Integrating Public Health and Health Care Strategies to Address the Opioid Epidemic: The Oregon Health Authority's Opioid Initiative.

CONTEXT: Oregon is experiencing an opioid overdose epidemic, similar to the United States as a whole. To address this crisis, the Oregon Health Authority (OHA) implemented a strategic Opioid Initiative, convening stakeholders and integrating public health and health care system activities across sectors. Recent data indicate progress: from 2015 to 2016, Oregon had the sharpest decline in prescription opioid overdose deaths of any state. PROGRAM: The Opioid Initiative, launched in 2015, focuses on integrating efforts to improve patient care and safety, and population health, by increasing access to nonopioid pain treatment, supporting medication-assisted treatment and naloxone access for people taking opioids, decreasing opioid prescribing, and using data to inform policies and interventions. IMPLEMENTATION: Four OHA projects highlight the integration: (1) a Medicaid Coordinated Care Organization Performance Improvement Project focused on decreasing risky opioid prescribing; (2) Health Evidence Review Commission guidelines that set coverage standards for opioid and nonopioid back pain treatments for Medicaid recipients; (3) statewide opioid prescribing guidelines; and (4) an opioid data dashboard. Each project involves a partnership between governmental public health, public and private health care systems, and external stakeholders. PROGRESS: From 2015 to 2017, the number of Oregonians on 90 or more Morphine Equivalent Doses (MEDs) decreased by 37%, from 11.1 per 1000 residents quarterly to 7.0 per 1000 residents quarterly. Prescription opioid overdose deaths decreased 20% from 4.5 per 100 000 in 2015 to 3.6 per 100 000 in 2016. Within the Medicaid population, the percentage of clients on 120 or more MEDs for 30 consecutive days decreased 27%, from 2.3% in December 2015 to 1.6% in September 2017. DISCUSSION: Oregon's integrated approach to address the opioid crisis spans public health and health care systems, engages key stakeholders, and uses data and evidence to inform policies. The progress to date is promising and may assist other states seeking to identify effective strategies to decrease opioid prescribing, misuse, and overdose.

Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI Chart Review.

OBJECTIVE: Studies of adult hospital patients have identified medical errors as a significant cause of morbidity and mortality. Little is known about the frequency and nature of pediatric patient safety events in the out-of-hospital setting. We sought to quantify pediatric patient safety events in EMS and identify patient, call, and care characteristics associated with potentially severe events. METHODS: As part of the Children's Safety Initiative -EMS, expert panels independently reviewed charts of pediatric critical ambulance transports in a metropolitan area over a three-year period. Regression models were used to identify factors associated with increased risk of potentially severe safety events. Patient safety events were categorized as: Unintended injury; Near miss; Suboptimal action; Error; or Management complication ("UNSEMs") and their severity and potential preventability were assessed. RESULTS: Overall, 265 of 378 (70.1%) unique charts contained at least one UNSEM, including 146 (32.8%) errors and 199 (44.7%) suboptimal actions. Sixty-one UNSEMs were categorized as potentially severe (23.3% of UNSEMs) and nearly half (45.3%) were rated entirely preventable. Two factors were associated with heightened risk for a severe UNSEM: (1) age 29 days to 11 months (OR 3.3, 95% CI 1.25-8.68); (2) cases requiring resuscitation (OR 3.1, 95% CI 1.16-8.28). Severe UNSEMs were disproportionately higher among cardiopulmonary arrests (8.5% of cases, 34.4% of severe UNSEMs). CONCLUSIONS: During high-risk out-of-hospital care of pediatric patients, safety events are common, potentially severe, and largely preventable. Infants and those requiring resuscitation are important areas of focus to reduce out-of-hospital pediatric patient safety events.

Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study.

BACKGROUND: Long-term efficacy of opioids for non-cancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use. OBJECTIVE: To examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients. DESIGN: Retrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges. PARTICIPANTS: Patients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients. MAIN MEASURES: Exposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation ("initiation month"). OUTCOME: Proportion of patients with six or more opioid fills during the subsequent year ("long-term users"). KEY RESULTS: There were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs. CONCLUSIONS: Early opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.

Using prescription monitoring program data to characterize out-of-pocket payments for opioid prescriptions in a state Medicaid program.

