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.

Contribution of Continuous Virtual Monitoring to Hospital Safety, Quality, and Value of Care for COVID-19 Patients.

Introduction: The rapid onset of the COVID-19 pandemic increased hospital admissions and shortages for personal protective equipment (PPE) used to slow the spread of infections. In addition, nurses treating COVID-19 patients have time-consuming guidelines to properly don and doff PPE to prevent the spread. Methods: To address these issues, the Medical University of South Carolina repurposed continuous virtual monitoring (CVM) systems to reduce the need for staff to enter patient rooms. The objective of this study was to identify the economic implications associated with using the CVM program for COVID-19 patients. We employed a time-driven activity-based costing approach to determine time and costs saved by implementing CVM. Results: Over the first 52 days of the pandemic, the use of the CVM system helped providers attend to patients needs virtually while averting 19,086 unnecessary in-person interactions. The estimated cost savings for the CVM program for COVID-19 patients in 2020 were $419,319, not including potential savings from avoided COVID-19 transmissions to health care workers. A total of 19,086 PPE changes were avoided, with savings of $186,661. After accounting for cost of the CVM system, the net savings provided an outstanding return on investment of 20.6 for the CVM program for COVID-19 patient care. Conclusion: The successful and cost saving repurposing of CVM systems could be expanded to other infectious disease applications, and be applied to high-risk groups, such as bone marrow and organ transplant patients.

Impact of the COVID-19 Pandemic on the Care Continuum of Youth Living with HIV: Qualitative Study of the Scale It Up Program Clinical Sites.

The study objective was to explore the impact of COVID-19 pandemic restrictions on the clinics' ability to provide continuous healthcare services to youth (15-24 years) living with HIV (YLWH). One focused semi-structured interview was conducted with each HIV clinic site-resulting in ten interviews. Data were analyzed using thematic analysis techniques assisted by NVIVO coding software and themes indicating barriers and facilitators to providing uninterrupted healthcare were elicited. Six themes were identified that affected the care continuum of YLWH: Timeframe of clinic preparation to address COVID-19 restrictions; impact on treatment cascade monitoring data; impact on patient care; impact on staff and services offered; software use and virtual visits; community impact. With careful planning and preparation, clinics were able to successfully implement a process of care that adapted to COVID-19 restrictions. Guidance is provided on how healthcare facilities can effectively incorporate strategies to provide continued services during pandemics and natural disasters.

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.

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.

Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study.

OBJECTIVE: Elevated systolic blood pressure (SBP) after successful revascularization (SR) via endovascular therapy (EVT) is a known predictor of poor outcome. However, the optimal SBP goal following EVT is still unknown. Our objective was to compare functional and safety outcomes between different SBP goals after EVT with SR. METHODS: This international multicenter study included 8 comprehensive stroke centers and patients with anterior circulation large vessel occlusion who were treated with EVT and achieved SR. SR was defined as modified thrombolysis in cerebral ischemia 2b to 3. Patients were divided into 3 groups based on SBP goal in the first 24 hours after EVT. Inverse probability of treatment weighting (IPTW) propensity analysis was used to assess the effect of different SBP goals on clinical outcomes. RESULTS: A total of 1,019 patients were included. On IPTW analysis, the SBP goal of <140mmHg was associated with a higher likelihood of good functional outcome and lower odds of hemicraniectomy compared to SBP goal of <180mmHg. Similarly, SBP goal of <160mmHg was associated with lower odds of mortality compared to SBP goal of <180mmHg. In subgroup analysis including only patients with pre-EVT SBP of ≥140mmHg, an SBP of <140mmHg was associated with a higher likelihood of good functional outcome, lower odds of symptomatic intracranial hemorrhage, and lower odds of requirement for hemicraniectomy compared to SBP goal of <180mmHg. INTERPRETATION: SBP goals of <140 and < 160mmHg following SR with EVT appear to be associated with better clinical outcomes than SBP of <180mmHg. ANN NEUROL 2020;87:830-839.

