The association of major adverse limb events and combination stent and atherectomy in patients undergoing revascularization for lower extremity peripheral artery disease.

BACKGROUND: The effectiveness of combined atherectomy and stenting relative to use of each procedure alone for the treatment of lower extremity peripheral artery disease has not been evaluated. AIMS: The objective of this study was to evaluate the short- and long-term major adverse limb event (MALE) following the receipt of stenting, atherectomy, and the combination of stent and atherectomy. METHODS: A retrospective cohort of patients undergoing atherectomy, stent, and combination stent atherectomy for lower extremity peripheral artery disease was derived from the Vascular Quality Initiative (VQI) data set. The primary outcome was MALE and was assessed in the short-term and long-term. Short-term MALE was assessed immediately following the procedure to discharge and estimated using logistic regression. Long-term MALE was assessed after discharge to end of follow-up and estimated using the Fine-Gray subdistribution hazard model. RESULTS: Among the 46,108 included patients, 6896 (14.95%) underwent atherectomy alone, 35,774 (77.59%) received a stent, and 3438 (7.5%) underwent a combination of stenting and atherectomy. The adjusted model indicated a significantly higher odds of short-term MALE in the atherectomy group (OR = 1.35; 95% confidence interval [CI]:1.16-1.57), and not significantly different odds (OR = 0.93; 95% CI:0.77-1.13) in the combination stent and atherectomy group when compared to stenting alone. With regard to long-term MALE, the model indicated that the likelihood of experiencing the outcome was slightly lower (HR = 0.90; 95% CI:0.82-0.98) in the atherectomy group, and not significantly different (HR = 0.92; 95% CI:0.82-1.04) in the combination stent and atherectomy group when compared to the stent group. CONCLUSIONS: Patients in the VQI data set who received combination stenting and atherectomy did not experience significantly different rates of MALE when compared with stenting alone. It is crucial to consider and further evaluate the influence of anatomical characteristics on treatment strategies and potential differential effects of comorbidities and other demographic factors on the short and long-term MALE risks.

Social determinants of health, substance use, and drug overdose prevention.

BACKGROUND: Fatal drug overdoses, now primarily driven by illicit opioids like fentanyl, continue to increase in the United States, reflecting a growing need for prevention and treatment strategies. Preventive interventions have primarily focused on curbing opioid prescribing, and treatment strategies target individuals. However, little is known about the broader social context surrounding these individuals. OBJECTIVE: This study examines the association between drug overdose mortality and social determinants of health (SDOH) across different levels of influence in the social-ecological model. METHODS: Data on drug overdose death and SDOH were collected at the county level for most mid-Atlantic states in 2019. Association between each characteristic and drug overdose mortality was measured through a bivariate analysis. Furthermore, a multivariate analysis was performed to detect risk factors of drug overdose death while adjusting for multiple comparisons. All statistical analyses were performed with SAS version 9.4. RESULTS: SDOH, including violent crime (P < 0.001), access to the Internet (P < 0.001), per capita income (P < 0.001), social vulnerability index (P = 0.001), and access to health care (P < 0.001), demonstrated a statistically significant positive association with drug overdose death. In contrast, vacancy rate was negatively associated with drug overdose mortality (P < 0.001). The association between drug overdose deaths and opioid prescription rates was not statistically significant (P = 0.412). CONCLUSION: Factors such as violent crime and social vulnerability demonstrated a statistically significant impact on drug overdose mortality. To address drug overdose crisis, health care system, community leaders, and policy makers' strategies should focus on socially vulnerable populations.

Impact of the naloxone standing order on trends in opioid fatal overdose: an ecological analysis.

