Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors.

BACKGROUND: Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation. OBJECTIVES: The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations. METHODS: We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations. RESULTS: Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors. CONCLUSIONS: These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care.

Projecting the Clinical and Economic Impacts of Changes to HIV Care Among Adolescents and Young Adults in the United States: Lessons From the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, many US youth with HIV (YHIV) used telehealth services; others experienced disruptions in clinic and antiretroviral therapy (ART) access. METHODS: Using the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent HIV microsimulation model, we evaluated 3 scenarios: 1) Clinic: in-person care; 2) Telehealth: virtual visits, without CD4 or viral load monitoring for 12 months, followed by return to usual care; and 3) Interruption: complete care interruption with no ART access or laboratory monitoring for 6 months (maximum clinic closure time), followed by return to usual care for 80%. We assigned higher 1-year retention (87% vs 80%) and lower cost/visit ($49 vs $56) for Telehealth vs Clinic. We modeled 2 YHIV cohorts with non-perinatal (YNPHIV) and perinatal (YPHIV) HIV, which differed by mean age (22 vs 16 years), sex at birth (85% vs 47% male), starting CD4 count (527/µL vs 635/µL), ART, mortality, and HIV-related costs. We projected life months (LMs) and costs/100 YHIV over 10 years. RESULTS: Over 10 years, LMs in Clinic and Telehealth would be similar (YNPHIV: 11 350 vs 11 360 LMs; YPHIV: 11 680 LMs for both strategies); costs would be $0.3M (YNPHIV) and $0.4M (YPHIV) more for Telehealth than Clinic. Interruption would be less effective (YNPHIV: 11 230 LMs; YPHIV: 11 620 LMs) and less costly (YNPHIV: $1.3M less; YPHIV: $0.2M less) than Clinic. Higher retention in Telehealth led to increased ART use and thus higher costs. CONCLUSIONS: Telehealth could be as effective as in-person care for some YHIV, at slightly increased cost. Short interruptions to ART and laboratory monitoring may have negative long-term clinical implications.

Mammogram Uptake from Social Determinants of Health Can Be Lost in Translation to Individual Patients.

Purpose: The objective of this study is to describe patterns in barriers to breast cancer screening uptake with the end goal of improving screening adherence and decreasing the burden of mortality due to breast cancer. This study looks at social determinants of health and their association to screening and mortality. It also investigates the extent that models trained on county data are generalizable to individuals. Methods: County level screening uptake and age adjusted mortality due to breast cancer are combined with the Centers for Disease Controls Social Vulnerability Index (SVI) to train a model predicting screening uptake rates. Patterns learned are then applied to de-identified electronic medical records from individual patients to make predictions on mammogram screening follow through. Results: Accurate predictions can be made about a county's breast cancer screening uptake with the SVI. However, the association between increased screening, and decreased age adjusted mortality, doesn't hold in areas with a high proportion of minority residents. It is also shown that patterns learned from county SVI data have little discriminative power at the patient level. Conclusion: This study demonstrates that social determinants in the SVI can explain much of the variance in county breast cancer screening rates. However, these same patterns fail to discriminate which patients will have timely follow through of a mammogram screening test. This study also concludes that the core association between increased screening and decreased age adjusted mortality does not hold in high proportion minority areas.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications.

BACKGROUND: The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied. OBJECTIVE: To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV. METHODS: We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm. RESULTS: In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (ß=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well. CONCLUSIONS: Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/11185.

Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020.

Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.

Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing.

OBJECTIVE: To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session. DESIGN: This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process. SETTING: Telerehabilitation and outpatient therapy evaluation. PARTICIPANTS: Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Marginal cost difference between telerehabilitation and outpatient therapy evaluations. RESULTS: Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation. CONCLUSIONS: Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.

Implementation and Evaluation of a Wraparound Virtual Care Program for Children with Medical Complexity.

