Objective To better understand patients’ reasoning for keeping unused opioid pills. Methods As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as “dispose,” “keep,” and “don’t know.” Baseline characteristics were compared between the “keep” and “dispose” groups. Verbatim responses categorized as “keep” were analyzed qualitatively using a team-based inductive approach with constant comparison across cases. Results One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills “just in case,” with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills “just in case” without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids. Conclusions This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.

The COVID-19 pandemic has placed significant strain on emergency departments (EDs) that were not designed to care for many patients who may be highly contagious. This report outlines how a busy urban ED was adapted to prepare for COVID-19 via 3 primary interventions: (1) creating an open-air care space in the ambulance bay to cohort, triage, and rapidly test patients with suspected COVID-19, (2) quickly constructing temporary doors on all open treatment rooms, and (3) adapting and expanding the waiting room. This description serves as a model by which other EDs can repurpose their own care spaces to help ensure safety of their patients and health care workers.

Methods: We are performing a qualitative study of ACOs using a purposive sampling strategy to identify early adopter organizations. We perform semi-structured interviews of key informants responsible for strategy, care redesign, and payment reform from each ACO (eg, Chief population health officer) and associated ED leadership (eg, Chair of emergency medicine). We analyze transcripts for key themes using a constant comparative method.Results: We present preliminary findings from 11 interviews across 4 sites. All sites were enrolled in the Medicare Shared Savings Program; however, sites varied in region and maturity with respect to population health initiatives. The Table describes care redesign examples by site. Nearly all sites were focused on reducing low-acuity ED visits and expanding alternate venues for acute unscheduled care (eg, urgent care). All sites were engaged in care redesign to reduce ED admission rates. All sites were expanding ED care coordination, although in different ways. All sites had programs to engage high-risk populations, older adults and frequent ED users were most frequently mentioned. All sites were engaged in initiatives to develop alternatives to inpatient hospitalization ranging from hospital at home to expanded use of direct transfer to skilled nursing facilities from the ED. Conversely, there has been no significant reform of payment for emergency medical care within these ACOs. All sites reported no change in fee-for-service reimbursement for ED services, while acknowledging that value-based payments for emergency care may require new payment methods and realignment of incentives. ED staffing models included independent contract groups, large national contract groups, and multispecialty faculty practices. ACO leaders at two sites indicated that future ED staffing contracts may incorporate value-based population health incentives. Respondents at two sites indicated fee-for-service EM payments are already tied to value. One site indicated that success in ACO value-based goals had led to decreased ED volume and revenue, raising significant challenges to the traditional academic mission of the ED. Nearly all informants expressed concern regarding reduced ED reimbursement given ACO efforts to reduce ED utilization and participation in alternative payment contracts, yet did not have a clear vision for reforming payment for ED services.Conclusions: Our preliminary findings suggest that care redesign within ACOs is generally impacting acute care delivery, particularly with respect to outpatient access and alternatives to hospitalization. Yet, to date, there has been little impact on methods of emergency medicine payment, which remain fee for service; further research is needed to determine how best to transition towards value-based payment for emergency medical care.