Background: Maryland expanded its "Statewide Naloxone Standing Order" (NSO) in 2017 to eliminate training and prescription requirements for obtaining naloxone, improve naloxone access, help reverse opioid overdose, and reduce overdose fatality rates.Objectives: To assess the change in the trends of fatal opioid overdose rates following the expansion of the Naloxone Standing Order (eNSO) and its association with the social determinants of health (SDoH).Methods: Data on overdose deaths and SDoH from 2015-2019 was collected and analyzed using interrupted time series and multivariate Poisson regression models to study the change in trends and the associations.Results: There was a significant decrease in the rate of fatal overdoses after the intervention: prescription opioid estimate number of deaths declined by .25 per 100,000 (p = .02), heroin estimate number of deaths declined by 1.83 per 100,000 (p < .001), fentanyl estimate number of deaths declined by 2.54 per 100,000 (p < .001). After controlling for eNOS implementation in Maryland, state-level estimates with high proportions of female residents and those with bachelor's degree or higher were associated with reduction in overdose, while state-level estimates with high proportions of African Americans and higher employment rates were associated with an increase in overdose.Conclusions: Our analysis shows that the expanded naloxone standing order is associated with reducing opioid-related overdose death rates. Even though we observed a significant reduction in overdose death rate in fentanyl-related deaths, the rate of deaths post-eNSO was still increasing, suggesting the need for additional measures to impact the rates of fentanyl.

Opioid use disorder in pregnancy: leveraging provider perceptions to inform comprehensive treatment.

BACKGROUND: Medications for opioid use disorder (MOUD) are recommended with adjuvant behavioral therapies, counseling, and other services for comprehensive treatment of maternal opioid use disorder. Inadequate access to treatment, lack of prescribing providers and complex delivery models are among known barriers to care. Multi-disciplinary provider input can be leveraged to comprehend factors that facilitate or inhibit treatment. The objective of this study is to explore provider perceptions of MOUD and factors critical to comprehensive treatment delivery to improve the care of pregnant women with opioid use disorder. METHODS: A qualitative research approach was used to gather data from individual provider and group semi-structured interviews. Providers (n = 12) responded to questions in several domains related to perceptions of MOUD, treatment delivery, access to resources, and challenges/barriers. Data were collected, transcribed, coded (by consensus) and emerging themes were analyzed using grounded theory methodology. RESULTS: Emerging themes revealed persistent gaps in treatment and challenges in provider, health systems and patient factors. Providers perceived MOUD to be a "lifeline" to women. CONCLUSIONS: Inconsistencies in treatment provision, access and uptake can be improved by leveraging provider perceptions, direct experiences and recommendations for an integrated team-based, patient-centered approach to guide the care of pregnant women with opioid use disorder.

Practice Transformation Analytics Dashboard for Clinician Engagement.

PURPOSE: Practice transformation in primary care is a movement toward data-driven redesign of care, patient-centered care delivery, and practitioner activation. A critical requirement for achieving practice transformation is availability of tools to engage practices. METHODS: A total of 48 practices with 109 practice sites participate in the Garden Practice Transformation Network in Maryland (GPTN-Maryland) to work together toward practice transformation and readiness for the Quality Payment Program implemented by the Centers for Medicare & Medicaid Services. Practice-specific data are collected in GPTN-Maryland by practices themselves and by practice transformation coaches, and are provided by the Centers for Medicare & Medicaid Services. These data are overwhelming to practices when presented piecemeal or together, a barrier to practices taking action to ensure progress on the transformation spectrum. The GPTN-Maryland team therefore created a practice transformation analytics dashboard as a tool to present data that are actionable in care redesign. RESULTS: When practices reviewed their data provided by the Centers for Medicare & Medicaid Services using the dashboard, they were often seeing, for the first time, cost data on their patients, trends in their key performance indicator data, and their practice transformation phase. Overall, 72% of practices found the dashboard engaging, and 48% found the data as presented to be actionable. CONCLUSIONS: The practice transformation analytics dashboard encourages practices to advance in practice transformation and improvement of patient care delivery. This tool engaged practices in discussions about data, care redesign, and costs of care, and about how to develop sustainable change within their practices. Research is needed to study the impact of the dashboard on costs and quality of care delivery.

Consumer Health Information Technology in the Prevention of Substance Abuse: Scoping Review.

