Racial Inequality in Receipt of Medications for Opioid Use Disorder.

BACKGROUND: Since 2010, Black persons in the United States have had a greater increase in opioid overdose-related mortality than other groups, but national-level evidence characterizing racial and ethnic disparities in the use of medications for opioid use disorder (OUD) is limited. METHODS: We used Medicare claims data from the 2016-2019 period for a random 40% sample of fee-for-service beneficiaries who were Black, Hispanic, or White; were eligible for Medicare owing to disability; and had an index event related to OUD (nonfatal overdose treated in an emergency department or inpatient setting, hospitalization with injection drug use-related infection, or inpatient or residential rehabilitation or detoxification care). We measured the receipt of medications to treat OUD (buprenorphine, naltrexone, and naloxone), the receipt of high-risk medications (opioid analgesics and benzodiazepines), and health care utilization, all in the 180 days after the index event. We estimated differences in outcomes according to race and ethnic group with adjustment for beneficiary age, sex, index event, count of chronic coexisting conditions, and state of residence. RESULTS: We identified 25,904 OUD-related index events among 23,370 beneficiaries, with 3937 events (15.2%) occurring among Black patients, 2105 (8.1%) among Hispanic patients, and 19,862 (76.7%) among White patients. In the 180 days after the index event, patients received buprenorphine after 12.7% of events among Black patients, after 18.7% of those among Hispanic patients, and after 23.3% of those among White patients; patients received naloxone after 14.4%, 20.7%, and 22.9%, respectively; and patients received benzodiazepines after 23.4%, 29.6%, and 37.1%, respectively. Racial differences in the receipt of medications to treat OUD did not change appreciably from 2016 to 2019 (buprenorphine receipt: after 9.1% of index events among Black patients vs. 21.6% of those among White patients in 2016, and after 14.1% vs. 25.5% in 2019). In all study groups, patients had multiple ambulatory visits in the 180 days after the index event (mean number of visits, 6.6 after events among Black patients, 6.7 after events among Hispanic patients, and 7.6 after events among White patients). CONCLUSIONS: Racial and ethnic differences in the receipt of medications to treat OUD after an index event related to this disorder among patients with disability were substantial and did not change over time. The high incidence of ambulatory visits in all groups showed that disparities persisted despite frequent health care contact. (Funded by the National Institute on Drug Abuse and the National Institute on Aging.).

Racial Inequality in Prescription Opioid Receipt - Role of Individual Health Systems.

BACKGROUND: Historically, the receipt of prescription opioids has differed among racial groups in the United States. Research has not sufficiently explored the contribution of individual health systems to these differences by examining within-system prescription opioid receipt according to race. METHODS: We used 2016 and 2017 Medicare claims data from a random 40% national sample of fee-for-service, Black and White beneficiaries 18 to 64 years of age who were attributed to health systems. We identified 310 racially diverse systems (defined as systems with ≥200 person-years each for Black and White patients). To test representativeness, we compared patient characteristics and opioid receipt among the patients in these 310 systems with those in the national sample. Within the 310 systems, regression models were used to explore the difference between Black and White patients in the following annual opioid measures: any prescription filled, short-term receipt of opioids, long-term receipt of opioids (one or more filled opioid prescriptions in all four calendar quarters of a year), and the opioid dose in morphine milligram equivalents (MME); models controlled for patient characteristics, state, and system. RESULTS: The national sample included 2,197,153 person-years, and the sample served by 310 racially diverse systems included 896,807 person-years (representing 47.4% of all patients and 56.1% of Black patients in the national sample). The national sample and 310-systems sample differed meaningfully only in the percent of person-years contributed by Black patients (21.3% vs. 25.9%). In the 310-systems sample, the crude annual prevalence of any opioid receipt differed slightly between Black and White patients (50.2% vs. 52.2%), whereas the mean annual dose was 36% lower among Black patients than among White patients (5190 MME vs. 8082 MME). Within systems, the adjusted race differences in measures paralleled the population trends: the annual prevalence of opioid receipt differed little, but the mean annual dose was higher among White patients than among Black patients in 91% of the systems, and at least 15% higher in 75% of the systems. CONCLUSIONS: Within individual health systems, Black and White patients received markedly different opioid doses. These system-specific findings could facilitate exploration of the causes and consequences of these differences. (Funded by the National Institute on Aging and the Agency for Healthcare Research and Quality.).

