Opioid Prescribing in the 2016 Medicare Fee-for-Service Population

BACKGROUND AND OBJECTIVES

Opioid use and misuse are prevalent and remain a national crisis. This study identified beneficiary characteristics associated with filling opioid prescriptions, variation in opioid dosing, and opioid use with average daily doses (ADDs) equal to 120 morphine milligram equivalents (MMEs) or more in the 100% Medicare fee-for-service (FFS) population.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

In a cohort of FFS beneficiaries with 12 months of Medicare Part D coverage in 2016, we examined patient factors associated with filling an opioid prescription (n = 20,880,490) and variation in ADDs (n = 7,325,031) in a two-part model. Among those filling opioids, we also examined the probability of ADD equal to 120 MMEs or more via logistic regression.

RESULTS

About 35% of FFS beneficiaries had one or more opioid prescription fills in 2016 and 1.5% had ADDs equal to 120 MMEs or more. Disability-eligible beneficiaries and beneficiaries with multiple chronic conditions were more likely to fill opioids, to have higher ADDs or were more likely to have ADD equal to 120 MMEs or more. Beneficiaries with chronic obstructive pulmonary disease (COPD) were more likely to fill opioids (odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.46-1.47), have higher ADDs (rate ratio = 1.06, 95% CI = 1.06-1.06) when filled and were more likely to have ADD equal to 120 MMEs or more (OR = 1.23, 95% CI = 1.21-1.24). Finally, black and Hispanic beneficiaries were less likely to fill opioids, had lower overall doses and were less likely to have ADDs equal to 120 MMEs or more compared to white beneficiaries.

CONCLUSION

Several beneficiary subgroups have underappreciated risk of adverse events associated with ADD equal to 120 MMEs or more that may benefit from opioid optimization interventions that balance pain management and adverse event risk, especially beneficiaries with COPD who are at risk for respiratory depression.

Quality Measures for Managing Prescription of Antipsychotic Medication Among Youths: Factors Associated With Health Plan Performance

OBJECTIVE

This study examined the performance of health plans on two HEDIS measures: metabolic monitoring of children and adolescents prescribed an antipsychotic and use of first-line psychosocial care for children and adolescents prescribed an antipsychotic for a nonindicated use. Plan characteristics and other contextual factors that may be associated with health plan performance were examined to identify potential strategies for improving care.

METHODS

The study population included 279 commercial and 169 Medicaid health plans that voluntarily submitted data for care provided in 2016. Bivariate associations between performance on the two measures and each plan characteristic (eligible population size, region, profit status, model type, and operating in a state with legislation on prior authorization for antipsychotics) were examined. Main-effects multivariable linear regression models were used to examine the combined association of plan characteristics with each measure.

RESULTS

Performance rates on both measures were comparable for commercial and Medicaid plans. Among commercial plans, not-for-profit plans outperformed for-profit plans on both measures. Commercial and Medicaid plans in the North performed significantly better on the metabolic monitoring measure. Commercial plans in the South and Medicaid plans in the West performed significantly worse on the first-line psychosocial care measure. Plans operating in states requiring prior authorization performed significantly better on the metabolic monitoring measure.

CONCLUSIONS

This study identified key plan characteristics and other contextual factors associated with health plan performance on quality measures related to pediatric antipsychotic prescribing. Findings suggest that quality measures, in conjunction with policies such as prior authorization, can encourage better care delivery to vulnerable populations.

Food supply and bioenergy production within the global cropland planetary boundary

Supplying food for the anticipated global population of over 9 billion in 2050 under changing climate conditions is one of the major challenges of the 21^st century. Agricultural expansion and intensification contributes to global environmental change and risks the long-term sustainability of the planet. It has been proposed that no more than 15% of the global ice-free land surface should be converted to cropland. Bioenergy production for land-based climate mitigation places additional pressure on limited land resources. Here we test normative targets of food supply and bioenergy production within the cropland planetary boundary using a global land-use model. The results suggest supplying the global population with adequate food is possible without cropland expansion exceeding the planetary boundary. Yet this requires an increase in food production, especially in developing countries, as well as a decrease in global crop yield gaps. However, under current assumptions of future food requirements, it was not possible to also produce significant amounts of first generation bioenergy without cropland expansion. These results suggest that meeting food and bioenergy demands within the planetary boundaries would need a shift away from current trends, for example, requiring major change in the demand-side of the food system or advancing biotechnologies.

Evaluation of Gastric pH and Serum Gastrin Concentrations in Cats with Chronic Kidney Disease

Background

Chronic kidney disease (CKD) is a highly prevalent condition in cats. Advanced CKD is associated with hyporexia and vomiting, which typically are attributed to uremic toxins and gastric hyperacidity. However, gastric pH studies have not been performed in cats with CKD.

Hypothesis/Objectives

To determine if cats with CKD have decreased gastric pH compared to age‐matched, healthy cats. Based on previous work demonstrating an association of hypergastrinemia and CKD, we hypothesized that cats with CKD would have decreased gastric pH compared to healthy, age‐matched control cats.

