Healthcare visits by smokers: Does cessation treatment differ based on clinical condition?

INTRODUCTION: Persons with behavioral health conditions are disproportionally burdened by their tobacco use. Research is limited on how often this patient population is offered tobacco cessation interventions at healthcare visits. This study examines if cessation treatment offered at healthcare visits differs based on the clinical condition. METHODS: Using data from the 2015-2018 National Ambulatory Medical Care Survey (NAMCS), we examined tobacco cessation counseling and medications (bupropion, nicotine replacement therapies and varenicline) from 4,590 visits by patients with current tobacco use. Separate multivariate logistic regressions were used to assess whether the odds of receiving tobacco cessation treatment varied by three groups of clinical conditions: (1) substance use disorder and/or alcohol use disorder, (2) depression, and (3) physical conditions. RESULTS: The odds of being offered smoking cessation counseling are 4.02 times greater for visits by patients with substance use disorder and/or alcohol use disorder compared to visits by patients with depression (p<.001), while the odds of receiving smoking cessation medication are 2.36 times greater for visits by patients with depression compared to visits by patients with substance use disorder and/or alcohol use disorder (p<.01). Visits by patients with substance use disorder and/or alcohol use disorder have 2.36 times the odds of receiving any combination of tobacco cessation treatment compared to visits by patients with depression (p<.001). CONCLUSIONS: Providers are offering cessation treatment at visits by patients with behavioral health conditions at either higher or comparable rates to those without, however, tobacco cessation treatment continues to be underutilized by providers during office visits. IMPLICATIONS: The results of our study have implications for increasing educational opportunities for healthcare providers to improve their confidence in offering tobacco cessation treatment to patients with behavioral health conditions. These patients are motivated to quit smoking, yet cessation treatment is underutilized in this population despite having a greater health effect than most other clinical interventions. Incorporating tobacco cessation education in medical school curricula and post-graduate training can help eliminate barriers for physicians to routinely provide cessation assistance. Collaboration between clinicians and behavioral health providers can also enhance tobacco treatment support and improve cessation rates.

Effects of Practice Ownership and Integration of Health Services on Adherence to Diabetes Guidelines.

OBJECTIVE: There has been a trend toward hospital systems and insurers acquiring privately owned physician practices and subsequently converting them into vertically integrated practices. The purpose of this study is to observe whether this change in ownership of a medical practice influences adherence to clinical guidelines for the management of type 1 and type 2 diabetes. METHODS: This is an observational study using pooled cross-sectional data (2014-2016 and 2018-2019) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. A total of 7499 chronic routine follow ups and preventative care visits to non-integrated (solo and group physician practices) and integrated practices were analyzed to see whether guideline concordant care was provided. Measures included 7 services that are recommended annually for individuals with type 1 and type 2 diabetes (HbA1c, lipid panel, serum creatinine, depression screening, influenza immunization, foot examination, and BMI). RESULTS: Compared to non-integrated physician practices, vertically integrated practices had higher rates of hemoglobin A1C testing (odds ratio 1.58 [95% CI 1.07-2.33], P < .05), serum creatine testing (odds ratio 1.53 [95% CI 1.02-2.29], P < .05), foot examinations (odds ratio 2.03 [95% CI 0.98-4.22], P = .058), and BMI measuring (odds ratio 1.54 [95% CI 0.99-2.39], P = .054). There was no significant difference in lipid panel testing, depression screenings, or influenza immunizations. CONCLUSIONS: Our results show that integrated medical practices have a higher adherence to diabetes practice guidelines than non-integrated practices. However, rates of services provided regardless of ownership were low.

Provision of Pediatric Dental Services by Pediatric Dentists Versus General Dentists: Secondary Dental Analysis of Medical Expenditure Panel Surveys.

