Composition of buprenorphine prescribing networks in Medicaid and association with quality of care.

INTRODUCTION: Despite Medicaid's outsized role in delivering and financing medications for opioid use disorder (MOUD), little is known about the extent to which buprenorphine prescriber networks vary across Medicaid health plans, and whether network characteristics affect quality of treatment received. In this observational cross-sectional study, we used 2018-2019 Medicaid claims in Oregon to assess network variation in the numbers and types of buprenorphine prescribers, as well as the association of prescriber and network characteristics with quality of care. METHODS: We describe prescribers (MD/DOs and advanced practice providers) of OUD-approved buprenorphine formulations to patients with an OUD diagnosis, across networks. For each patient who initiated buprenorphine treatment during 2018, we assigned a "usual prescriber" and assessed four measures of quality in the 180d following initiation: 1) continuous receipt of buprenorphine; 2) receipt of any behavioral health counseling services; 3) receipt of any urine drug screen; and 4) receipt of any prescription for a benzodiazepine. We used multivariable linear regressions to examine the association of prescriber and network characteristics with quality of buprenorphine care following initiation. RESULTS: We identified 645 providers who prescribed buprenorphine to 20,739 eligible Medicaid enrollees with an OUD diagnosis. The composition of buprenorphine prescriber networks varied in terms of licensing type, specialty, and panel size, with the majority of prescribers providing buprenorphine to small panels of patients. In the 180 days following initiation, a third of patients were maintained on buprenorphine; 69.9 % received behavioral health counseling; 88.4 % had a urine drug screen; and 11.3 % received a benzodiazepine prescription. In regression analyses, while no single network characteristic was associated with higher quality across all examined measures, each one unit increase in prescriber-to-enrollee ratio was associated with a 1.18 p.p. increase in the probability of continuous buprenorphine maintenance during the 180 days following initiation (95 % confidence interval = [0.21, 2.15], p = 0.017). CONCLUSIONS: Medicaid plans may be able to leverage their networks to provide higher quality care. Our findings, which should be interpreted as descriptive only, suggest that higher prescriber-to-enrollee ratio is associated with increased buprenorphine maintenance. Future research should focus on isolating the causal relationships between MOUD prescribing network design and patient outcomes.

Adolescent Residential Addiction Treatment In The US: Uneven Access, Waitlists, And High Costs.

Drug overdose deaths among adolescents are increasing in the United States. Residential treatment facilities are one treatment option for adolescents with substance use disorders, yet little is known about their accessibility or cost. Using the Substance Abuse and Mental Health Services Administration's treatment locator and search engine advertising data, we identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. We called facilities while role-playing as the aunt or uncle of a sixteen-year-old child with a recent nonfatal overdose, to inquire about policies and costs. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. We were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly.

Association between treatment setting and outcomes among oregon medicaid patients with opioid use disorder: a retrospective cohort study.

BACKGROUND: Residential treatment is a common approach for treating opioid use disorder (OUD), however, few studies have directly compared it to outpatient treatment. The objective of this study was to compare OUD outcomes among individuals receiving residential and outpatient treatment. METHODS: A retrospective cohort study used linked data from a state Medicaid program, vital statistics, and the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episodes Dataset (TEDS) to compare OUD-related health outcomes among individuals treated in a residential or outpatient setting between 2014 and 2017. Multivariable Cox proportional hazards and logistic regression models examined the association between treatment setting and outcomes (i.e., opioid overdose, non-overdose opioid-related and all-cause emergency department (ED) visits, hospital admissions, and treatment retention) controlling for patient characteristics, co-morbidities, and use of medications for opioid use disorders (MOUD). Interaction models evaluated how MOUD use modified associations between treatment setting and outcomes. RESULTS: Of 3293 individuals treated for OUD, 957 (29%) received treatment in a residential facility. MOUD use was higher among those treated as an outpatient (43%) compared to residential (19%). The risk of opioid overdose (aHR 1.39; 95% CI 0.73-2.64) or an opioid-related emergency department encounter or admission (aHR 1.02; 95% CI 0.80-1.29) did not differ between treatment settings. Independent of setting, MOUD use was associated with a significant reduction in overdose risk (aHR 0.45; 95% CI 0.23-0.89). Residential care was associated with greater odds of retention at 6-months (aOR 1.71; 95% CI 1.32-2.21) but not 1-year. Residential treatment was only associated with improved retention for individuals not receiving MOUD (6-month aOR 2.05; 95% CI 1.56-2.71) with no benefit observed in those who received MOUD (aOR 0.75; 95% CI 0.46-1.29; interaction p = 0.001). CONCLUSIONS: Relative to outpatient treatment, residential treatment was not associated with reductions in opioid overdose or opioid-related ED encounters/hospitalizations. Regardless of setting, MOUD use was associated with a significant reduction in opioid overdose risk.

