Opioid and High-Risk Prescribing Among Racial and Ethnic Minority Veterans.

INTRODUCTION: The purpose of this study is to compare opioid prescribing and high-risk prescribing by race and ethnicity in a national cohort of U.S. veterans. METHODS: A cross-sectional analysis of veteran characteristics and healthcare use was performed on electronic health record data for 2018 Veterans Health Administration users and enrollees in 2022. RESULTS: Overall, 14.8% received an opioid prescription. The adjusted odds of being prescribed an opioid were lower for all race/ethnicity groups than for non-Hispanic White veterans, except for non-Hispanic multiracial (AOR=1.03; 95% CI=0.999, 1.05) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=1.03, 1.09) veterans. The odds of any day of overlapping opioid prescriptions (i.e., opioid overlap) were lower for all race/ethnicity groups than for the non-Hispanic White group, except for the non-Hispanic American Indian/Alaska Native group (AOR=1.01; 95% CI=0.96, 1.07). Similarly, all race/ethnicity groups had lower odds of any day of daily dose >120 morphine milligram equivalents than the non-Hispanic White group, except for the non-Hispanic multiracial (AOR=0.96; 95% CI=0.87, 1.07) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=0.96, 1.17) groups. Non-Hispanic Asian veterans had the lowest odds for any day of opioid overlap (AOR=0.54; 95% CI=0.50, 0.57) and daily dose >120 morphine milligram equivalents (AOR=0.43; 95% CI=0.36, 0.52). For any day of opioid-benzodiazepine overlap, all races/ethnicities had lower odds than non-Hispanic White. Non-Hispanic Black/African American (AOR=0.71; 95% CI=0.70, 0.72) and non-Hispanic Asian (AOR=0.73; 95% CI=0.68, 0.77) veterans had the lowest odds of any day of opioid-benzodiazepine overlap. CONCLUSIONS: Non-Hispanic White and non-Hispanic American Indian/Alaska Native veterans had the greatest likelihood to receive an opioid prescription. When an opioid was prescribed, high-risk prescribing was more common in White and American Indian/Alaska Native veterans than in all other racial/ethnic groups. As the nation's largest integrated healthcare system, the Veterans Health Administration can develop and test interventions to achieve health equity for patients experiencing pain.

Comparing Outpatient Opioids, High-Risk Prescribing, and Opioid Poisoning Between Transgender and Cisgender Veterans: A Cross-sectional Analysis.

INTRODUCTION: Transgender veterans have a high prevalence of substance use disorder and physical and mental-health comorbidities, which are associated with prescription opioid use and overdose risk. This study compares receipt of outpatient opioids, high-risk opioid prescribing, and opioid poisoning between transgender and cisgender (i.e., nontransgender) veterans. METHODS: A secondary analysis of Veterans Health Administration health record data from January 1, 2018 to December 31, 2018 was conducted in 2021. Transgender veterans (n=9,686) were randomly matched to 3 cisgender veterans (n=29,058) on the basis of age and county. Using the same matching criteria, a second cohort was created of all transgender veterans and a matched sample of cisgender veterans who were prescribed an outpatient opioid (n=7,576). Stratified Cox proportional hazard regression measured the RR of each prescription outcome and opioid poisoning. RESULTS: Transgender veterans had a 20% higher risk of being prescribed any outpatient opioid than cisgender veterans (adjusted RR=1.20, 95% CI=1.13, 1.27). Transgender and cisgender veterans who were prescribed an opioid did not have different risks of high-risk prescribing: overlapping opioid prescriptions (adjusted RR=0.93, 95% CI=0.85, 1.02), daily dose >120 morphine milligram equivalents (adjusted RR=0.86, 95% CI=0.66, 1.10), or overlapping opioid and benzodiazepine prescriptions (adjusted RR=1.05, 95% CI=0.96, 1.14). Overall, transgender veterans had more than twice the risk of opioid poisoning than cisgender veterans (RR=2.76, 95% CI=1.57, 4.86). The risk of opioid poisoning did not differ between transgender and cisgender veterans who were prescribed an opioid (RR=1.09, 95% CI=0.56, 2.11). CONCLUSIONS: Transgender veterans had a greater risk of being prescribed an outpatient opioid than cisgender veterans but did not have different risks of high-risk opioid prescribing.