Hospital Capabilities Associated With Behavioral Health Integration Within Emergency Departments.

OBJECTIVES: To identify hospital capabilities associated with behavioral health (BH) processes in emergency departments (EDs). RESEARCH DESIGN: Six hundred two hospital responses to the 2017/2018 National Survey of Healthcare Organizations and Systems were linked to 2017 American Hospital Association Annual Survey data. Separate multivariable regressions estimated how hospital capabilities (the use of quality improvement methods, approaches to disseminate best patient-care practices, barriers to using care delivery innovations, and inpatient beds for psychiatric or substance use) were associated with each of 4 ED-based BH processes: mental health and substance use disorder screening, team-based approaches to BH, telepsychiatry, and direct referrals to community-based BH clinicians. Models controlled for hospital structural characteristics and area-level socioeconomic factors. RESULTS: Most hospitals screened for BH conditions and provided direct referrals to community-based BH clinicians. Approximately half of the hospitals used a team approach to BH. A minority had implemented telepsychiatry. Each additional process used to disseminate best patient-care practices was associated with more screening for BH conditions (an increase of 4.07 points on the screening index, P <0.01) and greater likelihood of using a team approach to BH [4.41 percentage point ( P <0.01) increase]. Hospitals reporting more barriers to the use of care delivery innovations reported less screening and use of a team approach [a decrease of 0.15 points on the screening index ( P <0.01) and 0.28 percentage points reduction in likelihood of team approach use ( P <0.001) for 1-point increase in the barrier index]. CONCLUSIONS: Research and interventions focused on removing innovation barriers or adding processes to disseminate best practices offer a path to accelerate BH integration in hospital EDs.

Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study.

BACKGROUND: Guidelines recommend shared decision-making (SDM) around mammography screening for women ≥ 75 years old. OBJECTIVE: To use microsimulation modeling to estimate the lifetime benefits and harms of screening women aged 75, 80, and 85 years based on their individual risk factors (family history, breast density, prior biopsy) and comorbidity level to support SDM in clinical practice. DESIGN, SETTING, AND PARTICIPANTS: We adapted two established Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the remaining lifetime benefits and harms of screening U.S. women born in 1940, at decision ages 75, 80, and 85 years considering their individual risk factors and comorbidity levels. Results were summarized for average- and higher-risk women (defined as having breast cancer family history, heterogeneously dense breasts, and no prior biopsy, 5% of the population). MAIN OUTCOMES AND MEASURES: Remaining lifetime breast cancers detected, deaths (breast cancer/other causes), false positives, and overdiagnoses for average- and higher-risk women by age and comorbidity level for screening (one or five screens) vs. no screening per 1000 women. RESULTS: Compared to stopping, one additional screen at 75 years old resulted in six and eight more breast cancers detected (10% overdiagnoses), one and two fewer breast cancer deaths, and 52 and 59 false positives per 1000 average- and higher-risk women without comorbidities, respectively. Five additional screens over 10 years led to 23 and 31 additional breast cancer cases (29-31% overdiagnoses), four and 15 breast cancer deaths avoided, and 238 and 268 false positives per 1000 average- and higher-risk screened women without comorbidities, respectively. Screening women at older ages (80 and 85 years old) and high comorbidity levels led to fewer breast cancer deaths and a higher percentage of overdiagnoses. CONCLUSIONS: Simulation models show that continuing screening in women ≥ 75 years old results in fewer breast cancer deaths but more false positive tests and overdiagnoses. Together, clinicians and 75 + women may use model output to weigh the benefits and harms of continued screening.

Collaborative Modeling to Compare Different Breast Cancer Screening Strategies: A Decision Analysis for the US Preventive Services Task Force.

