Infusion Pump Education: A Quality Improvement Project.

PURPOSE: This quality improvement project was designed to increase the number of registered nurses who have been educated and are proficient in working with the infusion medical pumps used for patients receiving continuous peripheral nerve block or epidural infusions. Our aim was to increase by 10% the percentage of nurses who are proficient with infusion pumps and increase by 25% the ability of nursing staff on 4 West at Brooke Army Medical Center to hang a new infusion bag and subsequently program the pump. DESIGN: Our outcome measured pre and post intervention surveys and timing exercises assessing the ability and efficiency of the nurses hanging new infusion bags and programming the pumps. METHODS: We gathered baseline data via surveys and a timing exercise. We then implemented a visual aid with simple instructions affixed to the pump and formally educated the nursing staff. Finally, we measured the results via surveys and repeated the timing exercise. FINDINGS: We achieved both of our objectives. We increased the number of registered nurses who were educated and who were proficient in working with the infusion medical pumps. Prior to the project, 80% of the nurses felt proficient with infusion pumps and 45% of nurses were able to hang a new infusion bag. After the visual aid was affixed to the pumps and the nurses were educated, 95% of nurses felt proficient with infusion pumps and 91% were able to hang a new infusion bag. Nurses also showed an increase in efficiency in hanging a new infusion bag with an average decreased time to successful programing of 41 seconds. CONCLUSION: This project demonstrated that affixing visual aids and formalizing hands-on education can lead to significantly increased proficiency with infusion medical pumps and efficiency in hanging a new infusion bag. Ultimately, we hope this may lead to significant reductions in hospital cost by limiting time spent by physicians and nurses changing infusion bags and increase the quality of patient care by decreasing the amount of time patient analgesia is delayed.

Impact of Undertreatment of Depression on Suicide Risk Among Children and Adolescents With Major Depressive Disorder: A Microsimulation Study.

Undertreatment of depression is common among children and adolescents, but evidence of the impact of undertreatment of depression on risk of suicide is limited due to the low base rate of suicide in the population and lack of sufficient data sources. We developed a microsimulation model that uses evidence from multiple sources to study the impact of different durations of antidepressant treatment on suicide risk in a synthesized sample that is nationally representative of children and adolescents with major depressive disorder. Compared with receiving no treatment, suicide rate and risk of suicide attempt both decreased with increasing duration of antidepressant treatment (for 12 weeks, suicide rate ratios = 0.78 (95% credible interval (CrI): 0.58, 1.15), 36 weeks, 0.65 (95% CrI: 0.44, 0.90), and 52 weeks, 0.63 (95% CrI: 0.45, 0.72); for suicide attempt: 12 weeks, suicide risk ratios = 0.68 (95% CrI: 0.62, 0.69), 36 weeks, 0.56 (95% CrI: 0.52, 0.57), and 52 weeks, 0.55 (95% CrI: 0.51, 0.56). The suicide rate and risk of suicide attempt were lower in children than in adolescents. Males had a lower risk of suicide attempt but higher suicide rate than females. The findings from the microsimulation model show that completion of 12-36 weeks of antidepressant treatment may reduce suicide attempt and suicide among children and adolescents with major depressive disorder.

Caregiver Burden in Caregivers of Children With Special Health Care Needs and Association With Chronic Pain.

BACKGROUND/OBJECTIVES: Chronic noncancer pain (CNCP) affects millions of individuals in the United States but evidence of its prevalence among caregivers of children with special health care needs is sparse. We sought to estimate the prevalence of CNCP and its association with caregiver burden, in a nationally representative sample. METHODS: Retrospective cross-sectional study using pooled Medical Expenditure Panel Survey data for 2010-2015. Within interviewed households, family groups consisting of at least 1 parent and 1 child (0-17 y) were identified. CNCP was identified by one or more International Classification of Diseases, Ninth Revision (ICD-9)-CM codes utilizing previously published approaches. Level of caregiver burden was defined using a validated screener questionnaire identifying children with high burden of care (ie, special health care needs), for example, high or low burden. We estimated prevalence of CNCP as a function of caregiver burden, as well as the association of risk factors with CNCP, including parent sociodemographic features, clinical diagnoses, and family level characteristics. RESULTS: We identified 46,525 caregivers of whom 3.6% reported experiencing high caregiving burden. The prevalence of CNCP was 25.5% and 14.0% among parents with high compared with low caregiving burden, respectively. Odds of CNCP were higher among parents with high compared to those with lower caregiver burden (odds ratio=1.29, 95% confidence interval=1.06-1.55). Being obese, experiencing disability, and having a mental health diagnosis were associated with higher odds of CNCP. CONCLUSIONS: Chronic pain is more common among caregivers with high caregiver burden. Our findings highlight the need to further explore the nature and impact of risk factors on caregiver health and disability.

