Telehealth Utilization for Opioid Use Disorder: A Nationwide Analysis Before and After the COVID-19 Public Health Emergency Declaration.

Introduction: The COVID-19 pandemic has led to the rapid and widespread adoption of telehealth services. Telehealth may aid in bridging gaps in access to care. The specific impact of telehealth on opioid use disorder (OUD) and its treatment remains uncertain. Methods: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of(a) OUD treatments with and without telehealth support and (b) prescriptions for medications for opioid use disorder (MOUD) with and without telehealth support among individuals diagnosed with OUD. Results: In a study population of 1,340,506 individuals, OUD diagnosis rates were 5 per 1,000 in-person and 1 per 1,000 via telehealth. COVID-19 decreased in-person OUD diagnoses by 0.89 per 1,000, while telehealth diagnoses increased by 0.83 per 1,000. In-person MOUD treatment rates increased by 0.07 per 1,000 during COVID-19, while telehealth rates remained low. The onset of COVID-19 saw a 1.13 per 1,000 higher increase in telehealth-supported MOUD treatment compared to solely in-person treatment. Conclusions: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of (a) OUD treatments with and without telehealth support and (b) prescriptions for MOUD with and without telehealth support among individuals diagnosed with OUD.

Association of race/ethnicity and patient care experiences with healthcare utilization and healthcare costs among prostate cancer survivors: A SEER-CAHPS study.

INTRODUCTION: This study aimed to evaluate the association of race/ethnicity and patient care experiences (PCEs) with healthcare utilization and costs among US older adults with prostate cancer (PCa). MATERIALS AND METHODS: The study used data from 2007 to 2015 Surveillance, Epidemiology, and End Results dataset linked to Medicare Consumer Assessment of Healthcare Providers and Systems survey and Medicare claims (SEER-CAHPS). We identified males aged ≥65 years who completed a CAHPS survey within 6-60 months post-PCa diagnosis. Covariate-adjusted associations of six CAHPS PCE composite measures with any emergency department visit and any inpatient stay (using logistic regressions), and with total part A and part B Medicare costs (using generalized linear models) were examined by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, and other). RESULTS: Among 1834 PCa survivors, a 1-point higher score for getting care quickly was associated with higher odds (odds ratio 1.08; 95% confidence interval [CI]: 1.02-1.15; p = 0.009) of any inpatient stay in Hispanic patients. Higher total costs were associated with a 1-point higher score for getting needed care among Hispanic patients ($590.84; 95% CI: $262.15, $919.53; p < 0.001); a 1-point higher score for getting care quickly among Hispanic patients ($405.26; 95% CI: $215.83, $594.69; p < 0.001); and a 1-point higher score for customer service among patients belonging to other races ($361.69; 95% CI: $15.68, $707.69; p = 0.04). DISCUSSION: We observed differential associations by race/ethnicity between PCEs and healthcare utilization and costs. Further research is needed to explore the causes of these associations.

Identifying Risk Factors for Cardiovascular Events Among Active-Duty Service Members and Veterans Prescribed Nonsteroidal Anti-Inflammatory Drugs (NSAIDs).

Background: Oral NSAIDs are widely used analgesic medications for the treatment of musculoskeletal and inflammatory conditions. NSAIDs are associated with adverse effects that arise from COX enzyme inhibition including cardiovascular events. The combined role of patient and prescription factors associated with NSAID use on cardiovascular risk is not well characterized. Objective: The purpose of this study is to identify the risk factors with cardiovascular events among NSAID users. Methods: This study is a retrospective, nested case-control study, within the DAVINCI database, among active-duty service members and veterans with at least one NSAID pharmacy claim between fiscal year (FY) 2015-FY2020. Inclusion criteria individuals ≥18 years of age received a prescription NSAID for ≥7-day supply and a duration ≥1 month overall. Cases experienced nonfatal myocardial infarction, nonfatal stroke, or new onset heart failure. Ten controls were selected per case. Risk factors were identified through logistic regression modeling. Results: The risk factors with strongest association to the primary outcome included age starting at 45 up to 75 and older, the first 90 days of NSAID exposure, cerebrovascular disease, cardiomyopathy, and history of myocardial infarction. Cox-selectivity and dose did not appear to be clinically significant in their association with cardiovascular events. Conclusion: The results of this study indicate that age, initial NSAID exposure, and comorbidities are more predictive than NSAID-specific factors such as COX-selectivity and dose. The results provide the framework for development of a risk score to improve prediction of NSAID-associated cardiovascular events.

