Changes in Medication Utilization and Adherence Associated with Homeless Adults' Entry into Permanent Supportive Housing.

BACKGROUND: Permanent supportive housing (PSH) programs, which have grown over the last decade, have been associated with changes in health care utilization and spending. However, little is known about the impact of such programs on use of prescription drugs critical for managing chronic diseases prevalent among those with unstable housing. OBJECTIVE: To evaluate the effects of PSH on medication utilization and adherence among Medicaid enrollees in Pennsylvania. DESIGN: Difference-in-differences study comparing medication utilization and adherence between PSH participants and a matched comparison cohort from 7 to 18 months before PSH entry to 12 months post PSH entry. SUBJECTS: Pennsylvania Medicaid enrollees (n = 1375) who entered PSH during 2011-2016, and a propensity-matched comparison cohort of 5405 enrollees experiencing housing instability who did not receive PSH but received other housing services indicative of episodic or chronic homelessness (e.g., emergency shelter stays). MAIN MEASURES: Proportion with prescription fill, mean proportion of days covered (PDC), and percent adherent (PDC ≥ 80%) for antidepressants, antipsychotics, anti-asthmatics, and diabetes medications. KEY RESULTS: The PSH cohort saw a 4.77% (95% CI 2.87% to 6.67%) relative increase in the proportion filling any prescription, compared to the comparison cohort. Percent adherent among antidepressant users in the PSH cohort rose 7.41% (95% CI 0.26% to 14.57%) compared to the comparison cohort. While utilization increased in the other medication classes among the PSH cohort, differences from the comparison cohort were not statistically significant. CONCLUSIONS: PSH participation is associated with increases in filling prescription medications overall and improved adherence to antidepressant medications. These results can inform state and federal policy to increase PSH placement among Medicaid enrollees experiencing homelessness.

Changes in Care Associated With Integrating Medicare and Medicaid for Dual-Eligible Individuals.

Importance: There is growing interest in expanding integrated models, in which 1 insurer manages Medicare and Medicaid spending for dually eligible individuals. Fully integrated dual-eligible special needs plans (FIDE-SNPs) are one of the largest integrated models, but evidence about their performance is limited. Objective: To evaluate changes in care associated with integrating Medicare and Medicaid coverage in a FIDE-SNP in Pennsylvania. Design, Setting, and Participants: This cohort study using a difference-in-differences analysis compared changes in care between 2 cohorts of dual-eligible individuals: (1) an integration cohort composed of Medicare Dual Eligible Special Needs Plan enrollees who joined a companion Medicaid plan following a 2018 state reform mandating Medicaid managed care (leading to integration), and (2) a comparison cohort with nonintegrated coverage before and after the start of Medicaid managed care. Analyses were conducted between February 2022 and June 2023. Main Outcomes and Measures: Analyses examined outcomes in 4 domains: use of home- and community-based services (HCBS), care management and coordination, hospital stays and postacute care, and long-term nursing home stays. Results: The study included 7967 individuals in the integration cohort and 3832 individuals in the comparison cohort. In the integration cohort, the mean (SD) age at baseline was 63.3 (14.7) years, and 5268 individuals (66.1%) were female and 2699 (33.9%) were male. In the comparison cohort, the mean (SD) age at baseline was 64.8 (18.6) years, and 2341 individuals (61.1%) were female and 1491 (38.9%) were male. At baseline, integration cohort members received a mean (SD) of 2.83 (8.70) days of HCBS per month and 3.34 (3.56) medications for chronic conditions per month, and the proportion with a follow-up outpatient visit after a hospital stay was 0.47. From baseline through 3 years after integration, HCBS use increased differentially in the integration vs comparison cohorts by 0.61 days/person-month (95% CI, 0.28-0.94; P < .001). However, integration was not associated with changes in care management and coordination, including medication use for chronic conditions (-0.02 fills/person-month; 95% CI, -0.10 to 0.06; P = .65) or follow-up outpatient care after a hospital stay (-0.01 visits/hospital stay; 95% CI, -0.04 to 0.03; P = .61). Hospital stays did not change differentially between the cohorts. Unmeasured factors contributing to differential mortality limited the ability to identify changes in long-term nursing home stays associated with integration. Conclusions and Relevance: In this cohort study with a difference-in-differences analysis of 2 cohorts of individuals dually eligible for Medicare and Medicaid, integration was associated with greater HCBS use but not with other changes in care patterns. The findings highlight opportunities to strengthen how integrated programs manage care and a need to further evaluate their performance.

