Affordable Care Act Medicaid Expansion was Associated With Reductions in the Proportion of Hospitalizations That are Potentially Preventable Among Hispanic and White Adults.

OBJECTIVE: Using data on 5 years of postexpansion experience, we examined whether the coverage gains from Affordable Care Act Medicaid expansion among Black, Hispanic, and White individuals led to improvements in objective indicators of outpatient care adequacy and quality. RESEARCH DESIGN: For the population of adults aged 45-64 with no insurance or Medicaid coverage, we obtained data on census population and hospitalizations for ambulatory care sensitive conditions (ACSCs) during 2010-2018 in 14 expansion and 7 nonexpansion states. Our primary outcome was the percentage share of hospitalizations due to ACSC out of all hospitalizations ("ACSC share") among uninsured and Medicaid-covered patients. Secondary outcomes were the population rate of ACSC and all hospitalizations. We used multivariate regression models with an event-study difference-in-differences specification to estimate the change in the outcome measures associated with expansion in each of the 5 postexpansion years among Hispanic, Black, and White adults. PRINCIPAL FINDINGS: At baseline, ACSC share in the expansion states was 19.0%, 14.5%, and 14.3% among Black, Hispanic, and White adults. Over the 5 years after expansion, Medicaid expansion was associated with an annual reduction in ACSC share of 5.3% (95% CI, -7.4% to -3.1%) among Hispanic and 8.0% (95% CI, -11.3% to -4.5%) among White adults. Among Black adults, estimates were mixed and indicated either no change or a reduction in ACSC share. CONCLUSIONS: After Medicaid expansion, low-income Hispanic and White adults experienced a decrease in the proportion of potentially preventable hospitalizations out of all hospitalizations.

Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies.

BACKGROUND: The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. OBJECTIVE: This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. DESIGN: We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. APPROACH: We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. KEY RESULTS: We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. CONCLUSION: TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.

Hospitalization as an opportunity to engage underserved individuals in shared decision-making for lung cancer screening: results from two randomized pilot trials.

PURPOSE: Medicare requires tobacco dependence counseling and shared decision-making (SDM) for lung cancer screening (LCS) reimbursement. We hypothesized that initiating SDM during inpatient tobacco treatment visits would increase LCS among patients with barriers to proactively seeking outpatient preventive care. METHODS: We collected baseline assessments and performed two pilot randomized trials at our safety-net hospital. Pilot 1 tested feasibility, acceptability, and preliminary efficacy of a nurse practitioner initiating SDM for LCS during hospitalization (Inpatient SDM). We collected qualitative data on barriers encountered during Pilot 1. Pilot 2 added a community health worker (CHW) to address barriers to LCS completion (Inpatient SDM + CHW-navigation). For both studies, preliminary efficacy was an intention-to-treat analysis of LCS completion at 3 months between intervention and comparator (furnishing of LCS decision aid only) groups. RESULTS: Baseline assessments showed that patients preferred in-person LCS discussions versus self-reviewing materials; overall 20% had difficulty understanding written information. In Pilot 1, 4% (2/52) in Inpatient SDM versus 2% (1/48, comparator) completed LCS (p = 0.6), despite 89% (89/100) desiring LCS. Primary care providers noted that competing priorities and patient factors (e.g., social barriers to keeping appointments) prevented the intervention from working as intended. In Pilot 2, 50% (5/10) in Inpatient SDM + CHW-navigation versus 9% (1/11, comparator) completed LCS (p < 0.05). Many patients were ineligible due to recent diagnostic chest CT (Pilot 1: 255/659; Pilot 2: 239/527). CONCLUSIONS: Inpatient SDM + CHW-navigation shows promise to improve LCS rates among underserved patients who smoke, but feasibility is limited by recent diagnostic chest CT among inpatients. Implementing CHW-navigation in other clinical settings may facilitate LCS for underserved patients. TRAIL REGISTRATION: ClinicalTrials.gov Identifier: NCT03276806 (8 September 2017); NCT03793894 (4 January 2019).

Do Urine Drug Tests Reveal Substance Misuse Among Patients Prescribed Opioids for Chronic Pain?

BACKGROUND: Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited. OBJECTIVE: Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain. DESIGN: Retrospective cohort study. SUBJECTS: Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period. MAIN MEASURES: Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning. KEY RESULTS: Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18-34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9-12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1-2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5-3.7]) were more likely to have a concerning UDT result. CONCLUSIONS: Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.

