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Jones JA, Gibson G, Cabral HJ, Wehler CJ, Orner MB, Jurasic MM. Effectiveness of fluorides in root caries prevention, Department of Veterans Affairs (2009-2018). SPECIAL CARE IN DENTISTRY 2024; 44:575-583. [PMID: 37322562 PMCID: PMC10721720 DOI: 10.1111/scd.12894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 05/23/2023] [Accepted: 06/07/2023] [Indexed: 06/17/2023]
Abstract
AIMS The aim of this study was to examine the effectiveness of topical fluorides in prevention of root caries-related treatment in high caries risk Veterans. METHODS This retrospective analysis of longitudinal data examined the effectiveness of professionally applied or prescription (Rx) fluoride treatment, in VHA clinics from FY 2009-2018. Professional fluoride treatments included 5% Sodium Fluoride (NaF) varnish (22 600 ppm fluoride), 2% NaF gel/rinse (9050 ppm fluoride), and 1.23% APF gel (12 300 ppm fluoride). The Rx for daily home use was 1.1% NaF paste/gel (5000 ppm fluoride). Outcomes studied were new root caries restorations or extractions and percent of patients with treatment over 1 year. Logistic regressions were adjusted for age, gender, race, ethnicity, chronic medical or psychiatric conditions, number of medication classes, anticholinergic drugs, smoking, baseline root caries treatment, preventive care, and time between first-last restoration in the index year. RESULTS Root caries at baseline was associated with a high risk for new root caries. Veterans without root caries during the index year who received a fluoride gel/rinse intervention were 32-40% less likely to receive caries-related treatment for root caries during the follow-up period. Once Veterans had root caries, fluorides did not exhibit a positive effect. CONCLUSION In older adults with high caries risk, early fluoride prevention is key, before root caries requires treatment.
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Affiliation(s)
- Judith A Jones
- University of Detroit Mercy School of Dentistry, Detroit, Michigan, USA
| | - Gretchen Gibson
- Oral Health Quality Group, Veterans Health Administration, Office of Dentistry, Fayetteville, Arkansas, USA
| | - Howard J Cabral
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Carolyn J Wehler
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
- Oral Health Quality Group, Veterans Health Administration, Office of Dentistry, Bedford, Massachusetts, USA
| | - Michelle B Orner
- Oral Health Quality Group, Veterans Health Administration, Office of Dentistry, Bedford, Massachusetts, USA
| | - M Marianne Jurasic
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
- Oral Health Quality Group, Veterans Health Administration, Office of Dentistry, Bedford, Massachusetts, USA
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Suda KJ, Boyer TL, Blosnich JR, Cashy JP, Hubbard CC, Sharp LK. Opioid and High-Risk Prescribing Among Racial and Ethnic Minority Veterans. Am J Prev Med 2023; 65:863-875. [PMID: 37302514 DOI: 10.1016/j.amepre.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The purpose of this study is to compare opioid prescribing and high-risk prescribing by race and ethnicity in a national cohort of U.S. veterans. METHODS A cross-sectional analysis of veteran characteristics and healthcare use was performed on electronic health record data for 2018 Veterans Health Administration users and enrollees in 2022. RESULTS Overall, 14.8% received an opioid prescription. The adjusted odds of being prescribed an opioid were lower for all race/ethnicity groups than for non-Hispanic White veterans, except for non-Hispanic multiracial (AOR=1.03; 95% CI=0.999, 1.05) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=1.03, 1.09) veterans. The odds of any day of overlapping opioid prescriptions (i.e., opioid overlap) were lower for all race/ethnicity groups than for the non-Hispanic White group, except for the non-Hispanic American Indian/Alaska Native group (AOR=1.01; 95% CI=0.96, 1.07). Similarly, all race/ethnicity groups had lower odds of any day of daily dose >120 morphine milligram equivalents than the non-Hispanic White group, except for the non-Hispanic multiracial (AOR=0.96; 95% CI=0.87, 1.07) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=0.96, 1.17) groups. Non-Hispanic Asian veterans had the lowest odds for any day of opioid overlap (AOR=0.54; 95% CI=0.50, 0.57) and daily dose >120 morphine milligram equivalents (AOR=0.43; 95% CI=0.36, 0.52). For any day of opioid-benzodiazepine overlap, all races/ethnicities had lower odds than non-Hispanic White. Non-Hispanic Black/African American (AOR=0.71; 95% CI=0.70, 0.72) and non-Hispanic Asian (AOR=0.73; 95% CI=0.68, 0.77) veterans had the lowest odds of any day of opioid-benzodiazepine overlap. CONCLUSIONS Non-Hispanic White and non-Hispanic American Indian/Alaska Native veterans had the greatest likelihood to receive an opioid prescription. When an opioid was prescribed, high-risk prescribing was more common in White and American Indian/Alaska Native veterans than in all other racial/ethnic groups. As the nation's largest integrated healthcare system, the Veterans Health Administration can develop and test interventions to achieve health equity for patients experiencing pain.
