Who are we missing? Underrepresentation of data sources used for pharmacoepidemiology research in the United States.

PURPOSE: Research using healthcare databases often includes patients frequently excluded from clinical trials; yet it is not known whether commonly used data represents the overall population or specific sub-populations of interest. We aimed to examine population representativeness from data sources in recent research studies in the United States (US). METHODS: We identified data sources from abstracts accepted to the 34th International Conference on Pharmacoepidemiology & Therapeutic Risk Management. The final sample included research studies using ≥1 data source from the US. We classified data sources broadly as claims, linkage, electronic health records (EHR), survey, distributed data network, and other. Studies using claims and EHRs were further classified into more specific categories, including special populations of interest (eg, children). RESULTS: We identified 356 abstracts. The majority used claims data (n = 201, 56.5%), followed by data linkages (n = 46, 12.9%), and EHR data (n = 39, 11.0%). Among EHR studies, most (n = 16, 41.0%) came from network data sources (eg, Kaiser Permanente). Almost half (49.4%) of claims-based studies used commercial claims data sources, followed by Medicare (22.1%), Medicaid (11.3%), and Medicare Supplemental (6.1%). Only 15% of studies included children in the study population (n = 53), with 8% focused on a pediatric topic (n = 27). CONCLUSIONS: We find that certain populations in the US are under-represented in pharmacoepidemiology, particularly Medicaid enrollees and children. Researchers should strive to utilize data sources that may be more representative of the US population, particularly vulnerable populations.

Toward a Health Data Strategy for North Carolina.

In recent years, North Carolina has attracted significant national attention due to numerous health care reforms underway across government and the private sector. These reforms encompass new incentives, new partnerships, and new models of delivering care, and collectively, they have important implications for health care data.

Risk Factors and Outcomes of Opioid Users with and Without Concurrent Benzodiazepine Use in the North Carolina Medicaid Population.

BACKGROUND: Concurrent use of opioids and benzodiazepines is associated with increased risk of opioid overdose and death. Clinical guidelines recommend against this practice and quality measures incentivize plans to minimize concurrent use. OBJECTIVE: To compare comorbidities, risky opioid-related behaviors such as high daily doses or multiple prescribers or pharmacies, and outcomes of users of opioids with and without benzodiazepine in the 2017-2018 North Carolina Medicaid population. METHODS: This was a retrospective claims analysis that used 2017-2018 North Carolina Medicaid enrollment and administrative claims data to describe 3 populations: (1) opioid users who concurrently used benzodiazepine for at least 30 days, (2) opioid users who used some benzodiazepine for 0 to less than 30 overlapping days, and (3) opioid users who did not use benzodiazepines. RESULTS: From 2017 to 2018, 6% of opioid users concurrently used opioids and benzodiazepines for at least 30 days, and 14% used some benzodiazepine for less than 30 overlapping days. Persons filling prescriptions for opioids and benzodiazepines were more likely to have mood disorders and more likely to have depression than opioid users who did not use benzodiazepines. Compared with those not using benzodiazepines, opioid users using benzodiazepine were also more likely to have higher daily opioid doses (at least 90 morphine milligram equivalents), at least 3 prescribers, and at least 3 pharmacies for opioid prescriptions. Although enrollees with at least 30 days of overlapping benzodiazepines and opioids had a higher percentage diagnosed with opioid use disorder compared with those with less than 30 days (30% vs. 13%), a similar percentage received medication-assisted treatment continuously for 90 days (2.6% vs. 2.7%) during 2017-2018. Users of opioids and benzodiazepines, whether for at least 30 overlapping days or less, had higher 1-year cumulative incidences of all-cause outpatient emergency department visits (64% and 65% vs. 52%) and all-cause hospitalizations (25% and 21% vs. 14%) compared with opioid users without benzodiazepine use. CONCLUSIONS: Despite guidelines and quality measures, patients continue to use opioids and benzodiazepines concurrently. Addressing underlying mood disorders and depression, curbing risky opioid-related behaviors, and increasing access to medication-assisted treatment may benefit this population. DISCLOSURES: This project was supported by Arnold Ventures (formerly Arnold Foundation). Hung reports personal fees from CVS Health and Blue Cross Blue Shield Association, unrelated to this work. Maciejewski reports Amgen stock ownership due to spouse employment, unrelated to this work. McKethan reports personal fees from North Carolina Department of Health and Human Services. All other authors have nothing to disclose. Part of this content was presented as a poster at AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.

Engaging Beneficiaries In Medicaid Programs That Incentivize Health-Promoting Behaviors.