Expanding Inpatient Addiction Consult Services Through Accountable Care Organizations for Medicaid Enrollees: A Modeling Study.

INTRODUCTION: Addiction consult services (ACS) care for hospitalized patients with substance use disorder, including opioid use disorder (OUD). Medicaid Accountable Care Organizations (ACOs) could enhance access to ACS. This study extends data from Oregon's only ACS to Oregon's 15 regional Medicaid Coordinated Care Organizations (CCOs) to illustrate the potential value of enhanced in- and out-patient care for hospitalized patients with OUD. The study objectives were to estimate the effects of (1) expanding ACS care through CCOs in Oregon, and (2) increasing community treatment access within CCOs, on post-discharge OUD treatment engagement. METHODS: We used a validated Markov model, populated with Oregon Medicaid data from April 2015 to December 2017, to estimate study objectives. RESULTS: Oregon Medicaid patients hospitalized with OUD with care billed to a CCO (n = 5878) included 1298 (22.1%) patients engaged in post-discharge OUD treatment. Simulation of referral to an ACS increased post-discharge OUD treatment engagement to 47.0% (95% confidence interval [CI] 45.7%, 48.3%), or 2684 patients (95% CI 2610, 2758). Ten of fifteen (66.7%) CCOs had fewer than 20% of patients engage in post-discharge OUD care. Without ACS, increasing outpatient treatment such that 20% of patients engage increased the patients engaging in post-discharge OUD care from 12.9% or 296 patients in care at baseline to 20% (95% CI 18.1%, 21.4%) or 453 (95% CI 416, 491). DISCUSSION: ACOs can improve care for patients hospitalized with OUD. Implementing ACS in ACO networks can potentially improve post-discharge OUD treatment engagement, but community treatment systems must be prepared to accept more patients as inpatient addiction care improves.

Evaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptions.

BACKGROUND: In 2015, Oregon's Medicaid program implemented a performance improvement project to reduce high-dose opioid prescribing across its 16 coordinated care organizations (CCOs). The objective of this study was to evaluate the effect of that program on prescription opioid use and outcomes. METHODS: Using Medicaid claims data from 2014 to 2017, we conducted interrupted time-series analyses to examine changes in the prescription opioid use and overdose rates before (July 2014 to June 2015) and after (January 2016 to December 2017) implementation of Oregon's high-dose policy initiative (July 2015 to December 2015). Prescribing outcomes were: 1) total opioid prescriptions 2) high-dose [> 90 morphine milligram equivalents per day] opioid prescriptions, and 3) proportion of opioid prescriptions that were high-dose. Opioid overdose outcomes included emergency department visits or hospitalizations that involved an opioid-related poisoning (total, heroin-involved, non-heroin involved). Analyses were performed at the state and CCO level. RESULTS: There was an immediate reduction in high dose opioid prescriptions after the program was implemented (- 1.55 prescription per 1000 enrollee; 95% CI - 2.26 to - 0.84; p < 0.01). Program implementation was also associated with an immediate drop (- 1.29 percentage points; 95% CI - 1.94 to - 0.64 percentage points; p < 0.01) and trend reduction (- 0.23 percentage point per month; 95% CI - 0.33 to - 0.14 percentage points; p < 0.01) in the monthly proportion of high-dose opioid prescriptions. The trend in total, heroin-involved, and non-heroin overdose rates increased significantly following implementation of the program. CONCLUSIONS: Although Oregon's high-dose opioid performance improvement project was associated with declines in high-dose opioid prescriptions, rates of opioid overdose did not decrease. Policy efforts to reduce opioid prescribing risks may not be sufficient to address the growing opioid crisis.

Designing and validating a Markov model for hospital-based addiction consult service impact on 12-month drug and non-drug related mortality.

