Association Between Adverse Social Determinants of Health and Suicide Death.

OBJECTIVE: The aim of this study was to identify adverse social determinants of health (SDoH) International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code prevalence among individuals who died by suicide and to examine associations between documented adverse SDoH and suicide. RESEARCH DESIGN: A case-control study using linked medical record, insurance claim, and mortality data from 2000 to 2015 obtained from 9 Mental Health Research Network-affiliated health systems. We included 3330 individuals who died by suicide and 333,000 randomly selected controls matched on index year and health system location. All individuals in the study (cases and controls) had at least 10 months of enrollment before the study index date. The index date for the study for each case and their matched controls was the suicide date for that given case. RESULTS: Adverse SDoH documentation was low; only 6.6% of cases had ≥1 documented adverse SDoH in the year before suicide. Any documented SDoH and several specific adverse SDoH categories were more frequent among cases than controls. Any documented adverse SDoH was associated with higher suicide odds [adjusted odds ratio (aOR)=2.76; 95% CI: 2.38-3.20], as was family alcoholism/drug addiction (aOR=18.23; 95% CI: 8.54-38.92), being an abuse victim/perpetrator (aOR=2.53; 95% CI: 1.99-3.21), other primary support group problems (aOR=1.91; 95% CI: 1.32-2.75), employment/occupational maladjustment problems (aOR=8.83; 95% CI: 5.62-13.87), housing/economic problems (aOR: 6.41; 95% CI: 4.47-9.19), legal problems (aOR=27.30; 95% CI: 12.35-60.33), and other psychosocial problems (aOR=2.58; 95% CI: 1.98-3.36). CONCLUSIONS: Although documented SDoH prevalence was low, several adverse SDoH were associated with increased suicide odds, supporting calls to increase SDoH documentation in medical records. This will improve understanding of SDoH prevalence and assist in identification and intervention among individuals at high suicide risk.

Examining sociodemographic correlates of opioid use, misuse, and use disorders in the All of Us Research Program.

BACKGROUND: The All of Us Research Program enrolls diverse US participants which provide a unique opportunity to better understand the problem of opioid use. This study aims to estimate the prevalence of opioid use and its association with sociodemographic characteristics from survey data and electronic health record (EHR). METHODS: A total of 214,206 participants were included in this study who competed survey modules and shared EHR data. Adjusted logistic regressions were used to explore the associations between sociodemographic characteristics and opioid use. RESULTS: The lifetime prevalence of street opioids was 4%, and the nonmedical use of prescription opioids was 9%. Men had higher odds of lifetime opioid use (aOR: 1.4 to 3.1) but reduced odds of current nonmedical use of prescription opioids (aOR: 0.6). Participants from other racial and ethnic groups were at reduced odds of lifetime use (aOR: 0.2 to 0.9) but increased odds of current use (aOR: 1.9 to 9.9) compared with non-Hispanic White participants. Foreign-born participants were at reduced risks of opioid use and diagnosed with opioid use disorders (OUD) compared with US-born participants (aOR: 0.36 to 0.67). Men, Younger, White, and US-born participants are more likely to have OUD. CONCLUSIONS: All of Us research data can be used as an indicator of national trends for monitoring the prevalence of receiving prescription opioids, diagnosis of OUD, and non-medical use of opioids in the US. The program employs a longitudinal design for routinely collecting health-related data including EHR data, that will contribute to the literature by providing important clinical information related to opioids over time. Additionally, this data will enhance the estimates of the prevalence of OUD among diverse populations, including groups that are underrepresented in the national survey data.

Assessing the differential item functioning of PHQ-9 items for diverse racial and ethnic adults with mental health and/or substance use disorder diagnoses: A retrospective cohort study.