Medicaid programs are increasingly adopting incentive programs to improve health behaviors among beneficiaries. There is limited evidence on what incentives are being offered to Medicaid beneficiaries, how programs are engaging beneficiaries, and how programs are evaluated. In 2017-18 we synthesized available information on these programs and interviewed eighty policy stakeholders to identify the rationale behind key program design decisions and stakeholders' recommendations for beneficiary engagement and program evaluation. Key underlying program rationales included improving the use of preventive services and promoting personal responsibility. Beneficiary engagement strategies emphasized meeting members where they are and offering prizes or services customized for certain groups. Stakeholders recommended collaborating with external evaluators to design and conduct robust evaluations of incentive programs. Finally, stakeholders recommended aligning beneficiary incentives with provider incentives and other payment reforms through the use of common meaningful measures to streamline program evaluation.

Integrating Health Information Technology to Achieve Seamless Care Transitions.

Improving care transitions, or "handoffs" as patients migrate from one care setting to another, is a priority across stakeholder groups and health-care settings and additionally is included in national health-care goals set forth in the National Quality Strategy. Although many demonstrations of improved care transitions have succeeded, particularly for hospital discharges, ensuring consistent, high-quality, and safe transitions of care remains challenging. This paper highlights the potential for health information technology to become an increasing part of effective transitional care interventions, with the potential to reduce the resource burden currently associated with effective care transitions, the ability to spread improved practices to larger numbers of patients and providers efficiently and at scale, and, as health technology interoperability increases, the potential to facilitate critical information flow and feedback loops to clinicians, patients, and caregivers across disparate information systems and care settings.

How it's done: Keys to implementation of delivery system reform.

The vision of Obamacare - including the expansion of health care coverage to millions more Americans - rests in no small part on the reduction of health care waste and the spread of cheaper, more sustainable models of health care delivery. Though this will require thoughtful policy, powerful payment incentives and innovative new models of care delivery, it will also require all health care industry stakeholders to execute rapid, large-scale change in practice much more effectively. This paper offers nine strategies for more successfully managing this transformative change.

Health information technology: transforming chronic disease management and care transitions.

Adoption of health information technology (HIT) is a key effort in improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety.

Secondary uses of electronic health record data: benefits and barriers.

In the primary use of health data, patient health information in electronic health records (EHRs) directly informs each individual's care. In secondary use, patient data would be aggregated to improve health care delivery, yet several technological and policy barriers may slow implementation-but may be amenable to intervention.

An early status report on the Beacon Communities' plans for transformation via health information technology.

The Beacon Community Program is part of a federal strategy for using health information technology as a foundation to improve the nation's health care system. In particular, Beacon Communities seek to increase the quality and efficiency of health care, improve the health of individuals and communities, and inform similar initiatives in other parts of the country. Each Beacon Community has set quality, efficiency, and health-related goals, and each is deploying multiple technology-enabled interventions to achieve them. Yet achieving large-scale and sustainable health care improvement also requires an implementation framework that can foster innovation and continuous learning from results. Based on the early experiences of the seventeen diverse Beacon Communities, this paper describes program design features that characterize how these initiatives are organized.

Beacon communities aim to use health information technology to transform the delivery of care.

The Beacon Community Program, authorized under the 2009 American Recovery and Reinvestment Act (ARRA), aims to demonstrate the potential for health information technology to enable local improvements in health care quality, cost efficiency, and population health. If successful, these communitywide efforts will yield important lessons that will assist other communities seeking to harness technology to achieve and sustain health care improvements. This paper highlights key programmatic details that reflect the meaningful use of technology in the fifteen Beacon communities. It describes the innovations they propose and provides insight into current and future challenges.

A national strategy to put accountable care into practice.

The concept of accountable care organizations (ACOs) has been set forth in recently enacted national health reform legislation as a strategy to address current shortcomings in the U.S. health care system. This paper focuses on implementation issues related to these organizations, building on some initial examples. We seek to clarify definitions and key principles, provide an update on implementation in the context of other reforms, and address emerging issues that will affect the organizations' success. Finally, building on the initial experience of several organizations that are implementing accountable care and complementary reforms, we propose a national strategy to identify and expand successful approaches to accountable care implementation.

Uniting the tribes of health system improvement.

Nested within a growing national consensus that the performance of the US healthcare system needs to be improved are largely distinct "tribes" of experts with varying interpretations of what would constitute improvement: the quality improvement tribe, the payment reform tribe, the consumer engagement tribe, and the HIT tribe.

Reforming the Medicaid disproportionate-share hospital program.

Congress and the Obama administration are considering redirecting federal spending on the Medicaid disproportionate-share hospital (DSH) program to help pay for health reform. In this paper, we propose linking federal Medicaid DSH funding to state-level Medicaid enrollment or uninsured populations, or both. This approach could produce as much as $44 billion in federal savings over time without exposing hospitals to uncertain or across-the-board spending cuts. It could also gradually address state variations in Medicaid DSH funding. We also offer ideas to ensure that DSH spending is more directly connected than it is now to improvements in care for vulnerable populations.