Gaps in Confirmatory Fibrosis Risk Assessment in Primary Care Patients with Nonalcoholic Fatty Liver Disease.

BACKGROUND: As recommendations for non-invasive fibrosis risk assessment in nonalcoholic fatty liver disease (NAFLD) emerge, it is not known how often they are performed in primary care. AIMS: We investigated the completion of confirmatory fibrosis risk assessment in primary care patients with NAFLD and indeterminate-risk or greater Fibrosis-4 Index (FIB-4) and NAFLD Fibrosis Scores (NFS). METHODS: This retrospective cohort study of electronic health record data from a primary care clinic identified patients with diagnoses of NAFLD from 2012 through 2021. Patients with a diagnosis of a severe liver disease outcome during the study period were excluded. The most recent FIB-4 and NFS scores were calculated and categorized by advanced fibrosis risk. Charts were reviewed to identify the outcome of a confirmatory fibrosis risk assessment by liver elastography or liver biopsy for all patients with indeterminate-risk or higher FIB-4 (≥ 1.3) and NFS (≥ - 1.455) scores. RESULTS: The cohort included 604 patients diagnosed with NAFLD. Two-thirds of included patients (399) had a FIB-4 or NFS score greater than low-risk, 19% (113) had a high-risk FIB-4 (≥ 2.67) or NFS (≥ 0.676) score, and 7% (44) had high-risk FIB-4 and NFS values. Of these 399 patients with an indication for a confirmatory fibrosis test, 10% (41) underwent liver elastography (24) or liver biopsy (18) or both (1). CONCLUSIONS: Advanced fibrosis is a key indicator of future poor health outcomes in patients with NAFLD and a critical signal for referral to hepatology. Significant opportunities exist to improve confirmatory fibrosis risk assessment in patients with NAFLD.

Opioid Use Patterns in a Statewide Adult Medicaid Population Undergoing Elective Lumbar Spine Surgery.

STUDY DESIGN: Retrospective administrative database review. OBJECTIVE: Analyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population. SUMMARY OF BACKGROUND DATA: Opioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients. MATERIALS AND METHODS: Longitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU). RESULTS: A total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001). CONCLUSIONS: Most SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.

Surgical prescription opioid trajectories among state Medicaid enrollees.

OBJECTIVE: The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN: Retrospective cohort. SETTING: Administrative claims data. PATIENTS AND PARTICIPANTS: Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS: More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS: Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.

Estimating the Economic Burden of Acute Myocardial Infarction in the US: 12 Year National Data.

BACKGROUND: Acute myocardial infarction (AMI) carries a substantial mortality and morbidity burden. The purpose of this study is to provide annual mean cost per patient and national level estimates of direct and indirect costs (lost productivity from morbidity and premature mortality) associated with AMI. METHODS: Nationally representative data spanning 12 years (2003-2014) with a sample of 324,869 patients with AMI from the Medical Expenditure Panel Survey (MEPS) were analyzed. A novel 2-part model was used to examine the excess direct cost associated with AMI, controlling for covariates. To estimate lost productivity from morbidity, an adjusted Generalized Linear Model was used for the differential in wage earnings between participants with and without AMI. Lost productivity from premature mortality was estimated based on published data. RESULTS: The total annual cost of AMI in 2016 dollars was estimated to be $84.9 billion, including $29.8 billion in excess direct medical expenditures, $14.6 billion in lost productivity from morbidity and $40.5 billion in lost productivity from premature mortality between 2003 and 2014. In the adjusted regression, the overall excess direct medical expenditure of AMI was $7,076 (95% confidence interval [CI] $6,028-$8,125) higher than those without AMI. After adjustment, annual wages for patients with AMI were $10,166 (95% CI -$12,985 to -$7,347) lower and annual missed work days were 5.9 days (95% CI 3.57-8.27) higher than those without AMI. CONCLUSIONS: The study finds that the economic burden of AMI is substantial, for which effective prevention could result in significant health and productivity cost savings.

Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003-2014.