Resilience and diabetes self-management among African-American men receiving primary care at an urban safety-net hospital: a cross-sectional survey.

BACKGROUND: Resilience is the ability to adapt to adverse life events. Studies that explore diabetes self-management interventions integrating resilience in African-Americans with diabetes include few African-American men, who have higher diabetes-related mortality and complication rates compared to African-American women. DESIGN: We conducted a cross-sectional study of African-American men with uncontrolled diabetes living in diabetes hotspots. We measured resilience levels using the General Self Efficacy Scale (GSES), adherence to diabetes self-management behaviors using the Diabetes Self-Management Questionnaire (DSMQ), and incarceration history by phone survey. We categorized participants as higher or lower resilience level and higher or lower adherence to diabetes self-management behaviors. Using multivariable logistic regression, we examined the relationship between resilience and adherence to diabetes self-management behaviors. Our model accounted for potential confounders, including age, incarceration history, and socioeconomic factors. RESULTS: Of 234 patients contacted by mail and phone, 94 (40.2%) completed the survey. Mean age was 60.6 years, 59.5% reported an annual household income of less than $20,000, and 29.8% reported a history of incarceration. The mean unadjusted GSES score was 25.0 (sd 5.2; range: 0-30, higher scores indicate greater resilience), and the mean DSMQ score was 7.34 (sd 1.78; range: 0-10, higher scores indicate greater adherence to diabetes self-management behaviors). In multivariable analyses, higher levels of resilience were associated with higher adherence to diabetes self-management behaviors (aOR = 9.68, 95% CI 3.01, 31.12). History of incarceration was negatively associated with higher adherence to diabetes self-management behaviors (aOR = 0.23, 95% CI 0.06, 0.81). CONCLUSIONS: Resilience and personal history of incarceration are associated with adherence to diabetes self-management behaviors among African-American men residing in diabetes hotspots. Future interventions should incorporate resilience training to improve diabetes self-management behaviors. At a societal level, social determinants of health that adversely affect African-American men, such as structural racism and mass incarceration, need to be eliminated.

Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States.

BACKGROUND: Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy. MATERIALS AND METHODS: Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy. RESULTS: Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals. CONCLUSIONS: Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.

Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients with COVID-19 at an Urban Safety-Net Medical Center - Boston, Massachusetts, 2020.

As of July 5, 2020, approximately 2.8 million coronavirus disease 2019 (COVID-19) cases and 130,000 COVID-19-associated deaths had been reported in the United States (1). Populations historically affected by health disparities, including certain racial and ethnic minority populations, have been disproportionally affected by and hospitalized with COVID-19 (2-4). Data also suggest a higher prevalence of infection with SARS-CoV-2, the virus that causes COVID-19, among persons experiencing homelessness (5). Safety-net hospitals,† such as Boston Medical Center (BMC), which provide health care to persons regardless of their insurance status or ability to pay, treat higher proportions of these populations and might experience challenges during the COVID-19 pandemic. This report describes the characteristics and clinical outcomes of adult patients with laboratory-confirmed COVID-19 treated at BMC during March 1-May 18, 2020. During this time, 2,729 patients with SARS-CoV-2 infection were treated at BMC and categorized into one of the following mutually exclusive clinical severity designations: exclusive outpatient management (1,543; 56.5%), non-intensive care unit (ICU) hospitalization (900; 33.0%), ICU hospitalization without invasive mechanical ventilation (69; 2.5%), ICU hospitalization with mechanical ventilation (119; 4.4%), and death (98; 3.6%). The cohort comprised 44.6% non-Hispanic black (black) patients and 30.1% Hispanic or Latino (Hispanic) patients. Persons experiencing homelessness accounted for 16.4% of patients. Most patients who died were aged ≥60 years (81.6%). Clinical severity differed by age, race/ethnicity, underlying medical conditions, and homelessness. A higher proportion of Hispanic patients were hospitalized (46.5%) than were black (39.5%) or non-Hispanic white (white) (34.4%) patients, a finding most pronounced among those aged <60 years. A higher proportion of non-ICU inpatients were experiencing homelessness (24.3%), compared with homeless patients who were admitted to the ICU without mechanical ventilation (15.9%), with mechanical ventilation (15.1%), or who died (15.3%). Patient characteristics associated with illness and clinical severity, such as age, race/ethnicity, homelessness, and underlying medical conditions can inform tailored strategies that might improve outcomes and mitigate strain on the health care system from COVID-19.

