Suicide Mortality Among Formerly Incarcerated People Compared With the General Population in North Carolina, 2000-2020.

We aimed to compare rates and characteristics of suicide mortality in formerly incarcerated people with those of the general population in North Carolina. We conducted a retrospective cohort study of 266,400 people released from North Carolina state prisons between January 1, 2000, and March 1, 2020. Using direct and indirect standardization by age, sex, and calendar year, we calculated standardized suicide mortality rates and standardized mortality ratios comparing formerly incarcerated people with the North Carolina general population. We evaluated effect modification by race/ethnicity, sex, age, and firearm involvement. Formerly incarcerated people had approximately twice the overall suicide mortality of the general population for 3 years after release, with the highest rate of suicide mortality being observed in the 2-week period after release. In contrast to patterns in the general population, formerly incarcerated people had higher rates of non-firearm-involved suicide mortality than firearm-involved suicide mortality. Formerly incarcerated female, White and Hispanic/Latino, and emerging adult people had a greater elevation of suicide mortality than their general-population peers compared with other groups. These findings suggest a need for long-term support for formerly incarcerated people as they return to community living and a need to identify opportunities for interventions that reduce the harms of incarceration for especially vulnerable groups. This article is part of a Special Collection on Mental Health.

Ethnoracial Differences in Premenopausal Hysterectomy: The Role of Symptom Severity.

OBJECTIVE: To evaluate whether greater symptom severity can explain higher hysterectomy rates among premenopausal non-Hispanic Black compared with White patients in the U.S. South rather than potential overtreatment of Black patients. METHODS: Using electronic health record data from 1,703 patients who underwent hysterectomy in a large health care system in the U.S. South between 2014 and 2017, we assessed symptom severity to account for differences in hysterectomy rates for noncancerous conditions among premenopausal non-Hispanic Black, non-Hispanic White, and Hispanic patients. We used Poisson generalized linear mixed modeling to estimate symptom severity (greater than the 75th percentile on composite symptom severity scores of bleeding, bulk, or pelvic pain) as a function of race-ethnicity. We calculated prevalence ratios (PRs). We controlled for factors both contra-indicating and contributing to hysterectomy. RESULTS: The overall median age of non-Hispanic White (n=1,050), non-Hispanic Black (n=565), and Hispanic (n=158) patients was 40 years. The White and Black patients were mostly insured (insured greater than 95%), whereas the Hispanic patients were often uninsured (insured 58.9%). White and Black patients were mostly treated outside academic medical centers (nonmedical center: 63.7% and 58.4%, respectively); the opposite was true for Hispanic patients (nonmedical center: 34.2%). Black patients had higher bleeding severity scores compared with Hispanic and White patients (median 8, 7, and 4 respectively) and higher bulk scores (median 3, 1, and 0, respectively), but pain scores differed (median 3, 5, and 4, respectively). Black and Hispanic patients were disproportionately likely to have severe symptoms documented on two or more symptoms (referent: not severe on any symptoms) (adjusted PR [Black vs White] 3.02, 95% CI 2.29-3.99; adjusted PR [Hispanic vs White] 2.61, 95% CI 1.78-3.83). Although Black and Hispanic patients were more likely to experience severe symptoms, we found no racial and ethnic differences in the number of alternative treatments attempted before hysterectomy. CONCLUSION: We did not find evidence of overtreatment of Black patients. Our findings suggest potential undertreatment of Black and Hispanic patients with uterine-sparing alternatives earlier in their disease progression.