BACKGROUND: Addiction is one of the most rapidly growing epidemics that currently plagues nations around the world. In the United States, it has cost the government more than US $700 billion a year in terms of health care and other associated costs and is also associated with serious social, physical, and mental consequences. Increasing efforts have been made to tackle this issue at different levels, from primary prevention to rehabilitation across the globe. With the use of digital technology rapidly increasing, an effort to leverage the consumer health information technologies (CHITs) to combat the rising substance abuse epidemic has been underway. CHITs are identified as patient-focused technological platforms aimed to improve patient engagement in health care and aid them in navigating the complex health care system. OBJECTIVE: This review aimed to provide a holistic and overarching view of the breadth of research on primary prevention of substance abuse using CHIT conducted over nearly past five decades. It also aimed to map out the changing landscape of CHIT over this period. METHODS: We conducted a scoping review using the Arksey and O'Malley's modified methodological framework. We searched 4 electronic databases (PubMed, Cochrane, Scopus, and EMBASE). Papers were included if the studies addressed the use of CHIT for primary prevention of substance abuse and were published in English between 1809 and 2018. Studies that did not focus solely on primary prevention or assessed additional comorbid conditions were eliminated. RESULTS: Forty-two papers that met our inclusion criteria were included in the review. These studies were published between 1970 and 2018 and were not restricted by geography, age, race, or sex. The review mapped studies using the most commonly used CHIT platforms for substance abuse prevention from mass media in the 1970s to mobile and social media in 2018. Moreover, 191 studies that were exclusively focused on alcohol prevention were excluded and will be addressed in a separate paper. The studies included had diverse research designs although the majority were randomized controlled trials (RCT) or review papers. Many of the RCTs used interventions based on different behavioral theories such as family interactions, social cognitive theories, and harm-minimization framework. CONCLUSIONS: This review found CHIT platforms to be efficacious and cost-effective in the real-world settings. We also observed a gradual shift in the types and use of CHIT platforms over the past few decades and mapped out their progression. In addition, the review detected a shift in consumer preferences and behaviors from face-to-face interactions to technology-based platforms. However, the studies included in this review only focused on the aspect of primary prevention. Future reviews could assess the effectiveness of platforms for secondary prevention and for prevention of substance abuse among comorbid populations.

What motivates people with substance use disorders to pursue treatment? A patient-centered approach to understanding patient experiences and patient-provider interactions.

OBJECTIVES: To identify and define potential positive and negative factors in patient experiences and patient-provider interactions that are associated with the pursuit and maintenance of treatment by those suffering from substance use disorders (SUD). METHODS: Two focus groups with patients in treatment for SUD were performed. The focus groups focused on questions aimed at mapping factors associated with initiating and maintaining treatment along the transtheoretical model of change. Four in-depth interviews with healthcare providers involved in the treatment of patients with SUD were also conducted to understand providers' perspective on similar factors. RESULTS: Fourteen patients were included in the focus groups. Patients identified their life prior to treatment as chaotic and further identified internal and external factors that influenced seeking treatment. The four healthcare providers identified primarily social issues such as lack of housing as an external barrier. Both patients and providers cited the importance of a trusting and empathetic relationship between the patient and providers, as well as the patient's willingness to change as primary motivating factors for the initiation and maintenance of treatment. CONCLUSIONS: From a patient and provider perspective, facilitators and barriers for initiating and maintaining may vary by person and are multifactorial.

Tree-based Claims Algorithm for Measuring Pretreatment Quality of Care in Medicare Disabled Hepatitis C Patients.

BACKGROUND: To help broaden the use of machine-learning approaches in health services research, we provide an easy-to-follow framework on the implementation of random forests and apply it to identify quality of care (QC) patterns correlated with treatment receipt among Medicare disabled patients with hepatitis C virus (HCV). METHODS: Using Medicare claims 2006-2009, we identified 1936 patients with 6 months continuous enrollment before HCV diagnosis. We ran a random forest on 14 pretreatment QC indicators, extracted the forest's representative tree, and aggregated its terminal nodes into 4 QC groups predictive of treatment. To explore determinants of differential QC receipt, we compared patient-level and county-level (linked AHRF data) characteristics across QC groups. RESULTS: The strongest predictors of treatment included "liver biopsy," "HCV genotype testing," "specialist visit," "HCV viremia confirmation," and "iron overload testing." High QC [n=360, proportion treated (pt)=33.3%] was defined for patients with at least 2 from the above-mentioned metrics. Good QC patients (n=302, pt=12.3%) had either "HCV genotype testing" or "specialist visit," whereas fair QC (n=282, pt=7.1%) only had "HCV viremia confirmation." Low QC patients (n=992, pt=2.5%) had none of the selected metrics. The algorithm accuracy of predicting treatment was 70% sensitivity and 78% specificity. HIV coinfection, drug abuse, and residence in counties with higher supply of hospitals with immunization and AIDS services correlated with lower QC. CONCLUSIONS: Machine-learning techniques could be useful in exploring patterns of care. Among Medicare disabled HCV patients, the receipt of more QC indicators was associated with higher treatment rates. Future research is needed to assess determinants of differential QC receipt.