Purpose: The purpose of the study was to determine whether visiting only a pediatric dentist (as opposed to visiting only a general dentist) was associated with the provision of preventive dental services for a U.S.-based pediatric population (those 18 years and younger). Methods: This study analyzed pooled Medical Expenditure Panel Survey data from 2018 and 2019 to compare the use of certain preventive dental services (i.e., examination, radiographs, prophylaxis, dental sealant, and fluoride treatment) among those who reported visiting a pediatric dentist versus those who visited a general dentist. Survey procedures were used in Stata 14.0 to perform multivariable logistic regression analyses. Results: Controlling for demographic and insurance variables, children who visited only pediatric dentists had statistically significantly greater odds of receiving radiographs (adjusted odds ratio [AOR] equals 1.22; 95 percent confidence interval [95% CI] equals 1.01 to 1.48; P=0.04), fluoride treatment (AOR equals 1.57; 95% CI equals 1.30 to 1.90; P≤0.001), and sealants (AOR equals 1.63; 95% CI equals 1.24 to 2.16; P=0.001) compared to children who visited only general dentists. There was no statistically significant difference in the provision of periodic examinations and prophylaxis services. Conclusion: Based on the nationally representative data evaluated, pediatric dentists are more likely to provide more optimal preventive services than general dentists (i.e., radiographs, fluoride treatments, and sealants) to children in the United States.

Racial and Ethnic Disparities in Emergency Department Wait Times for Headache.

Headache is a common complaint of individuals seeking treatment in the emergency department (ED). Because pain is subjective, medical evaluation is susceptible to implicit bias that can lead to disparities in wait times. The aim of this study was to determine whether there are racial and ethnic disparities in ED wait times for headache. Our study used the 2015-2018 National Hospital Ambulatory Care Surveys (NHAMCS), a nationally representative sample of ambulatory care visits to EDs. Our sample consisted of visits made by adults for headaches, which were identified using ICD-10 diagnosis codes and NHAMCS reason for visit codes. There were 12,301,655 ED visits for headache represented by our sample. The mean wait time for headache visits was 38.1 min (95%CI: 31.1, 45.0). The mean wait time for Non-Hispanic White patients, non-Hispanic Black patients, Hispanic patients, and the other race and ethnicity groups were 34.7 min (95%CI: 27.5, 42.0), 46.4 min (95%CI: 26.5, 66.4), 37.9 min (95%CI: 19.4, 56.3), and 21.0 min (95%CI: 6.3, 35.7) respectively. After controlling for patient- and hospital-level covariates, visits by non-Hispanic Black patients had 40% (95%CI: -0.01, 0.81, p = 0.056) longer wait times and visits by Hispanic patients had 39% (95%CI: -0.03, 0.80, p = 0.068) longer wait times than visits by non-Hispanic White patients. While our findings suggest that there may be longer wait times for visits by non-Hispanic Black and Hispanic patients compared to visits by non-Hispanic White patients, further research is needed to confirm these findings and determine causes of wait times disparities in the ED.

Racial inequities in emergency department wait times for pregnancy-related concerns.

OBJECTIVE: Emergency department care is common among US pregnant women. Given the increased likelihood of serious and life-threatening pregnancy-related health conditions among Black mothers, timeliness of emergency department care is vital. The objective of this study was to evaluate racial/ethnic variations in emergency department wait times for receiving obstetrical care among a nationally representative population. METHODS: The study used pooled 2016-2018 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of emergency department visits. Regression models were estimated to determine whether emergency department wait time was associated with the race/ethnicity of the perinatal patient. Adjusted models controlled for age, obesity status, insurance type, whether the patient arrived by ambulance, triage status, presence of a patient dashboard, and region. RESULTS: There were a total of 821 reported pregnancy-related visits in the National Hospital Ambulatory Medical Care Survey sample of emergency department visits. Of those 821 visits, 40.6% were among White women, 27.7% among Black women, and 27.5% among Hispanic women. Mean wait times differed substantially by race/ethnicity. After adjusting for potential confounders, Black women waited 46% longer than White women with emergency department visits for pregnancy problems (p < .05). Those reporting another race waited 95% longer for pregnancy problems in the emergency department than White women (p < .05). CONCLUSION: Findings from this study document significant racial/ethnic differences in wait times for perinatal emergency department care. Although inequities in wait times may emerge across the spectrum of care, documenting the factors influencing racial disparities in wait times are critical to promoting equitable perinatal health outcomes.

Tobacco Cessation Counseling and Medications Provided by Physicians to Tobacco Users During Primary Care Visits.