Importance: The effects of breast cancer incidence changes and advances in screening and treatment on outcomes of different screening strategies are not well known. Objective: To estimate outcomes of various mammography screening strategies. Design, Setting, and Population: Comparison of outcomes using 6 Cancer Intervention and Surveillance Modeling Network (CISNET) models and national data on breast cancer incidence, mammography performance, treatment effects, and other-cause mortality in US women without previous cancer diagnoses. Exposures: Thirty-six screening strategies with varying start ages (40, 45, 50 years) and stop ages (74, 79 years) with digital mammography or digital breast tomosynthesis (DBT) annually, biennially, or a combination of intervals. Strategies were evaluated for all women and for Black women, assuming 100% screening adherence and "real-world" treatment. Main Outcomes and Measures: Estimated lifetime benefits (breast cancer deaths averted, percent reduction in breast cancer mortality, life-years gained), harms (false-positive recalls, benign biopsies, overdiagnosis), and number of mammograms per 1000 women. Results: Biennial screening with DBT starting at age 40, 45, or 50 years until age 74 years averted a median of 8.2, 7.5, or 6.7 breast cancer deaths per 1000 women screened, respectively, vs no screening. Biennial DBT screening at age 40 to 74 years (vs no screening) was associated with a 30.0% breast cancer mortality reduction, 1376 false-positive recalls, and 14 overdiagnosed cases per 1000 women screened. Digital mammography screening benefits were similar to those for DBT but had more false-positive recalls. Annual screening increased benefits but resulted in more false-positive recalls and overdiagnosed cases. Benefit-to-harm ratios of continuing screening until age 79 years were similar or superior to stopping at age 74. In all strategies, women with higher-than-average breast cancer risk, higher breast density, and lower comorbidity level experienced greater screening benefits than other groups. Annual screening of Black women from age 40 to 49 years with biennial screening thereafter reduced breast cancer mortality disparities while maintaining similar benefit-to-harm trade-offs as for all women. Conclusions: This modeling analysis suggests that biennial mammography screening starting at age 40 years reduces breast cancer mortality and increases life-years gained per mammogram. More intensive screening for women with greater risk of breast cancer diagnosis or death can maintain similar benefit-to-harm trade-offs and reduce mortality disparities.

Breast cancer risk characteristics of women undergoing whole-breast ultrasound screening versus mammography alone.

BACKGROUND: There are no consensus guidelines for supplemental breast cancer screening with whole-breast ultrasound. However, criteria for women at high risk of mammography screening failures (interval invasive cancer or advanced cancer) have been identified. Mammography screening failure risk was evaluated among women undergoing supplemental ultrasound screening in clinical practice compared with women undergoing mammography alone. METHODS: A total of 38,166 screening ultrasounds and 825,360 screening mammograms without supplemental screening were identified during 2014-2020 within three Breast Cancer Surveillance Consortium (BCSC) registries. Risk of interval invasive cancer and advanced cancer were determined using BCSC prediction models. High interval invasive breast cancer risk was defined as heterogeneously dense breasts and BCSC 5-year breast cancer risk ≥2.5% or extremely dense breasts and BCSC 5-year breast cancer risk ≥1.67%. Intermediate/high advanced cancer risk was defined as BCSC 6-year advanced breast cancer risk ≥0.38%. RESULTS: A total of 95.3% of 38,166 ultrasounds were among women with heterogeneously or extremely dense breasts, compared with 41.8% of 825,360 screening mammograms without supplemental screening (p < .0001). Among women with dense breasts, high interval invasive breast cancer risk was prevalent in 23.7% of screening ultrasounds compared with 18.5% of screening mammograms without supplemental imaging (adjusted odds ratio, 1.35; 95% CI, 1.30-1.39); intermediate/high advanced cancer risk was prevalent in 32.0% of screening ultrasounds versus 30.5% of screening mammograms without supplemental screening (adjusted odds ratio, 0.91; 95% CI, 0.89-0.94). CONCLUSIONS: Ultrasound screening was highly targeted to women with dense breasts, but only a modest proportion were at high mammography screening failure risk. A clinically significant proportion of women undergoing mammography screening alone were at high mammography screening failure risk.

