Who Provides Outpatient Clinical Care for Adults With ADHD? Analysis of Healthcare Claims by Types of Providers Among Private Insurance and Medicaid Enrollees, 2021.

OBJECTIVE: To characterize provider types delivering outpatient care overall and through telehealth to U.S. adults with ADHD. METHOD: Using employer-sponsored insurance (ESI) and Medicaid claims, we identified enrollees aged 18 to 64 years who received outpatient care for ADHD in 2021. Billing provider codes were used to tabulate the percentage of enrollees receiving ADHD care from 10 provider types overall and through telehealth. RESULTS: Family practice physicians, psychiatrists, and nurse practitioners/psychiatric nurses were the most common providers for adults with ESI, although the distribution of provider types varied across states. Lower percentages of adults with Medicaid received ADHD care from physicians. Approximately half of adults receiving outpatient ADHD care received ADHD care by telehealth. CONCLUSION: Results may inform the development of clinical guidelines for adult ADHD and identify audiences for guideline dissemination and education planning.

A Narrative Review of Literature Examining Studies Researching the Impact of Law on Health and Economic Outcomes.

CONTEXT: Public health policy can play an important role in improving public health outcomes. Accordingly, there has been an increasing emphasis by policy makers on identifying and implementing evidence-informed public health policy interventions. PROGRAM OR POLICY: Growth and refinement of the field of research assessing the impact of legal interventions on health outcomes, known as legal epidemiology, prompted this review of studies on the relationship between laws and health or economic outcomes. IMPLEMENTATION: Authors systematically searched 8 major literature databases for all English language journal articles that assessed the effect of a law on health and economic outcomes published between January 1, 2009, and September 18, 2019. This search generated 12 570 unique articles 177 of which met inclusion criteria. The team conducting the systematic review was a multidisciplinary team that included health economists and public health policy researchers, as well as public health lawyers with expertise in legal epidemiological research methods. The authors identified and assessed the types of methods used to measure the laws' health impact. EVALUATION: In this review, the authors examine how legal epidemiological research methods have been described in the literature as well as trends among the studies. Overall, 3 major themes emerged from this study: (1) limited variability in the sources of the health data across the studies, (2) limited differences in the methodological approaches used to connect law to health outcomes, and (3) lack of transparency surrounding the source and quality of the legal data relied upon. DISCUSSION: Through highlighting public health law research methodologies, this systematic review may inform researchers, practitioners, and lawmakers on how to better examine and understand the impacts of legal interventions on health and economic outcomes. Findings may serve as a source of suggested practices in conducting legal epidemiological outcomes research and identifying conceptual and method-related gaps in the literature.

Telemental Health Utilization in Commercial Health Insurance Plans in the United States From 2010 Through 2019.

Objective: We sought to characterize patterns of utilization of telemental health among commercially insured individuals over the decade preceding COVID-19.Methods: We developed telemental health service groups from the US PharMetrics Plus database, using diagnostic codes to identify those diagnosed with mental health conditions and procedure codes to capture mental health visits delivered via telehealth sessions. We analyzed 2 indicators of utilization between January 1, 2010, and December 31, 2019: (1) the percentage of patients with mental health needs who used telemental health services and (2) the percentage of all mental health services provided via telehealth. We stratified our analyses by year, patient gender, patient age, and geographic region.Results: The proportion of mental health visits delivered via telemental health increased from 0.002% to 0.162% between 2010 and 2019. A larger proportion of males received telemental health services as compared to females; however, the proportion of mental health visits delivered via telehealth was higher for females than for males. Patients aged 18 to 34 years and those in the western US had the highest utilization compared to other age groups and geographic regions.Conclusions: Telemental health utilization comprised a small fraction of overall mental health services and beneficiaries in the IQVIA PharMetrics Plus claims data, but increased over time, with differences documented in utilization based on patient gender, patient age, geographic region, and type of telemental health claim. Evidence from this study may serve as a pre-pandemic baseline for comparison against future evaluations of telehealth expansion policies.

Trends in Stimulant Prescription Fills Among Commercially Insured Children and Adults - United States, 2016-2021.

