Association of Opioid Use Disorder Diagnosis with Management of Acute Low Back Pain: A Medicare Retrospective Cohort Analysis.

BACKGROUND: Practice guidelines recommend nonpharmacologic and nonopioid therapies as first-line pain treatment for acute pain. However, little is known about their utilization generally and among individuals with opioid use disorder (OUD) for whom opioid and other pharmacologic therapies carry greater risk of harm. OBJECTIVE: To determine the association between a pre-existing OUD diagnosis and treatment of acute low back pain (aLBP). DESIGN: Retrospective cohort study using 2016-2019 Medicare data. PARTICIPANTS: Fee-for-service Medicare beneficiaries with a new episode of aLBP. MAIN MEASURES: The main independent variable was OUD diagnosis measured prior to the first LBP claim (i.e., index date). Using multivariable logistic regressions, we assessed the following outcomes measured within 30 days of the index date: (1) nonpharmacologic therapies (physical therapy and/or chiropractic care), and (2) prescription opioids. Among opioid recipients, we further assessed opioid dose and co-prescription of gabapentin. Analyses were conducted overall and stratified by receipt of physical therapy, chiropractic care, opioid fills, or gabapentin fills during the 6 months before the index date. KEY RESULTS: We identified 1,263,188 beneficiaries with aLBP, of whom 3.0% had OUD. Two-thirds (65.8%) did not receive pain treatments of interest at baseline. Overall, nonpharmacologic therapy receipt was less prevalent and opioid and nonopioid pharmacologic therapies were more common among beneficiaries with OUD than those without OUD. Beneficiaries with OUD had lower odds of receiving nonpharmacologic therapies (aOR = 0.62, 99%CI = 0.58-0.65) and higher odds of prescription opioid receipt (aOR = 2.24, 99%CI = 2.17-2.32). OUD also was significantly associated with increased odds of opioid doses ≥ 90 morphine milligram equivalents/day (aOR = 2.43, 99%CI = 2.30-2.56) and co-prescription of gabapentin (aOR = 1.15, 99%CI = 1.09-1.22). Similar associations were observed in stratified groups though magnitudes differed. CONCLUSIONS: Medicare beneficiaries with aLBP and OUD underutilized nonpharmacologic pain therapies and commonly received opioids at high doses and with gabapentin. Complementing the promulgation of practice guidelines with implementation science could improve the uptake of evidence-based nonpharmacologic therapies for aLBP.

Initial treatment approaches and healthcare utilization among veterans with low back pain: a propensity score analysis.

BACKGROUND: Opioid prescriptions for Veterans with low back pain (LBP) persist despite the availability of PT, a lower medical risk treatment option. Patterns of treatment and subsequent healthcare utilization for Veterans with LBP are unknown. The purpose of this study was to evaluate the association of physical therapy (PT) and opioids and outcomes of spinal surgery and chronic opioid use for Veterans with incident LBP. METHODS: We conducted a retrospective cohort study identifying Veterans with a new diagnosis of LBP using ICD codes from the Veterans Administration national database from 2012 to 2017. Veterans were classified into three treatment groups based on the first treatment received within 30 days of incident LBP: receipt of PT, opioids, or neither PT nor opioids. Outcomes, events of spinal surgery and chronic opioid use, were identified beginning on day 31 up to one year following initial treatment. We used propensity score matching to account for the potential selection bias in evaluating the associations between initial treatment and outcomes. RESULTS: There were 373,717 incident cases of LBP between 2012 and 2017. Of those 28,850 (7.7%) received PT, 48,978 (13.1%) received opioids, and 295,889 (79.2%) received neither PT or opioids. Pain, marital status and the presence of cardiovascular, pulmonary, or metabolic chronic conditions had the strongest statistically significant differences between treatment groups. Veterans receiving opioids compared to no treatment had higher odds of having a spinal surgery (2.04, 99% CI: 1.67, 2.49) and progressing to chronic opioid use (11.8, 99% CI: 11.3, 12.3). Compared to Veterans receiving PT those receiving opioids had higher odds (1.69, 99% CI: 1.21, 2.37) of having spinal surgery and progressing to chronic opioid use (17.8, 99% CI: 16.0, 19.9). CONCLUSION: Initiating treatment with opioids compared to PT was associated with higher odds of spinal surgery and chronic opioid use for Veterans with incident LBP. More Veterans received opioids compared to PT as an initial treatment for incident LBP. Our findings can inform rehabilitation care practices for Veterans with incident LBP.