Objectives: Children and adolescents with medical complexity benefit from care coordination and specialized pediatric care, but many access barriers exist. We implemented a virtual wraparound model to support patients with medical complexity and their families and used an economic framework to measure outcomes. Methods: Children with medical complexity were identified and enrolled in a virtual complex care program with a dedicated multidisciplinary team, which provided care coordination, education, parental support, acute care triage, and virtual visits. A retrospective pre- and postanalysis of data obtained from the Hospital Industry Data Institute (HIDI) database measured inpatient, outpatient, and emergency department (ED) utilization and charges before implementation and during the 2-year program. Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate. Conclusions: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.

Assessment of the Cost Burden of Episodic Recurrent Vestibular Vertigo in the US.

Importance: Understanding of the economic burden of recurrent vestibular causes of vertigo and areas contributing to the cost is needed. Objective: To analyze and identify the factors contributing to the direct medical costs associated with Ménière disease (MD), vestibular migraine (VM), and benign paroxysmal positional vertigo (BPPV). Design, Setting, and Participants: This economic evaluation used MarketScan Commercial Database claims data from 2018 to identify the non-Medicare patient population with the diagnoses of MD, VM, or BPPV. Data were analyzed January 1 to December 31, 2018. Main Outcomes and Measures: The total direct medical costs associated with MD, VM, and BPPV. Results: A total of 53 210 patients (mean [SD] age, 47.8 [11.8] years; 67.6% female) were included in this study, with 34 738 normal comparisons. There were 5783 (10.9%) patients with MD, 3526 (6.6%) patients with VM, and 43 901 (82.5%) patients with BPPV in the data set. Mean age and sex were different across the different vestibular disorders. Across the different groups, patients with no comorbidities or with a Charlson Comorbidity Index score of zero ranged from 98.4% to 98.8%. Around 5% of patients were hospitalized with inpatient stay lasting between 4.6 and 5.2 days. After adjusting for age, sex, and comorbidities, there were large differences in mean adjusted annual payments/direct costs across the different groups (MD, $9579; VM, $11 371; and BPPV, $8247). This equated to a total incremental estimated cost of $60 billion compared with the normal population. The number of outpatient brain magnetic resonance imaging or computed tomography scans per patient ranged anywhere from 1 to 20, while the number of inpatient brain magnetic resonance imaging or computed tomography scans per patient ranged anywhere from 1 to 6. A heat map of the total cost expenditure indicated that the costs were concentrated around the Midwest, Lake Michigan, and the East Coast. Conclusions and Relevance: In this economic evaluation, the 3 most common causes of recurrent vertigo-MD, VM, and BPPV-had considerable medical costs associated with them. Extraneous imaging orders and vestibular testing are factors to consider for cost reduction. However, further research and widespread education is needed to optimize the diagnosis, treatment, and care of patients presenting with vestibular disorders or dizziness.

Dabigatran and Wet AMD, Results From Retinal Pigment Epithelial Cell Monolayers, the Mouse Model of Choroidal Neovascularization, and Patients From the Medicare Data Base.

Background: Age-related macular degeneration (AMD), the leading cause of irreversible blindness in elderly Caucasian populations, includes destruction of the blood-retina barrier (BRB) generated by the retinal pigment epithelium-Bruch's membrane complex (RPE/BrM), and complement activation. Thrombin is likely to get access to those structures upon BRB integrity loss. Here we investigate the potential role of thrombin in AMD by analyzing effects of the thrombin inhibitor dabigatran. Material and Methods: MarketScan data for patients aged ≥65 years on Medicare was used to identify association between AMD and dabigatran use. ARPE-19 cells grown as mature monolayers were analyzed for thrombin effects on barrier function (transepithelial resistance; TER) and downstream signaling (complement activation, expression of connective tissue growth factor (CTGF), and secretion of vascular endothelial growth factor (VEGF)). Laser-induced choroidal neovascularization (CNV) in mouse is used to test the identified downstream signaling. Results: Risk of new wet AMD diagnosis was reduced in dabigatran users. In RPE monolayers, thrombin reduced TER, generated unique complement C3 and C5 cleavage products, led to C3d/MAC deposition on cell surfaces, and increased CTGF expression via PAR1-receptor activation and VEGF secretion. CNV lesion repair was accelerated by dabigatran, and molecular readouts suggest that downstream effects of thrombin include CTGF and VEGF, but not the complement system. Conclusions: This study provides evidence of association between dabigatran use and reduced exudative AMD diagnosis. Based on the cell- and animal-based studies, we suggest that thrombin modulates wound healing and CTGF and VEGF expression, making dabigatran a potential novel treatment option in AMD.