The Ubiquitin-specific Protease USP36 Associates with the Microprocessor Complex and Regulates miRNA Biogenesis by SUMOylating DGCR8.

miRNA biogenesis is a cellular process that produces mature miRNAs from their primary transcripts, pri-miRNAs, via two RNAse III enzyme complexes: the Drosha-DGCR8 microprocessor complex in the nucleus and the Dicer-TRBP complex in the cytoplasm. Emerging evidence suggests that miRNA biogenesis is tightly regulated by posttranscriptional and posttranslational modifications and aberrant miRNA biogenesis is associated with various human diseases including cancer. DGCR8 has been shown to be modified by SUMOylation. Yet, the SUMO ligase mediating DGCR8 SUMOylation is currently unknown. Here, we report that USP36, a nucleolar ubiquitin-specific protease essential for ribosome biogenesis, is a novel regulator of DGCR8. USP36 interacts with the microprocessor complex and promotes DGCR8 SUMOylation, specifically modified by SUMO2. USP36-mediated SUMOylation does not affect the levels of DGCR8 and the formation of the Drosha-DGCR8 complex, but promotes the binding of DGCR8 to pri-miRNAs. Consistently, abolishing DGCR8 SUMOylation significantly attenuates its binding to pri-miRNAs and knockdown of USP36 attenuates pri-miRNA processing, resulting in marked reduction of tested mature miRNAs. Induced expression of a SUMOylation-defective mutant of DGCR8 inhibits cell proliferation. Together, these results suggest that USP36 plays an important role in regulating miRNA biogenesis by SUMOylating DGCR8. Significance: This study identifies that USP36 mediates DGCR8 SUMOylation by SUMO2 and is critical for miRNA biogenesis. As USP36 is frequently overexpressed in various human cancers, our study suggests that deregulated USP36-miRNA biogenesis pathway may contribute to tumorigenesis.

Hurricane Florence and suicide mortality in North Carolina: a controlled interrupted time-series analysis.

BACKGROUND: Natural disasters are associated with increased mental health disorders and suicidal ideation; however, associations with suicide deaths are not well understood. We explored how Hurricane Florence, which made landfall in September 2018, may have impacted suicide deaths in North Carolina (NC). METHODS: We used publicly available NC death records data to estimate associations between Hurricane Florence and monthly suicide death rates using a controlled, interrupted time series analysis. Hurricane exposure was determined by using county-level support designations from the Federal Emergency Management Agency. We examined effect modification by sex, age group, and race/ethnicity. RESULTS: 8363 suicide deaths occurred between January 2014 and December 2019. The overall suicide death rate in NC between 2014 and 2019 was 15.53 per 100 000 person-years (95% CI 15.20 to 15.87). Post-Hurricane, there was a small, immediate increase in the suicide death rate among exposed counties (0.89/100 000 PY; 95% CI -2.69 to 4.48). Comparing exposed and unexposed counties, there was no sustained post-Hurricane Florence change in suicide death rate trends (0.02/100 000 PY per month; 95% CI -0.33 to 0.38). Relative to 2018, NC experienced a statewide decline in suicides in 2019. An immediate increase in suicide deaths in Hurricane-affected counties versus Hurricane-unaffected counties was observed among women, people under age 65 and non-Hispanic black individuals, but there was no sustained change in the months after Hurricane Florence. CONCLUSIONS: Although results did not indicate a strong post-Hurricane Florence impact on suicide rates, subgroup analysis suggests differential impacts of Hurricane Florence on several groups, warranting future follow-up.

The Back Pain Consortium (BACPAC) Research Program: Structure, Research Priorities, and Methods.

In 2019, the National Health Interview survey found that nearly 59% of adults reported pain some, most, or every day in the past 3 months, with 39% reporting back pain, making back pain the most prevalent source of pain, and a significant issue among adults. Often, identifying a direct, treatable cause for back pain is challenging, especially as it is often attributed to complex, multifaceted issues involving biological, psychological, and social components. Due to the difficulty in treating the true cause of chronic low back pain (cLBP), an over-reliance on opioid pain medications among cLBP patients has developed, which is associated with increased prevalence of opioid use disorder and increased risk of death. To combat the rise of opioid-related deaths, the National Institutes of Health (NIH) initiated the Helping to End Addiction Long-TermSM (HEAL) initiative, whose goal is to address the causes and treatment of opioid use disorder while also seeking to better understand, diagnose, and treat chronic pain. The NIH Back Pain Consortium (BACPAC) Research Program, a network of 14 funded entities, was launched as a part of the HEAL initiative to help address limitations surrounding the diagnosis and treatment of cLBP. This paper provides an overview of the BACPAC research program's goals and overall structure, and describes the harmonization efforts across the consortium, define its research agenda, and develop a collaborative project which utilizes the strengths of the network. The purpose of this paper is to serve as a blueprint for other consortia tasked with the advancement of pain related science.

Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids.

BACKGROUND: In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes. METHODS: Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter. RESULTS: Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity. CONCLUSIONS AND RELEVANCE: This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.

"Cookbook medicine": Exploring the impact of opioid prescribing limits legislation on clinical practice and patient experiences.

Opioid dependence and overdose are serious public health concerns. States have responded by enacting legislation regulating opioid-prescribing practices. Through in-depth interviews with clinicians, state officials, and organizational stakeholders, this paper examines opioid prescribing limits legislation (PLL) in North Carolina and how it impacts clinical practice. Since the advent of PLL, clinicians report being more mindful when prescribing opioids and as expected, writing for shorter durations for both acute and postoperative pain. But clinicians also report prescribing opioids less frequently for acute pain, refusing to write second opioid prescriptions, foisting responsibility for patient pain care onto other clinicians, and no longer writing opioid prescriptions for chronic pain patients. They directly credit PLL for these changes, including institutional policies enacted in response to PLL, and, to a lesser degree, notions of "do no harm." However, we argue that misapplication of and ambiguities in PLL along with defensive medicine practices whereby clinicians and their institutions center their legal interests over patient care, amplify these restrictive changes in clinical practice. Clinicians' narratives reveal downstream consequences for patients including undertreated pain, being viewed as drug-seeking when questioning opioid-prescribing decisions, and having to overuse the medical system to achieve pain relief.

Feasibility of a best-worst scaling exercise to set priorities for autism research.

BACKGROUND: The preferences of autism stakeholders regarding the top priorities for future autism research are largely unknown. OBJECTIVE: This study had two objectives: First, to examine what autism stakeholders think new research investments should be and the attributes of investment that they consider important, and second, to explore the feasibility, acceptability and outcomes of two prioritization exercises among autism stakeholders regarding their priorities for future research in autism. DESIGN: This was  a prospective stakeholder-engaged iterative study consisting of best-worst scaling (BWS) and direct prioritization exercise. SETTING AND PARTICIPANTS: A national snowball sample of 219 stakeholders was included: adults with autism, caregivers, service providers and researchers. MAIN OUTCOME MEASURES: The main outcomes measures were attributes that participants value in future research investments, and priority research investments for future research. RESULTS: Two hundred and nineteen participants completed the exercises, of whom 11% were adults with autism, 58% were parents/family members, 37% were service providers and 21% were researchers. Among stakeholders, the BWS exercises were easier to understand than the direct prioritization, less frequently skipped and yielded more consistent results. The proportion of children with autism affected by the research was the most important attribute for all types of stakeholders. The top three priorities among future research investments were (1) evidence on which child, family and intervention characteristics lead to the best/worst outcomes; (2) evidence on how changes in one area of a child's life are related to changes in other areas; and (3) evidence on dietary interventions. Priorities were similar for all stakeholder types. CONCLUSIONS: The values and priorities examined here provide a road map for investigators and funders to pursue autism research that matters to stakeholders. PATIENT OR PUBLIC CONTRIBUTION: Stakeholders completed a BWS and direct prioritization exercise to inform us about their priorities for future autism research.

Innovations in suicide prevention research (INSPIRE): a protocol for a population-based case-control study.

