Health Care Use Among Patients Retroactively Insured via a Hospital-Based Insurance Linkage Program.

OBJECTIVE: Over 25% of the 27 million uninsured individuals in the United States are eligible for Medicaid. Many hospitals have insurance linkage programs that assist eligible patients with enrollment, but little is known about the impact of these programs on care utilization. This research assessed health care utilization and health outcomes among patients enrolled in Medicaid via a hospital-based insurance linkage program. METHODS: This retrospective cohort study included adults aged 18-64 admitted to the hospital from 2016 to 2021. Those who obtained insurance retroactively via insurance linkage (RI) were compared with those who presented with Medicaid (MI) or remained uninsured (UI). The primary outcome was the presence of at least one visit with a primary care provider (PCP) in the 12 months following index admission. Secondary outcomes included having an assigned PCP, ED revisits, and hospital readmissions. For patients with diabetes and hypertension, 12-month hemoglobin A1c (HbA1c) and blood pressure (BP) readings were tracked. RESULTS: Of 3882 patients admitted with no insurance, 2905 (74.8%) were enrolled in insurance (RI). In multivariable analysis, RI patients were 14% more likely (OR 1.14, p = 0.020) to have completed at least one PCP visit by 12 months after index admission compared to those with preexisting Medicaid (MI), and uninsured patients were 29% less likely (OR 0.71, p = 0.003). MI and RI patients also had more ED revisits (p < 0.001) and greater 12-month reductions in blood pressure (p < 0.001) compared with uninsured patients. CONCLUSION: Hospital-based insurance linkage reached three-quarters of uninsured patients and was associated with increased utilization of acute and outpatient health care services. An acute care encounter represents an opportunity to connect patients to insurance, a key step toward improving their health outcomes.

Association between patient-reported onset-to-door time and mortality in patients hospitalized with COVID-19 disease.

INTRODUCTION: Timely hospital presentation and treatment are critical for recovery from coronavirus disease (COVID-19). However, the relationship between symptom onset-to-door time and key clinical outcomes, such as inpatient mortality, has been poorly understood due to the difficulty of retrospectively measuring symptom onset in observational data. This study examines the association between patient-reported symptom onset-to-door time (ODT) and mortality among patients hospitalized and treated for COVID-19 disease. METHODS: We conducted a retrospective cohort study of emergency department (ED) encounters of patients with COVID-19 disease who were hospitalized and received remdesivir and/or dexamethasone between March 1, 2020, and March 1, 2022. The exposure was patient-reported ODT in days. The outcome of interest was inpatient mortality, including referral to hospice care. We used multivariable logistic regression to examine the association between ODT and mortality while adjusting for patient characteristics, hospital sites, and seasonality. We tested whether severe illness on hospital presentation modified the association between ODT and mortality. Severe illness was defined by Emergency Severity Index triage level 1 or 2 and hypoxia (SpO2 < 94%). RESULTS: Of the 3451 ED hospitalizations included, 439 (12.7%) resulted in mortality, and 1693 (49.1%) involved patients with severe illness on hospital presentation. Greater ODT was significantly associated with lower odds of inpatient mortality (adjusted odds ratio (AOR) = 0.96, 95% CI = 0.93-1.00, P = 0.023). There was a statistically significant interaction between ODT and severe illness at hospital arrival on mortality, suggesting the negative association between ODT and mortality specifically pertained to patients who were not severely ill upon ED presentation (AOR = 0.93, 95% CI = 0.87-1.00, P = 0.035). The adjusted probability of mortality was significantly lower for non-severely ill, hospitalized patients who presented on days 8-14 (5.2%-3.3%) versus days 0-3 (9.4%-7.5%) after symptom onset. CONCLUSION: More days between symptom onset and hospital arrival were associated with lower mortality among hospitalized patients treated for COVID-19 disease, particularly if they did not have severe illness at ED presentation. However, onset-to-door time was not associated with mortality among hospitalized patients with severe illness at ED presentation. Collectively, these results suggest that non-severely ill COVID-19 patients who require hospitalization are less likely to decompensate with each passing day without severe illness. These findings may continue to guide clinical care delivery for hospitalized COVID-19 patients.

Association of ICU Admission and Outcomes in Sepsis and Acute Respiratory Failure.