Incidence of Poststroke Depression in Patients With Poststroke Dysphagia.

PURPOSE: Poststroke dysphagia and poststroke depression (PSD) can have devastating effects on stroke survivors, including increased burden of care, higher health care costs, poor quality of life, and greater mortality; however, there is a dearth of research examining depression in patients diagnosed with dysphagia after stroke. Thus, we aimed to study the incidence of PSD in patients with poststroke dysphagia to provide foundational knowledge about this patient population. METHOD: We conducted a retrospective, cross-sectional study of individuals with a primary diagnosis of acute ischemic stroke (AIS) and secondary diagnoses of dysphagia and/or depression using administrative claims data from the 2017 Medicare 5% Limited Data Set. RESULTS: The proportion of depression diagnosis in patients with poststroke dysphagia was significantly higher than the proportion of depression diagnosis in those without poststroke dysphagia during acute hospitalization: 12.01% versus 9.52%, respectively (p = .003). CONCLUSIONS: Our results demonstrated that persons with poststroke dysphagia were as, or slightly more, likely to have PSD compared to the general stroke population, and to our knowledge, they establish the first reported incidence of PSD in Medicare patients with dysphagia after AIS. Future research is warranted to further explore the effects of PSD on poststroke dysphagia.

Feasibility of Using Electronic Health Records for Cascade Monitoring and Cost Estimates in Implementation Science Studies in the Adolescent Trials Network for HIV/AIDS Interventions.

BACKGROUND: One of the most difficult areas in the fight against HIV/AIDS is reaching out to youth aged 13 to 24 years. The proportion of youth living with HIV/AIDS on antiretroviral therapy (ART) and who are virally undetectable is low, highlighting significant challenges for reaching the Joint United Nations Program on HIV targets. OBJECTIVE: This study aimed to assess the feasibility of obtaining key clinical indicators and monitoring treatment, viral suppression, and retention components of the youth HIV treatment cascade in Adolescent Trials Network for HIV/AIDS Interventions clinics using electronic health record (EHR) downloads and to provide baseline characteristics for the study participants. METHODS: EHR data were systematically obtained from multiple clinical sites and used to meaningfully capture clinical characteristics, initiation of antiretrovirals, and retention in care, which are part of the Centers for Disease Control and Prevention's 4 continuum of care measures. In addition, this study used standard cost values attached to Current Procedural Terminology codes to estimate the cost per visit. RESULTS: Only 2 of the 4 Centers for Disease Control and Prevention treatment cascade measures were assessed using routine EHR data. EHR data are not adequate for monitoring HIV testing or linkage to care because denominator data are not available. However, the data work well for measuring ART initiation and adequately for retention in care. The sites were broadly able to provide information for the required data. However, in most cases, these data are insufficient for identifying patterns of missed appointments because such misses are not captured in the EHR system. Sites with good access to data management resources can operate more efficiently for cascade monitoring study purposes. CONCLUSIONS: Data other than EHRs are needed to measure HIV testing and linkage to youth care. EHR data are useful for measuring ART initiation and work moderately well for measuring retention in care. Site data management resources should be part of the selection process when looking for site partners for clinical studies that plan to use EHR data. Study planners should determine the feasibility of additional funding for organizations in need of additional information technology or data management resources.

A Modification of Time-Driven Activity-Based Costing for Comparing Cost of Telehealth and In-Person Visits.

