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BACKGROUND: States have implemented policies to decrease clinically unnecessary opioid prescribing, but few studies have examined how state policies affect opioid dispensing rate trends for surgical patients. OBJECTIVE: To examine trends in the perioperative opioid dispensing rates for fee-for-service Medicare beneficiaries and the effects of select state policies. DESIGN AND PARTICIPANTS: A retrospective cohort study using 2006 to 2018 Medicare claims data for individuals undergoing surgical procedures for which opioid analgesic treatment is common. EXPOSURES: State policies mandating prescription drug monitoring program (PDMP; PDMP policies) use, initial opioid prescription duration limit (duration limit policies), and mandated continuing medical education (CME; CME pain policies) on pain management. MAIN MEASURES: Opioid dispensing rates, days' supply, and the daily morphine milligram equivalent dose (MMED). KEY RESULTS: The percentage of Medicare beneficiaries dispensed opioids in the perioperative period increased from 2007 to 2018; MMED and days' supply decreased over the same period, with significant variation by age, sex, and race. None of the three state policies affected the likelihood of Medicare beneficiaries being dispensed perioperative opioids. However, CME pain policies and duration limit policies were associated with decreased days' supply and decreased MMED in the several years following implementation, respectively. CONCLUSION: While we observed a slight increase in the rate of Medicare beneficiaries dispensed opioids perioperatively and a substantial decrease in MMED and days' supply for those receiving opioids, state policies examined had relatively modest effects on the main measures. Our findings suggest that these state policies may have a limited impact on opioid dispensing for a patient population that is commonly dispensed opioid analgesics to help control surgical pain, and as a result may have little direct effect on clinical outcomes for this population. Changes in opioid dispensing for this population may be the result of broader societal trends than such state policies.
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OBJECTIVES: To identify factors associated with clinicians' likelihood and intensity of applying fluoride varnish (FV) overall and for visits paid by Medicaid and private insurers. STUDY DESIGN: Observational study using claims data. METHODS: Using the Massachusetts All-Payer Claims Database (2016-2018), we conducted a repeated cross-sectional study of 2911 clinicians (7277 clinician-year observations) providing well-child visits to children aged 1 to 5 years. Zero-inflated negative binomial models estimated the probability of a clinician applying FV and the number of visits with FV applications, overall and separately for visits paid by Medicaid and private insurers. RESULTS: A total of 30.9% of clinician-years applied FV at least once, and overall, an average of 8.4% of a clinician's well-child visits included FV annually. Controlling for all covariates, having a higher percentage of patients insured by Medicaid was associated with applying FV (OR, 1.35; 95% CI, 1.23-1.45) and a higher expected number of applications (OR, 1.05; 95% CI, 1.02-1.09). Additionally, having a higher percentage of patients aged 1 to 5 years was associated with applying FV (OR, 1.20; 95% CI, 1.01-1.43), but not the number of applications. Similar associations were observed among visits paid by private insurers. CONCLUSIONS: Despite clinical recommendations and mandated insurance reimbursements, the likelihood and intensity of FV applications was low for most pediatric primary care clinicians. Clinician behavior was associated with patient-panel characteristics, suggesting the need for interventions that account for these differences.
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Fluoretos Tópicos , Medicaid , Humanos , Pré-Escolar , Lactente , Estados Unidos , Medicaid/estatística & dados numéricos , Estudos Transversais , Feminino , Masculino , Fluoretos Tópicos/uso terapêutico , Fluoretos Tópicos/administração & dosagem , Massachusetts , Padrões de Prática Médica/estatística & dados numéricos , Revisão da Utilização de Seguros , Seguro Saúde/estatística & dados numéricosRESUMO
OBJECTIVE: To review evidence on post-acute care (PAC) use and disparities related to race and ethnicity and rurality in the United States over the past 2 decades among individuals who underwent major joint replacement (MJR). DESIGN: Systematic review. SETTING AND PARTICIPANTS: We included studies that examined US PAC trends and racial and ethnic and/or urban vs rural differences among individuals who are aged ≥18 years with hospitalization after MJR. METHODS: We searched large academic databases (PubMed, CINAHL, Embase, Web of Science, and Scopus) for peer-reviewed, English language articles from January 1, 2000, and January 26, 2022. RESULTS: Seventeen studies were reviewed. Studies (n = 16) consistently demonstrated that discharges post-MJR to skilled nursing facilities (SNFs) or nursing homes (NHs) decreased over time, whereas evidence on discharges to inpatient rehab facilities (IRFs), home health care (HHC), and home without HHC services were mixed. Most studies (n = 12) found that racial and ethnic minority individuals, especially Black individuals, were more frequently discharged to PAC institutions than white individuals. Demographic factors (ie, age, sex, comorbidities) and marital status were not only independently associated with discharges to institutional PAC, but also among racial and ethnic minority individuals. Only one study found urban-rural differences in PAC use, indicating that urban-dwelling individuals were more often discharged to both SNF/NH and HHC than their rural counterparts. CONCLUSIONS AND IMPLICATIONS: Despite declines in institutional PAC use post-MJR over time, racial and minority individuals continue to experience higher rates of institutional PAC discharges compared with white individuals. To address these disparities, policymakers should consider measures that target multimorbidity and the lack of social and structural support among socially vulnerable individuals. Policymakers should also consider initiatives that address the economic and structural barriers experienced in rural areas by expanding access to telehealth and through improved care coordination.