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.

Do Hospitals Providing Telehealth in Emergency Departments Have Lower Emergency Department Costs?

Background: Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Introduction: Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. Materials and Methods: A panel of data for 2010-2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. Results: After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. Conclusions: TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

Cost-effectiveness evaluation of the PROPPR trial transfusion protocols.

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.

A Longitudinal Examination of the Asthma Medication Ratio in Children with Medicaid.

Background/Objective: An efficient and accurate strategy for identifying children with asthma at high-risk for exacerbation is needed. The objective of this study is to conduct a longitudinal examination of the asthma medication ratio (AMR) (#of controller medication claims/(# of controller medication claims + # of rescue medication claims)) in Medicaid-funded children with asthma. This measure has the potential to be a near real-time risk assessment tool.Methods: We conducted a retrospective analysis of 2013-2014 Truven Health Medicaid data. We analyzed pharmacy and medical claims for a cohort of children with asthma. We identified patients age 2-17 years with at least one claim for an inhaled corticosteroid. We calculated an AMR for rolling 3-month periods and examined the proportion who were classified as low risk (AMR ≥ .5), high-risk (AMR < .5) and no medication claims (no asthma medication claims). Using logistic regression, we tested how the AMR predicted severe exacerbations.Results: 214,452 eligible children were identified. The mean age is 7.8 years. 8-9% had a high-risk AMR in any given period. High-risk AMR is associated with increased odds of a severe exacerbation in the subsequent 3 months (compared to all other children) (OR 1.7-1.9 depending on time period evaluated).Conclusions: In this analysis of Medicaid-insured children with asthma, we found that the AMR is a reliable predictor of exacerbations. This will inform the development of an AMR-based risk assessment and communication intervention.

Using Inferred Mobility Status to Estimate the Time to Major Depressive Disorder Diagnosis Post-Spinal Cord Injury.

OBJECTIVE: Estimate (1) prevalence of major depressive disorder (MDD) diagnosis; (2) risk factors associated with MDD diagnosis; (3) time at which MDD is diagnosed post-spinal cord injury (SCI); and (4) interaction of inferred mobility status (IMS) in a commercially insured population over 3 years. DESIGN: Retrospective longitudinal cohort design. SETTING: A commercial insurance claims database from January 1, 2010 to December 31, 2013. PARTICIPANTS: Individuals with an index cervical or thoracic SCI in 2011 or 2012, without history of MDD ≤30 days pre-SCI (N=1409). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Prevalence of, risk factors associated with, and time to MDD diagnosis post-SCI. A stratified survival analysis using IMS, based upon durable medical equipment (DME) claims, was also completed. RESULTS: Post-SCI, 294 out of 1409 (20.87%) were diagnosed with new-onset MDD. Significant (P<.05) risk factors included: employment, length of index hospitalization, discharge from index hospitalization with healthcare services, rehabilitation services post-SCI, and 2 of 5 IMS comparisons. Median time to MDD was 86 days. Survival analysis demonstrated a significant difference between 6 of 10 IMS comparisons. Regarding new-onset or recurring MDD, 432 out of 1409 (30.66%) were diagnosed post-SCI. Significant risk factors included: female, employment, length of index hospitalization, discharge from index hospitalization with healthcare services, rehabilitation services post-SCI, MDD>30 days pre-SCI, catheter claims, and 2 of 5 IMS comparisons. Median time to MDD was 74 days. Survival analysis demonstrated a significant difference between 4 of 10 IMS comparisons. CONCLUSIONS: Prevalence of MDD post-SCI is greater than the general population. Stratification by IMS illustrated that individuals with greater inferred reliance on DME are at a greater risk for MDD and have shorter time to MDD diagnosis post-SCI.

Teleneurology Network to Improve Access to Neurologists for Patients in Rural Areas: A Real-World Experience.

