Publications by authors named "Rachel M Ancona"

15 Publications

  • Page 1 of 1

Missed HIV diagnoses when screening only emergency department patients who have blood samples obtained for other clinical purposes.

Am J Emerg Med 2021 Jul 21;50:102-105. Epub 2021 Jul 21.

Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA. Electronic address:

Objective: Emergency departments (EDs) are highly valued settings for HIV screening. Most large-volume ED HIV screening programs have attenuated operational barriers by screening only ED patients who already have a blood sample available for other clinical reasons. Our objective was to estimate the proportion of HIV positive patients who are missed when an ED excludes patients for whom HIV screening would be the only indication to obtain a blood sample.

Methods: This cross-sectional analysis used existing electronic records of patients seen between 2017 and 2019 by an urban, academic ED and its HIV screening program, which includes patients regardless of whether they receive other ED blood testing. The primary outcome was the proportion of patients tested by the screening program who were newly diagnosed with HIV (Sample 1) for whom HIV screening would be the only indication for venipuncture. We secondarily 1) estimate the proportion of ED patients who received venipuncture using a representative sample of consecutively approached participants which prospectively recorded whether patients had blood obtained or intravenous catheter placement during usual ED care (Sample 2) and 2) report patient characteristics including HIV risk factors for those with and without ED venipuncture for both groups.

Results: Of 41 persons newly diagnosed with HIV by the ED screening program (Sample 1), 13 (31.7%, 95%CI 18.6-48.2) did not undergo venipuncture for any reason other than their HIV test. The proportion of ED visits without a venipuncture (Sample 2) was 44.2% (95% CI 41.9-46.6). Patient characteristics were similar for both groups.

Conclusions: Screening only those patients with a blood sample already available or easily obtainable due to usual ED care, misses many opportunities for earlier HIV diagnosis. Innovation in research, policy, and practice is needed to overcome still unaddressed barriers to ED HIV screening when HIV screening is the only indication for collection of a biological sample.
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http://dx.doi.org/10.1016/j.ajem.2021.07.031DOI Listing
July 2021

Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial.

JAMA Netw Open 2021 Jul 1;4(7):e2117763. Epub 2021 Jul 1.

Denver Public Health, Denver, Colorado.

Importance: The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown.

Objective: To compare strategies for HIV screening when integrated into usual ED practice.

Design, Setting, And Participants: This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021.

Interventions: Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays.

Main Outcomes And Measures: New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs).

Results: A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47).

Conclusions And Relevance: Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses.

Trial Registration: ClinicalTrials.gov Identifier: NCT01781949.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.17763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314142PMC
July 2021

Incidence of opioid use disorder in the year after discharge from an emergency department encounter.

J Am Coll Emerg Physicians Open 2021 Jun 22;2(3):e12476. Epub 2021 Jun 22.

University of Cincinnati College of Medicine Department of Emergency Medicine Cincinnati Ohio USA.

Objective: Therapeutic opioid exposure is associated with long-term use. How much later use is due to opioid use disorder (OUD) and the incidence of OUD without preceding therapeutic exposure are unknown. We preliminarily explored the association between emergency department opioid prescriptions and subsequent OUD.

Methods: This retrospective cohort study queried electronic health records for discharged adult patients in the year before (2014) and after (2016) their first encounter in 2015 at either of 2 EDs in a Midwestern healthcare system. OUD was defined by diagnosis codes and prescription history. Patients with OUD history before the index encounter were excluded. We report OUD incidence within 1 year, with time to first indicator of OUD among those with a repeat health system encounter post index using a Cox proportional hazards model. Secondary outcomes were sources of therapeutic opioid exposure and frequency of risk factors associated with OUD among those who developed OUD.

Results: Of the 49,904 unique, adult ED patients without history of OUD, 669 (1.3%; 95% CI, 1.2-1.4) had health records indicating OUD within 12 months. The proportion of ED patients with OUD at 12 months was 1.5% (95% CI, 1.2-1.9) if prescribed an opioid at index and 1.3% (95% CI, 1.2-1.4) if not. Of the 669 who developed OUD, 80 (12.0%) were prescribed an opioid at the index ED visit, 54 (8%) received an opioid prescription at a subsequent ED visit, and median time to OUD was 4.5 months (interquartile range 1.6-7.6, range 0.0-11.9). When controlling for demographics, mental health, and prior opioid prescriptions, there was no difference in OUD incidence between patients who did or did not receive an initial ED opioid prescription (HR, 1.1; 95% CI, 0.9-1.4).