Patient-Physician Discussions on Lung Cancer Screening: A Missed Teachable Moment to Promote Smoking Cessation.

INTRODUCTION: Little is known about whether patients and physicians perceive lung cancer screening (LCS) as a teachable moment to promote smoking cessation or the degree to which physicians in "real world" settings link LCS discussions with smoking cessation counseling. We sought to characterize patient and physician perspectives of discussions about smoking cessation during LCS. METHODS: We conducted a qualitative study (interviews and focus groups) with 21 physicians and 28 smokers screened in four diverse hospitals. Transcripts were analyzed for characteristics of communication about smoking cessation and LCS, the perceived effect on motivation to quit smoking, the degree to which physicians leverage LCS as a teachable moment to promote smoking cessation, and suggestions to improve patient-physician communication about smoking cessation in the context of LCS. RESULTS: Patients reported that LCS made them more cognizant of the health consequences of smoking, priming them for a teachable moment. While physicians and patients both acknowledged that smoking cessation counseling was frequent, they described little connection between their discussions regarding LCS and smoking cessation counseling. Physicians identified several barriers to integrating discussions on smoking cessation and LCS. They volunteered communication strategies by which LCS could be leveraged to promote smoking cessation. CONCLUSIONS: LCS highlights the harms of smoking to patients who are chronic, heavy smokers and thus may serve as a teachable moment for promoting smoking cessation. However, this opportunity is typically missed in clinical practice. IMPLICATIONS: LCS highlights the harms of smoking to heavily addicted smokers. Yet both physicians and patients reported little connection between LCS and tobacco treatment discussions due to multiple barriers. On-site tobacco treatment programs and post-screening messaging tailored to the LCS results are needed to maximize the health outcomes of LCS, including smoking quit rates and longer-term smoking-related morbidity and mortality.

Reasons for Opioid Discontinuation and Unintended Consequences Following Opioid Discontinuation Within the TOPCARE Trial.

OBJECTIVE: To identify reasons for opioid discontinuation and post-discontinuation outcomes among patients in the Transforming Opioid Prescribing in Primary Care (TOPCARE) study. DESIGN: In TOPCARE, an intervention to improve adherence to opioid prescribing guidelines, randomized intervention primary care providers (PCPs) received nurse care manager support, an electronic registry, academic detailing, and electronic tools, and control PCPs received electronic tools only. SETTING: Four Boston safety net primary care practices. SUBJECTS: Patients in both TOPCARE study arms who discontinued opioid therapy during the trial. METHODS: Through chart review, we examined the reason for discontinuation and post-discontinuation outcomes: one or more PCP visits, one or more pain-related emergency department (ED) visits, evidence of opioid use disorder (OUD), and referral for OUD treatment. RESULTS: Opioid discontinuations occurred in 83/586 (14.2%) intervention and 42/399 (10.5%) control patients (P = 0.09). Among patients who discontinued opioids, 81 (65%) discontinued for misuse, with no difference by group (P = 0.38). Aberrancy in monitoring (e.g., discordant urine drug test results) was the most common type of misuse prompting discontinuation (occurring in (51/83 [61%] of intervention patients vs 19/42 [45%, P = 0.08] of control patients). Intervention patients who discontinued opioids had less PCP follow-up (65% vs 88%, P < 0.01) compared with control patients. We found no differences between groups for pain-related ED visits, evidence of OUD, or OUD treatment referral following discontinuation. CONCLUSIONS: The decreased follow-up among TOPCARE intervention patients who discontinued opioids highlights the need to understand unintended consequences of involuntary opioid discontinuations resulting from interventions to reduce opioid risk.

Intranasal Naloxone for Opioid Overdose.

This JAMA Insights describes indications for naloxone use in preventing opioid overdoses and benefits vs barriers to its availability following FDA approval of its availability without a prescription.

Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study.

BACKGROUND: Guidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings. OBJECTIVE: To characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making. DESIGN: Qualitative study entailing semi-structured interviews and focus groups. PARTICIPANTS: We enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net). APPROACH: Using content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making. KEY RESULTS: Clinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making. CONCLUSIONS: Due to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening's rationale, trade-offs, and process.