BACKGROUND: Improving health equity in depression care and suicide screening requires that measures like the Patient Health Questionnaire 9 (PHQ-9) function similarly for diverse racial and ethnic groups. We evaluated PHQ-9 differential item functioning (DIF) between racial/ethnic groups in a retrospective cohort study of secondary electronic health record (EHR) data from eight healthcare systems. METHODS: The population (n = 755,156) included patients aged 18-64 with mental health and/or substance use disorder (SUD) diagnoses who had a PHQ-9 with no missing item data in the EHR for primary care or mental health visits between 1/1/2009-9/30/2017. We drew two random samples of 1000 from the following racial/ethnic groups originally recorded in EHRs (n = 14,000): Hispanic, and non-Hispanic White, Black, Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, multiracial. We assessed DIF using iterative hybrid ordinal logistic regression and item response theory with p < 0.01 and 1000 Monte Carlo simulations, where change in model R2 > 0.01 represented non-negligible (e.g., clinically meaningful) DIF. RESULTS: All PHQ-9 items displayed statistically significant, but negligible (e.g., clinically unmeaningful) DIF between compared groups. The negligible DIF varied between random samples, although six items showed negligible DIF between the same comparison groups in both random samples. LIMITATIONS: Our findings may not generalize to disaggregated racial/ethnic groups or persons without mental health and/or SUD diagnoses. CONCLUSIONS: We found the PHQ-9 had clinically unmeaningful cross-cultural DIF for adult patients with mental health and/or SUD diagnoses. Future research could disaggregate race/ethnicity to discern if within-group identification impacts PHQ-9 DIF.

Diagnosed Posttraumatic Stress Disorder and Other Trauma-Associated Stress Disorders and Risk for Suicide Mortality.

OBJECTIVE: Strong evidence exists for posttraumatic stress disorder (PTSD) as a risk factor for suicidal thoughts and behaviors across diverse populations. However, few empirical studies have examined PTSD and other trauma-associated stress disorders as risk factors for suicide mortality among health system populations. This study aimed to assess trauma-associated stress diagnoses as risk factors for suicide mortality in a U.S. health system population. METHODS: This case-control, matched-design study examined individuals who died by suicide between 2000 and 2015 and had received care from nine U.S. health systems affiliated with the Mental Health Research Network (N=3,330). Individuals who died by suicide were matched with individuals from the general health system population (N=333,000): 120 individuals with PTSD who died by suicide were matched with 1,592 control group members, 84 with acute reaction to stress were matched with 2,218 control individuals, and 331 with other stress reactions were matched with 8,174 control individuals. RESULTS: After analyses were adjusted for age and sex, individuals with any trauma-associated stress condition were more likely to have died by suicide. Risk was highest among individuals with PTSD (adjusted OR [AOR]=10.10, 95% CI=8.31-12.27), followed by those with other stress reactions (AOR=5.38, 95% CI=4.78-6.06) and those with acute reaction to stress (AOR=4.49, 95% CI=3.58-5.62). Patterns of risk remained the same when the analyses were adjusted for any comorbid psychiatric condition. CONCLUSIONS: All trauma-associated stress disorders are risk factors for suicide mortality, highlighting the importance of health system suicide prevention protocols that consider the full spectrum of traumatic stress diagnoses.

Are People Who Die by Intentional Medication Poisoning Dispensed Those Medications in the Year Prior to Death?

OBJECTIVE: The rate of suicidal poisoning in the United States has increased substantially over the past 20 years. Understanding whether prescription medications used for self-poisoning were recently dispensed would help inform suicide prevention efforts. Alternatively, medications for self-poisoning could have been formerly dispensed or collected from friends, family, or illicit sources. METHODS: Among those who died by intentional opioid and psychotropic poisonings, we conducted a descriptive study to determine what proportion had a recently filled prescription that could have been the means of suicide. Subjects were all people who died by intentional poisoning across nine health-care systems within the NIH-funded Mental Health Research Network. RESULTS: Among the 3,300 people who died by suicide, 700 died by any poisoning and 194 died by intentional opioid or psychotropic/hypnotic medication poisoning. Among those who died by intentional opioid poisoning 73% were dispensed an opioid in the year prior. Among those who died by intentional psychotropic/hypnotic poisoning, 83% were dispensed any psychotropic and 61% were dispensed a hypnotic in prior year. Most people were continuously dispensed the same medications used in their intentional poisonings in the year prior to death. CONCLUSIONS: Our results indicate that most medications used in suicidal overdose were likely recently dispensed. Therefore, future suicide prevention studies and prevention resources should focus on medication safety interventions such as lethal-means counseling for medication access, limiting quantities dispensed, opioid antagonists, and blister packs. HIGHLIGHTSUnderstanding whether medications used for self-poisoning were recently dispensed or formerly/never dispensed would help inform future studies and suicide prevention efforts.We found that most people who died by intentional poisoning with opioids or psychotropic/hypnotic medications received frequent dispensings of the medication used for self-poisoning in the year prior to death.Future suicide prevention studies and efforts should focus on medication safety interventions such as lethal-means counseling for medication access, limiting quantities dispensed, opioid antagonists, and blister packs.