Healthcare Utilization Among Children Receiving Permanent Supportive Housing.

BACKGROUND AND OBJECTIVES: Permanent supportive housing (PSH) integrates long-term housing and supports for families and individuals experiencing homelessness. Although PSH is frequently provided to families with children, little is known about the impacts of PSH among children. We examined changes in health care visits among children receiving PSH compared with similar children who did not receive PSH. METHODS: We analyzed Pennsylvania Medicaid administrative data for children entering PSH between 2011 and 2016, matching to a comparison cohort with similar demographic and clinical characteristics who received non-PSH housing services. We conducted propensity score-weighted difference-in-differences (DID) analyses to compare changes in health care visits 3 years before and after children entered PSH versus changes in the comparison cohort. RESULTS: We matched 705 children receiving PSH to 3141 in the comparison cohort. Over 3 years following PSH entry, dental visits among children entering PSH increased differentially relative to the comparison cohort (DID: 12.70 visits per 1000 person-months, 95% confidence interval: 3.72 to 21.67). We did not find differential changes in preventive medicine visits, hospitalizations, or emergency department (ED) visits overall. When stratified by age, children ≤5 years old at PSH entry experienced a greater decrease in ED visits relative to the comparison cohort (DID: -13.16 visits per 1000 person-months, 95% confidence interval: -26.23 to -0.10). However, emergency visit trends before PSH entry differed between the cohorts. CONCLUSIONS: Children in PSH had relatively greater increases in dental visits, and younger children entering PSH may have experienced relative reductions in ED visits. Policymakers should consider benefits to children when evaluating the overall value of PSH.

Association Between Hospital Adoption of an Emergency Department Treatment Pathway for Opioid Use Disorder and Patient Initiation of Buprenorphine After Discharge.

Importance: Emergency department (ED)-based initiation of buprenorphine has been shown to increase engagement in outpatient treatment and reduce the risk of subsequent opioid overdose; however, rates of buprenorphine treatment in the ED and follow-up care for opioid use disorder (OUD) remain low in the US. The Opioid Hospital Quality Improvement Program (O-HQIP), a statewide financial incentive program designed to increase engagement in OUD treatment for Medicaid-enrolled patients who have ED encounters, has the potential to increase ED-initiated buprenorphine treatment. Objective: To evaluate the association between hospitals attesting to an ED buprenorphine treatment O-HQIP pathway and patients' subsequent initiation of buprenorphine treatment. Design, Setting, and Participants: This cohort study included Pennsylvania patients aged 18 to 64 years with continuous Medicaid enrollment 6 months before their OUD ED encounter and at least 30 days after discharge between January 1, 2016, and December 31, 2020. Patients with a claim for medication for OUD 6 months before their index encounter were excluded. Exposures: Hospital implementation of an ED buprenorphine treatment O-HQIP pathway. Main Outcomes and Measures: The main outcome was patients' receipt of buprenorphine within 30 days of their index OUD ED visit. Between August 2021 and January 2023, data were analyzed using a difference-in-differences method to evaluate the association between hospitals' O-HQIP attestation status and patients' treatment with buprenorphine after ED discharge. Results: The analysis included 17 428 Medicaid-enrolled patients (female, 43.4%; male, 56.6%; mean [SD] age, 37.4 [10.8] years; Black, 17.5%; Hispanic, 7.9%; White, 71.6%; other race or ethnicity, 3.0%) with OUD seen at O-HQIP-attesting or non-O-HQIP-attesting hospital EDs. The rate of prescription fills for buprenorphine within 30 days of an OUD ED discharge in the O-HQIP attestation hospitals before the O-HQIP intervention was 5%. The O-HQIP attestation was associated with a statistically significant increase (2.6 percentage points) in prescription fills for buprenorphine within 30 days of an OUD ED discharge (ß, 0.026; 95% CI, 0.005-0.047). Conclusions and Relevance: In this cohort study, the O-HQIP was associated with an increased initiation of buprenorphine in patients with OUD presenting to the ED. These findings suggest that statewide incentive programs may effectively improve outcomes for patients with OUD.

