A case series in individuals with multiple sclerosis using direct current electrical stimulation to inhibit spasticity and improve functional outcomes.

Background and Purpose: Multiple sclerosis (MS) has a high incidence of debilitating spasticity. Central Nervous System (CNS) intrafusal settings have an impact on spasticity level. Mechanoreceptors of the Peripheral Nervous System (PNS) communicate monosynaptically with the central nervous system (CNS). This case series assesses feasibility of multimodal treatment of individuals with MS using a direct current electrical stimulation (DC) to influence mechanoreceptors. Case Description and Intervention: Seven MS diagnosed participants with Expanded Disability Status Scale (EDSS) = 6.0-8.0 completed 18 visits over 6 weeks of using DC combined with neuromuscular reeducation. Design included pre-, post- outcome measures of EDSS, 12-item MS Walking Scale (MSWS-12), Range of Motion (ROM), Manual Muscle Testing (MMT), Modified Ashworth Test (MAT), Timed 25-Foot walk (T25WT), Timed Up and Go (TUG) and the Multiple Sclerosis Impact Scale-29 (MSIS-29). Outcome: 125 out of a possible 126 visits were completed, demonstrating a high level of tolerance. Individual results included trends towards improvement in spasticity and agonists. Discussion: This case series design of seven heterogenous subjects with MS is a low sample size for statistical analysis and should be considered a pilot. The study demonstrates a high level of feasibility and possible correlations to consider. Further research is warranted.

Findings From Implementing a Patient Experience Survey in a Quality Measurement System for Substance Abuse Disorder Treatment Facilities in 6 States.

OBJECTIVES: Patient experience surveys (PESs) are an important component of determining the quality of health care. There is an absence of PES data available to people seeking to identify higher quality substance use disorder treatment providers. Our project aimed to correct this by implementing a PES for substance use disorder treatment providers and publicly disseminating PES information. METHODS: We created a population frame of all addiction providers in 6 states. Providers were asked to disseminate a survey invitation letter directing patients to a survey Web site. No personally identifiable information was exchanged. We developed a 10-question survey, reflecting characteristics National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), Substance Abuse and Mental Health Services Administration (SAMHSA) have identified as reflecting higher-quality addiction treatment. RESULTS: Nineteen percent of facilities participated; among participating facilities, 9627 patients completed the survey. Patient experience varied significantly by facility with the percentage of a facility's patients who chose the most positive answer varying widely. We calculated that between-facility reliability will meet or exceed 0.80 for facilities with 20 or more responding patients. We searched for but did not find evidence of data falsification. CONCLUSIONS: This cost-efficient survey protocol is low burden for providers and patients. Results suggest significant differences in quality of care among facilities, and facility-level results are important to provide to consumers when they evaluate the relative patient-reported quality of facilities. The data are not designed to provide population-based statistics. As more facilities and patients per facility participate, public-facing PES data will be increasingly useful to consumers seeking to compare and choose facilities.

Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care.

GENERAL PURPOSE: To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

To compare the incidence of new or worsened pressure injuries (PIs) and associated risk factors for their development in inpatient post-acute care settings: long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). The authors investigated Medicare Part A SNF resident stays and LTCH patient stays that ended between October 1, 2016 and December 31, 2016 and IRF patient stays that ended between October 1, 2016 and March 31, 2017. They calculated the incidence of new or worsened PIs using the specifications of the National Quality Forum-endorsed PI quality measure #0678: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened . The incidences of new or worsened stages 2 through 4 PIs varied across settings: 1.23% in SNFs, 1.56% in IRFs, and 3.07% in LTCHs. Seven risk factors were positively and consistently associated with new or worsened PIs across settings: limited bed mobility, bowel incontinence, low body mass index, diabetes/peripheral vascular disease/peripheral arterial disease, advanced age, urinary incontinence, and dual urinary and bowel incontinence. These findings provide empirical support for the alignment of risk factors for the PI quality measures across post-acute care settings.

