The importance of identification when measuring performance in addiction treatment.

Background: Identifying and effectively treating individuals with substance use disorders (SUDs) is an important priority for state Medicaid programs, given the enormous toll that SUDs take on individuals, their families, and their communities. In this paper, we describe how the Healthcare Effectiveness Data and Information Set (HEDIS) measure "Identification of Alcohol and Other Drug Services" can be used, along with eligible population prevalence rates, to expand states' ability to track how well their Medicaid programs identify enrollees with SUDs and link them with treatment (measured by initiation and engagement performance measures). Methods: We use the 2009 Medicaid MAX data on utilization and enrollment along with information from the National Survey of Drug Use and Health (NSDUH) to obtain state-level estimates of alcohol and drug abuse and dependence among Medicaid beneficiaries for 7 illustrative states. We calculate identification, initiation, and engagement measures using specifications from the National Committee on Quality Assurance (NCQA). Results: NSDUH data showed that the eligible population prevalence rate (the average rate of alcohol or drug abuse or dependence) among the 7 states was 10.0%, whereas the average identification rate was 2.9%. The gap between the prevalence and identification rates ranged from 5.1% to 11.0% among the 7 states. The initiation rates ranged from 36.9% to 57.1%. The states' engagement rates ranged from 11.8% to 31.1%, although rates differ by age, gender, and race/ethnicity in some states. Conclusion: Including identification along with initiation and engagement measures allows states to determine how well they are performing in a more complete spectrum from need, to recognition and documentation of enrollees with SUDs, to initiation of treatment, to continuation of early treatment.

Use of Inpatient Behavioral Health Services by Children and Adolescents With Private Insurance Coverage.

OBJECTIVE: This study examined trends in hospitalizations of youths for behavioral health conditions in acute care hospital nonpsychiatric beds, acute care hospital psychiatric and detoxification beds, and specialty psychiatric hospitals. METHODS: Using data on hospitalizations for behavioral health conditions in 2009 (N=21,805) and 2014 (N=27,550) from the MarketScan Commercial Claims and Encounters database, this study examined the percentage of youths (ages two to 18) with one or more hospitalizations, by demographic characteristic and bed type, and the behavioral health diagnoses for which patients were hospitalized. RESULTS: The greatest increase in hospitalizations of youths occurred in acute care hospital psychiatric and detoxification beds. The percentage of hospitalizations for suicidal ideation or self-harm injuries increased by 17.8 (N=526) to 30.0 (N=1,249) percentage points, depending on bed type. CONCLUSIONS: The continued trend of rising hospitalizations of youths is consistent with recent studies showing a doubling of hospitalizations of youths for suicide and self-harm.

Prevalence and screening for anaemia in mild to moderate Crohn's disease and ulcerative colitis in the United States, 2010-2014.

BACKGROUND AND AIMS: Anaemia affects up to 74% patients with Crohn's disease (CD) and ulcerative colitis (UC) and is correlated with decreased quality of life. The European Crohn's and Colitis Organisation (ECCO) recommends at least annual screening for iron-deficiency anaemia. We aimed to determine the prevalence of anaemia, frequency of anaemia screening and factors associated with anaemia in a retrospective study of mild to moderate inflammatory bowel disease (IBD) in the USA. METHODS: Adults with at least two outpatient encounters for IBD between 2010 through 2014 who contributed laboratory information were identified from MarketScan, a US commercial claims database. Hospitalised patients were considered severe and excluded from the study. WHO criteria defined anaemia. Iron-deficiency anaemia was evaluated using ferritin and C reactive protein. RESULTS: The eligible population included 17 059 adults, 43.9% with CD. During the 2-year median follow-up period, 68.1% of patients with CD and 65.3% of patients with UC were screened for anaemia. The prevalence of anaemia among those screened was 32.4% in CD and 27.6% in UC. Among 669 persons with sufficient information, 79.2% of those with CD and 85.1% of those with UC had iron-deficiency anaemia. Factors associated with anaemia were similar for those with CD and UC and included ≥6 IBD-related outpatient visits, female sex, age and smoking. CONCLUSIONS: More than 30% of patients with IBD in the USA were not screened for anaemia during a 2-year period. Approximately 82% of anaemic patients were iron deficient, although the absence of ferritin results limited the findings. Incorporation of screening for anaemia and, in particular, iron deficiency, should be a component of international treatment guidelines.

