Predictors of substance use treatment initiation and engagement among adult and adolescent Medicaid recipients.

Background: It is important to understand patterns and predictors of initiation and engagement in treatment for Medicaid-covered individuals with substance use disorders because Medicaid is a major source of payment for addiction treatment in the United States. Our analysis examined similarities and differences in predictors between adults and adolescents. Methods: An analysis of Oregon Medicaid claims data for the time period January 2010 through June 2015 assessed rates of substance use and of treatment initiation and engagement using the Healthcare Effectiveness Data and Information Set (HEDIS) definitions. The analysis included individuals aged 13-64 with a new alcohol and other drug dependence diagnosis who met the HEDIS enrollment criteria and did not have cancer. We created 4 logistic regression models to assess treatment initiation and engagement, separately for adults (ages 18-64) and adolescents (ages 13-17). Independent predictors included age, gender, race, the interaction of gender and race, urban/rural residence, presence of any chronic disease, a psychiatric diagnosis, or a pain diagnosis. Results: Among adults, odds of initiation were lower in white males than in nonwhite males, white females, and nonwhite females. Conversely, among adolescents, odds of initiation were higher in white males than in the other gender/race groups. Predictors of initiation also went in opposite directions for presence of a psychiatric diagnosis (negative in adults, positive in adolescents) and urban residence (positive in adults, negative in adolescents). We found similar patterns in models of engagement, although for engagement those with a psychiatric diagnosis had lower odds of engagement in both adults and adolescents. Conclusions: Predictors of treatment initiation and engagement for alcohol and drug use disorders differed between adults and adolescents on Medicaid. A better understanding of these differences will enable development of targeted treatment programs that are effective within age groups.

The association of federal Medicaid abortion funding restrictions with adverse obstetric outcomes among United States Medicaid recipients.

OBJECTIVE: We examine the association of the Hyde Amendment with obstetrical outcomes in a national Medicaid population. STUDY DESIGN: We conducted a national study of Medicaid-funded abortions to determine the association of restrictions on adolescent, preterm, low-birth weight, and short interpregnancy interval births using administrative data. RESULTS: States that restricted coverage for abortion had a higher median rate of adolescent (10.2%; vs 7.4%; p-value < 0.001), preterm (11.4%; vs 10.1%; p < 0.001), short interpregnancy interval, (13.0% vs 9.6%; p < 0.001), and low birth weight births (10.2% vs 8.7%; p = 0.003) than states where Medicaid provided comprehensive coverage. CONCLUSIONS: Restricting federal funds for abortion is associated with adverse outcomes. IMPLICATIONS: When Medicaid does not provide comprehensive coverage for abortion care, few abortions are provided and higher rates of adverse obstetrical outcomes are noted.

Project Nurture Integrates Care And Services To Improve Outcomes For Opioid-Dependent Mothers And Their Children.

Children born to women with substance use disorders are at high risk for early foster care placement, which is associated with long-term adverse outcomes for children and places additional pressure on state budgets. Poor outcomes for drug-dependent mothers and their children may be further exacerbated by a lack of coordination between the health care and human services sectors. Project Nurture is an innovative model in Portland, Oregon, that integrates maternity care, substance use treatment, and social service coordination for Medicaid beneficiaries. This study assessed the impact of Project Nurture on a range of patient and child welfare outcomes. Among the "treatment" population of opioid-dependent women enrolled in Medicaid, Project Nurture was associated with reductions in child maltreatment, placement of children in foster care, and increases in both prenatal visits and maternal lengths-of-stay in the hospital, compared to opioid-dependent women enrolled in Medicaid in Oregon counties not served by the project. These results suggest that models based in a clinical setting that engage the human services sector may improve overall outcomes, even though the difficulty in sharing savings across sectors presents challenges to sustainability.

Variations in prescription drug monitoring program use by prescriber specialty.

BACKGROUND: Although prescription drug monitoring programs (PDMPs) have been widely implemented to potentially reduce abuse of prescription opioids, there is limited data on variations in PDMP use by prescriber specialty. Such knowledge may guide targeted interventions to improve PDMP use. METHODS: Using data from Washington state Medicaid program, we performed a retrospective cohort study of opioid prescribers and their PDMP queries between Nov 1, 2013 and Oct 31, 2014. PDMP registration was mandatory for emergency physicians, but not for other providers. The unit of analysis was the prescriber. The primary outcome was any prescriber queries of the PDMP. We used multivariate regression models to identify variations in PDMP queries by prescriber specialty, as well as to explore explanatory pathways for observed variations. RESULTS: We studied 17,390 providers who prescribed opioids, including 8718 (50%) who were not registered with PDMP, 4767 (27%) who were registered but had no recorded use of the PDMP, and 3905 (23%) PDMP users (queries/user: median 18, IQR 5-64). Compared to general medicine physicians, PDMP use was higher for emergency physicians (OR 1.4, 95%CI: 1.2-1.7), and lower for surgical specialists (OR 0.1, 95%CI: 0.08-0.1), obstetrician-gynecologists (OR 0.2, 95%CI: 0.1-0.2) and dentists (OR 0.4, 95%CI: 0.4-0.5). Higher use by emergency physicians appeared to be mediated by higher registration rates, rather than by provider level predilection to use the PDMP. CONCLUSIONS: A minority of opioid prescribers to Medicaid beneficiaries used the PDMP. We identified variations in PDMP use by prescriber specialty. Interventions to increase PDMP queries should target both PDMP registration and PDMP use after registration, as well as specialties with current low use rates.

Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit.

OBJECTIVE: Washington State mandated seven hospital "best practices" in July 2012, several of which may affect emergency department (ED) opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use. METHODS: We performed a retrospective, observational analysis of ED visits by Medicaid fee-for-service beneficiaries in Washington State, between July 1, 2011, and June 30, 2013. We used an interrupted time-series design to control for temporal trends and patient characteristics. The primary outcome was any opioid dispensing within 3 days after an ED visit. The secondary outcome was total morphine milligram equivalents (MMEs) dispensed within 3 days. RESULTS: We analyzed 266,614 ED visits. Mandates were associated with a small reduction in opioid dispensing after an ED visit (-1.5%, 95% confidence interval [CI] = -2.8% to -0.15%). The mandates were associated with decreased opioid dispensing in 42,496 ED visits by patients with prior risky opioid use behavior (-4.7%, 95% CI = -7.1% to -2.3%) and in 20,238 visits by patients with chronic opioid use (-3.6%, 95% CI = -5.6% to -1.7%). Mandates were not associated with reductions in MMEs per dispense in the overall cohort or in either subgroup. CONCLUSIONS: Washington State best practice mandates were associated with small but nonselective reductions in opioid prescribing rates. States should focus on alternative policies to further reduce opioid dispensing in subgroups of high-risk and chronic users.

The use of scripting at triage and its impact on elopements.

OBJECTIVES: The objective of this study was to measure the effect of scripting language at triage on the likelihood of elopements, controlling for patient volume and other potential confounding variables. METHODS: This was a pre- and postintervention cohort study using the same 5-month period (November 2007-March 2008 and November 2008-March 2009, respectively) that included in the analysis all patients 21 years of age and older, who presented to the triage window in the emergency department (ED) waiting room (not by ambulance). As part of the scripting, triage nurses informed patients of the longest waiting time (at that point in time) for any patients still waiting to be brought back from the waiting room into the ED. Rates of elopement were compared between patients who did and did not receive the scripting, controlling for individual and daily ED variables. RESULTS: A total of 24,390 ED visits were included in this analysis. The elopement rate was 4.4% among ED patients in the prescripting period, compared to 2.3% in the postscripting period. In a multivariate logistic regression model, the use of scripting was significantly associated with decreased odds of elopement, compared to the nonscripting group (odds ratio [OR] = 0.61, 95% confidence interval [CI] = 0.46 to 0.80). CONCLUSIONS: The use of triage scripting was found to significantly reduce elopement rates in patients placed in the ED waiting room, even after controlling for other confounding variables. Scripting is a simple and underutilized technique that can have a positive effect for patients and the ED.

The financial impact of ambulance diversion on inpatient hospital revenues and profits.

OBJECTIVES: The objective was to study the association between ambulance diversion and weekly inpatient hospital revenues and profits. METHODS: This was a retrospective review of administrative data from one academic medical center from July 1, 2003, to December 31, 2006. Given the high amount of daily variability, inpatient hospital revenues and profits were collapsed by week and evaluated in four categories: no diversion, mild diversion (from >0 and <10 hours), moderate diversion (>10 and <20 hours), and high diversion (>20 hours). Revenues and profits for two categories of patients admitted to the hospital were calculated: 1) patients admitted from the emergency department (ED; i.e., those arriving by ambulance and by other means) and 2) electively admitted patients. RESULTS: A total of 166,460 ED patients were included in the analysis. Inpatient hospital revenues were included from 85,111 patients, 28,665 of which were admissions from the ED (33.7%). For patients admitted from the ED, the average weekly revenues during periods of high diversion were $265K higher than periods of no diversion. For patients admitted on an elective basis, revenues were significantly higher when comparing periods of mild divert to high diversion (an additional $415K weekly). The overall increase in profitability was significant for periods of severe divert compared to no divert ($119K per week). CONCLUSIONS: Periods of greater diversion are associated with higher inpatient revenues and profits for ED, electively admitted patients, and the overall inpatient hospital population. Therefore, no financial disincentive exists from an inpatient perspective for the boarding of admitted patients in the ED and increasing periods of diversion. Efforts to decrease ambulance diversion must therefore be based on other rationales, like patient safety, quality of care, and improving access to care, or new models of reimbursement that reward hospitals for reducing ambulance diversion.

The effect of emergency department crowding on clinically oriented outcomes.

BACKGROUND: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated. OBJECTIVES: The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs). METHODS: We reviewed the English-language literature for the years 1989-2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included "ED crowding,""ED overcrowding,""mortality,""time to treatment,""patient satisfaction,""quality of care," and others. RESULTS: A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints. CONCLUSIONS: A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.