Interventions to Improve Outcomes for High-Need, High-Cost Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Chronic disease patients who are the greatest users of healthcare services are often referred to as high-need, high-cost (HNHC). Payers, providers, and policymakers in the United States are interested in identifying interventions that can modify or reduce preventable healthcare use among these patients, without adversely impacting their quality of care and health. We systematically reviewed the evidence on the effectiveness of complex interventions designed to change the healthcare of HNHC patients, modifying cost and utilization, as well as clinical/functional, and social risk factor outcomes. METHODS: We searched 8 electronic databases (January 2000 to March 2021) and selected non-profit organization and government agency websites for randomized controlled trials and observational studies with comparison groups that targeted HNHC patients. Two investigators independently screened each study and abstracted data into structured forms. Study quality was assessed using standard risk of bias tools. Random-effects meta-analysis was conducted for outcomes reported by at least 3 comparable samples. RESULTS: Forty studies met our inclusion criteria. Interventions were heterogenous and classified into 7 categories, reflecting the predominant service location/modality (home, primary care, ambulatory intensive caring unit [aICU], emergency department [ED], community, telephonic/mail, and system-level). Home-, primary care-, and ED-based interventions resulted in reductions in high-cost healthcare services (ED and hospital use). ED-based interventions also resulted in greater use of primary care. Primary care- and ED-based interventions reduced costs. System-level transformation interventions did not reduce costs. DISCUSSION: We found limited evidence of intervention effectiveness in relation to cost and use, and additional evidence is needed to strengthen our confidence in the findings. Few studies reported patient clinical/functional or social risk factor outcomes (e.g., homelessness) or sufficient details for determining why individual interventions work, for whom, and when. Future evaluations could provide additional insights, by including intermediate process outcomes and patients' experiences, in assessing the impact of these complex interventions. PROSPERO REGISTRATION NUMBER: CRD42020161179.

Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis.

BACKGROUND: Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers. PURPOSE: To identify characteristics and criteria to distinguish HNHC patients. DATA SOURCES: Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022. STUDY SELECTION: English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost. DATA EXTRACTION: Independent, dual-review extraction and quality assessment. DATA SYNTHESIS: The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC. LIMITATION: Little evidence distinguished potentially preventable or modifiable health care use from overall use. CONCLUSION: A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).

Development and validation of a claim-based provider-level measurement of use of medications to treat opioid use disorder.

OBJECTIVE: Medication for opioid use disorder (MOUD) is effective but underused. Measuring the percentage of a provider's patients with an opioid use disorder (OUD) who receive MOUD may drive quality improvement and stimulate greater use of medications. This study introduces and tests a provider-level measure of MOUD receipt. METHODS: The study used claims and enrollment data from 32 states in the 2014 Medicaid Analytic Extract to measure the proportion of a provider's patients who received MOUD within 30 days of their OUD diagnosis. The research team assessed measure reliability with several tests to establish the effect of provider on MOUD receipt; and assessed the validity by correlation with a measure of emergency department visits or hospitalizations related to substance use. RESULTS: The sample included 434,484 individuals treated for OUD by one or more of 9398 providers. The mean provider score was 38 %, indicating that 38 % of the average provider's patients received an MOUD within 30 days of an OUD diagnosis (44 % for clinicians [N = 5344] and 31 % for facilities [N = 4054]). Provider performance varied considerably. The interquartile ranges were 11 %-79 % and 9 %-45 % among clinicians and facilities, respectively. The measure reliably distinguished between lower- and higher-performing providers and demonstrated convergent validity, as indicated by a significant and moderately sized negative correlation between MOUD receipt and substance use-related hospitalizations or emergency department visits. CONCLUSIONS: The measure may help to improve access to MOUD and OUD outcomes by identifying providers who could benefit from technical assistance, quality improvement initiatives, and resources to expand MOUD prescribing.

Mental health emergency department visits: An exploration of case definitions in North Carolina.

BACKGROUND: Mental health (MH) disorders comprise a high disease burden and have long-lasting impacts. To improve MH, it is important to define public health MH surveillance. METHODS: We compared MH related definitions using ICD-10-CM codes: The Council of State and Territorial Epidemiologists' (CSTE) surveillance indicators for all MH, mood or depressive, schizophrenic, and drug/alcohol-induced disorders; and North Carolina's (NC) syndromic surveillance system's definition for anxiety/mood/psychotic disorders, and suicide/self-harm. We compared code definitions and frequent codes in 2019 emergency department (ED) data for those age ≥ 10 years. RESULTS: CSTE's definition resulted in over one million MH-related visits (23% of all ED visits) and NC's definitions in 451,807 MH-related visits (9% of all ED visits). Using CSTE's broadest definition, nicotine use was the most common visit type; using NC's definitions, it was major depressive disorder. CONCLUSIONS: Standardizing population-level MH indicators benefits surveillance efforts. Given its prevalence, efforts should focus on documenting MH to improve treatment and prevention.

Development, Testing, and Dissemination of a Public-Facing Tool to Help Consumers Find Higher-Quality Addiction Treatment.

