The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System.

BACKGROUND: Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain - Army soldiers returning from deployment. METHODS: Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008-2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures. RESULTS: In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care. CONCLUSIONS: Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management.

Psychometric Performance of the SF-6D Quality of Life Measure in an Outpatient Population with Bipolar Disorder.

BACKGROUND: Bipolar disorder is among the top 10 causes of disability worldwide. The Short-Form Six-Dimension (SF-6D) is a frequently used measure of preference-based health-related quality of life (HRQOL). However, this measure's psychometric performance has not been tested in outpatient patients with bipolar disorder. AIMS OF THE STUDY: This study assessed the psychometric properties of the SF-6D, including convergent validity, known-groups validity, and responsiveness. METHODS: We examined convergent validity between the SF-6D and four condition-specific measures of functioning (LIFE-RIFT), life satisfaction (QLESQ), depressive symptoms (MADRS), and manic symptoms (YMRS). We used known-groups validity tests to compare the SF-6D health utility values estimated for patients in different clinical states, including depression, mania, hypomania, and recovered. We assessed the responsiveness of the SF-6D by comparing the sensitivity of the SF-6D utility values to longitudinal changes in the four condition-specific measures during the same period of time. We conducted all analyses using data from 2,627 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) clinical trial. RESULTS: The SF-6D demonstrated moderate (0.3-0.7) convergence with the LIFE-RIFT, QLESQ, and MADRS measures. Convergence with the manic symptoms measure (YMRS) was weak (<0.3). For known-groups validity, the SF-6D distinguished the recovered state from the three symptomatic clinical states. For responsiveness, the measure did not show floor or ceiling effects. The SF-6D utility value increased when mental health improved, with a small ES of 0.3 over the 1-year period, which was comparable to the four condition-specific measures. DISCUSSION: The SF-6D demonstrated moderate convergent validity, moderate responsiveness, and it can distinguish the differences between known-groups that had been identified in literature. The SF-6D may be a suitable measure of preference-based HRQOL for patients with bipolar disorder, but caution is needed due to its lower convergence with the YMRS mania scale. LIMITATIONS: The subsample of patients in manic episode was small, which may reduce the reliability of study findings regarding this specific clinical state. In terms of generalizability, the STEP-BD study sample is based on patients who received treatment in bipolar specialty clinics affiliated with academic medical centers, which may be different from other outpatient clinics. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The mean health utility value for patients with hypomania is significantly lower than the mean value for recovered patients. This finding emphasizes the importance of treating hypomania. IMPLICATION FOR HEALTH POLICIES: This study validates an existing approach toward generating health utility values for bipolar disorder. These utility values can be used to create quality-adjusted life years (QALYs), which are the most commonly used measure of health benefit in cost-effectiveness studies. IMPLICATIONS FOR FURTHER RESEARCH: Studies with larger samples of patients with mania are needed to study measures of health utility in this patient population.

Examining differences in prescription opioid use behaviors among U.S. adults with and without disabilities.

We aimed to identify differences in prescription opioid-related behaviors between adults with and without disabilities in the U.S. We analyzed data from the 2015-2017 National Survey on Drug Use and Health (128,740 individuals; weighted N of 244,831,740) to examine disability-based differences in (1) reasons and sources of last prescription opioid misuse and, in multivariate models overall and stratified by disability, the likelihood of (2) prescription opioid use, and if used, (3) misuse and prescription opioid use disorder (OUD), overall and stratified by disability. Adults with disabilities were 11% more likely than adults without disabilities to report any past-year prescription opioid use, adjusted for sociodemographic, health, and behavioral health characteristics. However, among adults with any prescription opioid use, which is more common among people with disabilities, likelihood of prescription OUD did not vary by disability status. Pain relief as the reason for last misuse was associated with 18% increased likelihood of prescription OUD, if any use. To reduce risk of opioid misuse among people with disabilities, accessible and inclusive chronic pain management services are essential. Further, the substance use treatment field should provide accessible and inclusive services, and be aware of the need for pain management by many people with disabilities, which may include the use of prescription opioids. These findings highlight essential opportunities for public health and policies to improve access, accommodations, and quality of health and behavioral health care for people with disabilities, and to encourage a holistic perspective of people with disabilities and their needs.

Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among Adults.

OBJECTIVE: To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. PARTICIPANTS: Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). DESIGN: Secondary analyses of a statewide population-based cross-sectional survey. MAIN MEASURES: Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. RESULTS: In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. CONCLUSION: Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

The impact of the introduction of generic aromatase inhibitors on adherence to hormonal therapy over the full course of 5-year treatment for breast cancer.

BACKGROUND: High out-of-pocket costs (OOPCs) often are found to be inversely associated with adherence to medical treatment. The introduction of generic aromatase inhibitors (GAIs) significantly reduced the OOPCs of patients. The objective of the current study was to explore the impact of the introduction of GAIs on adjuvant hormone therapy (AHT) adherence over the full course of breast cancer treatment. METHODS: Women aged ≥65 years who were diagnosed with hormone receptor-positive breast cancer from 2007 through mid-2009 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Multivariate logistic regression was used to estimate the likelihood of AHT initiation and an interrupted time series model was used to predict the association between the introduction of GAIs and AHT adherence. The model was stratified further using Medicare low-income subsidy (LIS) status. RESULTS: A total of 10,905 women were included, approximately 62.8% of whom initiated AHT within the first year of their breast cancer diagnosis. Adjusted adherence among LIS beneficiaries was 11.4% higher than among non-LIS beneficiaries (P < .001). Non-LIS beneficiaries had an overall decreasing trend of adherence (-0.035; P < .001) prior to the introduction of GAIs. They experienced a 3.4% increase in the slope 6 months after the first GAI, anastrozole, entered the market, and an additional 0.8% increase in the slope 6 months after letrozole and exemestane were introduced (P < .001). Adherence change among LIS patients was small and statistically insignificant. CONCLUSIONS: With the introduction of GAIs, the decrease trend of adherence to therapy atteunated over the course of treatment. Although the successful implementation of the Medicare LIS program minimized the OOPCs for financially vulnerable patients, policymakers should be cautious not to introduce disparities for those who may be of low income but ineligible for such a program.

Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration.

BACKGROUND: Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined. OBJECTIVE: To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA). DESIGN AND PARTICIPANTS: A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group. EXPOSURES: NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports. MAIN MEASURES: Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018. KEY RESULTS: The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts. CONCLUSIONS: NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.

Evaluating the feasibility and impact of case rate payment for recovery support navigator services: a mixed methods study.

BACKGROUND: Acute 24-h detoxification services (detox) are necessary but insufficient for many individuals working towards long-term recovery from opiate, alcohol or other drug addiction. Longer engagement in substance use disorder (SUD) treatment can lead to better health outcomes and reductions in overall healthcare costs. Connecting individuals with post-detox SUD treatment and supportive services is a vital next step. Toward this end, the Massachusetts Medicaid program reimburses Community Support Program staff (CSPs) to facilitate these connections. CSP support services are typically paid on a units-of-service basis. As part of a larger study testing health care innovations, one large Medicaid insurer developed a new cadre of workers, called Recovery Support Navigators (RSNs). RSNs performed similar tasks to CSPs but received more extensive training and coaching and were paid an experimental case rate (a flat negotiated reimbursement). This sub-study evaluates the feasibility and impact of case rate payments for RSN services as compared to CSP services paid fee-for-service. METHODS: We analyzed claims data and RSN service data for a segment of the Massachusetts Medicaid population who had more than one detox admission in the last year and also engaged in post-discharge CSP or RSN services. Qualitative data from key informant interviews and Learning Collaboratives with CSPs and RSNs supplemented the findings. RESULTS: Clients receiving RSN services under the case rate utilized the service significantly longer than clients receiving CSP services under unit-based billing. This resulted in a lower average cost per member per month for RSN clients. However, when calculating total SUD treatment costs per member, RSN client costs were 50% higher than CSP client costs. Provider organizations employing RSNs successfully implemented case rate billing. Benefits included allowing time for outreach efforts and training and coaching, activities not paid under the unit-based system. Yet, RSNs identified staffing and larger systems level challenges to consider when using a case rate payment model. CONCLUSIONS: Addiction is a chronic disease that requires long-term investments. Case rate billing offers a promising option for payers and providers as it promotes continued engagement with service providers. To fully realize the benefits of case rate billing, however, larger systems level changes are needed.