Rationale: Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness. Objectives: To measure the benefits of ICU admission for patients with sepsis or acute respiratory failure. Methods: At 27 United States hospitals across two health systems from 2013 to 2018, we performed a retrospective cohort study using two-stage instrumental variable quantile regression with a strong instrument (hospital capacity strain) governing ICU versus ward admission among high-acuity patients (i.e., laboratory-based acute physiology score v2 ⩾ 100) with sepsis and/or acute respiratory failure who did not require mechanical ventilation or vasopressors in the emergency department. Measurements and Main Results: Among patients with sepsis (n = 90,150), admission to the ICU was associated with a 1.32-day longer hospital length of stay (95% confidence interval [CI], 1.01-1.63; P < 0.001) (when treating deaths as equivalent to long lengths of stay) and higher in-hospital mortality (odds ratio, 1.48; 95% CI, 1.13-1.88; P = 0.004). Among patients with respiratory failure (n = 45,339), admission to the ICU was associated with a 0.82-day shorter hospital length of stay (95% CI, -1.17 to -0.46; P < 0.001) and reduced in-hospital mortality (odds ratio, 0.75; 95% CI, 0.57-0.96; P = 0.04). In sensitivity analyses of length of stay, excluding, ignoring, or censoring death, results were similar in sepsis but not in respiratory failure. In subgroup analyses, harms of ICU admission for patients with sepsis were concentrated among older patients and those with fewer comorbidities, and the benefits of ICU admission for patients with respiratory failure were concentrated among older patients, highest-acuity patients, and those with more comorbidities. Conclusions: Among high-acuity patients with sepsis who did not require life support in the emergency department, initial admission to the ward, compared with the ICU, was associated with shorter length of stay and improved survival, whereas among patients with acute respiratory failure, triage to the ICU compared with the ward was associated with improved survival.

Variability in opioid use disorder clinical presentations and treatment in the emergency department: A mixed-methods study.

BACKGROUND: There is strong evidence for emergency department (ED)-initiated treatment of opioid use disorder (OUD). However, implementation is variable, and ED management of OUD may differ by clinical presentation. Our aim was to use mixed methods to explore variation in ED-based OUD care by patient clinical presentation and understand barriers and facilitators to ED implementation of OUD treatment across scenarios. METHODS: We analyzed treatment outcomes in OUD-related visits within three urban, academic EDs from 12/2018 to 7/2020 following the implementation of interventions to increase ED-initiated OUD treatment. We assessed differences in treatment with medications for OUD (MOUDs) by clinical presentation (overdose, withdrawal, others). These data were integrated with results from 5 focus groups conducted with 28 ED physicians and nurses January to April 2020 to provide a richer understanding of clinician perspectives on caring for ED patients with OUD. RESULTS: Of the 1339 total opioid-related visits, there were 265 (20%) visits for overdose, 123 (9%) for withdrawal, and 951 (71%) for other OUD-related conditions. 23% of patients received MOUDs during their visit or at discharge. Treatment with MOUDs was least common in overdose presentations (6%) and most common in withdrawal presentations (69%, p < 0.001). Buprenorphine was prescribed at discharge in 15% of visits, including 42% of withdrawal visits, 14% of other OUD-related visits, and 5% of overdose visits (p < 0.001). In focus groups, clinicians highlighted variation in ED presentations among patients with OUD. Clinicians also highlighted key aspects necessary for successful treatment initiation including perceived patient receptivity, provider confidence, and patient clinical readiness. CONCLUSIONS: ED-based treatment of OUD differed by clinical presentation. Clinician focus groups identified several areas where targeted guidance or novel approaches may improve current practices. These results highlight the need for tailored clinical guidance and can inform health system and policy interventions seeking to increase ED-initiated treatment for OUD.

Patient and clinician perspectives of a remote monitoring program for COVID-19 and lessons for future programs.

COVID Watch is a remote patient monitoring program implemented during the pandemic to support home dwelling patients with COVID-19. The program conferred a large survival advantage. We conducted semi-structured interviews of 85 patients and clinicians using COVID Watch to understand how to design such programs even better. Patients and clinicians found COVID Watch to be comforting and beneficial, but both groups desired more clarity about the purpose and timing of enrollment and alternatives to text-messages to adapt to patients' preferences as these may have limited engagement and enrollment among marginalized patient populations. Because inclusiveness and equity are important elements of programmatic success, future programs will need flexible and multi-channel human-to-human communication pathways for complex clinical interactions or for patients who do not desire tech-first approaches.