Conclusions: A small but meaningful proportion of the ED population will develop OUD within 1 year even without ED opioid prescription. Though we found no association between ED opioid prescription and later OUD, further study is warranted given the complexity factors influencing OUD incidence, ongoing ED opioid exposure, and limitations inherent to this study design.
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http://dx.doi.org/10.1002/emp2.12476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219283PMC
June 2021

Cost awareness intervention for combat gauze utilization in an academic trauma center emergency department.

Am J Emerg Med 2021 May 14. Epub 2021 May 14.

Dept. of Emergency Medicine, Univ. of Cincinnati College of Medicine, Cincinnati, OH, United States. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2021.05.031DOI Listing
May 2021

HIV detection by an emergency department HIV screening program during a regional outbreak among people who inject drugs.

PLoS One 2021 18;16(5):e0251756. Epub 2021 May 18.

Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States of America.

Objective: Multiple HIV outbreaks among persons who inject drugs (PWID) have occurred in the US since 2015. Emergency departments (EDs), recognized as essential venues for HIV screening, may play a unique role in identifying undiagnosed HIV among PWID, who frequently present for complications of injection drug use (IDU). Our objective was to describe changes in HIV diagnoses among PWID detected by an ED HIV screening program and estimate the program's contribution to HIV diagnoses among PWID county-wide during the emergence of a regional HIV outbreak.

Methods: This was a retrospective study of electronically queried clinical records from an urban, safety-net ED's HIV screening program and publicly available HIV surveillance data for its surrounding county, Hamilton County, Ohio. Outcomes included the change in number of HIV diagnoses and the ED's contribution to case identification county-wide, overall and for PWID during 2014-2018.

Results: During 2014-2018, the annual number of HIV diagnoses made by the ED program increased from 20 to 42 overall, and from 1 to 18 for PWID. We estimated that the ED contributed 18% of HIV diagnoses in the county and 22% of diagnoses among PWID.

Conclusions: The ED program contributed 1 in 5 new HIV diagnoses among PWID county-wide, further illustrating the importance of ED HIV screening programs in identifying undiagnosed HIV infections. In areas experiencing increasing IDU, HIV screening in EDs can provide an early indication of increasing HIV diagnoses among PWID and can substantially contribute to case-finding during an HIV outbreak.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251756PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130938PMC
May 2021

Estimated proportion of an urban academic emergency department patient population eligible for HIV preexposure prophylaxis.

Am J Emerg Med 2021 May 4;48:198-202. Epub 2021 May 4.

University of Cincinnati, Department of Emergency Medicine, Cincinnati, OH, USA; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA. Electronic address:

Objective: Pre-exposure prophylaxis (PrEP) is a highly effective but underutilized method of HIV prevention. Emergency departments (EDs) have access to at-risk populations meeting CDC eligibility criteria for PrEP. Characterizing this population could help motivate, develop, and implement ED interventions to promote PrEP uptake.

Methods: This cross-sectional study explored the proportion of patients from an urban, academic ED who met CDC 2017 PrEP eligibility criteria using three existing datasets that mimic patient selection strategies for HIV screening: 1) study of consecutively approached ED patients from 2008 to 2009 (analogous to non-targeted screening), 2) patients of the ED's HIV screening program in 2017 (analogous to risk-targeted screening), and 3) electronic health record (EHR) diagnostic codes in 2017 (analogous to EHR selected screening). The primary outcome was the proportion eligible for PrEP referral. Secondary outcomes included proportion by risk group: men who have sex with men (MSM), heterosexual men and women (HMW), and persons who inject drugs (PWID).

Results: The proportion eligible for PrEP was: 568/1970 (28.8%, 95% CI: 26.9-30.9) for consecutively approached patients, 552/3884 (14%, 95% CI: 13-15) for risk-targeted patients, and 605/66287 (0.9%, 95% CI: 0.8-1.0) for EHR diagnoses of all patients. For the two datasets with behavioral risk information, the proportion eligible was: MSM 1-2%, HMW 12-28%, and PWID 1-4%.