Clinical effectiveness and cost savings in diabetes care, supported by pharmacist counselling.

OBJECTIVE: To determine the effectiveness and cost savings of a real-world, continuous, pharmacist-delivered service with an employed patient population with diabetes over a 5-year period. SETTING: The Patients, Pharmacists Partnerships (P3 Program) was offered as an "opt-in" benefit to employees of 6 public and private self-insured employers in Maryland and Virginia. Care was provided in ZIP code-matched locations and at 2 employers' worksites. PRACTICE DESCRIPTION: Six hundred two enrolled patients with type 1 and 2 diabetes were studied between July 2006 and May 2012 with an average follow-up of 2.5 years per patient. Of these patients, 162 had health plan cost and utilization data. A network of 50 trained pharmacists provided chronic disease management to patients with diabetes using a common process of care. Communications were provided to patients and physicians. PRACTICE INNOVATION: Employers provided incentives for patients who opted in, including waived medication copayments and free diabetes self-monitoring supplies. The service was provided at no cost to the patient. A Web-based, electronic medical record that complied with the Health Insurance Portability and Accountability Act helped to standardize care. Quality assurance was conducted to ensure the standard of care. EVALUATION: Glycosylated hemoglobin (A1c), blood pressure, and total health care costs (before and after enrollment). RESULTS: Statistically significant improvements were shown by mean decreases in A1c (-0.41%, P <0.001), low-density lipoprotein levels (-4.7 mg/dL, P = 0.003), systolic blood pressure (-2.3 mm Hg, P = 0.001), and diastolic blood pressure (-2.4 mm Hg, P <0.001). Total annual health care costs to employers declined by $1031 per beneficiary after the cost of the program was deducted. This 66-month real-world study confirms earlier findings. Employers netted savings through improved clinical outcomes and reduced emergency and hospital utilization when comparing costs 12 months before and after enrollment. CONCLUSION: The P3 program had positive clinical outcomes and economic outcomes. Pharmacist-provided comprehensive medication therapy management services should be included as a required element of insurance offered by employers and health insurance exchanges.

Predicting Factors of Depression, Antidepressant Use and Positive Response to Antidepressants in Perinatal and Postpartum Women.

BACKGROUND: In the United States, there is a disparity in knowledge of nationwide depression prevalence, the antidepressant use and the antidepressant responses during perinatal/postpartum periods. OBJECTIVE: This study investigated the predicting factors of depression, antidepressant use and positive antidepressant response during the perinatal/postpartum periods. METHOD: The 2007-2012 National Health and Nutrition Examination Surveys (NHANES) were combined to identify adult pregnant women, those within the 18-month postpartum period (n=492) and their depression statuses via demographics, health care accessibility, antidepressant use and illicit drug use information. The characteristics of different study groups were compared (depression versus no-depression groups, antidepressant users versus non-antidepressant users, and antidepressant responders versus antidepressant non-responders). Multivariable logistic regression analysis was used to predict factors of perinatal depression (PND)/ postpartum depression (PPD), antidepressant use and antidepressant positive response in PND/PPD. RESULTS: PND/PPD individuals had higher rates of mental health visits. No predicting factor for developing PND/PPD was shown. Antidepressant users were significantly older with insurance and recent health checkups/ mental visits. Being below the poverty level and having some health care accessibility are predictors for being on antidepressants. Recent non-illicit drug use is a predictor for PND/PPD symptom improvement while on antidepressants. CONCLUSION: The group of those with social-economic disadvantages was more likely to be on antidepressants for PND/PPD. Illicit drug users were less likely to show improvement with antidepressants. The safety and efficacy of antidepressant use during this period is controversial. More studies need to focus on the barriers involving antidepressant treatments, the safety and outcomes of antidepressants for PND/PPD management.

Contextual analysis of determinants of late diagnosis of hepatitis C virus infection in medicare patients.