Medication Trends in the Military: A Comparative Analysis of Prescribing Patterns Among Service Members Seen by a Pharmacist and Implications for Medical Readiness.

INTRODUCTION: Medications play a critical role supporting the health of military service members. Little is known about the broad use of medications prescribed to this population. Active duty service members (ADSMs), while often younger and having fewer diagnosed comorbid conditions, face unique health challenges that benefit from pharmacotherapy. Understanding prescribing patterns is instrumental to illuminate potential areas for research and to guide education so that military health care professionals can maintain competency, improve outcomes, and support medical readiness. This study aimed to characterize commonly dispensed medications among ADSMs and to compare these prescriptions with those of the general population. MATERIALS AND METHODS: A retrospective, cross-sectional analysis using data extracted contained in the Military Health System Information Platform focused on ADSMs who consulted with a clinical pharmacist during the 2019 fiscal year. Descriptive statistics were used to summarize patient and prescription data. The 100 most frequently prescribed medications and 20 most frequently prescribed therapeutic classes were identified. Analyses were performed using Statistical Analysis System (SAS) software, and a non-metric multidimensional scaling plot was generated in R to illustrate the relationships between the 20 most frequently used therapeutic classes and the branches of service. RESULTS: The study analyzed 719,788 prescriptions for 30,012 service members, revealing a high prescription rate for pain, inflammation, and psychiatric condition treatments. Antidepressants and nonsteroidal anti-inflammatory drugs were among the most commonly prescribed across all military branches. Some medication uses varied, which may indicate distinct needs within different service branches. CONCLUSIONS: Understanding medication patterns among ADSMs may be able to help health care professionals proactively address pharmacological challenges and optimize pharmaceutical use in this unique population. This knowledge can also aid in the development of training modules focused on medication side effects, interactions, counseling, and implications on military deployment for the most commonly used medications. Future examination into prescribing cascades and medication use related to proton-pump inhibitors, docusate, benzonatate, and muscle relaxants may identify opportunities to provide better care or lower cost.

Patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS).

OBJECTIVE: This study aims to assess the patient-centeredness and psychometric properties of the Defense and Veterans Pain Rating Scale 2.0 (DVPRS) as a patient-reported outcome measure (PROM) for pain assessment in a military population. DESIGN: A critical evaluation of the DVPRS was conducted, considering its fit-for-purpose as a PROM and its patient-centeredness using the National Health Council's Rubric to Capture the Patient Voice. SETTING: The study focused on the use of the DVPRS within the Department of Defense (DoD) and Veterans Health Administration (VA) healthcare settings. SUBJECTS: The DVPRS was evaluated based on published studies and information provided by measure developers. The assessment included content validity, reliability, construct validity, and ability to detect change. Patient-centeredness and patient engagement were assessed across multiple domains. METHODS: Two independent reviewers assessed the DVPRS using a tool/checklist/questionnaire, and any rating discrepancies were resolved through consensus. The assessment included an evaluation of psychometric properties and patient-centeredness based on established criteria. RESULTS: The DVPRS lacked sufficient evidence of content validity, with no patient involvement in its development. Construct validity was not assessed adequately, and confirmatory factor analysis was not performed. Patient-centeredness and patient engagement were also limited, with only a few domains showing meaningful evidence of patient partnership. CONCLUSIONS: The DVPRS as a PROM for pain assessment in the military population falls short in terms of content validity, construct validity, and patient-centeredness. It requires further development and validation, including meaningful patient engagement, to meet current standards and best practices for PROMs.

Association of race/ethnicity and patient care experiences with receipt of definitive treatment among prostate cancer survivors: a SEER-CAHPS study.

