Prescription Opioid Dose Reductions and Potential Adverse Events: a Multi-site Observational Cohort Study in Diverse US Health Systems

BACKGROUND

In response to the opioid crisis in the United States, population-level prescribing of opioids has been decreasing; there are concerns, however, that dose reductions are related to potential adverse events.

OBJECTIVE

Examine associations between opioid dose reductions and risk of 1-month potential adverse events (emergency department (ED) visits, opioid overdose, benzodiazepine prescription fill, all-cause mortality).

DESIGN

This observational cohort study used electronic health record and claims data from eight United States health systems in a prescription opioid registry (Clinical Trials Network-0084). All opioid fills (excluding buprenorphine) between 1/1/2012 and 12/31/2018 were used to identify baseline periods with mean morphine milligram equivalents daily dose of  ≥ 50 during six consecutive months.

PATIENTS

We identified 60,040 non-cancer patients with  ≥ one 2-month dose reduction period (600,234 unique dose reduction periods).

MAIN MEASURES

Analyses examined associations between dose reduction levels (1- < 15%, 15- < 30%, 30- < 100%, 100% over 2 months) and potential adverse events in the month following a dose reduction using logistic regression analysis, adjusting for patient characteristics.

KEY RESULTS

Overall, dose reduction periods involved mean reductions of 18.7%. Compared to reductions of 1- < 15%, dose reductions of 30- < 100% were associated with higher odds of ED visits (OR 1.14, 95% CI 1.10, 1.17), opioid overdose (OR 1.41, 95% CI 1.09-1.81), and all-cause mortality (OR 1.39, 95% CI 1.16-1.67), but lower odds of a benzodiazepine fill (OR 0.83, 95% CI 0.81-0.85). Dose reductions of 15- < 30%, compared to 1- < 15%, were associated with higher odds of ED visits (OR 1.08, 95% CI 1.05-1.11) and lower odds of a benzodiazepine fill (OR 0.93, 95% CI 0.92-0.95), but were not associated with opioid overdose and all-cause mortality.

CONCLUSIONS

Larger reductions for patients on opioid therapy may raise risk of potential adverse events in the month after reduction and should be carefully monitored.

Association of initial opioid prescription duration and an opioid refill by pain diagnosis: Evidence from outpatient settings in ten US health systems

OBJECTIVE

The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription.

METHODS

We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription.

RESULTS

Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3-4 days' supply).

CONCLUSIONS

Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined.

Development and implementation of a prescription opioid registry across diverse health systems

Objective

Develop and implement a prescription opioid registry in 10 diverse health systems across the US and describe trends in prescribed opioids between 2012 and 2018.

Materials and Methods

Using electronic health record and claims data, we identified patients who had an outpatient fill for any prescription opioid, and/or an opioid use disorder diagnosis, between January 1, 2012 and December 31, 2018. The registry contains distributed files of prescription opioids, benzodiazepines and other select medications, opioid antagonists, clinical diagnoses, procedures, health services utilization, and health plan membership. Rates of outpatient opioid fills over the study period, standardized to health system demographic distributions, are described by age, gender, and race/ethnicity among members without cancer.

Results

The registry includes 6 249 710 patients and over 40 million outpatient opioid fills. For the combined registry population, opioid fills declined from a high of 0.718 per member-year in 2013 to 0.478 in 2018, and morphine milligram equivalents (MMEs) per fill declined from 985 MMEs per fill in 2012 to 758 MMEs in 2018. MMEs per member declined from 692 MMEs per member in 2012 to 362 MMEs per member in 2018.

Conclusion

This study established a population-based opioid registry across 10 diverse health systems that can be used to address questions related to opioid use. Initial analyses showed large reductions in overall opioid use per member among the combined health systems. The registry will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use.

Quality of Nursing Homes Admitting Working-Age Adults With Serious Mental Illness

OBJECTIVE

This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness.

METHODS

The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates.

RESULTS

Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11.

CONCLUSIONS

These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.

Characteristics of Working-Age Adults With Schizophrenia Newly Admitted to Nursing Homes

OBJECTIVES

Persons aged <65 years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a contemporary understanding of the characteristics and management of working-age adults (22-64 years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored.

DESIGN

This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare.

SETTING AND PARTICIPANTS

This study examines working-age (22-64 years) adults with schizophrenia at admission to a nursing home.

METHODS

Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented.

RESULTS

Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms.

CONCLUSIONS AND IMPLICATIONS

Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged <65 years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care.

Infants Exposed To Homelessness: Health, Health Care Use, And Health Spending From Birth To Age Six

Homeless infants are known to have poor birth outcomes, but the longitudinal impact of homelessness on health, health care use, and health spending during the early years of life has received little attention. Linking Massachusetts emergency shelter enrollment records for the period 2008-15 with Medicaid claims, we compared 5,762 infants who experienced a homeless episode with a group of 5,553 infants matched on sex, race/ethnicity, location, and birth month. Infants born during a period of unstable housing resulting in homelessness had higher rates of low birthweight, respiratory problems, fever, and other common conditions; longer neonatal intensive care unit stays; more emergency department visits; and higher annual spending. Differences in most health conditions persisted for two to three years. Asthma diagnoses, emergency department visits, and spending were significantly higher through age six. While screening and access to health care can be improved for homeless infants, long-term solutions require a broader focus on housing and income.

A randomised phase II trial of hydroxychloroquine and imatinib versus imatinib alone for patients with chronic myeloid leukaemia in major cytogenetic response with residual disease

In chronic-phase chronic myeloid leukaemia (CP-CML), residual BCR-ABL1+ leukaemia stem cells are responsible for disease persistence despite TKI. Based on in vitro data, CHOICES (CHlorOquine and Imatinib Combination to Eliminate Stem cells) was an international, randomised phase II trial designed to study the safety and efficacy of imatinib (IM) and hydroxychloroquine (HCQ) compared with IM alone in CP-CML patients in major cytogenetic remission with residual disease detectable by qPCR. Sixty-two patients were randomly assigned to either arm. Treatment 'successes' was the primary end point, defined as ≥0.5 log reduction in 12-month qPCR level from trial entry. Selected secondary study end points were 24-month treatment 'successes', molecular response and progression at 12 and 24 months, comparison of IM levels, and achievement of blood HCQ levels >2000 ng/ml. At 12 months, there was no difference in 'success' rate (p = 0.58); MMR was achieved in 80% (IM) vs 92% (IM/HCQ) (p = 0.21). At 24 months, the 'success' rate was 20.8% higher with IM/HCQ (p = 0.059). No patients progressed. Seventeen serious adverse events, including four serious adverse reactions, were reported; diarrhoea occurred more frequently with combination. IM/HCQ is tolerable in CP-CML, with modest improvement in qPCR levels at 12 and 24 months, suggesting autophagy inhibition maybe of clinical value in CP-CML.

Describing the resource utilisation and costs associated withvertebral fractures: the Build Better Bones with Exercise (B3E) Pilot Trial

This analysis examined costs/resources of 141 women with vertebral fractures, randomised to a home exercise programme or control group. Total, mean costs and the incremental cost-effectiveness ratio (ICER) were calculated. Quality of life was collected. Cost drivers were caregiver time, medications and adverse events (AEs). Results show adding an exercise programme may reduce the risk of AEs.