Conclusions: A large subgroup of this ED population was eligible for PrEP referral. EDs are a compelling setting for development and implementation of HIV prevention interventions to assist in national efforts to expand PrEP.
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http://dx.doi.org/10.1016/j.ajem.2021.04.087DOI Listing
May 2021

Variation in Participation in Nurse-Driven Emergency Department Hepatitis C Screening.

Adv Emerg Nurs J 2021 Apr-Jun 01;43(2):138-144

Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio (Drs Lane, Lyons, and Punches and Ms Ancona); and University of Cincinnati College of Nursing, Cincinnati, Ohio (Punches).

Emergency departments (EDs) are an important potential site for public health screening programs, although implementation of such programs can be challenging. Potential barriers include system-level issues (e.g., funding and time pressures) and individual provider-level issues (e.g., awareness and acceptance). This cross-sectional evaluation of a nurse-driven, triage-based hepatitis C virus (HCV) screening program in an urban, academic ED assessed variation in nurse participation from April to November 2017. For this program, electronic health record (EHR) prompts for HCV screening were integrated into nurses' triage workflow. Process measures evaluating HCV screening participation were abstracted from the EHR for all ED encounters with patient year of birth between 1945 and 1965. Registered nurses who routinely worked in triage and were full-time employees throughout the study period were included for analysis. The primary outcome was the proportion of eligible ED encounters with completed HCV screening, by nurse. Of 14,375 ED encounters, 3,375 (23.5%, 95% confidence interval [CI]: 22.8, 24.2) had completed HCV screening and 1,408 (9.8%, 95% CI: 3.9, 10.3) had HCV screening EHR sections opened by the triage nurse but closed without action; the remainder of encounters had no activity in HCV screening EHR sections. Among the 93 eligible nurses, 22 nurses (24%, 95% CI: 16, 34) completed HCV screening for more than 70% of encounters, whereas 10 nurses (11%, 95% CI: 6, 19) never completed HCV screening. The proportion of eligible encounters with completed HCV screening was 11.0% higher (95% CI: 9.8, 12.6) for encounters seen between 7 a.m. and 7 p.m. than between 7 p.m. and 7 a.m. (27.5% and 16.3%, respectively). In conclusion, wide variation in individual nurse participation in HCV screening suggests individual-level barriers are a more significant barrier to ED screening than previously recognized. Implementation research should expand beyond questions of resource availability and procedural streamlining to evaluate and address staff knowledge, beliefs, attitudes, and motivation.
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http://dx.doi.org/10.1097/TME.0000000000000349DOI Listing
September 2021

Naloxone provision to emergency department patients recognized as high-risk for opioid use disorder.

Am J Emerg Med 2021 02 11;40:173-176. Epub 2020 Nov 11.

Dept. of Emergency Medicine, Univ. of Cincinnati College of Medicine, Cincinnati, OH, United States of America. Electronic address:

Introduction: Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician.

Methods: This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone.

Results: Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1-33.8). Naloxone provision occurred for 33.6% (95% CI 30.5-36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0-19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4-30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011-0.33]) for naloxone provision compared to those only referred to outpatient treatment.

Conclusion: A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment "bundle" as a conceptual model for care of ED patients with suspected OUD.
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http://dx.doi.org/10.1016/j.ajem.2020.10.061DOI Listing
February 2021

Clarifying the volume of estimated need for public health and prevention services within an emergency department population.

J Am Coll Emerg Physicians Open 2020 Oct 23;1(5):845-851. Epub 2020 Jul 23.

Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati Ohio USA.

Objectives: Emergency departments (EDs) are called to implement public health and prevention initiatives, such as infectious disease screening. The perception that ED resources are insufficient is a primary barrier. Resource needs are generally conceptualized in terms of total number of ED encounters, without formal calculation of the number of encounters for which a service is required. We illustrate potential differences in the estimated volume of service need relative to ED census using the examples of HIV and hepatitis C (HCV) screening.