PURPOSE: This study aimed to evaluate the association of race/ethnicity, patient care experiences (PCEs), and receipt of definitive treatment and treatment modality among older adults in the United States (US) with localized prostate cancer (PCa). METHODS: Using Surveillance, Epidemiology and End Results dataset linked to Medicare Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) for 2007-2015, we identified men aged ≥ 65 years who completed a CAHPS survey within one year before and one year after PCa diagnosis. Associations of race/ethnicity (non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, non-Hispanic Asian (NHA), and other) and of interactions between race/ethnicity and PCEs (getting needed care, getting care quickly, doctor communication, and care coordination) with the receipt of definitive PCa treatment and treatment modality within 3 and 6 months of diagnosis were examined using logistic regressions. RESULTS: Among 1,438 PCa survivors, no racial/ethnic disparities in the receipt of definitive treatment were identified. However, NHB patients were less likely to receive surgery (vs. radiation) within 3 and 6 months of PCa diagnosis than NHW patients (OR 0.397, p = 0.006 and OR 0.419, p = 0.005), respectively. Among NHA patients, a 1-point higher score for getting care quickly was associated with lower odds (OR 0.981, p = 0.043) of receiving definitive treatment within 3 months of PCa diagnosis, whereas among NHB patients, a 1-point higher score for doctor communication was associated with higher odds (OR 1.023, p = 0.039) of receiving definitive treatment within 6 months of PCa diagnosis. DISCUSSION: We observed differential associations between PCEs and receipt of definitive treatment based on patient race/ethnicity. Further research is needed to explore these associations.

Venous Access: National Guideline and Registry Development (VANGUARD): Advancing Patient-Centered Venous Access Care Through the Development of a National Coordinated Registry Network.

There are over 8 million central venous access devices inserted each year, many in patients with chronic conditions who rely on central access for life-preserving therapies. Central venous access device-related complications can be life-threatening and add tens of billions of dollars to health care costs, while their incidence is most likely grossly mis- or underreported by medical institutions. In this communication, we review the challenges that impair retention, exchange, and analysis of data necessary for a meaningful understanding of critical events and outcomes in this clinical domain. The difficulty is not only with data extraction and harmonization from electronic health records, national surveillance systems, or other health information repositories where data might be stored. The problem is that reliable and appropriate data are not recorded, or falsely recorded, at least in part because policy, payment, penalties, proprietary concerns, and workflow burdens discourage completeness and accuracy. We provide a roadmap for the development of health care information systems and infrastructure that address these challenges, framed within the context of research studies that build a framework of standardized terminology, decision support, data capture, and information exchange necessary for the task. This roadmap is embedded in a broader Coordinated Registry Network Learning Community, and facilitated by the Medical Device Epidemiology Network, a Public-Private Partnership sponsored by the US Food and Drug Administration, with the scope of advancing methods, national and international infrastructure, and partnerships needed for the evaluation of medical devices throughout their total life cycle.

The association of major adverse limb events and combination stent and atherectomy in patients undergoing revascularization for lower extremity peripheral artery disease.

BACKGROUND: The effectiveness of combined atherectomy and stenting relative to use of each procedure alone for the treatment of lower extremity peripheral artery disease has not been evaluated. AIMS: The objective of this study was to evaluate the short- and long-term major adverse limb event (MALE) following the receipt of stenting, atherectomy, and the combination of stent and atherectomy. METHODS: A retrospective cohort of patients undergoing atherectomy, stent, and combination stent atherectomy for lower extremity peripheral artery disease was derived from the Vascular Quality Initiative (VQI) data set. The primary outcome was MALE and was assessed in the short-term and long-term. Short-term MALE was assessed immediately following the procedure to discharge and estimated using logistic regression. Long-term MALE was assessed after discharge to end of follow-up and estimated using the Fine-Gray subdistribution hazard model. RESULTS: Among the 46,108 included patients, 6896 (14.95%) underwent atherectomy alone, 35,774 (77.59%) received a stent, and 3438 (7.5%) underwent a combination of stenting and atherectomy. The adjusted model indicated a significantly higher odds of short-term MALE in the atherectomy group (OR = 1.35; 95% confidence interval [CI]:1.16-1.57), and not significantly different odds (OR = 0.93; 95% CI:0.77-1.13) in the combination stent and atherectomy group when compared to stenting alone. With regard to long-term MALE, the model indicated that the likelihood of experiencing the outcome was slightly lower (HR = 0.90; 95% CI:0.82-0.98) in the atherectomy group, and not significantly different (HR = 0.92; 95% CI:0.82-1.04) in the combination stent and atherectomy group when compared to the stent group. CONCLUSIONS: Patients in the VQI data set who received combination stenting and atherectomy did not experience significantly different rates of MALE when compared with stenting alone. It is crucial to consider and further evaluate the influence of anatomical characteristics on treatment strategies and potential differential effects of comorbidities and other demographic factors on the short and long-term MALE risks.