INTRODUCTION: The established guidelines for treating tobacco use and dependency is brief provider intervention to assist those willing to quit by providing access to medication and/or behavioral counseling. The purpose of the study is to determine the extent of cessation treatment offered by providers during primary care visits by patients who are current tobacco users, and to examine associations between patient factors and treatment received. METHODS: Using data from the 2015 to 2018 National Ambulatory Medical Care Survey (NAMCS), we examined tobacco cessation counseling and medications from 4590 visits by patients with current tobacco use. Separate multivariate logistic regressions were used to assess whether the odds of receiving tobacco cessation treatment varied by age, gender, race/ethnicity, and payment source. RESULTS: Of visits by current tobacco users, 18.4% included cessation counseling, 5.5% included cessation medication, and 22.1% included at least 1 type of treatment. Visits by patients with Medicare had 44% greater odds of including counseling (CI = 1%-205%) and treatment (OR = 1.44; 95% CI = 1.01-2.06). Visits classified as "other payment type" had 73% greater odds of including counseling (OR = 1.73; 95% CI = 1.05-2.84). Visits by women had 86% greater odds of including medication (CI = 17%-294%). CONCLUSIONS: Tobacco cessation treatment is underutilized by providers during primary care visits. Further research is necessary to understand and address barriers to providing routine cessation assistance.

Disparities in Offered Anxiety Treatments Among Minorities.

PURPOSE: The primary purpose of this article was to determine if race and ethnicity played a role in if primary care physicians offered anxiety treatment in office visits by adult patients who were diagnosed with an anxiety disorder(s). METHODS: This study pooled data from the 2011 to 2018 National Ambulatory Medical Care Survey (NAMCS) that included adult patients with an anxiety disorder and the type of treatment offered to them. Logistic regressions were performed to examine the odds of offered anxiety treatment in office visits by non-Hispanic Black, Hispanic, and other race/ethnicity patients compared to office visits by non-Hispanic White patients. RESULTS: Physicians offered anxiety treatment in more than half of office visits where the patient was diagnosed with an anxiety disorder. Providers offered counseling or talk therapy in less than 13% of all office visits. Office visits by non-Hispanic Black patients had half the odds of being offered counseling/talk therapy (P = .068) compared to those by non-Hispanic White patients. CONCLUSIONS: These findings suggest that statistically significant differences in the offering of any anxiety treatments in office visits to minorities compared to non-Hispanic White patients do not exist; however, there are still differences in the rates of counseling/talk therapy offered in office visits by minorities versus non-minorities. Future studies may want to examine reasons for lower rates of counseling/talk therapy offered to minority and majority patients and the specific pharmacological or therapeutic treatments offered to different races.

Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA.

BACKGROUND: After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources. OBJECTIVE: To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening. DESIGN: Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. PARTICIPANTS: Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543). MAIN MEASURES: Cancer screening procedures were coded as low value using USPSTF age thresholds. KEY RESULTS: Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians. CONCLUSIONS: Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.

Costs and Savings Associated With the Police Use of the interRAI Brief Mental Health Screener.

Background: The police response to calls for service identified as being related to mental health continues to be highly controversial. Strategies to improve the police response include Crisis Intervention Team (CIT) training and various forms of co-response models neither of which have been subjected to comprehensive evaluations, particularly as to cost-efficiency. A new approach is the use of the interRAI Brief Mental Health Screener to enhance police officer ability to identify persons with serious mental disorders. The purpose of the current study is to evaluate the costs and cost efficiency of the police response to mental health calls using the interRAI Brief Mental Health Screener. Method: Secondary data was analyzed from the use of the screener from 2018 to 2020 by police officers in a mid-sized Canadian city. Changes were measured in the overall number of interactions police officers had with persons with mental health disorders, the number of incidents where police officers referred the person to hospital, and the time officers remained in the emergency department. Results: A total of 6,727 assessments were completed with involuntary referrals decreasing by 30%, and voluntary referrals by 34%. The overall time police officers were involved in involuntary referrals decreased from 123 min in 2018 to 113 min in 2020. The average emergency department wait time for voluntary referrals dropped from 41 min in 2018 to 27 min in 2020, while involuntary referrals decreased from 61 min in 2018 to 42 min in 2020. Each averted involuntary referral to the emergency department resulted in a savings of $81, on average during the study period. Conclusion: An analysis of the costs and costs savings associated with the use of the screener demonstrate that it is a worthwhile investment for police services. An additional benefit is its ability to collect mental health statistics that may be useful to police leaders to justify budgets. Future studies should attempt to devise some method of collecting pre-implementation data that would reveal the true costs and cost-efficiency of using the BMHS, which have been shown to be significant in the current study however, undoubtedly are under-estimated.