Latent Class Analysis of Prescribing Behavior of Primary Care Physicians in the Veterans Health Administration.

BACKGROUND: Benzodiazepines, opioids, proton-pump inhibitors (PPIs), and antibiotics are frequently prescribed inappropriately by primary care physicians (PCPs), without sufficient consideration of alternative options or adverse effects. We hypothesized that distinct groups of PCPs could be identified based on their propensity to prescribe these medications. OBJECTIVE: To identify PCP groups based on their propensity to prescribe benzodiazepines, opioids, PPIs, and antibiotics, and patient and PCP characteristics associated with identified prescribing patterns. DESIGN: Retrospective cohort study using VA data and latent class regression analyses to identify prescribing patterns among PCPs and examine the association of patient and PCP characteristics with class membership. PARTICIPANTS: A total of 2524 full-time PCPs and their patient panels (n = 2,939,636 patients), from January 1, 2017, to December 31, 2018. MAIN MEASURES: We categorized PCPs based on prescribing volume quartiles for the four drug classes, based on total days' supply dispensed of each medication by the PCP to their patients (expressed as days' supply per 1000 panel patient-days). We used latent class analysis to group PCPs based on prescribing and used multinomial logistic regression to examine patient and PCP characteristics associated with latent class membership. KEY RESULTS: PCPs were categorized into four groups (latent classes): low intensity (23% of cohort), medium-intensity overall/high-intensity PPI (36%), medium-intensity overall/high-intensity opioid (20%), and high intensity (21%). PCPs in the high-intensity group were predominantly in the highest quartile of prescribers for all four drugs (68% in the highest quartile for benzodiazepine, 86% opioids, 64% PPIs, 62% antibiotics). High-intensity PCPs (vs. low intensity) were substantially less likely to be female (OR: 0.30, 95% CI: 0.21-0.42) or practice in the northeast versus other census regions (OR: 0.10, 95% CI: 0.06-0.17). CONCLUSIONS: VA PCPs can be classified into four clearly differentiated groups based on their prescribing of benzodiazepines, opioids, PPIs, and antibiotics, suggesting an underlying typology of prescribing. High-intensity PCPs were more likely to be male.

An Interrupted Time-series Evaluation of the Association Between State Laws Mandating Prescriber Use of Prescription Drug Monitoring Programs and Discontinuation of Chronic Opioid Therapy in US Veterans.

BACKGROUND: Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care. METHODS: We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome). RESULTS: We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates. CONCLUSION: We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.

Long-term depression incidence and associated mortality among African American and White prostate cancer survivors.

BACKGROUND: Depression is common after a diagnosis of prostate cancer and may contribute to poor outcomes, particularly among African Americans. The authors assessed the incidence and management of depression and its impact on overall mortality among African American and White veterans with localized prostate cancer. METHODS: The authors used the Veterans Health Administration Corporate Data Warehouse to identify 40,412 African American and non-Hispanic White men diagnosed with localized prostate cancer from 2001 to 2013. Patients were followed through 2019. Multivariable logistic regression was used to measure associations between race and incident depression, which were ascertained from administrative and depression screening data. Cox proportional hazards models were used to measure associations between incident depression and all-cause mortality, with race-by-depression interactions used to assess disparities. RESULTS: Overall, 10,013 veterans (24.5%) were diagnosed with depression after a diagnosis of prostate cancer. Incident depression was associated with higher all-cause mortality (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.23-1.32). African American veterans were more likely than White veterans to be diagnosed with depression (29.3% vs 23.2%; adjusted odds ratio [aOR], 1.15; 95% CI, 1.09-1.21). Among those with depression, African Americans were less likely to be prescribed an antidepressant (30.4% vs 31.7%; aOR, 0.85; 95% CI, 0.77-0.93). The hazard of all-cause mortality associated with depression was greater for African American veterans than White veterans (aHR, 1.32 [95% CI, 1.26-1.38] vs 1.15 [95% CI, 1.07-1.24]; race-by-depression interaction P < .001). CONCLUSIONS: Incident depression is common among prostate cancer survivors and is associated with higher mortality, particularly among African American men. Patient-centered strategies to manage incident depression may be critical to reducing disparities in prostate cancer outcomes.

Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans From 2004 to 2018.

Importance: Conservative management (ie, active surveillance or watchful waiting) is a guideline-based strategy for men with low-risk and intermediate-risk prostate cancer. However, use of conservative management is controversial for African American patients, who have worse prostate cancer outcomes compared with White patients. Objective: To examine the association of African American race with the receipt and duration of conservative management in the Veterans Health Administration (VA), a large equal-access health system. Design, Setting, and Participants: This cohort study used data from the VA Corporate Data Warehouse for 51 543 African American and non-Hispanic White veterans diagnosed with low-risk and intermediate-risk localized node-negative prostate cancer between January 1, 2004, and December 31, 2013. Men who did not receive continuous VA care were excluded. Data were analyzed from February 1 to June 30, 2020. Exposures: All patients received either definitive therapy (ie, prostatectomy, radiation, androgen deprivation therapy) or conservative management (ie, active surveillance or watchful waiting). Main Outcomes and Measures: Receipt of conservative management and (for patients receiving conservative management) time from diagnosis to definitive therapy. Results: The median (interquartile range) age of the 51 543 veterans in our cohort was 65 (61-70) years, and 14 830 veterans (28.8%) were African American individuals. Compared with White veterans, African American veterans were more likely to have intermediate-risk disease (18 988 [51.7%] vs 8526 [57.5%]), 3 or more comorbidities (15 438 [42.1%] vs 7614 [51.3%]), and high disability-related or income-related needs (9078 [24.7%] vs 4614 [31.1%]). Overall, 20 606 veterans (40.0%) received conservative management. African American veterans with low-risk disease (adjusted relative risk, 0.95; 95% CI, 0.92-0.98; P < .001) and intermediate-risk disease (adjusted relative risk, 0.92; 95% CI, 0.87-0.97; P = .002) were less likely to receive conservative management than White veterans. Compared with White veterans, African American veterans with low-risk disease (adjusted hazard ratio, 1.71; 95% CI, 1.50-1.95; P < .001) and intermediate-risk disease (adjusted hazard ratio, 1.46; 95% CI, 1.27-1.69; P < .001) who received conservative management were more likely to receive definitive therapy within 5 years of diagnosis (restricted mean survival time [SE] at 5 years, 1679 [5.3] days vs 1740 [2.4] days; P < .001). Conclusions and Relevance: In this study, conservative management was less commonly used and less durable for African American veterans than for White veterans. Prospective trials should assess the comparative effectiveness of conservative management in African American men with prostate cancer.

Identifying sociodemographic profiles of veterans at risk for high-dose opioid prescribing using classification and regression trees.

