In 2016, over 65 million individuals were displaced from their homes due to human rights abuses, and 262,000 people applied for asylum in the USA. Individuals who have experienced persecution are present in many primary and specialty clinics. A medical forensic evaluation can increase the likelihood of a successful asylum case. This paper reviews the legal framework for asylum and the contribution forensic evaluations can make to this vulnerable population. Physicians without asylum expertise can help these patients by recognizing their legal right to residential protection and referring them to lawyers and physicians with expert skills. Performing forensic examinations of asylum seekers offers physicians the opportunity to collaborate with attorneys, immigration officials, and human rights experts. Clinicians who do this work find it personally and professionally rewarding, especially when they impart their expert knowledge and skills to future clinicians by involving trainees in these evaluations. Physicians who encounter refugees or asylum seekers in their roles as providers or as preceptors should have familiarity with the field of asylum medicine to enhance the comprehensive care they deliver.

BackgroundPotentially inappropriate prescribing (PIP) may contribute to opioid overdose.ObjectiveTo examine the association between PIP and adverse events.DesignCohort study.ParticipantsThree million seventy-eight thousand thirty-four individuals age =?18, without disseminated cancer, who received prescription opioids between 2011 and 2015.Main MeasuresWe defined PIP as (a) morphine equivalent dose =?100 mg/day in =?3 months; (b) overlapping opioid and benzodiazepine prescriptions in =?3 months; (c) =?4 opioid prescribers in any quarter; (d) =?4 opioid-dispensing pharmacies in any quarter; (e) cash purchase of prescription opioids on =?3 occasions; and (f) receipt of opioids in 3 consecutive months without a documented pain diagnosis. We used Cox proportional hazards models to identify PIP practices associated with non-fatal opioid overdose, fatal opioid overdose, and all-cause mortality, controlling for covariates.Key ResultsAll six types of PIP were associated with higher adjusted hazard for all-cause mortality, four of six with non-fatal overdose, and five of six with fatal overdose. Lacking a documented pain diagnosis was associated with non-fatal overdose (adjusted hazard ratio [AHR] 2.21, 95% confidence interval [CI] 2.02–2.41), as was high-dose opioids (AHR 1.68, 95% CI 1.59–1.76). Co-prescription of benzodiazepines was associated with fatal overdose (AHR 4.23, 95% CI 3.85–4.65). High-dose opioids were associated with all-cause mortality (AHR 2.18, 95% CI 2.14–2.23), as was lacking a documented pain diagnosis (AHR 2.05, 95% CI 2.01–2.09). Compared to those who received opioids without PIP, the hazard for fatal opioid overdose with one, two, three, and =?four PIP subtypes were 4.24, 7.05, 10.28, and 12.99 (test of linear trend, p?

BackgroundMichigan’s approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs).ObjectiveAssess PCPs’ perspectives about the impact of HMP on their patients and practices.DesignIn 2014–2015, we conducted semi-structured interviews then a statewide survey of PCPs.SettingInterviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail.ParticipantsInterviewees were physician (n =?16) and non-physician practitioners (n =?3). All Michigan PCPs caring for =?12 HMP enrollees were surveyed (response rate 55.5%, N =?2104).MeasurementsPCPs’ experiences with HMP patients and recent changes in their practices.ResultsInterviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients’ access to urgent appointments worsened.LimitationsPCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with = 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias.ConclusionsPCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients’ access did not diminish, perhaps due to reported practice changes.

BackgroundClinical and community samples indicate that eating disorders (EDs) and disordered eating behaviors (DEBs) may co-occur among adolescents and young adults at a weight status classified as overweight or obese.ObjectiveTo determine the prevalence of EDs and DEBs among young adults at a weight status classified as overweight or obese using a nationally representative sample and to characterize differences in prevalence by sex, race/ethnicity, sexual orientation, and socioeconomic status.DesignCross-sectional nationally representative data collected from Wave III of the National Longitudinal Study of Adolescent to Adult Health (Add Health).ParticipantsYoung adults ages 18–24 years old.Main MeasuresED diagnosis and DEBs (self-reported binge eating or unhealthy weight control behaviors including vomiting, fasting/skipping meals, or laxative/diuretic use to lose weight). Covariates: age, sex, race/ethnicity, sexual orientation, weight status, and education.Key ResultsOf the 14,322 young adults in the sample, 48.6% were at a weight status classified as overweight or obese. Compared to young adults at a weight status classified as underweight or normal weight, those at a weight status classified as overweight or obese reported a higher rate of DEBs (29.3 vs 15.8% in females, 15.4 vs 7.5% in males). Logistic regression analyses demonstrated that odds of engaging in DEBs were 2.32 (95% confidence interval 2.05–2.61) times higher for females compared to males; 1.66 (1.23–2.24) times higher for Asian/Pacific Islander compared to White; 1.62 (1.16–2.26) times higher for homosexual or bisexual compared to heterosexual; 1.26 (1.09–1.44) times higher for high school or less versus more than high school education; and 2.45 (2.16–2.79) times higher for obesity compared to normal weight, adjusting for all covariates.ConclusionsThe high prevalence of DEBs particularly in young adults at a weight status classified as overweight or obese underscores the need for screening, referrals, and tailored interventions for DEBs in this population.