Health Diagnoses and Service Utilization in the Year Before Youth and Young Adult Suicide.

OBJECTIVE: Suicide rates among young people are rising. Health care visits provide opportunities for identification and intervention, yet studies have been limited by small or circumscribed samples. This study sought to expand the knowledge base by examining health care encounters and diagnoses among young people who later died by suicide. METHODS: This case-control study examined diagnoses of mental and general medical disorders and health care utilization in the 30 and 365 days before suicide death in nine large U.S. health care systems. Data (years 2000-2015) from 445 suicide decedents ages 10-24 years were matched with data from 4,450 control group patients. RESULTS: Suicide decedents were more likely to have at least one mental disorder diagnosis (51% vs. 16%; adjusted OR [AOR]=5.74, 95% CI=4.60-7.18) and had higher rates of nearly all mental health conditions. Substance use disorders were common (12%) and more likely (AOR=8.50, 95% CI=5.53-13.06) among suicide decedents. More than one in three (42%) suicide decedents had a health care visit in the month before death, and nearly all (88%) had a visit in the previous year. CONCLUSIONS: Despite the greater likelihood of suicide associated with mental disorder diagnoses, such disorders were present among only 51% of suicide decedents. High rates of health care utilization among suicide decedents indicate a need for improving identification of mental health conditions and suicide risk across the health care system. Increased substance use screening may help identify youths at high risk because substance use disorders were significantly more prevalent and likely among suicide decedents.

Effect of the STRIDE fall injury prevention intervention on falls, fall injuries, and health-related quality of life.

BACKGROUND: Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster-randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community-dwelling older adults age ≥70 at increased fall injury risk. METHODS: We assessed fall-related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health-related quality of life (HRQOL) using the EQ-5D-5L and EQ-VAS. We used Poisson models to assess intervention effects on falls, fall-related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL. RESULTS: For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93-1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80-1.08; p = 0.337) for self-reported fractures, 0.89 (95% CI, 0.73-1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77-1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89-1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non-significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ-5D-5L (intervention minus control) was 0.009 (95% CI, -0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, -0.006 to 0.015; p = 0.384) at 24 months. CONCLUSIONS: Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient-, practice-, and organization-level operational strategies to increase the real-world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects. CLINICALTRIALS: gov identifier: NCT02475850.

Demographic differences in willingness to share electronic health records in the All of Us Research Program.

OBJECTIVE: Participant willingness to share electronic health record (EHR) information is central to success of the National Institutes of Health All of Us Research Program (AoURP). We describe the demographic characteristics of participants who decline access to their EHR data. MATERIALS AND METHODS: We included participants enrolling in AoURP between June 6, 2017 and December 31, 2019 through the Trans-American Consortium for the Health Care Systems Research Network (TACH). TACH is a consortium of health care systems spanning 6 states, and an AoURP research partner. RESULTS: We analyzed data for 25 852 participants (89.3% of those enrolled). Mean age = 52.0 years (SD 16.8), with 66.5% White, 18.7% Black/African American, 7.7% Hispanic, 32.5% female, and 76% with >a high school diploma. Overall, 2.3% of participants declined to share access to their EHR data (range across TACH sites = 1.3% to 3.5%). Younger age, female sex, and education >high school were significantly associated with decline to share EHR data, odds ratio (95% confidence interval) = 1.26 (1.19-1.33), 1.74 (1.42-2.14), and 2.44 (1.86-3.21), respectively. Results were similar when several sensitivity analyses were performed. DISCUSSION: AoURP seeks a dataset reflecting our nation's diversity in all aspects of participation. Those under-represented in biomedical research may be reluctant to share access to their EHR data. CONCLUSION: In our data, race and ethnicity were not independently related to participant decision to decline access to their EHR information. Results suggest that the value of the AoURP dataset is unlikely to be constrained by the size or the racial/ethnic composition of this subgroup.

