Interactive network visualization of opioid crisis research: a tool for reinforcing data linkage skills for public health policy researchers.

Background: Public health policy researchers face a persistent challenge in identifying and integrating relevant data, particularly in the context of the U.S. opioid crisis, where a comprehensive approach is crucial. Purpose: To meet this new workforce demand health policy and health economics programs are increasingly introducing data analysis and data visualization skills. Such skills facilitate data integration and discovery by linking multiple resources. Common linking strategies include individual or aggregate level linking (e.g., patient identifiers) in primary clinical data and conceptual linking (e.g., healthcare workforce, state funding, burnout rates) in secondary data. Often, the combination of primary and secondary datasets is sought, requiring additional skills, for example, understanding metadata and constructing interlinkages. Methods: To help improve those skills, we developed a 2-step process using a scoping method to discover data and network visualization to interlink metadata. Results: We show how these new skills enable the discovery of relationships among data sources pertinent to public policy research related to the opioid overdose crisis and facilitate inquiry across heterogeneous data resources. In addition, our interactive network visualization introduces (1) a conceptual approach, drawing from recent systematic review studies and linked by the publications, and (2) an aggregate approach, constructed using publicly available datasets and linked through crosswalks. Conclusions: These novel metadata visualization techniques can be used as a teaching tool or a discovery method and can also be extended to other public policy domains.

The Impact of State Medicaid Eligibility and Benefits Policy on Neonatal Abstinence Syndrome Hospitalizations.

Rates of neonatal abstinence syndrome (NAS) resulting from opioid misuse are rising. However, policies to treat opioid misuse during pregnancy are unclear. We apply a difference-in-differences design to national pediatric discharge records to examine the effects of state Medicaid policies on NAS. Among states in which Medicaid covered two clinically-recommended medications for treating opioid misuse (buprenorphine, methadone), the Affordable Care Act's Medicaid expansion reduced Medicaid-covered NAS hospitalizations. Medicaid expansion did not affect NAS hospitalizations in other expansion states. These findings imply a nuanced relationship between Medicaid policy and NAS that should be considered in addressing opioid misuse among pregnant women.

Designing Difference-in-Difference Studies with Staggered Treatment Adoption: Key Concepts and Practical Guidelines.

Difference-in-difference (DID) estimators are a valuable method for identifying causal effects in the public health researcher's toolkit. A growing methods literature points out potential problems with DID estimators when treatment is staggered in adoption and varies with time. Despite this, no practical guide exists for addressing these new critiques in public health research. We illustrate these new DID concepts with step-by-step examples, code, and a checklist. We draw insights by comparing the simple 2 × 2 DID design (single treatment group, single control group, two time periods) with more complex cases: additional treated groups, additional time periods of treatment, and treatment effects possibly varying over time. We outline newly uncovered threats to causal interpretation of DID estimates and the solutions the literature has proposed, relying on a decomposition that shows how the more complex DIDs are an average of simpler 2 × 2 DID subexperiments.

Opioid Prescriptions Prior to Emergency Department Dental Visits: A Comparison of Dental Health Professional Shortage Areas (DPSAs) and Non-DPSAs Using Electronic Health Records.

Although prior research has linked dental conditions and opioid prescribing in the U.S., it is not yet known whether the receipt of opioid prescriptions prior to seeking emergency care for dental conditions differs in geographical areas that are underserved by health care professionals (Dental Professional Shortage Areas, DPSAs) compared to other areas. Using Indiana's state-wide electronic health records from January 1, 2016 to October 31, 2020, we examine if patients from DPSAs presenting at the emergency department (ED) for dental conditions are more likely to have received opioid prescriptions in the 30 days prior to their visit, compared to patients from other areas. A higher rate of opioid receipt among DPSA individuals may indicate an association between lower availability of dental professionals and the use of opioids as a coping strategy. We note that our study design has several limitations (such as a lack of data on prescription use after the ED visit) and does not prove causation. We find that individuals experiencing dental condition ED visits in DPSAs are 16% more likely (than those in non-DPSAs) to have filled an opioid prescription in the 30 days prior to the ED visit, after controlling for age, gender, and race/ethnicity. This result is statistically significant at the 1% level. The baseline rate of opioid filling in the 30 days prior to the ED visit is 12% in DPSAs. These correlational results suggest that unmet dental needs might be substantially connected to opioid prescriptions, although further research is needed to establish whether this relationship is causal.