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Affiliation(s)
- Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Taylor L Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Colin C Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Lisa K Sharp
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Illinois, Chicago
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Hatch MN, Etingen B, Raad J, Siddiqui S, Stroupe KT, Smith BM. Dual utilization of Medicare and VA outpatient care among Veterans with spinal cord injuries and disorders. J Spinal Cord Med 2023; 46:716-724. [PMID: 35108176 PMCID: PMC10446768 DOI: 10.1080/10790268.2022.2027321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D. DESIGN Retrospective, cross-sectional, observational study. PARTICIPANTS Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011. INTERVENTIONS N/A. OUTCOME MEASURES Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use. RESULTS 65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users. CONCLUSION A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.
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Affiliation(s)
- Maya N Hatch
- Spinal Cord Injury/Disorder Center, Long Beach Veterans Affairs (VA) Medical Center, Long Beach, California, USA
- Physical Medicine & Rehabilitation Department, UC Irvine School of Medicine, Irvine, California, USA
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Department of VA Hospital, Chicago, Illinois, USA
| | - Jason Raad
- Econometrica, Inc, Bethesda, Massachusetts, USA
| | - Sameer Siddiqui
- Spinal Cord Injury/Disorder Center, Louis Stokes Cleveland (VA) Medical Center, Cleveland, Ohio, USA
- Department of Physical Medicine & Rehabilitation, Case Western Reserve University, Cleveland, Ohio, USA
| | - Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Department of VA Hospital, Chicago, Illinois, USA
| | - Bridget M Smith
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Department of VA Hospital, Chicago, Illinois, USA
- Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Comparing Outpatient Opioids, High-Risk Prescribing, and Opioid Poisoning Between Transgender and Cisgender Veterans: A Cross-sectional Analysis. Am J Prev Med 2022; 63:168-177. [PMID: 35396161 DOI: 10.1016/j.amepre.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Transgender veterans have a high prevalence of substance use disorder and physical and mental-health comorbidities, which are associated with prescription opioid use and overdose risk. This study compares receipt of outpatient opioids, high-risk opioid prescribing, and opioid poisoning between transgender and cisgender (i.e., nontransgender) veterans. METHODS A secondary analysis of Veterans Health Administration health record data from January 1, 2018 to December 31, 2018 was conducted in 2021. Transgender veterans (n=9,686) were randomly matched to 3 cisgender veterans (n=29,058) on the basis of age and county. Using the same matching criteria, a second cohort was created of all transgender veterans and a matched sample of cisgender veterans who were prescribed an outpatient opioid (n=7,576). Stratified Cox proportional hazard regression measured the RR of each prescription outcome and opioid poisoning. RESULTS Transgender veterans had a 20% higher risk of being prescribed any outpatient opioid than cisgender veterans (adjusted RR=1.20, 95% CI=1.13, 1.27). Transgender and cisgender veterans who were prescribed an opioid did not have different risks of high-risk prescribing: overlapping opioid prescriptions (adjusted RR=0.93, 95% CI=0.85, 1.02), daily dose >120 morphine milligram equivalents (adjusted RR=0.86, 95% CI=0.66, 1.10), or overlapping opioid and benzodiazepine prescriptions (adjusted RR=1.05, 95% CI=0.96, 1.14). Overall, transgender veterans had more than twice the risk of opioid poisoning than cisgender veterans (RR=2.76, 95% CI=1.57, 4.86). The risk of opioid poisoning did not differ between transgender and cisgender veterans who were prescribed an opioid (RR=1.09, 95% CI=0.56, 2.11). CONCLUSIONS Transgender veterans had a greater risk of being prescribed an outpatient opioid than cisgender veterans but did not have different risks of high-risk opioid prescribing.