Introduction: Cost studies of telehealth (TH) and virtual visits are few and report mixed results of the economic impact of virtual care and TH. Largely missing from the literature are studies that identify the cost of delivering TH versus in-person care. The objective was to demonstrate a modified time-driven activity-based costing (TDABC) approach to compare weighted labor cost of an in-person pediatric clinic sick visit before COVID-19 to the same virtual and in-person sick-visit during COVID-19. Methods: We examined visits before and during COVID-19 using: (1) recorded structured interviews with providers; (2) iterative workflow mapping; (3) electronic health records time stamps for validation; (4) standard cost weights for wages; and (5) clinic CPT billing code mix for complexity weighs. We examined the variability in estimated time using a decision tree model and Monte Carlo simulations. Results: Workflow charts were created for the clinic before COVID-19 and during COVID-19. Using TDABC and simulations for varying time, the weighted cost of clinic labor for sick visit before COVID-19 was $54.47 versus $51.55 during COVID-19. Discussion: The estimated mean labor cost for care during the pandemic has not changed from the pre-COVID period; however, this lack of a difference is largely because of the increased use of TH. Conclusions: Our TDABC approach is feasible to use under virtual working conditions; requires minimal provider time for execution; and generates detailed cost estimates that have "face validity" with providers and are relevant for economic evaluation.

The Impact of Timing on Clinical and Economic Outcomes During Inter-ICU Transfer of Acute Respiratory Failure Patients: Time and Tide Wait for No One.

Approximately one in 30 patients with acute respiratory failure (ARF) undergoes an inter-ICU transfer. Our objectives are to describe inter-ICU transfer patterns and evaluate the impact of timing of transfer on patient-centered outcomes. DESIGN: Retrospective, quasi-experimental study. SETTING: We used the Healthcare Cost and Utilization Project State Inpatient Databases in five states (Florida, Maryland, Mississippi, New York, and Washington) during 2015-2017. PARTICIPANTS: We selected patients with International Classification of Diseases, 9th and 10th Revision codes of respiratory failure and mechanical ventilation who underwent an inter-ICU transfer (n = 6,718), grouping as early (≤ 2 d) and later transfers (3+ d). To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographic, clinical, and hospital variables. MAIN OUTCOMES: Inhospital mortality, hospital length of stay (HLOS), and cumulative charges related to inter-ICU transfer. RESULTS: Six-thousand seven-hundred eighteen patients with ARF underwent inter-ICU transfer, 68% of whom (n = 4,552) were transferred early (≤ 2 d). Propensity score matching yielded 3,774 well-matched patients for this study. Unadjusted outcomes were all superior in the early versus later transfer cohort: inhospital mortality (24.4% vs 36.1%; p < 0.0001), length of stay (8 vs 22 d; p < 0.0001), and cumulative charges ($118,686 vs $308,977; p < 0.0001). Through doubly robust multivariable modeling with random effects at the state level, we found patients who were transferred early had a 55.8% reduction in risk of inhospital mortality than those whose transfer was later (relative risk, 0.442; 95% CI, 0.403-0.497). Additionally, the early transfer cohort had lower HLOS (20.7 fewer days [13.0 vs 33.7; p < 0.0001]), and lower cumulative charges ($66,201 less [$192,182 vs $258,383; p < 0.0001]). CONCLUSIONS AND RELEVANCE: Our study is the first to use a large, multistate sample to evaluate the practice of inter-ICU transfers in ARF and also define early and later transfers. Our findings of favorable outcomes with early transfer are vital in designing future prospective studies evaluating evidence-based transfer procedures and policies.

Budget impact and pharmacy costs with targeted use of oliceridine for postsurgical pain in patients at high risk of opioid-related adverse events.

BACKGROUND: Oliceridine, a new class of µ-opioid receptor agonist, may be associated with fewer opioid-related adverse events (ORAEs) due to its unique mechanism of action. Thus, it may provide a cost-effective alternative to conventional opioids such as morphine. PATIENTS AND METHODS: Using a decision tree with a 24-hour time horizon, we calculated costs for medication and management of the three most common AEs (oxygen saturation <90%, vomiting, somnolence) following postoperative oliceridine or morphine in high-risk patients. Costs were enumerated as differences in cost of analgesics and resource utilization in the first 24 hours post-surgery. An economic model compared expected AEs and costs in a blended cohort where elderly/obese patients at higher risk for ORAEs received oliceridine while those presumed to be at lower risk received morphine with a cohort that received morphine alone. RESULTS: In high-risk patients, use of oliceridine resulted in overall savings of $363,944 (in 1,000 patients). Implementing a targeted approach of oliceridine utilization in patients with high risk for ORAEs can save a typical hospital system $122,296 in total cost of care. CONCLUSION: Use of oliceridine in postoperative care among patients at high risk provides a favorable health economic benefit compared to the use of morphine.