BACKGROUND: Suicide deaths have been increasing for the past 20 years in the USA resulting in 45 979 deaths in 2020, a 29% increase since 1999. Lack of data linkage between entities with potential to implement large suicide prevention initiatives (health insurers, health institutions and corrections) is a barrier to developing an integrated framework for suicide prevention. OBJECTIVES: Data linkage between death records and several large administrative datasets to (1) estimate associations between risk factors and suicide outcomes, (2) develop predictive algorithms and (3) establish long-term data linkage workflow to ensure ongoing suicide surveillance. METHODS: We will combine six data sources from North Carolina, the 10th most populous state in the USA, from 2006 onward, including death certificate records, violent deaths reporting system, large private health insurance claims data, Medicaid claims data, University of North Carolina electronic health records and data on justice involved individuals released from incarceration. We will determine the incidence of death from suicide, suicide attempts and ideation in the four subpopulations to establish benchmarks. We will use a nested case-control design with incidence density-matched population-based controls to (1) identify short-term and long-term risk factors associated with suicide attempts and mortality and (2) develop machine learning-based predictive algorithms to identify individuals at risk of suicide deaths. DISCUSSION: We will address gaps from prior studies by establishing an in-depth linked suicide surveillance system integrating multiple large, comprehensive databases that permit establishment of benchmarks, identification of predictors, evaluation of prevention efforts and establishment of long-term surveillance workflow protocols.

Linking Electronic Health Records to the American Community Survey: Feasibility and Process.

Objectives. To assess linkages of patient data from a health care system in the southeastern United States to microdata from the American Community Survey (ACS) with the goal of better understanding health disparities and social determinants of health in the population. Methods. Once a data use agreement was in place, a stratified random sample of approximately 200 000 was drawn of patients aged 25 to 74 years with at least 2 visits between January 1, 2016, and December 31, 2019. Information from the sampled electronic health records (EHRs) was transferred securely to the Census Bureau, put through the Census Person Identification Validation System to assign Protected Identification Keys (PIKs) as unique identifiers wherever possible. EHRs with PIKs assigned were then linked to 2001-2017 ACS records with a PIK. Results. PIKs were assigned to 94% of the sampled patients. Of patients with PIKs, 15.5% matched to persons sampled in the ACS. Conclusions. Linking data from EHRs to ACS records is feasible and, with adjustments for differential coverage, will advance understanding of social determinants and enhance the ability of integrated delivery systems to reflect and affect the health of the populations served. (Am J Public Health. 2022;112(6):923-930. https://doi.org/10.2105/AJPH.2022.306783).

Supporting research, protecting data: one institution's approach to clinical data warehouse governance.

Institutions must decide how to manage the use of clinical data to support research while ensuring appropriate protections are in place. Questions about data use and sharing often go beyond what the Health Insurance Portability and Accountability Act of 1996 (HIPAA) considers. In this article, we describe our institution's governance model and approach. Common questions we consider include (1) Is a request limited to the minimum data necessary to carry the research forward? (2) What plans are there for sharing data externally?, and (3) What impact will the proposed use of data have on patients and the institution? In 2020, 302 of the 319 requests reviewed were approved. The majority of requests were approved in less than 2 weeks, with few or no stipulations. For the remaining requests, the governance committee works with researchers to find solutions to meet their needs while also addressing our collective goal of protecting patients.

Implementation of mandatory opioid prescribing limits in North Carolina: healthcare administrator and prescriber perspectives.

BACKGROUND: Recent increases in state laws to reduce opioid prescribing have demonstrated a need to understand how they are interpreted and implemented in healthcare systems. The purpose of this study was to explore the systems, strategies, and resources that hospital administrators and prescribers used to implement the 2017 North Carolina Strengthen Opioid Prevention (STOP) Act opioid prescribing limits, which limited initial prescriptions to a five (for acute) or seven (for post-surgical) days' supply. METHODS: We interviewed 14 hospital administrators and 38 prescribers with degrees in medicine, nursing, pharmacy, business administration and public health working across North Carolina. Interview guides, informed by the Consolidated Framework for Implementation Research, explored barriers and facilitators to implementation. Interview topics included communication, resources, and hospital system support. Interviews were recorded and transcribed, then analyzed using flexible coding, integrating inductive and deductive coding, to inform analytic code development and identify themes. RESULTS: We identified three main themes around implementation of STOP act mandated prescribing limits: organizational communication, prescriber education, and changes in the electronic medical record (EMR) systems. Administrators reflected on implementation in the context of raising awareness and providing reminders to facilitate changes in prescriber behavior, operationalized through email and in-person communications as well as dedicated resources to EMR changes. Prescribers noted administrative communications about prescribing limits often focused on legality, suggesting a directive of the organization's policy rather than a passive reminder. Prescribers expressed a desire for more spaces to have their questions answered and resources for patient communications. While hospital administrators viewed compliance with the law as a priority, prescribers reflected on concerns for adequately managing their patients' pain and limited time for clinical care. CONCLUSIONS: Hospital administrators and prescribers approached implementation of the STOP act prescribing limits with different mindsets. While administrators were focused on policy compliance, prescribers were focused on their patients' needs. Strategies to implement the mandate then had to balance patient needs with policy compliance. As states continue to legislate to prevent opioid overdose deaths, understanding how laws are implemented by healthcare systems and prescribers will improve their effectiveness through tailoring and maximizing available resources.

