Abstract Background: Rising rates of substance use, particularly the use of synthetic opioids, have led to increases in fatal overdoses and injection-associated infections. Harm reduction, including infection prevention via provision of educational interventions and sterile syringes and other supplies, is an approach to minimize risk of severe outcomes. Although harm reduction services (HRS) are highly evidence-based, implementation in most healthcare settings has been limited. The aim of this study was to identify facilitators and barriers to the implementation of HRS to inform strategies for increasing access and facilitating the adoption of a comprehensive bundle of harm reduction resources within the VHA. Methods: Qualitative interviews were conducted using a semi-structured interview guide. Interviews explored how harm reduction is currently understood and implemented by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis. After barriers and facilitators were identified, they were mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR – ERIC) tool. Results: 15 interviews with VHA providers (physicians, social workers, pharmacists, and directors of addiction and mental health services) were conducted across 5 sites. Multiple barriers and few facilitators to the provision of HRS were identified. Existing HRS were thought to be fragmented and dependent on the knowledge, time, and comfort level of individual providers. Participants also highlighted stigma around substance use, limited support, and burdensome regulatory requirements. Existing infrastructure, social programming, and local champions were highlighted as facilitators. Given these factors, implementation strategies that may be bundled to promote adoption of HRS include engagement of champions, communications and educational strategies, existing policies, and creation of dashboards, tracking, and feedback systems. Conclusions: HRS are effective and evidence-based, yet their adoption into traditional healthcare settings has been limited. Mapping of barriers to evidence-based implementation strategies may help improve integration of HRS into VHA healthcare, however, challenges addressing stigma remain a substantial barrier. More research is needed to identify implementation strategies that are most effective for addressing barriers imposed by stigma.
Resurgences of COVID-19 cases are a grave public health concern. Hence, there is an urgent need for health care systems to rapidly and systematically learn from their responses to earlier waves of COVID-19. To meet this need, this article delineates how we adapted the World Health Organization's After Action Review (AAR) framework to use within our health care system of the United States Department of Veterans Affairs. An AAR is a structured, methodical evaluation of actions taken in response to an event (e.g., recent waves of COVID-19). It delivers an actionable report regarding (i) what was expected, (ii) what actually happened, (iii) what went well, and (iv) what could have been done differently, and thus what changes are needed for future situations. We share as an example our examination of Mental Health Residential Rehabilitation and Treatment Programs in Massachusetts (a COVID-19 hotspot). Our work can be further adapted, beyond residential treatment, as a consistent framework for reviewing COVID-19 responses across multiple health care programs. This will identify both standardized and tailored preparations that the programs can make for future waves of the pandemic. Given the expected resurgences of COVID-19 cases, the time to apply AAR is now.
Abstract Background Harm reduction strategies can decrease morbidity and mortality associated with substance use. Various barriers limit conversation around substance use between clinicians and patients. Graphic medicine techniques can inform and encourage patient-centered conversations about substance use. We describe the co-development of a harm reduction-focused graphic medicine comic that depicts the infectious risks associated with injection drug use and patient-centered approaches to providing education about potential risk mitigation strategies. Methods We formed a co-design group of veterans with lived experience with substance use, physicians, health services researchers, and community-based harm reduction leaders. Over the course of ten sessions, the co-design team developed a storyline and key messages, reviewed draft content and worked with a graphic designer to develop a comic incorporating the veterans’ input. During each session, co-design leads presented drafts of the comic and invited feedback from the group. The comic was edited and adapted via this iterative process. Results The comic depicts a fictionalized clinical vignette in which a patient develops an injection-related abscess and presents to their primary care provider. The dialogue highlights key healthcare principles, including patient autonomy and agency, and highlights strategies for safer use, rather than emphasizing abstinence. Feedback from co-design group participants highlights lessons learned during the development process. Discussion Graphic medicine is ideally suited for a patient-centered curriculum about harm reduction. This project is one of several interventions that will be integrated into VA facilities nationally to support incorporation of harm reduction principles into the care of persons who inject drugs.