Exploration of the association of selected pain diagnoses with risky alcohol use among active duty soldiers.

BACKGROUND: Pain and its consequences remain of concern, particularly in high-risk occupations such as the military. Alcohol is a legal and accessible means of self-medication, and risky alcohol use is associated with potentially serious consequences. This exploratory analysis aimed to better understand the association of selected pain diagnoses with risky alcohol use among soldiers returning from deployment. Methods: Analysis of data from active duty soldiers returning from Afghanistan or Iraq deployments in fiscal years 2008-2011 who completed Department of Defense health questionnaires after deployment (n = 267,100). Each questionnaire included self-reported alcohol consumption and items yielding AUDIT-C screening scores. Military Health System data were used to identify diagnoses of pain-related conditions. Results: About 70% of soldiers had none of the selected pain diagnoses either pre- or post-deployment. 10% had incident pain diagnoses (only post-deployment), 7% had persistent pain diagnoses (both pre- and post-deployment), and 13% had remitted pain diagnoses (only pre-deployment). On the AUDIT-C, 39% screened positive for at-risk drinking and 6% were likely to have severe alcohol problems. Half of the respondents reported any binge drinking; 20% at least monthly binge drinking. Logistic regression analyses found reduced odds of risky alcohol use post-deployment in association with incident and persistent pain diagnoses, compared to no pain diagnoses pre- or post-deployment. Conclusions: Pain diagnoses, binge drinking, and risky alcohol use were prevalent among this sample of Army soldiers. An inverse relationship was found between pain diagnosis (incident, persistent) and risky alcohol use post-deployment. Attention should continue to be paid to risky alcohol use in this population, yet these exploratory findings do not suggest that soldiers with the pain diagnoses used in this study are at greater risk. Combat exposure, traumatic brain injury, and psychological health were more important predictors, and should continue to warrant enhanced alcohol screening.

Cost Savings from a Navigator Intervention for Repeat Detoxification Clients.

BACKGROUND: Many clients with substance use disorders (SUD) have multiple admissions to a 24-hour level of care for detoxification without ever progressing to SUD treatment. In the US, health insurers have become concerned about the high costs and ineffective results of repeat detox admissions. For other diseases, health systems increasingly target high-risk, high-cost patients with individually tailored interventions delivered by `navigators' who help patients negotiate the complex health care system. Patient incentives are another increasingly common intervention. AIMS OF THE STUDY: (i) To examine how health care spending was affected by an intervention intended to improve entry to SUD treatment among clients who had multiple detox admissions. (ii) To see whether spending effects, overall and by type of service, differed by intervention arm. (iii) To assess whether the intervention resulted in net savings from the payer perspective, after subtracting implementation costs. METHODS: The intervention was implemented in a segment of the Massachusetts Medicaid population, and used Recovery Support Navigators (RSNs) who were trained to effectively engage and connect clients with SUD to follow-up care and community resources. Services were funded using a flat daily rate per client. Additionally, in one of the two intervention arms, clients were offered successive incentive payments for meeting pre-specified milestones to reinforce recovery-oriented behaviors. For this paper, multivariate analyses of claims and administrative data were used to measure the intervention's effect on health care spending, and to estimate net savings to the payer. RESULTS: Health care spending grew 1.6 percentage points more slowly for intervention-enrolled members than for others, implying gross savings of $68 per member per month. After subtracting intervention-related costs, net savings were estimated at $57 per member per month. The intervention was also associated with shifts in the health care service mix from more to less acute settings. DISCUSSION: While the results for total spending did not reach statistical significance, they suggest some potential for insurers to reduce the health care costs associated with repeat detox utilization by using a navigator-based intervention. Analyses reported elsewhere found that this intervention had favorable effects on rates of initiation of SUD treatment. Limitations of the study include the fact that neither subjects nor sites were randomized between study groups; lack of data on crime or productivity outcomes; low participant use of RSN services; and a policy change which altered the participant pool and truncated follow-up for some. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest some potential for payers to reduce the health care costs associated with repeat detox by using a navigator-based intervention. To the extent that this results in shifting resources from repeat detox to actual treatment, the result should provide longer term benefit to the population coping with SUD. IMPLICATIONS FOR HEALTH POLICY: These results may encourage Medicaid and other payers to further experiment with similar interventions using navigators to decrease health care costs and improved the lives of SUD patients. IMPLICATIONS FOR FURTHER RESEARCH: It could be informative to test similar navigator interventions for detox patients in other settings where enrollment periods are longer.