Differences in racial/ethnic disparities in patient care experiences between prostate cancer survivors and males without cancer: A SEER-CAHPS study.

INTRODUCTION: Our purpose was to evaluate whether racial/ethnic disparities in patient care experiences (PCEs) differ between males with prostate cancer ("PCa group") and males without cancer ("non-cancer group"). MATERIALS AND METHODS: This retrospective study used 2007-2015 National Cancer Institute's Surveillance, Epidemiology and End Results registry data linked to Consumer Assessment of Healthcare Providers and Systems surveys. PCa and non-cancer groups were propensity score matched 1:5 on demographic and clinical characteristics. Differences in racial/ethnic disparities (DRD) (non-Hispanic Black [NHB], Hispanic, non-Hispanic Asian [NHA], and Other Races compared to non-Hispanic White [NHW]) in PCEs (getting needed care, getting care quickly, doctor communication, customer service, and getting needed prescription drugs) were compared between matched PCa and non-cancer groups. Per prior literature, DRD in PCE scores were categorized as small (<3), medium (≥3 but <5) or large (≥5). RESULTS: There were 7312 males in the PCa group and 36,559 matched males in the non-cancer group. Within each group, all racial/ethnic minority categories reported worse scores compared to NHW individuals (p < 0.05) for ≥3 PCE composite measures. Compared to PCa group, a larger NHA-NHW difference was observed in non-cancer group for getting needed care (-4.65 in PCa vs. -7.77 in non-cancer; DRD = 3.11, p = 0.029) and doctor communication (-2.46 in PCa vs. -4.85 in non-cancer; DRD = 2.38, p = 0.023). DISCUSSION: In both PCa and non-cancer groups, racial/ethnic minorities reported worse experiences compared to NHW individuals for several PCE measures. However, the difference in getting needed care and doctor communication between NHA and NHW individuals were more pronounced in non-cancer group than PCa group.

Evidence-based objective performance criteria for the evaluation of hip and knee replacement devices and technologies.

BACKGROUND: Objective performance criteria (OPC) is a novel method to provide minimum performance standards and improve the regulated introduction of original or incremental device innovations in order to prevent patients from being exposed to potentially inferior designs whilst allowing timely access to improvements. We developed 2-year safety and effectiveness OPC for total hip and knee replacement (THR and TKR). METHODS: Analyses of large databases were conducted using various data sources: a systematic literature review; a direct data analysis from The Functional Outcomes Research for Comparative Effectiveness in Total Joint Replacement and Quality Improvement Registry (FORCE-TJR) and the Kaiser Permanente Implant Registry (KPIR); and claims data analyses from longitudinal discharge data in New York and California states. The literature review included U.S. patients (≥18 years) who received THR or TKR for primary end-stage osteoarthritis and prospectively collected data on patient-reported outcome measures (PROMs) from at least 100 subjects and/or 2-year implant survival for at least 250 implants. Random effects models were used for meta-analysis. RESULTS: Data were available from a total of 951 100 patients. After screening of 7979 abstracts, 294 studies underwent full-text review and 31 studies contributed to the evidence synthesis (333 995 implants). Direct data analysis of FORCE-TJR contributed 9223 joint replacement patients to the construction of OPC for effectiveness; KPIR contributed 262 044 patients for the construction of OPC for safety. Claims database analysis contributed 345 838 patients to the construction of safety OPC. OPC for safety were constructed for cumulative incidences of 2-year all-cause and septic revision (THR/TKR 2.0%/1.6% and 0.6%/0.7%), and OPC for effectiveness were constructed based on four disease-specific and three general health-related quality of life PROMs (HOOS/KOOS 87.1/80.6; HSS/KSS function 94.4/90.6; SF-12/SF-36, PCS 46.5/41.9, EQ-5D 0.88/0.84). CONCLUSION: This study is the first to construct a 2-year OPC for the safety and effectiveness of THR and TKR based on U.S. real-world data. Based on these OPC, potential benchmarks for (single-arm study) evaluation of new device innovations are suggested for a regulated and safe introduction to the (commercial) market.

Racial/Ethnic Disparities in Patient Care Experiences among Prostate Cancer Survivors: A SEER-CAHPS Study.