Warm Handoffs and Attendance at Initial Integrated Behavioral Health Appointments.

Though integrated behavioral health programs often encourage primary care physicians to refer patients by means of a personal introduction (warm handoff), data are limited regarding the benefits of warm handoffs. We conducted a retrospective study of adult primary care patients referred to behavioral health clinicians in an urban, safety-net hospital to investigate the association between warm handoffs and attendance rates at subsequent initial behavioral health appointments. In multivariable analyses, patients referred via warm handoffs were not more likely to attend initial appointments (OR = 0.96; 95% CI, 0.79-1.18; P = .71). A prospective study is necessary to confirm the role of warm handoffs.

A Hepatitis C Treatment Program Based in a Safety-Net Hospital Patient-Centered Medical Home.

Hepatitis C virus (HCV) infection is a major public health problem. Urban safety-net hospitals are a prime location for HCV treatment delivery. Showing that physicians in primary care settings can deliver HCV infection care is important to expand treatment; models doing so in the era of newer oral HCV medications are needed. This article describes an innovative and successful HCV primary care treatment program in a patient-centered medical home based at an urban, safety-net hospital. The program is public health oriented in that a central team member is a public health social worker who performs population management and addresses underlying social determinants of health to facilitate engagement in HCV treatment. Other team members include general internists trained to treat HCV infections, a pharmacist, and a pharmacy technician. The program is funded with revenue generated by the 340b drug discount program, which allows providers to generate revenue when patients fill prescriptions at pharmacies in safety-net settings, as insurance reimbursements for medications exceed the cost at which safety-net providers purchase medications. During the course of 1 year, the program received 302 referrals. Of these approximately 23% have received treatment.

Massachusetts Health Reform's Effect on Hospitals' Racial Mix of Patients and on Patients' Use of Safety-net Hospitals.

BACKGROUND: Because of residential segregation and a lack of health insurance, minorities often receive care in different facilities than whites. Massachusetts (MA) health reform provided insurance to previously uninsured patients, which enabled them to potentially shift inpatient care to nonminority-serving or nonsafety-net hospitals. OBJECTIVES: Examine whether MA health reform affected hospitals' racial mix of patients, and individual patients' use of safety-net hospitals. RESEARCH DESIGN: Difference-in-differences analysis of 2004-2009 inpatient discharge data from MA, compared with New York (NY), and New Jersey (NJ), to identify postreform changes, adjusting for secular changes. SUBJECTS: (1) Hospital-level analysis (discharges): 345 MA, NY, and NJ hospitals; (2) patient-level analysis (patients): 39,921 patients with ≥2 hospitalizations at a safety-net hospital in the prereform period. MEASURES: Prereform to postreform changes in percentage of discharges that are minority (black and Hispanic) at minority-serving hospitals; adjusted odds of patient movement from safety-net hospitals (prereform) to nonsafety-net hospitals (postreform) by age group and state. RESULTS: Treating NJ as the comparison state, MA reform was associated with an increase of 5.8% (95% CI, 1.4%-10.3%) in the percentage of minority discharges at MA minority-serving hospitals; with NY as the comparison state, the change was 2.1% (95% CI, -0.04% to 4.3%). Patient movement from safety-net to nonsafety-net hospitals was greater in MA than comparison states (difference-in-differences adjusted OR=1.3; 95% CI, 1.0-1.7; P=0.04). CONCLUSIONS: Following MA health reform, the safety-net remains an important component of the health care system.

Using Photovoice and Asset Mapping to Inform a Community-Based Diabetes Intervention, Boston, Massachusetts, 2015.