OBJECTIVE: The authors aimed to describe the development and testing of quality measures included in a public-facing addiction treatment facility search engine. METHODS: An addiction treatment facility survey was created that queried providers in six U.S. states about whether they offered the services and used the processes identified by federal agencies and nonprofit organizations as signs of higher-quality addiction treatment. Four insurance claims-based quality measures were created to capture the percentage of a provider's patients with opioid use disorder receiving opioid use disorder medications, who filled prescriptions for such medication for at least 180 days, who received follow-up care after treatment for substance use disorder in inpatient or residential settings, or who had a substance use disorder-related hospitalization or emergency department visit. A patient experience-of-care survey captured patients' perceptions of the quality of the addiction treatment. The project was undertaken from November 2018 through July 2020. RESULTS: The authors tested the measures by using 1,245 facility surveys, 7,970 patients' experience-of-care surveys, and four claims-based measures submitted by 129, 136, 283, and 408 addiction treatment providers. Statistical testing demonstrated that the quality measures were reliable and valid. The quality measure scores varied among providers, capturing a wide performance range. A public website containing quality measures launched in July 2020 in the six states and has been accessed by thousands of consumers. CONCLUSIONS: This study developed valid, reliable, and useful addiction treatment quality measures. Dissemination of these measures may help consumers select among providers and help providers, policy makers, and payers improve quality.

Examining Social Risk Factors in a Pressure Ulcer Quality Measure for Three Post-Acute Care Settings.

OBJECTIVE: To describe and explore relationships between social demographic factors and incidence or worsening of pressure ulcer scores among post-acute care (PAC) settings. DESIGN: The authors present the incidence of new or worsening pressure ulcers stratified by self-reported patient race and sex. Investigators used logistic regression modeling to examine relative risk of developing new or worsened pressure ulcers by sociodemographic status and multiple regression modeling to estimate the relative contribution of facility-level factors on rates of new or worsening pressure ulcers. SETTING: Three PAC settings: long-term care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities. PARTICIPANTS: Medicare Part A residents and patients with complete stays in PAC facilities during 2015. MAIN OUTCOME MEASURE: The incidence of new or worsened pressure ulcers as calculated using the specifications of the National Quality Forum-endorsed pressure ulcer quality measure #0678. MAIN RESULTS: The sample included 1,566,847 resident stays in 14,822 skilled nursing facilities, 478,292 patient stays in 1,132 inpatient rehabilitation facilities, and 121,834 patient stays in 397 long-term care hospitals. Significant differences in new or worsened pressure ulcer incidence rates by sociodemographic factors were found in all three settings. Black race, male sex, and advanced age were significant predictors of new or worsened ulcers, although controlling for health conditions reduced the racial disparity. The authors noted significant differences among facilities based on ownership type, urban/rural location, and sociodemographic makeup of facilities' residents/patients. CONCLUSIONS: There is evidence of disparities in the incidence of new or worsened pressure ulcers across PAC settings, suggesting publicly available quality data may be used to identify and ameliorate these problems.

Impact of State Psychiatric Hospital Waitlists on Monthly Admissions.

OBJECTIVE: This study estimated the effects of a waitlist policy on the monthly number and case mix of admissions to state psychiatric hospitals (SPHs) in North Carolina (NC). METHODS: Descriptive analyses compared pre/postwaitlist differences in the monthly number and case mix of nonforensic adult admissions (N=72,035) to NC's four SPHs by using data from the three years before and the three years after the waitlist announcement. Hospital-level fixed-effects regression models further evaluated the waitlist policy's impact on the number and case mix of admissions. RESULTS: Regression results confirmed that the waitlist policy was associated with both fewer admissions and changes to the case mix of admissions, including a 4.2% decrease in the percentage of monthly admissions by patients with diagnoses of substance abuse disorders (p=.002) across all months postwaitlist (partially offset by an increase of patients with diagnoses of severe mental illness alone). CONCLUSIONS: Waitlists led to reduced monthly admissions and altered case mix following implementation at NC SPHs.

Use of quality measures for Medicaid behavioral health services by state agencies: implications for health care reform.

OBJECTIVE: The structure-process-outcome quality framework espoused by Donabedian provides a conceptual way to examine and prioritize behavioral health quality measures used by states. This report presents an environmental scan of the quality measures and satisfaction surveys that state Medicaid managed care and behavioral health agencies used prior to Medicaid expansion in 2014. METHODS: Data were collected by reviewing online documents related to Medicaid managed care contracts for behavioral health, quality strategies, quality improvement plans, quality and performance indicators data, annual outcomes reports, performance measure specification manuals, legislative reports, and Medicaid waiver requests for proposals. RESULTS: Information was publicly available for 29 states. Most states relied on process measures, along with some structure and outcome measures. Although all states reported on at least one process measure of behavioral health quality, 52% of states did not use any outcomes measures and 48% of states had no structure measures. A majority of the states (69%) used behavioral health measures from the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set, and all but one state in the sample (97%) used consumer experience-of-care surveys. Many states supplemented these data with locally developed behavioral health indicators that rely on administrative and nonadministrative data. CONCLUSIONS: State Medicaid agencies are using nationally recognized as well as local measures to assess quality of behavioral health care. Findings indicate a need for additional nationally endorsed measures in the area of substance use disorders and treatment outcomes.