INTRODUCTION: People with opioid use disorder (OUD) have high rates of discharge against medical advice from the hospital. Interventions for addressing these patient-directed discharges (PDDs) are lacking. We sought to explore the impact of methadone treatment for OUD on PDD. METHODS: Using electronic record and billing data from an urban safety-net hospital, we retrospectively examined the first hospitalization on a general medicine service for adults with OUD from January 2016 through June 2018. Associations with PDD compared to planned discharge were examined using multivariable logistic regression. Administration patterns of maintenance therapy versus new in-hospital initiation of methadone were examined using bivariate tests. RESULTS: During the study time period, 1,195 patients with OUD were hospitalized. 60.6% of patients received medication for OUD, of which 92.8% was methadone. Patients who received no treatment for OUD had a 19.1% PDD rate while patients initiated on methadone in-hospital had a 20.5% PDD rate and patients on maintenance methadone during the hospitalization had a 8.6% PDD rate. In multivariable logistic regression, methadone maintenance was associated with lower odds of PDD compared to no treatment (aOR 0.53, 95% CI 0.34-0.81), while methadone initiation was not (aOR 0.89, 95% CI 0.56-1.39). About 60% of patients initiated on methadone received 30 mg or less per day. CONCLUSIONS: In this study sample, maintenance methadone was associated with nearly a 50% reduction in the odds of PDD. More research is needed to assess the impact of higher hospital methadone initiation dosing on PDD and if there is an optimal protective dose.

Objective

To explore US provider perspectives about self-sourced medication abortion and how their attitudes and clinic practices changed in the context of the COVID-19 pandemic.

Study design

We conducted a multi-method study of survey and interview data. We performed 40 baseline interviews and surveys in spring 2019 and 36 follow-up surveys and ten interviews one year later. We compared pre- and post-Likert scale responses of provider views on the importance of different aspects of standard medication abortion assessment and evaluation (e.g., related to ultrasounds and blood-typing). We performed content analysis of the follow-up interviews using deductive-inductive analysis.

Results

Survey results revealed that clinics substantially changed their medication abortion protocols in response to COVID-19, with more than half increasing their gestational age limits and introducing telemedicine for follow-up of a medication abortion. Interview analysis suggested that physicians were more supportive of self-sourced medication abortion in response to changing clinic protocols that decreased in-clinic assessment and evaluation for medication abortion, and as a result of physicians' altered assessments of risk in the context of COVID-19. Having evidence already in place that supported these practice changes made the implementation of new protocols more efficient, while working in a state with restrictive abortion policies thwarted the flexibility of clinics to adapt to changes in standards of care.

Conclusion

This exploratory study reveals that the COVID-19 pandemic has altered clinical assessment of risk and has shifted practice towards a less medicalized model. Further work to facilitate person-centered abortion information and care can build on initial modifications in response to the pandemic.

Implications

COVID-19 has shifted clinician perception of risk and has catalyzed a change in clinical protocols for medication abortion. However, state laws and policies that regulate medication abortion limit physician ability to respond to changes in risk assessment.

We adapted the Quality of Contraceptive Counseling (QCC) scale, originally constructed in Mexico, for Ethiopia and India to expand its utility for measurement of client experiences with counseling. Scale items were modified based on prior research on women's preferences for counseling in each country, and refined through cognitive interviews (n = 20 per country). We tested the items through client exit surveys in Addis Ababa, Ethiopia (n = 599), and Vadodara, India (n = 313). Psychometric analyses revealed the adapted scales were valid and reliable for use, and the final scales retained content validity according to the original published QCC construct definition. Specifically, confirmatory factor analysis revealed high factor loadings for almost all items on the original dimensions: Information Exchange, Interpersonal Relationship, Disrespect and Abuse. Internal consistency reliability was high in both settings (Alpha = 0.92 for QCC-Ethiopia and 0.74 for QCC-India). Final item pools contained 26 items in the QCC-Ethiopia Scale and 23 in the QCC-India Scale. Correlation analyses established convergent validity. QCC Scales and subscales fill a gap in measurement tools for ensuring high quality of care and fulfillment of human rights in contraceptive services, and consistent findings across continents suggest versatility in use across different contexts.