INTRODUCTION: Diabetes self-management takes place within a complex social and environmental context.  This study's objective was to examine the perceived and actual presence of community assets that may aid in diabetes control. METHODS: We conducted one 6-hour photovoice session with 11 adults with poorly controlled diabetes in Boston, Massachusetts.  Participants were recruited from census tracts with high numbers of people with poorly controlled diabetes (diabetes "hot spots").  We coded the discussions and identified relevant themes.  We further explored themes related to the built environment through community asset mapping.  Through walking surveys, we evaluated 5 diabetes hot spots related to physical activity resources, walking environment, and availability of food choices in restaurants and food stores. RESULTS: Community themes from the photovoice session were access to healthy food, restaurants, and prepared foods; food assistance programs; exercise facilities; and church.  Asset mapping identified 114 community assets including 22 food stores, 22 restaurants, and 5 exercise facilities.  Each diabetes hot spot contained at least 1 food store with 5 to 9 varieties of fruits and vegetables.  Only 1 of the exercise facilities had signage regarding hours or services.  Memberships ranged from free to $9.95 per month.  Overall, these findings were inconsistent with participants' reports in the photovoice group. CONCLUSION: We identified a mismatch between perceptions of community assets and built environment and the objective reality of that environment. Incorporating photovoice and community asset mapping into a community-based diabetes intervention may bring awareness to underused neighborhood resources that can help people control their diabetes.

The association between benzodiazepine prescription and aberrant drug-related behaviors in primary care patients receiving opioids for chronic pain.

BACKGROUND: Benzodiazepine use has been associated with addiction-related risks, but little is known about its association with aberrant drug-related behaviors in patients receiving opioids for chronic pain. The authors examined the association between receipt of a benzodiazepine prescription and 2 aberrant drug-related behaviors, early opioid refills and illicit drug (cocaine) use in patients receiving opioids for noncancer chronic pain. METHODS: This was a retrospective cohort study of 847 patients with ≥1 visit to either a hospital-based primary care clinic or one of two community health centers between September 1, 2011, and August 31, 2012. All patients received ≥3 opioid prescriptions written at least 21 days apart within 6 months, and ≥1 urine drug screen during the study period. A Cox proportional hazards model estimated the hazard of a second early opioid refill, defined as an opioid prescription written 7-25 days after the previous prescription for the same drug, as a function of time-varying benzodiazepine prescription. A logistic regression model examined the relationship between benzodiazepine prescription and a positive urine test for cocaine. Models were adjusted for demographics and mental/substance use disorder diagnoses. RESULTS: Twenty-three percent (n = 196) of patients received ≥1 benzodiazepine prescription during the study period. Twenty-two percent (n = 183) of patients had ≥2 early opioid refills, and 11% (n = 93) had ≥1 positive urine drug tests for cocaine. Receipt of benzodiazepine prescription was associated with an increased hazard of having a second early opioid refill, adjusted hazard ratio = 1.54 (95% confidence interval [CI]: 1.09-2.18), but not associated with a positive cocaine test, adjusted odds ratio = 1.07 (95% CI: 0.55-2.23). CONCLUSIONS: Among primary care patients receiving chronic opioid therapy, benzodiazepine prescription was associated with early opioid refills but not with cocaine use. Further research should better elucidate the risks and benefits of prescribing benzodiazepines to patients receiving opioids for chronic pain.

Clinical Operations Variables are Associated With Blood Pressure Outcomes.

BACKGROUND: Uncontrolled blood pressure (BP), among patients diagnosed and treated for the condition, remains an important clinical challenge; aspects of clinical operations could potentially be adjusted if they were associated with better outcomes. OBJECTIVES: To assess clinical operations factors' effects on normalization of uncontrolled BP. RESEARCH DESIGN: Observational cohort study. SUBJECTS: Patients diagnosed with hypertension from a large urban clinical practice (2005-2009). MEASURES: We obtained clinical data on BP, organized by person-month, and administrative data on primary care provider (PCP) staffing. We assessed the resolution of an episode of uncontrolled BP as a function of time-varying covariates including practice-level appointment volume, individual clinicians' appointment volume, overall practice-level PCP staffing, and number of unique PCPs. RESULTS: Among the 7409 unique patients representing 50,403 person-months, normalization was less likely for the patients in whom the episode starts during months when the number of unique PCPs were high [the top quintile of unique PCPs was associated with a 9 percentage point lower probability of normalization (P<0.01) than the lowest quintile]. Practice appointment volume negatively affected the likelihood of normalization [episodes starting in months with the most appointments were associated with a 6 percentage point reduction in the probability of normalization (P=0.01)]. Neither clinician appointment volume nor practice clinician staffing levels were significantly associated with the probability of normalization. CONCLUSIONS: Findings suggest that clinical operations factors can affect clinical outcomes like BP normalization, and point to the importance of considering outcome effects when organizing clinical care.

Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting.

