and helped two-thirds of interested patients with basic video visit capability successfully complete a video visit. Increasing the programs reach will require outreach solutions that do not rely solely on phone calls. Routinely highlighting the benefits of video visits, partnering with community-based organizations to overcome structural barriers to telehealth use, and offering in-real-time technology support will help increase the programs efficacy.

Abstract United States (US) migrants are often characterised as experiencing unhealthy nutrition transitions. 'Looking-back' into dietary behaviours and the processes that affect dietary changes before migration may improve counselling interventions. We conducted a qualitative study of an indigenous Zapotecan transnational community based in Monterey, California, and Oaxaca, Mexico. Four focus groups and 29 interviews were conducted with transnational participants concerning health beliefs around and dietary differences between the US and Oaxaca. Analysis focused on nutrition-related themes. The four major themes were: (1) the paradox between participants' experience growing up with food insecurity and fond memories of a healthier diet; (2) mothers' current kitchen struggles as they contend with changes in food preferences and time demands, and the role 'care packages' play in alleviating these challenges; (3) positive views about home-grown versus store-bought vegetables; and (4) the role of commercial nutritional supplements and the support they provide. Counselling implications include (1) taking a detailed medical/social history to explore experiences with food insecurity and views on the role of nutrition in maintaining health and (2) exploring patients' struggles with different dietary preferences within their families. Transnational experiences may provide new insights for dietary counselling and patient-centred health communication.

Objective

The COVID-19 pandemic prompted unprecedented expansion of telemedicine services. We sought to describe clinician experiences providing telemedicine to publicly-insured, low-income patients during COVID-19.

Methods

Online survey of ambulatory clinicians in an urban safety-net hospital system, conducted May 28 2020-July 14 2020.

Results

Among 311 participants (response rate 48.3%), 34.7% (N=108/311) practiced in primary/urgent care, 37.0% (N=115/311) medical specialty and 7.7% (N=24/311) surgical clinics. 87.8% (273/311) had conducted telephone visits, 26% (81/311) video. Participants reported observing both technical and non-technical patient barriers. Clinicians reported concerns about the diagnostic safety of telephone (58.9%, 129/219) vs video (35.3%, 24/68). However, clinician comfort with telemedicine was high (89.3% (216/242) for telephone, 91.0% (61/67) for video), with many clinicians (220/239 or 92.1% telephone, 60/66 or 90.9% video) planning to continue telemedicine after COVID-19.

Conclusions

Clinicians in a safety-net healthcare system report high comfort with and intention to continue telemedicine after the pandemic, despite patient challenges and safety concerns.

Background

The COVID-19 pandemic prompted safety-net health care systems to rapidly implement telemedicine services with little prior experience, causing disparities in access to virtual visits. While much attention has been given to patient barriers, less is known regarding system-level factors influencing telephone versus video-visit adoption. As telemedicine remains a preferred service for patients and providers, and reimbursement parity will not continue for audio visits, health systems must evaluate how to support higher-quality video visit access.

Objective

This study aimed to assess health system-level factors and their impact on telephone and video visit adoption to inform sustainability of telemedicine for ambulatory safety-net sites.

Methods

We conducted a cross-sectional survey among ambulatory care clinicians at a hospital-linked ambulatory clinic network serving a diverse, publicly insured patient population between May 28 and July 14, 2020. We conducted bivariate analyses assessing health care system-level factors associated with (1) high telephone adoption (4 or more visits on average per session); and (2) video visit adoption (at least 1 video visit on average per session).

Results

We collected 311 responses from 643 eligible clinicians, yielding a response rate of 48.4%. Clinician respondents (N=311) included 34.7% (n=108) primary or urgent care, 35.1% (n=109) medical, and 7.4% (n=23) surgical specialties. Our sample included 178 (57.2%) high telephone adopters and 81 (26.05%) video adopters. Among high telephone adopters, 72.2% utilized personal devices for telemedicine (vs 59.0% of low telephone adopters, P=.04). Video nonadopters requested more training in technical aspects than adopters (49.6% vs 27.2%, P<.001). Primary or urgent care had the highest proportion of high telephone adoption (84.3%, compared to 50.4% of medical and 37.5% of surgical specialties, P<.001). Medical specialties had the highest proportion of video adoption (39.1%, compared to 14.8% of primary care and 12.5% of surgical specialties, P<.001).

Conclusions

Personal device access and department specialty were major factors associated with high telephone and video visit adoption among safety-net clinicians. Desire for training was associated with lower video visit use. Secure device access, clinician technical trainings, and department-wide assessments are priorities for safety-net systems implementing telemedicine.

Staphylococcus aureus is a common cause of bloodstream infection and methicillin-resistant S. aureus (MRSA) is a growing threat worldwide. We evaluated the incidence rate of S. aureus bacteremia (SAB) and MRSA from population-based surveillance in all hospitals from two Thai provinces. Infections were classified as community-onset (CO) when blood cultures were obtained ≤ 2 days after hospital admission and as hospital-onset (HO) thereafter. The incidence rate of HO-SAB could only be calculated for 2009-2014 when hospitalization denominator data were available. Among 147,524 blood cultures, 919 SAB cases were identified. Community-onset S. aureus bacteremia incidence rate doubled from 4.4 (95% confidence interval [CI]: 3.3-5.8) in 2006 to 9.3 per 100,000 persons per year (95% CI: 7.6-11.2) in 2014. The highest CO-SAB incidence rate was among adults aged 50 years and older. Children less than 5 years old had the next highest incidence rate, with most cases occurring among neonates. During 2009-2014, there were 89 HO-SAB cases at a rate of 0.13 per 1,000 hospitalizations per year (95% CI: 0.10-0.16). Overall, MRSA prevalence among SAB cases was 10% (90/911) and constituted 7% (55/736) of CO-SAB and 20% (22/111) of HO-SAB without a clear temporal trend in incidence rate. In conclusion, CO-SAB incidence rate has increased, whereas MRSA incidence rate remained stable. The increasing CO-SAB incidence rate, especially the burden on older adults and neonates, underscores the importance of strong SAB surveillance to identify and respond to changes in bacteremia trends and antimicrobial resistance.