Effects of social distancing policy on labor market outcomes.

US workers receive unemployment benefits if they lose their job, but not for reduced working hours. In alignment with the benefits incentives, we find that the labor market responded to COVID-19 and related closure-policies mostly on the extensive (12 pp outright job loss) margin. Exploiting timing variation in state closure-policies, difference-in-differences (DiD) estimates show, between March 12 and April 12, 2020, employment rate fell by 1.7 pp for every 10 extra days of state stay-at-home orders (SAH), with little effect on hours worked/earnings among those employed. Forty percentage of the unemployment was due to a nationwide shock, rest due to social-distancing policies, particularly among "non-essential" workers.

Changes in Employment in the US Health Care Workforce, 2016-2022.

This study examines the rate of employment in US health care in the postpandemic period, through the end of 2022.

Transparency in Coverage Data and Variation in Prices for Common Health Care Services.

This cross-sectional study describes the health care prices publicly posted by Humana and the price variations by geography, service, and other factors.

Racial And Ethnic Disparities In Buprenorphine Receipt Among Medicare Beneficiaries, 2015-19.

We examined Medicare Part D claims from the period 2015-19 to identify state and national racial and ethnic disparities in buprenorphine receipt among Medicare disability beneficiaries with diagnosed opioid use disorder or opioid overdose. Racial and ethnic disparities in buprenorphine use remained persistently high during the study period, especially for Black beneficiaries, suggesting the need for targeted interventions and policies.

How are state telehealth policies associated with services offered by substance use disorder treatment facilities? Evidence from 2019 to 2022.

BACKGROUND: The COVID-19 pandemic led several states to adopt policies permitting the delivery of substance use disorder treatment (SUDT) by telehealth. We assess the impact of state-level telehealth policies in 2020 that specifically permitted audio or audiovisual forms of telehealth offerings among SUDT facilities. PROCEDURE: Cross-sectional analysis of secondary data from between 2019 and 2022. Pre-pandemic, federal law permitted states to allow audiovisual telehealth modes for SUDT to a limited extent. 2020 laws permitted states to allow audio-only modes for the first time and strengthened ability to offer audiovisual modes. We compared national SUDT facility self-reported telehealth offerings in 2020 and beyond to 2019, in states that in 2020 had policies permitting audiovisual and audio only, compared to other states. MAIN FINDINGS: Among outpatient SUDT facilities (n = 5227) present in all four years of our data, the proportion offering telehealth increased from 18% (n = 921) in 2019-26% in 2020, 60% in 2021, and 79% in 2022. We estimate an audiovisual and audio only policy in 2020 was associated with an increase in telehealth offering rates in 2022 of +16.5% points (pp) (95% CI [+10.4,+22.6]) compared to the rates in states with no such listed policy. There was little evidence of an influence on telehealth offering in 2020 (-2.9 pp, CI [-9.0,+3.2]) and 2021 (+0.6 pp, CI [-5.5,+6.7]). CONCLUSIONS: The enactment of state-level telehealth policies that allow audio and audiovisual modalities may have increased SUDT facilities' likelihood of offering telehealth services two years after enactment.

Racial/ethnic disparities in timely receipt of buprenorphine among Medicare disability beneficiaries.

BACKGROUND: Medicare disability beneficiaries (MDBs) have disproportionately high risk of opioid use disorder (OUD) and related harms given high rates of comorbidities and high-dose opioid prescribing. Despite this increased risk, little is known about timely receipt of medication for opioid use disorder (MOUD), including potential disparities by patient race/ethnicity or moderation by county-level characteristics. METHODS: National Medicare claims for a sample of MDBs with incident OUD diagnosis between March 2016 and June 2019 were linked with county-level data. Multivariable mixed effects Cox proportional hazards models estimated time (in days) to buprenorphine receipt within 180 days of incident OUD diagnosis. Primary exposures included individual-level race/ethnicity and county-level buprenorphine prescriber availability, percent non-Hispanic white (NHW) residents, and Social Deprivation Index (SDI) score. RESULTS: The sample (n=233,079) was predominantly White (72.3%), ≥45 years old (76.3%), and male (54.8%). Black (adjusted hazard ratio [aHR]=0.50; 95% CI, 0.47-0.54), Asian/Pacific Islander (aHR=0.54; 95% CI, 0.41-0.72), Hispanic/Latinx (aHR=0.81; 95% CI, 0.76-0.87), and Other racial/ethnic groups (aHR=0.75; 95% CI, 0.58-0.97) had a lower likelihood of timely buprenorphine than non-Hispanic white beneficiaries after adjusting for individual and county-level confounders. Timely buprenorphine receipt was positively associated with county-level buprenorphine prescriber availability (aHR=1.05; 95% CI, 1.04-1.07), percent non-Hispanic white residents (aHR=1.01; 95% CI, 1.00-1.01), and SDI (aHR=1.06; 95% CI, 1.01-1.10). CONCLUSIONS: Racial/ethnic disparities highlight the need to improve access to care for underserved groups. Implementing equity-focused quality and performance measures and developing interventions to increase office-based buprenorphine prescribing in predominantly minority race/ethnicity counties may reduce disparities in timely access to medication for OUD.