Background: The need for neurologists has been steadily increasing over the past few years. The implementation of teleneurology networks could serve as a potential solution to this need. Methods: A retrospective review of the Medical University of South Carolina (MUSC) Teleneurology records for all consults performed between August 2014 and July 2018 was conducted. Collected data included number of consults, baseline characteristics, final diagnosis, and number of providers and hospitals over the study period. Results: A total of 4,542 Teleneurology consults were performed during the study period. The most common diagnosis was cerebrovascular disease, followed by seizure disorders. The number of consults per month increased throughout the study period from three in August 2014 to 257 in July 2018. The number of community hospitals covered has increased from 3 hospitals in August 2014 to 14 hospitals throughout the state of South Carolina in July 2018. Conclusion: Over 4 years, the MUSC teleneurology program has evolved into a robust partnership with 14 partner hospitals, and is now delivering more than 250 expert neurology consultations monthly to patients throughout the state of South Carolina.

Population Health Indicators Associated with a Statewide Telestroke Program.

Background: Studies show that telestroke (TS) improves rural access to care and outcome for stroke patients receiving TS services, but population health impacts of TS are not known. We examine impacts associated with South Carolina's (SC) statewide TS network on an entire state population of patients suffering acute ischemic stroke (AIS) as TS became available across SC counties. Methods: A population health study using Donabedian's conceptual model and an ecological design to describe the change observed over time in use of thrombolysis and endovascular therapy (EVT) as the SC TeleStroke Network (SCTN) diffused across SC counties. Changes in county rates of stroke mortality and discharge destination are reported. The unit of interest is the population rate for AIS patients living in a SC county. Patients' county of residence at the time of hospitalization defined county cohorts. Relative risks were estimated using logistic regression adjusted for age >75 years. Results: Overall tissue plasminogen activator (tPA) rate was 6.28%, and EVT rate was 1.10%. Patients living where SCTN was available had a 25% higher likelihood of receiving tPA (adjusted relative risk [ARR] = 1.25, 95% confidence interval [CI] = 1.15-1.36) and lower risks of mortality (ARR = 0.91; 95% CI = 0.84-0.99) or discharge to skilled nursing (ARR = 0.93; 95% CI = 0.89-0.97). Conclusions: TS diffusion affects the structure of the health system serving a county, as well as the processes of care delivered in the emergency department; these changes are associated with measurable population health improvements. Results support a population benefit of TS implementation.

The Effect of Frailty on Discharge Location for Medicare Beneficiaries After Acute Stroke.

OBJECTIVE: To examine the effect of frailty on poststroke discharge location with respect to stroke severity and create a risk-adjusted model for understanding the effects of frailty on discharge to an inpatient rehabilitation facility. DESIGN: Retrospective cohort. SETTING: A 2014 5% Medicare sample. PARTICIPANTS: Patients hospitalized for a first-time acute ischemic stroke (N=7258). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A prehospitalization 6-month baseline was used to calculate a frailty score. Logistic regression to predict odds of discharge to inpatient rehabilitation was used to calculate for 3 levels of baseline frailty, controlling for patient demographics, stroke severity, and comorbidities. RESULTS: About 1603 patients were discharged to inpatient rehabilitation. Patients who were nonfrail (odds ratio [OR] 1.716; 95% confidence interval [95% CI], 1.463-2.013) or prefrail (OR 1.519; 95% CI, 1.296-1.779) were more likely to be discharged to inpatient rehabilitation. The final logistic regression model had a C-statistic of 0.63. Most of the patients discharged to inpatient rehabilitation were nonfrail (44.2%) and had moderate strokes (38.9%). Individuals who were frail and suffered a moderate (OR 0.78; 95% CI, 0.558-1.091) or severe stroke (OR 0.509; 95% CI, 0.358-0.721) were less likely to be discharged to an inpatient rehabilitation facility. CONCLUSIONS: A lack of a claims-based measure for prestroke functional ability makes it difficult to understand discharge decision-making patterns for individuals' poststroke. Prestroke frailty was found to have a significant effect on predicating inpatient rehabilitation discharge after an acute stroke when controlling for stroke severity, comorbidities, and age. Further investigation is warranted to examine differences in rehabilitation utilization based on frailty and to quantify the effect of rehabilitation on frailty status in individuals poststroke.

Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair.

PURPOSE: The goal of this study was to determine whether the timing of preoperative shoulder injections is associated with an increased risk of revision rotator cuff repair following primary rotator cuff repair (RCR). METHODS: A retrospective analysis of claims data of privately insured subjects from the MarketScan database for the years 2010 to 2014 was conducted. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Laterality for the injection, index procedure, and subsequent surgery were verified for all subjects. RESULTS: A total of 4,959 subjects with an arthroscopic RCR were identified, 392 of whom required revision RCR within the following 3 years. Patients who had an injection within 6 months preceding the index surgery were at a much higher risk of undergoing reoperation for revision RCR: 0 to 3 months prior, adjusted odds ratio (AOR) 1.375 (95% confidence interval [CI], 1.027-1.840); 3 to 6 months prior, AOR 1.822 (95% CI, 1.290-2.573); and 6 to 12 months prior, AOR 1.237 (95% CI, 0.787-1.943). CONCLUSIONS: Patients who had received an injection within 6 months prior to RCR were much more likely to undergo a revision cuff repair within the following 3 years. The risk of reoperation significantly declines if there is more than 6 months between injection and RCR. Consideration should be given to minimizing preoperative injections in patients requiring RCR or delaying primary RCR for 6 months following injection. LEVEL OF EVIDENCE: Level III, therapeutic study.

Changes in Efficiency and Quality of Nursing Electronic Health Record Documentation After Implementation of an Admission Patient History Essential Data Set.

The objective of this quality improvement study was to evaluate whether electronic health record system timers and event logs can measure the efficiency and quality of a clinical process in an electronic health record. Using an experimental pre- and post-nonrandomized prospective cohort design, the researchers introduced a newly defined admission patient history essential data set and examined the electronic health record event files and timers to analyze the nursing experience from an efficiency and quality perspective. The researchers evaluated efficiency by measuring the time and clicks required to complete an admission history. The average active time spent documenting the admission patient history decreased by 72% from the preintervention measure (mean = 9.30 minutes) to the postintervention measure (mean = 2.55 minutes). The number of clicks decreased by 76% from the preintervention number of clicks (mean = 151.5) to the postintervention number of clicks (mean = 35.93). The quality of documentation was measured as the proportion of completed essential items and the frequency of completing an assessment in one sequence. The capture of essential data elements improved by almost 6%, and admission patient history data completed in one sequence increased by 24%. These study results demonstrate that system timers and event logs can measure the preintervention and postintervention changes in efficiency and quality of a defined clinical workflow into an electronic health record.

Dose and Duration of Opioid Use in Propensity Score-Matched, Privately Insured Opioid Users With and Without Spinal Cord Injury.

OBJECTIVES: To (1) compare the opioid utilization patterns in opioid users with spinal cord injury (SCI) to a propensity score-matched general population of opioid users without SCI; and (2) identify characteristics of persons with SCI associated with long-term and/or high-dose use of opioids. DESIGN: Quasi-experimental analysis of archival data. SETTING: Data used for the analysis were derived from Thompson Reuters MarketScan Commercial Claims and Encounters Databases for the years 2012 to 2013. PARTICIPANTS: Participants (N=2908; aged 18-64y) included opioid users with SCI (n=1454) and propensity score-matched opioid users without SCI (n=1454). The cohorts were matched using demographics including comorbidities, hospital admissions, age, sex, and geographic region. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medical and pharmacy claims from 2012 to 2013 MarketScan data were analyzed to characterize whether persons were short-term (<90d) or long-term (≥90d) opioid users, and whether persons had high (≥120mg) or low (<120mg) average daily morphine equivalents. RESULTS: Persons with SCI were significantly more likely to be long-term users of low-dose, short-acting opioids (P<.0001) and more likely to be taking high morphine-equivalent doses of long-acting opioids (P<.0001) than matched controls. Among persons with SCI, those with lumbar/sacral injuries had more days' supply of high-dose, long-acting opioids than did persons with thoracic or cervical injuries. CONCLUSIONS: Persons with SCI are prescribed opioids for longer durations and at higher morphine-equivalent doses than controls, which may increase the risk of opioid dependence or adverse drug events. Findings should be considered in the development of practice guidelines for alternate pain management options or opioid dependence interventions for persons with SCI.