INTRODUCTION

This exploratory economic analysis examined the health resource utilisation and costs experienced by women with vertebral fractures, and explored the effects of home exercise on those costs.

METHODS

Women ≥ 65 years with one or more X-ray-confirmed vertebral fractures were randomised 1:1 to a 12-month home exercise programme or equal attention control group. Clinical and health system resources were collected during monthly phone calls and daily diaries completed by participants. Intervention costs were included. Unit costs were applied to health system resources. Quality of life (QoL) information was collected via EQ-5D-5L at baseline, 6 and 12 months.

RESULTS

One hundred and forty-one women were randomised. Overall total costs (CAD 2018) were $664,923 (intervention) and $614,033 (control), respectively. The top three cost drivers were caregiver time ($250,269 and $240,811), medications ($151,000 and $122,145) and AEs ($58,807 and $71,981). The mean cost per intervention participant of $9365 ± $9988 was higher compared with the mean cost per control participant of $8772 ± $9718. The mean EQ-5D index score was higher for the intervention participants (0.81 ± 0.11) compared with that of controls (0.79 ± 0.13). The differences in quality-adjusted life year (QALY) (0.02) and mean cost ($593) were used to calculate the ICER of $29,650.

CONCLUSIONS

Women with osteoporosis with a previous fracture experience a number of resources and associated costs that impact their care and quality of life. Caregiver time, medications and AEs are the biggest cost drivers for this population. The next steps would be to expand this feasibility study with more participants, longer-term follow-up and more regional variability.

European LeukemiaNet 2020 recommendations for treating chronic myeloid leukemia

The therapeutic landscape of chronic myeloid leukemia (CML) has profoundly changed over the past 7 years. Most patients with chronic phase (CP) now have a normal life expectancy. Another goal is achieving a stable deep molecular response (DMR) and discontinuing medication for treatment-free remission (TFR). The European LeukemiaNet convened an expert panel to critically evaluate and update the evidence to achieve these goals since its previous recommendations. First-line treatment is a tyrosine kinase inhibitor (TKI; imatinib brand or generic, dasatinib, nilotinib, and bosutinib are available first-line). Generic imatinib is the cost-effective initial treatment in CP. Various contraindications and side-effects of all TKIs should be considered. Patient risk status at diagnosis should be assessed with the new EUTOS long-term survival (ELTS)-score. Monitoring of response should be done by quantitative polymerase chain reaction whenever possible. A change of treatment is recommended when intolerance cannot be ameliorated or when molecular milestones are not reached. Greater than 10% BCR-ABL1 at 3 months indicates treatment failure when confirmed. Allogeneic transplantation continues to be a therapeutic option particularly for advanced phase CML. TKI treatment should be withheld during pregnancy. Treatment discontinuation may be considered in patients with durable DMR with the goal of achieving TFR.

Correlates of specialty substance use treatment among adults with opioid use disorders

AIMS

To identify factors associated with the receipt of specialty substance use treatment among adults with opioid use disorders (OUD).

DESIGN

Cross-sectional study based on 2010-2014 National Surveys on Drug Use and Health (NSDUH).

SETTING AND PARTICIPANTS

Adults with a past-year OUD (n = 2488). The sample is representative of non-institutionalized US adults.

MEASUREMENTS

Past-year OUD was determined using DSM-IV criteria. Past-year specialty substance use treatment was defined as receiving treatment for drug use at any of the following locations: rehabilitation facilities, hospitals (inpatient only), outpatient mental health centers, private doctors' offices, or methadone clinics. Multivariable logistic regression models were used to measure the independent association between potential correlates and specialty substance use treatment receipt.

FINDINGS

Of adults with an OUD, 8.3% received past-year specialty substance use treatment. In a fully adjusted logistic regression model, the following factors were associated with increased odds of receiving specialty substance use treatment: ≥ 35 years old (adjusted Odds Ratio (aOR) = 2.55, 95% Confidence Interval (CI) = 1.04-6.26); unemployment (aOR = 1.92, 95% CI = 1.02-3.61); not in the labor force (aOR = 2.16, 95% CI = 1.15-4.06); never been married (aOR = 2.14, 95% CI = 1.04-4.39); arrested in past 12 months (aOR = 4.43, 95% CI = 2.45-7.99); opioid dependence (aOR = 3.82, 95% CI = 2.06-7.10); alcohol use disorder (aOR = 2.44, 95% CI = 1.44-4.11); and another drug use disorder (aOR = 3.22, 95% CI = 1.95-5.32). Living in a non-metropolitan county (aOR = 0.29, 95% CI = 0.12-0.68) and fair/poor health (aOR = 0.38, 95% CI = 0.17-0.86) were associated with decreased odds of receiving specialty substance use treatment.

CONCLUSIONS

These findings suggest a need for the following efforts: strategies to increase individuals' recognition of their need for OUD treatment, expansion of insurance coverage for substance use treatment, expansion of earlier intervention services, adoption of a chronic care approach to substance use treatment, and an expansion of treatment capacity for rural communities.

Screening mammography among nursing home residents in the United States: Current guidelines and practice

OBJECTIVE

United States (US) guidelines regarding when to stop routine breast cancer screening remain unclear. No national studies to-date have evaluated the use of screening mammography among US long-stay nursing home residents. This cross-sectional study was designed to identify prevalence, predictors, and geographic variation of screening mammography among that population in the context of current US guidelines.

MATERIALS AND METHODS

Screening mammography prevalence, identified with Physician/Supplier Part B claims and stratified by guideline age classification (65-74, ≥75 years), was estimated for all women aged ≥65 years residing in US Medicare- and Medicaid- certified nursing homes (≥1 year) with an annual Minimum Data Set (MDS) 3.0 assessment, continuous Medicare Part B enrollment, and no clinical indication for screening mammography as of 2011 (n = 389,821). The associations between resident- and regional- level factors, and screening mammography, were estimated by crude and adjusted prevalence ratios from robust Poisson regressions clustered by facility.

RESULTS

Women on average were 85.4 (standard deviation ±8.1) years old, 77.9% were disabled, and 76.3% cognitively impaired. Screening mammography prevalence was 7.1% among those aged 65-74 years (95% Confidence Interval (CI): 6.8%-7.3%) and 1.7% among those ≥75 years (95% CI, 1.7%-1.8%), with geographic variation observed. Predictors of screening in both age groups included race, cognitive impairment, frailty, hospice, and some comorbidities.

CONCLUSIONS

These results shed light on the current screening mammography practices in US nursing homes. Thoughtful consideration about individual screening recommendations and the implementation of more clear guidelines for this special population are warranted to prevent overscreening.

Health Care Utilization and Expenditures of Homeless Family Members Before and After Emergency Housing

OBJECTIVES

To describe longitudinal health service utilization and expenditures for homeless family members before and after entering an emergency shelter.

METHODS

We linked Massachusetts emergency housing assistance data with Medicaid claims between July 2008 and June 2015, constructing episodes of health care 12 months before and 12 months after families entered a shelter. We modeled emergency department visits, hospital admissions, and expenditures over the 24-month period separately for children and adults.

RESULTS

Emergency department visits, hospital admissions, and expenditures rose steadily before shelter entry and declined gradually afterward, ending, in most cases, near the starting point. Infants, pregnant women, and individuals with depression, anxiety, or substance use disorder had significantly higher rates of all outcomes. Many children's emergency department visits were potentially preventable.