INTRODUCTION: Addiction consult services (ACS) engage hospitalized patients with opioid use disorder (OUD) in care and help meet their goals for substance use treatment. Little is known about how ACS affect mortality for patients with OUD. The objective of this study was to design and validate a model that estimates the impact of ACS care on 12-month mortality among hospitalized patients with OUD. METHODS: We developed a Markov model of referral to an ACS, post-discharge engagement in SUD care, and 12-month drug-related and non-drug related mortality among hospitalized patients with OUD. We populated our model using Oregon Medicaid data and validated it using international modeling standards. RESULTS: There were 6,654 patients with OUD hospitalized from April 2015 through December 2017. There were 114 (1.7%) drug-related deaths and 408 (6.1%) non-drug related deaths at 12 months. Bayesian logistic regression models estimated four percent (4%, 95% CI = 2%, 6%) of patients were referred to an ACS. Of those, 47% (95% CI = 37%, 57%) engaged in post-discharge OUD care, versus 20% not referred to an ACS (95% CI = 16%, 24%). The risk of drug-related death at 12 months among patients in post-discharge OUD care was 3% (95% CI = 0%, 7%) versus 6% not in care (95% CI = 2%, 10%). The risk of non-drug related death was 7% (95% CI = 1%, 13%) among patients in post-discharge OUD treatment, versus 9% not in care (95% CI = 5%, 13%). We validated our model by evaluating its predictive, external, internal, face and cross validity. DISCUSSION: Our novel Markov model reflects trajectories of care and survival for patients hospitalized with OUD. This model can be used to evaluate the impact of other clinical and policy changes to improve patient survival.

Identifying opioid dose reductions and discontinuation among patients with chronic opioid therapy.

PURPOSE: To identify and systematically categorize opioid dose reductions and discontinuations in large administrative datasets. METHODS: Using a dataset of Oregon Medicaid beneficiaries linked with prescription drug monitoring program (PDMP) data between 2014 and 2017, we identified patients with high-dose chronic opioid therapy (COT), ≥84 consecutive days with an average daily MME of ≥50 on each of those days. We categorized patients into four mutually exclusive groups based on the trajectory of opioid use in the year after COT: abrupt discontinuation, dose reduction and discontinuation, dose reduction without discontinuation, and stable or increasing dose. Finally, we examined prescription patterns in each category. RESULTS: Among individuals with high-dose COT, 7636 (37.1%) had an abrupt discontinuation, 2577 (12.5%) had a dose reduction and discontinuation, 7739 (37.6%) had a dose reduction without discontinuation, and 2623 (12.8%) had a stable or increasing dose in the year following the COT episode. Among those who discontinued opioid use (n = 10 213, 49.6%), three in four (74.8%) did so without evidence of tapering. Patients who discontinued opioid use were younger, had higher daily MME during COT, and were more likely to have filled a benzodiazepine or had a multiple provider or multiple pharmacy episode compared to patients who did not discontinue opioid use. CONCLUSIONS: Dose reductions and discontinuations after a COT episode can be identified in large administrative datasets. Those with a discontinuation were more likely to have riskier prescription profiles during their COT episode.

Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018.

BACKGROUND: Injection drug use has far-reaching social, economic, and health consequences. Serious bacterial infections, including skin/soft tissue infections, osteomyelitis, bacteremia, and endocarditis, are particularly morbid and mortal consequences of injection drug use. METHODS: We conducted a population-based retrospective cohort analysis of hospitalizations among patients with a diagnosis code for substance use and a serious bacterial infection during the same hospital admission using Oregon Hospital Discharge Data. We examined trends in hospitalizations and costs of hospitalizations attributable to injection drug use-related serious bacterial infections from January 1, 2008 through December 31, 2018. RESULTS: From 2008 to 2018, Oregon hospital discharge data included 4,084,743 hospitalizations among 2,090,359 patients. During the study period, hospitalizations for injection drug use-related serious bacterial infection increased from 980 to 6,265 per year, or from 0.26% to 1.68% of all hospitalizations (P<0.001). The number of unique patients with an injection drug use-related serious bacterial infection increased from 839 to 5,055, or from 2.52% to 8.46% of all patients (P<0.001). While hospitalizations for all injection drug use-related serious bacterial infections increased over the study period, bacteremia/sepsis hospitalizations rose most rapidly with an 18-fold increase. Opioid use diagnoses accounted for the largest percentage of hospitalizations for injection drug use-related serious bacterial infections, but hospitalizations for amphetamine-type stimulant-related serious bacterial infections rose most rapidly with a 15-fold increase. People living with HIV and HCV experienced increases in hospitalizations for injection drug use-related serious bacterial infection during the study period. Overall, the total cost of hospitalizations for injection drug use-related serious bacterial infections increased from $16,305,129 in 2008 to $150,879,237 in 2018 (P<0.001). CONCLUSIONS: In Oregon, hospitalizations for injection drug use-related serious bacterial infections increased dramatically and exacted a substantial cost on the health care system from 2008 to 2018. This increase in hospitalizations represents an opportunity to initiate substance use disorder treatment and harm reduction services to improve outcomes for people who inject drugs.