OBJECTIVE: To identify sociodemographic profiles of patients prescribed high-dose opioids. DESIGN: Cross-sectional cohort study. SETTING/PATIENTS: Veterans dually-enrolled in Veterans Health Administration and Medicare Part D, with ≥1 opioid pre-scription in 2012. MAIN OUTCOME MEASURES: We identified five patient-level demographic characteristics and 12 community variables re-flective of region, socioeconomic deprivation, safety, and internet connectivity. Our outcome was the proportion of vet-erans receiving >120 morphine milligram equivalents (MME) for ≥90 consecutive days, a Pharmacy Quality Alliance measure of chronic high-dose opioid prescribing. We used classification and regression tree (CART) methods to identify risk of chronic high-dose opioid prescribing for sociodemographic subgroups. RESULTS: Overall, 17,271 (3.3 percent) of 525,716 dually enrolled veterans were prescribed chronic high-dose opioids. CART analyses identified 35 subgroups using four sociodemographic and five community-level measures, with high-dose opioid prescribing ranging from 0.28 percent to 12.1 percent. The subgroup (n = 16,302) with highest frequency of the outcome included veterans who were with disability, age 18-64 years, white or other race, and lived in the Western Census region. The subgroup (n = 14,835) with the lowest frequency of the outcome included veterans who were with-out disability, did not receive Medicare Part D Low Income Subsidy, were >85 years old, and lived in communities within the second and sixth to tenth deciles of community public assistance. CONCLUSIONS: Using CART analyses with sociodemographic and community-level variables only, we identified sub-groups of veterans with a 43-fold difference in chronic high-dose opioid prescriptions. Interactions among disability, age, race/ethnicity, and region should be considered when identifying high-risk subgroups in large populations.

Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis.

BACKGROUND: Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. OBJECTIVE: To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. DESIGN: Observational study using Veterans Health Administration (VA) encounter and prescription data. SETTING AND PARTICIPANTS: Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve"). MEASUREMENTS: We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. RESULTS: We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). CONCLUSIONS: ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.

Use of a medication-based risk adjustment index to predict mortality among veterans dually-enrolled in VA and medicare.

BACKGROUND: There is systemic undercoding of medical comorbidities within administrative claims in the Department of Veterans Affairs (VA). This leads to bias when applying claims-based risk adjustment indices to compare outcomes between VA and non-VA settings. Our objective was to compare the accuracy of a medication-based risk adjustment index (RxRisk-VM) to diagnostic claims-based indices for predicting mortality. METHODS: We modified the RxRisk-V index (RxRisk-VM) by incorporating VA and Medicare pharmacy and durable medical equipment claims in Veterans dually-enrolled in VA and Medicare in 2012. Using the concordance (C) statistic, we compared its accuracy in predicting 1 and 3-year all-cause mortality to the following models: demographics only, demographics plus prescription count, or demographics plus a diagnostic claims-based risk index (e.g., Charlson, Elixhauser, or Gagne). We also compared models containing demographics, RxRisk-VM, and a claims-based index. RESULTS: In our cohort of 271,184 dually-enrolled Veterans (mean age = 70.5 years, 96.1% male, 81.7% non-Hispanic white), RxRisk-VM (C = 0.773) exhibited greater accuracy in predicting 1-year mortality than demographics only (C = 0.716) or prescription counts (C = 0.744), but was less accurate than the Charlson (C = 0.794), Elixhauser (C = 0.80), or Gagne (C = 0.810) indices (all P < 0.001). Combining RxRisk-VM with claims-based indices enhanced its accuracy over each index alone (all models C ≥ 0.81). Relative model performance was similar for 3-year mortality. CONCLUSIONS: The RxRisk-VM index exhibited a high level of, but slightly less, accuracy in predicting mortality in comparison to claims-based risk indices. IMPLICATIONS: Its application may enhance the accuracy of studies examining VA and non-VA care and enable risk adjustment when diagnostic claims are not available or biased. LEVEL OF EVIDENCE: Level 3.

Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case-Control Study.

Background: More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems. Objective: To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose. Design: Nested case-control study. Setting: VA and Medicare Part D. Participants: Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions. Measurements: The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications. Results: Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005). Limitation: Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems. Conclusion: Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety. Primary Funding Source: U.S. Department of Veterans Affairs.

Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes: The Veterans Health Administration's Homeless Patient Aligned Care Teams.