Competitive effects of federal and state opioid restrictions: Evidence from the controlled substance laws.

A significant concern in the policy landscape of the U.S. opioid crisis is whether supply-side controls can reduce opioid prescribing without harmful substitution. We consider an unstudied policy: the federal Controlled Substance Act (CSA) restrictions placed in August 2014 on tramadol, the second most popular opioid medication. This was followed seven weeks later by CSA restrictions for hydrocodone combination products, the leading opioids on the market. Using regression discontinuity design (RDD) models, based on the timing of the (up-)scheduling changes, to explore spillover effects, we find that tightening prescribing restrictions on one opioid reduces its use, but increases prescribing of close competitors, leading to no reduction in total opioid prescriptions.This suggests that supply restrictions are not effective in reducing opioid prescribing the presence of close substitutes that remain unrestricted.

Mortality and Discharge Location of Intensive Care Patients With Alzheimer Disease and Related Dementia.

BACKGROUND: Intensive care unit (ICU) utilization has increased among patients with Alzheimer disease and related dementia (ADRD), although outcomes are poor. OBJECTIVES: To compare ICU discharge location and subsequent mortality between patients with and patients without ADRD enrolled in Medicare Advantage. METHODS: This observational study used Optum's Clinformatics Data Mart Database from years 2016 to 2019 and included adults aged >67 years with continuous Medicare Advantage coverage and a first ICU admission in 2018. Alzheimer disease and related dementia and comorbid conditions were identified from claims. Outcomes included discharge location (home vs other facilities) and mortality (within the same calendar month of discharge and within 12 months after discharge). RESULTS: A total of 145 342 adults met inclusion criteria; 10.5% had ADRD and were likely to be older, female, and have more comorbid conditions. Only 37.6% of patients with ADRD were discharged home versus 68.6% of patients who did not have ADRD (odds ratio [OR], 0.40; 95% CI, 0.38-0.41). Both death in the same month as discharge (19.9% vs 10.3%; OR, 1.54; 95% CI, 1.47-1.62) and death in the 12 months after discharge (50.8% vs 26.2%; OR, 1.95; 95% CI, 1.88-2.02) were twice as common among patients with ADRD. CONCLUSIONS: Patients with ADRD have lower home discharge rates and greater mortality after an ICU stay than patients without ADRD.

Trends in Methadone Dispensing for Opioid Use Disorder After Medicare Payment Policy Changes.