Prescription Opioid Dispensing Patterns Prior to Heroin Overdose in a State Medicaid Program: a Case-Control Study.

BACKGROUND: A large proportion of individuals who use heroin report initiating opioid use with prescription opioids. However, patterns of prescription opioid use preceding heroin-related overdose have not been described. OBJECTIVE: To describe prescription opioid use in the year preceding heroin overdose. DESIGN: Case-control study comparing prescription opioid use with a heroin-involved overdose, non-heroin-involved opioid overdose, and non-overdose controls from 2015 to 2017. PARTICIPANTS: Oregon Medicaid beneficiaries with linked administrative claims, vital statistics, and prescription drug monitoring program data. MAIN MEASURES: Opioid, benzodiazepine, and other central nervous system depressant prescriptions preceding overdose; among individuals with one or more opioid prescription, we assessed morphine milligram equivalents per day, overlapping prescriptions, prescriptions from multiple prescribers, long-term use, and discontinuation of long-term use. KEY RESULTS: We identified 1458 heroin-involved overdoses (191 fatal) and 2050 non-heroin-involved opioid overdoses (266 fatal). In the 365 days prior to their overdose, 45% of individuals with a heroin-involved overdose received at least one prescribed opioid compared with 78% of individuals who experienced a non-heroin-involved opioid overdose (p < 0.001). For both heroin- and non-heroin-involved overdose cases, the likelihood of receiving an opioid increased with age. Among heroin overdose cases with an opioid dispensed, the rate of multiple pharmacy use was the only high-risk opioid pattern that was greater than non-overdose controls (adjusted odds ratio 3.2; 95% confidence interval 1.48 to 6.95). Discontinuation of long-term opioid use was not common prior to heroin overdose and not higher than discontinuation rates among non-overdose controls. CONCLUSIONS: Although individuals with a heroin-involved overdose were less likely to receive prescribed opioids in the year preceding their overdose relative to non-heroin opioid overdose cases, prescription opioid use was relatively common and increased with age. Discontinuation of long-term prescription opioid use was not associated with heroin-involved overdose.

Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: a Propensity-Matched Analysis.

BACKGROUND: Hospitalizations due to medical and surgical complications of substance use disorder (SUD) are rising. Most hospitals lack systems to treat SUD, and most people with SUD do not engage in treatment after discharge. OBJECTIVE: Determine the effect of a hospital-based addiction medicine consult service, the Improving Addiction Care Team (IMPACT), on post-hospital SUD treatment engagement. DESIGN: Cohort study using multivariable analysis of Oregon Medicaid claims comparing IMPACT patients with propensity-matched controls. PARTICIPANTS: 18-64-year-old Oregon Medicaid beneficiaries with SUD, hospitalized at an Oregon hospital between July 1, 2015, and September 30, 2016. IMPACT patients (n = 208) were matched to controls (n = 416) using a propensity score that accounted for SUD, gender, age, race, residence region, and diagnoses. INTERVENTIONS: IMPACT included hospital-based consultation care from an interdisciplinary team of addiction medicine physicians, social workers, and peers with lived experience in recovery. IMPACT met patients during hospitalization; offered pharmacotherapy, behavioral treatments, and harm reduction services; and supported linkages to SUD treatment after discharge. OUTCOMES: Healthcare Effectiveness Data and Information Set (HEDIS) measure of SUD treatment engagement, defined as two or more claims on two separate days for SUD care within 34 days of discharge. RESULTS: Only 17.2% of all patients were engaged in SUD treatment before hospitalization. IMPACT patients engaged in SUD treatment following discharge more frequently than controls (38.9% vs. 23.3%, p < 0.01; aOR 2.15, 95% confidence interval [CI] 1.29-3.58). IMPACT participation remained associated with SUD treatment engagement when limiting the sample to people who were not engaged in treatment prior to hospitalization (aOR 2.63; 95% CI 1.46-4.72). CONCLUSIONS: Hospital-based addiction medicine consultation can improve SUD treatment engagement, which is associated with reduced substance use, mortality, and other important clinical outcomes. National expansion of such models represents an opportunity to address an enduring gap in the SUD treatment continuum.