Variation in statin prescription among veterans with HIV and known atherosclerotic cardiovascular disease.

BACKGROUND: People with HIV have increased atherosclerotic cardiovascular disease (ASCVD) risk, worse outcomes following incident ASCVD, and experience gaps in cardiovascular care, highlighting the need to improve delivery of preventive therapies in this population. OBJECTIVE: Assess patient-level correlates and inter-facility variations in statin prescription among Veterans with HIV and known ASCVD. METHODS: We studied Veterans with HIV and existing ASCVD, ie, coronary artery disease (CAD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD), who received care across 130 VA medical centers for the years 2018-2019. We assessed correlates of statin prescription using two-level hierarchical multivariable logistic regression. Median odds ratios (MORs) were used to quantify inter-facility variation in statin prescription. RESULTS: Nine thousand six hundred eight Veterans with HIV and known ASCVD (mean age 64.3 ± 8.9 years, 97% male, 48% Black) were included. Only 68% of the participants were prescribed any-statin. Substantially higher statin prescription was observed for those with diabetes (adjusted odds ratio [OR] = 2.3, 95% confidence interval [CI], 2.0-2.6), history of coronary revascularization (OR = 4.0, CI, 3.2-5.0), and receiving antiretroviral therapy (OR = 3.0, CI, 2.7-3.4). Blacks (OR = 0.7, CI, 0.6-0.9), those with non-coronary ASCVD, ie, ICVD and/or PAD only, (OR 0.53, 95% CI: 0.48-0.57), and those with history of illicit substance use (OR=0.7, CI, 0.6-0.9) were less likely to be prescribed statins. There was significant variation in statin prescription across VA facilities (10th, 90th centile: 55%, 78%), with an estimated 20% higher likelihood of difference in statin prescription practice for two clinically similar individuals treated at two comparable facilities (adjusted MOR = 1.21, CI, 1.18-1.24), and a greater variation observed for Blacks or those with non-coronary ASCVD or history of illicit drug use. CONCLUSION: In an analysis of large-scale VA data, we found suboptimal statin prescription and significant interfacility variation in statin prescription among Veterans with HIV and known ASCVD, particularly among Blacks and those with a history of non-coronary ASCVD.

Remnant cholesterol is prospectively associated with cardiovascular disease events and all-cause mortality in kidney transplant recipients: the FAVORIT study.

BACKGROUND: The cholesterol content of circulating triglyceride-rich lipoproteins is characterized as remnant cholesterol, although little is known about its role in the development of cardiovascular disease (CVD) outcomes, all-cause mortality or transplant failure in kidney transplant recipients (KTRs). Our primary aim was to investigate the prospective association of remnant cholesterol and the risk of CVD events in renal transplant recipients with secondary aims evaluating remnant cholesterol and renal graft failure and all-cause mortality among participants in the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial. METHODS: Among 4110 enrolled participants, 98 were excluded for missing baseline remnant cholesterol levels and covariates. Nonfasting remnant cholesterol levels were calculated based on the lipid profiles in 3812 FAVORIT trial participants at randomization. A Wilcoxon-type test for trend was used to compare baseline characteristics across remnant cholesterol quartiles. Cox proportional hazards regression was used to evaluate the association of baseline remnant cholesterol levels with time to primary and secondary study outcomes. RESULTS: During a median follow-up of 4.0 years we documented 548 CVD incident events, 343 transplant failures and 452 all-cause deaths. When comparing the highest quartile (quartile 4) to quartile 1, proportional hazard modeling revealed a significant increase in CVD risk {hazard ratio [HR] 1.32 [95% confidence interval (CI) 1.04-1.67]} and all-cause mortality risk [HR 1.34 (95% CI 1.01-1.69)]. A nonsignificant increase in transplant failure was seen as well [HR 1.20 (95% CI 0.87-1.64)]. CONCLUSIONS: Remnant cholesterol is associated with CVD and all-cause mortality in long-term KTRs. A randomized controlled clinical trial in KTRs that assesses the potential impact of remnant cholesterol-lowering therapy on these outcomes may be warranted.