Effect of Clinical Decision Support on Cardiovascular Risk Among Adults With Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia: A Cluster Randomized Clinical Trial.

IMPORTANCE: Adults with schizophrenia, schizoaffective disorder, or bipolar disorder, collectively termed serious mental illness (SMI), have shortened life spans compared with people without SMI. The leading cause of death is cardiovascular (CV) disease. OBJECTIVE: To assess whether a clinical decision support (CDS) system aimed at primary care clinicians improves CV health for adult primary care patients with SMI. DESIGN, SETTING, AND PARTICIPANTS: In this cluster randomized clinical trial conducted from March 2, 2016, to September 19, 2018, restricted randomization assigned 76 primary care clinics in 3 Midwestern health care systems to receive or not receive a CDS system aimed at improving CV health among patients with SMI. Eligible clinics had at least 20 patients with SMI; clinicians and their adult patients with SMI with at least 1 modifiable CV risk factor not at the goal set by the American College of Cardiology/American Heart Association guidelines were included. Statistical analysis was conducted on an intention-to-treat basis from January 10, 2019, to December 29, 2021. INTERVENTION: The CDS system assessed modifiable CV risk factors and provided personalized treatment recommendations to clinicians and patients. MAIN OUTCOMES AND MEASURES: Patient-level change in total modifiable CV risk over 12 months, summed from individual modifiable risk factors (smoking, body mass index, low-density lipoprotein cholesterol level, systolic blood pressure, and hemoglobin A1c level). RESULTS: A total of 80 clinics were randomized; 4 clinics were excluded for having fewer than 20 eligible patients, leaving 42 intervention clinics and 34 control clinics. A total of 8937 patients with SMI (4922 women [55.1%]; mean [SD] age, 48.4 [13.5] years) were enrolled. There was a 4% lower rate of increase in total modifiable CV risk among intervention patients relative to control patients (relative rate ratio [RR], 0.96; 95% CI, 0.94-0.98). The intervention favored patients who were 18 to 29 years of age (RR, 0.89; 95% CI, 0.81-0.98) or 50 to 59 years of age (RR, 0.93; 95% CI, 0.90-0.96), Black (RR, 0.93; 95% CI, 0.88-0.98), or White (RR, 0.96; 95% CI, 0.94-0.98). Men (RR, 0.96; 95% CI, 0.94-0.99) and women (RR, 0.95; 95% CI, 0.92-0.97), as well as patients with any SMI subtype (bipolar disorder: RR, 0.96; 95% CI, 0.94-0.99; schizoaffective disorder: RR, 0.94; 95% CI, 0.90-0.98; schizophrenia: RR, 0.92; 95% CI, 0.85-0.99) also benefited from the intervention. Despite treatment effects favoring the intervention, there were no significant differences in individual modifiable risk factors. CONCLUSIONS AND RELEVANCE: This CDS intervention resulted in a rate of change in total modifiable CV risk that was 4% lower among intervention patients compared with control patients. Results were driven by the cumulative effects of incremental and mostly nonsignificant changes in individual modifiable risk factors. These findings emphasize the value of using CDS to prompt early primary care intervention for adults with SMI. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02451670.

Feasibility of preemptive pharmacogenetic testing in colorectal cancer patients within a community oncology setting.

