7 research outputs found
Access to Health Care Through Catamount Health; Do Providers Know Enough to Refer?
Background: On November 1, 2007, Vermont launched âCatamount Health,â a state-sponsored private insurance plan. The goal: to close the gap between privately insured and Medicaid insured Vermonters. Previous programs such as Dr. Dynasaur and VHAP were already in place to care for children and low-income residents respectively. Now, under the umbrella title of âGreen Mountain Care,â Catamount Health joins them. Catamount Health offers private coverage through either Blue Cross/Blue Shield of VT or MVP Health Care, the cost of which is offset by the state according to income level and household size. To qualify for Catamount, an individual must have an income of at least 1.6 million dollars to fund a large-scale advertising campaign on television, radio, newspaper, and on foot. Following this campaign, there is a high likelihood that Vermonters will bring questions and concerns about Catamount to their physician offices and community leaders, emphasizing the importance of a well-educated provider.https://scholarworks.uvm.edu/comphp_gallery/1021/thumbnail.jp
Nonâpharmacological care for opioid withdrawal in newborns.
BACKGROUND: The prevalence of substance use, both prescribed and nonâprescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Nonâpharmacological care is the firstâline treatment for substance withdrawal in newborns. Despite the widespread use of nonâpharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, nonâpharmacological care practices in this population. Evaluation of safety and efficacy of nonâpharmacological practices could provide clear guidance for clinical practice. OBJECTIVES: To evaluate the safety and efficacy of nonâpharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does nonâpharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent nonâpharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization? SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasiâRCTs, and cluster trials. SELECTION CRITERIA: We included trials comparing single or bundled nonâpharmacological interventions to no nonâpharmacological treatment or different single or bundled nonâpharmacological interventions. We assessed nonâpharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized nonâpharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the motherâinfant dyad. We presented nonârandomized studies identified in the search process narratively. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication. MAIN RESULTS: We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 nonârandomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, nonâoscillating waterbed, or a lowâstimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternalâinfant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) â1 day, 95% confidence interval [CI) â2.82 to 0.82; 30 infants; very lowâcertainty evidence) and the one study of support of the maternalâinfant dyad (MD â8.9 days, 95% CI â19.84 to 2.04; 14 infants; very lowâcertainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; lowâcertainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very lowâcertainty evidence), and one study of support of the maternalâinfant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very lowâcertainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternalâinfant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very lowâcertainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very lowâcertainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD â0.28, 95% CI â1.15 to 0.59; 194 infants; very lowâcertainty evidence) and one study of feeding practices reported weight nadir (MD â0.8, 95% CI â2.24 to 0.64; 46 infants; very lowâcertainty evidence). AUTHORS' CONCLUSIONS: We are uncertain whether nonâpharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very lowâ to lowâcertainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize nonâpharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger wellâdesigned studies are needed to determine the effect of nonâpharmacological care for opioid withdrawal in newborns