A successful intervention to improve medication adherence in Black patients with hypertension: Mediation analysis of 28-site TEAM trial.

BACKGROUND: We previously reported the main effects and cost-effectiveness of a successful multifaceted Team Education and Adherence Monitoring (TEAM) intervention to improve refill adherence in Black patients with hypertension. It is important to identify the key mediators or intervention components that contributed to this intervention effect. OBJECTIVES: This study aimed to conduct a "mediation analysis" to determine which intervention components had the largest effect on refill adherence and assess patient satisfaction with pharmacy care. METHODS: A cluster-randomized trial was conducted among 576 Black patients in 28 pharmacies (14 TEAM, 14 control). TEAM participants were invited to 6 visits with a pharmacist-technician team that monitored the patient's blood pressure and used a 9-item Brief Medication Questionnaire, Brief Goal Check, and other novel tools to identify and reduce barriers to adherence in Black patients. Control participants received printed information only. Refill adherence was defined as >80% days covered (proportion of days covered) per refill records during months 7 to 12 (postintervention); potential mediators and patient satisfaction were assessed using a research questionnaire administered at month 6. A structural probit model examined 4 potential mediators that might explain intervention success. RESULTS: Of 4 potential mediators, the most important factors in explaining the improvement in refill adherence (postintervention) were greater pharmacist collaboration with patient in barrier reduction (68.5% of total indirect effect) and patient use of a pillbox (27.2% of total indirect effect). Pharmacist contact with physician and suggestion of a change in regimen did not have significant effects on adherence. TEAM participants were more likely than control participants to rate their pharmacist care as "very satisfactory" (80.2% vs. 44.2%, P < 0.001) and technician care as "very satisfactory" (81.2% vs. 47.4%, P < 0.001). CONCLUSION: Refill adherence and satisfaction can be improved in Black patients with hypertension by implementing a collaborative TEAM model with novel tools that enable community pharmacists and technicians to help identify and reduce the core barriers to adherence. Our results can be used to individualize and improve patient care and adherence outcomes in this vulnerable population.

Frequency and Predictors of Suboptimal Prescribing Among a Cohort of Older Male Residents with Urinary Tract Infections.

BACKGROUND: Unnecessary antibiotic treatment of suspected urinary tract infections (UTI) is common in long-term care facilities (LTCFs). However, less is known about the extent of suboptimal treatment, in terms of antibiotic choice, dose, and duration, after the decision to use antibiotics has been made. METHODS: We described the frequency of potentially suboptimal treatment among residents with an incident UTI (the first during the study with none in the year prior) in Department of Veterans Affairs (VA) community living centers (CLCs; 2013-2018). Time trends were analyzed using Joinpoint regression. Residents with UTIs receiving potentially suboptimal treatment were compared with those receiving optimal treatment, to identify resident characteristics predictive of suboptimal antibiotic treatment, using multivariable unconditional logistic regression models. RESULTS: We identified 21 938 residents with an incident UTI treated in 120 VA CLCs, of whom 96.0% were male. Potentially suboptimal antibiotic treatment was identified in 65.0% of residents and decreased 1.8% annually (P < .05). Potentially suboptimal initial drug choice was identified in 45.6% of residents, suboptimal dose frequency in 28.6%, and longer than recommended duration in 12.7%. Predictors of suboptimal antibiotic treatment included prior fluoroquinolone exposure (adjusted odds ratio, 1.38), chronic renal disease (1.19), age ≥85 years (1.17), prior skin infection (1.14), recent high white blood cell count (1.08), and genitourinary disorder (1.08). CONCLUSION: Similar to findings in non-VA facilities, potentially suboptimal treatment was common but improving in CLC residents with an incident UTI. Predictors of suboptimal antibiotic treatment should be targeted with antibiotic stewardship interventions to improve UTI treatment.

Use of Antiretroviral Therapy for a US Medicaid Enrolled Pediatric Cohort with HIV.