CONCLUSIONS

Increased service utilization and expenditures begin months before families become homeless and are potentially preventable with early intervention. Infants are at greater risk. Public Health Implications. Early identification and intervention to prevent homeless episodes, focusing on family members with behavioral health disorders, who are pregnant, or who have young children, may save money and improve family health.

Prescription contraception use and adherence by women with substance use disorders

BACKGROUND AND AIMS

Unintended pregnancy rates are high among women with substance use disorders (SUDs), which could be explained partly by lower use of and adherence to contraception. We aimed to test: (1) the association of SUD with prescription contraceptive use, contraceptive method selection and adherence; (2) whether practices participating in the Patient-Centered Medical Home Initiative (PCMHI) had better contraceptive use and adherence for patients with SUD; and (3) for differences in the association of SUD with adherence by type of contraceptive used.

DESIGN

Retrospective cohort analysis of claims and encounter data.

SETTING

Massachusetts, USA.

PARTICIPANTS

A total of 47 902 women aged 16-45 years enrolled in Medicaid or Commonwealth Care in Massachusetts between 2010 and 2014.

MEASUREMENTS

We examined three dependent variables: (1) use of a reversible prescription contraceptive during 2012; (2) the contraceptive methods used; and (3) the proportion of days covered by a prescription contraceptive in the year following the first prescription contraceptive claim. The primary predictor was diagnosed SUD, defined as at least one claim for an alcohol or drug use disorder.

FINDINGS

SUD was associated with lower rates of prescription contraceptive use during 2012 [19.2 versus 23.9%; adjusted odds ratio (aOR) = 0.79, P < 0.001]. SUD was associated with decreased selection of long-acting reversible contraception (LARC) compared with short-acting contraception (SARC) (42.8 versus 44.5%; aOR = 0.83, P = 0.011). There was no significant association between SUD and adherence (aOR = 0.84, P = 0.068). PCMHI enrollment did not alter the relationship between SUD and contraceptive use or adherence. Contraceptive method did not impact the relationship between SUD and adherence.

CONCLUSION

Women with substance use disorders are less likely to use prescription contraceptives, especially long-acting methods, but are not significantly less likely to adhere to them once prescribed than women without substance use disorders.

"I do not have time. Is there a handout I can use?": combining physicians' needs and behavior change theory to put physical activity evidence into practice

Guidelines for physical activity exist and following them would improve health. Physicians can advise patients on physical activity. We found barriers related to physicians' knowledge, a lack of tools and of physician incentives, and competing demands for limited time with a patient. We discuss interventions that could reduce these barriers.

INTRODUCTION

Uptake of physical activity (PA) guidelines would improve health and reduce mortality in older adults. However, physicians face barriers in guideline implementation, particularly when faced with needing to tailor recommendations in the presence of chronic disease. We performed a behavioral analysis of physician barriers to PA guideline implementation and to identify interventions. The Too Fit To Fracture physical activity recommendations were used as an example of disease-specific PA guidelines.

METHODS

Focus groups and semi-structured interviews were conducted with physicians and nurse practitioners in Ontario, stratified by type of physician, geographic area, and urban/rural, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the behavior change wheel framework, themes were categorized into capability, opportunity and motivation, and interventions were identified.

RESULTS

Fifty-nine family physicians, specialists, and nurse practitioners participated. Barriers were as follows: Capability-lack of exercise knowledge or where to refer; Opportunity-pragmatic tools, fit within existing workflow, available programs that meet patients' needs, physical activity literacy and cultural practices; Motivation-lack of incentives, not in their scope of practice or professional identity, competing priorities, outcome expectancies. Interventions selected: education, environmental restructuring, enablement, persuasion. Policy categories: communications/marketing, service provision, guidelines.

CONCLUSIONS

Key barriers to PA guideline implementation among physicians include knowledge on where to refer or what to say, access to pragmatic programs or resources, and things that influence motivation, such as competing priorities or lack of incentives. Future work will report on the development and evaluation of knowledge translation interventions informed by the barriers.

Access to New Medications for Hepatitis C for Medicaid Members: A Retrospective Cohort Study

BACKGROUND

Sofosbuvir (SOF)- or simeprevir (SIM)-containing regimens are highly effective for treating chronic hepatitis C virus (HCV) infection. These regimens, however, are expensive. Most payers have implemented prior authorization (PA) requirements to ensure that patients who can benefit most have priority for these medications. While many Medicaid programs limit access to those with advanced disease or to members who do not have active substance use disorder (SUD), the Massachusetts Medicaid (MassHealth) Primary Care Clinician (PCC) plan does not limit access based on disease severity or presence of SUD. Evaluating PA requests for SOF and/or SIM among MassHealth members will offer a useful example of early uptake among Medicaid members and will identify patient groups who might face barriers to treatment at the provider or patient level.

OBJECTIVES

To (a) evaluate the percentage of MassHealth PCC members with HCV who had a PA request, along with the percentage of requests approved, and (b) identify characteristics associated with PA requests for SOF or SIM among Massachusetts Medicaid (MassHealth) members with HCV.

METHODS

This retrospective cohort study used enrollment, medical claims, and PA request data from MassHealth PCC members from December 6, 2012, to July 31, 2014. The sample included members with 1 or more claims with an ICD-9-CM code for HCV during this time who were continuously enrolled from December 6, 2013, to July 31, 2014. Enrollment and medical claims data for the cohort with HCV were linked to a database containing information collected from PA requests. The overall percentage of members with HCV and a PA request for SOF and/or SIM between December 6, 2013, and July 31, 2014, and the percentage of requests approved were calculated. Chi-square statistics were used to compare demographic and clinical characteristics among members with HCV who did and did not have a request. Logistic regression was used to estimate the strength of associations between patient characteristics and a PA treatment request, adjusting for clinical and demographic variables.

RESULTS

Of 6,849 members identified with HCV, 346 (5.1%) had a PA request for SOF and/or SIM submitted to MassHealth. Compared with members with HCV who did not have a PA request for SOF or SIM, those with a PA request for these new treatments were more likely to be male (P = 0.01), older (P < 0.001), white race (P = 0.04), have standard MassHealth insurance (P = 0.01), and less likely to be homeless (P < 0.001). Members with a PA request were also more likely to have been treated for HCV in the past year and have advanced disease (hepatic decompensation, cirrhosis, or liver transplant) but less likely to have SUD (P < 0.001 for each). Ninety percent of requests for SOF or SIM were approved; few demographic or clinical characteristics were associated with approval. In adjusted analyses, predictors of PA request were aged 50-64 years (odds ratio (OR) = 2.0, 95% CI = 1.1-3.7 vs. aged < 30 years); hepatic decompensation (OR = 1.6, 95% CI = 1.2-2.3); cirrhosis (OR = 3.0, 95% CI = 2.2-4.1); liver transplant (OR = 3.0, 95% CI = 1.4-6.5); substance use (OR = 0.6, 95% CI = 0.5-0.8); recent HCV treatment (OR = 1.6, 95% CI = 1.0-2.6); comorbidity (OR = 0.95, 95% CI = 0.91-0.98) for 1-unit increase in Diagnostic Cost Group score; and care at a hospital outpatient department (OR = 2.0, 95% CI = 1.2-3.2 vs. group practice).

