Coordination of Care Is Associated With Survival and Health Care Utilization in a Population-Based Study of Patients With Cirrhosis.

BACKGROUND & AIMS: Improving care coordination for patients with high-intensity specialty care needs, such as cirrhosis, can increase quality of healthcare and reduce utilization. We examined the relationship between care concentration and risk of hospitalization for patients with cirrhosis. METHODS: We performed a retrospective cohort study of 26,006 Medicare enrollees with cirrhosis with more than 4 outpatient visits over 180 days. We collected data on 2 validated measures of care concentration: the usual provider of care (UPC) index, a measure of the proportion of a patient's total visits that is with their most regularly seen provider, and the continuity of care (COC) index, a measure of care density and dispersion. Both use a scale of 0 to 1. Time to death or liver transplantation was evaluated using a multivariable Cox proportional hazards model. Hospital days and 30-day readmissions per person-year were evaluated in negative binomial models. RESULTS: The median COC score was 0.40 (interquartile range, 0.26-0.60) and the median UPC was 0.60 (interquartile range, 0.50-0.80). Increasing care concentration (based on COC and UPC index scores) were associated with increased mortality and hospitalization. The highest 25th percentile of COC and UPC scores were associated with adjusted hazard ratios for mortality of 1.20 (95% CI, 1.10-1.31) and 1.14 (95% CI, 1.06-1.24), adjusted incidence rate ratios for hospital days of 1.12 (95% CI, 1.02-1.23) and 1.10 (95% CI, 1.01-1.20), and adjusted incidence rate ratios for readmissions of 1.19 (95% CI, 1.06-1.34) and 1.12 (95% CI, 1.00-1.25), respectively. CONCLUSIONS: Based on a study of Medicare enrollees, care concentration is low among patients with cirrhosis. However, increased concentration is associated with increased mortality and increased healthcare utilization. These data indicate that, to optimize outcomes for persons with cirrhosis, team-based care might be necessary.

Dental Opioid Prescriptions and Overdose Risk in Patients and Their Families.

INTRODUCTION: It is unknown whether dental opioid prescriptions are associated with opioid overdose in patients or their family members, who may have access to patients' opioids. METHODS: During July-October 2020, the 2011-2018 IBM MarketScan Dental, IBM MarketScan Commercial, and Medicaid Multi-State Databases were analyzed. Two analyses were conducted. In the patient analysis, dental procedures for privately and publicly insured patients aged 13-64 years were identified. The exposure was ≥1 initial prescription (dispensed opioid prescription within 3 days of the procedure). The association between the exposure and ≥1 overdose within 90 days of the procedure was evaluated using logistic regression. In the family analysis, procedures for privately insured patients in family plans were identified. The association between the exposure and ≥1 overdose in a family member within 90 days was evaluated using logistic regression. In both analyses, the average marginal effect of the exposure was calculated, representing the change in the probability of the outcome if all versus if no procedures were associated with ≥1 initial prescription. RESULTS: The patient analysis included 8,544,098 procedures. When ≥1 initial prescription did and did not occur, the 90-day risk of overdose was 5.8 versus 2.2 per 10,000 procedures (average marginal effect=1.5, 95% CI=1.2, 1.8). The family analysis included 3,461,469 procedures. When ≥1 initial prescription did and did not occur, the 90-day risk of overdose in a family member was 1.7 versus 1.0 per 10,000 procedures (average marginal effect=0.4, 95% CI=0.1, 0.7). CONCLUSIONS: Findings further highlight the importance of avoiding unnecessary dental opioid prescribing.

A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgery.

BACKGROUND: Surgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures. METHODS: The Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents). RESULTS: A total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P < .001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P < .001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250-400) in 2010 and 225 (150-375) in 2017 (P < .0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92-5.27; P < .0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09-1.20; P < .00001), tobacco use (odds ratio 1.79; confidence interval: 1.37-2.36; P < .0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23-1.82); there was no significant association with procedure performed. CONCLUSION: Over 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.

Effect of injury location and severity on opioid use after trauma.