BACKGROUND: One in 3 US adults has high blood pressure, or hypertension. As prior projections suggest hypertension is the costliest of all cardiovascular diseases, it is important to define the current state of healthcare expenditures related to hypertension. METHODS AND RESULTS: We used a nationally representative database, the Medical Expenditure Panel Survey, to calculate the estimated annual healthcare expenditure for patients with hypertension and to measure trends in expenditure longitudinally over a 12-year period. A 2-part model was used to estimate adjusted incremental expenditures for individuals with hypertension versus those without hypertension. Sex, race/ethnicity, education, insurance status, census region, income, marital status, Charlson Comorbidity Index, and year category were included as covariates. The 2003-2014 pooled data include a total sample of 224 920 adults, of whom 36.9% had hypertension. Unadjusted mean annual medical expenditure attributable to patients with hypertension was $9089. Relative to individuals without hypertension, individuals with hypertension had $1920 higher annual adjusted incremental expenditure, 2.5 times the inpatient cost, almost double the outpatient cost, and nearly triple the prescription medication expenditure. Based on the prevalence of hypertension in the United States, the estimated adjusted annual incremental cost is $131 billion per year higher for the hypertensive adult population compared with the nonhypertensive population. CONCLUSIONS: Individuals with hypertension are estimated to face nearly $2000 higher annual healthcare expenditure compared with their nonhypertensive peers. This trend has been relatively stable over 12 years. Healthcare costs associated with hypertension account for about $131 billion. This warrants intense effort toward hypertension prevention and management.

Effect of frailty on resource use and cost for Medicare patients.

Aim: The effects of frailty and multiple chronic conditions (MCCs) on cost of care are rarely disentangled in archival data studies. We identify the marginal contribution of frailty to medical care cost estimates using Medicare data. Materials & methods: Use of the Faurot frailty score to identify differences in acute medical events and cost of care for patients, controlling for MCCs and medication use. Results: Estimated marginal cost of frailty was US$10,690 after controlling for demographics, comorbid conditions, polypharmacy and use of potentially inappropriate medications. Conclusion: Frailty contributes greatly to cost of care, but while often correlated, is not synonymous with MCCs. Thus, it is important to control separately for frailty in studies that compare medical care use and cost.

Chaos to complexity: leveling the playing field for measuring value in primary care.

RATIONALE, AIMS AND OBJECTIVES: Develop a risk-stratification model that clusters primary care patients with similar co-morbidities and social determinants and ranks 'within-practice' clusters of complex patients based on likelihood of hospital and emergency department (ED) utilization. METHODS: A retrospective cohort analysis was performed on 10 408 adults who received their primary care at the Medical University of South Carolina University Internal Medicine clinic. A two-part generalized linear regression model was used to fit a predictive model for ED and hospital utilization. Agglomerative hierarchical clustering was used to identify patient subgroups with similar co-morbidities. RESULTS: Factors associated with increased risk of utilization included specific disease clusters {e.g. renal disease cluster [rate ratio, RR = 5.47; 95% confidence interval (CI; 4.54, 6.59) P < 0.0001]}, low clinic visit adherence [RR = 0.33; 95% CI (0.28, 0.39) P < 0.0001] and census measure of high poverty rate [RR = 1.20; 95% CI (1.11, 1.28) P < 0.0001]. In the cluster model, a stable group of four clusters remained regardless of the number of additional clusters forced into the model. Although the largest number of high-utilization patients (top 20%) was in the multiple chronic condition cluster (1110 out of 4728), the largest proportion of high-utilization patients was in the renal disease cluster (67%). CONCLUSIONS: Risk stratification enhanced with disease clustering organizes a primary care population into groups of similarly complex patients so that care coordination efforts can be focused and value of care can be maximized.

Sustained Improvement in Blood Pressure Control for a Multiracial Cohort: Results of a Patient-centered Medical Home Quality Improvement Initiative.