The Florida Cohort study: methodology, initial findings and lessons learned from a multisite cohort of people living with HIV in Florida.

In 2013, Florida had the highest rate of new HIV infections and only 56% of persons living with HIV (PLWH) were virally suppressed. In response, we initiated a new HIV cohort in Florida to better understand issues affecting HIV health outcomes. This manuscript will describe the procedures of the Florida Cohort; summarize information regarding enrollment, follow-up, and findings to date; and discuss challenges and lessons learned during the establishment of a multisite cohort of PLWH. Florida Cohort participants were enrolled from eight clinics and community-based organizations geographically diverse counties across Florida. Data were obtained from participant questionnaires, medical records, and state surveillance data. From 2014-2018, 932 PLWH (44% ≥50 years, 64% male, 55% black, 20% Latinx) were enrolled. At baseline, 83% were retained in care and 75% were virally suppressed. Research findings to date have focused on outcomes such as the HIV care continuum, HIV-related comorbidities, alcohol and drug use, and mHealth interventions interest. Strengths included the diversity of the sample and the linkage of participant surveys with existing surveillance data. However, the study had several challenges during planning and follow-up. The lessons learned from this study can be helpful when initiating a new longitudinal cohort study.

Impact of an Emergency Department-to-Home Transitional Care Intervention on Health Service Use in Medicare Beneficiaries: A Mixed Methods Study.

BACKGROUND: Hospital-based acute care [emergency department (ED) visits and hospitalizations] that is preventable with high-quality outpatient care contributes to health care system waste and patient harm. OBJECTIVE: To test the hypothesis that an ED-to-home transitional care intervention reduces hospital-based acute care in chronically ill, older ED visitors. RESEARCH DESIGN: Convergent, parallel, mixed-methods design including a randomized controlled trial. SETTING: Two diverse Florida EDs. SUBJECTS: Medicare fee-for-service beneficiaries with chronic illness presenting to the ED. INTERVENTION: The Coleman Care Transition Intervention adapted for ED visitors. MEASURES: The main outcome was hospital-based acute care within 60 days of index ED visit. We also assessed office-based outpatient visits during the same period. RESULTS: The Intervention did not significantly reduce return ED visits or hospitalizations or increase outpatient visits. In those with return ED visits, the Intervention Group was less likely to be hospitalized than the Usual Care Group. Interview themes describe a cycle of hospital-based acute care largely outside patients' control that may be difficult to interrupt with a coaching intervention. CONCLUSIONS AND RELEVANCE: Structural features of the health care system, including lack of access to timely outpatient care, funnel patients into the ED and hospital admission. Reducing hospital-based acute care requires increased focus on the health care system rather than patients' care-seeking decisions.

Service utilization in Medicaid HIV specialty plans versus standard plans among enrollees diagnosed with HIV/AIDS in Florida, U.S.A.

In the United States (U.S.), to contain costs many state Medicaid programs offer specialty health insurance plans for costly conditions such as HIV/AIDS. This study compared service utilization between Florida Medicaid enrollees diagnosed with HIV/AIDS in standard Medicaid managed care plans to enrollees in HIV/AIDS specialty plans. We found lower mean utilization among HIV/AIDS enrollees in specialty plans compared to enrollees with HIV/AIDS in standard MMA plans for all services except inpatient which was approximately the same. While fewer emergency visits is a desired outcome, lower rates of other services may indicate suboptimal management of patients or lower engagement in care among enrollees in HIV/AIDS specialty plans. Continuous monitoring of experiences of patients in HIV/AIDS specialty plans is warranted to determine whether the observed utilization patterns represent better management through reductions in low value care or reduced engagement in care, and whether these utilization patterns persist.

The Underuse of STI Prevention Counseling in Primary Care.

Although sexually transmitted infection (STI) rates are increasing in the United States, prevention efforts remain limited. This study examined how often STI prevention counseling is given during primary care office visits using nationally representative data. Sexually transmitted infection prevention counseling occurred in 0.6% of visits and differences by patient race and physician specialty were observed.