Use of Systematic Methods to Improve Disease Identification in Administrative Data: The Case of Severe Sepsis.

BACKGROUND: Selection of International Classification of Diseases (ICD)-based coded information for complex conditions such as severe sepsis is a subjective process and the results are sensitive to the codes selected. We use an innovative data exploration method to guide ICD-based case selection for severe sepsis. METHODS: Using the Nationwide Inpatient Sample, we applied Latent Class Analysis (LCA) to determine if medical coders follow any uniform and sensible coding for observations with severe sepsis. We examined whether ICD-9 codes specific to sepsis (038.xx for septicemia, a subset of 995.9 codes representing Systemic Inflammatory Response syndrome, and 785.52 for septic shock) could all be members of the same latent class. RESULTS: Hospitalizations coded with sepsis-specific codes could be assigned to a latent class of their own. This class constituted 22.8% of all potential sepsis observations. The probability of an observation with any sepsis-specific codes being assigned to the residual class was near 0. The chance of an observation in the residual class having a sepsis-specific code as the principal diagnosis was close to 0. Validity of sepsis class assignment is supported by empirical results, which indicated that in-hospital deaths in the sepsis-specific class were around 4 times as likely as that in the residual class. CONCLUSIONS: The conventional methods of defining severe sepsis cases in observational data substantially misclassify sepsis cases. We suggest a methodology that helps reliable selection of ICD codes for conditions that require complex coding.

Examining Racial and Ethnic Differences in Nursing Home Quality.

BACKGROUND: Identifying racial/ethnic differences in quality is central to identifying, monitoring, and reducing disparities. Although disparities across all individual nursing home residents and disparities associated with between-nursing home differences have been established, little is known about the degree to which quality of care varies by race//ethnicity within nursing homes. A study was conducted to measure within-facility differences for a range of publicly reported nursing home quality measures. METHODS: Resident assessment data on approximately 15,000 nursing homes and approximately 3 million residents (2009) were used to assess eight commonly used and publicly reported long-stay quality measures: the proportion of residents with weight loss, with high-risk and low-risk pressure ulcers, with incontinence, with depressive symptoms, in restraints daily, and who experienced a urinary tract infection or functional decline. Each measure was stratified by resident race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic), and within-facility differences were examined. RESULTS: Small but significant differences in care on average were found, often in an unexpected direction; in many cases, white residents were experiencing poorer outcomes than black and Hispanic residents in the same facility. However, a broad range of differences in care by race/ethnicity within nursing homes was also found. CONCLUSION: The results suggest that care is delivered equally across all racial/ethnic groups in the same nursing home, on average. The results support the call for publicly reporting stratified nursing home quality measures and suggest that nursing home providers should attempt to identify racial/ethnic within-facility differences in care.

Alcohol Use and HIV Testing in a National Sample of Women.