Animals

10 CKD cats; 9 healthy control cats.

Methods

All cats with concurrent disease were excluded on the basis of history, physical examination, CBC, plasma biochemistry profile, urinalysis, urine culture, serum total thyroxine concentration, and serum symmetric dimethylarginine concentration (controls only) obtained within 24 hours of pH monitoring and assessment of serum gastrin concentrations. Serum for gastrin determination was collected, and 12‐hour continuous gastric pH monitoring was performed in all cats. Serum gastrin concentration, mean pH, and percentage time that gastric pH was strongly acidic (pH <1 and <2) were compared between groups.

Results

No significant differences in serum gastrin concentrations were observed between groups (medians [range]: CKD, 18.7 ng/dL [<10–659.0]; healthy, 54.6 ng/dL [<10–98.0]; P‐value = 0.713) or of any pH parameters including mean ± SD gastric pH (CKD, 1.8 ± 0.5; healthy, 1.6 ± 0.3; P‐value = 0.23).

Conclusions and Clinical Importance

These findings suggest that cats with CKD may not have gastric hyperacidity compared to healthy cats and, therefore, may not need acid suppression. Thus, further studies to determine if there is a benefit to acid suppression in cats with CKD are warranted.

Adoption of innovative and evidence-based practices for children and adolescents in state-supported mental health clinics: a qualitative study

Background

This study examined how mental health clinic administrators decided whether or not to adopt evidence-based and other innovative practices by exploring their views of implementation barriers and facilitators and operation of these views in assessment of implementation costs and benefits.

Methods

Semi-structured interviews were conducted with 75 agency chief executive officers and program directors of 34 New York State-licensed mental health clinics serving children and adolescents.

Results

Three interconnected themes relating to barriers and facilitators were identified, namely costs and benefits associated with adoption, capacity for adoption, and acceptability of new practices. The highest percentage of participants (86.7%) mentioned costs as a barrier, followed by limited capacity (55.9%) and lack of acceptability (52.9%). The highest percentage (82.3%) of participants identified available capacity as a facilitator, followed by acceptability (41.2%) and benefits or limited costs (24.0%). Assessment of costs and benefits exhibited several principles of behavioural economics, including loss aversion, temporal discounting use of heuristics, sensitivity to monetary incentives, decision fatigue, framing, and environmental influences.

Conclusions

The results point to opportunities for using agency leader models to develop strategies to facilitate implementation of evidence-based and innovative practices for children and adolescents.

Pituitary Macrotumor Causing Narcolepsy-Cataplexy in a Dachshund

Familial narcolepsy secondary to breed‐specific mutations in the hypocretin receptor 2 gene and sporadic narcolepsy associated with hypocretin ligand deficiencies occur in dogs. In this report, a pituitary mass is described as a unique cause of narcolepsy‐cataplexy in a dog. A 6‐year‐old male neutered Dachshund had presented for acute onset of feeding‐induced cataplexy and was found to have a pituitary macrotumor on magnetic resonance imaging (MRI). Cerebral spinal fluid hypocretin‐1 levels were normal, indicating that tumor effect on the ventral lateral nucleus of the hypothalamus was not the cause of the dog's narcolepsy‐cataplexy. The dog was also negative for the hypocretin receptor 2 gene mutation associated with narcolepsy in Dachshunds, ruling out familial narcolepsy. The Dachshund underwent stereotactic radiotherapy (SRT), which resulted in reduction in the mass and coincident resolution of the cataplectic attacks. Nine months after SRT, the dog developed clinical hyperadrenocorticism, which was successfully managed with trilostane. These findings suggest that disruptions in downstream signaling of hypocretin secondary to an intracranial mass effect might result in narcolepsy‐cataplexy in dogs and that brain MRI should be strongly considered in sporadic cases of narcolepsy‐cataplexy.

Climate analogues suggest limited potential for intensification of production on current croplands under climate change

Climate change could pose a major challenge to efforts towards strongly increase food production over the coming decades. However, model simulations of future climate-impacts on crop yields differ substantially in the magnitude and even direction of the projected change. Combining observations of current maximum-attainable yield with climate analogues, we provide a complementary method of assessing the effect of climate change on crop yields. Strong reductions in attainable yields of major cereal crops are found across a large fraction of current cropland by 2050. These areas are vulnerable to climate change and have greatly reduced opportunity for agricultural intensification. However, the total land area, including regions not currently used for crops, climatically suitable for high attainable yields of maize, wheat and rice is similar by 2050 to the present-day. Large shifts in land-use patterns and crop choice will likely be necessary to sustain production growth rates and keep pace with demand.

Simulations of the impact of future climate change on crop yield vary considerably. Here, the authors use a climate analogue approach to estimate the response of maximum attainable yield to climate change and predict that large shifts in land use and crop choice would be required to meet demand.