INTRODUCTION: Pharmacogenetics, in hand with precision medicine in oncology, represents an opportunity to holistically tailor a patient's treatment regimen using both somatic and germline variants to improve efficacy and decrease toxicity. Colorectal cancer patients represent a population with frequent use of fluoropyrimidine and irinotecan and are an ideal opportunity for implementation of preemptive pharmacogenetics as evidence supports pharmacogenetic testing for DPYD and UGT1A1 to reduce fluoropyrimidine and irinotecan toxicities. METHODS: This was a single arm proof-of-concept study at a large community-based health system. Participants provided samples for pharmacogenetic testing via an external vendor prior to chemotherapy initiation and an oncology pharmacist was responsible for pharmacogenetic interpretation and pharmacogenetic-guided therapeutic recommendation to the treating provider. RESULTS: A total of 24 (60%) participants had a UGT1A1 variant. All participants (100%) were DPYD*1/*1. Results were available and interpreted for 29/40 (72.5%) participants prior to scheduled chemotherapy initiation (p value <0.014). Of the participants whose results were available in 5 weekdays or less (n = 23), 20 (87%) were communicated with the treating provider prior to scheduled chemotherapy administration. A total turnaround time of 5 days or less was significantly associated with PGx feasibility in a community-based oncology clinic (p = 0.03). CONCLUSIONS: In conclusion, we were able to show that implementation of preemptive pharmacogenetic testing into a community oncology clinic with results interpretation available prior to scheduled initiation of chemotherapy was feasible. As pharmacogenetic testing in oncology expands, pharmacists should be prepared to optimize supportive medication regimens as well as chemotherapy with pharmacogenetic results.

Overcoming gaps: regional collaborative to optimize capacity management and predict length of stay of patients admitted with COVID-19.

OBJECTIVE: Ensuring an efficient response to COVID-19 requires a degree of inter-system coordination and capacity management coupled with an accurate assessment of hospital utilization including length of stay (LOS). We aimed to establish optimal practices in inter-system data sharing and LOS modeling to support patient care and regional hospital operations. MATERIALS AND METHODS: We completed a retrospective observational study of patients admitted with COVID-19 followed by 12-week prospective validation, involving 36 hospitals covering the upper Midwest. We developed a method for sharing de-identified patient data across systems for analysis. From this, we compared 3 approaches, generalized linear model (GLM) and random forest (RF), and aggregated system level averages to identify features associated with LOS. We compared model performance by area under the ROC curve (AUROC). RESULTS: A total of 2068 patients were included and used for model derivation and 597 patients for validation. LOS overall had a median of 5.0 days and mean of 8.2 days. Consistent predictors of LOS included age, critical illness, oxygen requirement, weight loss, and nursing home admission. In the validation cohort, the RF model (AUROC 0.890) and GLM model (AUROC 0.864) achieved good to excellent prediction of LOS, but only marginally better than system averages in practice. CONCLUSION: Regional sharing of patient data allowed for effective prediction of LOS across systems; however, this only provided marginal improvement over hospital averages at the aggregate level. A federated approach of sharing aggregated system capacity and average LOS will likely allow for effective capacity management at the regional level.

Evaluating the Cross-Cultural Measurement Invariance of the PHQ-9 between American Indian/Alaska Native Adults and Diverse Racial and Ethnic Groups.

BACKGROUND: The Patient Health Questionnaire-9 (PHQ-9), a self-reported depression screening instrument for measurement-based care (MBC), may have cross-cultural measurement invariance (MI) with a regional group of American Indian/Alaska Native (AI/AN) and non-Hispanic White adults. However, to ensure health equity, research was needed on the cross-cultural MI of the PHQ-9 between other groups of AI/AN peoples and diverse populations. METHODS: We assessed the MI of the one-factor PHQ-9 model and five previously identified two-factor models between non-Hispanic AI/AN adults (ages 18-64) from healthcare systems A (n=1,759) and B (n=2,701) using secondary data and robust maximum likelihood estimation. We then tested either fully or partially invariant models for MI between either combined or separate AI/AN groups, respectively, and Hispanic (n=7,974), White (n=7,974), Asian (n=6,988), Black (n=6,213), and Native Hawaiian/Pacific Islander (n=1,370) adults from healthcare system B. All had mental health or substance use disorder diagnoses and were seen in behavioral health or primary care from 1/1/2009-9/30/2017. RESULTS: The one-factor PHQ-9 model was partially invariant, with two-factor models partially, or in one case fully, invariant between AI/AN groups. The one-factor model and three two-factor models were partially invariant between all seven groups, while a two-factor model was fully invariant and another partially invariant between a combined AI/AN group and other racial and ethnic groups. CONCLUSIONS: Achieving health equity in MBC requires ensuring the cross-cultural validity of measurement tools. Before comparing mean scores, PHQ-9 models should be assessed for individual racial and ethnic group fit for adults with mental health or substance use disorders.