Impact of the Early Phase of the COVID-19 Pandemic on US Healthcare Workers: Results from the HERO Registry.

BACKGROUND: The HERO registry was established to support research on the impact of the COVID-19 pandemic on US healthcare workers. OBJECTIVE: Describe the COVID-19 pandemic experiences of and effects on individuals participating in the HERO registry. DESIGN: Cross-sectional, self-administered registry enrollment survey conducted from April 10 to July 31, 2020. SETTING: Participants worked in hospitals (74.4%), outpatient clinics (7.4%), and other settings (18.2%) located throughout the nation. PARTICIPANTS: A total of 14,600 healthcare workers. MAIN MEASURES: COVID-19 exposure, viral and antibody testing, diagnosis of COVID-19, job burnout, and physical and emotional distress. KEY RESULTS: Mean age was 42.0 years, 76.4% were female, 78.9% were White, 33.2% were nurses, 18.4% were physicians, and 30.3% worked in settings at high risk for COVID-19 exposure (e.g., ICUs, EDs, COVID-19 units). Overall, 43.7% reported a COVID-19 exposure and 91.3% were exposed at work. Just 3.8% in both high- and low-risk settings experienced COVID-19 illness. In regression analyses controlling for demographics, professional role, and work setting, the risk of COVID-19 illness was higher for Black/African-Americans (aOR 2.32, 99% CI 1.45, 3.70, p < 0.01) and Hispanic/Latinos (aOR 2.19, 99% CI 1.55, 3.08, p < 0.01) compared with Whites. Overall, 41% responded that they were experiencing job burnout. Responding about the day before they completed the survey, 53% of participants reported feeling tired a lot of the day, 51% stress, 41% trouble sleeping, 38% worry, 21% sadness, 19% physical pain, and 15% anger. On average, healthcare workers reported experiencing 2.4 of these 7 distress feelings a lot of the day. CONCLUSIONS: Healthcare workers are at high risk for COVID-19 exposure, but rates of COVID-19 illness were low. The greater risk of COVID-19 infection among race/ethnicity minorities reported in the general population is also seen in healthcare workers. The HERO registry will continue to monitor changes in healthcare worker well-being during the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT04342806.

Early Follow-up After Colorectal Surgery Reduces Postdischarge Emergency Department Visits.