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Importance: Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). Objective: To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. Design, Setting, and Participants: This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Exposure: Race and ethnicity of NH residents. Main Outcomes and Measures: Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Results: Of 2â¯098â¯385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39â¯873 (1.9%) were Asian, 229â¯112 (10.9%) were Black or African American, 99â¯304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1â¯713â¯670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1â¯355â¯143 (64.6%) were female; 128â¯997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). Conclusions and Relevance: In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.
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Hospitalização , Casas de Saúde , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etnologia , Estudos Transversais , Hospitalização/estatística & dados numéricos , Casas de Saúde/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Estados Unidos/epidemiologia , População Branca/estatística & dados numéricos , Brancos , Hispânico ou Latino , Indígena Americano ou Nativo do Alasca , Asiático , Negro ou Afro-Americano , Havaiano Nativo ou Outro Ilhéu do Pacífico , Grupos RaciaisRESUMO
This cross-sectional study creates a dataset and dashboard of US state- and territory-level COVID-19 policies specific to nursing homes and home health care agencies.
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COVID-19 , Serviços de Assistência Domiciliar , Casas de Saúde , SARS-CoV-2 , COVID-19/epidemiologia , Humanos , Casas de Saúde/estatística & dados numéricos , Serviços de Assistência Domiciliar/estatística & dados numéricos , Estados Unidos/epidemiologia , Política de Saúde , Efeitos Psicossociais da Doença , PandemiasRESUMO
BACKGROUND: We examined the number and characteristics of high-volume buprenorphine prescribers and the nature of their buprenorphine prescribing from 2009 to 2018. METHODS: In this observational cohort study, IQVIA Real World retail pharmacy claims data were used to characterize trends in high-volume buprenorphine prescribers (clinicians with a mean of 30 or more active patients in every month that they were an active prescriber) during 2009-2018. Very high-volume prescribing (mean of 100+ patients per month) was also examined. RESULTS: Overall, 94,491 clinicians prescribed buprenorphine dispensed during 2009-2018. The proportion of active prescribers meeting high-volume criteria increased from 7.4 % in 2009 to 16.7 % in 2018. High-volume prescribers accounted for 80 % of dispensed buprenorphine prescriptions during 2009-2018; very high-volume prescribers accounted for 26 %. Adult primary care physicians consistently comprised the majority of high-volume prescribers. Addiction specialists were much more likely to be high-volume prescribers compared to other specialties, including psychiatrists and pain specialists. By 2018, the proportion of prescriptions from high-volume prescribers paid by Medicaid had doubled to 40 %, accompanied by a decline in both self-pay and commercial insurance. High-volume prescribers were overwhelmingly concentrated in urban counties with the highest fatal overdose rates. In 2018, the highest density of high-volume prescribers was in New England and the mid-Atlantic region. CONCLUSIONS: Growth in high-volume prescribers outpaced the overall growth in buprenorphine prescribers across 2009-2018. High-volume prescribers play an increasingly central role in providing medication for OUD in the U.S., yet results indicate key regional variation in the availability of high-volume buprenorphine prescribers.
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Buprenorfina , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Buprenorfina/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Tratamento de Substituição de Opiáceos/tendências , Padrões de Prática Médica/tendências , Adulto , Masculino , Feminino , Pessoa de Meia-Idade , Estados Unidos , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Antagonistas de Entorpecentes/uso terapêutico , Analgésicos Opioides/uso terapêuticoRESUMO
BACKGROUND: The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. METHODS: Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS: Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSIONS: Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.