BACKGROUND: Patient-centered medical homes incorporate strategies to increase healthcare access as a means of improving health at the patient and population level. We hypothesized that quality improvement initiatives based in a patient-centered medical home would improve hypertension control for adult patients, regardless of race. METHODS: This prospective cohort study included patients of a hospital-based Internal Medicine practice in the southeastern U.S. whose systolic blood pressure was uncontrolled (criteria ≥140mmHg) prior to patient-centered medical home certification. Mean systolic blood pressure and hypertension control rates were calculated from the average of the four quarterly means prior to patient-centered medical home designation and again from the last 4 quarters of the five-year study period (final). Quality improvement interventions included patient identification, multidisciplinary team meetings, targeted outreach, and dedicated office visits for addressing hypertension. Primary outcomes included the change in systolic blood pressure and the change in the proportion of the cohort with hypertension control. Chi-square, two sample t-tests, and ANOVA were used for comparison (SAS 9.3). RESULTS: The inception cohort had 1,702 patients (64% nonwhite, 36% white) with systolic blood pressure ≥140mmHg. Mean systolic blood pressure significantly decreased while hypertension control rates increased in both races after patient-centered medical home certification. White adults had lower mean systolic blood pressure and higher control rates at baseline and study conclusion compared to nonwhite adults. Similar trends persisted regardless of the number of office visits. CONCLUSIONS: The analysis of blood pressure before and after designation of an Internal Medicine clinic as a patient-centered medical home reveals disparities in rates of chronic disease control. Team-based outreach improves hypertension control for patients regardless of race or visit number. These findings suggest that patient-centered medical homes and a multidisciplinary care approach, not limited to increased access, improve chronic disease control and should be considered for diverse outpatient clinics.

Effect of the Economic Recession on Primary Care Access for the Homeless.

Primary care access (PCA) for the homeless can prove challenging, especially during periods of economic distress. In the United States, the most recent recession may have presented additional barriers to accessing care. Limited safety-net resources traditionally used by the homeless may have also been used by the non-homeless, resulting in delays in seeking treatment for the homeless. Using hospitalizations for ambulatory care sensitivity (ACS) conditions as a proxy measure for PCA, this study investigated the recession's impact on PCA for the homeless and non-homeless in four states. The State Inpatient Databases were used to identify ACS admissions. Findings from this study indicate the recession was a barrier to PCA for homeless people who were uninsured. Ensuring that economically-disadvantaged populations have the ability to obtain insurance coverage is crucial to facilitating PCA. With targeted outreach efforts, the Affordable Care Act provides an opportunity for expanding coverage to the homeless.

When Should ED Physicians Use an HIE? Predicting Presence of Patient Data in an HIE.

OBJECTIVES: Health information exchanges (HIEs) make possible the construction of databases to characterize patients as multisystem users (MSUs), those visiting emergency departments (EDs) of more than one hospital system within a region during a 1-year period. HIE data can inform an algorithm highlighting patients for whom information is more likely to be present in the HIE, leading to a higher yield HIE experience for ED clinicians and incentivizing their adoption of HIE. Our objective was to describe patient characteristics that determine which ED patients are likely to be MSUs and therefore have information in an HIE, thereby improving the efficacy of HIE use and increasing ED clinician perception of HIE benefit. METHODS: Data were extracted from a regional HIE involving four hospital systems (11 EDs) in the Charleston, South Carolina area. We used univariate and multivariable regression analyses to develop a predictive model for MSU status. RESULTS: Factors associated with MSUs included younger age groups, dual-payer insurance status, living in counties that are more rural, and one of at least six specific diagnoses: mental disorders; symptoms, signs, and ill-defined conditions; complications of pregnancy, childbirth, and puerperium; diseases of the musculoskeletal system; injury and poisoning; and diseases of the blood and blood-forming organs. For patients with multiple ED visits during 1 year, 43.8% of MSUs had ≥4 visits, compared with 18.0% of non-MSUs (P < 0.0001). CONCLUSIONS: This predictive model accurately identified patients cared for at multiple hospital systems and can be used to increase the likelihood that time spent logging on to the HIE will be a value-added effort for emergency physicians.

Frequency and costs of hospital transfers for ambulatory care-sensitive conditions.