Prescription stimulant use, primarily for the treatment of attention-deficit/hyperactivity disorder (ADHD), has increased among adults in the United States during recent decades, while remaining stable or declining among children and adolescents (1,2). MarketScan commercial claims data were analyzed to describe trends in prescription stimulant fills before and during the COVID-19 pandemic (2016-2021) by calculating annual percentages of enrollees aged 5-64 years in employer-sponsored health plans who had one or more prescription stimulant fills overall and by sex and age group. Overall, the percentage of enrollees with one or more prescription stimulant fills increased from 3.6% in 2016 to 4.1% in 2021. The percentages of females aged 15-44 years and males aged 25-44 years with prescription stimulant fills increased by more than 10% during 2020-2021. Future evaluation could determine if policy and health system reimbursement changes enacted during the pandemic contributed to the increase in stimulant prescriptions. Stimulants can offer substantial benefits for persons with ADHD, but also pose potential harms, including adverse effects, medication interactions, diversion and misuse, and overdoses. Well-established clinical guidelines exist for ADHD care, but only for children and adolescents* (3); clinical practice guidelines for adult ADHD could help adults also receive accurate diagnoses and appropriate treatment.

Defining Opioid-related Problems Using a Health Care Safety Net Institution's Inpatient Electronic Health Records: Limitations of Diagnosis-based Definitions.

BACKGROUND: Measuring clinically relevant opioid-related problems in health care systems is challenging due to the lack of standard definitions and coding practices. Well-defined, opioid-related health problems (ORHPs) would improve prevalence estimates and evaluation of clinical interventions, crisis response, and prevention activities. We sought to estimate prevalence of opioid use disorder (OUD), opioid misuse, and opioid poisoning among inpatients at a large, safety net, health care institution. METHODS: Our study included events documented in the electronic health records (EHRs) among hospitalized patients at Denver Health Medical Center during January 1, 2017 to December 31, 2018. Multiple EHR markers (ie, opioid-related diagnostic codes, clinical assessment, laboratory results, and free-text documentation) were used to develop diagnosis-based and extended definitions for OUD, opioid misuse, and opioid poisoning. We used these definitions to estimate number of hospitalized patients with these conditions. RESULTS: During a 2-year study period, 715 unique patients were identified solely using opioid-related diagnostic codes; OUD codes accounted for the largest proportion (499/715, 69.8%). Extended definitions identified an additional 973 unique patients (~136% increase), which includes 155/973 (15.9%) who were identified by a clinical assessment marker, 1/973 (0.1%) by a laboratory test marker, and 817/973 (84.0%) by a clinical documentation marker. CONCLUSIONS: Solely using diagnostic codes to estimate prevalence of clinically relevant ORHPs missed most patients with ORHPs. More inclusive estimates were generated using additional EHR markers. Improved methods to estimate ORHPs among a health care system's patients would more fully estimate organizational and economic burden to more efficiently allocate resources and ensure capacity to provide clinical services.

Impact of rural hospital closures on hospitalizations and associated outcomes for ambulatory and emergency care sensitive conditions.

PURPOSE: The purpose of this paper is to examine the impact of rural hospital closures on age-adjusted hospitalization rates for ambulatory care sensitive condition (ACSC) and emergency care sensitive condition (ECSC) and associated outcomes, such as length of stay and in-hospital mortality in hospital service areas (HSAs) that utilized the closed hospital. METHODS: We used the State Inpatient Data from the Healthcare Cost and Utilization Project for 9 states from 2010 to 2017 and classified admissions as ACSC or ECSC. We compared age-adjusted admission rates and length of stay (LOS) for ACSC and ECSC rates and age adjusted in-hospital mortality rate for ECSC among rural ZIP codes in HSAs with a closure to rural ZIP codes in HSAs without closures. We used propensity score-weighted regression analysis and event study design. FINDINGS: Findings suggest that ACSC admission rates started to increase right before the closure. However, this increase levels off 2 years after closure. LOS for ACSC significantly decreased almost a year after closure. ECSC admissions showed a significant decrease for a few quarters 1 year before the closure. CONCLUSIONS: Rural hospital closures were associated with increase in ACSC admissions right before closure and for nearly 2 years post closure as well as decrease in ECSC admissions before closure. As rural hospitals continue to close, efforts to ensure communities affected by these closures maintain access to primary health care may help eliminate increases in costly preventable hospital admissions for ACSC while ensuring access for emergency care services.

Modeling the Transmission of COVID-19: Impact of Mitigation Strategies in Prekindergarten-Grade 12 Public Schools, United States, 2021.