CONCLUSIONS

Antiviral treatment with SOF and/or SIM was requested for a relatively small proportion of MassHealth members with HCV, with nearly all approved. Prescriber prioritization or patient barriers to care, rather than the PA process, determined access to treatment in this Medicaid population. Support may be needed to ensure patients with SUD benefit from advances in HCV treatment.

DISCLOSURES

No outside funding supported this research. Internal funding was provided by the Commonwealth of Massachusetts. Lavitas has received compensation from University of Tennessee Advanced Studies in Medicine for development of CPE activity. Graham has consulted for the National Viral Hepatitis Roundtable and the Department of Health and Human Services, has received payment from Medscape for CME development, and is employed by Trek Therapeutics. Jeffrey has received payment for guest lectures at Boston University and Harvard University. Study concept and design were primarily contributed by Clark and Clements, along with Graham, Lenz, and Jeffrey. Kunte collected the data, which were interpreted by Graham, Lenz, and Jeffrey, with assistance from Lavitas, Clark, and Clements. The manuscript was written primarily by Clements, along with O'Connell and assisted by Graham, and revised by all the authors.

A comparison of clofarabine with ara-C, each in combination with daunorubicin as induction treatment in older patients with acute myeloid leukaemia

The study was designed to compare clofarabine plus daunorubicin vs daunorubicin/ara-C in older patients with acute myeloid leukaemia (AML) or high-risk myelodysplastic syndrome (MDS). Eight hundred and six untreated patients in the UK NCRI AML16 trial with AML/high-risk MDS (median age, 67 years; range 56-84) and normal serum creatinine were randomised to two courses of induction chemotherapy with either daunorubicin/ara-C (DA) or daunorubicin/clofarabine (DClo). Patients were also included in additional randomisations; ± one dose of gemtuzumab ozogamicin in course 1; 2v3 courses and ± azacitidine maintenance. The primary end point was overall survival. The overall response rate was 69% (complete remission (CR) 60%; CRi 9%), with no difference between DA (71%) and DClo (66%). There was no difference in 30-/60-day mortality or toxicity: significantly more supportive care was required in the DA arm even though platelet and neutrophil recovery was significantly slower with DClo. There were no differences in cumulative incidence of relapse (74% vs 68%; hazard ratio (HR) 0.93 (0.77-1.14), P=0.5); survival from relapse (7% vs 9%; HR 0.96 (0.77-1.19), P=0.7); relapse-free (31% vs 32%; HR 1.02 (0.83-1.24), P=0.9) or overall survival (23% vs 22%; HR 1.08 (0.93-1.26), P=0.3). Clofarabine 20 mg/m2 given for 5 days with daunorubicin is not superior to ara-C+daunorubicin as induction for older patients with AML/high-risk MDS.

European LeukemiaNet recommendations for the management and avoidance of adverse events of treatment in chronic myeloid leukaemia

Most reports on chronic myeloid leukaemia (CML) treatment with tyrosine kinase inhibitors (TKIs) focus on efficacy, particularly on molecular response and outcome. In contrast, adverse events (AEs) are often reported as infrequent, minor, tolerable and manageable, but they are increasingly important as therapy is potentially lifelong and multiple TKIs are available. For this reason, the European LeukemiaNet panel for CML management recommendations presents an exhaustive and critical summary of AEs emerging during CML treatment, to assist their understanding, management and prevention. There are five major conclusions. First, the main purpose of CML treatment is the antileukemic effect. Suboptimal management of AEs must not compromise this first objective. Second, most patients will have AEs, usually early, mostly mild to moderate, and which will resolve spontaneously or are easily controlled by simple means. Third, reduction or interruption of treatment must only be done if optimal management of the AE cannot be accomplished in other ways, and frequent monitoring is needed to detect resolution of the AE as early as possible. Fourth, attention must be given to comorbidities and drug interactions, and to new events unrelated to TKIs that are inevitable during such a prolonged treatment. Fifth, some TKI-related AEs have emerged which were not predicted or detected in earlier studies, maybe because of suboptimal attention to or absence from the preclinical data. Overall, imatinib has demonstrated a good long-term safety profile, though recent findings suggest underestimation of symptom severity by physicians. Second and third generation TKIs have shown higher response rates, but have been associated with unexpected problems, some of which could be irreversible. We hope these recommendations will help to minimise adverse events, and we believe that an optimal management of them will be rewarded by better TKI compliance and thus better CML outcomes, together with better quality of life.

High CIP2A levels correlate with an antiapoptotic phenotype that can be overcome by targeting BCL-XL in chronic myeloid leukemia

Cancerous inhibitor of protein phosphatase 2A (CIP2A) is a predictive biomarker of disease progression in many malignancies, including imatinib-treated chronic myeloid leukemia (CML). Although high CIP2A levels correlate with disease progression in CML, the underlying molecular mechanisms remain elusive. In a screen of diagnostic chronic phase samples from patients with high and low CIP2A protein levels, high CIP2A levels correlate with an antiapoptotic phenotype, characterized by downregulation of proapoptotic BCL-2 family members, including BIM, PUMA and HRK, and upregulation of the antiapoptotic protein BCL-XL. These results suggest that the poor prognosis of patients with high CIP2A levels is due to an antiapoptotic phenotype. Disrupting this antiapoptotic phenotype by inhibition of BCL-XL via RNA interference or A-1331852, a novel, potent and BCL-XL-selective inhibitor, resulted in extensive apoptosis either alone or in combination with imatinib, dasatinib or nilotinib, both in cell lines and in primary CD34(+) cells from patients with high levels of CIP2A. These results demonstrate that BCL-XL is the major antiapoptotic survival protein and may be a novel therapeutic target in CML.

Long-term benefits and risks of frontline nilotinib vs imatinib for chronic myeloid leukemia in chronic phase: 5-year update of the randomized ENESTnd trial

In the phase 3 Evaluating Nilotinib Efficacy and Safety in Clinical Trials–Newly Diagnosed Patients (ENESTnd) study, nilotinib resulted in earlier and higher response rates and a lower risk of progression to accelerated phase/blast crisis (AP/BC) than imatinib in patients with newly diagnosed chronic myeloid leukemia in chronic phase (CML-CP). Here, patients' long-term outcomes in ENESTnd are evaluated after a minimum follow-up of 5 years. By 5 years, more than half of all patients in each nilotinib arm (300 mg twice daily, 54% 400 mg twice daily, 52%) achieved a molecular response 4.5 (MR^4.5; BCR-ABL⩽0.0032% on the International Scale) compared with 31% of patients in the imatinib arm. A benefit of nilotinib was observed across all Sokal risk groups. Overall, safety results remained consistent with those from previous reports. Numerically more cardiovascular events (CVEs) occurred in patients receiving nilotinib vs imatinib, and elevations in blood cholesterol and glucose levels were also more frequent with nilotinib. In contrast to the high mortality rate associated with CML progression, few deaths in any arm were associated with CVEs, infections or pulmonary diseases. These long-term results support the positive benefit-risk profile of frontline nilotinib 300 mg twice daily in patients with CML-CP.

Frequent Emergency Department Visits and Hospitalizations Among Homeless People With Medicaid: Implications for Medicaid Expansion

OBJECTIVES

We examined factors associated with frequent hospitalizations and emergency department (ED) visits among Medicaid members who were homeless.