OBJECTIVE: Recent data have suggested that persistent opioid use is prevalent following trauma. The effect of type of injury and total injury burden is not known. We sought to characterize the relationship between injury location and severity and risk of persistent opioid use. METHODS: We investigated postdischarge opioid utilization among patients who were admitted for trauma between January 2010 and June 2017 using the Optum Clinformatics Database. New persistent opioid use (NPOU) was defined as one of the following scenarios: (1) two separate opioid prescription fills between 0 and 14 days postdischarge and having 1+ fills in the 91 to 180 days following discharge or (2) filling a prescription in the 15 to 90 days following discharge in addition to a filling in the 91 to 180 day postdischarge period. Multivariable logistic regression was used to assess the relationship between injury type and severity with new persistent opioid use development. RESULTS: A total of 26,437 opioid-naive patients were included in the analysis. Overall, 2,277 patients (8.6%) met the criteria for NPOU. After adjustment for confounding, NPOU was significantly more common for patients with injury to the extremities (adjusted odds ratio [aOR], 1.75; 95% confidence interval [CI], 1.57-1.94) or abdomen (adjusted odds ratio [aOR], 1.42; 95% CI, 1.22-1.64). Importantly, patients with maximum Abbreviated Injury Scale score of ≥2 for any body region had 1.49-fold odds of NPOU compared with patients with score of 1 (95% CI, 1.28-1.73), while no difference was seen across groupings of total injury burden based on Injury Severity Score. CONCLUSION: New persistent opioid use is common among patients suffering from trauma. In addition, patients suffering from extremity and abdominal injuries are at highest risk. Maximum individual region injury severity predicts development of new persistent use, whereas total injury severity does not. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Increased opioid prescription fills after dental procedures performed before weekends and holidays.

BACKGROUND: Excess opioid prescriptions place patients and communities at risk of experiencing opioid-related morbidity. The authors designed a study to test the hypothesis that opioid prescription fills would be more common after dental procedures performed the day before a weekend or holiday than other weekdays. METHODS: The authors performed a retrospective cohort study of 2,060,317 people, integrating Truven Health MarketScan insurance claims to evaluate variation in opioid fills for dental procedures performed the day before a weekend or holiday compared with other weekdays. Opioid-naïve people, aged 13 through 64 years, with eligible procedures from 2013 through 2017 were included. The primary outcome measure was a prescription opioid fill on the same date as the dental procedure. RESULTS: Multivariable logistic regression results showed significantly higher odds of filling an opioid prescription for patients with procedures the day before weekends and holidays (adjusted odds ratio, 1.27; 95% confidence interval, 1.26 to 1.28) than for patients with procedures on other weekdays. In addition, the youngest age category, 13 through 29 years, had the highest odds of filling an opioid prescription compared with other age categories (reference category: patients aged 50-64 years, adjusted odds ratio, 1.43; 95% confidence interval, 1.41 to 1.44). CONCLUSIONS: Outpatient dental procedures performed the day before a weekend or holiday were associated with a 27% increased adjusted odds of filling a prescription for an opioid. PRACTICAL IMPLICATIONS: Although patients and dentists might be concerned about the challenges of unmanaged pain on weekends and holidays, opioids are not warranted for most dental procedures and should be replaced with patient education and nonopioid analgesics. Oral health care professionals concerned about postprocedural pain control should consider scheduling complex procedures earlier in the week, when emergency care is available to reduce unwarranted preemptive prescribing of opioids, which might be driving increased opioid fills before weekends and holidays.

Association of Opioid Use With Pain and Satisfaction After Dental Extraction.

Importance: Dentists commonly prescribe opioids to relieve pain after tooth extraction. Understanding the differences in patient-reported outcomes between opioid users and nonusers could encourage the adoption of more conservative and appropriate prescribing practices in dental medicine. Objective: To evaluate whether pain and satisfaction scores reported by patients who used opioids after tooth extraction were similar to the levels reported by patients with no opioid use. Design, Setting, and Participants: This quality improvement study was conducted in the 14 dental clinics of the University of Michigan School of Dentistry. Eligible adult patients of these clinics who underwent routine or surgical extractions between June 1, 2017, and December 31, 2017, were contacted by telephone within 6 months of the procedure. Patients were surveyed about the type of extraction, use of prescription opioid (if given), use of nonopioid analgesics, pain levels, and satisfaction with care after the procedure. Data analysis was conducted from February 1, 2018, to July 31, 2018. Main Outcomes and Measures: The primary outcome was self-reported pain as assessed by the question, "Thinking back, how would you rate your pain in the first week after your dental procedure?" with a 4-point pain scale of no pain, minimal pain, moderate pain, or severe pain. Secondary outcomes included self-reported satisfaction with care as assessed by a Likert scale ranging from 1 to 10, in which 1 was extremely dissatisfied and 10 was extremely satisfied. Results: The final cohort comprised 329 patients, of whom 155 (47.1%) underwent surgical extraction (mean [SD] age, 41.8 [18.1] years; 80 [51.6%] were men) and 174 (52.9%) underwent routine extraction (mean [SD] age, 52.4 [17.9] years; 79 [45.4%] were men). Eighty patients (51.6%) with surgical extraction and 68 (39.1%) with routine extraction used opioids after their procedure. In both extraction groups, patients who used opioids reported higher levels of pain compared with those who did not use opioids (surgical extraction group: 51 [63.8%] vs 34 [45.3%], P < .001; routine extraction group: 44 [64.7%] vs 35 [33.0%], P < .001). No statistically significant difference in satisfaction was found between groups after surgical extraction (median [interquartile range] scores: 9 [7-10] for nonopioid group vs 9 [8-10] for opioid group) and routine extraction (median [interquartile range] scores: 10 [8-10] for nonopioid group vs 9 [7-10] for opioid group). Conclusions and Relevance: This study found that patients who used opioids after tooth extraction reported significantly higher levels of pain compared with nonusers, but no difference in satisfaction was observed.