Factors that influence the use of community assets by people with physical disabilities: results of participatory mapping in Envigado, Colombia.

BACKGROUND: Disability is an evolving concept that results from the complex interaction between a person with an impairment and the context in which he/she lives. There is limited understanding on the types, access and use of community assets valuable for people with disabilities, and the role of contextual factors in Colombia. Our goal with this work was to identify the factors at the levels of the socio-ecological framework, and their interaction, that influence the use of community assets among people with physical disabilities and community stakeholders in Envigado, Colombia. METHODS: Using participatory mapping, a community based participatory approach, we carried out an assessment of community assets identified by people with disabilities and rehabilitation professionals. In-depth interviews (n = 32) informed the design of two participatory mapping activities, one among people with disabilities (n = 5) and a second with rehabilitation professionals (n = 4). Results were presented in a community forum to receive feedback on the findings. RESULTS: Main findings indicate a chain of contextual factors that limit access and use of assets stemming from the personal (e.g. financial resources, inaccessible housing), interpersonal level (e.g. lack of a personal assistance or aid), and community levels (e.g. lack of accessible public transportation and inaccessible buildings). In most cases these barriers are heightened by system level barriers (e.g. lack of effective enforcement of the legal framework). CONCLUSIONS: Identifying these contextual factors, and their interactions, calls for stronger enforcement of the existing legal framework through articulated work between different stakeholders, so that people with disabilities can enjoy community assets.

Experiences with rehabilitation and impact on community participation among adults with physical disability in Colombia: perspectives from stakeholders using a community based research approach.

BACKGROUND: Despite representing 70 million people in Latin America, access to comprehensive rehabilitation and participation in the community remains a challenge for persons with disability (PWDs) in the region. Through enactment of the Disability Law, Colombia has made improvements to recognize and address some of the barriers for PWDs, including access to comprehensive rehabilitation. However access remains limited with significant disconnect between perspectives of various stakeholders and the needs of the population. We examined the unique perceptions on access to comprehensive rehabilitation services and participation of PWDs. We also explored the perspective of caregivers of PWDs, rehabilitation professionals, and other stakeholders on the experiences of PWDs. Our goal was to identify gaps in the implementation of comprehensive rehabilitation programs, and barriers to access resources for comprehensive rehabilitation or services that would impact participation of PWDs. METHODS: Qualitative study conducted in 2017. Data was collected from a purposive sample of adults with physical disability, aged 18-44 years, who had received rehabilitation services at a local partner organization and with different backgrounds and experiences with disability. Purposive sampling was also conducted with caregivers, rehabilitation professionals, and other stakeholders. Socio-demographic information was collected and semi-structured interviews were conducted by a research team member, recorded, transcribed and analyzed using a thematic analysis method to identify main themes related to our aim. CES University ethical review board approved this study. RESULTS: Thirty-two participants were interviewed: eight were male, 42.1 ± 11.1 years old, and 44% (n = 14) were PWDs. Three main themes were identified among all the participants: the meaning of rehabilitation, challenges to access services, and participation. Challenges to access services had three sub-themes: barriers to personal mobility, perceptions and knowledge on disability, and navigating the system. CONCLUSION: The main focus of rehabilitation as perceived by stakeholders is still on functional rehabilitation. If healthcare personnel is better trained on disability and if those with disabilities are actively involved in the developing these programs, the focus may evolve to a comprehensive and equitable rehabilitation process that fosters full participation.