METHODS

We included 6494 Massachusetts Medicaid members who received services from a health care for the homeless program in 2010. We used negative binomial regression to examine variables associated with frequent utilization.

RESULTS

Approximately one third of the study population had at least 1 hospitalization and two thirds had 1 or more ED visits. More than 70% of hospitalizations and ED visits were incurred by only 12% and 21% of these members, respectively. Homeless individuals with co-occurring mental illness and substance use disorders were at greatest risk for frequent hospitalizations and ED visits (e.g., incidence rate ratios [IRRs] = 2.9-13.8 for hospitalizations). Individuals living on the streets also had significantly higher utilization (IRR = 1.5).

CONCLUSIONS

Despite having insurance coverage, homeless Medicaid members experienced frequent hospitalizations and ED visits. States could consider provisions under the Patient Protection and Affordable Care Act (e.g., Medicaid expansion and Health Homes) jointly with housing programs to meet the needs of homeless individuals, which may improve the quality and cost effectiveness of care.

Second generation tyrosine kinase inhibitors prevent disease progression in high-risk (high CIP2A) chronic myeloid leukaemia patients

High cancerous inhibitor of PP2A (CIP2A) protein levels at diagnosis of chronic myeloid leukaemia (CML) are predictive of disease progression in imatinib-treated patients. It is not known whether this is true in patients treated with second generation tyrosine kinase inhibitors (2G TKI) from diagnosis, and whether 2G TKIs modulate the CIP2A pathway. Here, we show that patients with high diagnostic CIP2A levels who receive a 2G TKI do not progress, unlike those treated with imatinib (P=<0.0001). 2G TKIs induce more potent suppression of CIP2A and c-Myc than imatinib. The transcription factor E2F1 is elevated in high CIP2A patients and following 1 month of in vivo treatment 2G TKIs suppress E2F1 and reduce CIP2A; these effects are not seen with imatinib. Silencing of CIP2A, c-Myc or E2F1 in K562 cells or CML CD34+ cells reactivates PP2A leading to BCR-ABL suppression. CIP2A increases proliferation and this is only reduced by 2G TKIs. Patients with high CIP2A levels should be offered 2G TKI treatment in preference to imatinib. 2G TKIs disrupt the CIP2A/c-Myc/E2F1 positive feedback loop, leading to lower disease progression risk. The data supports the view that CIP2A inhibits PP2Ac, stabilising E2F1, creating a CIP2A/c-Myc/E2F1 positive feedback loop, which imatinib cannot overcome.

Variation in long-term antipsychotic polypharmacy and high-dose prescribing across physicians and hospitals

OBJECTIVES

This study had two aims: to measure the prevalence of long-term prescribing of high doses of antipsychotics and antipsychotic polypharmacy in a large Canadian province and to estimate the relative contributions of patient-, physician-, and hospital-level factors.

METHODS

Government hospital discharge, physician, and pharmaceutical claims data were linked to identify individuals with schizophrenia who in 2004 had antipsychotics available to them for at least 11 months. Individuals on a high dose throughout that period, as well as individuals on multiple concurrent antipsychotics (polypharmacy), were identified. Logistic and generalized linear mixed models using patient-, physician-, and hospital-level predictors were estimated.

RESULTS

Among the 12,150 individuals identified, 11.9% were on a high dose and 10.4% on antipsychotic polypharmacy continually, with 3.7% in both groups. After adjustment for potential confounders, analyses showed that systematic propensity for physicians to prescribe high doses accounted for 10.9% of the remaining unexplained variance, and physicians as a group who prescribed high doses across a hospital or psychiatry department accounted for 3.0%. For antipsychotic polypharmacy the corresponding percentages were 9.7% and 6.2%. Even after adjustment, the variation in high-dose prescribing and antipsychotic polypharmacy remained substantial.

CONCLUSIONS

Long-term high-dose and antipsychotic polypharmacy prescribing appeared partly driven by some physicians' and some hospitals' propensities to prescribe in this way independently of patient characteristics. Given the weight of the evidence against high-dose prescribing and antipsychotic polypharmacy, measures addressed to physicians and hospitals most likely to prescribe high doses, antipsychotic polypharmacy, or both should be considered.

Dual glutathione-S-transferase-θ1 and -μ1 gene deletions determine imatinib failure in chronic myeloid leukemia

Approximately 40% of patients with chronic myeloid leukemia (CML) receiving imatinib fail treatment. There is an increased risk of CML in subjects with (i) deletions of genes encoding glutathione-S-transferase (GST)-θ1 (GSTT1) and -μ1, (GSTM1) and (ii) the GST-π1 (GSTP1) single-nucleotide polymorphism (SNP) Ile105Val (GSTP1*B; rs1695); however, their effects on imatinib treatment outcome are not known. Here, we assess the role of these GSTs in relation to imatinib treatment outcome in 193 CML patients. Deletion of GSTT1 alone, or in combination with deletion of the GSTM1 gene, significantly increased the likelihood of imatinib failure (P = 0.021 and P < 0.001, respectively). The GSTP1*B SNP was not associated with time to imatinib failure. Losses of the GSTT1 and GSTM1 genes are therefore important determinants of imatinib failure in CML. Screening for GSTT1 and GSTM1 gene deletions during diagnosis may identify patients who may be better treated using an alternative therapy.

The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence

OBJECTIVE

To assess the impact of a 2008 dose-based prior authorization policy for Massachusetts Medicaid beneficiaries using buprenorphine + naloxone for opioid addiction treatment. Doses higher than 16 mg required progressively more frequent authorizations.

DATA SOURCES

Mediciaid claims for 2007 and 2008 linked with Department of Public Health (DPH) service records.

STUDY DESIGN

We conducted time series for all buprenorphine users and a longitudinal cohort analysis of 2,049 individuals who began buprenorphine treatment in 2007. Outcome measures included use of relapse-related services, health care expenditures per person, and buprenorphine expenditures.

DATA COLLECTION/EXTRACTION METHODS

We used ICD-9 codes and National Drug Codes to identify individuals with opioid dependence who filled prescriptions for buprenorphine. Medicaid and DPH data were linked with individual identifiers.

PRINCIPAL FINDINGS

Individuals using doses >24 mg decreased from 16.5 to 4.1 percent. Relapses increased temporarily for some users but returned to previous levels within 3 months. Buprenorphine expenditures decreased but total expenditures did not change significantly.

CONCLUSION

Prior authorization policies strategically targeted by dose level appear to successfully reduce use of higher than recommended buprenorphine doses. Savings from these policies are modest and may be accompanied by brief increases in relapse rates. Lower doses may decrease diversion of buprenorphine.

The effects of supported employment in Latino consumers with severe mental illness

OBJECTIVE

Despite the large number of Latinos living in the United States, little research has evaluated the effectiveness of different vocational rehabilitation programs for individuals with severe mental illness in this rapidly growing minority population. This article presents a secondary analysis of a randomized, controlled trial comparing supported employment with 2 other vocational rehabilitation programs in 3 ethnic/racial groups of participants with severe mental illness: Latinos, non-Latino African Americans, and non-Latino Whites.