FIM-Minimum Data Set Motor Item Bank: Short Forms Development and Precision Comparison in Veterans.

OBJECTIVE: To improve the practical use of the short forms (SFs) developed from the item bank, we compared the measurement precision of the 4- and 8-item SFs generated from a motor item bank composed of the FIM and the Minimum Data Set (MDS). DESIGN: The FIM-MDS motor item bank allowed scores generated from different instruments to be co-calibrated. The 4- and 8-item SFs were developed based on Rasch analysis procedures. This article compared person strata, ceiling/floor effects, and test SE plots for each administration form and examined 95% confidence interval error bands of anchored person measures with the corresponding SFs. We used 0.3 SE as a criterion to reflect a reliability level of .90. SETTING: Veterans' inpatient rehabilitation facilities and community living centers. PARTICIPANTS: Veterans (N=2500) who had both FIM and the MDS data within 6 days during 2008 through 2010. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Four- and 8-item SFs of FIM, MDS, and FIM-MDS motor item bank. RESULTS: Six SFs were generated with 4 and 8 items across a range of difficulty levels from the FIM-MDS motor item bank. The three 8-item SFs all had higher correlations with the item bank (r=.82-.95), higher person strata, and less test error than the corresponding 4-item SFs (r=.80-.90). The three 4-item SFs did not meet the criteria of SE <0.3 for any theta values. CONCLUSIONS: Eight-item SFs could improve clinical use of the item bank composed of existing instruments across the continuum of care in veterans. We also found that the number of items, not test specificity, determines the precision of the instrument.

Polypharmacy and adverse drug events among propensity score matched privately insured persons with and without spinal cord injury.

STUDY DESIGN: Retrospective quasi-experimental design. OBJECTIVES: To compare the incidence of adverse drug events (ADEs) between persons with and without spinal cord injury (SCI), while controlling for all potential and available risk factors. SETTING: A commercially available claims dataset consisting of ~170 million patient cases in the United States between 2012 and 2013. METHODS: Participants (aged 18-64 years) included 2779 persons with polypharmacy and traumatic or non-traumatic SCI and 2779 propensity score-matched persons with polypharmacy without SCI. The cohorts were matched using demographic variables including number of concomitant prescriptions, comorbidities, hospital admissions, age, gender, and geographic region. Inpatient and outpatient claims records containing 395 distinct IDC-9 codes indicative of ADEs were extracted. Incidence and frequency of ADEs were compared between groups using logistic and Poisson regression, respectively. RESULTS: Persons with SCI were significantly more likely to experience an ADE than matched controls (Odds Ratio = 1.45, p < 0.0001). Among persons with ADEs (n = 1552), individuals with SCI experienced fewer ADEs over time than matched controls (Incidence Rate Ratio = 0.91, p < 0.0001). CONCLUSIONS: While persons with SCI and polypharmacy are at a greater risk for experiencing an ADE, their medical care after an ADE may be better managed than that of a matched control population. There may be a need for practice guidelines that facilitate proactive identification of persons with SCI at the highest risk of ADE. Steps may then be taken to mitigate risk, in contrast to current practice trends that appear to take a reactive approach after an ADE has occurred.