Emergency department utilization by individuals with opioid use disorder who were recently incarcerated.

Individuals with opioid use disorder (OUD) are highly represented among the incarcerated population and are frequent utilizers of the emergency department (ED). Medications for opioid use disorder (MOUD) are a recognized treatment option for individuals with OUD. Although the field recognizes the benefits of MOUD, we know little about what mitigating effects MOUD offered in jail might have on post-release ED utilization. In this retrospective cohort analysis, we searched electronic medical records (EMR) for incarcerations in the Santa Clara County jail between 8/1/2019 and 8/31/2021 for individuals with OUD (N = 4352) and collected demographic and medication administration data for these individuals. Individuals are considered as having received MOUD if they have at least one administration of methadone, naltrexone, or extended release (XR) buprenorphine during their incarceration. We also collected ED visit data from the same EMR for the 28 days following release from the identified incarcerations. Using logistic regression, we compared ED use within 24 h and 28 days for individuals who are incarcerated and treated with MOUD with those not receiving treatment. Individuals who received methadone or XR buprenorphine during their incarceration were less likely to present at the 28 days following release than those not receiving treatment, after controlling for age, race, sex assigned at birth, preferred language, and housing status. Most individuals accessing the ED within 28 days of release do so within the first seven days, and the greatest volume occurred in the first 24 h. Individuals released before noon had a lower likelihood of ED presentation within 24 h than those released in the afternoon. Offering methadone and XR buprenorphine to individuals with OUD who are incarcerated is beneficial in mitigating ED utilization within 28 days of release, although further research is needed to understand what other contributing variables, especially those related to follow-up care, could be influencing these results. If possible, release times for individuals could be shifted to the morning to maximize reduction in ED use within 24 h of release. Alternatively, further research should investigate why release times appear to influence ED utilization.

Will J ，Abare M ，Olson M ，Chyorny A ，Wilhelm-Leen E ... -  《-》

Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling.

Elwenspoek MM ，Thom H ，Sheppard AL ，Keeney E ，O'Donnell R ，Jackson J ，Roadevin C ，Dawson S ，Lane D ，Stubbs J ，Everitt H ，Watson JC ，Hay AD ，Gillett P ，Robins G ，Jones HE ，Mallett S ，Whiting PF ... -  《-》

Comparison of Two Modern Survival Prediction Tools, SORG-MLA and METSSS, in Patients With Symptomatic Long-bone Metastases Who Underwent Local Treatment With Surgery Followed by Radiotherapy and With Radiotherapy Alone.