BackgroundNew persistent opioid use is a common postoperative complication, with 6% of previously opioid-naïve patients continuing to fill opioid prescriptions 3–6 months after surgery. Despite these risks, it is unknown which specialties prescribe opioids to these vulnerable patients.ObjectiveTo identify specialties prescribing opioids to surgical patients who develop new persistent opioid use.Design, Setting, and ParticipantsUsing a national dataset of insurance claims, we identified opioid-naïve patients aged 18–64 years undergoing surgical procedures (2008–2014) who continued filling opioid prescriptions 3 to 6 months after surgery. We then examined opioid prescriptions claims during the 12 months after surgery, and identified prescribing physician specialty using National Provider Identifier codes.Main MeasuresPercentage of opioid prescriptions provided by each specialty evaluated at 90-day intervals during the 12 months after surgery.Key ResultsWe identified 5276 opioid-naïve patients who developed new persistent opioid use. During the first 3 months after surgery, surgeons accounted for 69% of opioid prescriptions, primary care physicians accounted for 13%, Emergency Medicine accounted for 2%, Physical Medicine & Rehabilitation (PM&R)/Pain Medicine accounted for 1%, and all other specialties accounted for 15%. In contrast, 9 to 12 months after surgery, surgeons accounted for only 11% of opioid prescriptions, primary care physicians accounted for 53%, Emergency Medicine accounted for 5%, PM&R/Pain Medicine accounted for 6%, and all other specialties provided 25%.ConclusionsAmong surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. By 9 to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians. Enhanced care coordination between surgeons and primary care physicians could allow earlier identification of patients at risk for new persistent opioid use to prevent misuse and dependence.

BackgroundManaging depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown.ObjectiveIn a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression.Design and ParticipantsWe conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n?=?27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration’s national 2013 PCMH Survey of Healthcare Experiences of Patients.Main MeasuresWe assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1.Key ResultsAmong those who did not receive depression treatment in Y1 (n?=?4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n?=?22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2.ConclusionsIn a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients’ subsequent initiation and continuation of depression treatment over time—a relationship that could affect physical and mental health outcomes.

BackgroundThe Chronic Care Model (CCM) has been endorsed by experts to reduce disparities in chronic disease outcomes but benefits may be slow to appear in low-income populations.ObjectiveTo evaluate the effect of CCM implementation on systolic blood pressure (SBP) control in minority patients with diabetes mellitus (DM).DesignRetrospective study from 2012 to 2016 in two primary care clinics with primarily uninsured, Hispanic patients.PatientsFour 2-year cohorts of patients aged 18–75 with DM and SBP =?140 mmHg on HTN drugs in year 1 and SBP measured 1 year later in year 2.InterventionImplementation of CCM for DM in January 2014 involved: electronic medical record revision, a DM registry, hypertension (HTN) treatment protocol, team education, performance feedback, and case management.Main MeasureSBP

BackgroundThere is a lack of comprehensive view of the association between acute exacerbation of COPD (AECOPD) and the risk of acute cardiovascular events.ObjectiveTo determine the association of AECOPD with 30-day and 1-year incidences of acute cardiovascular event.DesignSelf-controlled case series analysis using population-based datasets from three US states from 2005 through 2011.ParticipantsPatients aged =?40 years with AECOPD.Main MeasuresThe primary outcome was a composite of an ED visit or hospitalization for acute cardiovascular events, including acute myocardial infarction, heart failure, atrial fibrillation, pulmonary embolism, and stroke. We compared the incidence of each patient’s acute cardiovascular event during the first 30-day period before the index AECOPD (30-day reference period) in comparison with that during the 30-day period after the index AECOPD. Likewise, with the 1-year period before the index AECOPD as reference, we also estimated incidence rate ratios (IRRs) for each patient’s outcomes during 1-year period after the index AECOPD.Key ResultsOverall, there were 362,867 patients with an ED visit or hospitalization for AECOPD. Compared with the 30-day reference period, the incidence of acute cardiovascular event in the 30-day period after the AECOPD was significantly higher (IRR, 1.34; 95%CI, 1.30–1.39; P?