BACKGROUND: Out-of-pocket payment for prescription opioids is believed to be an indicator of abuse or diversion, but few studies describe its epidemiology. Prescription drug monitoring programs (PDMPs) collect controlled substance prescription fill data regardless of payment source and thus can be used to study this phenomenon. OBJECTIVE: To estimate the frequency and characteristics of prescription fills for opioids that are likely paid out-of-pocket by individuals in the Oregon Medicaid program. RESEARCH DESIGN: Cross-sectional analysis using Oregon Medicaid administrative claims and PDMP data (2012 to 2013). SUBJECTS: Continuously enrolled nondually eligible Medicaid beneficiaries who could be linked to the PDMP with two opioid fills covered by Oregon Medicaid. MEASURES: Patient characteristics and fill characteristics for opioid fills that lacked a Medicaid pharmacy claim. Fill characteristics included opioid name, type, and association with indicators of high-risk opioid use. RESULTS: A total of 33 592 Medicaid beneficiaries filled a total of 555 103 opioid prescriptions. Of these opioid fills, 74 953 (13.5%) could not be matched to a Medicaid claim. Hydromorphone (30%), fentanyl (18%), and methadone (15%) were the most likely to lack a matching claim. The 3 largest predictors for missing claims were opioid fills that overlapped with other opioids (adjusted odds ratio [aOR] 1.37; 95% confidence interval [CI], 1.34-1.4), long-acting opioids (aOR 1.52; 95% CI, 1.47-1.57), and fills at multiple pharmacies (aOR 1.45; 95% CI, 1.39-1.52). CONCLUSIONS: Prescription opioid fills that were likely paid out-of-pocket were common and associated with several known indicators of high-risk opioid use.

Preparing a prescription drug monitoring program data set for research purposes.

PURPOSE: To develop a complete and consistent prescription drug monitoring program (PDMP) data set for use by drug safety researchers in evaluating patterns of high-risk use and potential abuse of scheduled drugs. METHODS: Using publically available data references from the US Food and Drug Administration and the Centers for Disease Control and Prevention, we developed a strategic methodology to assign drug categories based on pharmaceutical class for the majority of prescriptions in the PDMP data set. We augmented data elements required to calculate morphine milligram equivalents and assigned duration of action (short-acting or long acting) properties for a majority of opioids in the data set. RESULTS: About 10% of prescriptions in the PDMP data set did not have a vendor-assigned drug category, and 20% of opioid prescriptions were missing data needed to calculate risk metrics. Using inclusive methods, 19 133 167 (>99.9%) of prescriptions in the PDMP data set were assigned a drug category. For the opioid category, augmenting data elements resulted in 10 760 669 (99.8%) having required values to calculate morphine milligram equivalents and evaluate duration of action properties. CONCLUSIONS: Drug safety researchers who require a complete and consistent PDMP data set can use the methods described here to ensure that prescriptions of interest are assigned consistent drug categories and complete opioid risk variable values. Copyright © 2016 John Wiley & Sons, Ltd.

Unnecessary Use of Red Lights and Sirens in Pediatric Transport.

INTRODUCTION: Approximately 25.5 million pediatric patients are treated in Emergency Departments around the United States annually. Roughly 7% of these patients are transported by ambulance; of these, approximately 7% arrive in ambulances running red lights and sirens (RLS). Compared to those transporting without RLS, emergency vehicles employing RLS are involved in more accidents and are associated with more fatalities. OBJECTIVE: To characterize the use of RLS in pediatric transports and identify factors associated with unnecessary use of RLS. METHODS: As part of the Children's Safety Initiative (CSI-EMS), a large, multi-phased National Institutes of Health-funded study, we conducted a medical record review of all pediatric RLS transports in an urban EMS system over a 4-year period (2008-11). A standardized chart abstraction tool was adapted for the out-of-hospital setting and pilot tested. Charts were independently reviewed by physicians and paramedics, with disagreements arbitrated by a pediatric emergency physician. Reviewers were asked to judge whether RLS transport was necessary and to provide comments justifying their position. Descriptive statistics were used to measure the frequency of unnecessary transports and logistic regression analysis was employed to identify factors associated with unnecessary use of RLS. RESULTS: Of 490 RLS transports, experts identified 96 (19.6%) as unnecessary use of RLS. Necessary and unnecessary RLS transports had similar patient sex and duration of transport, though unnecessary use of RLS tended to increase with patient age. The call reasons that represented the largest proportion of unnecessary RLS transports were trauma (49.0%), respiratory distress (16.7%), and seizure/altered mental status (11.5%). Compared with necessary RLS transports, unnecessary RLS transports were less likely to require resuscitation, airway management, or medication administration. Univariate analysis revealed that patient vital signs within normal limits were associated with increased risk of unnecessary RLS transport, with the most pronounced effect seen in the normal GCS score group (odds ratio 7.74, p-value 0.001). CONCLUSIONS: This analysis identified patient and transport characteristics associated with unnecessary use of RLS. Our results could help serve as the basis for designing and prospectively evaluating protocols for use of RLS, potentially mitigating the risk associated with transport in pediatric patients.

