Effect of a Predictive Analytics-Targeted Program in Patients on Opioids: a Stepped-Wedge Cluster Randomized Controlled Trial.

BACKGROUND: Risk of overdose, suicide, and other adverse outcomes are elevated among sub-populations prescribed opioid analgesics. To address this, the Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM)-a provider-facing dashboard that utilizes predictive analytics to stratify patients prescribed opioids based on risk for overdose/suicide. OBJECTIVE: To evaluate the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among high-risk Veterans. DESIGN: A 23-month stepped-wedge cluster randomized controlled trial in all 140 VHA medical centers between 2018 and 2020. PARTICIPANTS: A total of 44,042 patients actively prescribed opioid analgesics with high STORM risk scores (i.e., percentiles 1% to 5%) for an overdose or suicide-related event. INTERVENTION: A mandate requiring providers to perform case reviews on opioid analgesic-prescribed patients at high risk of overdose/suicide. MAIN MEASURES: Nine serious adverse events (SAEs), case review completion, number of risk mitigation strategies, and all-cause mortality. KEY RESULTS: Mandated review inclusion was associated with a significant decrease in all-cause mortality within 4 months of inclusion (OR: 0.78; 95% CI: 0.65-0.94). There was no detectable effect on SAEs. Stepped-wedge analyses found that mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk (OR: 5.1; 95% CI: 3.64-7.23) and received more risk mitigation strategies than non-mandated patients (0.498; CI: 0.39-0.61). CONCLUSIONS: Among VHA patients prescribed opioid analgesics, identifying high risk patients and mandating they receive an interdisciplinary case review was associated with a decrease in all-cause mortality. Results suggest that providers can leverage predictive analytic-targeted population health approaches and interdisciplinary collaboration to improve patient outcomes. TRIAL REGISTRATION: ISRCTN16012111.

Randomized Policy Evaluation of the Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM).

BACKGROUND: The Veterans Health Administration (VHA) developed a dashboard Stratification Tool for Opioid Risk Mitigation (STROM) to guide clinical practice interventions. VHA released a policy mandating that high-risk patients of an adverse event based on the STORM dashboard are to be reviewed by an interdisciplinary team of clinicians. AIM: Randomized program evaluation to evaluate if patients in the oversight arm had a lower risk of opioid-related serious adverse events (SAEs) or death compared to those in the non-oversight arm. SETTING AND PARTICIPANTS: One-hundred and forty VHA facilities (aka medical centers) were randomly assigned to two groups: oversight and non-oversight arms. VHA patients who were prescribed opioids between April 18, 2018, and November 8, 2019, were included in the cohort. PROGRAM DESCRIPTION: We hypothesized that patients cared for by VHA facilities that received the policy with the oversight accountability language would achieve lower opioid-related SAEs or death. PROGRAM EVALUATION: We did not observe a relationship between the oversight arm and opioid-related SAEs or death. Patients in the non-oversight arm had a significantly higher chance of receiving a case review compared to those in the oversight arm. DISCUSSION: Even though our findings were unexpected, the STORM policy overall was likely successful in focusing the provider's attention on very high-risk patients.

Respiratory co-infections with COVID-19 in the Veterans Health Administration, 2020.

Reporting of Coronavirus disease 2019 (COVID-19) co-infections with other respiratory pathogens has varied. We evaluated 825,280 molecular and/or viral culture respiratory assays within the Veterans Health Administration from September 29, 2019 to May 31, 2020. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in 10,222 of 174,746 (5.8%) individuals. 30,063 (17.2%) of 174,746 individuals tested for SARS-CoV-2 had additional respiratory pathogen testing; co-infection was identified in 56 of 3757 (1.5%) individuals positive for SARS-CoV-2. Among those negative for SARS-CoV-2, 1022 of 26,306 (3.9%) were positive for at least 1 respiratory pathogen. Compared to COVID-19 mono-infection, individuals with COVID-19 co-infection had lower odds of being female. Compared to non-COVID-19 respiratory pathogen infection, individuals with COVID-19 co-infection had lower odds of being female, were hospitalized more frequently, had higher odds of death, and were younger at death. Our findings suggest COVID-19 co-infections were rare; however, not all COVID-19 patients were concurrently tested for other respiratory pathogens and seasonal decreases in other respiratory pathogens were occurring as COVID-19 emerged.

COVID-19 Infections Among Healthcare Personnel in the United States Veterans Health Administration, March to August, 2020.

OBJECTIVE: We investigated COVID-19 infection and death among healthcare personnel (HCP) in the United States Veterans Health Administration. METHODS: HCP with positive Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) reverse transcription polymerase chain reaction tests between March 1 and August 31, 2020 were included. Risk ratios were calculated for sex, age, race/ethnicity, Veteran status, occupation category, facility of employment by inpatient COVID-19 test percent positivity and death. RESULTS: Five thousand nine hundred twenty five HCP were COVID-19-infected out of 131,606 tested (4.5% positivity). Highest risk for COVID-19 infection included: HCP working in hospitals with more than 15% inpatient COVID-19 test positivity, nursing staff, non-Hispanic Black, and Hispanic or Latino HCP and HCP who were Veterans. Among 18 HCP who died after COVID-19 infection, male sex, age more than or equal to 65 years, and Veteran status were significant risk factors. CONCLUSIONS: Robust national surveillance testing methods are needed to accurately monitor HCP COVID-19 infections and deaths to improve HCP safety.