BACKGROUND: Thirty-day readmissions, emergency department visits, and observation stays are common after colorectal surgery (9%-25%, 8%-12%, and 3%-5%), yet it is unknown to what extent planned postdischarge care can decrease the frequency of emergency department visits. OBJECTIVE: This study's aim was to determine whether early follow-up with the surgical team reduces 30-day emergency department visits. DESIGN: This retrospective cohort study used a central data repository of clinical and administrative data for 2013 through 2018. SETTING: This study was conducted in a large statewide health care system (10 affiliated hospitals, >300 practices). PATIENTS: All adult patients undergoing colorectal surgery were included unless they had a length of stay <1 day or died during the index hospitalization. INTERVENTION: Early (<10 days after discharge) versus late (≥10 days) follow-up at the outpatient surgery clinic, or no outpatient surgery clinic follow-up, was assessed. MAIN OUTCOME MEASURES: The primary outcome measured was the time to 30-day postdischarge emergency department visit. RESULTS: Our cohort included 3442 patients undergoing colorectal surgery; 38% of patients had an early clinic visit. Overall, 11% had an emergency department encounter between 11 and 30 days after discharge. Those with early follow-up had decreased emergency department encounters (adjusted HR 0.13; 95% CI, 0.08-0.22). An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters. Nationwide, this could potentially prevent 8433 unplanned visits each year with an estimated cost savings of $49 million annually. LIMITATIONS: We used retrospective data and were unable to assess for health care utilization outside our health system. CONCLUSIONS: Early follow-up within 10 days of adult colorectal surgery is associated with decreased subsequent emergency department encounters. See Video Abstract at http://links.lww.com/DCR/B330. EL SEGUIMIENTO TEMPRANO DESPUÉS DE LA CIRUGÍA COLORRECTAL REDUCE LAS VISITAS AL SERVICIO DE URGENCIAS POSTERIOR AL ALTA: Los readmisión a los treinta días, las visitas al servicio de urgencias y las estancias de observación son comunes después de la cirugía colorrectal, 9-25%, 8-12% y 3-5%, respectivamente. Sin embargo, se desconoce en qué medida la atención planificada posterior al alta puede disminuir la frecuencia de las visitas al servicio de urgencias.Determinar si el seguimiento temprano con el equipo quirúrgico reduce las visitas a 30 días al servicio de urgencias.Este estudio de cohorte retrospectivo utilizó un depósito central de datos clínicos y administrativos para 2013-2018.Gran sistema de salud estatal (10 hospitales afiliados,> 300 consultorios).Se incluyeron todos los pacientes adultos de cirugía colorrectal a menos que tuvieran una estadía <1 día o murieran durante el índice de hospitalización.Temprano (<10 días después del alta) versus tardío (≥10 días) o sin seguimiento en la clínica de cirugía ambulatoria.Tiempo para la visita al servicio de urgencias a 30 días después del alta.Nuestra cohorte incluyó 3.442 pacientes de cirugía colorrectal; El 38% de los pacientes tuvieron una visita temprana a clínica. En total, el 11% tuvo un encuentro con el servicio de urgencias entre 11 y 30 días después de ser dado de alta. Aquellos con seguimiento temprano disminuyeron las visitas al servicio de urgencias (HR 0,13; IC del 95%: 0,08 a 0,22). Además, una visita temprana a la clínica en un plazo de 10 días, en comparación con 14 días, evitó 142 encuentros adicionales en el servicio de urgencias. A nivel nacional, esto podría prevenir 8.433 visitas no planificadas cada año con un ahorro estimado de $ 49 millones anuales.Utilizamos datos retrospectivos y no pudimos evaluar la utilización de la atención médica fuera de nuestro sistema de salud.El seguimiento temprano dentro de los 10 días de la cirugía colorrectal en adultos se asocia con una disminución de los encuentros posteriores en el servicio de urgencias. Consulte Video Resumen en http://links.lww.com/DCR/B330. (Traducción-Dr. Gonzalo Hagerman).

National Institutes of Health Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services.

Expert groups, including the U.S. Preventive Services Task Force (USPSTF), recommend a range of clinical preventive services for persons at average risk for disease. Use of these services often is substantially lower among racial and ethnic minority groups, rural residents, and persons of lower socioeconomic status. On 19 and 20 June 2019, the National Institutes of Health (NIH) convened the Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services to assess the available evidence on disparities in the use of 10 USPSTF-recommended clinical preventive services for cancer, heart disease, and diabetes. The workshop was cosponsored by the NIH Office of Disease Prevention; National Institute on Minority Health and Health Disparities; National Cancer Institute; National Heart, Lung, and Blood Institute; and National Institute of Diabetes and Digestive and Kidney Diseases. A multidisciplinary working group developed the agenda, and an Evidence-based Practice Center prepared the evidence report. During the workshop, invited experts considered the evidence, with discussion among attendees. After weighing evidence from the review, presentations, and public comments, an independent panel prepared a draft report that was posted for public comment. This final report summarizes the panel's findings, identifying current gaps in knowledge. The panel made 26 recommendations for new research and methods development to improve implementation of proven services to reduce disparities in preventable conditions.