Examination of Differences in Nonmedical Supplemental Benefit Coverage for Dual-Eligible Enrollees in Medicare Advantage Plans in 2021.

This cross-sectional study uses Medicare Advantage benefit package data for 2021 to examine differences in the coverage of nonmedical supplemental benefits­such as transportation services and food and meal assistance­for dual-eligible enrollees with health-related social needs.

The impact of opioid prescribing report cards in Medicaid.

BACKGROUND: Performance feedback has been used for decades to improve health care quality and safety, with varying degrees of success. One example is the use of customized report cards that target inappropriate prescribing of high-risk medications, including opioids. Randomized controlled trials suggest that report cards are an effective tool to change opioid prescribing behavior, but their effectiveness in community settings is unclear. OBJECTIVE: To evaluate the impact of opioid prescribing report cards, which were mailed to Medicaid providers in Philadelphia, Pennsylvania. METHODS: Using a quasi-experimental approach, we compared trends in opioid prescribing by Medicaid providers in Philadelphia, who received a report card in late 2017, with Medicaid providers in surrounding counties, who did not receive report cards. First, we used propensity score matching to balance observed differences in the treatment and comparison groups; matching variables included provider specialty, sex, and selected characteristics of providers' Medicaid patient panels. We then estimated a difference-in-differences model to isolate the impact of report cards on opioid prescribing. RESULTS: The analytical sample included 1,598 providers in Philadelphia and 2,117 providers in surrounding counties, who prescribed opioids to 99,548 Medicaid patients during the study period. Although the number of Medicaid patients receiving opioids and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month. CONCLUSIONS: After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization. DISCLOSURES: Drs Candon and Rothbard and Ms Shen received funding from Community Behavioral Health in Philadelphia, Pennsylvania. Drs Xue, Cole, and Donohue received funding from Pennsylvania Department of Human Services. Neither Community Behavioral Health nor the Pennsylvania Department of Human Services was involved in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.

Persistent polypharmacy and fall injury risk: the Health, Aging and Body Composition Study.

BACKGROUND: Older adults receive treatment for fall injuries in both inpatient and outpatient settings. The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient injuries. We examined the association between persistent polypharmacy and treated fall injury risk from inpatient and outpatient settings in community-dwelling older adults. METHODS: The Health, Aging and Body Composition Study included 1764 community-dwelling adults (age 73.6 ± 2.9 years; 52% women; 38% black) with Medicare Fee-For-Service (FFS) claims at or within 6 months after 1998/99 clinic visit. Incident fall injuries (N = 545 in 4.6 ± 2.9 years) were defined as the initial claim with an ICD-9 fall E-code and non-fracture injury, or fracture code with/without a fall code from 1998/99 clinic visit to 12/31/08. Those without fall injury (N = 1219) were followed for 8.1 ± 2.6 years. Stepwise Cox models of fall injury risk with a time-varying variable for persistent polypharmacy (defined as ≥6 prescription medications at the two most recent consecutive clinic visits) were adjusted for demographics, lifestyle characteristics, chronic conditions, and functional ability. Sensitivity analyses explored if persistent polypharmacy both with and without fall risk increasing drugs (FRID) use were similarly associated with fall injury risk. RESULTS: Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk (hazard ratio [HR]: 1.31 [1.06, 1.63]) after adjusting for covariates. Persistent polypharmacy with FRID use was associated with a 48% increase in fall injury risk (95%CI: 1.10, 2.00) vs. those who had non-persistent polypharmacy without FRID use. Risks for persistent polypharmacy without FRID use (HR: 1.22 [0.93, 1.60]) and non-persistent polypharmacy with FRID use (HR: 1.08 [0.77, 1.51]) did not significantly increase compared to non-persistent polypharmacy without FRID use. CONCLUSIONS: Persistent polypharmacy, particularly combined with FRID use, was associated with increased risk for treated fall injuries from inpatient and outpatient settings. Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk.