Women's health providers as vaccine providers in public health emergencies.

OBJECTIVE: To understand women's health providers' vaccine practices and challenges to administering vaccines during public health emergencies. STUDY DESIGN: We surveyed a sample of women's health providers in Washington and California in 2010-2011 about their vaccine practices, perceptions, and emergency preparedness activities related to the 2009-2010 influenza campaign and ongoing pertussis outbreaks. RESULTS: Of the 215 practices surveyed, 152 (70.7%) completed the survey. Most (83.8%) practices considered it standard of care to ask about vaccines and to require, encourage, or offer vaccines to their staff (84.8%). However, only a minority of practices have participated in emergency preparedness exercises (19.3%), actual emergency responses (4.6%), or medical surge capacity initiatives (1.3%). Notably, the challenges and barriers to providing vaccinations in a public health emergency were not practice-level factors such as storage space, staff illness, or reporting, but instead were factors such as vaccine supply, billing, and public interest. CONCLUSION: Women's health providers have generally not been included in preparedness and emergency response activities despite their continuing vaccination efforts. Focusing on women's health providers' involvement in preparedness activities may improve opportunities to vaccinate an important high-risk group, especially in public health emergencies.

Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery).

Lumbar fusion surgery is usually prompted by chronic back pain, and many patients receive long-term preoperative opioid analgesics. Many expect surgery to eliminate the need for opioids. We sought to determine what fraction of long-term preoperative opioid users discontinue or reduce dosage postoperatively; what fraction of patients with little preoperative use initiate long-term use; and what predicts long-term postoperative use. This retrospective cohort study included 2491 adults undergoing lumbar fusion surgery for degenerative conditions, using Oregon's prescription drug monitoring program to quantify opioid use before and after hospitalization. We defined long-term postoperative use as ≥4 prescriptions filled in the 7 months after hospitalization, with at least 3 occurring >30 days after hospitalization. Overall, 1045 patients received long-term opioids preoperatively, and 1094 postoperatively. Among long-term preoperative users, 77.1% continued long-term postoperative use, and 13.8% had episodic use. Only 9.1% discontinued or had short-term postoperative use. Among preoperative users, 34.4% received a lower dose postoperatively, but 44.8% received a higher long-term dose. Among patients with no preoperative opioids, 12.8% became long-term users. In multivariable models, the strongest predictor of long-term postoperative use was cumulative preoperative opioid dose (odds ratio of 15.47 [95% confidence interval 8.53-28.06] in the highest quartile). Cumulative dose and number of opioid prescribers in the 30-day postoperative period were also associated with long-term use. Thus, lumbar fusion surgery infrequently eliminated long-term opioid use. Opioid-naive patients had a substantial risk of initiating long-term use. Patients should have realistic expectations regarding opioid use after lumbar fusion surgery.

High-risk prescribing and opioid overdose: prospects for prescription drug monitoring program-based proactive alerts.