Statewide Prehabilitation Program and Episode Payment in Medicare Beneficiaries.

BACKGROUND: Prehabilitation has been shown to improve postoperative outcomes in a variety of patient populations undergoing major operations. The feasibility, generalizability, and value of broad implementation of prehabilitation outside the research environment are unknown. METHODS: Medicare claims data from 2014 to 2017 were used to conduct a multicenter (21 Michigan hospitals) pragmatic cohort study. Patients and controls were followed for the duration of their index surgical hospitalization and for 90 days postoperatively. Medicare beneficiaries older than 18 years who underwent inpatient surgical procedures at a participating hospital during the study time period were eligible for inclusion. The prehabilitation program involved a home-based walking program with supplementary education on nutrition, smoking cessation, and psychological preparation for surgical procedure. Data were analyzed with an intention-to-treat approach using t-tests and Wilcoxon rank sum tests. Propensity score matching used comorbidities and demographic factors to match controls to patients in a 2:1 manner with an exact match required for operation type. RESULTS: Patients (n = 523) and controls (n = 1,046) had no significant differences in demographic factors or comorbidities. Patients had significantly shorter median hospital length of stay (6 vs 7 days; p < 0.01) than controls and were more likely to be discharged to home (65.6% vs 57.0%, p < 0.01). Total episode payments were significantly lower for patients compared with controls ($31,641 vs $34,837; p = 0.04). Patients had significantly lower post-acute care payments for skilled nursing facility ($941 vs $1,566; p = 0.02) and home health ($829 vs $960; p = 0.03) services. CONCLUSIONS: Participation in a prehabilitation program in Michigan was associated with shorter length of stay and lower total episode payments after operation. Payers and hospitals should invest in the implementation of simple home-based prehabilitation programs.

Incidence and predictors of new persistent opioid use following inflammatory bowel disease flares treated with oral corticosteroids.

BACKGROUND: Opioids are commonly prescribed to manage pain associated with inflammatory bowel disease (IBD). It is unknown what percentage of patients develop new persistent opioid use following a steroid-treated IBD flare. AIM: To identify the incidence and the predictors of new persistent opioid use following an IBD flare. METHODS: We used a national insurance claim dataset to identify patients with IBD who received an opioid medication around the time of a corticosteroid-treated IBD flare. Patients were stratified as previously opioid naïve, intermittent users, or chronic users. The incidence of persistent opioid use among the opioid-naïve cohort was evaluated along with associated predictors. RESULTS: We identified 15 119 IBD patients who received opioids around the time of a flare. 5411 (35.8%) were opioid-naïve patients of which 35.0% developed persistent opioid use after the flare. Factors associated with new persistent opioid use include a history of depression (hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.13-1.47), substance abuse (HR 1.36, 95% CI 1.2-1.54), chronic obstructive pulmonary disease (COPD) (HR 1.17, 95% CI 1.04-1.3), as well as, Crohn's disease (HR 1.26, 95% CI 1.14-1.4) or indeterminate colitis (HR 1.6, 95% CI 1.36-1.88). CONCLUSIONS: New persistent opioid use is common in IBD patients who experience a flare, especially among those with mental health disorders, COPD, and Crohn's disease or indeterminate colitis. These findings can be helpful in risk-stratifying patients when choosing an acute pain therapy and providing counselling before choosing to prescribe opioids to opioid-naïve patients experiencing an IBD flare.