Racial Disparities in Healthcare Utilization Among Individuals with Cardiometabolic Risk Factors and Comorbid Anxiety Disorder.

OBJECTIVE: This study addresses racial/ethnic differences in adverse health care utilization among individuals with comorbid anxiety disorder and cardiometabolic syndrome (CMetS) risk factors. METHODS: Utilizing 2011-2015 Medical Expenditure Panel Survey (MEPS) data, logistic regression models were estimated to determine the likelihood of receiving CMetS-related medical treatment in the emergency department (ED) or via inpatient services and to determine if the likelihood is associated with race/ethnicity. Adjusted models controlled for age, sex, and insurance type. RESULTS: Significant racial-ethnic differences were observed for utilization (any emergency department and/or inpatient visit). The odds of non-Hispanic Black respondents reporting emergency department and/or inpatient utilization was 2.39 (p < 0.05) times the odds of non-Hispanic White respondents. CONCLUSION: Racial-ethnic variation in adverse healthcare utilization suggests an opportunity to improve care and outcomes for persons diagnosed with comorbid anxiety disorder and cardiometabolic syndrome. Integrated interventions could simultaneously improve mental health and facilitate CMetS disease self-management.

Associations Between Nonclinical Services and Patient-Experience Outcomes in US Acute Care Hospitals.

BACKGROUND: Patient experience is an important measure of hospital quality and performance. Since the passage of the Affordable Care Act, patient experiences with their care encounters are embedded into the framework of payment incentives. However, drivers of patient experience in the context of the supportive, nonclinical, services that relate to patient care have not been as well understood. AIMS: To assess the role of organizational factors on patient experience. METHODS: This cross-sectional analysis integrates hospital patient-experience scores from Hospital Consumer Assessment of Healthcare Providers and Systems, and Centers for Medicaid and Medicare Service data from 2013 to 2015 (N = 3392). Based on hospitals with "top-box" responses, the aggregate proportion of hospital patients responding "always" on a Likert scale represented a top-box hospital. Domains were split at the mean for analysis (above average = 1). Multivariable logistic regression models for each domain were analyzed against hospital factors and services, including offering a patient education center, patient-enabling services, and language services. RESULTS: Most hospitals reported a full-time hospitalist (64.4%) and a patient education center (60.4%), while fewer provided enabling/support services (33.7%). In multivariable models, small and medium hospitals performed better compared to the largest hospitals (300+ beds; P < .0001). Structurally, medium and small hospitals reported significantly greater odds of top-box patient-experience versus large hospitals. Across all domains, only hospitals with patient education centers returned better performance (adjusted odds ratio: 1.27-1.64; P = .0002-.0166). DISCUSSION/CONCLUSION: Patient education centers provide relevant information at the point of service and may improve overall patient experience of care. Given the growing reliance on accountable care delivery models, opportunities to partner with community health education partners may be profitable.

Gender differences in nurse practitioners: job satisfaction and patterns of care.

BACKGROUND: Although workforce diversity has been cited as an important workforce issue, the contemporary U.S. nurse practitioner (NP) workforce is dominated by females. Provider diversity, specifically gender, has been found to directly influence patient preference. However, lack of gender diversity in the NP workforce has never been specifically evaluated in terms of job satisfaction and patterns of care. PURPOSE: The purpose of this study was to assess and evaluate NP gender, job satisfaction and practice patterns of care for U.S. clinical NPs. METHODS: This study used the 2012 National Sample Survey of Nurse Practitioners (NSSNP). Participants meeting inclusion criteria totaled 8,978 NPs, of which 92.8% were female. RESULTS: Although overall job satisfaction was not shown to be significantly different between genders, several patterns of care were found to be significant. Of the 11 measured patterns of care in the NSSNP, six were significantly different between genders, with a female majority indicating that they performed these services most often. In only one rendered service, performed medical procedures, did male NPs indicate that they did more than females. IMPLICATIONS FOR PRACTICE: This study suggests the importance of a gender-diversified U.S. nurse practitioner workforce. This is indicated by differences highlighted in patterns of care by NP gender, which has been postulated to influence patient outcomes, including perceived quality of care and engagement in the health care process. Patient preferences for same-gender NPs, particularly patients with privacy issues, warrant further exploration.