Estimation of Breast Cancer Overdiagnosis in a U.S. Breast Screening Cohort.

BACKGROUND: Mammography screening can lead to overdiagnosis-that is, screen-detected breast cancer that would not have caused symptoms or signs in the remaining lifetime. There is no consensus about the frequency of breast cancer overdiagnosis. OBJECTIVE: To estimate the rate of breast cancer overdiagnosis in contemporary mammography practice accounting for the detection of nonprogressive cancer. DESIGN: Bayesian inference of the natural history of breast cancer using individual screening and diagnosis records, allowing for nonprogressive preclinical cancer. Combination of fitted natural history model with life-table data to predict the rate of overdiagnosis among screen-detected cancer under biennial screening. SETTING: Breast Cancer Surveillance Consortium (BCSC) facilities. PARTICIPANTS: Women aged 50 to 74 years at first mammography screen between 2000 and 2018. MEASUREMENTS: Screening mammograms and screen-detected or interval breast cancer. RESULTS: The cohort included 35 986 women, 82 677 mammograms, and 718 breast cancer diagnoses. Among all preclinical cancer cases, 4.5% (95% uncertainty interval [UI], 0.1% to 14.8%) were estimated to be nonprogressive. In a program of biennial screening from age 50 to 74 years, 15.4% (UI, 9.4% to 26.5%) of screen-detected cancer cases were estimated to be overdiagnosed, with 6.1% (UI, 0.2% to 20.1%) due to detecting indolent preclinical cancer and 9.3% (UI, 5.5% to 13.5%) due to detecting progressive preclinical cancer in women who would have died of an unrelated cause before clinical diagnosis. LIMITATIONS: Exclusion of women with first mammography screen outside BCSC. CONCLUSION: On the basis of an authoritative U.S. population data set, the analysis projected that among biennially screened women aged 50 to 74 years, about 1 in 7 cases of screen-detected cancer is overdiagnosed. This information clarifies the risk for breast cancer overdiagnosis in contemporary screening practice and should facilitate shared and informed decision making about mammography screening. PRIMARY FUNDING SOURCE: National Cancer Institute.

Cost-Effectiveness of Screening Mammography Beyond Age 75 Years : A Cost-Effectiveness Analysis.

BACKGROUND: The cost-effectiveness of screening mammography beyond age 75 years remains unclear. OBJECTIVE: To estimate benefits, harms, and cost-effectiveness of extending mammography to age 80, 85, or 90 years according to comorbidity burden. DESIGN: Markov microsimulation model. DATA SOURCES: SEER (Surveillance, Epidemiology, and End Results) program and Breast Cancer Surveillance Consortium. TARGET POPULATION: U.S. women aged 65 to 90 years in groups defined by Charlson comorbidity score (CCS). TIME HORIZON: Lifetime. PERSPECTIVE: National health payer. INTERVENTION: Screening mammography to age 75, 80, 85, or 90 years. OUTCOME MEASURES: Breast cancer death, survival, and costs. RESULTS OF BASE-CASE ANALYSIS: Extending biennial mammography from age 75 to 80 years averted 1.7, 1.4, and 1.0 breast cancer deaths and increased days of life gained by 5.8, 4.2, and 2.7 days per 1000 women for comorbidity scores of 0, 1, and 2, respectively. Annual mammography beyond age 75 years was not cost-effective, but extending biennial mammography to age 80 years was ($54 000, $65 000, and $85 000 per quality-adjusted life-year [QALY] gained for women with CCSs of 0, 1, and ≥2, respectively). Overdiagnosis cases were double the number of deaths averted from breast cancer. RESULTS OF SENSITIVITY ANALYSIS: Costs per QALY gained were sensitive to changes in invasive cancer incidence and shift of breast cancer stage with screening mammography. LIMITATION: No randomized controlled trials of screening mammography beyond age 75 years are available to provide model parameter inputs. CONCLUSION: Although annual mammography is not cost-effective, biennial screening mammography to age 80 years is; however, the absolute number of deaths averted is small, especially for women with comorbidities. Women considering screening beyond age 75 years should weigh the potential harms of overdiagnosis versus the potential benefit of averting death from breast cancer. PRIMARY FUNDING SOURCE: National Cancer Institute and National Institutes of Health.