BACKGROUND: Schools are an integral part of the community; however, congregate settings facilitate transmission of SARS-CoV-2, presenting a challenge to school administrators to provide a safe, in-school environment for students and staff. METHODS: We adapted the Centers for Disease Control and Prevention's COVIDTracer Advanced tool to model the transmission of SARS-CoV-2 in a school of 596 individuals. We estimate possible reductions in cases and hospitalizations among this population using a scenario-based analysis that accounts for (a) the risk of importation of infection from the community; (b) adherence to key Centers for Disease Control and Prevention-recommended mitigation strategies: mask wearing, cleaning and disinfection, hand hygiene, and social distancing; and (c) the effectiveness of contact tracing interventions at limiting onward transmission. RESULTS: Low impact and effectiveness of mitigation strategies (net effectiveness: 27%) result in approximately 40% of exposed staff and students becoming COVID-19 cases. When the net effectiveness of mitigation strategies was 69% or greater, in-school transmission was mostly prevented, yet importation of cases from the surrounding community could result in nearly 20% of the school's population becoming infected within 180 days. The combined effects of mitigation strategies and contact tracing were able to prevent most onward transmission. Hospitalizations were low among children and adults (<0.5% of the school population) across all scenarios examined. CONCLUSIONS: Based on our model, layering mitigation strategies and contact tracing can limit the number of cases that may occur from transmission in schools. Schools in communities with substantial levels of community spread will need to be more vigilant to ensure adherence of mitigation strategies to minimize transmission. Our results show that for school administrators, teachers, and parents to provide the safest environment, it is important to utilize multiple mitigation strategies and contract tracing that reduce SARS CoV-2 transmission by at least 69%. This will require training, reinforcement, and vigilance to ensure that the highest level of adherence is maintained over the entire school term.

Trends in State-Level Pharmacy-Based Naloxone Dispensing Rates, 2012-2019.

INTRODUCTION: Improving access to naloxone is an important public health strategy in the U.S. This study examines the state-level trends in naloxone dispensing from 2012 to 2019 for all 50 states and the District of Columbia. METHODS: Data from IQVIA Xponent were used to examine the trends and geographic inequality in annual naloxone dispensing rates and the number of naloxone prescriptions dispensed per high-dose opioid prescription from 2012 to 2019 and from 2016 to 2019 to correspond with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain release. Annual percentage change was estimated using linear regression. Analyses were conducted in 2020. RESULTS: Naloxone dispensing rates and the number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 2012 to 2019 across all states and the District of Columbia. Average state-level naloxone dispensing rates increased from 0.55 per 100,000 population in 2012 to 45.60 in 2016 and 292.31 in 2019. Similarly, the average number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 0.002 in 2012 to 0.24 in 2016 and 3.04 in 2019. Across both measures of naloxone dispensing, the geographic inequality gap increased during the study period. In 2019, the number of naloxone prescriptions dispensed per 100 high-dose opioid prescriptions ranged from 1.04 to 16.64 across states. CONCLUSIONS: Despite increases in naloxone dispensing across all states, dispensing rates remain low, with substantial variation and increasing disparities over time at the state level. This information may be helpful in efforts to improve naloxone access and in designing state-specific intervention programs.

Estimating costs of hospitalizations associated with opioid use disorder or opioid misuse at a large, urban safety-net hospital-Denver, Colorado, 2017.

INTRODUCTION: The national and state economic burden of the opioid crisis is substantial. This study estimated the number of hospitalizations associated with opioid use disorder (OUD) or opioid misuse (OM) and the cost of those hospitalizations at Denver Health (DH) Medical Center, a large, urban safety-net hospital. METHODS: For 2017, direct inpatient medical costs for hospitalizations associated with OUD or OM at DH Medical Center were estimated and categorized by group and insurance type. Data were from the DH electronic health records database that included charge data. Hospitalizations associated with OUD or OM were identified using diagnostic codes and an expanded set of inclusion criteria including diagnostic codes, opioid withdrawal assessments, opioid-related admission notes, and medication prescriptions to treat OUD. Costs were estimated using cost-to-charge ratios specific to DH. RESULTS: During 2017, 220 hospitalizations, $9,834,979 in total charges, $3,690,724 in estimated total costs, and $2,115,990 in total reimbursements were identified using diagnostic codes. Using the most expansive set of inclusion criteria, 739 hospitalizations, $35,033,157 in total charges, $13,346,099 in estimated total costs, and $7,020,877 in total reimbursements were identified. Of the 739 hospitalizations, Medicaid covered 546 hospitalizations (74 %), the largest proportion of total reimbursement (65 %), with estimated total costs of $10,135,048 (77 %). CONCLUSIONS: Our study identified considerable costs for hospitalizations associated with OUD or OM for DH. Estimating costs for hospitalizations associated with OUD or OM through use of expanded inclusion methodology can guide future program planning to allocate resources efficiently for hospitals such as DH Medical Center.

