Evidence for Misspecification of a Nationally Used Quality Measure for Substance Use Treatment

Initiation and Receipt of Medication for Opioid Use Disorder Among Adolescents and Young Adults in 4 State Medicaid Programs in 2018: Improving Medicaid Quality Metrics

BACKGROUND

Medications for opioid use disorder (MOUD) in youth can reduce harms but many youths do not receive MOUD. Improving quality metrics of MOUD among youth can advance interventions for youth with opioid use disorder (OUD).

METHODS

We relied on 2018 Medicaid claims data from California, Colorado, Massachusetts, and New Mexico. We calculated the percentage of youth with OUD included in the quality metric for initiation, and the percentage who initiated by state. We also calculated the percentage excluded from the quality metric for initiation because they have an existing episode of OUD care and their MOUD receipt. We compared the characteristics of those who initiated/received MOUD to those who did not and compared state estimates after adjusting for age and health conditions.

RESULTS

Estimates of initiation exclude about half of the youth with OUD because they were in an existing episode of OUD care and could not be observed initiating. Among youth in a new episode of OUD care, only about 1 in 4 initiated and state estimates varied from 18.9% to 40.1%. Among youth with an existing episode of OUD care, more than half received MOUD and state estimates ranged from 35.2% to 71.3%. Youth who initiated MOUD or received MOUD with an existing OUD had more severe OUD but fewer co-occurring substance use disorders or mental or physical health diagnoses. After adjusting for age and health conditions, MOUD still varied substantially across states.

CONCLUSIONS

Most youth with a new OUD diagnosis do not initiate MOUD but more than half of the youth in an existing OUD diagnosis receive MOUD. MOUD quality metrics that are disaggregated, adjusted, and inclusive of youth in an existing episode of care provide additional insight into opportunities to better support youth who might choose MOUD. State differences should be further studied for insight into policies that may affect MOUD.

Predictors of substance use disorder treatment initiation and engagement among adolescents enrolled in Medicaid

Background: Adolescents with substance use disorders (SUD) should receive timely access to treatment to improve lifelong outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement in treatment (IET) performance measure was intended to promote quality improvement for patients with SUD. Yet, few studies have assessed predictors of measure performance among adolescents or other engagement in mental health services, which is critical to understanding disparities in treatment quality or opportunities for targeted improvement strategies. The present study reports the rates and predictors of IET among adolescents with SUD, as well as receipt of any mental health services. Methods: The sample included adolescents enrolled in Medicaid in 14 states who had a qualifying diagnosis for SUD (2009-2013) and met HEDIS IET performance measure eligibility criteria. Three outcomes were assessed, including initiation of SUD treatment within 14 days of qualifying diagnosis, engagement in SUD treatment (2 or more encounters) within 30 days of initiation, and receipt of any mental health services (1 or more encounters) within 30 days of initiation. Logistic regression was used to identify demographic and clinical characteristics associated with outcomes. Results: Among 20,602 adolescents who met eligibility criteria, 49.5% initiated SUD treatment, 48.5% engaged in SUD treatment, and 70% received any mental health service. Adolescents with higher levels of clinical need (e.g., medical complexity, mental health comorbidity, and multiple SUD diagnoses) had significantly higher odds of initiating, but lower odds of engaging in treatment or receiving any mental health service. Conclusions: To increase the delivery of SUD treatment, efforts should target adolescents with co-occurring mental health needs, many of whom are receiving mental health services after SUD diagnosis. Integrating addiction and mental health services could address these missed opportunities.

Association of Adverse Events in Opioid Addiction Treatment With Quality Measure for Continuity of Pharmacotherapy

ABSTRACT

Several quality measures for continuity of substance use care are being used in accountability programs, but it is not known whether they are predictive of better patient outcomes. We analyzed whether opioid use disorder (OUD) patients in the care of clinicians and practices with higher rates on one of these measures-continuity of pharmacotherapy for OUD-have a lower risk of overdose and detox events using Medicare data. For a 10-percentage point increase in an individual clinician's measure rate, the estimated odds ratios of a patient experiencing each of these two events were 0.92 (95% confidence interval [CI] 0.85 to 0.99) for overdose and 0.83 (95% CI 0.75 to 0.92) for detox. The corresponding estimates at the practice level were 0.90 (95% CI 0.85 to 0.95) for overdose and 0.83 (95% CI 0.77 to 0.89) for detox. These results suggest that a clinician's or practice's higher measure rate for continuity of pharmacotherapy for OUD is predictive of their patients' lower likelihood of having an adverse event. The findings contribute to a growing body of evidence on the importance of treatment continuity for OUD and support the validity of measuring continuity in provider-level accountability programs.