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COVID-19 , Oxigenação por Membrana Extracorpórea , Disparidades em Assistência à Saúde , Medicaid , Medicare , Humanos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , COVID-19/terapia , Masculino , Feminino , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Idoso , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Adulto , Mortalidade Hospitalar , Alta do Paciente/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Nursing home (NH) residents' vulnerability to COVID-19 underscores the importance of infection preventionists (IPs) within NHs. Our study aimed to determine whether training and credentialing of NH IPs were associated with resident COVID-19 deaths. METHODS: This retrospective observational study utilized data from the Centers for Disease Control and Prevention's National Healthcare Safety Network NH COVID-19 Module and USAFacts, from May 2020 to February 2021, linked to a 2018 national NH survey. We categorized IP personnel training and credentialing into four groups: (1) LPN without training; (2) RN/advanced clinician without training; (3) LPN with training; and (4) RN/advanced clinician with training. Multivariable linear regression models of facility-level weekly deaths per 1000 residents as a function of facility characteristics, and county-level COVID-19 burden (i.e., weekly cases or deaths per 10,000 population) were estimated. RESULTS: Our study included 857 NHs (weighted n = 14,840) across 489 counties and 50 states. Most NHs had over 100 beds, were for profit, part of chain organizations, and located in urban areas. Approximately 53% of NH IPs had infection control training and 82% were RNs/advanced clinicians. Compared with NHs employing IPs who were LPNs without training, NHs employing IPs who were RNs/advanced clinicians without training had lower weekly COVID-19 death rates (-1.04 deaths per 1000 residents; 95% CI -1.90, -0.18), and NHs employing IPs who were LPNs with training had lower COVID-19 death rates (-1.09 deaths per 1000 residents; 95% CI -2.07, -0.11) in adjusted models. CONCLUSIONS: NHs with LPN IPs without training in infection control had higher death rates than NHs with LPN IPs with training in infection control, or NHs with RN/advanced clinicians in the IP role, regardless of IP training. IP training of RN/advanced clinician IPs was not associated with death rates. These findings suggest that efforts to standardize and improve IP training may be warranted.
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COVID-19 , Humanos , Estados Unidos/epidemiologia , Casas de Saúde , Instituições de Cuidados Especializados de Enfermagem , Controle de Infecções , CredenciamentoRESUMO
BACKGROUND: The number of pregnant women with opioid use disorder (OUD) has increased over time. Although effective treatment options exist, little is known about the extent to which women receive treatment during pregnancy and at what stage of pregnancy care is initiated. METHODS: Using a national private health insurance claims database, we identified women aged 13-49 who gave birth in 2006-2019 and had an OUD or nonfatal opioid overdose (NFOO) diagnosis during the year prior to or at delivery. We then identified women who received their first OUD treatment prior to or during pregnancy. In this cross-sectional study, we investigated how rates and timing of the initial OUD treatment changed over time. Furthermore, we examined factors associated with early initiation of OUD treatment among birthing people. RESULTS: Of the 7057 deliveries from 6747 women with OUD or NFOO, 63.3 % received any OUD treatment. Rates of OUD treatment increased from 42.9 % in 2006 to 69 % in 2019. Of those treated, in 2006, 54.5 % received their first treatment prior to conception and 24.2 % initiated care during the 1st trimester. In 2019, 68.9 % received their first treatment prior to conception, and 15.1 % initiated care during the 1st trimester. The percentage of women who were first treated in the 2nd trimester or later decreased from 21.2 % in 2006 to 16.1 % in 2019. Factors associated with early treatment initiation include being 25 years or older (age 25-34: aOR, 1.51, 95 % CI, 1.28-1.78; age 35-49: aOR, 1.82, 95 % CI, 1.39-2.37), living in urban areas (aOR, 1.28; 95 % CI, 1.05-1.56), having pre-existing behavioral health comorbidities such as anxiety disorders (aOR, 1.8; 95 % CI, 1.40-2.32), mood disorders (aOR, 1.63; 95 % CI, 1.02-2.61), and substance use disorder other than OUD (aOR, 2.56; 95 % CI, 2.03-3.32). CONCLUSION: Overall, rates of OUD treatment increased over time, and more women initiated OUD treatment prior to conception. Despite these improvements, over one-third of pregnant women with OUD/NFOO either received no treatment or did not initiate care until the 3rd trimester in 2019. Future research should examine barriers to OUD treatment initiation among pregnant women.
