Intravascular Microaxial Left Ventricular Assist Device Manufacturer Payments to Cardiologists and Use of Devices.

This study examines whether payments from a left ventricular assist device manufacturer to cardiologists performing percutaneous coronary intervention were associated with any use of the devices.

Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up.

Importance: In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community. Objective: To determine whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up. Design, Setting, and Participants: This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Data analyses were performed February 1 to December 15, 2023. Exposure: Implementation of payments for TCM. Main Outcomes and Measures: Timely postdischarge primary care follow-up, defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up. Results: The study sample comprised 79 125 965 eligible discharges. Of these, 55.4% were female; 1.5% were Asian, 12.1% Black, 5.6% Hispanic, and 79.0% were White individuals; and 79.6% were beneficiaries aged 65 years and older. Timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Interrupted time-series analyses demonstrated an increased slope of timely primary care follow-up after the introduction of TCM services (pre-TCM slope, 0.12% per quarter vs post-TCM slope, 0.29% per quarter; difference, 0.13%; 95% CI, 0.02% to 0.22%). Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients (difference-in-differences in pre-TCM vs post-TCM slope, -0.14%; 95% CI, -0.25% to -0.2%) and patients who were Medicaid dual-eligible (difference-in-differences pre-TCM vs post-TCM slope, -0.21%; 95% CI, -0.35% to -0.07%). Conclusions: These findings indicate that Medicare's introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up.

Management of Inpatient Elevated Blood Pressures : A Systematic Review of Clinical Practice Guidelines.

BACKGROUND: Management of elevated blood pressure (BP) during hospitalization varies widely, with many hospitalized adults experiencing BPs higher than those recommended for the outpatient setting. PURPOSE: To systematically identify guidelines on elevated BP management in the hospital. DATA SOURCES: MEDLINE, Guidelines International Network, and specialty society websites from 1 January 2010 to 29 January 2024. STUDY SELECTION: Clinical practice guidelines pertaining to BP management for the adult and older adult populations in ambulatory, emergency department, and inpatient settings. DATA EXTRACTION: Two authors independently screened articles, assessed quality, and extracted data. Disagreements were resolved via consensus. Recommendations on treatment targets, preferred antihypertensive classes, and follow-up were collected for ambulatory and inpatient settings. DATA SYNTHESIS: Fourteen clinical practice guidelines met inclusion criteria (11 were assessed as high-quality per the AGREE II [Appraisal of Guidelines for Research & Evaluation II] instrument), 11 provided broad BP management recommendations, and 1 each was specific to the emergency department setting, older adults, and hypertensive crises. No guidelines provided goals for inpatient BP or recommendations for managing asymptomatic moderately elevated BP in the hospital. Six guidelines defined hypertensive urgency as BP above 180/120 mm Hg, with hypertensive emergencies requiring the addition of target organ damage. Hypertensive emergency recommendations consistently included use of intravenous antihypertensives in intensive care settings. Recommendations for managing hypertensive urgencies were inconsistent, from expert consensus, and focused on the emergency department. Outpatient treatment with oral medications and follow-up in days to weeks were most often advised. In contrast, outpatient BP goals were clearly defined, varying between 130/80 and 140/90 mm Hg. LIMITATION: Exclusion of non-English-language guidelines and guidelines specific to subpopulations. CONCLUSION: Despite general consensus on outpatient BP management, guidance on inpatient management of elevated BP without symptoms is lacking, which may contribute to variable practice patterns. PRIMARY FUNDING SOURCE: National Institute on Aging. (PROSPERO: CRD42023449250).

Outcomes After Initiation of Medications for Alcohol Use Disorder at Hospital Discharge.