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Jurasic MM, Gibson G, Orner MB, Wehler CJ, Jones JA, Cabral HJ. Topical Fluoride Effectiveness in High Caries Risk Adults. J Dent Res 2022; 101:898-904. [PMID: 35264049 DOI: 10.1177/00220345221081524] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This retrospective analysis of longitudinal data was developed to determine which types, combinations, and intensities of topical fluorides more effectively prevent new caries-related restorations and extractions in high caries risk adults. We included data from October 1, 2008, through June 30, 2018, from electronic dental and medical records and pharmacy database from the US Department of Veterans Affairs. Veterans who were eligible for continuing and comprehensive care, met the criteria of high caries risk (received 2 or more caries-related restorations within a 365-d period), and had 3 y of follow-up were included. Multivariable logistic regression models estimated the odds of caries-related treatment during the 1-y observation period, controlling for age, gender, race and ethnicity, illness burden (Selim comorbidity index), use of prescription medications, attendance at dental prophylaxis appointments, number of caries-related restorations during the index year, and time between first and last caries-related restoration during the index year. The study sample included 68,757 veterans, who were primarily male (91.5%), were White (73.6%), had a mean age of 59.2 ± 13.5 y, and had significant medical comorbidity as measured by the Selim index (3.7 ± 2.4 physical and 1.3 ± 1.2 mental diagnoses). They had 10.8 ± 6.3 prescription VA drug classes, took 0.6 ± 0.8 strong anticholinergic medications, and had 3.9 ± 2.6 teeth restored due to caries during the index year. Adjusted multivariable logistic regression models showed veterans who received a varnish or gel/rinse fluoride intervention versus no fluoride had an approximately 29% decreased odds of receiving caries-related treatment during the observation period (gel/rinse adjusted odds ratio [AOR] = 0.72; 95% confidence interval [CI], 0.67-0.76; varnish AOR = 0.71; 95% CI, 0.67-0.75). The receipt of a varnish and gel/rinse did not demonstrate statistically better odds than each intervention alone (AOR = 0.69; 95% CI, 0.64-0.75). A dose-response effect was observed. Two-plus applications of varnish versus none (AOR = 0.73; 95% CI, 0.69-0.77) and 2-plus applications of gel/rinse versus none (AOR = 0.71; 95% CI, 0.67-0.75) were more effective than 1 application of either modality versus none.
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Affiliation(s)
- M M Jurasic
- General Dentistry and Health Policy and Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA.,VHA Office of Dentistry, Oral Health Quality Group, VA Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - G Gibson
- Oral Health Quality Group, VHA Office of Dentistry, Fayetteville, AR, USA
| | - M B Orner
- VA Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - C J Wehler
- VHA Office of Dentistry, Oral Health Quality Group, VA Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,General Dentistry, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
| | - J A Jones
- University of Detroit Mercy School of Dentistry, Detroit, MI, USA
| | - H J Cabral
- Biostatistics, Boston University School of Public Health, Boston, MA, USA
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Cai S, Bakerjian D, Bang H, Mahajan SM, Ota D, Kiratli J. Data acquisition process for VA and non-VA emergency department and hospital utilization by veterans with spinal cord injury and disorders in California using VA and state data. J Spinal Cord Med 2022; 45:254-261. [PMID: 32543354 PMCID: PMC8986188 DOI: 10.1080/10790268.2020.1773028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Context: To identify VA and non-VA Emergency Department (ED) and hospital utilization by veterans with spinal cord injury and disorders (SCI/D) in California.Design: Retrospective cohort study.Setting: VA and Office of Statewide Health Planning and Development (OSHPD) in California.Participants: Total 300 veterans admitted to the study VA SCI/D Center for initial rehabilitations from 01/01/1999 through 08/17/2014.Interventions: N/A.Outcome Measures: Individual-level ED visits and hospitalizations during the first-year post-rehabilitation.Results: Among 145 veterans for whom ED visit data available, 168 ED visits were identified: 94 (55.2%) at non-VA EDs and 74 (44.8%) at the VA ED, with a mean of 1.16 (±2.21) ED visit/person. Seventy-seven (53.1%) veterans did not visit any ED. Of 68 (46.9%) veterans with ≥ one ED visit, 20 (29.4%) visited the VA ED only, 34 (50.0%) visited non-VA EDs only, and 14 (20.6%) visited both VA and non-VA EDs. Among 212 Veterans for whom hospitalization data were available, 247 hospitalizations were identified: 82 (33.2%) non-VA hospitalizations and 165 (66.8%) VA hospitalization with a mean of 1.17 (±1.62) hospitalizations/person. One hundred-seven (50.5%) veterans had no hospitalizations. Of 105 veterans with ≥ one hospitalization, 58 (55.2%) were hospitalized at the study VA hospital, 15 (14.3%) at a non-VA hospital, and 32 (30.5%) at both VA and non-VA hospitals.Conclusion: Non-VA ED and hospital usage among veterans with SCI/D occurred frequently. The acquisition of non-VA healthcare data managed by state agencies is vital to accurately and comprehensively evaluate needs and utilization rates among veteran populations.