Body Composition by Computed Tomography vs Dual-Energy X-ray Absorptiometry: Long-Term Prediction of All-Cause Mortality in the Health ABC Cohort.

BACKGROUND: Body composition assessment by computed tomography (CT) predicts health outcomes in diverse populations. However, its performance in predicting mortality has not been directly compared to dual-energy X-ray absorptiometry (DXA). Additionally, the association between different body compartments and mortality, acknowledging the compositional nature of the human body, is not well studied. Compositional data analysis, which is applied to multivariate proportion-type data set, may help to account for the interrelationships of body compartments by constructing log ratios of components. Here, we determined the associations of baseline CT-based measures of mid-thigh cross-sectional areas versus DXA measures of body composition with all-cause mortality in the Health ABC cohort, using both traditional (individual body compartments) and compositional data analysis (using ratios of body compartments) approaches. METHODS: The Health ABC study assessed body composition in 2911 older adults in 1996-1997. We investigated the individual and ratios of (by compositional analysis) body compartments assessed by DXA (lean, fat, and bone masses) and CT (muscle, subcutaneous fat area, intermuscular fat, and bone) on mortality, using Cox proportional hazard models. RESULTS: Lower baseline muscle area by CT (hazard ratio [HR]men = 0.56; 95% confidence interval [95% CI]: 0.48-0.67, HRwomen = 0.60; 95% CI: 0.48-0.74) and fat mass by DXA (HRmen = 0.48; 95% CI: 0.24-0.95) were predictors of mortality in traditional Cox regression analysis. Consistently, compositional data analysis revealed that lower muscle area versus IMF, muscle area versus bone area, and lower fat mass versus lean mass were associated with higher mortality in both sexes. CONCLUSION: Both CT measure of muscle area and DXA fat mass (either individually or relative to other body compartments) were strong predictors of mortality in both sexes in a community research setting.

Cardiovascular disease risk and the time to insulin initiation for Medicaid enrollees with type 2 diabetes.

AIMS: We evaluated the relationship between the timing of insulin initiation and cardiovascular diseases (CVD) risk in Pennsylvania Medicaid enrollees with type 2 diabetes (T2D). METHODS: We included 17,873 enrollees (age 47.4 ± 10.3 years; range 18-64 years) initially treated with non-insulin glucose-lowering agents (GLAs) in 2008-2016. Based on clinical guidelines, we identified early (N = 1,158; 6%; insulin initiation ≤ 6 months after first-line GLAs), in-time (N = 569; 3%; 6-12 months), delayed (N = 2,761; 15%; >12 months), and non-insulin users (N = 13,385; 75%). The Prentice-Williams-Peterson (PWP) models with inverse probability weighting estimated CVD risk across the four groups and the change in risk after insulin initiation. RESULTS: Regardless of time to insulin initiation, insulin users had higher CVD risks after first-line GLAs than non-insulin users (aHR: early: 2.0 [1.5-2.5], in-time: 1.8 [1.2-2.6], delayed: 1.9 [1.6-2.3]). However, we found only a borderline increase in CVD risk after insulin initiation vs. before in early (aHR: 1.4 [1.1-1.8]) and delayed users (aHR: 1.3 [1.0-1.7]), and no increase in in-time users (aHR: 1.3 [0.9-2.0]). CONCLUSIONS: We observed no gains in CVD benefits from insulin initiation in the early stages of pharmacotherapy possibly because CVD developed before insulin initiation. Additional management of hypertension and dyslipidemia may be important to reduce CVD risk in this young and middle-aged T2D cohort.