Association of Household Opioid Availability and Prescription Opioid Initiation Among Household Members.

Importance: Increases in prescription opioid use in the United States have been attributed to changing prescribing guidelines and attitudes toward pain relief; however, the spread of opioid use within households through drug diversion may also be a contributing factor. Objective: To investigate whether individuals living in a household with a prescription opioid user are more likely to initiate prescription opioids themselves, compared with individuals in households with a prescription nonsteroidal anti-inflammatory drug (NSAID) user. Design, Setting, and Participants: This was a retrospective cohort study using administrative health care claims data from 2000 to 2014 of commercial insurance beneficiaries sharing a health plan with continuous prescription drug coverage, without opioid or NSAID use in the prior year. Enrollees were followed from the date of the first prescription filled by a household member for an eligible opioid or NSAID until initiation of prescription opioids, disenrollment, or administrative censoring after 1 year or the end of follow-up on December 31, 2014. Risk of opioid initiation was derived from inverse probability-weighted (IPW) Kaplan-Meier estimators that adjusted for potential confounders, prognostic factors, and predictors of censoring. Exposure: Outpatient pharmacy dispensing of a prescription opioid or prescription NSAID. Main Outcomes and Measures: Incident outpatient pharmacy fill for a prescription opioid by a household member. Results: From 2000 to 2014, 12 695 280 individuals were exposed to prescription opioids and 6 359 639 to prescription NSAIDS through an index prescription to a household member. The IPW estimated risk of opioid initiation in the subsequent year was 11.83% (95% CI, 11.81%-11.85%) among individuals exposed to prescription opioids in the household, compared with 11.11% (95% CI, 11.09%-11.14%) among individuals exposed to prescription NSAIDs, resulting in a risk difference of 0.71% (95% CI, 0.68%-0.74%). An unmeasured confounder that is modestly associated with the exposure (eg, prevalence difference = 0.9%) and the outcome (eg, risk difference = 0.9) after adjustment for all measured variables could explain our observed estimate of the overall risk difference (0.71%). Conclusions and Relevance: Living in a household with a prescription opioid user may increase risk of prescription opioid use, which may reflect both increased access to these products as well as shared risk factors, such as prescriber preference and prescription drug monitoring.

A Novel Screening Method to Identify Late-Stage Dementia Patients for Palliative Care Research and Practice.

CONTEXT: Investigators need novel methods for timely identification of patients with serious illness to test or implement new palliative care models. OBJECTIVES: The study's aim was to develop an electronic health record (EHR) phenotype to identify patients with late-stage dementia for a clinical trial of palliative care consultation. METHODS: We developed a computerized method to identify patients with dementia on hospital admission. Within a data warehouse derived from the hospital's EHR, we used search terms of age, admission date, and ICD-9 and ICD-10 diagnosis codes to create an EHR dementia phenotype, followed by brief medical record review to confirm late-stage dementia. We calculated positive predictive value, false discovery rate, and false negative rate of this novel screening method. RESULTS: The EHR phenotype screening method had a positive predictive value of 76.3% for dementia patients and 24.5% for late-stage dementia patients; a false discovery rate of 23.7% for dementia patients and 75.5% for late-stage dementia patients compared to physician assessment. The sensitivity of this screening method was 59.7% to identify hospitalized patients with dementia. Daily screening-including confirmatory chart reviews-averaged 20 minutes and was more feasible, efficient, and more complete than manual screening. CONCLUSION: A novel method using an EHR phenotype plus brief medical record review is effective to identify hospitalized patients with late-stage dementia. In health care systems with similar clinical data warehouses, this method may be applied to serious illness populations to improve enrollment in clinical trials of palliative care or to facilitate access to palliative care services.