Pharmacogenomics education, research and clinical implementation in the state of Minnesota.

Several healthcare organizations across Minnesota have developed formal pharmacogenomic (PGx) clinical programs to increase drug safety and effectiveness. Healthcare professional and student education is strong and there are multiple opportunities in the state for learners to gain workforce skills and develop advanced competency in PGx. Implementation planning is occurring at several organizations and others have incorporated structured utilization of PGx into routine workflows. Laboratory-based and translational PGx research in Minnesota has driven important discoveries in several therapeutic areas. This article reviews the state of PGx activities in Minnesota including educational programs, research, national consortia involvement, technology, clinical implementation and utilization and reimbursement, and outlines the challenges and opportunities in equitable implementation of these advances.

Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study.

BACKGROUND/OBJECTIVES: In the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability. DESIGN: Pragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries. SETTING: A total of 86 primary care practices within 10 U.S. healthcare systems. PARTICIPANTS: A random subsample of 743 persons aged 75 and older. MEASUREMENTS: The well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument. RESULTS: Participants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference. CONCLUSIONS: STRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.

Pharmacist's attitudes and knowledge of pharmacogenomics and the factors that may predict future engagement.

BACKGROUND: While pharmacists are well positioned to implement pharmacogenomic testing in healthcare systems, uptake has been limited. OBJECTIVE: The primary objective of this survey was to determine how post-graduate education and training influences pharmacist's knowledge and attitudes of pharmacogenomic testing. METHODS: Survey questions were developed by the study team, and responses were collected electronically using REDCap™. The electronic survey was sent to all pharmacists (n=161) within a large, multi-state healthcare system by email. RESULTS: A total of 75 (47%) respondents completed all aspects of the survey. The majority of respondents were female (60%), worked in acute care settings (57%), were full-time employees (80%), and worked in an urban area (85%), with many graduating in or after 2010 (43%). For post-graduate education, 36% of respondents completed a Post-Graduate Year One Residency (PGY-1), and 27% had a board certification. Those that completed a PGY-1 residency were significantly more likely to have received formal training or education on pharmacogenomics than those who had not. They also assessed their own knowledge of pharmacogenomic resources and guidelines higher than those without PGY-1 training. More recent graduates were also significantly more likely to have received formal training or education on pharmacogenomics. Additionally, pharmacists who completed a PGY-1 residency were more likely to respond favorably to pharmacogenomics being offered through pharmacy services. Pharmacists with board certification were more comfortable interpreting results of a pharmacogenomic test than those without board certification. CONCLUSIONS: Pharmacists who have completed a PGY-1 residency or received board certification appear more comfortable with interpretation and implementation of pharmacogenomic testing.

Pharmacist's attitudes and knowledge of pharmacogenomics and the factors that may predict future engagement

BACKGROUND: While pharmacists are well positioned to implement pharmacogenomic testing in healthcare systems, uptake has been limited. OBJECTIVE: The primary objective of this survey was to determine how post-graduate education and training influences pharmacist's knowledge and attitudes of pharmacogenomic testing. METHODS: Survey questions were developed by the study team, and responses were collected electronically using REDCapTM. The electronic survey was sent to all pharmacists (n=161) within a large, multi-state healthcare system by email. RESULTS: A total of 75 (47%) respondents completed all aspects of the survey. The majority of respondents were female (60%), worked in acute care settings (57%), were full-time employees (80%), and worked in an urban area (85%), with many graduating in or after 2010 (43%). For post-graduate education, 36% of respondents completed a Post-Graduate Year One Residency (PGY-1), and 27% had a board certification. Those that completed a PGY-1 residency were significantly more likely to have received formal training or education on pharmacogenomics than those who had not. They also assessed their own knowledge of pharmacogenomic resources and guidelines higher than those without PGY-1 training. More recent graduates were also significantly more likely to have received formal training or education on pharmacogenomics. Additionally, pharmacists who completed a PGY-1 residency were more likely to respond favorably to pharmacogenomics being offered through pharmacy services. Pharmacists with board certification were more comfortable interpreting results of a pharmacogenomic test than those without board certification. CONCLUSIONS: Pharmacists who have completed a PGY-1 residency or received board certification appear more comfortable with interpretation and implementation of pharmacogenomic testing

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A Randomized Trial of a Multifactorial Strategy to Prevent Serious Fall Injuries.