Appropriate antiretroviral therapy use in children with Human Immunodeficiency Virus (HIV) is essential for optimizing clinical outcomes and preventing HIV transmission. To describe and determine correlates of HIV antiretroviral therapy (ART) persistence and implementation for children and adolescents in the United States. We studied Medicaid enrollees (ages 2-19 years) with HIV in 14 states in 2011 and 2012. We defined non-persistence as a discontinuation of an ART regimen for at least 90 days, and calculated implementation as the proportion of days on ART while persistent. We used Cox proportional regression and logistic regression to determine characteristics associated with ART non-persistence and poor (< 90%) implementation, respectively. Among those with ≥ 1 year of observation (n = 8679), 55.7% never received ART. For ART recipients (n = 3849), 34.9% discontinued ART. Correlates of ART non-persistence included older age (e.g., 15-19 vs. 2-5 years [adjusted hazard ratio (aHR) 2.9, 95% CI 2.1-4.0]; females vs. males (aHR 1.2; 1.1-1.3); mental health conditions (aHR 1.3; 1.1-1.5), drug/alcohol abuse (aHR 1.2; 1.0-1.5) and HIV-related conditions (aHR 1.2; 1.0-1.4). Those with an outpatient visit were less likely to discontinue an ART (aHR 0.32; 0.28-0.36). During persistent episodes, 42.3% had poor ART implementation. Correlates of poor implementation included females vs. males (aOR 1.2; 95% CI 1.0-1.3), Black vs. White race (aOR 1.3; 95% CI 1.1-1.7) and Hispanic/Latino vs. White (aOR 1.3; 1.0-1.8). Among Medicaid youth with HIV, there were low rates of ART exposure, and ART discontinuation was common. Correlates of persistence and implementation differed, suggesting a need for varying clinical interventions to improve connection to care and ensuring ongoing engagement with ART use.

Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study.

BACKGROUND: Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS: We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS: Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION: In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.

Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients.

BACKGROUND: Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain. OBJECTIVES: Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis. METHODS: We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. RESULTS: Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90. CONCLUSIONS: Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.

Variation in opioid analgesia administration and discharge prescribing for emergency department patients with suspected urolithiasis.

OBJECTIVE: Previous research has suggested caution about opioid analgesic usage in the emergency department (ED) setting and raised concerns about variations in prescription opioid analgesic usage, both across institutions and for whom they are prescribed. We examined opioid analgesic usage in ED patients with suspected urolithiasis across fifteen participating hospitals. METHODS: This is a secondary analysis of a clinical trial including adult ED patients with suspected urolithiasis. In multilevel models accounting for clustering by hospital, we assessed demographic, clinical, state-level, and hospital-level factors associated with opioid analgesic administration during the ED visit and prescription at discharge. RESULTS: Of 2352 participants, 67% received an opioid analgesic during the ED visit and 61% were prescribed one at discharge. Opioid analgesic usage varied greatly across hospitals, ranging from 46% to 88% (during visit) and 34% to 85% (at discharge). Hispanic patients were less likely than non-Hispanic white patients to receive opioid analgesics during the ED visit (OR 0.72, 95% CI 0.55-0.94). Patients with higher education (OR 1.29, 95% CI 1.05-1.59), health insurance coverage (OR 1.27, 95% CI 1.02-1.60), or receiving care in states with a prescription drug monitoring program (OR 1.64, 95% CI 1.06-2.53) were more likely to receive an opioid analgesic prescription at ED discharge. CONCLUSION: We found marked hospital-level differences in opioid analgesic administration and prescribing, as well as associations with education, healthcare insurance, and race/ethnicity groups. These data might compel clinicians and hospitals to examine their opioid use practices to ensure it is congruent with accepted medical practice.

Trends for and Clinical Factors Associated with Choice of Oral P2Y12 Inhibitors for Patients on Chronic Dialysis.