Factors associated with persistently high-cost health care utilization for musculoskeletal pain.

BACKGROUND: Musculoskeletal pain conditions incur high costs and produce significant personal and public health consequences, including disability and opioid-related mortality. Persistence of high-cost health care utilization for musculoskeletal pain may help identify system inefficiencies that could limit value of care. The objective of this study was to identify factors associated with persistent high-cost utilization among individuals seeking health care for musculoskeletal pain. METHODS: This was a retrospective cohort study of Medical Expenditure Panel Survey data (2008-2013) that included a non-institutionalized, population-based sample of individuals seeking health care for a musculoskeletal pain condition (n = 12,985). Expenditures associated with musculoskeletal pain conditions over two consecutive years were analyzed from prescribed medicine, office-based medical provider visits, outpatient department visits, emergency room visits, inpatient hospital stays, and home health visits. Persistent high-cost utilization was defined as being in the top 15th percentile for annual musculoskeletal pain-related expenditures over 2 consecutive years. We used multinomial regression to determine which modifiable and non-modifiable sociodemographic, health, and pain-related variables were associated with persistent high-cost utilization. RESULTS: Approximately 35% of direct costs for musculoskeletal pain were concentrated among the 4% defined as persistent high-cost utilizers. Non-modifiable variables associated with expenditure group classification included age, race, poverty level, geographic region, insurance status, diagnosis type and total number of musculoskeletal pain diagnoses. Modifiable variables associated with increased risk of high expenditure classification were higher number of missed work days, greater pain interference, and higher use of prescription medication for pain, while higher self-reported physical and mental health were associated with lower risk of high expenditure classification. CONCLUSIONS: Health care delivery models that prospectively identify these potentially modifiable factors may improve the costs and value of care for individuals with musculoskeletal pain prone to risk for high-cost care episodes.

Trends in anemia care in non-dialysis-dependent chronic kidney disease (CKD) patients in the United States (2006-2015).

BACKGROUND: The objective of the study was to examine overall anemia management trends in non-dialysis patients with chronic kidney disease (CKD) from 2006 to 2015, and to evaluate the impact of Trial to Reduced Cardiovascular Events with Ananesp Therapy (TREAT)'s study results (October 2009) and the US Food and Drug Administration (FDA)'s (June 2011) safety warnings and guidelines on the use of ESA therapy in the current treatment of anemia. METHODS: A retrospective cohort analysis of anemia management in CKD patients using Truven MarketScan Commercial and Medicare Supplemental databases was conducted. Monthly rates and types of anemia treatment for post-TREAT and post-FDA safety warning periods were compared to pre-TREAT period. Anemia management included ESA, intravenous iron, and blood transfusion. A time-series analysis using Autoregressive Integrated Moving Average (ARIMA) model and a Generalized Estimating Equation (GEE) model were used. RESULTS: Between 2006 and 2015, CKD patients were increasingly less likely to be treated with ESAs, more likely to receive intravenous iron supplementation, and blood transfusions. The adjusted probabilities of prescribing ESAs were 31% (odds ratio (OR) = 0.69, 95% confidence interval (CI): 0.67-0.71) and 59% (OR = 0.41, 95% CI: 0.40, 0.42) lower in the post-TREAT and post-FDA warning periods compared to pre-TREAT period. The probability of prescribing intravenous iron was increased in the post-FDA warning period (OR = 1.11, 95% CI: 1.03-1.19) although the increase was not statistically significant in the post-TREAT period (OR = 1.03, 95% CI: 0.94-1.12). The probabilities of prescribing blood transfusion during the post-TREAT and post-FDA warning periods increased by 14% (OR = 1.14, 95% CI: 1.06-1.23) and 31% (OR = 1.31, 95% CI: 1.22-1.39), respectively. Similar trends of prescribing ESAs and iron supplementations were observed in commercially insured CKD patients but the use of blood transfusions did not increase. CONCLUSIONS: After the 2011 FDA safety warnings, the use of ESA continued to decrease while the use of iron supplementation continued to increase. The use of blood transfusions increased significantly in Medicare patients while it remained stable in commercially insured patients. Results suggest the TREAT publication had effected treatment of anemia prior to the FDA warning but the FDA warning solidified TREAT's recommendations for anemia treatment for non- dialysis dependent CKD patients.