School mental health resources and adolescent mental health service use

OBJECTIVE

Although schools are identified as critical for detecting youth mental disorders, little is known about whether the number of mental health providers and types of resources that they offer influence student mental health service use. Such information could inform the development and allocation of appropriate school-based resources to increase service use. This article examines associations of school resources with past-year mental health service use among students with 12-month DSM-IV mental disorders.

METHOD

Data come from the U.S. National Comorbidity Survey Adolescent Supplement (NCS-A), a national survey of adolescent mental health that included 4,445 adolescent-parent pairs in 227 schools in which principals and mental health coordinators completed surveys about school resources and policies for addressing student emotional problems. Adolescents and parents completed the Composite International Diagnostic Interview and reported mental health service use across multiple sectors. Multilevel multivariate regression was used to examine associations of school mental health resources and individual-level service use.

RESULTS

Nearly half (45.3%) of adolescents with a 12-month DSM-IV disorder received past-year mental health services. Substantial variation existed in school resources. Increased school engagement in early identification was significantly associated with mental health service use for adolescents with mild/moderate mental and behavior disorders. The ratio of students to mental health providers was not associated with overall service use, but was associated with sector of service use.

CONCLUSIONS

School mental health resources, particularly those related to early identification, may facilitate mental health service use and may influence sector of service use for youths with DSM disorders.

Beyond context to the skyline: thinking in 3D

Sweeping and profound structural, regulatory, and fiscal changes are rapidly reshaping the contours of health and mental health practice. The community-based practice contexts described in the excellent review by Garland and colleagues are being fundamentally altered with different business models, regional networks, accountability standards, and incentive structures. If community-based mental health services are to remain viable, the two-dimensional and flat research and practice paradigm has to be replaced with three-dimensional thinking. Failure to take seriously the changes that are happening to the larger healthcare context and respond actively through significant system redesign will lead to the demise of specialty mental health services.

Engagement in Trauma-Specific CBT for Youth Post-9/11

Treatment participation was examined among youth enrolled in an evaluation of cognitive behavioral therapy (CBT) for trauma following the 9/11 World Trade Center disaster. Staff at nine agencies serving a predominantly low-income ethnically diverse population were trained to deliver CBT and structured engagement strategies. Four hundred and forty-five youth ages 5-19 were eligible for CBT, and 417 (94%) received at least one treatment session. Pretreatment and treatment show rates and overall dose were examined. Treatment participation rates were higher than those typically reported in community studies of children's mental health services. Regression analyses indicated variability across sites in treatment show rates with the highest rates at where services were delivered in schools. However, sites, demographic factors and trauma symptoms accounted for a small amount of variance in treatment participation overall. The study suggests structured engagement strategies, linked to evidence-based treatments may improve treatment participation for youth.

Family Peer Advocates: A Pilot Study of the Content and Process of Service Provision

Professional family peer advocates are increasingly employed by public mental health systems to deliver family-to-family support that reduces barriers families face in accessing children's mental health care. These services, however, are neither uniformly available nor standardized. This pilot study describes the process, content and context of family-to-family support services. Simulating a parent seeking services, a trained standardized parent participated as a client in meetings with advocates in four programs and collected data through structured observations, a structured survey, and session audiotapes. The "walk-through" process was determined to be feasible and acceptable to family peer advocates as a way of evaluating services. Four family peer advocates provided an average of 25 services during each 2-session simulation with the standardized parent, including the following: information and educational support, instruction and skills development, emotional and affirmational support, instrumental support, and advocacy. Findings also revealed variability in the range of services provided and identified challenges in aspects of service provision, such as boundaries of advocate roles, availability of confidential service environments, and addressing crises and parent concerns about child safety. This paper provides the first in-depth look at services provided by this emerging workforce.

Human exposure and internal dose assessments of acrylamide in food

This review provides a framework contributing to the risk assessment of acrylamide in food. It is based on the outcome of the ILSI Europe FOSIE process, a risk assessment framework for chemicals in foods and adds to the overall framework by focusing especially on exposure assessment and internal dose assessment of acrylamide in food. Since the finding that acrylamide is formed in food during heat processing and preparation of food, much effort has been (and still is being) put into understanding its mechanism of formation, on developing analytical methods and determination of levels in food, and on evaluation of its toxicity and potential toxicity and potential human health consequences. Although several exposure estimations have been proposed, a systematic review of key information relevant to exposure assessment is currently lacking. The European and North American branches of the International Life Sciences Institute, ILSI, discussed critical aspects of exposure assessment, parameters influencing the outcome of exposure assessment and summarised data relevant to the acrylamide exposure assessment to aid the risk characterisation process. This paper reviews the data on acrylamide levels in food including its formation and analytical methods, the determination of human consumption patterns, dietary intake of the general population, estimation of maximum intake levels and identification of groups of potentially high intakes. Possible options and consequences of mitigation efforts to reduce exposure are discussed. Furthermore the association of intake levels with biomarkers of exposure and internal dose, considering aspects of bioavailability, is reviewed, and a physiologically-based toxicokinetic (PBTK) model is described that provides a good description of the kinetics of acrylamide in the rat. Each of the sections concludes with a summary of remaining gaps and uncertainties.