The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale.

BACKGROUND: Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. METHODS/DESIGN: Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. DISCUSSION: The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.

A statewide effort to reduce high-dose opioid prescribing through coordinated care organizations.

BACKGROUND: Oregon's Medicaid program is delivered through 16 Coordinated Care Organizations (CCOs) participating in a statewide performance improvement program to reduce high-dose opioid prescribing. CCOs were allowed flexibility to develop their own dose targets and any policies, trainings, guidelines, and/or materials to meet these targets. In this study, we characterize CCO strategies to reduce high-dose opioid prescribing across the 16 CCOs. METHODS: We reviewed relevant CCO documents and conducted semi-structured interviews with CCO administrators to acquire opioid-related policies, practices, timelines and contextual factors. We applied a systematic coding procedure to develop a comprehensive description of each CCO's strategy. We used administrative data from the state to summarize contextual utilization data for each CCO. RESULTS: Most CCOs selected a target daily morphine milligram equivalent (MME) dose of 90 mg. Sixteen issued quantity limits related to dose, eight restricted specific drug formulations (short-acting or long-acting), and 11 allowed for time-limited taper plan periods for patients over threshold. Many CCOs also employed provider trainings, feedback reports, and/or onsite technical assistance. Other innovations included incentive measures, electronic health record alerts, and toolkits with materials on local alternative therapy resources and strategies for patient communication. CCOs leveraging collaborations with regional partners appeared to mount a greater intensity of interventions than independently operating CCOs. CONCLUSIONS: CCOs developed a diversity of interventions to confront high-risk opioid prescribing within their organization. As healthcare systems mount interventions to reduce risky opioid prescribing, it is critical to carefully describe these activities and examine their impact on process and health outcomes.

Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder.

People with substance use disorders (SUD) have high rates of hospitalization and readmission, long lengths of stay, and skyrocketing healthcare costs. Yet, models for improving care are extremely limited. We performed a needs assessment and then convened academic and community partners, including a hospital, community SUD organizations, and Medicaid accountable care organizations, to design a care model for medically complex hospitalized patients with SUD. Needs assessment showed that 58% to 67% of participants who reported active substance use said they were interested in cutting back or quitting. Many reported interest in medication for addiction treatment (MAT). Participants had high rates of costly readmissions and longer than expected length of stay. Community stakeholders identified long wait times and lack of resources for medically complex patients as key barriers. We developed the Improving Addiction Care Team (IMPACT), which includes an inpatient addiction medicine consultation service, rapid-access pathways to posthospital SUD treatment, and a medically enhanced residential care model that integrates antibiotic infusion and residential addiction care. We developed a business case and secured funding from Medicaid and hospital payers. IMPACT provides one pathway for hospitals, payers, and communities to collaboratively address the SUD epidemic. Journal of Hospital Medicine 2017;12:339-342.

Healthcare Coverage for HIV Provider Visits Before and After Implementation of the Affordable Care Act.