To develop a simple, valid model to identify patients at high risk of opioid overdose-related hospitalization and mortality, Oregon prescription drug monitoring program, Vital Records, and Hospital Discharge data were linked to estimate 2 logistic models; a first model that included a broad range of risk factors from the literature and a second simplified model. Receiver operating characteristic curves, sensitivity, and specificity of the models were analyzed. Variables retained in the final model were categories such as older than 35 years, number of prescribers, number of pharmacies, and prescriptions for long-acting opioids, benzodiazepines or sedatives, or carisoprodol. The ability of the model to discriminate between patients who did and did not overdose was reasonably good (area under the receiver operating characteristic curve = 0.82, Nagelkerke R = 0.11). The positive predictive value of the model was low. Computationally simple models can identify high-risk patients based on prescription history alone, but improvement of the predictive value of models may require information from outside the prescription drug monitoring program. Patient or prescription features that predict opioid overdose may differ from those that predict diversion.

Association of Prescription Drug Monitoring Program Use With Opioid Prescribing and Health Outcomes: A Comparison of Program Users and Nonusers.

Prescription drug monitoring programs (PDMPs) are a response to the prescription opioid epidemic, but their effects on prescribing and health outcomes remain unclear, with conflicting reports. We sought to determine if prescriber use of Oregon's PDMP led to fewer high-risk opioid prescriptions or overdose events. We conducted a retrospective cohort study from October 2011 through October 2014, using statewide PDMP data, hospitalization registry, and vital records. Early PDMP registrants (n = 927) were matched with clinicians who never registered during the study period, using baseline prescribing metrics in a propensity score. Generalized estimating equations were used to examine prescribing trends after PDMP registration, using 2-month intervals. We found a statewide decline in measures of per capita opioid prescribing. However, compared with nonregistrants, PDMP registrants did not subsequently have significantly fewer patients receiving high-dose prescriptions, overlapping opioid and benzodiazepine prescriptions, inappropriate prescriptions, prescriptions from multiple prescribers, or overdose events. At baseline, frequent PDMP users wrote fewer high-risk opioid prescriptions than infrequent users; this persisted during follow-up with few significant group differences in trend. Thus, although opioid prescribing declined statewide after implementing the PDMP, registrants did not show greater declines than nonregistrants. PERSPECTIVE: Factors other than PDMP use may have had greater influence on prescribing trends. Refinements in the PDMP program and related policies may be necessary to increase PDMP effects.

Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS.

OBJECTIVE: To describe the frequency and characterise the nature of patient safety events in paediatric out-of-hospital airway management. METHODS: We conducted a retrospective cross-sectional medical record review of all 'lights and sirens' emergency medicine services transports from 2008 to 2011 in patients <18 years of age in the Portland Oregon metropolitan area. A chart review tool (see online supplementary appendix) was adapted from landmark patient safety studies and revised after pilot testing. Expert panels of physicians and paramedics performed blinded reviews of each chart, identified safety events and described their nature. The primary outcomes were presence and severity of patient safety events related to airway management including oxygen administration, bag-valve-mask ventilation (BVM), airway adjuncts and endotracheal intubation (ETI).DC1SM110.1136/bmjopen-2016-012259.supp1supplementary appendix RESULTS: From the 11 328 paediatric transports during the study period, there were 497 'lights and sirens' (code 3) transports (4.4%). 7 transports were excluded due to missing data. Of the 490 transports included in the analysis, 329 had a total of 338 airway management procedures (some had more than 1 procedure): 61.6% were treated with oxygen, 15.3% with BVM, 8.6% with ETI and 2% with airway adjuncts. The frequency of errors was: 21% (71/338) related to oxygen use, 9.8% (33/338) related to BVM, 9.5% (32/338) related to intubation and 0.9% (3/338) related to airway adjunct use. 58% of intubations required 3 or more attempts or failed altogether. Cardiac arrest was associated with higher odds of a severe error. CONCLUSIONS: Errors in paediatric out-of-hospital airway management are common, especially in the context of intubations and during cardiac arrest.

Vaccine providers' perspectives on impact, challenges, and response during the California 2010 pertussis outbreak.