OBJECTIVES: Nursing home (NH) patients are frequently transferred to emergency departments (EDs) and/or hospitalized in situations in which transfer might have been avoided. This study describes the frequency of NH transfers for ambulatory care-sensitive conditions (ACSCs) and estimates associated expenditures. STUDY DESIGN: Retrospective cohort study of 62,379 NH patients with Medicare coverage receiving care in South Carolina between 2007 and 2009. METHODS: Subjects were analyzed to determine the frequency of acute ED or hospital care for conditions. Comparison is made to similar patients transferred for acute treatment of non-ACSCs. Generalized linear models were used to estimate the costs attributable to treating ACSCs. RESULTS: Over 3 years, 20,867 NH subjects were transferred from NHs to acute care facilities, and 85.3% of subjects had at least 1 episode of care for an ACSC. An average of 13,317 subjects per year were transferred for an average of 17,060 episodes of ED or hospital care per year between 2007 and 2009. More ACSC patients transferred to EDs were subsequently admitted to the hospital (50.4% vs 25%; P < .0001). In adjusted analyses, mean ED costs per episode of care ($401 vs $294; P < .0001) were higher, but mean hospitalization costs per episode of care were lower ($8356 vs $10,226; P < .0001) for ACSC patients compared with non-ACSC patients. CONCLUSIONS: A significant proportion of Medicare NH patients are treated acutely for ACSCs, which are associated with higher healthcare utilization and costs. Better access to onsite evaluation might enable significant cost savings and reduce morbidity in this population.

Improving internal medicine residents' falls assessment and evaluation: an interdisciplinary, multistrategy program.

Falls are a major problem in older adults, and physicians receive inadequate training in falls evaluation. A multicomponent program (lecture, academic detailing, and case studies) was implemented to enhance medical residents' knowledge, skills, decisions, and interventions made about falls as part of a larger project to improve assessment and care of older adults. Electronic medical record (EMR) template modifications provided cues and reminders, decision support, and documentation into the visit note. Nursing staff and the EMR prompted residents to evaluate patients with a history of falls. Knowledge and confidence were assessed using a pre- and postintervention questionnaire, and an attending physician assessed skills by direct observation of the Timed Up and Go Test (TUG). Effect on clinical actions was assessed using the EMR database. Participation in training of faculty and staff was high. Over the 3-month intervention period, an attending physician reviewed the detailing sheet outlining important points of the training with 86% of residents, and 64% demonstrated a TUG to an attending physician. Of 895 older adults seen, 15% (134) had a positive screen for falls, of whom 92% (123) had an EMR falls template completed, and 42% (56) had a TUG performed. Of the patients evaluated with the TUG, 53% (29) failed. A review of charts for patients who failed the screen or TUG revealed that the majority had special circumstances limiting their participation, even after a physical therapy evaluation. Education and system changes facilitated improvements in resident knowledge, skill, self-efficacy, and clinical action in screening, evaluating, and managing falls in older adults.

Screening mammography use in Medicare beneficiaries reflects 4-year mortality risk.

OBJECTIVE: Breast cancer screening guidelines recommend that women and physicians consider life expectancy when making screening decisions in older women. However, prior studies suggest that screening mammography patterns are dependent on age rather than health status or mortality risk of women. Our objective is to determine the association between 4-year mortality risk and use of screening mammography in women aged ≥ 65 years using Medicare Current Beneficiary Survey data. METHODS: The primary predictor variable is 4-year mortality risk derived from a published and validated prognostic index with 4 strata of increasing probability of death in 4 years (risk groups 1, 2, 3, and 4 with 4%, 15%, 42%, and 64% risk of 4-year mortality, respectively). The main outcome was self-reported receipt of mammography in the last year. RESULTS: There was a significant decreasing trend in the use of mammography with mortality risk groups 1, 2, 3, and 4 (62.7%, 51.5%, 36.6%, and 24%, respectively; trend test P<.001). The adjusted odds of mammography use were greatest in the low mortality risk group and show a gradual decline with increasing mortality risk for risk groups 1, 2, 3, and 4 (odds ratio [confidence interval]): 1.00; 0.69 [0.53-0.90]; 0.37 [0.27-0.49], and 0.22 [0.13-0.36], respectively. CONCLUSION: Screening mammography use in older Medicare beneficiaries seems to reflect their 4-year risk of mortality rather than age alone, suggesting that patients and providers consider prognosis in screening decisions. Prospective studies are needed to explore the use of the prognostic index as a mammography screening decision tool.

Project I See in NC: Initial results of a program to increase access to retinal examinations among diabetic individuals in North Carolina.