BACKGROUND: Before implementation of the Patient Protection and Affordable Care Act (ACA) in 2014, 100 000 persons living with human immunodeficiency virus (HIV) (PLWH) lacked healthcare coverage and relied on a safety net of Ryan White HIV/AIDS Program support, local charities, or uncompensated care (RWHAP/Uncomp) to cover visits to HIV providers. We compared HIV provider coverage before (2011-2013) versus after (first half of 2014) ACA implementation among a total of 28 374 PLWH followed up in 4 sites in Medicaid expansion states (California, Oregon, and Maryland), 4 in a state (New York) that expanded Medicaid in 2001, and 2 in nonexpansion states (Texas and Florida). METHODS: Multivariate multinomial logistic models were used to assess changes in RWHAP/Uncomp, Medicaid, and private insurance coverage, using Medicare as a referent. RESULTS: In expansion state sites, RWHAP/Uncomp coverage decreased (unadjusted, 28% before and 13% after ACA; adjusted relative risk ratio [ARRR], 0.44; 95% confidence interval [CI], .40-.48). Medicaid coverage increased (23% and 38%; ARRR, 1.82; 95% CI, 1.70-1.94), and private coverage was unchanged (21% and 19%; 0.96; .89-1.03). In New York sites, both RWHAP/Uncomp (20% and 19%) and Medicaid (50% and 50%) coverage were unchanged, while private coverage decreased (13% and 12%; ARRR, 0.86; 95% CI, .80-.92). In nonexpansion state sites, RWHAP/Uncomp (57% and 52%) and Medicaid (18% and 18%) coverage were unchanged, while private coverage increased (4% and 7%; ARRR, 1.79; 95% CI, 1.62-1.99). CONCLUSIONS: In expansion state sites, half of PLWH relying on RWHAP/Uncomp coverage shifted to Medicaid, while in New York and nonexpansion state sites, reliance on RWHAP/Uncomp remained constant. In the first half of 2014, the ACA did not eliminate the need for RWHAP safety net provider visit coverage.

Hepatitis C virus testing in adults living with HIV: a need for improved screening efforts.

OBJECTIVES: Guidelines recommend hepatitis C virus (HCV) screening for all people living with HIV (PLWH). Understanding HCV testing practices may improve compliance with guidelines and can help identify areas for future intervention. METHODS: We evaluated HCV screening and unnecessary repeat HCV testing in 8,590 PLWH initiating care at 12 U.S. HIV clinics between 2006 and 2010, with follow-up through 2011. Multivariable logistic regression examined the association between patient factors and the outcomes: HCV screening (≥1 HCV antibody tests during the study period) and unnecessary repeat HCV testing (≥1 HCV antibody tests in patients with a prior positive test result). RESULTS: Overall, 82% of patients were screened for HCV, 18% of those screened were HCV antibody-positive, and 40% of HCV antibody-positive patients had unnecessary repeat HCV testing. The likelihood of being screened for HCV increased as the number of outpatient visits rose (adjusted odds ratio 1.02, 95% confidence interval 1.01-1.03). Compared to men who have sex with men (MSM), patients with injection drug use (IDU) were less likely to be screened for HCV (0.63, 0.52-0.78); while individuals with Medicaid were more likely to be screened than those with private insurance (1.30, 1.04-1.62). Patients with heterosexual (1.78, 1.20-2.65) and IDU (1.58, 1.06-2.34) risk compared to MSM, and those with higher numbers of outpatient (1.03, 1.01-1.04) and inpatient (1.09, 1.01-1.19) visits were at greatest risk of unnecessary HCV testing. CONCLUSIONS: Additional efforts to improve compliance with HCV testing guidelines are needed. Leveraging health information technology may increase HCV screening and reduce unnecessary testing.

Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity.

Disparities in HIV care and outcomes negatively affect Black and Hispanic patients. Features of clinical communication may be a factor. This study is based on coding transcripts of 404 routine outpatient visits by people with HIV at four sites, using a validated system. In models adjusting for site and patient characteristics, with provider as a random effect, providers were more "verbally dominant" with Black patients than with others. There was more discussion about ARV adherence with both Black and Hispanic patients, but no more discussion about strategies to improve adherence. Providers made more directive utterances discussing ARV treatment with Hispanic patients. Possible interpretations of these findings are that providers are less confident in Black and Hispanic patients to be adherent; that they place too much confidence in their White, non-Hispanic patients; or that patients differentially want such discussion. The lack of specific problem solving and high provider directiveness suggests areas for improvement.

Association between U.S. state AIDS Drug Assistance Program (ADAP) features and HIV antiretroviral therapy initiation, 2001-2009.