Methods: This cross-sectional analysis adjusted the proportion of ED encounters in which patients are eligible for HIV and HCV screening according to a cascade of successively more restrictive patient selection criteria, presuming full implementation of each criterion. Parameter estimates for the proportion satisfying each selection criterion were derived from the electronic health records of an urban academic facility and its ED HIV and HCV screening program during 2 time periods. The primary outcome was the estimated reduction in proportion of ED visits eligible for screening after application of the entire cascade.

Results: There were 76,104 ED encounters during the study period. Applying all selection criteria reduced the number of required screens by 97.1% (95% confidence interval, 97.0-97.2) for HIV and 86.1% (95% confidence interval, 85.9-86.3) for HCV.

Conclusions: Using the example of HIV and HCV screening, the application of eligibility metrics reduces the volume of service need to a smaller, more feasible number than estimates from ED census alone. This approach might be useful for clarifying perceived service need and guiding operational planning.
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http://dx.doi.org/10.1002/emp2.12168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593451PMC
October 2020

Evaluation of low-intensity initiatives to improve linkage to care for emergency department patients with opioid use disorder.

Am J Emerg Med 2020 11 7;38(11):2391-2394. Epub 2020 Sep 7.

Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA.

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http://dx.doi.org/10.1016/j.ajem.2020.09.007DOI Listing
November 2020

Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services.

Am J Emerg Med 2020 09 11;38(9):1831-1833. Epub 2020 May 11.

University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America. Electronic address:

Objectives: Routine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation.

Methods: Cross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017-July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care.

Results: There were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%-8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%-23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services.

Conclusions: Patients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.
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http://dx.doi.org/10.1016/j.ajem.2020.05.020DOI Listing
September 2020

The Know∗Now Project: Facilitated Serosorting in HIV-Status Sexual Partner Communication.

AIDS Educ Prev 2017 10;29(5):432-442

Department of Emergency Medicine, University of Cincinnati.

An intervention was conducted providing access to clinic-verified HIV test results via a secure, web-based informatics platform to facilitate sexual partner HIV-status communication. Participants (N = 28) were men who have sex with men (MSM; HIV- n = 8, HIV+ n = 8) and heterosexuals (Non-MSM, n = 12). Focus groups with same-group members explored interest in using the intervention and baseline attitudes and practices relevant to serosorting. HIV-negative participants overwhelmingly expressed interest, regardless of MSM status. Interest among HIV-positive MSM was mixed. Six month follow-up interviews (n = 16) indicated 94% of all groups accessed the website, 69% had shown documented results to a sexual partner to initiate HIV-status discussion, and 88% reported future interest in using the 24/7 web-based tool with prospective sexual partners. Implications for future interventions facilitating HIV serosorting and sexual partner communication are discussed.
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http://dx.doi.org/10.1521/aeap.2017.29.5.432DOI Listing
October 2017

Pilot Integration of HIV Screening and Healthcare Settings with Multi- Component Social Network and Partner Testing for HIV Detection.

Curr HIV Res 2017 Nov;15(5):372-381

Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.

Background: Healthcare settings screen broadly for HIV. Public health settings use social network and partner testing ("Transmission Network Targeting (TNT)") to select high-risk individuals based on their contacts. HIV screening and TNT systems are not integrated, and healthcare settings have not implemented TNT.

Objective: The study aimed to evaluate pilot implementation of multi-component, multi-venue TNT in conjunction with HIV screening by a healthcare setting.

Methods: Our urban, academic health center implemented a TNT program in collaboration with the local health department for five months during 2011. High-risk or HIV positive patients of the infectious diseases clinic and emergency department HIV screening program were recruited to access social and partner networks via compensated peer-referral, testing of companions present with them, and partner notification services. Contacts became the next-generation index cases in a snowball recruitment strategy.

Results: The pilot TNT program yielded 485 HIV tests for 482 individuals through eight generations of recruitment with five (1.0%; 95% CI = 0.4%, 2.3%) new diagnoses. Of these, 246 (51.0%; 95% CI = 46.6%, 55.5%) reported that they had not been tested for HIV within the last 12 months and 383 (79.5%; 95% CI = 75.7%, 82.9%) had not been tested by the existing ED screening program within the last five years.