Are There Differences in Postoperative Opioid Prescribing Across Racial and Ethnic Groups? Assessment of an Academic Health System.

BACKGROUND: Previous studies have demonstrated racial disparities in opioid prescribing in emergency departments and after surgical procedures. Orthopaedic surgeons account for a large proportion of dispensed opioid prescriptions, yet there are few data investigating whether racial or ethnic disparities exist in opioid dispensing after orthopaedic procedures. QUESTIONS/PURPOSES: (1) Are Black, Hispanic or Latino, or Asian or Pacific Islander (PI) patients less likely than non-Hispanic White patients to receive an opioid prescription after an orthopaedic procedure in an academic United States health system? (2) Of the patients who do receive a postoperative opioid prescription, do Black, Hispanic or Latino, or Asian or PI patients receive a lower analgesic dose than non-Hispanic White patients when analyzed by type of procedure performed? METHODS: Between January 2017 and March 2021, 60,782 patients underwent an orthopaedic surgical procedure at one of the six Penn Medicine healthcare system hospitals. Of these patients, we considered patients who had not been prescribed an opioid within 1 year eligible for the study, resulting in 61% (36,854) of patients. A total of 40% (24,106) of patients were excluded because they did not undergo one of the top eight most-common orthopaedic procedures studied or their procedure was not performed by a Penn Medicine faculty member. Missing data consisted of 382 patients who had no race or ethnicity listed in their record or declined to provide a race or ethnicity; these patients were excluded. This left 12,366 patients for analysis. Sixty-five percent (8076) of patients identified as non-Hispanic White, 27% (3289) identified as Black, 3% (372) identified as Hispanic or Latino, 3% (318) identified as Asian or PI, and 3% (311) identified as another race ("other"). Prescription dosages were converted to total morphine milligram equivalents for analysis. Statistical differences in receipt of a postoperative opioid prescription were assessed with multivariate logistic regression models within procedure, adjusted for age, gender, and type of healthcare insurance. Kruskal-Wallis tests were used to assess for differences in the total morphine milligram equivalent dosage of the prescription, stratified by procedure. RESULTS: Almost all patients (95% [11,770 of 12,366]) received an opioid prescription. After risk adjustment, we found no differences in the odds of Black (odds ratio 0.94 [95% confidence interval 0.78 to 1.15]; p = 0.68), Hispanic or Latino (OR 0.75 [95% CI 0.47 to 1.20]; p = 0.18), Asian or PI (OR 1.00 [95% CI 0.58 to 1.74]; p = 0.96), or other-race patients (OR 1.33 [95% CI 0.72 to 2.47]; p = 0.26) receiving a postoperative opioid prescription compared with non-Hispanic White patients. There were no race or ethnicity differences in the median morphine milligram equivalent dose of postoperative opioid analgesics prescribed (p > 0.1 for all eight procedures) based on procedure. CONCLUSION: In this academic health system, we did not find any differences in opioid prescribing after common orthopaedic procedures by patient race or ethnicity. A potential explanation is the use of surgical pathways in our orthopaedic department. Formal standardized opioid prescribing guidelines may reduce variability in opioid prescribing. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparative Effectiveness of an Automated Text Messaging Service for Monitoring COVID-19 at Home.

BACKGROUND: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN: Retrospective cohort analysis. SETTING: Mid-Atlantic academic health system in the United States. PARTICIPANTS: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION: Observational study with the potential for unobserved confounding. CONCLUSION: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder.