MULTIMODAL IMAGING AND HISTOLOGIC CORRELATION OF ISOLATED METASTASIS OF PROSTATE ADENOCARCINOMA TO THE CHOROID.

PURPOSE: To provide correlative clinical-multimodal imaging-histopathologic findings of isolated prostatic choroidal metastasis. METHODS: Ophthalmologic examination, fluorescein angiogram, spectral-domain optical coherence tomography, fundus autofluorescence, computerized tomography, magnetic resonance imaging, positive emission tomography, CSF analysis, serologies, tissue pathology with immunohistochemistry, and examination of relevant literature. RESULTS: A 76-year-old man with a history of prostate adenocarcinoma was referred for 2 months of unilateral blurry vision. Fundus examination revealed elevated deep orange choroidal lesions in the macula with overlying retinal pigment epithelium mottling and subretinal fluid. Fluorescein angiogram demonstrated alternating areas of hypofluorescence and hyperfluorescence (staining) without leakage. Optical coherence tomography revealed dome-shaped and lumpy choroidal lesions with surrounding undulating "lumpy bumpy" and "rippled/seasick" patterns. Workup for a primary or additional metastatic lesion including computerized tomography of head/chest/abdomen/pelvis, lumbar puncture, magnetic resonance imaging brain, and whole-body positive emission tomography scan was negative. Full-thickness excisional chorioretinal biopsy was obtained through pars plana vitrectomy with diathermy and vertical scissors. Histologic examination revealed adenocarcinoma with weak positive staining for prostate specific antigen, moderate positive staining for P501S (prostein), and strong positive staining for prostatic acid phosphatase, consistent with metastasis from a prostate primary. Treatment consisted of local radiation with regression of the metastatic tumor. The patient is also on concomitant androgen deprivation treatment because there is a very high incidence of systemic recurrence due to hematogenous involvement. The patient's vision has continued to improve 6 months past treatment. CONCLUSION: The authors present a unique case to highlight the multimodal imaging and histology of a rare presentation of biopsy-proven, isolated metastasis of prostate adenocarcinoma to the choroid. Systemic workup is required, and if unrevealing of a primary or metastatic lesion, full-thickness chorioretinal biopsy and histopathology can provide a definitive diagnosis, allowing optimal treatment. Chorioretinal biopsy is a useful technique and may allow for visual preservation while also giving superior histologic quality.

Effect of Direct-to-Consumer Advertising on Asthma Medication Sales and Healthcare Use.

RATIONALE: The United States is one of only two countries that permit direct-to-consumer advertising (DTCA) of prescription drugs, and many questions remain regarding its effects. OBJECTIVES: To quantify the association between asthma-related DTCA, pharmacy sales, and healthcare use. METHODS: This was an ecological study from 2005 through 2009 using linked data from Nielsen (DTCA television ratings), the IMS Health National Prescription Audit (pharmacy sales), and the MarketScan Commercial Claims data (healthcare use) for 75 designated market areas in the United States. We used multilevel Poisson regression to model the relationship between DTCA and rates of prescriptions and use within and across designated market areas. Main outcome measures include (1) volume of total, new, and refilled prescriptions for advertised products based on pharmacy sales; (2) prescription claims for asthma medications; and asthma-related (3) emergency department use, (4) hospitalizations, and (5) outpatient encounters among the commercially insured. MEASUREMENTS AND MAIN RESULTS: Four Food and Drug Administration-approved asthma medicines were advertised during the period examined: (1) fluticasone/salmeterol (Advair), (2) mometasone furoate (Asmanex), (3) montelukast (Singulair), and (4) budesonide/formoterol (Symbicort). After adjustment, each additional televised advertisement was associated with 2% (incident rate ratio, 1.02; 95% confidence interval, 1.01-1.03) higher pharmacy sales rate from 2005 through 2009, although this effect varied across the three consistently advertised therapies examined. Among the commercially insured, DTCA was positively and significantly associated with emergency room visits related to asthma (incident rate ratio, 1.02; 95% confidence interval, 1.01-1.04), but there was no relationship with hospitalizations or outpatient encounters. CONCLUSIONS: Among this population, DTCA was associated with higher prescription sales and asthma-related emergency department use.