Engaging stakeholders in pharmacoepidemiology research: Current state and recommendations.

PURPOSE: Given current efforts to enhance patient-centered care and shared decision-making, the International Society of Pharmacoepidemiology Workgroup on Patient Engagement assessed patient and other stakeholder engagement in pharmacoepidemiology research and provides recommendations for the field. METHODS: A systematic review used MEDLINE and EMBASE to identify published literature from 2005 to 2016 addressing how stakeholders-patients, caregivers, and others-assisted researchers conducting pharmacoepidemiologic research. Three pairs of Workgroup members screened titles and abstracts to select articles for full-text review and analysis. Two Workgroup members abstracted the following data: research focus, characterization and role of stakeholders, and type(s) of engagement strategy employed. Data were summarized descriptively. RESULTS: We identified 5717 references for abstract screening. Of these, 69 met the criteria for full-text screening, and 11 were selected for data abstraction. Of these 11 studies, seven focused on the development of a research agenda and eight had stakeholders react or advise on an aspect of the study. Although patients were the most commonly identified stakeholders, advocacy groups and health care professionals were also frequently identified. Some studies reported the engagement of other stakeholders, including local government or policy experts. Engagement strategies varied, with five studies using more than one strategy. Studies often did not indicate the involvement of stakeholders in developing the study design or with implementation. CONCLUSIONS: Currently, few pharmacoepidemiology publications mention patient or other stakeholder engagement in the design, analysis, or reporting of research. This suggests that there are opportunities to expand stakeholder engagement and/or increase the transparency of reporting stakeholder engagement.

Emerging Multidrug-Resistant Candida duobushaemulonii Infections in Panama Hospitals: Importance of Laboratory Surveillance and Accurate Identification.

Candida duobushaemulonii, a yeast closely related to Candida auris, is thought to cause infections in rare cases and is often misidentified. In October 2016, the Panamanian Ministry of Health implemented laboratory surveillance for C. auris Suspected C. auris isolates were forwarded to the national reference laboratory for identification by matrix-assisted laser desorption ionization-time of flight mass spectrometry and antifungal susceptibility testing. Between November 2016 and May 2017, 17 of 36 (47%) isolates suspected to be C. auris were identified as C. duobushaemulonii. These 17 isolates were obtained from 14 patients at six hospitals. Ten patients, including three children, had bloodstream infections, and MICs for fluconazole, voriconazole, and amphotericin B were elevated. No resistance to echinocandins was observed. C. duobushaemulonii causes more invasive infections than previously appreciated and poses a substantial problem, given its resistance to multiple antifungals. Expanded laboratory surveillance is an important step in the detection and control of such emerging pathogens.

Attribute Development Using Continuous Stakeholder Engagement to Prioritize Treatment Decisions: A Framework for Patient-Centered Research.

OBJECTIVES: To develop a methodological approach for selecting, validating, and prioritizing attributes for health care decision making. METHODS: Participants (n = 48) were recruited from community support groups if they had a child aged 26 years or younger diagnosed with a coexisting mental health condition and cognitive impairment. Six in-depth interviews eliciting care management experiences were transcribed and coded into themes following the principles of grounded theory and the constant comparative method. Six focus groups involving 42 participants assessed the relevance, priority, and meaning and inter-relationship among the themes. The positive predictive value and sensitivity assessed agreement on thematic meaning. A final list was selected from the top priorities with good agreement as candidate attributes. Attribute levels reflecting the range of experiences in care management decisions emerged from the verbatim passages within each coded theme. RESULTS: Participants were the child's mother (73%), white (77%), married (69%), and on average 48 years old. The children were on average 14 years old; 44% had an intellectual disability, 25% had autism, and more than half had anxiety or attention-deficit/hyperactivity disorder. All 14 attributes identified from the in-depth interviews were deemed relevant. The positive predictive value exceeded 90%, and the sensitivity ranged from 64% to 89%. The final set of attributes formed the framework for care management decisions consisting of six attributes (medication, behavior, services, social, treatment effects, and school) each with three levels. CONCLUSIONS: A systematic approach grounded in qualitative methods produced a framework of relevant, important, and actionable attributes representing competing alternatives in clinical decisions.