BACKGROUND: Trends and clinical factors associated with prescribing choices for oral P2Y12 inhibitors (P2Y12-I) remain unknown for patients on chronic dialysis, i.e., with end-stage renal disease (ESRD). METHODS: From 2011-2014 U.S. Renal Data System registry, we identified 36,542 ESRD patients who received new prescriptions for P2Y12-I (median age 64.0 years and 54% males). Of the cohort, 93% were receiving hemodialysis and 7% on peritoneal dialysis. We analyzed trends and investigated clinical factors associated with specific P2Y12-I prescribed. RESULTS: Clopidogrel was prescribed for 95%, prasugrel for 3%, and ticagrelor for 2%. Clopidogrel was favored for those ≥75 years (18% of cohort). Compared to Caucasians, African Americans (36% of cohort) and Hispanics (19% of cohort) were less likely to receive prasugrel and ticagrelor (P<0.05). Patients receiving hemodialysis versus peritoneal dialysis were less likely to receive prasugrel over clopidogrel, adjusted odds ratio (aOR) 0.67 (0.55-0.82). Each additional year of dialysis decreased the odds of receiving prasugrel over clopidogrel, aOR 0.91 (0.85-0.98). History of atrial fibrillation reduced the odds of receiving ticagrelor or prasugrel over clopidogrel, aOR 0.69 (0.54-0.89) and 0.73 (0.60-0.89), respectively. Concomitant oral anticoagulant use was not associated with choice of P2Y12-I. Occurrence of non-ST segment elevation myocardial infarction or percutaneous coronary intervention within the 6-month period prior to the index date favored ticagrelor over prasugrel, aOR 1.31 (1.06-1.62) and 1.29 (1.01-1.66), respectively. However, prescribing trends favoring ticagrelor over prasugrel were not observed for deployment of drug-eluting, or multiple coronary stents. CONCLUSION: Between 2011 and 2014, clopidogrel remained the most common P2Y12-I whereas ticagrelor and prasugrel remained underutilized in ESRD patients. Prescribing practices for these drugs were based upon clinically approved indication for their use in the general population as well as perceived complexity of an ESRD patient including demographics, dialysis-related factors and comorbidities. Comparative effectiveness studies involving ESRD patients are needed to prove that ticagrelor and prasugrel are just as safe and effective as clopidogrel before clinicians can make informed decisions for choice of P2Y12-I in this patient population.

Efficacy of a community-based participatory and multilevel intervention to enhance hepatitis B virus screening and vaccination in underserved Korean Americans.

BACKGROUND: The primary objective of the current study was to evaluate the efficacy of a community-based participatory intervention program in improving hepatitis B virus (HBV) screening and vaccination among Korean Americans who were not previously screened. METHODS: A cluster randomized trial involving 32 Korean church-based community organizations (1834 participants) was conducted. Sixteen churches were randomly assigned to an HBV screening and vaccination multicomponent intervention condition (972 participants) and 16 were assigned to a general cancer education control condition (862 participants). The main components of the intervention program included interactive group education; patient navigation; and the engagement of health care providers, church leadership, and church members in the medical field. The application of community-based participatory research principles was monitored and evaluated. HBV screening and vaccination rates (self-reported and medical record verification) were assessed at 6-month and 12-month follow-ups, respectively. RESULTS: The results of the current study demonstrated significant efficacy in the HBV screening rate (92.5% in the intervention group vs 5.5% in the control group), 3-series HBV vaccination completion rate (84% in the intervention group vs 17.6% in the control group), and overall screening and vaccination compliance rate (87% in the intervention group vs 3.8% in the control group). Participants in the intervention group were significantly more likely to receive HBV screening (92.5%) compared with those in the control group (5.5%). In multivariate mixed-effect logistic regression analysis, the odds ratio for an intervention effect on HBV screening was 512.3 after adjusting for cluster effect and other demographic variables. With regard to vaccination rates, of the 332 participants who were screened with no immunity in the intervention group, 308 (92.8%) received at least 1 HBV vaccination, 300 (90.4%) received at least 2 shots, and 279 participants (84%) received all 3 shots. CONCLUSIONS: A combination of community-based participatory research and a multilevel approach may produce the most optimal results and be essential in producing a considerable effect for enhancing HBV screening and vaccination, particularly for Korean American populations with limited language proficiency and insurance coverage. Cancer 2018;124:973-82. © 2017 American Cancer Society.

Racial disparities in Medicaid home and community-based service utilization and expenditures among persons with multiple sclerosis.