METHOD

The data were drawn from a previously published randomized, controlled trial comparing supported employment with standard vocational rehabilitation services and a psychosocial clubhouse program in persons with severe mental illness (Mueser et al., 2004), including 64 Latinos, 91 non-Latino African Americans, and 43 non-Latino Whites. Comparisons were made between the 3 groups at baseline on demographic characteristics, clinical and psychosocial functioning, and quality of life. Within each ethnic/racial group, competitive employment and all paid employment outcomes were compared between the 3 vocational rehabilitation programs over the 2-year study period.

RESULTS

At baseline, the Latino participants had lower levels of education and disability income, were less likely to have worked competitively over the previous 5 years, had more severe symptoms, and worse psychosocial functioning than the non-Latino African American or non-Latino White participants. Latinos randomized to supported employment had better competitive and all-paid work outcomes than those assigned to either standard services or the psychosocial clubhouse program, similar to the non-Latino consumers. Rates of competitive work for consumers in supported employment were comparable across all 3 racial/ethnic groups.

DISCUSSION

Supported employment is effective at improving competitive work in Latinos with severe mental illness. Efforts should be made to increase access to supported employment in the growing population of Latinos with severe mental illness.

Health care utilization patterns of homeless individuals in Boston: preparing for Medicaid expansion under the Affordable Care Act

OBJECTIVES

We studied 6494 Boston Health Care for the Homeless Program (BHCHP) patients to understand the disease burden and health care utilization patterns for a group of insured homeless individuals.

METHODS

We studied merged BHCHP data and MassHealth eligibility, claims, and encounter data from 2010. MassHealth claims and encounter data provided a comprehensive history of health care utilization and expenditures, as well as associated diagnoses, in both general medical and behavioral health services sectors and across a broad range of health care settings.

RESULTS

The burden of disease was high, with the majority of patients experiencing mental illness, substance use disorders, and a number of medical diseases. Hospitalization and emergency room use were frequent and total expenditures were 3.8 times the rate of an average Medicaid recipient.

CONCLUSIONS

The Affordable Care Act provides a framework for reforming the health care system to improve the coordination of care and outcomes for vulnerable populations. However, improved health care coverage alone may not be enough. Health care must be integrated with other resources to address the complex challenges presented by inadequate housing, hunger, and unsafe environments.

A randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric disorders

Substance use disorders have a profound impact on the course of severe mental illnesses and on the family, but little research has evaluated the impact of family intervention for this population. To address this question, a randomized controlled trial was conducted comparing a brief (2-3 mo) Family Education (ED) program with a longer-term (9-18 mo) program that combined education with teaching communication and problem-solving skills, Family Intervention for Dual Disorders (FIDD). A total of 108 clients (77% schizophrenia-spectrum) and a key relative were randomized to either ED or FIDD and assessed at baseline and every 6 months for 3 years. Rates of retention of families in both programs were moderate. Intent-to-treat analyses indicated that clients in both programs improved in psychiatric, substance abuse, and functional outcomes, as did key relatives in knowledge of co-occurring disorders, burden, and mental health functioning. Clients in FIDD had significantly less severe overall psychiatric symptoms and psychotic symptoms and tended to improve more in functioning. Relatives in FIDD improved more in mental health functioning and knowledge of co-occurring disorders. There were no consistent differences between the programs in substance abuse severity or family burden. The findings support the utility of family intervention for co-occurring disorders, and the added benefits of communication and problem-solving training, but also suggest the need to modify these programs to retain more families in treatment in order to provide them with the information and skills they need to overcome the effects of these disorders.

Reduction of lesion-induced deficits in visual reversal learning following cross-modal training

Two experiments examined the effects of postoperative auditory intensity training on serial brightness reversal learning of visual decorticate rats. In Experiment 1 rats learned an avoidance response cued by a high intensity light prior to visual decortication. Six days later the rats were given either avoidance training with an auditory intensity cue, additional training with the preoperative visual cue, or no training. The next day all rats began a series of 8 brightness discrimination reversals. The no-training lesion group failed the early reversals but reached criterion in later reversals. Lesion rats retrained with visual cues failed early reversals with the low intensity light cue but not reversals with the high intensity cue. In contrast, lesion rats given auditory training easily reached criterion in all reversals. Experiment 2 followed a similar training sequence except auditory training was given after the second reversal. All rats showed rapid acquisition of all visual reversals subsequent to auditory training. These data suggest that generalization of a learning set by cross-modal transfer training with an intact modality can reduce reversal learning deficits following brain damage more efficiently than comparable training with the damaged system.

Antisocial Personality Disorder in People with Co-Occurring Severe Mental Illness and Substance Use Disorders: Clinical, Functional, and Family Relationship Correlates

Antisocial personality disorder (ASPD) is an important correlate of substance abuse severity in the addiction population and in people with co-occurring serious mental illness and addiction. Because family members often provide vital supports to relatives with co-occurring disorders, this study explored the correlates of ASPD in 103 people with co-occurring disorders (79% schizophrenia-schizoaffective, 21% bipolar disorder) in high contact with relatives participating in a family intervention study. Clients with ASPD were more likely to have bipolar disorder and to have been married, but less likely to have graduated from high school. ASPD was associated with more severe drug abuse and depression, worse functioning, and less planning-based social problem solving. The relatives of clients with ASPD also reported less planning-based problem solving, worse attitudes towards the client, and worse mental health functioning. Client ASPD was associated with less long-term exposure to family intervention. The findings suggest that clients with ASPD in addition to co-occurring disorders are a particularly disadvantaged group with greater illness severity, more impaired functioning, and more strained family relationships. These difficulties may pose special challenges to delivering family intervention for this group.

The evidence doesn't justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine

Many state Medicaid programs restrict access to buprenorphine, a prescription medication that relieves withdrawal symptoms for people addicted to heroin or other opiates. The reason is that officials fear that the drug is costlier or less safe than other therapies such as methadone. To find out if this is true, we compared spending, the use of services related to drug-use relapses, and mortality for 33,923 Massachusetts Medicaid beneficiaries receiving either buprenorphine, methadone, drug-free treatment, or no treatment during the period 2003-07. Buprenorphine appears to have significantly expanded access to treatment because the drug can be prescribed by a physician and taken at home compared with methadone, which by law must be administered at an approved clinic. Buprenorphine was associated with more relapse-related services but $1,330 lower mean annual spending than methadone when used for maintenance treatment. Mortality rates were similar for buprenorphine and methadone. By contrast, mortality rates were 75 percent higher among those receiving drug-free treatment, and more than twice as high among those receiving no treatment, compared to those receiving buprenorphine. The evidence does not support rationing buprenorphine to save money or ensure safety.

Disparities in routine breast cancer screening for Medicaid managed care members with a work-limiting disability

OBJECTIVE

Examine disparities in routine mammography for women who qualify for Medicaid, because of a work-limiting disability.

METHODS

Individual-level data were obtained for women enrolled in Massachusetts Medicaid Managed Care plans who met the 2007 Healthcare Effectiveness Data and Information Set (HEDIS) criteria for the breast cancer screening measure (n=35,171). Disability status was determined from Medicaid eligibility records. Mammography screening was modeled using multivariate logistic regression. Separate models for women with and without a disability were also estimated.