STUDY OBJECTIVE: There is strong evidence supporting emergency department (ED)-initiated buprenorphine for opioid use disorder, but less is known about how to implement this practice. Our aim was to describe implementation, maintenance, and provider adoption of a multicomponent strategy for opioid use disorder treatment in 3 urban, academic EDs. METHODS: We conducted a retrospective analysis of electronic health record data for adult patients with opioid use disorder-related visits before (March 2017 to November 2018) and after (December 2018 to July 2020) implementation. We describe patient characteristics, clinical treatment, and process measures over time and conducted an interrupted time series analysis using a patient-level multivariable logistic regression model to assess the association of the interventions with buprenorphine use and other outcomes. Finally, we report provider-level variation in prescribing after implementation. RESULTS: There were 2,665 opioid use disorder-related visits during the study period: 28% for overdose, 8% for withdrawal, and 64% for other conditions. Thirteen percent of patients received medications for opioid use disorder during or after their ED visit overall. Following intervention implementation, there were sustained increases in treatment and process measures, with a net increase in total buprenorphine of 20% in the postperiod (95% confidence interval 16% to 23%). In the adjusted patient-level model, there was an immediate increase in the probability of buprenorphine treatment of 24.5% (95% confidence interval 12.1% to 37.0%) with intervention implementation. Seventy percent of providers wrote at least 1 buprenorphine prescription, but provider-level buprenorphine prescribing ranged from 0% to 61% of opioid use disorder-related encounters. CONCLUSION: A combination of strategies to increase ED-initiated opioid use disorder treatment was associated with sustained increases in treatment and process measures. However, adoption varied widely among providers, suggesting that additional strategies are needed for broader uptake.

Variation in emergency department visit rates for opioid use disorder: Implications for quality improvement initiatives.

STUDY OBJECTIVE: Emergency departments (ED) are critical touchpoints for encounters among patients with opioid use disorder (OUD), but implementation of ED initiated treatment and harm reduction programs has lagged. We describe national patient, visit and hospital-level characteristics of ED OUD visits and characterize EDs with high rates of OUD visits in order to inform policies to optimize ED OUD care. METHODS: We conducted a descriptive, cross-sectional study with the 2017 Nationwide Emergency Department Sample (NEDS) from the Healthcare Cost and Utilization Project, using diagnostic and mechanism of injury codes from ICD-10 to identify OUD related visits. NEDS weights were applied to generate national estimates. We evaluated ED visit and clinical characteristics of all OUD encounters. We categorized hospitals into quartiles by rate of visits for OUD per 1000 ED visits and described the visit, clinical, and hospital characteristics across the four quartiles. RESULTS: In 2017, the weighted national estimate for OUD visits was 1,507,550. Overdoses accounted for 295,954. (19.6%) of visits. OUD visit rates were over 8× times higher among EDs in the highest quartile of OUD visit rate (22.9 per 1000 total ED visits) compared with EDs in the lowest quartile of OUD visit rate (2.7 per 1000 ED visits). Over three fifths (64.2%) of all OUD visits nationwide were seen by the hospitals in the highest quartile of OUD visit rate. These hospitals were predominantly in metropolitan areas (86.2%), over half were teaching hospitals (51.7%), and less than a quarter (23.3%) were Level 1 or Level 2 trauma centers. CONCLUSION: Targeting initial efforts of OUD care programs to high OUD visit rate EDs could improve care for a large portion of OUD patients utilizing emergency care.

Patient perspectives on naloxone receipt in the emergency department: a qualitative exploration.

BACKGROUND: Emergency departments (EDs) are important venues for the distribution of naloxone to patients at high risk of opioid overdose, but less is known about patient perceptions on naloxone or best practices for patient education and communication. Our aim was to conduct an in-depth exploration of knowledge and attitudes toward ED naloxone distribution among patients who received a naloxone prescription. METHODS: We conducted semi-structured telephone interviews with 25 adult participants seen and discharged from three urban, academic EDs in Philadelphia, PA, with a naloxone prescription between November 2020 and February 2021. Interviews focused on awareness of naloxone as well as attitudes and experiences receiving naloxone in the ED. We used thematic content analysis to identify key themes reflecting patient attitudes and experiences. RESULTS: Of the 25 participants, 72% had previously witnessed an overdose and 48% had personally experienced a non-fatal overdose. Nineteen participants (76%) self-disclosed a history of substance use or overdose, and one reported receiving an opioid prescription during their ED visit and no history of substance use. In interviews, we identified wide variability in participant levels of knowledge about overdose risk, the role of naloxone in reducing risk, and naloxone access. A subset of participants was highly engaged with community harm reduction resources and well versed in naloxone access and use. A second subset was familiar with naloxone, but largely obtained it through healthcare settings such as the ED, while a final group was largely unfamiliar with naloxone. While most participants expressed positive attitudes about receiving naloxone from the ED, the quality of discussions with ED providers was variable, with some participants not even aware they were receiving a naloxone prescription until discharge. CONCLUSIONS: Naloxone prescribing in the ED was acceptable and valued by most participants, but there are missed opportunities for communication and education. These findings underscore the critical role that EDs play in mitigating risks for patients who are not engaged with other healthcare or community health providers and can inform future work about the effective implementation of harm reduction strategies in ED settings.