Survival estimation for patients with symptomatic skeletal metastases ideally should be made before a type of local treatment has already been determined. Currently available survival prediction tools, however, were generated using data from patients treated either operatively or with local radiation alone, raising concerns about whether they would generalize well to all patients presenting for assessment. The Skeletal Oncology Research Group machine-learning algorithm (SORG-MLA), trained with institution-based data of surgically treated patients, and the Metastases location, Elderly, Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy model (METSSS), trained with registry-based data of patients treated with radiotherapy alone, are two of the most recently developed survival prediction models, but they have not been tested on patients whose local treatment strategy is not yet decided. (1) Which of these two survival prediction models performed better in a mixed cohort made up both of patients who received local treatment with surgery followed by radiotherapy and who had radiation alone for symptomatic bone metastases? (2) Which model performed better among patients whose local treatment consisted of only palliative radiotherapy? (3) Are laboratory values used by SORG-MLA, which are not included in METSSS, independently associated with survival after controlling for predictions made by METSSS? Between 2010 and 2018, we provided local treatment for 2113 adult patients with skeletal metastases in the extremities at an urban tertiary referral academic medical center using one of two strategies: (1) surgery followed by postoperative radiotherapy or (2) palliative radiotherapy alone. Every patient's survivorship status was ascertained either by their medical records or the national death registry from the Taiwanese National Health Insurance Administration. After applying a priori designated exclusion criteria, 91% (1920) were analyzed here. Among them, 48% (920) of the patients were female, and the median (IQR) age was 62 years (53 to 70 years). Lung was the most common primary tumor site (41% [782]), and 59% (1128) of patients had other skeletal metastases in addition to the treated lesion(s). In general, the indications for surgery were the presence of a complete pathologic fracture or an impending pathologic fracture, defined as having a Mirels score of ≥ 9, in patients with an American Society of Anesthesiologists (ASA) classification of less than or equal to IV and who were considered fit for surgery. The indications for radiotherapy were relief of pain, local tumor control, prevention of skeletal-related events, and any combination of the above. In all, 84% (1610) of the patients received palliative radiotherapy alone as local treatment for the target lesion(s), and 16% (310) underwent surgery followed by postoperative radiotherapy. Neither METSSS nor SORG-MLA was used at the point of care to aid clinical decision-making during the treatment period. Survival was retrospectively estimated by these two models to test their potential for providing survival probabilities. We first compared SORG to METSSS in the entire population. Then, we repeated the comparison in patients who received local treatment with palliative radiation alone. We assessed model performance by area under the receiver operating characteristic curve (AUROC), calibration analysis, Brier score, and decision curve analysis (DCA). The AUROC measures discrimination, which is the ability to distinguish patients with the event of interest (such as death at a particular time point) from those without. AUROC typically ranges from 0.5 to 1.0, with 0.5 indicating random guessing and 1.0 a perfect prediction, and in general, an AUROC of ≥ 0.7 indicates adequate discrimination for clinical use. Calibration refers to the agreement between the predicted outcomes (in this case, survival probabilities) and the actual outcomes, with a perfect calibration curve having an intercept of 0 and a slope of 1. A positive intercept indicates that the actual survival is generally underestimated by the prediction model, and a negative intercept suggests the opposite (overestimation). When comparing models, an intercept closer to 0 typically indicates better calibration. Calibration can also be summarized as log(O:E), the logarithm scale of the ratio of observed (O) to expected (E) survivors. A log(O:E) > 0 signals an underestimation (the observed survival is greater than the predicted survival); and a log(O:E) < 0 indicates the opposite (the observed survival is lower than the predicted survival). A model with a log(O:E) closer to 0 is generally considered better calibrated. The Brier score is the mean squared difference between the model predictions and the observed outcomes, and it ranges from 0 (best prediction) to 1 (worst prediction). The Brier score captures both discrimination and calibration, and it is considered a measure of overall model performance. In Brier score analysis, the "null model" assigns a predicted probability equal to the prevalence of the outcome and represents a model that adds no new information. A prediction model should achieve a Brier score at least lower than the null-model Brier score to be considered as useful. The DCA was developed as a method to determine whether using a model to inform treatment decisions would do more good than harm. It plots the net benefit of making decisions based on the model's predictions across all possible risk thresholds (or cost-to-benefit ratios) in relation to the two default strategies of treating all or no patients. The care provider can decide on an acceptable risk threshold for the proposed treatment in an individual and assess the corresponding net benefit to determine whether consulting with the model is superior to adopting the default strategies. Finally, we examined whether laboratory data, which were not included in the METSSS model, would have been independently associated with survival after controlling for the METSSS model's predictions by using the multivariable logistic and Cox proportional hazards regression analyses. Between the two models, only SORG-MLA achieved adequate discrimination (an AUROC of > 0.7) in the entire cohort (of patients treated operatively or with radiation alone) and in the subgroup of patients treated with palliative radiotherapy alone. SORG-MLA outperformed METSSS by a wide margin on discrimination, calibration, and Brier score analyses in not only the entire cohort but also the subgroup of patients whose local treatment consisted of radiotherapy alone. In both the entire cohort and the subgroup, DCA demonstrated that SORG-MLA provided more net benefit compared with the two default strategies (of treating all or no patients) and compared with METSSS when risk thresholds ranged from 0.2 to 0.9 at both 90 days and 1 year, indicating that using SORG-MLA as a decision-making aid was beneficial when a patient's individualized risk threshold for opting for treatment was 0.2 to 0.9. Higher albumin, lower alkaline phosphatase, lower calcium, higher hemoglobin, lower international normalized ratio, higher lymphocytes, lower neutrophils, lower neutrophil-to-lymphocyte ratio, lower platelet-to-lymphocyte ratio, higher sodium, and lower white blood cells were independently associated with better 1-year and overall survival after adjusting for the predictions made by METSSS. Based on these discoveries, clinicians might choose to consult SORG-MLA instead of METSSS for survival estimation in patients with long-bone metastases presenting for evaluation of local treatment. Basing a treatment decision on the predictions of SORG-MLA could be beneficial when a patient's individualized risk threshold for opting to undergo a particular treatment strategy ranged from 0.2 to 0.9. Future studies might investigate relevant laboratory items when constructing or refining a survival estimation model because these data demonstrated prognostic value independent of the predictions of the METSSS model, and future studies might also seek to keep these models up to date using data from diverse, contemporary patients undergoing both modern operative and nonoperative treatments. Level III, diagnostic study.

Lee CC ，Chen CW ，Yen HK ，Lin YP ，Lai CY ，Wang JL ，Groot OQ ，Janssen SJ ，Schwab JH ，Hsu FM ，Lin WH ... -  《-》

The impact of the implementation of medication for opioid use disorder and COVID-19 in a statewide correctional system on treatment engagement, postrelease continuation of care, and overdose.