RESULTS

Although unadjusted breast cancer screening rates were roughly equal for women with and without disability, after adjusting for confounders disability status had a significant negative association with screening mammography (OR=0.74; p<0.0001). Living farther from a mammography facility or having a diagnosis of domestic violence reduced the odds of screening for women with disabilities, but not for other women. Having a higher illness burden was more detrimental to screening for women with a disability than for those without. Both groups benefited similarly from the first 26 ambulatory care visits, but the impact of additional visits on screening was much larger among women with disabilities.

CONCLUSION

Nationwide, rates of routine mammography for Medicaid managed care plans averaged below 50% in 2006. Given that a majority of eligible women served by Medicaid have disabilities, and studies have shown that women with disabilities are more likely to be diagnosed with late stage disease, a focus on improving rates of screening for women with disabilities is overdue.

Chronic physical conditions in older adults with mental illness and/ or substance use disorders

OBJECTIVES

To examine the association between mental illness and chronic physical conditions in older adults and investigate whether co-occurring substance use disorders (SUDs) are associated with greater risk of chronic physical conditions beyond mental illness alone.

DESIGN

A retrospective cross-sectional study.

SETTING

Medicare and Medicaid programs in Massachusetts.

PARTICIPANTS

Massachusetts Medicare and Medicaid members aged 65 and older as of January 1, 2005 (N = 679,182).

MEASUREMENTS

Diagnoses recorded on Medicare and Medicaid claims were used to identify mental illness, SUDs, and 15 selected chronic physical conditions.

RESULTS

Community-dwelling older adults with mental illness or SUDs had higher adjusted risk for 14 of the 15 selected chronic physical conditions than those without these disorders; the only exception was eye diseases. Moreover, those with co-occurring SUDs and mental illness had the highest adjusted risk for 11 of these chronic conditions. For residents of long-term care facilities, mental illness and SUDs were only moderately associated with the risk of chronic physical conditions.

CONCLUSION

Community-dwelling older adults with mental illness or SUDs, particularly when they co-occurred, had substantially greater medical comorbidity than those without these disorders. For residents of long-term care facilities, the generally uniformly high medical comorbidity may have moderated this relationship, although their high prevalence of mental illness and SUDs signified greater healthcare needs. These findings strongly suggest the imminent need for integrating general medical care, mental health services, and addiction health services for older adults with mental illness or SUDs.

Behavioral disorders and diabetes-related outcomes among Massachusetts Medicare and Medicaid beneficiaries

OBJECTIVE

The study investigated whether Massachusetts beneficiaries of Medicare, Medicaid, or both programs who have behavioral disorders have higher rates of diabetes-related complications and hospitalizations.

METHODS

This was a retrospective study using merged Medicare and Medicaid claims data from Massachusetts in 2004 and 2005. The study included beneficiaries who had type 2 diabetes, who stayed in nursing homes for fewer than 90 days, and who were enrolled in Medicare or Medicaid (or both) for at least ten months during the study period. ICD-9-CM and Current Procedural Terminology codes were used to identify diabetes complications (eye complications, nephropathy, neuropathy, ischemic heart disease, cerebrovascular disease, lower-limb amputations, and diabetes-related hospitalizations). The rates of adverse diabetes outcomes were compared across behavioral disorders as identified by ICD-9-CM diagnoses. While adjusting for case mix, multivariate logistic regressions were performed to compare the odds of adverse diabetes outcomes among people with mental or substance use disorders with those without these disorders.

RESULTS

A total of 106,174 individuals met inclusion criteria. Results from adjusted analysis showed a mixed picture of the relationships between behavioral disorders and adverse diabetes outcomes. Although substance use disorders were associated with higher odds of lower-limb amputations and diabetes-related hospitalizations, beneficiaries with schizophrenia or paranoid states had lower odds of adverse diabetes outcomes.

CONCLUSIONS

Medicaid and Medicare beneficiaries with alcohol or drug use disorders had higher rates of adverse diabetes outcomes than other groups, whereas beneficiaries with mental disorders had lower rates of diabetes-related complications.

Predictors of prenatal and postpartum care adequacy in a medicaid managed care population

PURPOSE

To examine factors affecting prenatal and postpartum care for an insured, but vulnerable, population.

METHODS

Individual-level data on three measures of care adequacy were obtained for Massachusetts Medicaid Managed Care women who met the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set denominator criteria for the prenatal and postpartum care measures in 2007 (n = 1,882). We modeled individual compliance with each measure separately as a binomial logistic function with individual and neighborhood characteristics, provider type, and health plan as explanatory variables.

FINDINGS

In our sample, 85% of women initiated care in the first trimester, but only 62% met the goal of receiving more than 80% of the recommended number of prenatal visits. Just 60% had a timely postpartum care visit. Having a diagnosis of substance abuse or dependence reduced the odds of meeting all measures. Women with disabilities were less likely to attain two of the three measures of adequate care, as were women with other children in the household. Women who enrolled in Medicaid in the first trimester were more likely to receive the recommended number of prenatal visits than those who were enrolled before pregnancy.

CONCLUSION

Given the importance of prenatal and postpartum care for maternal and child health and the recent national declining trend in timely care, initiatives to improve rates of timely and adequate care are crucial and must include components tailored toward particularly vulnerable subpopulations.

Factors associated with Medicaid patients' access to buprenorphine treatment

Some studies have shown that patients entering buprenorphine treatment differ from those in other modalities. This study compares Massachusetts Medicaid beneficiaries who received buprenorphine, methadone or other treatment for opioid addiction in 2007. Patients' characteristics and comorbidities were identified through claims data, and associations between these factors and treatment type were investigated using multivariate analysis. Among patients receiving opioid agonist treatments, patients with prior buprenorphine treatment, HIV, bipolar disease, and other substance use disorders were more likely to receive buprenorphine treatment compared with methadone, whereas patients with heart failure, diabetes, hepatitis C, major depression, and anxiety were less likely to receive buprenorphine treatment. These differences may suggest variability in patient access, treatment preferences, and a need for different levels of services in different modalities. This information is important for understanding the impact of this new treatment in Medicaid populations and for developing treatment systems to best meet patients' needs.

Behavioral health disorders and adherence to measures of diabetes care quality

OBJECTIVE

To investigate whether Medicare and/or Medicaid beneficiaries with behavioral health disorders (BHDs) receive lower quality diabetes care.

STUDY DESIGN

Retrospective observational study using merged Medicare and Medicaid claims data from Massachusetts in calendar years 2004 and 2005.

METHODS

The study included beneficiaries who had type 2 diabetes, stayed at nursing homes for fewer than 90 days, and were enrolled in Medicare and/or Medicaid for at least 10 months during the study period. We used Current Procedural Terminology (CPT) codes to identify the receipt of 4 measures of diabetes care quality (ie, glycated hemoglobin tests, low-density lipoprotein cholesterol tests, nephropathy tests, eye examinations). The rates of adherence (defined by proportions of beneficiaries receiving appropriate services for each measure) were compared across different types of BHDs as identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses. Multivariate logistic regression was used to compare the odds of adherence among beneficiaries who had BHDs with the odds among beneficiaries who had no BHDs, while adjusting for case mix.

RESULTS

A total of 106,174 individuals met inclusion criteria. Results from adjusted analysis showed a mixed picture of the relationships between BHDs and adherence to quality measures. While substance use disorders were associated with lower adherence to quality measures, beneficiaries with diagnoses of schizophrenia or paranoid states had higher odds for adherence to quality measures.