Metformin and the risk of endometrial cancer: a population-based cohort study.

OBJECTIVE: While some observational studies have suggested a protective effect of metformin on incident cancer, concerns about potential bias remain. We compared the incidence of endometrial cancer in metformin versus sulfonylurea initiators. Research design and methods We conducted a retrospective cohort analysis using US healthcare claims (MarketScan®), 2000-2011. We identified new users of metformin versus sulfonylureas with no prior cancer diagnoses and followed them until a diagnosis of endometrial cancer, hysterectomy, treatment change, or disenrollment. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional hazards, using an as-treated analytic approach. Stabilized inverse probability of treatment weights were used to adjust for potential confounding at baseline. RESULTS: Of 541,128 eligible women, 456,838 (84%) initiated metformin and 84,290 (16%) initiated sulfonylurea. The treatment groups differed at baseline in terms of age and recent diagnosis codes for diabetes, polycystic ovarian syndrome, and endometrial hyperplasia. Over a median follow-up of 1.2 (IQR 0.4-2.3) years and a total of 2,030,914 person-years, 729 women developed endometrial cancer. Metformin initiation was associated with a lower risk of endometrial cancer in the unadjusted analysis (HR 0.81, 95% CI 0.67-0.97). However, after balancing baseline covariates across groups, metformin was not associated with a reduced risk of endometrial cancer (HR 1.09, 95% CI 0.88-1.35). This finding was consistent across multiple sensitivity analyses and subgroup analyses in diabetic patients and relevant age groups. CONCLUSIONS: In this population-based cohort of >500,000 women, initiating metformin compared with sulfonylureas was not associated with a reduced risk of developing endometrial cancer.

Using claims data to predict dependency in activities of daily living as a proxy for frailty.

PURPOSE: Estimating drug effectiveness and safety among older adults in population-based studies using administrative health care claims can be hampered by unmeasured confounding as a result of frailty. A claims-based algorithm that identifies patients likely to be dependent, a proxy for frailty, may improve confounding control. Our objective was to develop an algorithm to predict dependency in activities of daily living (ADL) in a sample of Medicare beneficiaries. METHODS: Community-dwelling respondents to the 2006 Medicare Current Beneficiary Survey, >65 years old, with Medicare Part A, B, home health, and hospice claims were included. ADL dependency was defined as needing help with bathing, eating, walking, dressing, toileting, or transferring. Potential predictors were demographics, International Classification of Diseases, Ninth Revision Clinical Modification diagnosis/procedure and durable medical equipment codes for frailty-associated conditions. Multivariable logistic regression was used to predict ADL dependency. Cox models estimated hazard ratios for death as a function of observed and predicted ADL dependency. RESULTS: Of 6391 respondents, 57% were female, 88% white, and 38% were ≥80. The prevalence of ADL dependency was 9.5%. Strong predictors of ADL dependency were charges for a home hospital bed (OR = 5.44, 95%CI = 3.28-9.03) and wheelchair (OR = 3.91, 95%CI = 2.78-5.51). The c-statistic of the final model was 0.845. Model-predicted ADL dependency of 20% or greater was associated with a hazard ratio for death of 3.19 (95%CI: 2.78, 3.68). CONCLUSIONS: An algorithm for predicting ADL dependency using health care claims was developed to measure some aspects of frailty. Accounting for variation in frailty among older adults could lead to more valid conclusions about treatment use, safety, and effectiveness.

The dynamics of carbon emissions, energy, income, and life expectancy: Regional comparative analysis.

This paper examines the linear effects of economic growth on carbon emissions and their impact on mortality and morbidity rates in specific regions sub-Sahara Africa, Middle-East and North Africa, Europe and Central Asia (SSA, MENA, ECA). By analyzing longitudinal data for 82 panels over 30 years, we investigate the relationships between energy usage, per capita GDP, life expectancy, and carbon emissions. Our estimation results show positive correlations between energy use, carbon production, and life expectancy in both the combined sample and individual regions. However, death rate has a negative relationship with carbon production in the combined sample, MENA, and SSA regions. Per capita GDP positively influences carbon emissions and life expectancy in the combined sample and ECA, MENA, and SSA regions. We also identify asymmetric relationships between per capita GDP and carbon production, with evidence supporting the Environmental Kuznets Curve hypothesis for the combined and ECA samples, and an N-trajectory for SSA. These findings emphasize the importance of region-specific approaches to sustainable development, considering the unique environmental and economic challenges each region faces. Policymakers should consider our research insights when designing policies to mitigate the negative impacts of economic progress on the environment.