INTRODUCTION: California has experienced its worst outbreak of pertussis in 50 y. In preparing for such outbreaks of pertussis, vaccine providers in the state play a key role in educating patients about the public health implications of vaccination, explaining the benefits to immunization, and facilitating patients' receipt of recommended immunizations. METHODS: We conducted a survey of 800 California vaccine providers to investigate provider level response to recent pertussis outbreaks and regulation by provider type and geography. RESULTS: Sixty-nine percent (533/777) of vaccine providers within the state of California responded to the survey. Fifty-three percent (278/527) of vaccine providers indicated that it was part of standard care at their practice or pharmacy location to ask adult patients about pertussis vaccine (Table 1) and this varied across practice types (P<0.0001). Fifty-seven percent of providers (270/476) indicated that the information they received from the state about pertussis during the 2010 California pertussis outbreak was very useful or useful, while 52% of providers indicated this information was neutral, not useful, not at all useful. Vaccine administration, patient groups seen, and challenges varied by provider type however meaningful differences among subpopulations to which the vaccine was administered were found between provider types (P<0.001, Table 2). CONCLUSION: The 2010 pertussis outbreak in California challenged vaccine providers in a way that changed the preparation, promotion, and planning for future outbreaks and emergency situations. Adaptability to the new state law and increased awareness of pertussis in the physician community were important in the number of patients receiving the vaccine. Also, forming partnerships with schools and health agencies were important in facilitating and promoting wide spread vaccination.

Nonmedical exemptions to immunization requirements in California: a 16-year longitudinal analysis of trends and associated community factors.

BACKGROUND: Rates of nonmedical exemptions to kindergarten-entry immunization requirements have increased over the past 2 decades, especially in states that permit philosophical exemptions and/or have easier administrative policies for obtaining nonmedical exemptions. We evaluated trends in school personal belief exemption rates over the period 1994-2009 in California, and associated school and community characteristics. METHODS: We used data on personal belief exemptions from 6392 public and private elementary schools from the California Department of Public Health, as well as census tract and school demographic data. Generalized estimating equations were used to model annual mean increases in personal belief exemption rates, and to identify school and community characteristics associated with personal belief exemption rates. RESULTS: Over the study period, the average school personal belief exemption rate increased from 0.6% in 1994 to 2.3% in 2009, an average of 9.2% (95% CI: 8.8-9.6%) per year. The average personal belief exemption rate among private schools over the entire study period was 1.77 (95% CI: 1.55-2.01) times that among public schools. The annual rate of increase was slightly higher among private schools (10.1%, 95% CI: 9.1-11.1%) than among public schools (8.8%, 95% CI: 8.4-9.2%). Schools located within census tracts classified as rural had 1.66 (95% CI: 1.26-2.08) times higher personal belief exemption rates than schools located within urban census tracts. Exemption rates were also associated with race, population density, education, and income. CONCLUSIONS: This study confirms concerns about increasing rates of nonmedical exemptions to kindergarten vaccine requirements within the state of California, using data collected over a 16-year period.

Gift card incentives and non-response bias in a survey of vaccine providers: the role of geographic and demographic factors.

This study investigates the effects of non-response bias in a 2010 postal survey assessing experiences with H1N1 influenza vaccine administration among a diverse sample of providers (N = 765) in Washington state. Though we garnered a high response rate (80.9%) by using evidence-based survey design elements, including intensive follow-up and a gift card incentive from Target, non-response bias could exist if there were differences between respondents and non-respondents. We investigated differences between the two groups for seven variables: road distance to the nearest Target store, practice type, previous administration of vaccines, region, urbanicity, size of practice, and Vaccines for Children (VFC) program enrollment. We also examined the effect of non-response bias on survey estimates. Statistically significant differences between respondents and non-respondents were found for four variables: miles to the nearest Target store, type of medical practice, whether the practice routinely administered additional vaccines besides H1N1, and urbanicity. Practices were more likely to respond if they were from a small town or rural area (OR = 7.68, 95% CI = 1.44-40.88), were a non-traditional vaccine provider type (OR = 2.08, 95% CI = 1.06-4.08) or a pediatric provider type (OR = 4.03, 95% CI = 1.36-11.96), or administered additional vaccines besides H1N1 (OR = 1.80, 95% CI = 1.03-3.15). Of particular interest, for each ten mile increase in road distance from the nearest Target store, the likelihood of provider response decreased (OR = 0.73, 95% CI = 0.60-0.89). Of those variables associated with response, only small town or rural practice location was associated with a survey estimate of interest, suggesting that non-response bias had a minimal effect on survey estimates. These findings show that gift card incentives alongside survey design elements and follow-up can achieve high response rates. However, there is evidence that practices farther from the nearest place to redeem gift cards may be less likely to respond to the survey.