The HIV/AIDS epidemic continues to disproportionately affect racial and ethnic minority groups and women in the United States. Prevention research suggests that reduced alcohol use and increased HIV testing are associated with lower incidence of HIV transmission among high-risk populations. Multivariable logistic regression analyses of the 2009 National Health Interview Survey data were performed for a national sample of 15,470 adult women to examine the relationship between alcohol use and likelihood of HIV testing. There is a significant association between level of alcohol use and HIV testing. Women who identified as heavy drinkers and moderate drinkers were significantly less likely to report ever testing for HIV. Findings add to the limited literature on the association between alcohol use and HIV testing behaviors among women. Given the incidence of HIV among women, this study highlights the importance of HIV testing, especially for alcohol-using women.

Combat-Acquired Traumatic Brain Injury, Posttraumatic Stress Disorder, and Their Relative Associations With Postdeployment Binge Drinking.

OBJECTIVE: To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD). METHODS: Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28 546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking. MAIN MEASURES: The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD-positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian. RESULTS: The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD. CONCLUSION: Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.

Admissions to detoxification after treatment: Does engagement make a difference?

BACKGROUND: Treatment engagement is a well-established performance measure for the treatment of substance use disorders. This study examined whether outpatient treatment engagement is associated with a reduced likelihood of subsequent detoxification admissions. METHODS: This study used administrative data on treatment services received by clients in specialty treatment facilities licensed in Massachusetts. The sample consisted of 11,591 adult clients who began an outpatient treatment episode in 2006. Treatment engagement was defined as receipt of at least 1 treatment service within 14 days of beginning a new outpatient treatment episode and receipt of at least 2 additional treatment services in the next 30 days. The outcome was a subsequent detoxification admission. Multilevel survival models examined the relationship between engagement and outcomes, with time to detoxification admission as the dependent variable censored at 365 days. RESULTS: Only 35% of clients met the outpatient engagement criteria, and 15% of clients had a detoxification admission within a year after beginning their outpatient treatment episode. Controlling for client demographics, insurance type, and substance use severity, clients who met the engagement criteria had a lower hazard of having a detoxification admission during the year following the index outpatient visit than those who did not engage (hazard ratio = 0.87, P < .01). CONCLUSIONS: Treatment engagement is a useful measure for monitoring quality of care. The findings from this study could help inform providers and policy makers on ways to target care and reduce the likelihood of more intensive services.

Racial/Ethnic disparities in patient experience with communication in hospitals: real differences or measurement errors?

BACKGROUND: An important aspect of medical care is clear and effective communication, which can be particularly challenging for individuals based on race/ethnicity. Quality of communication is measured systematically in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and analyzed frequently such as in the National Healthcare Disparities Report. Caution is needed to discern differences in communication quality from racial/ethnic differences in perceptions about concepts or expectations about their fulfillment. OBJECTIVES: To examine assumptions about the degree of commonality across racial/ethnic groups in their perceptions and expectations, and to investigate the validity of conclusions regarding racial/ethnic differences in communication quality. METHODS: We used 2007 HCAHPS data from the National CAHPS Benchmarking Database to construct racial/ethnic samples that controlled for other patient characteristics (828 per group). Using multiple-groups confirmatory factor analyses, we tested whether the factor structure and model parameters (ie, factor loadings, intercepts) differed across groups. RESULTS: We identified support for basic tests of equivalence across 7 racial/ethnic groups in terms of equivalent factor structure and loadings. Even stronger support was found for Communication with Doctors and Nurses. However, potentially important nonequivalence was found for Communication about Medicines, including instances of statistically significant differences between non-Hispanic whites and non-Hispanic blacks, Asians, and Native Hawaiian/other Pacific Islanders. CONCLUSIONS: Our results provide strongest support for racial/ethnic comparisons on Communication with Nurses and Doctors, and reason to caution against comparisons on Communication about Medicines due to significant differences in model parameters across groups; that is, a lack of invariance in the intercept.

Race/ethnicity and quality indicators for outpatient treatment for substance use disorders.