OBJECTIVE: The aim of this study was to compare adherence to opioid prescribing guidelines and potential opioid misuse in patients of resident vs attending physicians. DESIGN: Retrospective cross-sectional study. SETTING: Large primary care practice at a safety net hospital in New England. SUBJECTS: Patients 18-89 years old, with at least one visit to the primary care clinic within the past year and were prescribed long-term opioid treatment for chronic noncancer pain. METHODS: Data were abstracted from the electronic medical record by a trained data analyst through a clinical data warehouse. The primary outcomes were adherence to any one of two American Pain Society Guidelines: (1) documentation of at least one opioid agreement (contract) ever and (2) any urine drug testing in the past year, and evidence of potential prescription misuse defined as ≥2 early refills. We employed logistic regression analysis to assess whether patients' physician status predicts guideline adherence and/or potential opioid misuse. RESULTS: Similar proportions of resident and attending patients had a controlled substance agreement (45.1% of resident patients vs. 42.4% of attending patient, P = 0.47) or urine drug testing (58.6% of resident patients vs. 63.6% of attending patients, P = 0.16). Resident patients were more likely to have two or more early refills in the past year relative to attending patients (42.8% vs. 32.5%; P = 0.004). In the adjusted regression analysis, resident patients were more likely to receive early refills (odds ratio 1.82, 95% confidence interval 1.26-2.62) than attending patients. CONCLUSIONS: With some variability, residents and attending physicians were only partly compliant with national guidelines. Residents were more likely to manage patients with a higher likelihood of opioid misuse.

In-Hospital vs 30-Day Sepsis Mortality at US Safety-Net and Non-Safety-Net Hospitals.

Importance: In-hospital mortality of patients with sepsis is frequently measured for benchmarking, both by researchers and policymakers. Prior studies have reported higher in-hospital mortality among patients with sepsis at safety-net hospitals compared with non-safety-net hospitals; however, in critically ill patients, in-hospital mortality rates are known to be associated with hospital discharge practices, which may differ between safety-net hospitals and non-safety-net hospitals. Objective: To assess how admission to safety-net hospitals is associated with 2 metrics of short-term mortality (in-hospital mortality and 30-day mortality) and discharge practices among patients with sepsis. Design, Setting, and Participants: Retrospective, national cohort study of Medicare fee-for-service beneficiaries aged 66 years and older, admitted with sepsis to an intensive care unit from January 2011 to December 2019 based on information from the Medicare Provider Analysis and Review File. Data were analyzed from October 2022 to September 2023. Exposure: Admission to a safety-net hospital (hospitals with a Medicare disproportionate share index in the top quartile per US region). Main Outcomes and Measures: Coprimary outcomes: in-hospital mortality and 30-day mortality. Secondary outcomes: (1) in-hospital do-not-resuscitate orders, (2) in-hospital palliative care delivery, (3) discharge to a postacute facility (skilled nursing facility, inpatient rehabilitation facility, or long-term acute care hospital), and (4) discharge to hospice. Results: Between 2011 and 2019, 2 551 743 patients with sepsis (mean [SD] age, 78.8 [8.2] years; 1 324 109 [51.9%] female; 262 496 [10.3%] Black, 2 137 493 [83.8%] White, and 151 754 [5.9%] other) were admitted to 666 safety-net hospitals and 1924 non-safety-net hospitals. Admission to safety-net hospitals was associated with higher in-hospital mortality (odds ratio [OR], 1.09; 95% CI, 1.06-1.13) but not 30-day mortality (OR, 1.01; 95% CI, 0.99-1.04). Admission to safety-net hospitals was associated with lower do-not-resuscitate rates (OR, 0.86; 95% CI, 0.81-0.91), palliative care delivery rates (OR, 0.66; 95% CI, 0.60-0.73), and hospice discharge (OR, 0.82; 95% CI, 0.78-0.87) but not with discharge to postacute facilities (OR, 0.98; 95% CI, 0.95-1.01). Conclusions and Relevance: In this cohort study, among patients with sepsis, admission to safety-net hospitals was associated with higher in-hospital mortality but not with 30-day mortality. Differences in in-hospital mortality may partially be explained by greater use of hospice at non-safety-net hospitals, which shifts attribution of death from the index hospitalization to hospice. Future investigations and publicly reported quality measures should consider time-delimited rather than hospital-delimited measures of short-term mortality to avoid undue penalty to safety-net hospitals with similar short-term mortality.