Social and Systemic Barriers to Transition-Related Surgical Procedures for Transgender Americans.

Purpose: Transgender and gender-diverse (TGD) individuals in the United States face disproportionate barriers to health care access. This study compared characteristics of individuals who have and have not undergone gender-affirming surgery with the goal of identifying social and systemic barriers to transition-related surgery. Methods: Data were extracted from the 2015 United States Transgender Survey, a cross-sectional nonprobability sample of nearly 28,000 TGD adults. The primary outcome was having undergone gender-affirming surgery. Multivariable logistic regression models were constructed to determine correlates of receipt of gender-affirming surgery. A subgroup analysis was performed to explore differences by insurance types regarding coverage of surgical procedures and presence of in-network providers. Results: In total, 6009 (21.7%) participants underwent transition-related procedures. Increased odds of undergoing surgery were associated with older age, living in congruent gender, higher education attainment, and greater income. Decreased odds were linked with male sex assignment at birth, first recognizing TGD status at older ages, living in states without trans-protective health laws, no close transgender-knowledgeable health care provider, nonbinary status, and identifying as sexual minority. Residing in states without trans-protective health laws correlated with increased surgery denials over the previous 12-month period. Compared to White TGD individuals, TGD individuals who were Black, Latinx, or Another Race were significantly more likely to encounter health equity-related barriers to surgery. Conclusions: Gender-affirming surgery access is differentially distributed across demographic and modifiable equity-related factors amenable to interventions. Efforts are needed to address the number and geographic distribution of transgender health-competent providers, improve TGD legal protections, and increase access to health insurance for minority TGD individuals, who are disproportionately under/uninsured.

Impact of different interventions on preventing suicide and suicide attempt among children and adolescents in the United States: a microsimulation model study.

Introduction: Despite considerable investment in suicide prevention since 2001, there is limited evidence for the effect of suicide prevention interventions among children and adolescents. This study aimed to estimate the potential population impact of different interventions in preventing suicide-related behaviors in children and adolescents. Methods: A microsimulation model study used data from national surveys and clinical trials to emulate the dynamic processes of developing depression and care-seeking behaviors among a US sample of children and adolescents. The simulation model examined the effect of four hypothetical suicide prevention interventions on preventing suicide and suicide attempt in children and adolescents as follows: (1) reduce untreated depression by 20, 50, and 80% through depression screening; (2) increase the proportion of acute-phase treatment completion to 90% (i.e., reduce treatment attrition); (3) suicide screening and treatment among the depressed individuals; and (4) suicide screening and treatment to 20, 50, and 80% of individuals in medical care settings. The model without any intervention simulated was the baseline. We estimated the difference in the suicide rate and risk of suicide attempts in children and adolescents between baseline and different interventions. Results: No significant reduction in the suicide rate was observed for any of the interventions. A significant decrease in the risk of suicide attempt was observed for reducing untreated depression by 80%, and for suicide screening to individuals in medical settings as follows: 20% screened: -0.68% (95% credible interval (CI): -1.05%, -0.56%), 50% screened: -1.47% (95% CI: -2.00%, -1.34%), and 80% screened: -2.14% (95% CI: -2.48%, -2.08%). Combined with 90% completion of acute-phase treatment, the risk of suicide attempt changed by -0.33% (95% CI: -0.92%, 0.04%), -0.56% (95% CI: -1.06%, -0.17%), and -0.78% (95% CI: -1.29%, -0.40%) for reducing untreated depression by 20, 50, and 80%, respectively. Combined with suicide screening and treatment among the depressed, the risk of suicide attempt changed by -0.27% (95% CI: -0.dd%, -0.16%), -0.66% (95% CI: -0.90%, -0.46%), and -0.90% (95% CI: -1.10%, -0.69%) for reducing untreated depression by 20, 50, and 80%, respectively. Conclusion: Reducing undertreatment (the untreated and dropout) of depression and suicide screening and treatment in medical care settings may be effective in preventing suicide-related behaviors in children and adolescents.

