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Objectives To describe medical staff attitudes and perceived behaviors toward medication-assisted treatment (MAT) in a federally qualified health center (FQHC). The secondary objective was to identify the staff’s perceptions of using pharmacists during MAT. Design A cross-sectional, descriptive study using a 26-item Web-based survey was developed using the theory of planned behavior (TPB) and consisted of Likert scale and multiple-select options. Setting and participants Medical staff located at an FQHC in northwest Indiana were eligible to participate if they were 18 years or older. Corporate and administrative staff were not eligible to participate. Outcome measures Perceptions were measured using the 4 constructs of the TPB: attitude, perceived behavioral control, subjective norm, and intent. The data were analyzed using descriptive statistics. Results Of the 240 eligible respondents, 104 employees completed the survey, yielding a 43.3% response rate. The providers generally believed they had the knowledge (83.9% agree or strongly agree) to diagnose patients with opioid use disorder (OUD). From the perceived behavioral control construct, staff were confident of their ability to identify patients for MAT (65.2%); however, most believed they needed additional training on MAT (75%) from the attitude construct. From the subjective norm construct, more than half of the respondents believed that their employer wanted them to be involved in the treatment of a patient with OUD (60.7%). Commonly, from the intent construct, the staff favored adding pharmacists to the care team when managing patients with MAT (57.7%). Conclusion The staff expressed the need for additional training to provide MAT services and believed this would enable them to become an important part of the MAT team. Adding a trained pharmacist to the care team when managing patients with MAT was favored by the staff. The study showed that health professionals would be more comfortable if a pharmacist were available for MAT consultation.

Objectives The objective was to assess the impact of a pharmacist embedded within a primary care practice on quality measures of the Merit-Based Incentive Payment System (MIPS) and patient-centered medical home (PCMH) by characterizing (1) measure achievement after pharmacist involvement in care and (2) measure achievement separately for patients seen by the pharmacist and patients not seen by the pharmacist. Setting Multidisciplinary primary care practice in Charlotte, North Carolina. Practice description Pharmacists from an independent community pharmacy are highly integrated into the clinic. Pharmacists work alongside providers to furnish comprehensive care with a team-based approach. The initial focus for the pharmacist was on the Medicare annual wellness visits (AWV) and chronic care management (CCM). Practice innovation Quality measure achievement during face-to-face AWV, telephone-call CCM, or both. Evaluation From January 1, 2017, to February 2, 2018, 193 patients had an AWV, CCM, or both from the pharmacist. Measure achievement was characterized with the use of descriptive statistics. Results When characterizing quality measures before, during, and after pharmacist intervention for the clinic population, achievement of some measures improved and others worsened. However, for every measure evaluated, the cohort of patients seen by the pharmacist had a greater proportion of patients achieving the quality measure than the cohort of patients not seen by the pharmacist. The greatest differences were observed for influenza vaccination (41% of pharmacist cohort vs. 10% of nonpharmacist cohort), hemoglobin A1C control less than 9% (94% of pharmacist cohort vs. 67% of nonpharmacist cohort), and colorectal cancer screening (55% of pharmacist cohort vs. 28% of nonpharmacist cohort). Conclusion Pharmacist provision of clinical services may increase the likelihood of quality measure achievement. The pharmacist integration model addressed gaps in care that appeared to positively affect MIPS and PCMH quality measures. This has the potential to increase reimbursement through value-based payment models.

Introduction The NICE guideline for referral to specialist services with suspected colorectal cancer (CRC) was last updated in June 2015, with expansion of the criteria. This study aimed to compare referral patterns and clinical practice, in terms of the investigations performed, over two years before (01/06/2013–31/05/2015) and after (01/06/2015–31/05/2017) introduction of the updated guideline. Methods A retrospective study of all patients referred to our unit with a suspected CRC in the two years before and two years after introduction of the updated guideline compared referral rates, the number of colorectal and non-colorectal (non-CRC) cancers, the TNM stage of CRC and the investigations performed. Results The total number of referrals increased from 6075 to 7951, with the rate of CRC decreasing from 5.14% to 5.01% (p=0.08). The number of non-CRCs increased from 1.17% to 1.61% (p=0.02). There was no significant difference in the TNM stage of CRC (figure 1). The use of flexible sigmoidoscopy (17.01% vs. 28.52%, p=0.002) and CTC (9.54% vs. 17.78%, p=0.007) increased and the use of colonoscopy decreased (81.33% vs. 67.78%, p=0.0006). The use of CT (91.29% vs 92.59%) and MRI scanning was not significantly different between groups (figure 2). Conclusions CTC was more common in the later cohort, likely related to increasing availability of this imaging modality. This may also explain the increase in flexible sigmoidoscopy, as left sided lesions on CTC require flexible sigmoidoscopy only, rather than full colonoscopy. Expansion of the referral criteria has not significantly impacted on the number of new CRCs, but has increased the number of non-CRCs. In those presenting with symptoms such as anaemia, abdominal pain and weight loss, with an absence of specific lower gastrointestinal symptoms, CT would be a more appropriate initial investigation than luminal investigations. This will aid in the diagnosis of other significant pathologies, including the many non-CRCs detected via this referral pathway, whilst minimising exposure to invasive luminal investigations with their associated morbidity.

The right to be treated humanely when detained is universally recognized. Deficiencies in detention conditions and violence however subvert this right. When this occurs proper medico legal investigations are critical irrespective of the nature of death. Unfortunately the very context of custody raises serious concerns over the effectiveness and fairness of medico legal examinations. The aim of this manuscript is to identify and discuss the practical and ethical difficulties encountered in the medico legal investigation following deaths in custody. Data for this manuscript come from a larger project on Death in Custody that examined the causes of deaths in custody and the conditions under which these deaths should be investigated and prevented. A total of 33 stakeholders from forensic medicine law prison administration or national human rights administration were interviewed. Data obtained were analyzed qualitatively. Forensic experts are an essential part of the criminal justice process as they offer evidence for subsequent indictment and eventual punishment of perpetrators. Their independence when investigating a death in custody was deemed critical and lack thereof problematic. When experts were not independent concerns arose in relation to conflicts of interest biased perspectives and low quality forensic reports. The solutions to ensure independent forensic investigations of deaths in custody must be structural and simple: setting binding standards of practice rather than detailed procedures and relying on preexisting national practices as opposed to encouraging new practices that are unattainable for countries with limited resources. © 2014 Elsevier Ltd. All rights reserved.

Prisoners sometimes die in prison either due to natural illness violence suicide or a result of imprisonment. The purpose of this study is to understand deaths in custody using qualitative methodology and to argue for a comprehensive definition of death in custody that acknowledges deaths related to the prison environment. Interviews were conducted with 33 experts who primarily work as lawyers or forensic doctors with national and/or international organisations. Responses were coded and analysed qualitatively. Defining deaths in custody according to the place of death was deemed problematic. Experts favoured a dynamic approach emphasising the link between the detention environment and occurrence of death rather than the actual place of death. Causes of deaths and different patterns of deaths were discussed indicating that many of these deaths are preventable. Lack of an internationally recognised standard definition of death in custody is a major concern. Key aspects such as place time and causes of death as well as relation to the prison environment should be debated and incorporated into the definition. Systematic identification of violence within prison institutions is critical and efforts are needed to prevent unnecessary deaths in prison and to protect vulnerable prisoners. © 2014 Springer Science+Business Media Dordrecht.