The Association of Readmission Reduction Activities with Primary Care Practice Readmission Rates.

BACKGROUND: A great deal of research has focused on how hospitals influence readmission rates. While hospitals play a vital role in reducing readmissions, a significant portion of the work also falls to primary care practices. Despite this critical role of primary care, little empirical evidence has shown what primary care characteristics or activities are associated with reductions in hospital admissions. OBJECTIVE: To examine the relationship between practices' readmission reduction activities and their readmission rates. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study of 1,788 practices who responded to the National Survey of Healthcare Organizations and Systems (fielded 2017-2018) and 415,663 hospital admissions for Medicare beneficiaries attributed to those practices from 2016 100% Medicare claims data. We constructed mixed-effects logistic regression models to estimate practice-level readmission rates and a linear regression model to evaluate the association between practices' readmission rates with their number of readmission reduction activities. INTERVENTIONS: Standardized composite score, ranging from 0 to 1, representing the number of a practice's readmission reduction capabilities. The composite score was composed of 12 unique capabilities identified in the literature as being significantly associated with lower readmission rates (e.g., presence of care manager, medication reconciliation, shared-decision making, etc.). MAIN OUTCOMES AND MEASURES: Practices' readmission rates for attributed Medicare beneficiaries. KEY RESULTS: Routinely engaging in more readmission reduction activities was significantly associated (P < .05) with lower readmission rates. On average, practices experienced a 0.05 percentage point decrease in readmission rates for each additional activity. Average risk-standardized readmission rates for practices performing 10 or more of the 12 activities in our composite measure were a full percentage point lower than risk-standardized readmission rates for practices engaging in none of the activities. CONCLUSIONS: Primary care practices that engaged in more readmission reduction activities had lower readmission rates. These findings add to the growing body of evidence suggesting that engaging in multiple activities, rather than any single activity, is associated with decreased readmissions.

Mammography adherence in relation to function-related indicators in older women.

Prior studies of screening mammography patterns by functional status in older women show inconsistent results. We used Breast Cancer Surveillance Consortium-Medicare linked data (1999-2014) to investigate the association of functional limitations with adherence to screening mammography in 145,478 women aged 66-74 years. Functional limitation was represented by a claims-based function-related indicator (FRI) score which incorporated 16 items reflecting functional status. Baseline adherence was defined as mammography utilization 9-30 months after the index screening mammography. Longitudinal adherence was examined among women adherent at baseline and defined as time from the index mammography to end of the first 30-month gap in mammography. Multivariable logistic regression and Cox proportional hazards models were used to investigate baseline and longitudinal adherence, respectively. Subgroup analyses were conducted by age (66-70 vs. 71-74 years). Overall, 69.6% of participants had no substantial functional limitation (FRI score 0), 23.5% had some substantial limitations (FRI score 1), and 6.8% had serious limitations (FRI score ≥ 2). Mean age at baseline was 68.5 years (SD = 2.6), 85.3% of participants were white, and 77.1% were adherent to screening mammography at baseline. Women with a higher FRI score were more likely to be non-adherent at baseline (FRI ≥ 2 vs. 0: aOR = 1.13, 95% CI = 1.06, 1.20, p-trend < 0.01). Similarly, a higher FRI score was associated with longitudinal non-adherence (FRI ≥ 2 vs. 0: aHR = 1.16, 95% CI = 1.11, 1.22, p-trend < 0.01). Effect measures of FRI did not differ substantially by age categories. Older women with a higher burden of functional limitations are less likely to be adherent to screening mammography recommendations.

Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices.

PURPOSE: In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. METHODS: This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. RESULTS: More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). CONCLUSIONS: Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.

Association of Screening With Digital Breast Tomosynthesis vs Digital Mammography With Risk of Interval Invasive and Advanced Breast Cancer.