Conclusion: TNT complements population screening by more directly targeting high-risk individuals and by expanding the population receiving testing. Information from existing healthcare services could be used to seed TNT programs, or TNT could be implemented within healthcare settings. Research evaluating multi-component, multi-venue HIV detection is necessary to maximize complementary approaches while minimizing redundancy.
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http://dx.doi.org/10.2174/1570162X15666171017121301DOI Listing
November 2017

Lessons Learned From the Development and Parameterization of a Computer Simulation Model to Evaluate Task Modification for Health Care Providers.

Acad Emerg Med 2018 02 11;25(2):238-249. Epub 2017 Nov 11.

Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH.

Computer simulation is a highly advantageous method for understanding and improving health care operations with a wide variety of possible applications. Most computer simulation studies in emergency medicine have sought to improve allocation of resources to meet demand or to assess the impact of hospital and other system policies on emergency department (ED) throughput. These models have enabled essential discoveries that can be used to improve the general structure and functioning of EDs. Theoretically, computer simulation could also be used to examine the impact of adding or modifying specific provider tasks. Doing so involves a number of unique considerations, particularly in the complex environment of acute care settings. In this paper, we describe conceptual advances and lessons learned during the design, parameterization, and validation of a computer simulation model constructed to evaluate changes in ED provider activity. We illustrate these concepts using examples from a study focused on the operational effects of HIV screening implementation in the ED. Presentation of our experience should emphasize the potential for application of computer simulation to study changes in health care provider activity and facilitate the progress of future investigators in this field.
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http://dx.doi.org/10.1111/acem.13314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880547PMC
February 2018

Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction.

Ann Emerg Med 2016 08 11;68(2):202-8. Epub 2016 Feb 11.

Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH. Electronic address:

Study Objective: Opioid abuse and overdose constitute an ongoing health emergency. Many presume opioids have little potential for iatrogenic addiction when used as directed, particularly in short courses, as is typical of the emergency department (ED) setting. We preliminarily explore the possibility that initial exposure to opioids by EDs could be related to subsequent opioid misuse.

Methods: This cross-sectional study surveyed a convenience sample of patients reporting heroin or nonmedical opioid use at an urban, academic ED. We estimated the proportion whose initial exposure to opioids was a legitimate medical prescription and the proportion of those prescriptions that came from an ED. Secondary measurements included the proportion of patients receiving nonopioid substances before initial opioid exposure, the source of opioids between initial exposure and onset of regular nonmedical use, and time from initial prescription to opioid use disorder.

Results: Of 59 subjects, 35 (59%; 95% confidence interval [CI] 47% to 71%) reported they were first exposed to opioids by a legitimate medical prescription, and for 10 of 35 (29%; 95% CI 16% to 45%), the prescription came from an ED. Most medically exposed subjects (28/35; 80%; 95% CI 65% to 91%) reported nonopioid substance use or treatment for nonopioid substance use disorders preceding the initial opioid exposure. Emergency providers were a source of opioids between exposure and onset of regular nonmedical use in 11 of 35 cases (31%; 95% CI 18% to 48%). Thirty-one of the 35 medically exposed subjects reported the time of onset of nonmedical use; median time from exposure to onset of nonmedical use was 6 months for use to get high (N=25; interquartile range [IQR] 2 to 36), 12 months for regular use to get high (N=24; IQR 2 to 36), 18 months for use to avoid withdrawal (N=26; IQR 2 to 38), and 24 months for regular use to avoid withdrawal (N=27; IQR 2 to 48). Eleven subjects (36%; 95% CI 21% to 53%) began nonmedical use within 2 months, and 9 of 11 (82%; 95% CI 53% to 96%) reported nonopioid substance use or treatment for alcohol abuse before initial opioid exposure.

Conclusion: Although short-term opioid administration by emergency providers is unlikely to cause addiction by itself, ED opioid prescriptions may contribute to the development of addiction in some patients. There is an urgent need for further research to estimate long-term risks of short-course opioid therapy so that the risk of iatrogenic addiction can be appropriately balanced with the benefit of analgesia.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958587PMC
http://dx.doi.org/10.1016/j.annemergmed.2015.11.033DOI Listing
August 2016
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