Establishing the feasibility of measuring performance in use of addiction pharmacotherapy.

This paper presents the rationale and feasibility of standardized performance measures for use of pharmacotherapy in the treatment of substance use disorders (SUD), an evidence-based practice and critical component of treatment that is often underused. These measures have been developed and specified by the Washington Circle, to measure treatment of alcohol and opioid dependence with FDA-approved prescription medications for use in office-based general health and addiction specialty care. Measures were pilot tested in private health plans, the Veterans Health Administration (VHA), and Medicaid. Testing revealed that use of standardized measures using administrative data for overall use and initiation of SUD pharmacotherapy is feasible and practical. Prevalence of diagnoses and use of pharmacotherapy vary widely across health systems. Pharmacotherapy is generally used in a limited portion of those for whom it might be indicated. An important methodological point is that results are sensitive to specifications, so that standardization is critical to measuring performance across systems.

Psychiatric and medical comorbidities, associated pain, and health care utilization of patients prescribed buprenorphine.

This study describes the comorbidities and health care utilization of individuals treated with buprenorphine using the 2007-2009 MarketScan Research Databases. Buprenorphine recipients had a high prevalence of comorbidities associated with chronic pain, including back problems (42%), connective tissue disease (24-27%), and nontraumatic joint disorders (20-23%). Approximately 69% of recipients filled prescriptions for opioid agonist medications in the 6 months before buprenorphine initiation. Buprenorphine recipients were frequently diagnosed with anxiety (23-42%) and mood disorders (39-51%) and filled prescriptions for antidepressants (47-56%) and benzodiazepines (47-56%) at high rates. Surprisingly, only 53-54% of patients filling a prescription for buprenorphine had a coded opioid abuse/dependence diagnosis. Research is needed to better understand buprenorphine's effectiveness in the context of prescription drug abuse and the best way to coordinate services to address the patient's comorbid addiction, pain, and psychiatric illnesses.

Mental health spending by private insurance: implications for the mental health parity and addiction equity act.

OBJECTIVE: The study developed information on behavioral health spending and utilization that can be used to anticipate, evaluate, and interpret changes in health care spending following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). METHODS: Data were from the Thomson Reuters' MarketScan database of insurance claims between 2001 and 2009 from large group health plans sponsored by self-insured employers. Annual rates in growth of total health spending and behavioral health spending and the contribution of behavioral health spending to growth in spending for all diseases were determined. Separate analyses examined behavioral health and total health spending by 135 employers in 2008 and 2009, and simulations were conducted to determine how increases in use of mental health services after implementation of parity would affect overall health care expenditures. RESULTS: Across the nine years examined, behavioral health expenditures contributed .3%, on average, to the total rate of growth in all health expenditures, a contribution that fell to .1%, on average, when prescription drugs were excluded. About 2% of employers experienced an increased contribution by behavioral health spending of more than 1%. More than 90% of enrollees used well below the maximum 30 inpatient days or outpatient visits typical of health insurance plans before parity. Simulations indicated that even large increases in utilization would increase total health care expenditures by less than 1%. CONCLUSIONS: The MHPAEA is unlikely to have a large effect on the growth rate of employers' health care expenditures. The data provide baseline information to further evaluate the implementation effect of the MHPAEA.

What every hospitalist should know about the post-bariatric surgery patient.

Obesity is a growing worldwide epidemic, increasingly addressed through surgical options for weight loss. Benefits of these operations, such as weight loss and improvement or reversal of obesity-related comorbidities, are well established; however, postoperative complications do occur. This article will evaluate common causes for hospital admissions in the post-bariatric surgery population as they relate to the hospitalist who is often responsible for their care. Here we provide an overview of the most common bariatric procedures currently performed, early postoperative complications, late medical complications (ie, abdominal complaints, weight fluctuations, nutritional deficiencies, and metabolic bone disease), and late surgical complications that often affect these patients and result in hospital admissions. Special attention will be paid to radiologic pearls that can assist in the initial evaluation and diagnosis of these patients.

Revised cost estimates of Medicaid recipients with serious mental illness and HIV-AIDS.