Economic Evaluation of Quality Improvement Interventions Designed to Improve Glycemic Control in Diabetes: A Systematic Review and Weighted Regression Analysis.

OBJECTIVE: Quality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control among adults with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS: We used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLit, Centre for Reviews and Dissemination, New York Academy of Medicine's Grey Literature Report, and WorldCat (January 2004 to August 2016). We extracted data regarding intervention, study design, change in HbA1c, time horizon, perspective, incremental net cost (studies lasting ≤3 years), incremental cost-effectiveness ratio (ICER) (studies lasting ≥20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA1c and incremental net cost. RESULTS: Of 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA1c declined by 0.26% (95% CI 0.17-0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting ≤3 years, incremental net costs were $116 (95% CI -$612 to $843) per patient annually. Long-term ICERs were $100,000-$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000-$99,999/QALY in 1 RCT, $0-$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias. CONCLUSIONS: Diverse multifaceted QI interventions that lower HbA1c appear to be a fair-to-good value relative to usual care, depending on society's willingness to pay for improvements in health.

Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission: A Systematic Review and Meta-analysis.

Importance: Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value. Objective: To systematically review economic evaluations of QI interventions designed to reduce readmissions. Data Sources: Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016). Study Selection: Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs. Data Extraction and Synthesis: Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs. Main Outcomes and Measures: Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results: Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P = .006). Conclusions and Relevance: Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.

Regional and Gender Differences and Trends in the Anesthesiologist Workforce.

BACKGROUND: Concerns have long existed about potential shortages in the anesthesiologist workforce. In addition, many changes have occurred in the economy, demographics, and the healthcare sector in the last few years, which may impact the workforce. The authors documented workforce trends by region of the United States and gender, trends that may have implications for the supply and demand of anesthesiologists. METHODS: The authors conducted a national survey of American Society of Anesthesiologists members (accounting for >80% of all practicing anesthesiologists in the United States) in 2007 and repeated it in 2013. The authors used logistic regression analysis and Seemingly Unrelated Regression to test across several indicators under an overarching hypothesis. RESULTS: Anesthesiologists in Western states had markedly different patterns of practice relative to anesthesiologists in other regions in 2007 and 2013, including differences in employer type, the composition of anesthesia teams, and the time spent on monitored anesthesia care. The number and proportion of female anesthesiologists in the workforce increased between 2007 and 2013, and females differed from males in employment arrangements, compensation, and work hours. CONCLUSIONS: Regional differences remained stable during this time period although the reasons for these differences are speculative. Similarly, how and whether the gender difference in work hours and shift to younger anesthesiologists during this period will impact workforce needs is uncertain.

Population Health Management and the Second Golden Age of Arab Medicine: Promoting Health, Localizing Knowledge Industries, and Diversifying Economies in the GCC Countries.

Over the past half-century, the Gulf Cooperation Council (GCC) countries-Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates-have experienced rapid economic growth and, with it, dramatic lifestyle changes. Low levels of physical activity and calorie-dense diets have led to an increase in the prevalence of chronic disease, most prominently diabetes. After having successfully controlled communicable diseases and made advanced acute care accessible locally, the GCC countries now face the challenge of orienting their health care systems toward prevention and treatment of chronic diseases. In this study, Dr. Mattke and his colleagues argue that this challenge presents GCC countries with a historic opportunity to reestablish the thought leadership role that Arab medicine had in the Islamic Golden Age. They propose that GCC countries could apply their considerable wealth to design and implement innovative health care systems based on population health management principles and sophisticated health information technology. Taking this path would not only improve prevention and management of chronic disease in the GCC countries but also contribute to the diversification of their economies and localization of knowledge industries.