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Transtornos Relacionados ao Uso de Opioides , Humanos , Feminino , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Gravidez , Adulto , Estudos Transversais , Adulto Jovem , Adolescente , Pessoa de Meia-Idade , Complicações na Gravidez/tratamento farmacológico , Complicações na Gravidez/epidemiologia , Tratamento de Substituição de Opiáceos , Tempo para o Tratamento/estatística & dados numéricos , Overdose de Opiáceos/epidemiologia , Fatores de TempoRESUMO
We described Medicaid-insured women by receipt of perinatal opioid use disorder (OUD) treatment; and trends and disparities in treatment. Using 2007 to 2012 Medicaid Analytic eXtract data from 45 states and D.C., we identified deliveries among women with OUD. Regressions modeled the association between patient characteristics and receipt of any OUD treatment, medication for OUD (MOUD), and counseling alone during the perinatal period. Rates of any OUD treatment and MOUD for women with perinatal OUD increased over the study period, but trends differed by subgroup. Compared with non-Hispanic White women, Black and American Indian/Alaskan Native (AI/AN) women were less likely to receive any OUD treatment, and Black women were less likely to receive MOUD. Over time, the disparity in receipt of MOUD between Black and White women increased. Overall gains in OUD treatment were driven by improvements in perinatal OUD care for White women and obscured disparities for Black and AI/AN women.
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Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Feminino , Humanos , Gravidez , Negro ou Afro-Americano , Buprenorfina/uso terapêutico , Hispânico ou Latino , Medicaid , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estados Unidos , Brancos , Indígena Americano ou Nativo do AlascaRESUMO
Importance: Fluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited. Objective: To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate. Design, Setting, and Participants: Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023. Exposure: Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing. Main Outcomes and Measures: Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate. Results: The sample included 2405 clinicians, with 107â¯841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance. Conclusions and Relevance: In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.
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Fluoretos , Patient Protection and Affordable Care Act , Estados Unidos , Humanos , Criança , Fluoretos Tópicos/uso terapêutico , Estudos de Coortes , SeguradorasRESUMO
Background: Although use of buprenorphine for treating opioid use disorder increased over the past decade, buprenorphine utilization remains limited in lower-income and rural areas. We examine how the Affordable Care Act Medicaid expansion influenced buprenorphine initiation rates by county income and evaluate how associations differ by county rural-urban status. Methods: This study used nationwide 2009-2018 IQVIA retail pharmacy data and a comparative interrupted time series framework-a hybrid framework combining regression discontinuity and difference-in-difference approaches. We used piecewise linear estimation to quantify changes in buprenorphine initiation rates before and after Medicaid expansion. Results: The sample included observations from 376,704 county-months. We identified 5,227,340 new buprenorphine treatment episodes, with an average of 9.2 new buprenorphine episodes per month per 100,000 county residents. Among urban counties, those with the lowest median incomes experienced significantly larger increases in buprenorphine initiation rates associated with Medicaid expansion than counties with higher median incomes (5-year rates difference est=3525.3, se=1695.3, p = 0.04). However, among rural counties, there was no significant association between buprenorphine initiation rates and county median income after Medicaid expansion (5-year rates difference est=979.0, se=915.8, p = 0.29). Conclusions: Medicaid expansion was associated with a reduction in income-related buprenorphine disparities in urban counties, but not in rural counties. To achieve more equitable buprenorphine access, future policies should target low-income rural areas.
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OBJECTIVE: National guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application. METHODS: We conducted virtual semi-structured interviews with a purposive sample (eg, FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research (CFIR) served as the study's theoretical framework and data were analyzed using a modified grounded theory approach. RESULTS: Of the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: variation in perceived adequacy of reimbursement; differences in FV application across practice types; variation in processes, protocols, and priorities; external accountability for quality of care; and potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral health care; and desire for preventive care coordination with dentists. CONCLUSIONS: This study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.