PURPOSE: To evaluate racial/ethnic disparities in patient care experiences (PCEs) among prostate cancer (PCa) survivors. METHODS: This retrospective study used 2007-2015 National Cancer Institute Surveillance, Epidemiology and End Results registry data linked to Consumer Assessment of Healthcare Providers and Systems surveys. First survey ≥ 6 months post-PCa diagnosis was analyzed. We performed multivariable linear regression, adjusting for demographic and clinical covariates, to evaluate the association of race/ethnicity (non-Hispanic Whites (NHWs), non-Hispanic Black (NHBs), Hispanic, non-Hispanic Asian (NHAs), and other races) with PCE composite measures: getting needed care, doctor communication, getting care quickly, getting needed prescription drugs (Rx), and customer service. RESULTS: Among 7319 PCa survivors, compared to NHWs, Hispanics, NHBs and NHAs reported lower scores for getting care quickly (ß = -3.69; p = 0.002, ß = -2.44; p = 0.021, and ß = -6.44; p < 0.001, respectively); Hispanics scored worse on getting needed care (ß = -2.16; p = 0.042) and getting needed Rx (ß = -2.93; p = 0.009), and NHAs scored worse on customer service (ß = -7.60; p = 0.003), and getting needed Rx (ß = -3.08; p = 0.020). However, NHBs scored better than NHWs on doctor communication (ß = 1.95, p = 0.006). No statistically significant differences were found between other races and NHWs. CONCLUSIONS: Comparing to NHWs, Hispanics and NHAs reported worse experiences on several PCE composite measures, while NHBs reported worse scores on one but better scores on another PCE composite measure. Further research is needed to understand the reasons behind these disparities and their influence on healthcare utilization and health outcomes among PCa survivors.

Variability among Online Opioid Conversion Calculators Performing Common Palliative Care Conversions.

Introduction: Online opioid conversion calculators (OOCCs) are commonly used to aid conversion between opioids to overcome tolerance, reduce adverse effects, or challenges related to administration. The purpose of this study was to describe and characterize variability among OOCC used by health care practitioners when converting common opioids and doses encountered in the hospice and palliative care setting. Methods: We collected 58 quantitative surveys and performed sentiment analysis on 62 qualitative responses from adult learners primarily practicing in the palliative care setting and enrolled in an online palliative care Master of Science program through the University of Maryland, Baltimore, who were asked to perform opioid conversion calculations using realistic patient cases. Results: OOCC have substantial variability leading to a wide range of outputs, which may put patients at risk for opioid-related harm. Assessing participant sentiment toward OOCC showed most participants held a "Negative Sentiment" toward these calculators after the activity. Conclusion: Overall, findings reveal that given the same information, clinicians can come to widely different opioid doses and these differences can be amplified by OOCC. These differences can be particularly dangerous given the higher opioid doses commonly used in the palliative care setting. Considering the significant harm that can arise from an error when converting between opioids, clinicians should avoid the routine use of OOCC in real-world patient care settings. If an OOCC is used, organizations should endorse a specific calculator, provide training and education about the algorithm that supports the calculations, and encourage clinicians to use it only after their own manual calculation, which should be documented in the medical record.

Trajectories of Opioid Coverage After Long-Term Opioid Therapy Initiation Among a National Cohort of US Veterans.

PURPOSE: The objective of this study was to identify the trajectories that patients take after initiating long-term opioid therapy (LTOT). MATERIALS AND METHODS: Using a retrospective cohort design, veterans with chronic non-cancer pain (CNCP) initiating LTOT were identified. Group-based trajectory models were used to identify opioid therapy trajectories based on days of opioid supply (primary outcome) and average daily morphine milligram equivalent dose (AMME; secondary outcome) in each 180-day period following initiation of LTOT. RESULTS: A total of 438,398 veterans with CNCP initiated LTOT. Nine trajectories were identified: 33.7% with persistent, high days covered, 17.7% with persistent, moderate days covered, 16.6% with slow, persistent days-covered reduction, 2.4% with days-covered reduction followed by increase, 4.6% with delayed days-covered reduction, 4.1% with rapid days-covered reduction, 10.9% with moderate-paced discontinuation, 3.4% with delayed discontinuation, and 6.5% with rapid discontinuation. Patients following discontinuation trajectories were more likely to be younger, persons of color, use more supportive services (eg, physical therapy), and received less opioid days' supply and lower doses prior to initiating LTOT as compared to patients following persistent opioid days-covered trajectories. AMME trajectories were similar to days-covered trajectories. CONCLUSION: Among persons initiating LTOT, nine opioid trajectories emerged which can be broadly characterized into three main trajectory groups: persistent opioid therapy (2 trajectories), reductions in opioid therapy (4 trajectories), and discontinuation (3 trajectories). A majority of patients (51.4%) maintained persistent opioid therapy. Further research is needed to assess the risks of opioid-related adverse outcomes among the identified trajectories.