Importance: US Food and Drug Administration-approved medications for alcohol use disorder (MAUD) are significantly underused. Hospitalizations may provide an unmet opportunity to initiate MAUD, but few studies have examined clinical outcomes of patients who initiate these medications at hospital discharge. Objective: To investigate the association between discharge MAUD initiation and 30-day posthospitalization outcomes. Design, Setting, and Participants: This cohort study was conducted among patients with Medicare Part D who had alcohol-related hospitalizations in 2016. Data were analyzed from October 2022 to December 2023. Exposures: Discharge MAUD initiation was defined as oral naltrexone, acamprosate, or disulfiram pharmacy fills within 2 days of discharge. Main outcomes: The primary outcome was a composite of all-cause mortality or return to hospital (emergency department visits and hospital readmissions) within 30 days of discharge. Secondary outcomes included these components separately, return to hospital for alcohol-related diagnoses, and primary care or mental health follow-up within 30 days of discharge. Propensity score 3:1 matching and modified Poisson regressions were used to compare outcomes between patients who received and did not receive discharge MAUD. Results: There were 6794 unique individuals representing 9834 alcohol-related hospitalizations (median [IQR] age, 54 [46-62] years; 3205 hospitalizations among females [32.6%]; 1754 hospitalizations among Black [17.8%], 712 hospitalizations among Hispanic [7.2%], and 7060 hospitalizations among White [71.8%] patients). Of these, 192 hospitalizations (2.0%) involved discharge MAUD initiation. After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of the primary outcome (incident rate ratio, 0.58 [95% CI, 0.45 to 0.76]; absolute risk difference, -0.18 [95% CI, -0.26 to -0.11]). These findings were consistent among secondary outcomes (eg, incident rate ratio for all-cause return to hospital, 0.56 [95% CI, 0.43 to 0.73]) except for mortality, which was rare in both groups (incident rate ratio, 3.00 [95% CI, 0.42 to 21.22]). Discharge MAUD initiation was associated with a 51% decreased incidence of alcohol-related return to hospital (incident rate ratio, 0.49 [95% CI, 0.34 to 0.71]; absolute risk difference, -0.15 [95% CI, -0.22 to -0.09]). Conclusion and relevance: In this cohort study, discharge initiation of MAUD after alcohol-related hospitalization was associated with a large absolute reduction in return to hospital within 30 days. These findings support efforts to increase uptake of MAUD initiation at hospital discharge.

Older Adult and Primary Care Practitioner Perspectives on Using, Prescribing, and Deprescribing Opioids for Chronic Pain.

Importance: Guidelines recommend deprescribing opioids in older adults due to risk of adverse effects, yet little is known about patient-clinician opioid deprescribing conversations. Objective: To understand the experiences of older adults and primary care practitioners (PCPs) with using opioids for chronic pain and discussing opioid deprescribing. Design, Setting, and Participants: This qualitative study conducted semistructured individual qualitative interviews with 18 PCPs and 29 adults 65 years or older prescribed opioids between September 15, 2022, and April 26, 2023, at a Boston-based academic medical center. The PCPs were asked about their experiences prescribing and deprescribing opioids to older adults. Patients were asked about their experiences using and discussing opioid medications with PCPs. Main Outcome and Measures: Shared and conflicting themes between patients and PCPs regarding perceptions of opioid prescribing and barriers to deprescribing. Results: In total, 18 PCPs (12 [67%] younger that 50 years; 10 [56%] female; and 14 [78%] based at an academic practice) and 29 patients (mean [SD] age, 72 [5] years; 19 [66%] female) participated. Participants conveyed that conversations between PCPs and patients on opioid use for chronic pain were typically challenging and that conversations regarding opioid risks and deprescribing were uncommon. Three common themes related to experiences with opioids for chronic pain emerged in both patient and PCP interviews: opioids were used as a last resort, opioids were used to improve function and quality of life, and trust was vital in a clinician-patient relationship. Patients and PCPs expressed conflicting views on risks of opioids, with patients focusing on addiction and PCPs focusing on adverse drug events. Both groups felt deprescribing conversations were often unsuccessful but had conflicting views on barriers to successful conversations. Patients felt deprescribing was often unnecessary unless an adverse event occurred, and many patients had prior negative experiences tapering. The PCPs described gaps in knowledge on how to taper, a lack of clinical access to monitor patients during tapering, and concerns about patient resistance. Conclusions and Relevance: In this qualitative study, PCPs and older adults receiving long-term opioid therapy viewed the use of opioids as a beneficial last resort for treating chronic pain but expressed dissonant views on the risks associated with opioids, which made deprescribing conversations challenging. Interventions, such as conversation aids, are needed to support collaborative discussion about deprescribing opioids.

Primary Care Physicians In Medicare Advantage Were Less Costly, Provided Similar Quality Versus Regional Average.

The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9 percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.

Trends in Phenylephrine and Pseudoephedrine Sales in the US.

This study examines purchasing patterns regarding oral decongestants, concerns about their efficacy, and the need for timelier postmarket evaluation.