BACKGROUND: Injuries from falls are major contributors to complications and death in older adults. Despite evidence from efficacy trials that many falls can be prevented, rates of falls resulting in injury have not declined. METHODS: We conducted a pragmatic, cluster-randomized trial to evaluate the effectiveness of a multifactorial intervention that included risk assessment and individualized plans, administered by specially trained nurses, to prevent fall injuries. A total of 86 primary care practices across 10 health care systems were randomly assigned to the intervention or to enhanced usual care (the control) (43 practices each). The participants were community-dwelling adults, 70 years of age or older, who were at increased risk for fall injuries. The primary outcome, assessed in a time-to-event analysis, was the first serious fall injury, adjudicated with the use of participant report, electronic health records, and claims data. We hypothesized that the event rate would be lower by 20% in the intervention group than in the control group. RESULTS: The demographic and baseline characteristics of the participants were similar in the intervention group (2802 participants) and the control group (2649 participants); the mean age was 80 years, and 62.0% of the participants were women. The rate of a first adjudicated serious fall injury did not differ significantly between the groups, as assessed in a time-to-first-event analysis (events per 100 person-years of follow-up, 4.9 in the intervention group and 5.3 in the control group; hazard ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P = 0.25). The rate of a first participant-reported fall injury was 25.6 events per 100 person-years of follow-up in the intervention group and 28.6 events per 100 person-years of follow-up in the control group (hazard ratio, 0.90; 95% CI, 0.83 to 0.99; P = 0.004). The rates of hospitalization or death were similar in the two groups. CONCLUSIONS: A multifactorial intervention, administered by nurses, did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care. (Funded by the Patient-Centered Outcomes Research Institute and others; STRIDE ClinicalTrials.gov number, NCT02475850.).

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness.

BACKGROUND: Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia. METHODS: Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses. RESULTS: Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications. CONCLUSIONS: Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.

Variation in patterns of health care before suicide: A population case-control study.

BACKGROUND: The United States has experienced a significant rise in suicide. As decision makers identify how to address this national concern, healthcare systems have been identified as an optimal location for prevention. OBJECTIVE: To compare variation in patterns of healthcare use, by health setting, between individuals who died by suicide and the general population. DESIGN: Case-Control Study. SETTING: Eight healthcare systems across the United States. PARTICIPANTS: 2674 individuals who died by suicide between 2000 and 2013 along with 267,400 individuals matched on time-period of health plan membership and health system affiliation. MEASUREMENTS: Healthcare use in the emergency room, inpatient hospital, primary care, and outpatient specialty setting measured using electronic health record data during the 7-, 30-, 60-, 90-, 180-, and 365-day time periods before suicide and matched index date for controls. RESULTS: Healthcare use was more common across all healthcare settings for individuals who died by suicide. Nearly 30% of individuals had a healthcare visit in the 7-days before suicide (6.5% emergency, 16.3% outpatient specialty, and 9.5% primary care), over half within 30 days, and >90% within 365 days. Those who died by suicide averaged 16.7 healthcare visits during the year. The relative risk of suicide was greatest for individuals who received care in the inpatient setting (aOR = 6.23). There was both a large relative risk (aOR = 3.08) and absolute utilization rate (43.8%) in the emergency room before suicide. LIMITATIONS: Participant race/ethnicity was not available. The sample did not include uninsured individuals. CONCLUSIONS: This study provides important data about how care utilization differs for those who die by suicide compared to the general population and can inform decision makers on targeting of suicide prevention activities within health systems.