Demographic, Clinical, and Prescribing Characteristics Associated with Future Opioid Use in an Opioid-Naive Population in an Integrated Health System.

INTRODUCTION: Health systems and prescribers need additional tools to reduce the risk of opioid dependence, abuse, and overdose. Identifying opioid-naive individuals who are at risk of opioid dependence could allow for the development of needed interventions. METHODS: We conducted a retrospective cohort analysis of 23,804 adults in an integrated health system who had received a first opioid prescription between 2010 and 2015. We compared the demographic, clinical, and prescribing characteristics of individuals who later received a third opioid dispense at least 27 days later, indicating long-term opioid use, with those who did not. RESULTS: The strongest predictors of continued opioid use were an initial prescription dosage of 90 morphine milligram equivalence or more; prescription of extended-release opioids, rather than short-release; and being prescribed outside of a hospital setting. Patients with a third prescription were also more likely to be older than 45 years, white, and non-Hispanic and to have physical comorbidities or prior substance abuse or mental health diagnoses. DISCUSSION: Our findings are largely consistent with prior research but provide new insight into differences in continued opioid use by opioid type, prescribing location, ethnicity, and comorbidities. Together with previous research, our data support a pattern of higher opioid use among older adults but higher rates of diagnosed opioid abuse among younger adults. CONCLUSIONS: By identifying population characteristics associated with continued opioid use following a first prescription, our data pave the way for quality improvement interventions that target individuals who are at higher risk of opioid dependence.

Balancing Adherence and Expense: The Cost-Effectiveness of Two-Sample vs One-Sample Fecal Immunochemical Test.

Colorectal cancer (CRC) causes more than 50,000 deaths each year in the United States but early detection through screening yields survival gains; those diagnosed with early stage disease have a 5-year survival greater than 90%, compared to 12% for those diagnosed with late stage disease. Using data from a large integrated health system, this study evaluates the cost-effectiveness of fecal immunochemical testing (FIT), a common CRC screening tool. A probabilistic decision-analytic model was used to examine the costs and outcomes of positive test results from a 1-FIT regimen compared with a 2-FIT regimen. The authors compared 5 diagnostic cutoffs of hemoglobin concentration for each test (for a total of 10 screening options). The principal outcome from the analysis was the cost per additional advanced neoplasia (AN) detected. The authors also estimated the number of cancers detected and life-years gained from detecting AN. The following costs were included: program management of the screening program, patient identification, FIT kits and their processing, and diagnostic colonoscopy following a positive FIT. Per-person costs ranged from $33 (1-FIT at 150ng/ml) to $92 (2-FIT at 50ng/ml) across screening options. Depending on willingness to pay, the 1-FIT 50 ng/ml and the 2-FIT 50 ng/ml are the dominant strategies with cost-effectiveness of $11,198 and $28,389, respectively, for an additional AN detected. The estimates of cancers avoided per 1000 screens ranged from 1.46 to 4.86, depending on the strategy and the assumptions of AN to cancer progression.

Automated telephone calls to enhance colorectal cancer screening: economic analysis.

OBJECTIVES: To estimate the cost-effectiveness of an automated telephone intervention for colorectal cancer screening from a managed care perspective, using data from a pragmatic randomized controlled trial. METHODS: Intervention patients received calls for fecal occult blood testing (FOBT) screening. We searched patients' electronic medical records for any screening (defined as FOBT, flexible sigmoidoscopy, double-contrast barium enema, or colonoscopy) during follow-up. Intervention costs included project implementation and management, telephone calls, patient identification, and tracking. Screening costs included FOBT (kits, mailing, and processing) and any completed screening tests during follow-up. We estimated the incremental cost-effectiveness ratio (ICER) of the cost per additional screen. RESULTS: At 6 months, average costs for intervention and control patients were $37 (25% screened) and $34 (19% screened), respectively. The ICER at 6 months was $42 per additional screen, less than half what other studies have reported. Cost-effectiveness probability was 0.49, 0.84, and 0.99 for willingness-to-pay thresholds of $40, $100, and $200, respectively. Similar results were seen at 9 months. A greater increase in FOBT testing was seen for patients aged >70 years (45/100 intervention, 33/100 control) compared with younger patients (25/100 intervention, 21/100 control). The intervention was dominant for patients aged >70 years and was $73 per additional screen for younger patients. It increased screening rates by about 6% and costs by $3 per patient. CONCLUSIONS: At willingness to pay of $100 or more per additional screening test, an automated telephone reminder intervention can be an optimal use of resources.

Long-term prognosis of inducible ventricular flutter: not an innocent finding.

BACKGROUND: The prognostic significance of ventricular flutter (VFL) induced during programmed electrical stimulation (PES) is currently unknown. METHODS: This study examined patients who had PES-induced VFL and assessed their long-term prognosis compared with patients who had inducible sustained monomorphic ventricular tachycardia (SMVT). RESULTS: Of 3414 patients undergoing PES, 74 (2%) had sustained VFL. They were compared with a group of 71 patients undergoing PES in the same time frame who had inducible SMVT. Patients with inducible VFL had a higher ejection fraction than patients with SMVT (0.39 vs 0.33; P =.05). More aggressive pacing was required for arrhythmia induction in patients with VFL, with more stimuli (2.7 +/- 0.5 vs 2.2 +/- 0.6; P <.01) and tighter S(2), S(3), and S(4) intervals. After a mean follow-up of 30 +/- 31 months, the mortality rate was 34% in patients with VFL and 30% in patients with SMVT (P =.41). No difference in the 2 groups in overall survival or a combined end point of sudden death or appropriate implantable cardioverter defibrillator shock was revealed with Kaplan-Meier analysis. CONCLUSION: The long-term prognosis of patients with inducible VFL is similar to that of patients with inducible SMVT, even when VFL is induced with a relatively aggressive protocol.