Contribution of parasite and host genotype to immunopathology of schistosome infections.

Background: The role of pathogen genotype in determining disease severity and immunopathology has been studied intensively in microbial pathogens including bacteria, fungi, protozoa, and viruses, but is poorly understood in parasitic helminths. The medically important blood fluke Schistosoma mansoni is an excellent model system to study the impact of helminth genetic variation on immunopathology. Our laboratory has demonstrated that laboratory schistosome populations differ in sporocyst growth and cercarial production in the intermediate snail host and worm establishment and fecundity in the vertebrate host. Here, we (i) investigate the hypothesis that schistosome genotype plays a significant role in immunopathology and related parasite life history traits in the vertebrate mouse host and (ii) quantify the relative impact of parasite and host genetics on infection outcomes. Methods: We infected BALB/c and C57BL/6 mice with four different laboratory schistosome populations from Africa and the Americas. We quantified disease progression in the vertebrate host by measuring body weight and complete blood count (CBC) with differential over an infection period of 12 weeks. On sacrifice, we assessed parasitological (egg and worm counts, fecundity), immunopathological (organ measurements and histopathology), and immunological (CBC with differential and cytokine profiles) characteristics to determine the impact of parasite and host genetics. Results: We found significant variation between parasite populations in worm numbers, fecundity, liver and intestine egg counts, liver and spleen weight, and fibrotic area, but not in granuloma size. Variation in organ weight was explained by egg burden and by intrinsic parasite factors independent of egg burden. We found significant variation between infected mouse lines in cytokines (IFN-γ, TNF-α), eosinophil, lymphocyte, and monocyte counts. Conclusions: This study showed that both parasite and host genotype impact the outcome of infection. While host genotype explains most of the variation in immunological traits, parasite genotype explains most of the variation in parasitological traits, and both host and parasite genotype impact immunopathology outcomes.

Racial and Ethnic Disparities in Opioid Prescribing on Hospital Discharge Among Older Adults: A National Retrospective Cohort Study.

BACKGROUND: Disparities in opioid prescribing among racial and ethnic groups have been observed in outpatient and emergency department settings, but it is unknown whether similar disparities exist at discharge among hospitalized older adults. OBJECTIVE: To determine filled opioid prescription rates on hospital discharge by race/ethnicity among Medicare beneficiaries. DESIGN: Retrospective cohort study. PARTICIPANTS: Medicare beneficiaries 65 years or older discharged from hospital in 2016, without opioid fills in the 90 days prior to hospitalization (opioid-naïve). MAIN MEASURES: Race/ethnicity was categorized by the Research Triangle Institute (RTI), grouped as Asian/Pacific Islander, Black, Hispanic, other (American Indian/Alaska Native/unknown/other), and White. The primary outcome was an opioid prescription claim within 2 days of hospital discharge. The secondary outcome was total morphine milligram equivalents (MMEs) among adults with a filled opioid prescription. KEY RESULTS: Among 316,039 previously opioid-naïve beneficiaries (mean age, 76.8 years; 56.2% female), 49,131 (15.5%) filled an opioid prescription within 2 days of hospital discharge. After adjustment, Black beneficiaries were 6% less likely (relative risk [RR] 0.94, 95% CI 0.91-0.97) and Asian/Pacific Islander beneficiaries were 9% more likely (RR 1.09, 95% CI 1.03-1.14) to have filled an opioid prescription when compared to White beneficiaries. Among beneficiaries with a filled opioid prescription, mean total MMEs were lower among Black (356.9; adjusted difference - 4%, 95% CI - 7 to - 1%), Hispanic (327.0; adjusted difference - 7%, 95% CI - 10 to - 4%), and Asian/Pacific Islander (328.2; adjusted difference - 8%, 95% CI - 12 to - 4%) beneficiaries when compared to White beneficiaries (409.7). CONCLUSIONS AND RELEVANCE: Black older adults were less likely to fill a new opioid prescription after hospital discharge when compared to White older adults and received lower total MMEs. The factors contributing to these differential prescribing patterns should be investigated further.

A single locus determines praziquantel response in Schistosoma mansoni.

We previously performed a genome-wide association study (GWAS) to identify the genetic basis of praziquantel (PZQ) response in schistosomes, identifying two quantitative trait loci situated on chromosomes 2 and 3. We reanalyzed this GWAS using the latest (version 10) genome assembly showing that a single locus on chromosome 3, rather than two independent loci, determines drug response. These results reveal that PZQ response is monogenic and demonstrates the importance of high-quality genomic information.

Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.

OBJECTIVES: The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care. MATERIALS AND METHODS: Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression. RESULTS: Among 12 849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002). DISCUSSION AND CONCLUSION: Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.

Differences in Primary Care Follow-up After Acute Care Discharge Within and Across Health Systems: a Retrospective Cohort Study.

BACKGROUND: Timely primary care follow-up after acute care discharge may improve outcomes. OBJECTIVE: To evaluate whether post-discharge follow-up rates differ among patients discharged from hospitals directly affiliated with their primary care clinic (same-site), other hospitals within their health system (same-system), and hospitals outside their health system (outside-system). DESIGN: Retrospective cohort study. PATIENTS: Adult patients of five primary care clinics within a 14-hospital health system who were discharged home after a hospitalization or emergency department (ED) stay. MAIN MEASURES: Primary care visit within 14 days of discharge. A multivariable Poisson regression model was used to estimate adjusted rate ratios (aRRs) and risk differences (aRDs), controlling for sociodemographics, acute visit characteristics, and clinic characteristics. KEY RESULTS: The study included 14,310 discharges (mean age 58.4 [SD 19.0], 59.5% female, 59.5% White, 30.3% Black), of which 57.7% were from the same-site, 14.3% same-system, and 27.9% outside-system. By 14 days, 34.5% of patients discharged from the same-site hospital received primary care follow-up compared to 27.7% of same-system discharges (aRR 0.88, 95% CI 0.79 to 0.98; aRD - 6.5 percentage points (pp), 95% CI - 11.6 to - 1.5) and 20.9% of outside-system discharges (aRR 0.77, 95% CI [0.70 to 0.85]; aRD - 11.9 pp, 95% CI - 16.2 to - 7.7). Differences were greater for hospital discharges than ED discharges (e.g., aRD between same-site and outside-system - 13.5 pp [95% CI, - 20.8 to - 8.3] for hospital discharges and - 10.1 pp [95% CI, - 15.2 to - 5.0] for ED discharges). CONCLUSIONS: Patients discharged from a hospital closely affiliated with their primary care clinic were more likely to receive timely follow-up than those discharged from other hospitals within and outside their health system. Improving care transitions requires coordination across both care settings and health systems.

Contribution of parasite and host genotype to immunopathology of schistosome infections.

Background: The role of pathogen genotype in determining disease severity and immunopathology has been studied intensively in microbial pathogens including bacteria, fungi, protozoa, and viruses, but is poorly understood in parasitic helminths. The medically important blood fluke Schistosoma mansoni is an excellent model system to study the impact of helminth genetic variation on immunopathology. Our laboratory has demonstrated that laboratory schistosome populations differ in sporocyst growth and cercarial production in the intermediate snail host and worm establishment and fecundity in the vertebrate host. Here, we (i) investigate the hypothesis that schistosome genotype plays a significant role in immunopathology and related parasite life history traits in the vertebrate mouse host and (ii) quantify the relative impact of parasite and host genetics on infection outcomes. Methods: We infected BALB/c and C57BL/6 mice with four different laboratory schistosome populations from Africa and the Americas. We quantified disease progression in the vertebrate host by measuring body weight and complete blood count (CBC) with differential over an infection period of 12 weeks. On sacrifice, we assessed parasitological (egg and worm counts, fecundity), immunopathological (organ measurements and histopathology), and immunological (CBC with differential and cytokine profiles) characteristics to determine the impact of parasite and host genetics. Results: We found significant variation between parasite populations in worm numbers, fecundity, liver and intestine egg counts, liver and spleen weight, and fibrotic area, but not in granuloma size. Variation in organ weight was explained by egg burden and by intrinsic parasite factors independent of egg burden. We found significant variation between infected mouse lines in cytokines (IFN-γ, TNF-α), eosinophil, lymphocyte, and monocyte counts. Conclusions: This study showed that both parasite and host genotype impact the outcome of infection. While host genotype explains most of the variation in immunological traits, parasite genotype explains most of the variation in parasitological traits, and both host and parasite genotype impact immunopathology outcomes.

Trajectories of change in weekly and biweekly therapy.