Association between physician adoption of a new oral anti-diabetic medication and Medicare and Medicaid drug spending.

BACKGROUND: In the United States, there is well-documented regional variation in prescription drug spending. However, the specific role of physician adoption of brand name drugs on the variation in patient-level prescription drug spending is still being investigated across a multitude of drug classes. Our study aims to add to the literature by determining the association between physician adoption of a first-in-class anti-diabetic (AD) drug, sitagliptin, and AD drug spending in the Medicare and Medicaid populations in Pennsylvania. METHODS: We obtained physician-level data from QuintilesIMS Xponent™ database for Pennsylvania and constructed county-level measures of time to adoption and share of physicians adopting sitagliptin in its first year post-introduction. We additionally measured total AD drug spending for all Medicare fee-for-service and Part D enrollees (N = 125,264) and all Medicaid (N = 50,836) enrollees with type II diabetes in Pennsylvania for 2011. Finite mixture model regression, adjusting for patient socio-demographic/clinical characteristics, was used to examine the association between physician adoption of sitagliptin and AD drug spending. RESULTS: Physician adoption of sitagliptin varied from 44 to 99% across the state's 67 counties. Average per capita AD spending was $1340 (SD $1764) in Medicare and $1291 (SD $1881) in Medicaid. A 10% increase in the share of physicians adopting sitagliptin in a county was associated with a 3.5% (95% CI: 2.0-4.9) and 5.3% (95% CI: 0.3-10.3) increase in drug spending for the Medicare and Medicaid populations, respectively. CONCLUSIONS: In a medication market with many choices, county-level adoption of sitagliptin was positively associated with AD spending in Medicare and Medicaid, two programs with different approaches to formulary management.

Integration and Utilization of Peer Leaders for Diabetes Self-Management Support: Results From Project SEED (Support, Education, and Evaluation in Diabetes).

Purpose The purpose of the study was to evaluate the effectiveness of a peer leader-led (PL) diabetes self-management support (DSMS) group in achieving and maintaining improvements in A1C, self-monitoring of blood glucose (SMBG), and diabetes distress in individuals with diabetes. Diabetes self-management support is critical; however, effective, sustainable support models are scarce. Methods The study was a cluster randomized controlled trial of 221 people with diabetes from 6 primary care practices. Practices and eligible participants (mean age: 63.0 years, 63.8% female, 96.8% white, 28.5% at or below poverty level, 32.5% using insulin, A1C ≥7%: 54.2%) were randomized to diabetes self-management education (DSME) + PL DSMS (n = 119) or to enhanced usual care (EUC) (DSME + traditional DSMS with no PL; n = 102). Data were collected at baseline, after DSME (6 weeks), after DSMS (6 months), and after telephonic DSMS (12 months). Results Decreases in A1C occurred between baseline and post-DSME in both groups. Both groups sustained improvements during DSMS, but A1C levels increased during telephonic DSMS. Improvements in self-monitoring of blood glucose were observed in both groups following DSME and were sustained throughout. At study end, the intervention group was 4.3 times less likely to have diabetes regimen-related distress compared to EUC. Conclusions PL DSMS is as effective as traditional DSMS in helping participants to maintain glycemic control and self-monitoring of blood glucose (SMBG) and more effective at improving distress. With increasing diabetes prevalence and shortage of diabetes educators, it is important to integrate and use low-cost interventions in high-risk communities that build on available resources.