Importance: Digital breast tomosynthesis (DBT) was developed with the expectation of improving cancer detection in women with dense breasts. Studies are needed to evaluate interval invasive and advanced breast cancer rates, intermediary outcomes related to breast cancer mortality, by breast density and breast cancer risk. Objective: To evaluate whether DBT screening is associated with a lower likelihood of interval invasive cancer and advanced breast cancer compared with digital mammography by extent of breast density and breast cancer risk. Design, Setting, and Participants: Cohort study of 504 427 women aged 40 to 79 years who underwent 1 003 900 screening digital mammography and 375 189 screening DBT examinations from 2011 through 2018 at 44 US Breast Cancer Surveillance Consortium (BCSC) facilities with follow-up for cancer diagnoses through 2019 by linkage to state or regional cancer registries. Exposures: Breast Imaging Reporting and Data System (BI-RADS) breast density; BCSC 5-year breast cancer risk. Main Outcomes and Measures: Rates per 1000 examinations of interval invasive cancer within 12 months of screening mammography and advanced breast cancer (prognostic pathologic stage II or higher) within 12 months of screening mammography, both estimated with inverse probability weighting. Results: Among 504 427 women in the study population, the median age at time of mammography was 58 years (IQR, 50-65 years). Interval invasive cancer rates per 1000 examinations were not significantly different for DBT vs digital mammography (overall, 0.57 vs 0.61, respectively; difference, -0.04; 95% CI, -0.14 to 0.06; P = .43) or among all the 836 250 examinations with BCSC 5-year risk less than 1.67% (low to average-risk) or all the 413 061 examinations with BCSC 5-year risk of 1.67% or higher (high risk) across breast density categories. Advanced cancer rates were not significantly different for DBT vs digital mammography among women at low to average risk or at high risk with almost entirely fatty, scattered fibroglandular densities, or heterogeneously dense breasts. Advanced cancer rates per 1000 examinations were significantly lower for DBT vs digital mammography for the 3.6% of women with extremely dense breasts and at high risk of breast cancer (13 291 examinations in the DBT group and 31 300 in the digital mammography group; 0.27 vs 0.80 per 1000 examinations; difference, -0.53; 95% CI, -0.97 to -0.10) but not for women at low to average risk (10 611 examinations in the DBT group and 37 796 in the digital mammography group; 0.54 vs 0.42 per 1000 examinations; difference, 0.12; 95% CI, -0.09 to 0.32). Conclusions and Relevance: Screening with DBT vs digital mammography was not associated with a significant difference in risk of interval invasive cancer and was associated with a significantly lower risk of advanced breast cancer among the 3.6% of women with extremely dense breasts and at high risk of breast cancer. No significant difference was observed in the 96.4% of women with nondense breasts, heterogeneously dense breasts, or with extremely dense breasts not at high risk.

Prioritizing breast imaging services during the COVID pandemic: A survey of breast imaging facilities within the Breast Cancer Surveillance Consortium.

The COVID-19 pandemic disrupted breast cancer screening and diagnostic imaging in the United States. We sought to evaluate how medical facilities prioritized breast imaging services during periods of reduced capacity or upon re-opening after closures. In fall 2020, we surveyed 77 breast imaging facilities within the Breast Cancer Surveillance Consortium in the United States. The survey ascertained the pandemic's impact on clinical practices during March-September 2020. Nearly all facilities (97%) reported closing or operating at reduced capacity at some point during this period. All facilities were open by August 2020, though 14% were still operating at reduced capacity in September 2020. During periods of re-opening or reduced capacity, 93% of facilities reported prioritizing diagnostic breast imaging over breast cancer screening. For diagnostic imaging, facilities prioritized based on rescheduling canceled appointments (89%), specific indication for diagnostic imaging (89%), patient demand (84%), individual characteristics and risk factors (77%), and time since last imaging examination (72%). For screening mammography, facilities prioritized based on rescheduled cancelations (96%), patient demand (83%), individual characteristics and risk factors (73%), and time since last mammogram (71%). For biopsy services, more than 90% of facilities reported prioritization based on rescheduling of canceled exams, patient demand, patient characteristics and risk factors and level of suspicion on imaging. The observed patterns from this large and geographically diverse sample of facilities in the United States indicate that multiple factors were commonly used to prioritize breast imaging services during periods of reduced capacity.