CONCLUSIONS

Individuals with diabetes and substance use disorders receive lower quality diabetes care. Further studies to examine the factors associated with this disparity are needed.

Fully kinetic particle-in-cell simulations of a deuterium gas puff z pinch

We present the first fully kinetic, collisional, and electromagnetic simulations of the complete time evolution of a deuterium gas puff z pinch. Recent experiments with 15-MA current pinches have suggested that the dominant neutron-production mechanism is thermonuclear. We observe distinct differences between the kinetic and magnetohydrodynamic simulations in the pinch evolution with the kinetic simulations producing both thermonuclear and beam-target neutrons. The kinetic approach demonstrated in this Letter represents a viable alternative for performing future plasma physics calculations.

Family intervention for co-occurring substance use and severe psychiatric disorders: participant characteristics and correlates of initial engagement and more extended exposure in a randomized controlled trial

Clients with severe mental illness and substance use disorder (i.e., dual disorders) frequently have contact with family members, who may provide valuable emotional and material support, but have limited skills and knowledge to promote recovery. Furthermore, high levels of family conflict and stress are related to higher rates of relapse. The present study was a two-site randomized controlled trial comparing a comprehensive, behaviorally-based family intervention for dual disorders program (FIDD) to a shorter-term family psychoeducational program (FPE). The modal family was a single male son in his early 30s diagnosed with both alcohol and drug problems and a schizophrenia-spectrum disorder participating with his middle-aged mother, with whom he lived. Initial engagement rates following consent to participate in the study and the family intervention programs were moderately high for both programs (88% and 84%, respectively), but rates of longer term retention and exposure to the core elements of each treatment model were lower (61% and 55%, respectively). Characteristics of the relatives were the strongest predictors of successful initial engagement in the family programs with the most important predictor being relatives who reported higher levels of benefit related to the relationship with the client. Subsequent successful exposure to the family treatment models was more strongly associated with client factors, including less severity of drug abuse and male client gender. The results suggest that attention to issues of motivating relatives to participate in family intervention, and more focused efforts to address the disruptive effects of drug abuse on the family could improve rates of engagement and retention in family programs for dual disorders.

Impact of substance disorders on medical expenditures for medicaid beneficiaries with behavioral health disorders

OBJECTIVE

This study measured the impact of substance use disorders on Medicaid expenditures for behavioral and physical health care among beneficiaries with behavioral health disorders.

METHODS

Claims for Medicaid beneficiaries with behavioral health diagnoses in 1999 from Arkansas, Colorado, Georgia, Indiana, New Jersey, and Washington were analyzed. Behavioral health and general medical expenditures for individuals with diagnoses of substance use disorders were compared with expenditures for those without such diagnoses. States were analyzed separately with adjustment for confounders.

RESULTS

A total of 148,457 beneficiaries met selection criteria, and 43,457 (29.3%) had a substance use diagnosis. Compared with other beneficiaries with behavioral health disorders, individuals with diagnoses of substance use disorders had significantly higher expenditures for physical health problems in five of six states. Approximately half of the additional care and expenditures were for treatment of physical conditions. Differences declined but remained statistically significant after adjustment for higher overall disease burden among beneficiaries with addictions. Medical expenditures for individuals with diagnoses of substance use disorders increased significantly with age in five of six states, whereas behavioral health expenditures were stable or declined. Hospital admissions for psychiatric and general medical reasons were higher for those with diagnoses of substance use disorders.

CONCLUSIONS

The impact of addiction on Medicaid populations with behavioral health disorders is greater than the direct cost of mental health and addictions treatment. Higher medical expenditures can be partly attributed to greater prevalence of co-occurring physical disorders, but expenditures remained higher after adjustment for disease burden. Spending estimates based only on behavioral health diagnoses may significantly underestimate addictions-related costs, particularly for older adults.

The quality of asthma care among adults with substance-related disorders and adults with mental illness

OBJECTIVE

The purpose of this study was to investigate whether the presence of substance-related disorders or mental illness may affect the quality of medication management in asthma care.

METHODS

Claims from 1999 for adult Medicaid patients with persistent asthma from five states were analyzed. Sample sizes ranged from 1,207 to 5,815. The adjusted odds of meeting two quality-of-care measures for asthma were calculated: the Health Effectiveness Data and Information Set (HEDIS) measure of filling a single prescription for a controller medication and a non-HEDIS measure of achieving a ratio of long-term controller medications to total asthma medications of > or = .5.

RESULTS

Odds of achieving the HEDIS measure were lower for patients with substance-related or schizophrenia disorders in two states (range of odds ratio [OR]=.69, 95% confidence interval [CI]=.53-.90, to OR=.81, 95% CI=.69-.96), but the odds increased for patients with depressive disorders in two states (OR=1.34, CI= 1.12-1.61; OR=1.37, CI=1.05-1.77) and for patients with bipolar disorder in one state (OR=1.69, CI=1.13-2.55). Odds of achieving the ratio measure were lower for patients with substance-related disorders in four states (range of OR=.63, CI=.47-.88, to OR=.75, CI=.62-.92) and higher for patients with depressive disorders, although only in one state (OR=1.25, CI=1.03-1.53).

CONCLUSIONS

Patients with substance-related disorders and those with schizophrenia disorders may be receiving lower-quality asthma care, whereas patients with some other forms of mental illness may be receiving higher-quality care. Further studies are needed to identify the determinants of high-quality asthma care and the validity of quality measures based on administrative data in these populations.

Comparative evaluation of two asthma care quality measures among Medicaid beneficiaries

BACKGROUND

The relative performance of asthma care quality measures has not been evaluated in Medicaid populations.

METHODS

Using complete claims and pharmaceutical data for 19,076 patients with persistent asthma (based on Health Effectiveness and Data Information Set criteria) in five Medicaid populations, we compared the following two measures of asthma care quality: filling prescriptions for controller asthma medications within 1 year and the ratio of controller medication to the total number of asthma medication prescriptions filled within 1 year. We calculated whether meeting each quality measure was associated with decreased odds of emergency department (ED) treatment episodes. We then compared the odds ratios, receiver operating characteristic (ROC) curves, and deviances between models, using each measure to predict ED utilization in Medicaid populations.

RESULTS

Although meeting each measure was associated with lower odds of ED utilization, this decrease was larger if the controller asthma medication measure was met rather than the ratio measure. Additionally, models using the controller medication measure had greater areas under the ROC curve and smaller deviances than models using the ratio measure.

CONCLUSIONS

Both administrative measures of asthma care quality were associated with lower odds of ED utilization. The controller medication measure of asthma care quality may be better than the ratio measure in relation to emergency asthma care utilization by Medicaid beneficiaries.

Case selection for a Medicaid chronic care management program

Medicaid agencies are beginning to turn to care management to reduce costs and improve health care quality. One challenge is selecting members at risk of costly, preventable service utilization. Using claims data from the State of Vermont, we compare the ability of three pre-existing health risk predictive models to predict the top 10 percent of members with chronic conditions: Chronic Illness and Disability Payment System (CDPS), Diagnostic Cost Groups (DCG), and Adjusted Clinical Groups Predictive Model (ACG-PM). We find that the ACG-PM model performs best. However, for predicting the very highest-cost members (e.g, the 99th percentile), the DCG model is preferred.