Association of Sex With Risk of 2-Year Revision Among Patients Undergoing Total Hip Arthroplasty.

Importance: The worldwide population is aging and includes more female individuals than male individuals, with higher rates of total hip arthroplasty (THA) among female individuals. Although research on this topic has been limited to date, several studies are currently under way. Objectives: To evaluate the association between sex and 2-year revision after THA. Design, Setting, and Participants: This cohort study used data from statewide databases in New York and California between October 1, 2015, and December 31, 2018. Patients 18 years or older with osteoarthritis who underwent THA and had sex recorded in the database were included in the analysis. Exposure: Total hip arthroplasty. Main Outcomes and Measures: The outcome of interest was the difference in early, all-cause revision surgery rates after primary THA between women and men. The association of sex with the revision rate was examined using Cox proportional hazards regression analysis. Results: Of 132 826 patients included in the study, 74 002 (55.7%) were women; the mean (SD) age was 65.9 (11.0) years, and the median follow-up time was 1.3 years (range, 0.0-3.0 years). The 2-year revision rate was 2.5% (95% CI, 2.4%-2.6%) among women and 2.1% (95% CI, 2.0%-2.2%) among men. After adjusting for demographic characteristics, comorbidities, and facility volume, a minimal clinically meaningful difference was observed in revision rates despite women having a higher risk of all-cause revision compared with men (hazard ratio, 1.16; 95% CI, 1.07-1.26; P < .001). The risk of revision was increased among women compared with men in the subgroup of patients who were younger than 55 years (hazard ratio, 1.47; 95% CI, 1.20-1.81; P < .001). Conclusions and Relevance: In this cohort study, no clinically meaningful difference in all-cause revision rates after primary THA was found between men and women at 2-year follow-up. The modest difference in the risk of revision between men and women in a small subgroup of patients younger than 55 years suggests that the risk of revision in this population should be studied further.

Opioid prescribing and risks among commercially insured women undergoing pelvic organ prolapse repair.

PURPOSE: Opioid use after surgical repair for pelvic organ prolapse (POP) is intended for short-term post-operative pain. This study compared the incidence of opioid prescribing in women undergoing POP transabdominal repair with mesh and transvaginal native tissue repair. METHODS: A retrospective cohort of women undergoing POP transabdominal repair with mesh or transvaginal native tissue repair, was derived from a 10% random sample of enrollees from 2007 to 2015 within the IQVIA PharMetrics® Plus Database. Primary outcomes were any prescription of opioids and cumulative days of opioids prescribed in the 14- 180 days following surgical intervention. Inverse probability of treatment weights controlled for observed baseline confounders. Any opioid prescription was estimated using logistic regression and generalized linear regression for cumulative days of opioids prescribed. RESULTS: The cohort of 49 052 women who underwent POP surgical repair included 46 813 women with transvaginal native tissue repair and 2239 women with transabdominal repair with mesh. Women with a transabdominal repair with mesh had a 1.19 (95%CI: 1.09-1.31) significantly higher odds of receiving an opioid prescription than women with transvaginal native tissue repair. Post-operatively, over 29% of women received opioid prescriptions. Mean cumulative days of post-surgical opioid prescribing was 32.2 (SD = 43.1), and was not statistically different between groups. Thirteen percent of women were prescribed opioids for 90 days or more. CONCLUSIONS: Women undergoing POP with transabdominal mesh are more likely to receive prescriptions for opioids after surgery compared to transvaginal native tissue repair. Treatment plans that address pain while mitigating the risks associated with prolonged opioid prescribing should be employed.

Exploring the Use of State Medical Cannabis Legislation as a Proxy for Medical Cannabis Use Among Patients Receiving Chemotherapy.