BACKGROUND: In 2012, select Veterans Health Administration (VHA) facilities implemented a homeless-tailored medical home model, called Homeless Patient Aligned Care Teams (H-PACT), to improve care processes and outcomes for homeless Veterans. OBJECTIVE: The main aim of this study was to determine whether H-PACT offers a better patient experience than standard VHA primary care. RESEARCH DESIGN: We used multivariable logistic regressions to estimate differences in the probability of reporting positive primary care experiences on a national survey. SUBJECTS: Homeless-experienced survey respondents enrolled in H-PACT (n=251) or standard primary care in facilities with H-PACT available (n=1527) and facilities without H-PACT (n=10,079). MEASURES: Patient experiences in 8 domains from the Consumer Assessment of Healthcare Provider and Systems surveys. Domain scores were categorized as positive versus nonpositive. RESULTS: H-PACT patients were less likely than standard primary care patients to be female, have 4-year college degrees, or to have served in recent military conflicts; they received more primary care visits and social services. H-PACT patients were more likely than standard primary care patients in the same facilities to report positive experiences with access [adjusted risk difference (RD)=17.4], communication (RD=13.9), office staff (RD=13.1), provider ratings (RD=11.0), and comprehensiveness (RD=9.3). Standard primary care patients in facilities with H-PACT available were more likely than those from facilities without H-PACT to report positive experiences with communication (RD=4.7) and self-management support (RD=4.6). CONCLUSIONS: Patient-centered medical homes designed to address the social determinants of health offer a better care experience for homeless patients, when compared with standard primary care approaches. The lessons learned from H-PACT can be applied throughout VHA and to other health care settings.

Patterns of opioid prescriptions received prior to unintentional prescription opioid overdose death among Veterans.

BACKGROUND: Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans. OBJECTIVES: To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans. METHODS: In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008-2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012-2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only. RESULTS: Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death. CONCLUSIONS: Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.

Characteristics of dual drug benefit use among veterans with dementia enrolled in the Veterans Health Administration and Medicare Part D.

BACKGROUND: Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes. OBJECTIVE: To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia. METHODS: Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids. RESULTS: Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%). CONCLUSIONS: Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.

Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia.

OBJECTIVE: To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. DATA SOURCES/STUDY SETTING: National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. STUDY DESIGN: We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. DATA COLLECTION/EXTRACTION METHODS: Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. PRINCIPAL FINDINGS: Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. CONCLUSIONS: Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.

Receipt of Overlapping Opioid and Benzodiazepine Prescriptions Among Veterans Dually Enrolled in Medicare Part D and the Department of Veterans Affairs: A Cross-sectional Study.

Background: Overlapping use of opioids and benzodiazepines is associated with increased risk for overdose. Veterans receiving medications concurrently from the U.S. Department of Veterans Affairs (VA) and Medicare may be at higher risk for such overlap. Objective: To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions. Design: Cross-sectional. Setting: VA and Medicare. Participants: All veterans enrolled in VA and Medicare Part D who filled at least 2 opioid prescriptions in 2013 (n = 368 891). Measurements: Outcomes were the proportion of patients with a Pharmacy Quality Alliance (PQA) measure of opioid-benzodiazepine overlap (≥2 filled prescriptions for benzodiazepines with ≥30 days of overlap with opioids) and the proportion of patients with high-dose opioid-benzodiazepine overlap (≥30 days of overlap with a daily opioid dose >120 morphine milligram equivalents). Augmented inverse probability weighting regression was used to compare these measures by prescription drug source: VA only, Medicare only, or VA and Medicare (dual use). Results: Of 368 891 eligible veterans, 18.3% received prescriptions from the VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid-benzodiazepine overlap was larger for the dual-use group than the VA-only group (23.1% vs. 17.3%; adjusted risk ratio [aRR], 1.27 [95% CI, 1.24 to 1.30]) and Medicare-only group (23.1% vs. 16.5%; aRR, 1.12 [CI, 1.10 to 1.14]). The proportion with high-dose overlap was also larger for the dual-use group than the VA-only group (4.7% vs. 2.3%; aRR, 2.23 [CI, 2.10 to 2.36]) and Medicare-only group (4.7% vs. 2.9%; aRR, 1.06 [CI, 1.02 to 1.11]). Limitation: Data are from 2013 and cannot capture medications purchased without insurance; unmeasured confounding may remain in this cross-sectional study. Conclusion: Among a national cohort of veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with greater risk for receiving potentially unsafe overlapping prescriptions for opioids and benzodiazepines. Primary Funding Source: U.S. Department of Veterans Affairs.