BACKGROUND AND OBJECTIVES: Initiation and engagement, performance measures that focus on the frequency and timely receipt of services in the early stages of substance use disorders (SUD) treatment, are useful tools for assessing treatment quality differences across racial/ethnic groups. The purpose of this study was to examine whether there are racial/ethnic disparities in these quality indicators and to explore whether predictors of treatment initiation and engagement differ by clients' race/ethnicity. METHODS: This study used administrative data from outpatient treatment facilities licensed by the state of Massachusetts that receive public funding. The sample consisted of 10,666 adult clients (76% White, 13% Latino, 11% Black) who began an outpatient treatment episode in 2006. Client data were linked with facility data from the National Survey on Substance Abuse Treatment Services. Multilevel regressions were used to examine racial/ethnic disparities and to explore whether predictors for initiation and engagement differed by client's race/ethnicity. RESULTS: We did not find evidence of racial/ethnic disparities in treatment initiation or engagement. However, we found that predictors of initiation and engagement differed by client's race/ethnicity. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Disparities may be context specific, and thus it is important that they be examined at state or local levels. Our results point to the importance of examining predictors of quality indicators separately by group to better understand and address the needs of diverse client populations.

Clinician approaches to new spine pain cases in primary care: Balance of opioid prescribing and early linkage to exercise therapy and spinal manipulation.

RATIONALE, AIMS AND OBJECTIVES: Spine pain (SP) is common and often disabling. Clinical practice guidelines discourage opioid treatment and outline the value of varied nonpharmacologic therapies (NPTs). This study elucidates the amount of variability in primary-care clinicians' (PCPs') prescribing of opioids and in their cases' receipt of the two most common NPTs (exercise therapy and spinal manipulation). METHOD: The design was a retrospective cohort study examining variation in the treatment of PCPs' new SP cases, classified by receipt of (a) prescription of an opioid at the initial visit; (b) exercise therapy and/or spinal manipulation within 30 days of initial visit. The study was set in the primary care clinics at military treatment facilities of the US Military Health System in the period between October 2011 and September 2016. RESULTS: The majority of cases did not receive a study treatment (66.3%); 19.6% of cases received only NPT within 30 days of initial visit; 11.5% were prescribed only an opioid at the initial visit with receipt of both NPT and opioid during early treatment rare (2.6%). Exercise therapy within 30 days exhibited more than a twofold difference in interquartile percentile rates (IQR) (median provision 15.8%, IQR 9.8%-22.1%). The other treatments exhibited even greater variation; specifically, spinal manipulation (median 8.5%, IQR 3.3%-15.8%), and opioid at initial visit (median 10.3%, IQR 4.4%-18.2%). The availability of physical therapists and doctors of chiropractic had significant association with several clinical provision rates. CONCLUSION: Among providers of spine care for a sample of Army soldiers, there was substantial variation in the early provision of exercise therapy, spinal manipulation, and opioid prescriptions. The magnitude of the case-mix adjusted variation and its association with facility availability of providers suggests that quality of care initiatives may help reduce this variation.

Expanding access to medication treatment for opioid use disorders: Findings from the Washington State hub and spoke effort.

BACKGROUND: Opioid use disorder (OUD) is a leading cause of preventable death and injury nationwide. Efforts to increase the use of medication for opioid use disorder (MOUD) are needed. In 2017, Washington State implemented a Hub and Spoke (HS) model of care with the primary goal of expanding access to MOUD. We examined changes in MOUD utilization among Washington State Medicaid beneficiaries before and after HS implementation. METHODS: We used Medicaid claims data to examine longitudinal changes in MOUD use for beneficiaries with OUD. We conducted a comparative interrupted time series analysis to examine the association between HS policy implementation and rates of MOUD utilization, overall and by type of medication. RESULTS: Between 2016 and 2019, a period of increasing OUD prevalence, rates of MOUD utilization among Washington Medicaid beneficiaries increased overall from 39.7 to 50.5. Following HS implementation, rates of MOUD use grew at a significantly greater rate in the HS cohort than in the non-HS cohort (ß=0.54, SE=0.02, p< 0.0001, 95% CI 0.49, 0.59). Analyses by medication type show that this rate increase was primarily due to buprenorphine use (ß= 0.61, SE= 0.02, p< 0.0001, 95% CI 0.57, 0.65). CONCLUSION: Improved systems of care are needed to make MOUD accessible to all patients in need. The Washington HS model is one strategy that may facilitate and expand MOUD use, particularly buprenorphine. Over the study period, Washington State saw increased use of buprenorphine, which was an emphasis of their HS model.