People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for overdose after release. Medications for OUD (MOUD) are highly efficacious but not available to most incarcerated individuals. In 2018, Vermont began providing MOUD for all incarcerated individuals with OUD statewide. In 2020, the COVID-19 state of emergency began. We assessed the impact of both events on MOUD utilization and treatment outcomes. Analyses linked Vermont Department of Corrections administrative data and Medicaid claims data between 07/01/2017 and 03/31/2021. The study used logistic regression to analyze treatment engagement among all incarcerated individuals in Vermont. Multilevel modeling assessed change in clinical outcomes among release episodes that occurred among individuals with an OUD diagnosis Medicaid claim. Prescriptions for MOUD while incarcerated increased from 0.8% to 33.9% of the incarcerated population after MOUD implementation (OR = 67.4) and subsequently decreased with the onset of COVID-19 to 26.6% (OR = 0.7). After MOUD implementation, most prescriptions (63.1%) were to individuals who had not been receiving MOUD prior to incarceration, but this figure decreased to 53.9% with the onset of COVID-19 (OR = 0.7). Prescriptions for MOUD within 30 days after release increased from 33.9% of those with OUD before to 41.0% after MOUD implementation (OR = 1.4) but decreased to 35.6% with the onset of COVID-19 (OR = 0.8). Simultaneously, opioid-related nonfatal overdoses within 30 days after release decreased from 1.2% before to 0.8% after statewide MOUD implementation (OR = 0.3) but increased to 1.9% during COVID-19 (OR = 3.4). Fatal overdoses within 1 year after release decreased from 27 deaths before to ≤10 after statewide MOUD implementation and remained ≤10 during COVID-19. This longitudinal evaluation demonstrated increased treatment engagement and a decrease in opioid-related overdose following implementation of MOUD in a statewide correctional system. In contrast, these improvements were somewhat attenuated with the onset of COVID-19, which was associated with decreased treatment engagement and an increase in nonfatal overdoses. Considered together, these findings demonstrate the benefits of statewide MOUD for incarcerated individuals as well as the need to identify and address barriers to continuation of care following release from incarceration in the context of COVID-19.

Klemperer EM ，Wreschnig L ，Crocker A ，King-Mohr J ，Ramniceanu A ，Brooklyn JR ，Peck KR ，Rawson RA ，Evans EA ... -  《-》

Exemplar Hospital Initiation Trial to Enhance Treatment Engagement (EXHIT ENTRE): protocol for CTN-0098 an open-label randomized comparative effectiveness trial of extended-release buprenorphine versus treatment as usual on post-hospital treatment engagem

Hospitalizations involving opioid use disorder (OUD) are increasing. Addiction consultation services (ACS) initiate medications for opioid use disorder (MOUD) in hospital settings and arrange post-hospital follow-up for ongoing MOUD care. Engagement in MOUD following hospital discharge is hampered by challenges in timely access to MOUD. This protocol describes an open-label randomized comparative effectiveness trial comparing ACS treatment as usual (TAU) to a single injection of a 28-day formulation extended-release buprenorphine (XR-BUP) on MOUD engagement 34-days following hospital discharge. Six U.S. hospitals with ACS capable of prescribing all MOUD (i.e., methadone, buprenorphine, and extended-release naltrexone) recruit and randomize hospitalized patients with OUD who have not been on MOUD in the fourteen days prior to hospitalization. TAU may consist of any MOUD other than XR-BUP. Participants randomized to XR-BUP may receive any MOUD throughout their hospital stay and receive a 28-day XR-BUP injection within 72-hours of anticipated hospital discharge. There is no intervention beyond hospital stay. Participants are followed 34-, 90-, and 180-days following hospital discharge. The primary outcome is engagement in any MOUD 34-days following hospital discharge, which we hypothesize will be greater in the XR-BUP group. Randomizing 342 participants (171 per arm) provides 90% power to detect difference in the primary outcome between groups with an odds ratio of 2.1. Safety, secondary, and exploratory outcomes include: adverse events, MOUD engagement on days 90 and 180, opioid positive urine drug tests, self-reported drug use, hospital readmissions and emergency department visits, use of non-opioid drugs, fatal and non-fatal opioid overdose, all-cause mortality, quality of life, and cost-effectiveness. Data are analyzed by intention-to-treat, with pre-planned per-protocol and other secondary analyses that examine gender as an effect modifier, differences between groups, and impact of missingness. Engagement in MOUD care following hospitalization in individuals with OUD is low. This randomized comparative effectiveness trial can inform hospital ACS in medication selection to improve MOUD engagement 34-days following hospital discharge. NCT04345718.

Bart G ，Barth KS ，Baukol P ，Enns E ，Ghitza UE ，Harris J ，Jelstrom E ，Liebschutz JM ，Magane KM ，Voronca D ，Weinstein ZM ，Korthuis PT ... -  《-》