OPINION STATEMENT: The use of medical cannabis is expanding in the USA. Due to conflicting, low-quality evidence, many oncologists may not feel confident to recommend it to patients. Given the potential for legal and financial risks when conducting clinical trials with medical cannabis, the use of observational data should be explored. Observational data that directly capture medical cannabis use in relation to prescription medications and track the prevalence and patterns of cannabis use is sparse. To gain insights into the role medical cannabis plays in the pharmaceutical landscape, proxies such as cannabis legislation need to be explored. In the context of recommendation-nonadherent antiemetic prescribing among patients experiencing chemotherapy-induced nausea and vomiting, medical cannabis may be a suitable alternative to an antiemetic in states that allow medical cannabis. Findings suggest that legislation may impact the use of certain antiemetics in states with cannabis legislation in place. The presence or absence of legislation regarding medical cannabis use may serve as an early, observable surrogate marker of medical cannabis use in the community. In light of the paucity of clinical trials and observational datasets that capture cannabis use, there remains a tremendous need for the development of methodologies or standardized datasets that appropriately and reliably capture the use of medical cannabis to facilitate research into its clinical application and effect on prescription medication use. Standardizing the reporting and destigmatizing use could eliminate the dependence upon proxy measures as a substitute for more extensive data and go a long way in improving data capture, thus allowing us to generate knowledge and hypotheses from observational data until research conditions improve and allow for expanded clinical trials involving medical cannabis.

Initiation of Transdermal Fentanyl Among US Commercially Insured Patients Between 2007 and 2015.

INTRODUCTION: This study examined patterns of initial transdermal fentanyl (TDF) claims among US commercially insured patients and explored the risk of 30-day hospitalization among patients with and without prior opioid exposure necessary to produce tolerance. DESIGN: A retrospective cohort study of initial outpatient TDF prescriptions. SETTING: A 10% random sample of commercially insured enrollees within the IQVIA Health Plan Claims Database (formerly known as PharMetrics Plus). SUBJECTS: Individuals with a claim for TDF between 2007 and 2015. METHODS: The primary exposure was a new transdermal fentanyl claim, and the primary outcome was guideline concordance based on time and dose exposure. RESULTS: Among the 24,770 patients in the cohort, 4,848 (20%) patients had sufficient time exposure to opioids before TDF. Among those with sufficient time exposure, 3,971 (82%) had adequate opioid exposure based on the US Food and Drug Administration (FDA) package insert dosing guidance. Overall, 3,971 of the 24,770 (16%) patients received guideline-consistent TDF. An exploratory analysis of 30-day hospitalization after a TDF claim did not detect a difference in odds between guideline-consistent or -inconsistent groups when adjusted for variables known to influence the risk of opioid-induced respiratory depression. CONCLUSIONS: A majority of patients met FDA opioid dose thresholds for TDF but had insufficient time exposure based on package insert recommendations for tolerance. Exploratory analysis did not detect a difference in odds for all-cause hospitalization or respiratory-related 30-day hospitalization between guideline-consistent or -inconsistent TDF claims. Prescribers should continue to adhere to FDA TDF labeling, although certain aspects of the labeling should be reevaluated or clarified.

Nonprescription Medication Use in Hospice Patients.

OBJECTIVE: Patients admitted to hospice are more vulnerable to age-related physiologic changes, polypharmacy, and inappropriate medication use and monitoring. The objective of this study was to characterize the utilization of nonprescription medications in a hospice population. METHODS: This was a retrospective study designed to characterize nonprescription or over-the-counter medication use in hospice patients. Data for this study were provided by Seasons Hospice & Palliative Care, a national hospice organization with licenses to operate in 19 states and collected from January 1 to December 31, 2016. The most frequently utilized nonprescription medications, therapeutic classes, and the frequency of patients with at least 1 claim within a therapeutic class were summarized. RESULTS: The final study population included 62 639 orders representing 15 164 patients. The average age was 79.31 years with a standard deviation of 13.31 years. The average length of stay was 26.80 days with a standard deviation of 44.14 days. The top 5 most common medications were as follows: acetaminophen (25.15%), bisacodyl (21.69%), senna (8.35%), omeprazole (4.51%), and docusate (4.46%). Approximately 13 714 (29.67%) of patients were exposed to analgesics, 13 469 (29.14%) to laxatives, and 3535 (7.65%) to antacids or antigas medications. CONCLUSION: This study highlights numerous opportunities for improvement in the use of nonprescription medications among hospice patients. Reducing the use of nonprescription medications that are ineffective or produce unwanted side effects can contribute to improving the quality of care that patients receive.