BACKGROUND: Diabetic retinopathy is the leading cause of preventable blindness in adults. Project I See in NC was begun to determine whether access to eye screening for Medicaid recipients and uninsured patients with diabetes in North Carolina could be improved. METHODS: We targeted Medicaid recipients and uninsured adults with diabetes for screening in 2 Community Care of North Carolina Networks. Screenings were performed in primary care settings throughout 6 counties in the Northwest Community Care Network and 6 counties in Access III of Community Care of the Lower Cape Fear. Patients were screened using a high-resolution digital retinal camera with images read at a centralized reading center at Wake Forest School of Medicine. RESULTS: A total of 1,688 patients were screened from October 2005 through September 2007. Nearly 15% (282) were found to have mild, nonproliferative-to-proliferative retinopathy, while the majority of patients had no evidence of diabetic retinopathy. Nearly 12% (196) required referral to an ophthalmologist, with 5% (86) requiring urgent referral for potentially sight-threatening retinopathy. LIMITATIONS: We were not able to confirm which patients kept their ophthalmologic appointments; however, we are currently analyzing data from the Medicaid patients in our study who required ophthalmologic referral. CONCLUSIONS: Remote digital retinal screening for diabetic retinopathy is feasible in primary care settings in both urban and rural areas of North Carolina, and it may prove to be an effective means of reaching more patients who require annual screening examinations.

The impact of drug samples on prescribing to the uninsured.

OBJECTIVE: To determine whether drug samples are associated with physicians prescribing fewer generic, less costly medications. METHODS: We conducted a retrospective study at a large university-affiliated internal medicine practice containing over 70 physicians. Using a pharmacy database, we identified all prescriptions written to uninsured or Medicaid patients that belonged to one of four classes of chronic medications. For the 9 months before and after the clinic closed its drug sample closet, we calculated the percentage of medications prescribed as generics and the mean cost of a 30-day supply of a prescription. RESULTS: Of 8911 prescriptions, 1973 met inclusion criteria. For uninsured patients, the percentage of medications prescribed as generics rose from 12% to 30% after the clinic closed its drug sample closet (P = 0.004). By consecutive three month periods, the percentage of prescribed generic medications rose steadily to a maximum of 40% (P < 0.001). For Medicaid patients, there was no significant change in generic prescribing (63% generic with samples versus 65% generic without samples, P = 0.42). Two factors were associated with generic prescribing in logistic regression: the absence of drug samples (OR 4.54, 95% CI 1.37-15.0) and the prescriber being an attending physician (OR 5.26, 95% CI 2.24-12.4). There was no statistically significant change in cost for either group. CONCLUSIONS: Physicians were three times more likely to prescribe generic medications to uninsured patients after drug samples were removed from the office. Drug samples may paradoxically lead to higher costs if physicians with access to samples prescribe more brand-name only drugs.

Advanced heart failure: prognosis, uncertainty, and decision making.

Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care.

A cost-minimization analysis of diuretic-based antihypertensive therapy reducing cardiovascular events in older adults with isolated systolic hypertension.

BACKGROUND: Hypertension is among the most common chronic condition in middle-aged and older adults. Approximately 50 million Americans are currently diagnosed with this condition, and more than $18.7 billion is spent on hypertension management, including $3.8 billion for medications. There are numerous pharmacological agents that can be chosen to treat hypertension by physicians in clinical practices. The purpose of this study was to assess the cost of alternative antihypertensive treatments in older adults with isolated systolic hypertension (ISH). METHOD: Using the Systolic Hypertension in the Elderly Program (SHEP) and other data, a cost-minimization analysis was performed. The cost was presented as the cost of number-needed-to treat (NNT) of patients for 5 years to prevent one adverse event associated with cardiovascular disease (CVD). RESULT: It was found that the cost of 5 year NNT to prevent one adverse CVD event ranged widely from $6,843 to $37,408 in older patients with ISH. The incremental cost of the 5 year NNT was lower to treat older patients in the very high CVD risk group relative to patients in the lower CVD risk group, ranging from $456 to $15,511. Compared to the cost of the 5 year NNT of other commonly prescribed antihypertensive drugs, the cost of SHEP-based therapy is the lowest. The incremental costs of the 5 year NNT would be higher if other agents were used, ranging from $6,372 to $38,667 to prevent one CVD event relative to SHEP-based drug therapy. CONCLUSION: Antihypertensive therapy that is diuretic-based and that includes either low-dose reserpine or atenolol is an effective and relatively inexpensive strategy to prevent cardiovascular events in older adults with isolated systolic hypertension. Use of the diuretic-based therapy is the most cost-effective in patients at high risk for developing cardiovascular disease.