UNLABELLED: Patient- and county-level characteristics associated with advanced liver disease (ALD) at hepatitis C virus (HCV) diagnosis were examined in three Medicare cohorts: (1) elderly born before 1945; (2) disabled born 1945-1965; and (3) disabled born after 1965. We used Medicare claims (2006-2009) linked to the Area Health Resource Files. ALD was measured over the period of 6 months before to 3 months after diagnosis. Using weighted multivariate modified Poisson regression to address generalizability of findings to all Medicare patients, we modeled the association between contextual characteristics and presence of ALD at HCV diagnosis. We identified 1,746, 3,351, and 592 patients with ALD prevalence of 28.0%, 23.0%, and 15.0% for birth cohorts 1, 2, and 3. Prevalence of drug abuse increased among younger birth cohorts (4.2%, 22.6%, and 35.6%, respectively). Human immunodeficiency virus coinfection (prevalence ratio [PR] = 0.63; 95% confidence interval [CI]: 0.50-0.80; P = 0.001), dual Medicare/Medicaid eligibility (PR = 0.89; 95% CI: 0.80-0.98; P = 0.017), residence in counties with higher median household income (PR = 0.82; 95% CI: 0.71-0.95; P = 0.008), higher density of primary care providers (PR = 0.84; 95% CI: 0.73-0.98; P = 0.022), and more rural health clinics (PR = 0.90; 0.81-1.01; P = 0.081) were associated with lower ALD risk. End-stage renal disease (PR = 1.41; 95% CI: 1.21-1.63; P = 0.001), alcohol abuse (PR = 2.57; 95% CI: 2.33-2.84; P = 0.001), hepatitis B virus (PR = 1.32; 95% CI: 1.09-1.59; P = 0.004), and Midwest residence (PR = 1.22; 95% CI: 1.05-1.41; P = 0.010) were associated with higher ALD risk. Living in rural counties with high screening capacity was protective in the elderly, but associated with higher ALD risk among the disabled born 1945-1965. CONCLUSIONS: ALD prevalence patterns were complex and were modified by race, elderly/disability status, and the extent of health care access and screening capacity in the county of residence. These study results help inform treatment strategies for HCV in the context of coordinated models of care.

A Pilot study Evaluating a Community-based Intervention Focused on the ISHIB IMPACT Cardiovascular Risk Reduction Toolkit in African American Patients with Uncontrolled Hypertension.

OBJECTIVE: To evaluate blood pressure (BP) control utilizing the International Society on Hypertension in Blacks (ISHIB) cardiovascular risk reduction toolkit in an African American community with uncontrolled hypertension. METHODS: This is a randomized controlled pilot study conducted in two Baltimore community-based physicians' offices assigned adults (18-64 years) with uncontrolled hypertension (systolic blood pressure [SBP] ≤ 169 mm Hg; diastolic blood pressure [DBP] ≤ 109 mm Hg). The study compares usual care to a community-based intervention. In the usual care group, the patients' BP was managed by the treating physician based on their normal office patient care protocol. In the intervention group, usual care was provided but, a community health worker also gave comprehensive education and assessment to the patients based on the ISHIB IMPACT cardiovascular toolkit during study initiation and follow-up visits. The main outcome of study was change in BP from baseline to six months. A secondary outcome was the proportion of patients achieving BP < 135/< 85 mm Hg at six months. RESULTS: Fifty-four African American patients were enrolled; 37 completed six months of follow-up (usual care, n = 25; intervention, n = 12). At six months the mean (95% CI) change from baseline in SBP was significantly greater in the intervention group vs the usual care group: -34.75 (-46.55 to -22.95) mm Hg vs -5.65 (-12.84 to 1.54) mm Hg (P < .001). Mean (95% CI) change in DBP from baseline to six months was significantly greater for the intervention group vs the usual care group: -16.19 (-24.00 to -8.39) mm Hg vs -4.36 (-8.26 to -0.46) mm Hg (P = .009). Median change in BP was significantly greater for SBP in the intervention group compared with the usual care group (P = .007), but not for DBP (P = .197). The proportion of patients achieving BP < 135/ <85 at six months was 83% (10/12) in the intervention group vs 60% (15/25) in the usual care group (P = .263). CONCLUSIONS: This pilot study on the ISHIB IMPACT toolkit in managing uncontrolled hypertension in the African American community suggests better control of systolic BP and a tendency to better hypertension control with the community-based intervention. The findings support further studies in clinical settings serving African American hypertensive patients to assess effectiveness of approaches for improving BP control and related outcomes.