Oliceridine, a new class of opioid analgesics, administered directly into a vein, is a unique medication in that it provides pain relief equivalent to morphine and may have less costly side effects. It is given in a hospital/clinic or surgery center for the treatment of postoperative pain and can reduce costs compared to other opioid analgesics, possibly due to less side effects. An economic model was developed that compares morphine to oliceridine in patients more likely to experience sides effects due to traditional pain medications, comparing common side effects and pain relief following surgery. Although oliceridine costs more than morphine, in our economic model, the use of oliceridine resulted in cost savings ($363,944 US 2020 Dollars in 1,000 patients), and a positive return of investment of over 7 times, when compared to morphine.

Measuring Value: Cost-Effectiveness Analysis for Occupational Therapy.

Stroke rehabilitation is expensive, and recent changes to Medicare reimbursement demand more efficient interventions. The use of cost-effectiveness analysis (CEA) can help occupational therapy practitioners, rehabilitation directors, and payers better understand the value of occupational therapy and decide whether or not to implement new treatments. The objective of this article is to illustrate the contribution of CEA to stroke rehabilitation using a hypothetical new intervention as an example. What This Article Adds: This article facilitates an understanding of the importance of CEA to occupational therapy. It also explains how CEA improves consistency with reporting standards for cost-effectiveness studies.

High-risk opioid analgesic dispensing to adolescents 12-18 years old in South Carolina: 2010-2017.

PURPOSE: To evaluate "high-risk" opioid dispensing to adolescents, including daily morphine milligram equivalents (MME) above recommended amounts, the percentage of extended-release opioid prescriptions dispensed to opioid-naïve adolescents, and concurrent use of opioids and benzodiazepines, and to evaluate changes in those rates over time. METHODS: Retrospective cohort study of one state's prescription drug monitoring program data (2010-2017), evaluating adolescents 12-18 years old dispensed opioid analgesic prescriptions. Outcomes of interest were the quarterly frequencies of the high-risk measures. We utilized generalized linear regression to determine whether the rate of the outcomes changed over time. RESULTS: The quarterly percentage of adolescents ages 12-18 years old dispensed an opioid who received ≥90 daily MME declined from 4.1% in the first quarter (Q1) of 2010 to 3.4% in the final quarter (Q4) of 2017 (p < 0.0001). The frequency of adolescents dispensed ≥50 daily MME changed little over time. In 2010, the percentage of adolescents receiving an extended-release opioid who were opioid naïve was 60.7%, declining to 50.6% by Q4 of 2017 (p > 0.10 overall change 2010-2017). The percentage of adolescent opioid days overlapping with benzodiazepine days was 1.6% in Q1 of 2010, declining to 1.1% by Q4 of 2017 (p < 0.001). CONCLUSIONS: Among persons 12-18 years old dispensed an opioid analgesic, receipt of ≥90 daily MME declined during the years 2010-2017, as did the percentage of adolescent opioid days that overlapped with benzodiazepines. More than half of the individuals who received extended-release opioid analgesics were identified as opioid naïve and, counter to guidelines, received products intended for opioid-tolerant individuals.

Missing data methods for intensive care unit SOFA scores in electronic health records studies: results from a Monte Carlo simulation.

Aim: Missing data cause problems through decreasing sample size and the potential for introducing bias. We tested four missing data methods on the Sequential Organ Failure Assessment (SOFA) score, an intensive care research severity adjuster. Methods: Simulation study using 2015-2017 electronic health record data, where the complete dataset was sampled, missing SOFA score elements imposed and performance examined of four missing data methods - complete case analysis, median imputation, zero imputation (recommended by SOFA score creators) and multiple imputation (MI) - on the outcome of in-hospital mortality. Results: MI performed well, whereas other methods introduced varying amounts of bias or decreased sample size. Conclusion: We recommend using MI in analyses where SOFA score component values are missing in administrative data research.