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Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82-0.96]; P=0.003) for patients hospitalized during weeks when the hospital's proportion of patients with COVID-19 was >30%. The overall rates of motor deficits (P=0.25) did not increase, and the rates of reperfusion therapy did not decrease as the weekly COVID-19 burden increased. Black patients had lower 30-day mortality (aOR, 0.70 [95% CI, 0.69-0.72]; P<0.001) but higher rates of motor deficits (aOR, 1.14 [95% CI, 1.12-1.16]; P<0.001) than White individuals. Hispanic patients had lower 30-day mortality and similar rates of motor deficits compared with White individuals. There was no differential increase in adverse outcomes or reduction in reperfusion therapy among Black and Hispanic individuals compared with White individuals as the weekly COVID-19 burden increased. Conclusions This national study of Medicare patients found no evidence that the hospital COVID-19 burden exacerbated disparities in treatment and outcomes for Black and Hispanic individuals admitted with an acute ischemic stroke.
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COVID-19 , AVC Isquêmico , Acidente Vascular Cerebral , Idoso , Humanos , Negro ou Afro-Americano , COVID-19/terapia , Medicare , Pandemias , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Resultado do Tratamento , Estados Unidos/epidemiologia , Hispânico ou Latino , BrancosRESUMO
Importance: The COVID-19 pandemic disrupted usual care for emergent conditions, such as acute myocardial infarction (AMI). Understanding whether Black and Hispanic individuals experiencing AMI had greater increases in poor outcomes compared with White individuals during the pandemic has important equity implications. Objective: To investigate whether the COVID-19 pandemic was associated with increased disparities in treatment and outcomes among Medicare patients hospitalized with AMI. Design, Setting, and Participants: This cross-sectional study used Medicare data for patients hospitalized with AMI between January 2016 and November 2020. Patients were categorized as Hispanic, non-Hispanic Black, and non-Hispanic White. The association between race and ethnicity and outcomes as a function of the proportion of hospitalized patients with COVID-19 was evaluated using interrupted time series. Data were analyzed from October 2022 to June 2023. Exposure: The main exposure was a hospital's proportion of hospitalized patients with COVID-19 on a weekly basis as a proxy for care disruption during the pandemic. Main Outcomes and Measures: Revascularization, 30-day mortality, 30-day readmission, and nonhome discharges. Results: A total of 1â¯319â¯273 admissions for AMI (579â¯817 females [44.0%]; 122â¯972 Black [9.3%], 117â¯668 Hispanic [8.9%], and 1â¯078â¯633 White [81.8%]; mean [SD] age, 77 [8.4] years) were included. For patients with non-ST segment elevation MI (NSTEMI) overall, the adjusted odds of mortality and nonhome discharges increased by 51% (adjusted odds ratio [aOR], 1.51; 95% CI, 1.29-1.76; P < .001) and 32% (aOR, 1.32; 95% CI, 1.15-1.52; P < .001), respectively, and the odds of revascularization decreased by 27% (aOR, 0.73; 95% CI, 0.64-0.83; P < .001) among patients hospitalized during weeks with a high hospital COVID-19 burden (>30%) vs patients hospitalized prior to the pandemic. Black individuals with NSTEMI experienced a clinically insignificant 7% greater increase in the odds of mortality (aOR, 1.07; 95% CI, 1.00-1.15; P = .04) for each 10% increase in the COVID-19 hospital burden but no increases in readmissions or nonhome discharges or reductions in revascularization rates compared with White individuals. There were no differential increases in adverse outcomes among Hispanic compared with White patients with NSTEMI based on hospital COVID-19 burden. Increases in hospital COVID-19 burden were not associated with changes in outcomes or the use of revascularization in STEMI overall or by racial or ethnic group. Conclusions and Relevance: This study found that while hospital COVID-19 burden was associated with worse treatment and outcomes for NSTEMI, race and ethnicity-associated inequities did not increase significantly during the pandemic. These findings suggest the need for additional efforts to mitigate outcomes associated with the COVID-19 pandemic for patients admitted with AMI when the hospital COVID-19 burden is substantially increased.
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COVID-19 , Infarto do Miocárdio , Infarto do Miocárdio sem Supradesnível do Segmento ST , Estados Unidos/epidemiologia , Feminino , Humanos , Idoso , Pandemias , COVID-19/epidemiologia , Estudos Transversais , Medicare , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Resultado do TratamentoRESUMO
Importance: New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care. Objective: To evaluate changes in nursing home use among older adults with dementia following MLTC implementation. Design, Setting, and Participants: This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019. Exposure: Mandatory MLTC enrollment. Main Outcomes and Measures: Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators. Results: This sample included 463â¯947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year). Conclusions and Relevance: The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.