Association between mental health and comorbid obesity and hypertension among children and adolescents in the US.

This paper examines the association between mental health and comorbid obesity and hypertension among US children and adolescents using data from the National Health and Nutritional Examination Survey (NHANES). Questionnaires from NHANES were used to assess mental health during the previous 30 days. Respondents were then categorized into two groups namely "poor mental health" and "good mental health" based on their responses to these survey questions. Three multiple logistic regression models, based on these categories, are estimated to compute the odds ratios and 95% confidence intervals in the association of obesity and hypertension and mental health. As a select example, the results of Model 2 reveal that compared with respondents who are not obese, obese respondents have increased odds (OR = 1.24; P < 0.0001) of poor mental health. Furthermore compared with non-hypertensive respondents, hypertensive respondents have higher odds (OR = 2.96; P < 0.0001) of poor mental health. These findings have important implications for mental health management in younger populations. It brings into focus the maintenance of a healthy body mass index and hypertension control in mitigating poor mental health.

Increased prevalence of obstructive lung disease in patients with obstructive sleep apnea.

STUDY PURPOSES: This study aims to determine whether there is an increased prevalence of obstructive lung diseases (OLDs) in patients with obstructive sleep apnea (OSA). We also determined whether among the OLD patients there is a difference in the prevalences of specific chronic disease co-morbidities between patients with and without OSA. METHODS: The prevalences of COPD, asthma, and COPD combined with asthma (ICD-9 coding) were compared between 1,497 adult OSA patients and 1,489 control patients, who were matched for age, gender, geographic location, and primary care physician. The prevalences of specific co-morbidities were measured in the OLD groups between patients with OSA and the matched control group. RESULTS: COPD, asthma, and COPD combined with asthma were found to be more prevalent among OSA patients compared to the matched controls. Prevalences among patients with and without OSA, respectively, were COPD-7.6 and 3.7 % (P<0.0001), asthma-10.4 and 5.1 % (P<0.0001), COPD plus asthma-3.3 and 0.9 % (P<0.0001). The Charlson Comorbidity Index was greater for OSA patients (2.3 ± 0.2) than for controls (1.9 ± 1.8; P<0.0001). These trends held for all severity ranges of OSA. Patients with OSA and COPD were characterized by more severe hypoxia at night compared with the OSA patients without OLD. CONCLUSION: OSA was associated with an increased prevalence of OLDs.

Diabetes control through an educational intervention.

OBJECTIVE: We evaluated the effect of an educational intervention administered to patients or/and physicians on the reduction in HbA(1c) and achieving diabetic control in a high-risk primarily Black inner-city population. METHODS: The study was designed as a four-arm randomized clinical trial where an educational program on diabetes was offered to physicians only, patients only, and both physicians and their patients, while the fourth arm did not receive any instruction. We built regression models at 24 months of follow-up to assess the likelihood of reaching glycemic goal as well as to measure the absolute reduction in HbA(1c) controlling for arm assignment, insulin use, race, age, sex, smoking, insulin use, and having achieved blood pressure control. RESULTS: Between April 2005 and July 2007, there were 823 patients randomized into the study. In multivariate analyses, the intervention group in which only patients received education showed a trend toward achieving a significant mean reduction in HbA(1c) with 49% (P = .06) higher odds of reaching glycemic control and .12 (P = .06) greater absolute percentage point drop in HbA(1c) compared to the no education group. CONCLUSION: Although our study reports positive results, it warrants a special emphasis on the behavior of the patient. Study results bring attention to disease management programs such as peer support networks that empower the patients that shift some of the responsibility to them.

The Lived Experiences of Pregnant and Parenting Women in Recovery Toward Medication Treatment for Opioid Use Disorder.