BACKGROUND: U.S. state AIDS Drug Assistance Programs (ADAPs) are federally funded to provide antiretroviral therapy (ART) as the payer of last resort to eligible persons with HIV infection. States differ regarding their financial contributions to and ways of implementing these programs, and it remains unclear how this interstate variability affects HIV treatment outcomes. METHODS: We analyzed data from HIV-infected individuals who were clinically-eligible for ART between 2001 and 2009 (i.e., a first reported CD4+ <350 cells/uL or AIDS-defining illness) from 14 U.S. cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Using propensity score matching and Cox regression, we assessed ART initiation (within 6 months following eligibility) and virologic suppression (within 1 year) based on differences in two state ADAP features: the amount of state funding in annual ADAP budgets and the implementation of waiting lists. We performed an a priori subgroup analysis in persons with a history of injection drug use (IDU). RESULTS: Among 8,874 persons, 56% initiated ART within six months following eligibility. Persons living in states with no additional state contribution to the ADAP budget initiated ART on a less timely basis (hazard ratio [HR] 0.73, 95% CI 0.60-0.88). Living in a state with an ADAP waiting list was not associated with less timely initiation (HR 1.12, 95% CI 0.87-1.45). Neither additional state contributions nor waiting lists were significantly associated with virologic suppression. Persons with an IDU history initiated ART on a less timely basis (HR 0.67, 95% CI 0.47-0.95). CONCLUSIONS: We found that living in states that did not contribute additionally to the ADAP budget was associated with delayed ART initiation when treatment was clinically indicated. Given the changing healthcare environment, continued assessment of the role of ADAPs and their features that facilitate prompt treatment is needed.

Conformity of pediatric/adolescent HIV clinics to the patient-centered medical home care model.

The patient-centered medical home (PCMH) has been introduced as a model for providing high-quality, comprehensive, patient-centered care that is both accessible and coordinated, and may provide a framework for optimizing the care of youth living with HIV (YLH). We surveyed six pediatric/adolescent HIV clinics caring for 578 patients (median age 19 years, 51% male, and 82% black) in July 2011 to assess conformity to the PCMH. Clinics completed a 50-item survey covering the six domains of the PCMH: (1) comprehensive care, (2) patient-centered care, (3) coordinated care, (4) accessible services, (5) quality and safety, and (6) health information technology. To determine conformity to the PCMH, a novel point-based scoring system was devised. Points were tabulated across clinics by domain to obtain an aggregate assessment of PCMH conformity. All six clinics responded. Overall, clinics attained a mean 75.8% [95% CI, 63.3-88.3%] on PCMH measures-scoring highest on patient-centered care (94.7%), coordinated care (83.3%), and quality and safety measures (76.7%), and lowest on health information technology (70.0%), accessible services (69.1%), and comprehensive care (61.1%). Clinics moderately conformed to the PCMH model. Areas for improvement include access to care, comprehensive care, and health information technology. Future studies are warranted to determine whether greater clinic PCMH conformity improves clinical outcomes and cost savings for YLH.

Primary care provider cultural competence and racial disparities in HIV care and outcomes.

BACKGROUND: Health professional organizations have advocated for increasing the "cultural competence" (CC) of healthcare providers, to reduce racial and ethnic disparities in patient care. It is unclear whether provider CC is associated with more equitable care. OBJECTIVE: To evaluate whether provider CC is associated with quality of care and outcomes for patients with HIV/AIDS. DESIGN AND PARTICIPANTS: Survey of 45 providers and 437 patients at four urban HIV clinics in the U.S. MAIN MEASURES: Providers' self-rated CC was measured using a novel, 20-item instrument. Outcome measures included patients' receipt of antiretroviral (ARV) therapy, self-efficacy in managing medication regimens, complete 3-day ARV adherence, and viral suppression. KEY RESULTS: Providers' mean age was 44 years; 56 % were women, and 64 % were white. Patients' mean age was 45; 67 % were men, and 77 % were nonwhite. Minority patients whose providers scored in the middle or highest third on self-rated CC were more likely than those with providers in the lowest third to be on ARVs, have high self-efficacy, and report complete ARV adherence. Racial disparities were observed in receipt of ARVs (adjusted OR, 95 % CI for white vs. nonwhite: 6.21, 1.50-25.7), self-efficacy (3.77, 1.24-11.4), and viral suppression (13.0, 3.43-49.0) among patients of low CC providers, but not among patients of moderate and high CC providers (receipt of ARVs: 0.71, 0.32-1.61; self-efficacy: 1.14, 0.59-2.22; viral suppression: 1.20, 0.60-2.42). CONCLUSIONS: Provider CC was associated with the quality and equity of HIV care. These findings suggest that enhancing provider CC may reduce racial disparities in healthcare quality and outcomes.