Assuntos
Demência , Medicaid , Humanos , Feminino , Idoso , Estados Unidos , Masculino , Medicare , Estudos de Coortes , Serviços de Saúde Comunitária , Casas de Saúde , Cidade de Nova Iorque , Demência/terapiaRESUMO
BACKGROUND: Poor quality of care in nursing homes (NHs) with high proportions of Black residents has been a problem in the US and even more pronounced during the COVID-19 pandemic. Federal and state agencies are devoting attention to identifying the best means of improving care in the neediest facilities. It is important to understand environmental and structural characteristics that may have led to poor healthcare outcomes in NHs serving high proportions of Black residents pre-pandemic. METHODS: We conducted a cross-sectional observational study using multiple 2019 national datasets. Our exposure was the proportion of Black residents in a NH (i.e., none, <5%, 5%-19.9%, 20-49.9%, ≥50%). Healthcare outcomes examined were hospitalizations and emergency department (ED) visits, both observed and risk-adjusted. Structural factors included staffing, ownership status, bed count (0-49, 50-149, or ≥150), chain organization membership, occupancy, and percent Medicaid as a payment source. Environmental factors included region and urbanicity. Descriptive and multivariable linear regression models were estimated. RESULTS: In the 14,121 NHs, compared to NHs with no Black residents, NHs with ≥50% Black residents tended to be urban, for-profit, located in the South, have more Medicaid-funded residents, and have lower ratios of registered-nurse (RN) and aide hours per resident per day (HPRD) and greater ratios of licensed practical nurse HPRD. In general, as the proportion of Black residents in a NH increased, hospitalizations and ED visits also increased. DISCUSSION/IMPLICATIONS: As lower use of RNs has been associated with increased ED visits and hospitalizations in NHs generally, it is likely low RN use largely drove the differences in hospitalizations and ED visits in NHs with greater proportions of Black residents. Staffing is an area in which state and federal agencies should take action to improve the quality of care in NHs with larger proportions of Black residents.
Assuntos
COVID-19 , Pandemias , Estados Unidos , Humanos , Estudos Transversais , COVID-19/epidemiologia , Casas de Saúde , HospitalizaçãoRESUMO
BACKGROUND AND OBJECTIVES: Laws liberalizing access to medical marijuana are associated with reduced opioid analgesic use among adults, but little is known about the impact of such policies on adolescents and young adults. METHODS: This retrospective cohort study used 2005 to 2014 claims from MarketScan® Commercial database, which covers all 50 states and Washington D.C. The sample included 195,204 adolescent and young adult patients (aged 12-25) who underwent one of 13 surgical procedures. RESULTS: Of the 195,204 patients, 4.8% had prolonged opioid use. Several factors were associated with a higher likelihood of prolonged opioid use, including being female (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.21-1.33), longer hospital stay (aOR, 1.04; 95% CI, 1.02-1.06), greater days of index opioid supply (8-14 days: aOR, 1.39, 95% CI, 1.33-1.45; greater than 14 days: aOR, 2.42, 95% CI, 2.26-2.59), rural residence (aOR, 1.07; 95% CI, 1.01-1.14), and cholecystectomy (aOR, 1.16; 95% CI, 1.08-1.25). There was not a significant association of medical marijuana dispensary laws on prolonged opioid use (aOR, 0.98; 95% CI, 0.81-1.18). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Medical marijuana has been suggested as a substitute for opioids, but our results focusing on adolescents and young adults provide new evidence that this particularly vulnerable population does not exhibit reductions in prolonged use of opioids after surgery when they have legal access to medical marijuana. These findings are the first to demonstrate potentially important age differences in sustained use of opioids, and point to the need for prescriber oversight and management with this vulnerable population.