Role of Nurse Practitioners in Caring for Patients With Complex Health Needs.

OBJECTIVE: The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics. DESIGN: An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics. KEY RESULTS: In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%). CONCLUSIONS: Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.

Response to Propoxyphene Market Withdrawal: Analgesic Substitutes, Doses, and Adverse Events.

OBJECTIVE: Experts cautioned that patients affected by the November 2010 withdrawal of the opioid analgesic propoxyphene might receive riskier prescriptions. To explore this, we compared drug receipts and outcomes among propoxyphene users before and aftermarket withdrawal. STUDY DESIGN: Using OptumLabs data, we studied 3 populations: commercial, Medicare Advantage (MA) aged (age 65+ y) and MA disabled (age below 65 y) enrollees. The exposed enrollees received propoxyphene in the 3 months before market withdrawal (n=13,622); historical controls (unexposed) received propoxyphene 1 year earlier (n=9971). Regression models estimated daily milligrams morphine equivalent (MME), daily prescription acetaminophen dose, potentially toxic acetaminophen doses, nonopioid prescription analgesics receipt, emergency room visits, and diagnosed falls, motor vehicle accidents, and hip fractures. PRINCIPAL FINDINGS: Aged MA enrollees illustrate the experience of all 3 populations examined. Following the market withdrawal, propoxyphene users in the exposed cohort experienced an abrupt decline of 69% in average daily MME, compared with a 14% decline in the unexposed. Opioids were discontinued by 34% of the exposed cohort and 18% of the unexposed. Tramadol and hydrocodone were the most common opioids substituted for propoxyphene. The proportion of each group receiving ≥4 g of prescription acetaminophen per day decreased from 12% to 2% in the exposed group but increased from 6% to 8% among the unexposed. Adverse events were rare and not significantly different in exposed versus unexposed groups. CONCLUSIONS: After propoxyphene market withdrawal, many individuals experienced abrupt discontinuation of opioids. Policymakers might consider supporting appropriate treatment transitions and monitoring responses following drug withdrawals.

Airborne metals and polycyclic aromatic hydrocarbons in relation to mammographic breast density.

BACKGROUND: Breast density is strongly related to breast cancer. Identifying associations between environmental exposures and density may elucidate relationships with breast cancer. Metals and polycyclic aromatic hydrocarbons (PAHs) may influence breast density via oxidative stress or endocrine disruption. METHODS: Study participants (n = 222,581) underwent a screening mammogram in 2011 at a radiology facility in the Breast Cancer Surveillance Consortium. Zip code residential levels of airborne PAHs and metals (arsenic, cadmium, chromium, cobalt, lead, manganese, mercury, nickel, and selenium) were assessed using the 2011 EPA National Air Toxics Assessment. Breast density was measured using the Breast Imaging-Reporting and Data System (BI-RADS) lexicon. Logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CI) for the individual air toxics and dense breasts (BI-RADS 3 or 4). Weighted quantile sum (WQS) regression was used to model the association between the air toxic mixture and density. RESULTS: Higher residential levels of arsenic, cobalt, lead, manganese, nickel, or PAHs were individually associated with breast density. Comparing the highest to the lowest quartile, higher odds of having dense breasts were observed for cobalt (OR = 1.60, 95% CI 1.56-1.64) and lead (OR = 1.56, 95% CI 1.52-1.64). Associations were stronger for premenopausal women. The WQS index was associated with density overall (OR = 1.22, 95% CI 1.20-1.24); the most heavily weighted air toxics were lead and cobalt. CONCLUSIONS: In this first study to evaluate the association between air toxics and breast density, women living in areas with higher concentrations of lead and cobalt were more likely to have dense breasts.

State Legal Restrictions and Prescription-Opioid Use among Disabled Adults.