Cost-effectiveness and cost-benefit analysis of oliceridine in the treatment of acute pain.

Aim: Oliceridine, a new class of µ-opioid receptor agonist, is selective for G-protein signaling (analgesia) with limited recruitment of ß-arrestin (associated with adverse outcomes) and may provide a cost-effective alternative versus conventional opioid morphine for postoperative pain. Patients & methods: Using a decision tree with a 24-h time horizon, we calculated costs for medication and management of three most common adverse events (AEs; oxygen saturation <90%, vomiting and somnolence) following postoperative oliceridine or morphine use. Results: Using oliceridine, the cost for managing AEs was US$528,424 versus $852,429 for morphine, with a net cost savings of $324,005. Conclusion: Oliceridine has a favorable overall impact on the total cost of postoperative care compared with the use of the conventional opioid morphine.

Lay abstract Oliceridine, a new class of opioid pain medication, given in a vein, is a unique medication in that it provides pain relief comparable to morphine and may have less costly side effects. It is given in a hospital or surgery center for the treatment of postoperative pain and can save money compared with other opioid pain medicines due to fewer side effects. An economic model was developed to compare morphine to oliceridine for common side effects and pain relief following surgery. Oliceridine use resulted in a cost saving (US$324,005; 2020 US dollars) when compared with morphine.

Measuring the impact of the Affordable Care Act Medicaid expansion on access to primary care using an interrupted time series approach.

BACKGROUND: The Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act (ACA), was created to increase access to primary care, improve quality of care, and decrease healthcare costs. A key provision in the law that mandated expansion of state Medicaid programme changed when states were given the option to voluntarily expand Medicaid. Our study sought to measure the impact of ACA Medicaid expansion on preventable hospitalization (PH) rates, a measure of access to primary care. METHODS: We performed an interrupted time series analysis of quarterly hospitalization rates across eight states from 2012 to 2015. Segmented regression analysis was utilized to determine the impact of policy reform on PH rates. RESULTS: The Affordable Care Act's Medicaid expansion led to decreased rates of PH (improved access to care); however, the finding was not significant (coefficient estimate: -0.0059, CI -0.0225, 0.0107, p = 0.4856). Healthcare system characteristics, such as Medicaid spending per enrollee and Medicaid income eligibility, were associated with a significant decrease in rates of PH (improved access to care). However, the Medicaid-to-Medicare fee index (physician reimbursement) and states with a Democratic state legislature had a significant increase in rates of PH (poor access to care). CONCLUSION: Health policy reform and healthcare delivery characteristics impact access to care. Researchers should continue evaluating such policy changes across more states over longer periods of time. Researchers should translate these findings into cost analysis for state policy-makers to make better-informed decisions for their constituents. CONTRIBUTION TO KNOWLEDGE: Ambulatory care-sensitive conditions are a feasible method for evaluating policy and measuring access to primary care. Policy alone cannot improve access to care. Other factors (trust, communication, policy-makers' motivations and objectives, etc.) must be addressed to improve access.

An Economic Framework to Measure Value of Pediatric Telehealth.

Background: Health care is experiencing significant disruptive innovation with the use of technology, including telemedicine and virtual modalities to deliver care. These new models can dramatically improve access to care and reduce health care disparities for patients, especially in underserved and vulnerable populations like children. Problem: To assure diffusions and retention of new approaches they must be assessed for economic value. However, measuring telehealth programs using only an institutional financial viewpoint fails to convey all the societal value of such interventions, so economic studies of telehealth are needed but complex to design. Methods: We reviewed economic study guidelines, details from telehealth study research protocols, IRB submission questions, and telehealth study design literature. We then used an iterative consensus process to develop a framework for measuring value of virtual care at the societal level. Results: The work produced a set of tools that are useful for designing studies for measuring value of virtual care at the societal level. The framework and tools are presented in this report. Conclusions: The conceptual framework for economic evaluation was feasible for use when applied to measure pediatric telehealth value.