BACKGROUND: Medicaid home and community-based services (HCBS) provide services such as personal care, nursing, and home-delivered meals to aging adults and individuals with disabilities. HCBS are available to people across racial and ethnic groups, yet racial disparities in Medicaid HCBS utilization and expenditures have been understudied. Individuals with multiple sclerosis (MS) may be particularly impacted by HCBS, as nearly one-third requires assistance at home. The present study examined whether disparities exist in Medicaid HCBS utilization and expenditures among HCBS users with MS. METHODS: We used secondary data to conduct a retrospective cohort analyses including 7550 HCBS recipients with MS. Demographic data was obtained from the Medicaid Analytic eXtract Personal Summary file, Medicaid HCBS service utilization and expenditures were obtained from the Other Therapy file, and comorbidities from the Medicare Chronic Condition Warehouse. Univariate and bivariate statistics were used to describe the sample and provide comparisons of characteristic by race. Logistic regression predicted the likelihood of using HCBS type and gamma regression was used to predict Medicaid HCBS expenditures. RESULTS: Black HCBS users were younger, more likely to be female, and were more impaired than Whites. Multivariate analyses showed that Blacks were less likely to receive case management, equipment, technology and modification services, and nursing services compared to Whites. Additionally, Black men had the lowest Medicaid HCBS expenditures, while White men had the highest. CONCLUSIONS: Findings shed light on disparities among HCBS users with MS. As Blacks are already disproportionately affected by MS, these results reveal target areas for future research. Future work should examine the factors that contribute to these disparities, as well as determine the extent to which these inequities impact outcomes such as hospitalizations and nursing home admissions.

Availability of Medicaid home- and community-based services for older Americans and people with physical disabilities.

This article provides an overview of Medicaid home- and community-based services (HCBS) for older adults and individuals with physical disabilities by describing eligibility criteria, availability, and types of services. All 50 state Medicaid programs provide supplementary HCBS in addition to mandatory services. The amount, type, and eligibility for HCBS varied widely between states. Variation in service provision and eligibility rules has led to a patchwork of services from state to state, with the same person eligible for services in one state but not another.

Cost-Effectiveness of Solitaire Stent Retriever Thrombectomy for Acute Ischemic Stroke: Results From the SWIFT-PRIME Trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke).

BACKGROUND AND PURPOSE: Clinical trials have demonstrated improved 90-day outcomes for patients with acute ischemic stroke treated with stent retriever thrombectomy plus tissue-type plasminogen activator (SST+tPA) compared with tPA. Previous studies suggested that this strategy may be cost-effective, but models were derived from pooled data and older assumptions. METHODS: In this prospective economic substudy conducted alongside the SWIFT-PRIME trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke), in-trial costs were measured for patients using detailed medical resource utilization and hospital billing data. Utility weights were assessed at 30 and 90 days using the EuroQol-5 dimension questionnaire. Post-trial costs and life-expectancy were estimated for each surviving patient using a model based on trial data and inputs derived from a contemporary cohort of ischemic stroke survivors. RESULTS: Index hospitalization costs were $17 183 per patient higher for SST+tPA than for tPA ($45 761 versus $28 578; P<0.001), driven by initial procedure costs. Between discharge and 90 days, costs were $4904 per patient lower for SST+tPA than for tPA ($11 270 versus $16 174; P=0.014); total 90-day costs remained higher with SST+tPA ($57 031 versus $44 752; P<0.001). Higher utility values for SST+tPA led to higher in-trial quality-adjusted life years (0.131 versus 0.105; P=0.005). In lifetime projections, SST+tPA was associated with substantial gains in quality-adjusted life years (6.79 versus 5.05), cost savings of $23 203 per patient and was economically dominant when compared with tPA in 90% of bootstrap replicates. CONCLUSIONS: Among patients with acute ischemic stroke enrolled in the SWIFT-PRIME trial, SST increased initial treatment costs, but was projected to improve quality-adjusted life-expectancy and reduce healthcare costs over a lifetime horizon compared with tPA. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.

Relationship between vancomycin tolerance and clinical outcomes in Staphylococcus aureus bacteraemia.