Predictors of timely opioid agonist treatment initiation among veterans with and without HIV

BACKGROUND

Opioid use disorder (OUD) is prevalent among people with HIV (PWH). Opioid agonist therapy (OAT) is the most effective treatment for OUD and is associated with improved health outcomes, but is often not initiated. To inform clinical practice, we identified factors predictive of OAT initiation among patients with and without HIV.

METHODS

We identified 19,698 new clinical encounters of OUD between 2000 and 2012 in the Veterans Aging Cohort Study (VACS), a national observational cohort of PWH and matched uninfected controls. Mixed effects models examined factors predictive of OAT initiation within 30-days of a new OUD clinical encounter.

RESULTS

4.9% of both PWH and uninfected patients initiated OAT within 30 days of a new OUD clinical encounter. In adjusted models, participants with a psychiatric diagnosis (aOR = 0.54, 95% CI 0.47 - 0.62), PWH (aOR = 0.79, 95% CI 0.68-0.92), and rural residence (aOR = 0.56, 95% CI 0.39-0.78) had a lower likelihood of any OAT initiation, while African-American patients (aOR = 1.60, 95% CI 1.34-1.92), those with an alcohol related diagnosis (aOR = 1.76, 95% CI 1.48-2.08), diagnosis year 2005-2008 relative to 2000-2004 (aOR = 1.24, 95% CI 1.05-1.45), and patients with HCV (aOR = 1.50, 95% CI 1.27-1.77) had a greater likelihood of initiating any OAT within 30 days. Predictive factors were similar in the total sample and PWH only models.

CONCLUSIONS

PWH were less likely to receive timely OAT initiation than demographically similar uninfected patients. Given the health benefits of such treatment, the low rate of OAT initiation warrants focused efforts in both PWH and uninfected populations.

Developing an opioid use disorder treatment cascade: A review of quality measures

BACKGROUND

Despite increasing opioid overdose mortality, problems persist in the availability and quality of treatment for opioid use disorder (OUD). Three FDA-approved medications (methadone, buprenorphine, and naltrexone) have high quality evidence supporting their use, but most individuals with OUD do not receive them and many experience relapse following care episodes. Developing and organizing quality measures under a unified framework such as a Cascade of Care could improve system level practice and treatment outcomes. In this context, a review was performed of existing quality measures relevant to the treatment of OUD and the literature assessing the utility of these measures in community practice.

METHODS

Systematic searches of two national quality measure clearinghouses (National Quality Forum and Agency for Healthcare Research and Quality) were performed for measures that can be applied to the treatment of OUD. Measures were categorized as structural, process, or outcome measures. Second stage searches were then performed within Ovid/Medline focused on published studies investigating the feasibility, reliability, and validity of identified measures, predictors of their satisfaction, and related clinical outcomes.

RESULTS

Seven quality measures were identified that are applicable to the treatment of OUD. All seven were process measures that assess patterns of service delivery. One recently approved measure addresses retention in medication-assisted treatment for patients with OUD. Twenty-nine published studies were identified that evaluate the quality measures, primarily focused on initiation and engagement in care for addiction treatment generally. Most measures and related studies do not specifically incorporate the evidence base for the treatment of OUD or assess patient level outcomes such as overdose.

CONCLUSION

Despite considerable progress, gaps exist in quality measures for OUD treatment. Development of a unified quality measurement framework such as an OUD Treatment Cascade will require further elaboration and refinement of existing measures across populations and settings. Such a framework could form the basis for applying strategies at clinical, organizational, and policy levels to expand access to quality care and reduce opioid-related mortality.

A system-level study of initiation, engagement, and equity in outpatient substance use treatment

Understanding the nature of variations in the quality of substance use treatment is critical to ensuring equity in service delivery and maximizing treatment effectiveness. We used adapted versions of the US Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement measures to assess care quality in specialized outpatient services for substance use in Ontario, Canada. Using administrative data, we calculated rates of outpatient treatment initiation and engagement (N = 120,394 episodes) and investigated variation by client characteristics and treatment mandates. About half of clients who entered outpatient treatment met the criteria for initiation (i.e., had a second visit within 14 days) and 30% met the criteria for engagement (i.e., had another two visits within 30 days of initiation). The likelihood of treatment initiation and engagement was greater among older people, those with more education, those who were not mandated to enter treatment, and those with greater substance use at admission. People who entered treatment for cannabis were less likely to engage. Engagement was less likely among men than women, but gender differences were slight overall. This study demonstrates the feasibility of using adapted versions of two common measures to characterise care quality in substance use treatment services in the Canadian context. Overall, the magnitude of associations with client characteristics were quite small, suggesting that initiation and engagement were not overly localized to specific client subgroups. Findings suggest that the Ontario system has difficulty retaining clients who enter treatment and that most outpatient treatment involves care episodes of limited duration.