Healthcare utilization and readiness outcomes among soldiers with post-deployment at-risk drinking, by multimorbidity class.

Although alcohol use disorder (AUD) regularly co-occurs with other conditions, there has not been investigation of specific multimorbidity classes among military members with at-risk alcohol use. We used latent class analysis (LCA) to cluster 138,929 soldiers with post-deployment at-risk drinking based on their co-occurring psychological and physical health conditions and indicators of alcohol severity. We examined the association of these multimorbidity classes with healthcare utilization and military readiness outcomes. Latent class analysis was conducted on 31 dichotomous indicators capturing alcohol use severity, mental health screens, psychological and physical health diagnoses, and tobacco use. Longitudinal survival analysis was used to examine the relative hazards of class membership regarding healthcare utilization (e.g., emergency department visit, inpatient stay) and readiness outcomes (e.g., early separation for misconduct). Latent class analysis identified five classes: Class 1 -Relatively Healthy (51.6 %); Class 2 - Pain/Tobacco (17.3 %); Class 3 - Heavy Drinking/Pain/Tobacco (13.1 %); Class 4 - Mental Health/Pain/Tobacco (12.7 %); and Class 5 - Heavy Drinking/Mental Health/Pain/Tobacco (5.4 %). Musculoskeletal pain and tobacco use were prevalent in all classes, though highest in Classes 2, 4, and 5. Classes 4 and 5 had the highest hazards of all outcomes. Class 5 generally exhibited slightly higher hazards of all outcomes than Class 4, demonstrating the exacerbation of risk among those with heavy drinking/AUD in combination with mental health conditions and other multimorbidity. This study provides new information about the most common multimorbidity presentations of at-risk drinkers in the military so that targeted, individualized care may be employed. Future research is needed to determine whether tailored prevention and treatment approaches for soldiers in different multimorbidity classes is associated with improved outcomes.

Association of Disability Status and Type With Binge Drinking and Prescription Opioid Misuse Among Adults From a 3-State Sample.

BACKGROUND: Research examining at-risk substance use by disability status is limited, with little investigation into differences by disability type. We investigated binge drinking and prescription opioid misuse among adults with and without disabilities, and by type of disability, to inform need for assessment and intervention within these populations. METHODS: Secondary analyses of adults who completed the disability, alcohol, and prescription opioid misuse items in the 2018 Ohio, Florida, or Nebraska Behavioral Risk Factor Surveillance System surveys (n = 28 341), the only states that included prescription opioid misuse in 2018. Self-reported disability status (yes/no) relied on 6 standardized questions assessing difficulties with: vision, hearing, mobility, cognition, self-care, and independent living (dichotomous, nonmutually exclusive, for each disability). Logistic regression models estimated the association of disability status and type with (1) past 30-day binge drinking and (2) past-year prescription opioid misuse. Additional models were restricted to separate subsamples of adults who: (a) currently drink, (b) received a past-year prescription opioid, and (c) did not receive a past-year prescription opioid. RESULTS: One-third reported at least one disability, with mobility (19.5%), cognitive (11.5%), and hearing (10.2%) disability being the most common. Disability status was associated with lower odds of binge drinking (adjusted odds ratio [AOR] = 0.74, 95% confidence interval [CI] 0.68-0.80, P ≤ .01). However, among adults who currently drink, people with disabilities had higher odds of binge drinking (AOR = 1.11, 95% CI 1.01-1.22, P ≤ .05]. Disability was associated with higher odds of past-year prescription opioid misuse (AOR = 2.51, 95% CI 2.17-2.91, P ≤ .01). CONCLUSIONS: Adults with disabilities had higher odds of prescription opioid misuse, and among adults who currently drink, higher odds for binge drinking were observed. The magnitude of the association between disability status and prescription opioid misuse was particularly concerning. Providers should be trained to screen and treat for substance use problems for people with disabilities.