What motivates people with substance use disorders to pursue treatment? A patient-centered approach to understanding patient experiences and patient-provider interactions.

OBJECTIVES: To identify and define potential positive and negative factors in patient experiences and patient-provider interactions that are associated with the pursuit and maintenance of treatment by those suffering from substance use disorders (SUD). METHODS: Two focus groups with patients in treatment for SUD were performed. The focus groups focused on questions aimed at mapping factors associated with initiating and maintaining treatment along the transtheoretical model of change. Four in-depth interviews with healthcare providers involved in the treatment of patients with SUD were also conducted to understand providers' perspective on similar factors. RESULTS: Fourteen patients were included in the focus groups. Patients identified their life prior to treatment as chaotic and further identified internal and external factors that influenced seeking treatment. The four healthcare providers identified primarily social issues such as lack of housing as an external barrier. Both patients and providers cited the importance of a trusting and empathetic relationship between the patient and providers, as well as the patient's willingness to change as primary motivating factors for the initiation and maintenance of treatment. CONCLUSIONS: From a patient and provider perspective, facilitators and barriers for initiating and maintaining may vary by person and are multifactorial.

Association of Criminal Statutes for Opioid Use Disorder With Prevalence and Treatment Among Pregnant Women With Commercial Insurance in the United States.

Importance: Inadequate treatment of opioid use disorder (OUD) in pregnant women increases the risk of life-threatening consequences on maternal and fetal outcomes. Untreated OUD during pregnancy is associated with higher rates of adverse outcomes among newborns. Objective: To examine the variation in the prevalence of OUD and the use of medication-assisted treatment among commercially insured pregnant women according to region and state legislature. Design, Setting, and Participants: Cohort study in which the patient cohort used was derived from a 10% random sample of enrollees within the IQVIA PharMetrics Plus adjudicated claims and enrollment database from 2007 to 2015. The database consists of a 10% random sample of private health insurance recipients in the United States and contains claims and enrollment data that are representative of the commercially insured US population. The cohort comprised women (n = 110 285) between 18 and 45 years of age with a code indicating a delivery and continuous insurance enrollment 9 months before and 12 months after delivery. Data analysis was performed from December 2017 to May 2018. Exposures: Based on their state of residence, the women were classified into 4 different regions: South, Midwest, West, and Northeast. Those residing in states with statutes that imposed civil or criminal penalties for OUD diagnosis during pregnancy were placed in a separate population from those residing in states without these statutes. Main Outcomes and Measures: Diagnosis of OUD in the 9 months before delivery and the receipt of medication-assisted treatment in the 9 months before or 12 months after delivery. Results: The 110 285 pregnant women included in the analysis had a mean (SD) age of 30.26 (5.59) years, with most (67 771 [61.5%]) falling within the 26- to 35-year age range. Of this cohort, 277 women (0.25%) had a diagnosis of OUD and 312 (0.28%) received treatment. Among the 277 women with OUD, 127 (45.9%) received treatment. The prevalence of an OUD diagnosis and receipt of treatment within regions was statistically significant (OUD diagnosis by region: Midwest, 0.05%; North, 0.09%; South, 0.06%; West, 0.06%; χ23 = 45.1148 [P < .001]; OUD treatment by region: Midwest, 0.05%; North, 0.08%; South, 0.10%; West, 0.05%; χ23 = 26.5654 [P < .001]). The prevalence of OUD diagnosis was also statistically significant when comparing women residing in states with statutes with those in states without statutes (OUD diagnosis by criminal statutes: criminalization, 0.07%; no criminalization, 0.18%; χ21 = 14.6456 [P < .001]; OUD treatment by criminal statutes: criminalization, 0.12%; no criminalization, 0.17%; χ21 = 0.0895); the receipt of treatment was not statistically significant (P = .76). Conclusions and Relevance: These results appeared to show significant variations in the patterns of OUD diagnosis and receipt of medication-assisted treatment among pregnant women, suggesting the need to further explore the source of these variations.