BACKGROUND: Maternal misuse of prescription opioids and illicit drugs such as, heroin and non-pharmaceutical fentanyl analogs has increased in the last 2 decades and one in 5 women reported misuse of opioids. Medications for opioid use disorder (MOUD) are recommended for treating pregnant women with opioid use disorder (OUD). MOUD is effective in reducing cravings and negative outcomes, yet treatment is underutilized and varies in integration and intensity of resources across health systems. Exploring perceptions of MOUD delivery among pregnant/parenting women promises to uncover and address the underlying challenges to treatment, a perspective that may be different for providers and stakeholders. Therefore, our main purpose is to elicit patients' experiences and perceptions of MOUD, associated access to treatment, and availability of supportive resources during pregnancy/postpartum to inform OUD treatment. METHODS: Through a qualitative research approach we gathered data from individual interviews/focus group discussions for this pilot study. Pregnant and postpartum parenting women (n = 17) responded to questions related to perceptions of MOUD, access to treatment, and availability of social and psychosocial resources. Data were collected, transcribed, and coded (by consensus) and emerging themes were analyzed using grounded theory methodology. RESULTS: Emerging themes revealed positive uptake and perceptions of MOUD, continuing gaps in knowledge, negative impact of stigmatization, and limited access to programs and resources. Supportive relationships from family, peers, healthcare providers and child welfare staff, and co-located services were perceived as positive motivators to recovery. CONCLUSIONS: Through the unique lenses of women with lived experience, this study revealed several themes that can be transformative for women. Overall perceptions of MOUD were positive and likely to facilitate uptake and promote positive recovery outcomes. Bridging knowledge gaps will reduce anxieties, fears about neonatal opioid withdrawal syndrome and adverse maternal outcomes. Additionally, a deeper understanding of stigmatization and relationships can inform an integrated patient-centered approach to OUD treatment.

State-level policies and receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users.

OBJECTIVES: To evaluate the association of state-level policies on receipt of opioid regimens informed by Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day recommendations. DESIGN: A retrospective cohort study of new chronic opioid users (NCOUs). SETTING: Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new chronic use between January 2014 and March 2015. PARTICIPANTS: NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid prescription. INTERVENTIONS: State-level policies including Prescription Drug Monitoring Program (PDMP) robustness and cannabis policies involving the presence of medical dispensaries and state-wide decriminalization. MAIN OUTCOME MEASURES: NCOUs were placed in three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). Multinomial logistic regression was used to estimate the association of state-level policies with the thresholds while adjusting for relevant patient-specific factors. RESULTS: NCOUs in states with medium or high PDMP robustness had lower odds of receiving medium (adjusted odds ratio [AOR] 0.74; 95 percent confidence interval [CI]: 0.62-0.69) and high (AOR 0.74; 95 percent CI: 0.59-0.92) thresholds. With respect to cannabis policies, NCOUs in states with medical cannabis dispensaries had lower odds of receiving high (AOR 0.75; 95 percent CI: 0.60-0.93) thresholds, while cannabis decriminalization had higher odds of receiving high (AOR 1.24; 95 percent CI: 1.04-1.49) thresholds. CONCLUSION: States with highly robust PDMPs and medical cannabis dispensaries had lower odds of receiving higher opioid thresholds, while cannabis decriminalization correlated with higher odds of receiving high opioid thresholds.

Short-term healthcare resource utilization associated with receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users.

OBJECTIVE: To evaluate the impact of recent changes to the Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day threshold recommendations on healthcare utilization. DESIGN: A retrospective cohort study of new chronic opioid users (NCOUs). SETTING: Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new use between January 2014 and March 2015. PATIENTS: NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid -prescription. INTERVENTIONS: NCOU categorized by the CDC three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). MAIN OUTCOME MEASURES: Multivariable logistic regression was used to calculate adjusted odds of incurring an acute care encounter (ACE) (all-cause and opioid-related) between the thresholds (adjusted odds, 95 percent confidence interval). RESULTS: In adjusted analyses, when compared to low threshold, there was no difference in the odds of all-cause ACE across the medium (1.01, 0.94-1.28) and high (1.01, 0.84-1.22) thresholds. When compared to low threshold, a statistically insignificant increase was observed when evaluating opioid-related ACE among medium (1.86, 0.86-4.02) and high (1.51, 0.65-3.52) thresholds. CONCLUSIONS: There was no difference in odds of an all-cause or opioid-related ACE associated with the thresholds. Early-intervention programs and policies exploring reduction of MME/day among NCOUs may not result in short-term reduction in all-cause or opioid-related ACEs. Further assessment of potential long-term reduction in ACEs among this cohort may be insightful.