Geographic Trends in Pediatric Psychotropic Medication Dispensing Before and After the Start of the COVID-19 Pandemic.

OBJECTIVE: This study examined trends and geographic variability in dispensing of prescription psychotropic medications to U.S. youths before and after the start of the COVID-19 pandemic. METHODS: Using national data on prescription medication dispensing, the authors performed a cross-sectional study examining the monthly percent change in psychotropic medications dispensed (total N=95,639,975) to youths (ages 5-18 years) in 2020 versus 2019, across medication classes and geographic regions. RESULTS: For many medications, more were dispensed in March 2020 than in March 2019 and fewer in April-May 2020 versus April-May 2019. Stimulants had the largest decline: -26.4% in May 2020 versus May 2019. The magnitude of the monthly percent change varied by region. CONCLUSIONS: Fewer psychotropic medications were dispensed to U.S. youths after the start of the COVID-19 pandemic compared with 2019. Although some medication classes rebounded to prepandemic dispensing levels by September 2020, dispensing varied by class and region.

Comparing Outcomes after Oncoplastic Breast Reduction and Breast Reduction for Benign Macromastia.

BACKGROUND: Oncoplastic breast reconstruction improves cosmetic outcomes when compared to standard breast conservation therapy alone. The authors studied whether tailoring a breast reduction to a cancer resection affects complication rates by comparing (1) outcomes between oncoplastic and benign macromastia patients and (2) complication rates between the cancer side and the symmetrizing side of an oncoplastic reduction. METHODS: A retrospective chart review was performed on female patients who underwent either oncoplastic or benign breast reduction over 9 years by a single surgeon. Patient demographics, intraoperative data, and postoperative outcomes were gathered from the electronic medical record. Chi-square and t tests were performed when appropriate to determine significance. RESULTS: Of the 211 patients included in the study, 62 (29.4 percent) underwent oncoplastic breast reduction and 149 (70.6 percent) underwent breast reduction for benign macromastia. Total resection weight was greater in the benign group (p = 0.00). There was a higher rate of loss of nipple sensation in the oncoplastic group (p = 0.005) but no differences in any other complication. There was a higher complication rate in the oncologic breast when compared to the symmetrizing breast within the oncoplastic cohort (p = 0.039), but no differences in the rates of individual complications. CONCLUSIONS: Although the loss of nipple sensation was increased in patients undergoing oncoplastic breast reduction, all other outcomes were not significantly different between the two groups. The authors' findings indicate that oncoplastic breast reduction can be performed with a safety profile similar to that of a standard breast reduction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patterns of opioid and benzodiazepine use with gabapentin among disabled Medicare beneficiaries - A retrospective cohort study.

BACKGROUND: Our goal was to describe specific patterns associated with co-prescriptions of gabapentin, opioids, and benzodiazepines among disabled Medicare beneficiaries. METHODS: Using 2013-2015 Medicare data, we conducted a retrospective cohort study among fee-for-service disabled beneficiaries continuously enrolled in Medicare Parts A, B, and D. The index date was defined as the earliest fill date for a gabapentin, opioid, or benzodiazepine prescription. Monotherapy, dual therapy, and tri-therapy were defined as utilization of one, two, and three medication classes, respectively. Augmentation was defined as a prescription for a different medication class in addition to prescription for initial medication; switching referred to a change in prescription for a different medication class with no subsequent fills of initial medication. We used descriptive statistics, Kaplan Meier analyses and Cox proportional hazards to examine the association between initial therapy and monotherapy, dual therapy, tri-therapy, switching and augmentation. RESULTS: Among 151,552 disabled beneficiaries, gabapentin initiators were more likely to augment therapy (50.1%) when compared to opioid (28.7%) and benzodiazepine (38.7%) users. When compared to opioid initiators, the risk of augmentation (HR[95%CI]: 1.85[1.82-1.89]) and switching (1.62 [1.51-1.73]) was significantly higher among gabapentin initiators. Risk of augmentation was also significantly higher among beneficiaries with co-morbid pain and mental health conditions (p < 0.01). Overall, the majority of beneficiaries augmented and switched within 2-months and 4-months after initiating therapy, respectively. CONCLUSIONS: Given safety concerns associated with gabapentin, opioids, and benzodiazepines, it is imperative that the benefits and risks of co-prescribing these medications be examined comprehensively, especially for those in vulnerable sub-groups.

Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study.

Background: Gabapentin, opioids, and/or benzodiazepines are commonly prescribed for a variety of pain and psychiatric conditions. Despite the high likelihood of co-prescription of these medications, little is known about co-utilization of gabapentin (GABA), opioids (OP), and benzodiazepines (BZD) and associated public health outcomes. Methods: Using Medicare CCW Data, 2013-2016, we conducted a nested case-control study to examine the association between concurrent utilization of GABA, OP, and BZD and respiratory depression, opioid, and substance-related overdose among Medicare disabled beneficiaries. Cases and controls were Fee-for-service disabled beneficiaries who had a diagnosis of acute pain (AP), chronic pain (CP) or mental health conditions (MH) and received GABA, OP or BZD. Cases with respiratory depression, opioid or substance-related overdose were matched with up to 4 controls on socio-demographics, year of cohort entry and disease risk score. Primary exposure was concurrent medication utilization defined as an overlap of at least one day in prescriptions for GABA, OP and BZD. Findings: Across all cohorts, the majority of cases and controls were under 65, female, dually eligible and had prior histories of pain and mental health conditions. GABA+OP+BZD use was associated with increased odds of respiratory depression [AOR(95%CI)-AP: 1.35 (1.19-1.52), CP:1.24 (1.11-1.38) and MH: 1.16 (1.02-1.32) vs. OP only], opioid-related overdose [AP: 1.43 (1.04-1.98), CP: 1.47 (1.07-2.00) and MH: 1.44 (1.04-2.00) vs. OP only], and substance-related overdose [AP: 1.77 (1.26-2.50), CP: 1.70 (1.24-2.34) and MH: 1.92 (1.31-2.82) vs. GABA only]. While there were cohort differences in the association between GABA+OP and both respiratory depression and opioid-related overdose, GABA+OP and GABA+BZD use were associated with significantly higher odds of substance-related overdose across all clinical cohorts. Interpretation: Among Medicare disabled beneficiaries, concurrent utilization of gabapentin, opioids, and benzodiazepines is associated with multiple adverse outcomes. Given this, it is imperative that the benefits and risks of co-prescribing these medications be comprehensively examined. Funding: None.

Cost-Related Non-Utilization of Health Services and Self-Perceived Reactions to Race.

Purpose: There is limited information regarding the prevalence and predictors of cost-related non-utilization (CRNU), while there is increasing attention to the rising out-of-pocket cost of health services including prescription medications. Prior studies have not quantified the role of perceived racism despite its documented relationship with health services utilization. We examine perceptions of reactions to race and quantify their relationship with CRNU. Methods: This retrospective cross-sectional study utilized data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) public use file, an annual, state-based telephone survey of US adults aged 18 and older. We utilized data for four states that provided responses to five Reactions to Race items, including information about the self-perceived quality of the respondent's health care experience compared with people of other races (worse vs same or better) and whether the respondent experienced physical symptoms because of treatment due to their race. The three binary outcomes were: 1) did not visit a physician; 2) did not visit a physician due to cost; 3) did not fill a prescription due to cost. We estimated covariate-adjusted odds ratios associated with each outcome using logistic regression models. Results: The BRFSS sample consisted of 20,366 respondents of whom 8% were African American non-Hispanic, 12% were Hispanic and 73% were White. Three percent of respondents considered their experience to be worse than people of other races. Three percent of individuals reported physical symptoms because of treatment due to their race while 5% of respondents reported becoming emotionally upset because of treatment due to their race. The proportions for the three study outcomes were 11%, 13% and 7%, respectively. In covariate-adjusted models, a worse experience with the health care system was statistically significantly associated with CRNU (physician visit: 2.6 [95% CI: 1.6 - 4.3]). The experience of physical symptoms because of treatment due to race was statistically significantly associated with CRNU (physician visit: 2.6 [95% CI: 1.7 - 4]; prescription fills: 2.1 [1.2 - 3.6]). No Reactions to Race items were associated with general non-utilization. Conclusions: Negative perceptions of reactions to race during the time of health services utilization is positively associated with CRNU, ie, foregoing physician visits and prescription fills due to cost.