Commentary: Reducing youth firearm violence and the associated health disparities requires enhanced surveillance and modern behavioral intervention strategies - a commentary on Bottiani et al. (2021).

Youth firearm injury is a worsening public health crisis, and the risks are not distributed evenly. Bottiani et al. skillfully explicated those health disparities, described sociological factors underlying them, and explored avenues for prevention. We supplement their analysis by detailing problems and solutions related to a critical barrier to firearm violence prevention - the nonexistence both of reliable 'gold standard' nonfatal firearm injury surveillance data, and systems for near real-time surveillance of firearm injuries at granular spatial scales that would enable to optimization of rapid response protocols and neighborhood-based prevention programs. We conclude with a discussion of modern, scalable, behavioral intervention approaches that could be leveraged to fill the largely absent evidence base resulting from the documented underfunding of youth firearm violence prevention research.

Naloxone prescriptions following emergency department encounters for opioid use disorder, overdose, or withdrawal.

OBJECTIVE: To determine the rate at which commercially-insured patients fill prescriptions for naloxone after an opioid-related ED encounter as well as patient characteristics associated with obtaining naloxone. METHODS: This is a retrospective cohort study of adult patients discharged from the ED following treatment for an opioid-related condition from 2016 to 2018 using a commercial insurance claims database (Optum Clinformatics® Data Mart). The primary outcome was a pharmacy claim for naloxone in the 30 days following the ED encounter. A multivariable logistic regression model examined the association of patient characteristics with filled naloxone prescriptions, and predictive margins were used to report adjusted probabilities with 95% confidence intervals. RESULTS: 21,700 patients had opioid-related ED encounters during the study period, of which 1743 (8.0%) had encounters for heroin overdose, 8825 (40.7%) for overdose due to other opioids, 5400 (24.9%) for withdrawal, and 5732 (26.4%) for other opioid use disorder conditions. 230 patients (1.1%) filled a prescription for naloxone within 30 days. Patients with heroin overdose (2.6%; 95%CI 1.7 to 3.4), recent prescriptions for opioid analgesics (1.4%; 95%CI 1.1 to 1.7), recent prescriptions for buprenorphine (1.9%; 95%CI 1.0 to 2.9), and naloxone prescriptions in the prior year (3.3%; 95%CI 1.8 to 4.8) were more likely to obtain naloxone. The rate was significantly higher in 2018 [1.9% (95%CI 1.5 to 2.2)] as compared to 0.4% (95%CI 0.3 to 0.6) in 2016. CONCLUSIONS: Few patients use insurance to obtain naloxone by prescription following opioid-related ED encounters. Clinical and policy interventions should expand distribution of this life-saving medication in the ED.

Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study.

BACKGROUND: Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA. OBJECTIVE: To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose. DESIGN: Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses. PARTICIPANTS: Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose. MAIN MEASURES: Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults. KEY RESULTS: There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]). CONCLUSIONS: Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.

Impact of a State Opioid Prescribing Limit and Electronic Medical Record Alert on Opioid Prescriptions: a Difference-in-Differences Analysis.