OBJECTIVE: The aim of this brief report is to provide accurate 1996 baseline cost estimates for persons with co-occurring HIV and serious mental illness by revising original figures previously reported by the authors. METHODS: Data were examined for 23,729 adults who were enrolled in Medicaid in 1996. A comparison of utilization and cost of services was done for four groups: serious mental illness and HIV-AIDS, serious mental illness only, HIV-AIDS only, and neither condition. RESULTS: In 1996 persons with both illnesses had the highest annual medical and behavioral health treatment expenditures at $20,038 per person, followed by persons with only HIV-AIDS at $14,714. The cost of care for the HIV-AIDS population, regardless of the presence of serious mental illness, averaged $16,253 per person. CONCLUSIONS: Although the absolute costs found in this study were much higher than those reported in the authors' previous study, both studies showed that those with co-occurring illnesses had the highest cost.

Healthcare utilization of individuals with opiate use disorders: an analysis of integrated medicaid and state mental health/substance abuse agency data.

Data from the Substance Abuse and Mental Health Services Administration's Integrated Database (IDB) were used to examine the service use patterns of individuals with possible opiate use disorders in Washington State. Results indicate that regardless of Medicaid enrollment status, individuals who received mental health (MH) or substance abuse (SA) services only through state agencies received no inpatient substance abuse service. Furthermore, when compared with individuals who received at least one MH/SA service through Medicaid, those who received services only through the state agencies were less likely to have received any MH services and were more likely to have received residential SA services. This analysis highlights the importance of using integrated client data in providing a more comprehensive understanding of services to inform policy and raises significant questions about how regulatory requirements affecting different funding mechanisms might drive settings of care in ways not related to the care needed.

Mental health services for children in large, employer-based health plans, 1999.

This study examines 1999 data from Medstat's MarketScan database of privately insured employees of US firms and their dependents. Of enrolled children and adolescents ages 2-18, 6.6% had claims for mental health services. Average outpatient expenditures per user were $651. Of children/adolescents with claims for mental health services (MH claimants), 3.4% had inpatient MH services, with an average length of stay of 8.9 days and average MH-related inpatient expenditure per user of $7,048. One half of MH claimants who had pharmacy benefit data had claims for psychotropic medications, with average expenditures per user of $328. Whereas children/adolescent mental health users comprised 8.3% of all service users, expenditures for their care were 20.5% of all service expenditures for children/adolescents in private health plans. Results also highlight the importance of including data on psychotropic medication in analysis of children's MH services utilization, as well as the need to consider the use of psychotropic medications among children/adolescents who do not utilize other MH services.

Treatment with antidepressant medications in private health plans.

This study analyzed 2002 MarketScan data from a convenience sample of enrollees with private health insurance from the largest U.S. firms to examine utilization, expenditures, and factors associated with antidepressant prescriptions. Of enrollees, 11% received at least one antidepressant prescription during the year with average expenditures per enrollee of $51.55. Antidepressant prescriptions were more frequently used than any form of other mental health care and for 42% of users was not associated with any clearly identified mental health or "off-label" indication. In logistical regression analyses, health plan type, prescription days supply, gender, region, age, employment status, and subscriber status were associated with unexplained antidepressant prescription use.

Children's mental health services in fee-for-service Medicaid.

This study analyzed annual service use and payment data for children in racial/ ethnic subgroups in Medicaid Programs of four States, and compared service use of youth treated with mental health or substance abuse (MH/SA) conditions to youth without such conditions. In addition to geographic variation in rates (6.2 to 10.7 percent used MH/SA related care), results showed children who used MH/SA services to be disproportionately older, male, and white when compared with all Medicaid children. Examination of costs per claimant found costs for the MH/SA population of children to be three to six times greater than a comparison sample.

Use of mental health and substance abuse services among high-cost Medicaid enrollees.

Users of mental health and substance abuse (MH/SA) services were examined among nonelderly high-cost Medicaid enrollees in 10 states in 1995. Although MH/SA service users constitute 11% of all Medicaid enrollees, they make up nearly a third of high-cost enrollees. Adults account for two thirds of this high-cost MH/SA group, and most frequently qualify for Medicaid through disability-related eligibility categories. In contrast, a majority of children in the high-cost MH/SA group are eligible for Medicaid through child-related categories, rather than disability. In diagnostic makeup, the high-cost group was somewhat more likely to have serious disorders than the general Medicaid MH/SA user population.