Importance: A significant proportion of Medicare beneficiaries have a diagnosed opioid use disorder (OUD). Methadone and buprenorphine are both effective medications for the treatment of OUD (MOUDs); however, Medicare did not cover methadone until 2020. Objective: To examine trends in methadone and buprenorphine dispensing among Medicare Advantage (MA) enrollees after 2 policy changes in 2020 related to methadone access. Design, Setting, and Participants: This cross-sectional analysis of temporal trends in methadone and buprenorphine treatment dispensing assessed MA beneficiary claims from January 1, 2019, through March 31, 2022, captured by Optum's Clinformatics Data Mart. Of 9 870 791 MA enrollees included in the database, 39 252 had at least 1 claim for methadone, buprenorphine, or both during the study period. All available MA enrollees were included. Subanalyses by age and dual eligibility for Medicare and Medicaid status were conducted. Exposures: Study exposures were (1) the Centers for Medicare & Medicaid Services (CMS) Medicare bundled payment reimbursement policy for OUD treatment and (2) the Substance Abuse and Mental Health Administration and CMS Medicare policies designed to facilitate access to treatment for OUD, specifically during the COVID-19 pandemic. Main Outcomes and Measures: Study outcomes were trends in methadone and buprenorphine dispensing by beneficiary characteristics. National methadone and buprenorphine dispensing rates were calculated as claims-based dispensing rates per 1000 MA enrollees. Results: Among the 39 252 MA enrollees with at least 1 MOUD dispensing claim (mean age, 58.6 [95% CI, 58.57-58.62] years; 45.9% female), 195 196 methadone claims and 540 564 buprenorphine pharmacy claims were identified, for a total of 735 760 dispensing claims. The methadone dispensing rate for MA enrollees was 0 in 2019 because the policy did not allow any payment until 2020. Claims rates per 1000 MA enrollees were low initially, increasing from 0.98 in the first quarter of 2020 to 4.71 in the first quarter of 2022. Increases were primarily associated with dually eligible beneficiaries and beneficiaries younger than 65 years. National buprenorphine dispensing rates were 4.64 per 1000 enrollees in quarter 1 of 2019, increasing to 7.45 per 1000 enrollees in quarter 1 of 2022. Conclusions and Relevance: This cross-sectional study found that methadone dispensing increased among Medicare beneficiaries after the policy changes. Rates of buprenorphine dispensing did not provide evidence that beneficiaries substituted buprenorphine for methadone. The 2 new CMS policies represent an important first step in increasing access to MOUD treatment for Medicare beneficiaries.

Buprenorphine Treatment For Opioid Use Disorder: Comparison Of Insurance Restrictions, 2017-21.

Buprenorphine is a treatment medication that decreases mortality risks among people with opioid use disorder (OUD). Despite its efficacy, buprenorphine is underused in the US. Insurance restrictions are commonly cited as barriers to buprenorphine prescribing. Using Medicaid, Medicare Advantage, and commercial insurance formulary files, we examined insurance-imposed utilization restrictions for buprenorphine for OUD for each year from 2017 to 2021 by insurance type. Almost all plans covered immediate-release buprenorphine in 2021, with a general trend of decreasing prior authorization requirements and quantity limits since 2017. In contrast, two payers had relatively low coverage of extended-release buprenorphine, with only 46 percent of commercial plans and only 19 percent of Medicare Advantage plans covering this formulation. Even though most Medicaid plans covered extended-release buprenorphine in 2021, 37 percent required prior authorization. Policy makers and researchers concerned with buprenorphine insurance barriers should shift their attention to extended-release buprenorphine. State lawmakers could help address these barriers by mandating that insurers include extended-release buprenorphine on their preferred drug lists.

Trends in Abortion- and Contraception-Related Internet Searches After the US Supreme Court Overturned Constitutional Abortion Rights: How Much Do State Laws Matter?

Importance: The US Supreme Court ruling in Dobbs v Jackson Women's Health Organization on June 24, 2022, revealed immediate and distinct differences between states regarding abortion legality. Whether the ruling was associated with population-level changes in seeking information on reproductive health care-related information is unknown. Objective: To determine whether the US Supreme Court ruling on Dobbs v Jackson Women's Health Organization was associated with increased information seeking for reproductive health care access in the states with immediately effective (trigger and pre-Roe) abortion laws vs other states. Design, Setting, and Participants: This was a retrospective cross-sectional study of nationwide real-time internet search data by state-week from January 1, 2021, through July 16, 2022. Difference-in-difference event study estimates were used to evaluate abortion- and contraception-related internet searches after the Supreme Court draft majority decision was leaked on May 2, 2022, and the final ruling was issued on June 24, 2022, in states immediately affected vs other states. Data analyses were performed from July 18 to January 14, 2022. Exposures: The Supreme Court's draft majority decision leaked on May 2, 2022, and the final ruling on Dobbs v Jackson Women's Health Organization on June 24, 2022. Preexisting state trigger laws and pre-Roe bans that became effective immediately when Roe was overturned by the decision on Dobbs. Main Outcomes and Measures: Number of searches per 10 million Google queries in a state-week for terms related to abortion or contraception. Results: Searches for abortion-related terms increased from 16 302 to 75 746 per 10 million searches per state-week during the weeks before vs after the May 2, 2022, leak of the draft majority decision in states with trigger laws or abortion bans. This was a 42% (95% CI, 24%-59%) higher increase than in states with laws that protect abortion access. Searches for contraception also increased from 56 055 to 82 133 searches per state-week after the ruling in the states with abortion bans, 25% (95% CI, 13%-36%) higher than the increase in states protecting abortion access. Conclusions and Relevance: The findings of this retrospective cross-sectional study suggest that changes in internet searching for terms related to reproductive health care can capture immediate population-level changes in information-seeking behavior regarding reproductive health care access. These data are critical for shaping health policy discussions.