Assuntos
Cannabis , Maconha Medicinal , Transtornos Relacionados ao Uso de Opioides , Humanos , Adolescente , Adulto Jovem , Feminino , Estados Unidos/epidemiologia , Masculino , Analgésicos Opioides/uso terapêutico , Maconha Medicinal/uso terapêutico , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológicoRESUMO
BACKGROUND: Buprenorphine is a key medication to treat opioid use disorder (OUD). Since its approval in 2002, buprenorphine access has grown markedly, spurred by major federal and state policy changes. This study characterizes buprenorphine treatment episodes during 2007 to 2018 with respect to payer, provider specialty, and patient demographics. METHODS: In this observational cohort study, IQVIA Real World pharmacy claims data were used to characterize trends in buprenorphine treatment episodes across four time periods: 2007-2009, 2010-2012, 2013-2015, and 2016-2018. RESULTS: In total, we identified more than 4.1 million buprenorphine treatment episodes among 2 540 710 unique individuals. The number of episodes doubled from 652 994 in 2007-2009 to 1 331 980 in 2016-2018. Our findings indicate that the payer landscape changed dramatically, with the most pronounced growth observed for Medicaid (increased from 17% of episodes in 2007-2009 to 37% of episodes in 2016-2018), accompanied by relative declines for both commercial insurance (declined from 35 to 21%) and self-pay (declined from 27 to 11%). Adult primary care providers (PCPs) were the dominant prescribers throughout the study period. The number of episodes among adults older than 55 increased more than 3-fold from 2007-2009 to 2016-2018. In contrast, youth under age 18 experienced an absolute decline in buprenorphine treatment episodes. Buprenorphine episodes increased in length from 2007-2018, particularly among adults over age 45. CONCLUSIONS: Our findings demonstrate that the U.S. experienced clear growth in buprenorphine treatment-particularly for older adults and Medicaid beneficiaries-reflecting some key health policy and implementation success stories. Yet, since the prevalence of OUD and fatal overdose rate have also approximately doubled during this period, the observed growth in buprenorphine treatment did not demonstrably impact the pronounced treatment gap. To date, only a minority of individuals with OUD currently receive treatment, indicating continued need for systemic efforts to equitably improve treatment uptake.
Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Adolescente , Estados Unidos/epidemiologia , Humanos , Idoso , Pessoa de Meia-Idade , Buprenorfina/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Medicaid , Estudos de Coortes , Analgésicos Opioides/uso terapêuticoRESUMO
Importance: Expanding the use of buprenorphine for treating opioid use disorder is a critical component of the US response to the opioid crisis, but few studies have examined how state policies are associated with buprenorphine dispensing. Objective: To examine the association of 6 selected state policies with the rate of individuals receiving buprenorphine per 1000 county residents. Design, Setting, and Participants: This cross-sectional study used 2006 to 2018 US retail pharmacy claims data for individuals dispensed buprenorphine formulations indicated for treating opioid use disorder. Exposures: State implementation of policies requiring additional education for buprenorphine prescribers beyond waiver training, continuing medical education related to substance misuse and addiction, Medicaid coverage of buprenorphine, Medicaid expansion, mandatory prescriber use of prescription drug monitoring programs, and pain management clinic laws were examined. Main Outcomes and Measures: The main outcome was buprenorphine treatment months per 1000 county residents as measured using multivariable longitudinal models. Statistical analyses were conducted from September 1, 2021, through April 30, 2022, with revised analyses conducted through February 28, 2023. Results: The mean (SD) number of months of buprenorphine treatment per 1000 persons nationally increased steadily from 1.47 (0.04) in 2006 to 22.80 (0.55) in 2018. Requiring that buprenorphine prescribers receive additional education beyond that required to obtain the federal X-waiver was associated with significant increases in the number of months of buprenorphine treatment per 1000 population in the 5 years following implementation of the requirement (from 8.51 [95% CI, 2.36-14.64] months in year 1 to 14.43 [95% CI, 2.61-26.26] months in year 5). Requiring continuing medical education for physician licensure related to substance misuse or addiction was associated with significant increases in buprenorphine treatment per 1000 population in each of the 5 years following policy implementation (from 7.01 [95% CI, 3.17-10.86] months in the first year to 11.43 [95% CI, 0.61-22.25] months in the fifth year). None of the other policies examined was associated with a significant change in buprenorphine months of treatment per 1000 county residents. Conclusions and Relevance: In this cross-sectional study of US pharmacy claims, state-mandated educational requirements beyond the initial training required to prescribe buprenorphine were associated with increased buprenorphine use over time. The findings suggest requiring education for buprenorphine prescribers and training in substance use disorder treatment for all controlled substance prescribers as an actionable proposal for increasing buprenorphine use, ultimately serving more patients. No single policy lever can ensure adequate buprenorphine supply; however, policy maker attention to the benefits of enhancing clinician education and knowledge may help to expand buprenorphine access.