BACKGROUND: Previous data have demonstrated the clinical importance of vancomycin MIC values in Staphylococcus aureus bacteraemia (SAB); however, the impact of vancomycin tolerance (VT) is unknown. OBJECTIVES: To compare the frequency of clinical failure between patients with VT and non-VT isolates in SAB. METHODS: This was a retrospective cohort study of patients with SAB, excluding treatment <48 h or polymicrobial bacteraemia. The primary outcome was clinical failure (composite of 30 day mortality, non-resolving signs and symptoms, and 60 day recurrence). Vancomycin MIC and MBC were determined by broth microdilution. The association between VT (MBC/MIC ≥32) and clinical failure was evaluated by multivariable Poisson regression. RESULTS: Of the 225 patients, 26.7% had VT isolates. VT was associated with clinical failure (48.0% overall) in unadjusted analysis [68.3% (n = 41/60) versus 40.6% (n = 67/165); P < 0.001] and this relationship persisted in multivariable analysis (adjusted risk ratio, 1.74; 95% CI, 1.36-2.24; P < 0.001). The association between VT and clinical failure was also consistent within strata of methicillin susceptibility [methicillin susceptible (n = 125, risk ratio, 1.67; 95% CI, 1.20-2.32; P = 0.002); methicillin resistant (n = 100, risk ratio, 1.69; 95% CI, 1.14-2.51; P = 0.010)]. Among methicillin-susceptible SAB cases treated with ß-lactam therapy, VT remained associated with clinical failure (risk ratio, 1.77; 95% CI, 1.19-2.61; P = 0.004). CONCLUSIONS: VT was associated with clinical failure in SAB, irrespective of methicillin susceptibility or definitive treatment. VT may decrease the effectiveness of cell-wall-active therapy or be a surrogate marker of some other pathogen-specific factor associated with poor outcomes. Future research should evaluate if bactericidal non-cell-wall-active agents improve outcomes in VT SAB.

Medicaid Coverage of Smoking Cessation Counseling and Medication Is Underutilized for Pregnant Women.

INTRODUCTION: Policies to promote smoking cessation among Medicaid-insured pregnant women have the potential to assist a significant proportion of pregnant smokers. In 2010, Kansas Medicaid began covering smoking cessation counseling for pregnant smokers. Our aim was to evaluate the use of smoking cessation benefits provided to pregnant women as a result of the Kansas Medicaid policy change that provided reimbursement for physician-provided smoking cessation counseling. METHODS: We examined Kansas Medicaid claims data to estimate rates of delivery of smoking cessation treatment to Medicaid-insured pregnant women in Kansas from fiscal year 2010 through 2013. We analyzed the number of pregnant women who received physician-provided smoking cessation counseling indicated by procedure billing codes (ie, G0436 and G0437) and medication (ie, nicotine replacement therapy, bupropion, or varenicline) located in outpatient managed care encounter and fee-for-service claims data. We estimated the number of Medicaid-insured pregnant smokers using the national smoking prevalence (14%) in this population and the number of live births reported in Kansas. RESULTS: Annually from 2010 to 2013, approximately 27.2%-31.6% of pregnant smokers had claims for nicotine replacement therapy, bupropion, or varenicline. Excluding claims for bupropion, a medication commonly prescribed to treat depression, claims ranged from 9.3% to 11.1%. Following implementation of Medicaid coverage for smoking cessation counseling, less than 1% of estimated smokers had claims for counseling. CONCLUSIONS: This low claims rate suggests that simply changing policy is not sufficient to ensure use of newly implemented benefits, and that there probably remain critical gaps in smoking cessation treatment. IMPLICATIONS: This study evaluates the use of Medicaid reimbursement for smoking cessation counseling among low-income pregnant women in Kansas. We describe the Medicaid claims rates of physician-provided smoking cessation counseling for pregnant women, an evidence-based and universally recommended treatment approach for smoking cessation in this population. Our findings show that claims rates for smoking cessation benefits in this population are very low, even after policy changes to support provision of cessation assistance were implemented. Additional studies are needed to determine whether reimbursement is functioning as intended and identify potential gaps between policy and implementation of evidence-based smoking cessation treatment.

Pharmaceutical assistance programs to support smoking cessation medication access.