Abstract Background Rising rates of substance use, particularly synthetic opioids, have led to increases in fatal overdoses and injection-associated infections. Harm reduction, including infection prevention via provision of supplies and education, is an approach to minimize risk of severe outcomes. Although harm reduction services (HRS) are highly evidence-based, implementation in most healthcare settings is limited. The aim of this study was to identify facilitators and barriers to the implementation of HRS to inform strategies for increasing access and adoption of a comprehensive bundle of harm reduction resources within the VHA. Methods Qualitative interviews were conducted using a semi-structured interview guide and explored how harm reduction is currently understood and implemented by VHA providers and was designed to identify perceived gaps and barriers. Data were analyzed using a directed content analysis. After barriers and facilitators were identified, they were mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR – ERIC) tool. Results 15 interviews with VHA providers (physicians, social workers, pharmacists, and directors of addiction and mental health services) were conducted across 5 sites. Multiple barriers and few facilitators to the provision of HRS were identified (Table 1). Currently, HRS were thought to be fragmented and dependent on the knowledge, time, and comfort level of individual providers. Participants also highlighted stigma around substance use, limited support, and burdensome regulatory requirements. Existing infrastructure, social programming, and local champions were highlighted as facilitators. Given these factors, implementation strategies that may be bundled to promote adoption of HRS include engagement of champions, communications and educational strategies, existing policies, and creation of dashboards and tracking and feedback systems (Table 1). Conclusion HRS are effective, evidence-based, and patient-centered tools. Mapping of barriers to evidence-based implementation strategies may help improve integration of HRS into VHA healthcare, however, challenges addressing stigma remain a substantial barrier. Disclosures Westyn Branch-Elliman, MD, MMSc, DLA Piper,LLC/Medtronic: Advisor/Consultant|Gilead Pharmaceuticals: Grant/Research Support.
ABSTRACT: Objective: Although shared decision-making (SDM) can improve patient engagement, adherence, and outcomes, evidence on the use of SDM within the context of autism spectrum disorder (ASD) initial diagnosis and treatment planning remains limited. The goal of this study was to objectively assess the occurrence of SDM in these visits and to compare this assessment with parent and provider perceptions of SDM in the same encounter. Methods: After audio-recording and transcribing initial clinical visits between parents (n = 22) and developmental behavioral pediatricians (n = 6) discussing the diagnosis of ASD and treatment options, we used the OPTION 5 Item scale to assess the occurrence of SDM. Afterward, parents and providers completed the OPTION 5 Item , and parents also participated in a semistructured qualitative interview. Analysis consisted of descriptive statistics for OPTION 5 Item scores and a modified grounded theory framework for interviews. Results: Low levels of SDM were observed, with 41% of visits having no elements of SDM. On average, visits scored 1.1 of a possible 20 points on the OPTION 5 Item scale for SDM. By contrast, parents and providers indicated on the OPTION 5 Item scale that providers made a “moderate” to “skilled” effort to engage parents in SDM. Qualitative interviews with parents were consistent with their OPTION 5 Item ratings. Conclusion: The level of SDM determined by parent and provider reports was higher than the level of SDM determined by objective observation using a standard validated rating method. The findings reinforce the need for further research into barriers and facilitators of SDM methods and outcomes within ASD.
Healthcare must rapidly and systematically learn from earlier COVID-19 responses to prepare for future crises. This is critical for VA’s Mental Health Residential Rehabilitation and Treatment Programs (RRTPs), offering 24/7 care to Veterans for behavioral health and/or homelessness. We adapted the World Health Organization’s After Action Review (AAR) to conduct semi-structured small-group discussions with staff from two RRTPs and Veterans who received RRTP care during COVID-19, to examine COVID-19’s impact on these programs. Six thematic categories emerged through qualitative analysis (participant-checked and contextualized with additional input from program leadership), representing participants’ recommendations including: Keep RRTPs open (especially when alternative programs are inaccessible), convey reasons for COVID-19 precautions and programming changes to Veterans, separate recovery-oriented programming from COVID-19-related information-sharing, ensure Wi-Fi availability for telehealth and communication, provide technology training during orientation, and establish safe procedures for off-site appointments. AAR is easily applicable for organizations to debrief and learn from past experiences.
Lung cancer screening (LCS) has less benefit and greater potential for iatrogenic harm among people with multiple comorbidities and limited life expectancy. Yet, such individuals are more likely to undergo screening than healthier LCS-eligible people. We sought to understand how patients with marginal LCS benefit conceptualize their health and make decisions regarding LCS.
METHODS
We interviewed 40 people with multimorbidity and limited life expectancy, as determined by high Care Assessment Need scores, which predict 1-year risk of hospitalization or death. Patients were recruited from 6 Veterans Health Administration facilities after discussing LCS with their clinician. We conducted a thematic analysis using constant comparison to explore factors that influence LCS decision making.
RESULTS
Patients commonly held positive beliefs about screening and perceived LCS to be noninvasive. When posed with hypothetical scenarios of limited benefit, patients emphasized the nonlongevity benefits of LCS (eg, peace of mind, planning for the future) and generally did not consider their health status or life expectancy when making decisions regarding LCS. Most patients were unaware of possible additional evaluations or treatment of screen-detected findings, but when probed further, many expressed concerns about the potential need for multiple evaluations, referrals, or invasive procedures.
CONCLUSIONS
Patients in this study with multimorbidity and limited life expectancy were unaware of their greater risk of potential harm when accepting LCS. Given patient trust in clinician recommendations, it is important that clinicians engage patients with marginal LCS benefit in shared decision making, ensuring that their values of desiring more information about their health are weighed against potential harms from further evaluations.