Higher therapy session frequency has been found to result in faster recovery, but few studies have considered that clients follow diverse trajectories of change in psychotherapy. It is unknown how session frequency may affect the sizes and shapes of change trajectories. The present study examined clients' change trajectories in weekly and biweekly therapy in a naturalistic setting, as well as predictors of these trajectories. Using a sample of 5,102 clients receiving 3-10 therapy sessions at a university counseling center, we identified 886 clients attending approximately weekly therapy and 1,753 clients attending approximately biweekly therapy. We examined the change trajectories of the weekly and biweekly samples using latent growth mixture modeling (LGMM). Three trajectories were identified in weekly therapy: slow change (78.33%), early improvement (17.61%), and worse before better (4.06%), and in biweekly therapy: slow change (80.38%), early improvement (13.52%), and worse before better (6.1%). The worse before better subgroup in weekly therapy experienced greater deterioration than those in biweekly therapy. The slow change and early improvement subgroups in weekly therapy showed treatment outcome comparable to those of their respective counterparts in biweekly therapy. Clients' intake symptoms, including eating concerns, frustration/anger, depression, and academic concerns, significantly predicted change trajectories. Compared to biweekly therapy, weekly therapy leads to higher chances of early improvement and shortens the duration of suffering but results in greater deterioration for individuals who deteriorate in therapy. The impact of session frequency on treatment outcome varies across clients, and session frequency should be adjusted individually. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees.

BACKGROUND: A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure. METHODS: This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure. RESULTS: Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups. CONCLUSION: Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

The effects of a multimedia intervention on help-seeking process with a Chinese college student sample.

Little is known about encouraging help-seeking in non-English speaking settings and relatively little research has been directed to facilitate help-seeking among Chinese-speaking people. This study examined the effects of a multimedia intervention on barriers, attitudes, and intentions for seeking counseling in China. The multimedia intervention was informed by prior empirical research on models of help-seeking for counseling. A total of 200 participants were randomly assigned to one of the two conditions: (1) a help-seeking media-exposed intervention group and (2) a control group, who watched a hospital advertisement that was unrelated to mental health help-seeking. Results indicated that the intervention was effective at increasing both positive attitudes toward therapy and intentions to seek therapy. The intervention also improved participants' perceptions about treatment accessibility. This intervention is available and can be a resource for Chinese language populations (both within China and other countries), especially for immigrants, rural, and persons who might benefit from mental health treatments such as psychotherapy.

Evaluation of a benzodiazepine deprescribing quality improvement initiative for older adults in primary care.

BACKGROUND: Older adults are commonly prescribed long-term benzodiazepines for anxiety and insomnia despite evidence of risks and limited evidence of long-term benefits. Recent quality measures and guidelines have recommended benzodiazepine deprescribing, yet there is little real-world data on clinic-based deprescribing programs. METHODS: We developed a benzodiazepine deprescribing quality improvement program for older adults at a large US academic medical center. The program targeted adults aged 65 years and older who were prescribed chronic benzodiazepines by their primary care physician (PCP). PCPs were contacted to opt-out patients not suitable for deprescribing; then eligible patients were mailed a letter discussing patient-specific risks and advising them to discuss deprescribing with their PCP or a pharmacist who was available to support tapering. The primary outcomes were the number of patients who discussed deprescribing and who initiated a taper within 90 days of outreach. RESULTS: Of 504 older adults prescribed benzodiazepines, 133 (26%) were opted out by their PCPs leaving a cohort of 371 (median age 71 years [IQR 68-75], 58% female, 82% White). The median daily diazepam milligram equivalent was 5 mg (IQR 3-6 mg) and 30% were prescribed long-acting benzodiazepines. Three months following patient outreach, 97 patients (26%) had a documented discussion of benzodiazepines with their PCP or clinic pharmacist. Of these patients, 35 (36%) had documentation of a deprescribing discussion and 25 (26%) initiated a taper. At 12 months, 16 patients (64%) were tapered successfully, with nine (36%) patients taking a lower benzodiazepine dose and seven (28%) discontinuing benzodiazepines completely. CONCLUSIONS: A low-intensity benzodiazepine deprescribing outreach program led to deprescribing conversations for a minority of patients, but one-quarter of older adults who engaged in a conversation chose to taper and nearly two-thirds sustained reduced use. Incorporating benzodiazepine deprescribing into routine care may require more intensive population-health efforts to engage patients and clinicians.