OBJECTIVES: Rural smokers are more likely to be uninsured and live in poverty, which may pose significant cost barriers to accessing smoking cessation medications. As part of a randomized clinical trial, we provided support to connect low-income smokers with the use of pharmaceutical assistance programs (PAPs) to improve medication access. METHODS: Study participants were rural smokers enrolled in a randomized clinical trial testing in-office telemedicine versus telephone-based approaches to deliver counseling sessions. For potentially qualified participants, we developed a system to connect them with PAPs that provided smoking cessation medications at low or no cost. Participants reported medication utilization 3 and 6 months after randomization. RESULTS: Of the 560 study participants, 312 (55.7%) met initial screening criteria for PAP eligibility. Of those eligible, 104 (33.3%) initiated a PAP application, with 49 (15.7%) completing the application and ultimately receiving medications through the programs. Despite the availability of assistance with the PAP application process, overall medication use among those that were eligible for PAP was significantly lower than among participants with higher incomes or access to prescription insurance (60.4% vs. 51.3%; P = 0.04). Abstinence among PAP-eligible smokers was also lower at the 3-month follow-up (P = 0.01), but this difference was not present at the 6- and 12-month follow-up surveys. CONCLUSION: With substantial assistance, some low-income smokers without prescription insurance can get effective smoking cessation medications through PAPs, but overall access remains worse than among those with higher incomes or prescription insurance.

Indoor tobacco legislation is associated with fewer emergency department visits for asthma exacerbation in children.

BACKGROUND: During the past 3 decades, numerous cities and states have adopted laws that ban smoking in public indoor spaces. The rationale for these policies has been to protect nonsmokers from the adverse health effects of secondhand smoke. OBJECTIVE: To determine whether the implementation of indoor smoking legislation is associated with a decrease in emergency department visits for asthma in children. METHODS: This retrospective analysis used a natural experiment to estimate the impact of clean indoor air legislation on the rate of emergency department admissions for asthma exacerbation in children. Data were obtained from the Pediatric Health Information System. A Poisson regression was used for analyses and controlled for age, sex, race, payer source, seasonality, and secular trends. RESULTS: Asthma emergency department visits were captured from 20 hospitals in 14 different states plus the District of Columbia from July 2000 to January 2014 (n = 335,588). Indoor smoking legislation, pooled across all cities, was associated with a decreased rate of severe asthma exacerbation (adjusted rate ratio 0.83, 95% confidence interval 0.82-0.85, P < .0001). CONCLUSION: Indoor tobacco legislation is associated with a decrease in emergency department visits for asthma exacerbation. Such legislation should be considered in localities that remain without this legislation to protect the respiratory health of their children.

Effectiveness comparison of cardio-selective to non-selective ß-blockers and their association with mortality and morbidity in end-stage renal disease: a retrospective cohort study.

BACKGROUND: Within-class comparative effectiveness studies of ß-blockers have not been performed in the chronic dialysis setting. With widespread cardiac disease in these patients and potential mechanistic differences within the class, we examined whether mortality and morbidity outcomes varied between cardio-selective and non-selective ß-blockers. METHODS: Retrospective observational study of within class ß-blocker exposure among a national cohort of new chronic dialysis patients (N = 52,922) with hypertension and dual eligibility (Medicare-Medicaid). New ß-blocker users were classified according to their exclusive use of one of the subclasses. Outcomes were all-cause mortality (ACM) and cardiovascular morbidity and mortality (CVMM). The associations of cardio-selective and non-selective agents on outcomes were adjusted for baseline characteristics using Cox proportional hazards. RESULTS: There were 4938 new ß-blocker users included in the ACM model and 4537 in the CVMM model: 77 % on cardio-selective ß-blockers. Exposure to cardio-selective and non-selective agents during the follow-up period was comparable, as measured by proportion of days covered (0.56 vs. 0.53 in the ACM model; 0.56 vs 0.54 in the CVMM model). Use of cardio-selective ß-blockers was associated with lower risk for mortality (AHR = 0.84; 99 % CI = 0.72-0.97, p = 0.0026) and lower risk for CVMM events (AHR = 0.86; 99 % CI = 0.75-0.99, p = 0.0042). CONCLUSION: Among new ß-blockers users on chronic dialysis, cardio-selective agents were associated with a statistically significant 16 % reduction in mortality and 14 % in cardiovascular morbidity and mortality relative to non-selective ß-blocker users. A randomized clinical trial would be appropriate to more definitively answer whether cardio-selective ß-blockers are superior to non-selective ß-blockers in the setting of chronic dialysis.