The Role of Primary Care Experiences in Obtaining Treatment for Depression.

BACKGROUND: Managing 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. OBJECTIVE: In 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 PARTICIPANTS: We 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 MEASURES: We 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 RESULTS: Among 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. CONCLUSIONS: In 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.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams.

BACKGROUND: Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. OBJECTIVE: To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). RESEARCH DESIGN: We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. SUBJECTS: Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). MEASURES: Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. RESULTS: In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). CONCLUSIONS: VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

Impact of Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits on Potentially Unsafe Opioid Use.

OBJECTIVES: To estimate the prevalence and consequences of receiving prescription opioids from both the Department of Veterans Affairs (VA) and Medicare Part D. METHODS: Among US veterans enrolled in both VA and Part D filling 1 or more opioid prescriptions in 2012 (n = 539 473), we calculated 3 opioid safety measures using morphine milligram equivalents (MME): (1) proportion receiving greater than 100 MME for 1 or more days, (2) mean days receiving greater than 100 MME, and (3) proportion receiving greater than 120 MME for 90 consecutive days. We compared these measures by opioid source. RESULTS: Overall, 135 643 (25.1%) veterans received opioids from VA only, 332 630 (61.7%) from Part D only, and 71 200 (13.2%) from both. The dual-use group was more likely than the VA-only group to receive greater than 100 MME for 1 or more days (34.3% vs 10.9%; adjusted risk ratio [ARR] = 3.0; 95% confidence interval [CI] = 2.9, 3.1), have more days with greater than 100 MME (42.5 vs 16.9 days; adjusted difference = 16.4 days; 95% CI = 15.7, 17.2), and to receive greater than 120 MME for 90 consecutive days (7.8% vs 3.1%; ARR = 2.2; 95% CI = 2.1, 2.3). CONCLUSIONS: Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.

A national evaluation of homeless and nonhomeless veterans' experiences with primary care.

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record

Overlapping buprenorphine, opioid, and benzodiazepine prescriptions among veterans dually enrolled in Department of Veterans Affairs and Medicare Part D.

BACKGROUND: Buprenorphine is a key tool in the management of opioid use disorder, but there are growing concerns about abuse, diversion, and safety. These concerns are amplified for the Department of Veterans Affairs (VA), whose patients may receive care concurrently from multiple prescribers within and outside VA. To illustrate the extent of this challenge, we examined overlapping prescriptions for buprenorphine, opioids, and benzodiazepines among veterans dually enrolled in VA and Medicare Part D. METHODS: We constructed a cohort of all veterans dually enrolled in VA and Part D who filled an opioid prescription in 2012. We identified patients who received tablet or film buprenorphine products from either source. We calculated the proportion of buprenorphine recipients with any overlapping prescription (based on days supply) for a nonbuprenorphine opioid or benzodiazepine, focusing on veterans who received overlapping prescriptions from a different system than their buprenorphine prescription (Part D buprenorphine recipients receiving overlapping opioids or benzodiazepines from VA and vice versa). RESULTS: There were 1790 dually enrolled veterans with buprenorphine prescriptions, including 760 (43%) from VA and 1091 (61%) from Part D (61 veterans with buprenorphine from both systems were included in each group). Among VA buprenorphine recipients, 199 (26%) received an overlapping opioid prescription and 11 (1%) received an overlapping benzodiazepine prescription from Part D. Among Part D buprenorphine recipients, 208 (19%) received an overlapping opioid prescription and 178 (16%) received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients with cross-system opioid overlap, 25% (49/199) and 35% (72/208), respectively, had >90 days of overlap. CONCLUSIONS: Many buprenorphine recipients receive overlapping prescriptions for opioids and benzodiazepines from a different health care system than the one in which their buprenorphine was filled. These findings highlight a previously undocumented safety risk for veterans dually enrolled in VA and Medicare.