Family Adverse Experiences and Psychotropic Polypharmacy Among US Youth: 2009-2015.

OBJECTIVE: To determine if adverse family factors are associated with a higher likelihood of psychotropic polypharmacy among US youth with a mental health condition. METHODS: The 2009-2015 Medical Expenditure Panel Survey data were used to identify family characteristics of 5136 youth aged ≤18 years with an emotional or behavioral health condition. Family adversity was based on family size, number of parents in the household, parental education and income, and parent-reported physical and/or cognitive or mental health disability. Cluster analysis identified family adversity subgroups. Polypharmacy was defined as 3 or more psychotropic classes (eg, stimulants, antipsychotics, antidepressants, mood stabilizers, and sedatives) in at least 1 interview round in a calendar year. Weighted logistic regression evaluated associations between family adversity and psychotropic polypharmacy among youth. RESULTS: Nearly half (47.8%) of youth lived with parents who had a disability. Parents in the least socioeconomically disadvantaged cluster mainly had a mental illness, and 94% of parents in the most socioeconomically disadvantaged cluster had a parent-reported physical and/or cognitive disability and mental illness. Among youth, mood disorder (24.2%; 95% confidence interval [CI]: 12.6%-16.0%), antidepressant use (16.0%; 95% CI: 10.6%-21.5%), and antipsychotic use (7.5%; 95% CI: 5.4%-9.6%) were higher in the most socioeconomically disadvantaged cluster relative to the other clusters. Approximately 3% of youth received psychotropic polypharmacy. The odds of psychotropic polypharmacy were 2.7 (95% CI: 1.1-6.4) times greater among youth in the most relative to the least socioeconomically disadvantaged cluster. CONCLUSIONS: Higher use of psychotropic polypharmacy among youth with parents who have multiple disabilities raises concerns about oversight and monitoring of complex psychotropic treatment.

Care Management for Youth With Comorbid Developmental and Mental Health Conditions: A Discrete Choice Experiment Pilot Study.

OBJECTIVE: Caregivers of a child with a coexisting cognitive/intellectual and an emotional/behavior/developmental disability have difficult decisions regarding care management options for their child. This study aimed to pilot and refine an instrument to elicit caregivers' preferences in managing their child's care needs. METHODS: Subjects were 38 caregivers of a child aged 21 and younger with a coexisting cognitive/intellectual and an emotional/behavior/developmental disability. A mixed-methods design was used to develop and pilot a discrete choice experiment (DCE) to elicit care management preferences for their child. Six attributes of care management decisions were tested in the DCE: medication use, parental custody, time cost, social interactions, medication effects, and school placement. Subjects completed a paper-and-pencil survey after which a debriefing discussion was held to obtain feedback that would aid in refining the attribute descriptions. Conditional logistic regression generated mean scores for each attribute. Comments from the debriefing sessions were audio-recorded and used to modify the attribute descriptions. RESULTS: The majority (84%) of subjects were aged 40 years or older and a female caregiver. Common diagnoses of the children were autism spectrum disorder (55%) and attention-deficit/hyperactivity disorder (76%). Subjects preferred using fewer medications and maintaining decision-making authority as opposed to delegating authority to a third party. Medication effects on the child's mood were more important than effects on personality or body weight. CONCLUSIONS: The DCE was sensitive to caregivers' preferences for managing their child's coexisting cognitive/intellectual and emotional/behavior/developmental disability. Findings may help providers gauge treatment in a broader context of health outcomes.