BACKGROUND: In response to rising rates of opioid abuse and overdose, U.S. states enacted laws to restrict the prescribing and dispensing of controlled substances. The effect of these laws on opioid use is unclear. METHODS: We tested associations between prescription-opioid receipt and state controlled-substances laws. Using Medicare administrative data for fee-for-service disabled beneficiaries 21 to 64 years of age who were alive throughout the calendar year (8.7 million person-years from 2006 through 2012) and an original data set of laws (e.g., prescription-drug monitoring programs), we examined the annual prevalence of beneficiaries with four or more opioid prescribers, prescriptions yielding a daily morphine-equivalent dose (MED) of more than 120 mg, and treatment for nonfatal prescription-opioid overdose. We estimated how opioid outcomes varied according to eight types of laws. RESULTS: From 2006 through 2012, states added 81 controlled-substance laws. Opioid receipt and potentially hazardous prescription patterns were common. In 2012 alone, 47% of beneficiaries filled opioid prescriptions (25% in one to three calendar quarters and 22% in every calendar quarter); 8% had four or more opioid prescribers; 5% had prescriptions yielding a daily MED of more than 120 mg in any calendar quarter; and 0.3% were treated for a nonfatal prescription-opioid overdose. We observed no significant associations between opioid outcomes and specific types of laws or the number of types enacted. For example, the percentage of beneficiaries with a prescription yielding a daily MED of more than 120 mg did not decline after adoption of a prescription-drug monitoring program (0.27 percentage points; 95% confidence interval, -0.05 to 0.59). CONCLUSIONS: Adoption of controlled-substance laws was not associated with reductions in potentially hazardous use of opioids or overdose among disabled Medicare beneficiaries, a population particularly at risk. (Funded by the National Institute on Aging and others.).

Medicaid Expansion and Prescription Trends: Opioids, Addiction Therapies, and Other Drugs.

BACKGROUND: Opioid overdose deaths in the United States have climbed since 1999. In 2014, the Affordable Care Act prompted some states to expand Medicaid programs, providing low-cost prescription access to millions of Americans. Some have questioned whether Medicaid expansion might worsen the opioid crisis. OBJECTIVE: To test the association between the expansion of state Medicaid programs and Medicaid-paid prescriptions of opioid pain relievers and opioid addiction therapies. RESEARCH DESIGN: We analyzed the 2010-2016 Medicaid State Drug Utilization Data using a difference-in-differences regression approach, comparing prescriptions per enrollee between states that expanded Medicaid in 2014 and states that did not. We compared opioid pain relievers and opioid addiction therapies to 5 other commonly prescribed drug types important to the Medicaid expansion population (antidepressants, antihypertensives, diabetes medications, cholesterol treatments, and contraceptives) and to overall prescription volume. A secondary analysis compared opioid pain relievers and opioid addiction therapies, between states with high and low overdose death rates. RESULTS: We found overall prescription use per enrollee was higher after 2014. Relative growth in opioid pain reliever prescriptions was modest compared with growth in medications for depression, hypertension, diabetes, and high cholesterol. Growth in prescriptions used to treat opioid use disorder greatly outpaced other drugs, suggesting important gains in access to addiction treatments; growth was higher in states with higher pre-2014 overdose death rates. CONCLUSIONS: Our results suggest Medicaid expansion benefited a population with unique needs, and that Medicaid expansion could be a valuable tool in addressing the opioid overdose epidemic.

A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care.

PURPOSE: We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. METHODS: Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. RESULTS: Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). CONCLUSIONS: Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

How do economic downturns affect the mental health of children? Evidence from the National Health Interview Survey.

Research linking economic conditions and health often does not consider children's mental health problems, which are the most common and consequential health issues for children and adolescents. We examine the effects of unemployment rates and housing prices on well-validated child and adolescent mental health outcomes and use of special education services for emotional problems in the 2001-2013 National Health Interview Survey. We find that the effects of economic conditions on children's mental health are clinically and economically meaningful; children's mental health outcomes worsen as the economy weakens. The effects of economic conditions on child and adolescent mental health are pervasive, found in almost every subgroup that we examine. The use of special education services for emotional problems also rises when economic conditions worsen. Our analyses of possible mechanisms that link economic conditions to child mental health suggest that parental unemployment cannot fully explain the relationship between economic conditions and child mental health.