BACKGROUND: Prescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact. OBJECTIVE: Evaluate implementation of a state prescribing limit law and health system electronic medical record (EMR) alert on characteristics of new opioid prescriptions, refill rates, and clinical encounters. DESIGN: Difference-in-differences study comparing new opioid prescriptions from ambulatory practices in New Jersey (NJ) to controls in Pennsylvania (PA) from 1 year prior to the implementation of a NJ state prescribing limit (May 2016-May 2017) to 10 months after (May 2017-March 2018). PARTICIPANTS: Adults with new opioid prescriptions in an academic health system with practices in PA and NJ. INTERVENTIONS: State 5-day opioid prescribing limit plus health system and health system EMR alert. MAIN MEASURES: Changes in morphine milligram equivalents (MME) and tablet quantity per prescription, refills, and encounters, adjusted for patient and prescriber characteristics. KEY RESULTS: There were a total of 678 new prescriptions in NJ and 4638 in PA. Prior to the intervention, median MME/prescription was 225 mg in NJ and 150 mg in PA, and median quantity was 30 tablets in both. After implementation, median MME/prescription was 150 mg in both states, and median quantity was 20 in NJ and 30 in PA. In the adjusted model, there was a greater decrease in mean MME and tablet quantity in NJ relative to PA after implementation of the policy plus alert (- 82.99 MME/prescription, 95% CI - 148.15 to - 17.84 and - 10.41 tabs/prescription, 95% CI - 19.70 to - 1.13). There were no significant differences in rates of refills or encounters at 30 days based on exposure to the interventions. CONCLUSIONS: Implementation of a prescribing limit and EMR alert was associated with an approximately 22% greater decrease in opioid dose per new prescription in NJ compared with controls in PA. The combination of prescribing limits and alerts may be an effective strategy to influence prescriber behavior.

National Variation in Opioid Prescription Fills and Long-Term Use in Opioid Naïve Patients after Urological Surgery.

PURPOSE: Prescription opioid use is increasing, leading to increased addiction and mortality. Postoperative care is often the first exposure to opioids of a patient but little data exist on national prescription patterns in urology. We examined post-discharge opioid fills after urological procedures and the association with long-term use. MATERIALS AND METHODS: We identified patients in a private national insurance database who underwent 1 of 15 urological procedures between October 1, 2010 and September 30, 2014. Patients with an opioid fill in the preceding 6 months were excluded from study. Claims for opioids from 30 days before the operation until 7 days after discharge characterized an initial prescription. Factors associated with persistent opioid use (an opioid claim 91 to 180 days after the operation) and chronic opioid use (10 or more refills of a 120-day or greater supply in the year after the operation) were analyzed using multivariable logistic regression. RESULTS: Overall 96,580 patients were included in study, of whom 49,391 (51%) filled an initial opioid prescription. Variation in the initial prescribed amount existed within procedures. Persistent use occurred in 6.2% of patients while chronic use occurred in 0.8%. Increased prescription in patients treated with transurethral prostate resection, vasectomy, female sling surgery, cystoscopy and stent insertion were associated with an increased risk of persistent as well as chronic use. CONCLUSIONS: National variation in opioid prescribing practice exists after urological operations. Patients who fill larger amounts of opioids after certain major and minor urological procedures are at increased risk for long-term opioid use. This provides evidence for procedure specific prescribing guidelines to minimize risk and promote standardization.

Ridesharing and Motor Vehicle Crashes in 4 US Cities: An Interrupted Time-Series Analysis.

Uber, the world's largest ridesharing company, has reportedly provided over 2 billion journeys globally since operations began in 2010; however, the impact on motor vehicle crashes is unclear. Theoretically, ridesharing could reduce alcohol-involved crashes in locations where other modes of transportation are less attractive than driving one's own vehicle while under the influence of alcohol. We conducted interrupted time-series analyses using weekly counts of injury crashes and the proportion that were alcohol-involved in 4 US cities (Las Vegas, Nevada; Reno, Nevada; Portland, Oregon; and San Antonio, Texas). We considered that a resumption of Uber operations after a temporary break would produce a more substantial change in ridership than an initial launch, so we selected cities where Uber launched, ceased, and then resumed operations (2013-2016). We hypothesized that Uber's resumption would be associated with fewer alcohol-involved crashes. Results partially supported this hypothesis. For example, in Portland, Uber's resumption was associated with a 61.8% reduction (95% confidence interval: 38.7, 86.4) in the alcohol-involved crash rate (an absolute decrease of 3.1 (95% confidence interval: 1.7, 4.4) alcohol-involved crashes per week); however, there was no concomitant change in all injury crashes. Relationships between ridesharing and motor vehicle crashes differ between cities over time and may depend on specific local characteristics.

Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care-Sensitive Conditions.

STUDY OBJECTIVE: We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions. METHODS: We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions. RESULTS: Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania. CONCLUSION: We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.