Does paid sick leave encourage staying at home? Evidence from the United States during a pandemic.

We study the impact of a temporary U.S. paid sick leave mandate that became effective April 1st, 2020 on self-quarantining, proxied by physical mobility behaviors gleaned from cellular devices. We study this policy using generalized difference-in-differences methods, leveraging pre-policy county-level heterogeneity in the share of workers likely eligible for paid sick leave benefits. We find that the policy leads to increased self-quarantining as proxied by staying home. We also find that COVID-19 confirmed cases decline post-policy.

CMS Practice Assessment Tool validity for alternative payment models.

OBJECTIVES: To study the predictive validity of the CMS Practice Assessment Tool (PAT) among 632 primary care practices. STUDY DESIGN: Retrospective observational study. METHODS: The study included primary care physician practices recruited by the Great Lakes Practice Transformation Network (GLPTN), 1 of 29 CMS-awarded networks, and used data from 2015 to 2019. At enrollment, trained quality improvement advisers scored each of the PAT's 27 milestones by its degree of implementation based on interviews with staff, review of documents, direct observation of practice activity, and professional judgment. The GLPTN also tracked each practice's status regarding alternative payment model (APM) enrollment. Exploratory factor analysis (EFA) was used to identify summary scores; mixed-effects logistic regression was used to assess the relationship between derived scores with APM participation. RESULTS: EFA revealed that the PAT's 27 milestones could be summed into 1 overall score and 5 secondary scores. By the end of the 4-year project, 38% of practices were enrolled in an APM. A baseline overall score and 3 secondary scores were associated with increased odds of joining an APM (overall score: odds ratio [OR], 1.06; 95% CI, 0.99-1.12; P = .061; data-driven care quality score: OR, 1.11; 95% CI, 1.00-1.22; P = .040; efficient care delivery score: OR, 1.08; 95% CI, 1.03-1.13; P = .003; collaborative engagement score: OR, 0.88; 95% CI, 0.80-0.96; P = .005). CONCLUSIONS: These results demonstrate that the PAT has adequate predictive validity for APM participation.

A National Retrospective Study of Antidepressants' Effects on Overdose and Self-Harm Among Adults Treated With Opioid Analgesics.

OBJECTIVE: Because individuals with a history of depression who are receiving opioids are at higher risk for adverse events, the authors examined whether antidepressant treatment reduces risk for overdose and self-harm among individuals with a history of depression who receive opioids. METHODS: Commercial insurance claims of individuals with a history of depression receiving opioids from 2007 to 2017 were used to quantify the association between antidepressant fills and adverse events among individuals after initiation of opioid treatment; the authors accounted for selection into treatment and used discrete-time, proportional hazards survival models. RESULTS: Among 283,374 adults with a history of depression treatment, 8,203 experienced 47,486 adverse events from 2007 to 2017 in the 12 months after initiation of opioid treatment. Approximately half (N=144,052, 50.8%) filled an antidepressant prescription at least once in the 12 months after the opioid episode began. Individuals receiving antidepressants for at least 6 weeks had a reduced risk for any adverse event (adjusted odds ratio [AOR]=0.79, 95% confidence interval [CI]=0.65-0.97) as well as a reduced risk for opioid overdoses (AOR=0.78, 95% CI=0.64-0.96), overdoses from nonopioid controlled substances (AOR=0.76, 95% CI=0.62-0.94), overdoses from other substances (AOR=0.79, 95% CI=0.65-0.97), and other self-harm events (AOR=0.82, 95% CI=0.67-1.00). CONCLUSIONS: Individuals with a history of depression who received opioid analgesics had a significantly lower risk for overdose and self-harm after they had been taking antidepressants for at least 6 weeks. Universal screening for mood disorders among individuals receiving opioids, and promptly providing evidence-based depression treatment when appropriate, may reduce adverse events.