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Affiliation(s)
- Sujuan Cai
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA,The Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, California, USA,Correspondence to: Sujuan Cai, 3801 Miranda Ave. Building 7, VA Palo Alto Health Care System, Spinal Cord Injury/Disorder, Palo Alto, California94304, USA; Ph: 408-832-4205.
| | - Debra Bakerjian
- The Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, California, USA
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California at Davis, Davis, California, USA
| | - Satish M. Mahajan
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
| | - Doug Ota
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
| | - Jenny Kiratli
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
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Sjoberg H, Liu W, Rohs C, Ayele RA, McCreight M, Mayberry A, Battaglia C. Optimizing care coordination to address social determinants of health needs for dual-use veterans. BMC Health Serv Res 2022; 22:59. [PMID: 35022053 PMCID: PMC8754195 DOI: 10.1186/s12913-021-07408-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/13/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Veterans increasingly utilize both the Veteran's Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities. METHODS ACC had four core components: 1. Notification from non-VA ED providers of Veterans' ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran's VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 - 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge. RESULTS When compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13-30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%). CONCLUSION We developed and implemented a program addressing dual-users' SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.
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Affiliation(s)
- Heidi Sjoberg
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Wenhui Liu
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Carly Rohs
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
- Anschutz Medical Campus Colorado School of Public, University of Colorado, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Marina McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Ashlea Mayberry
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
- Anschutz Medical Campus Colorado School of Public, University of Colorado, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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Essien UR, Kim N, Magnani JW, Good CB, Litam TMA, Hausmann LRM, Mor MK, Gellad WF, Fine MJ. Association of Race and Ethnicity and Anticoagulation in Patients with Atrial Fibrillation Dually Enrolled in VA and Medicare: Effects of Medicare Part D on Prescribing Disparities. Circ Cardiovasc Qual Outcomes 2021; 15:e008389. [PMID: 34779655 DOI: 10.1161/circoutcomes.121.008389] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Racial and ethnic disparities in anticoagulation exist in atrial fibrillation (AF) management in Medicare and the Veterans Health Administration (VA), but the influence of dual VA and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare Part D enrollment on anticoagulation disparities. Methods: We identified patients with incident AF (2014-2018) dually enrolled in VA and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants, DOACs) within 90 days of AF diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare Part D enrollment and an interaction term for these variables. Results: In 43,789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare Part D. Overall, 29,680 (67.8%) patients initiated any anticoagulant, of which 17,568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (p= 0.001), and lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (p=0.001) initiated DOACs. Compared to White patients, Black patients had significantly lower initiation of any anticoagulant, adjusted odds ratio (aOR) 0.89; 95% CI 0.82-0.97. The aORs for DOAC initiation were significantly lower for Black (0.72; 95% CI, 0.65-0.81) and Hispanic (0.84; 95% CI, 0.70-1.00) than White patients.The interaction between race and ethnicity and Medicare Part D enrollment was non-significant for any anticoagulant (p=0.99) and DOAC (p=0.27) therapies. Conclusions: In dually enrolled VA and Medicare patients with AF, Black patients were less likely to initiate any anticoagulant and Black and Hispanic patients were less likely to initiate DOACs. Medicare Part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Mohanty AF, Levitan EB, King JB, Dodson JA, Vardeny O, Cook J, Herrick JS, He T, Patterson OV, Alba PR, Russo PA, Obi EN, Choi ME, Fang JC, Bress AP. Sacubitril/Valsartan Initiation Among Veterans Who Are Renin-Angiotensin-Aldosterone System Inhibitor Naïve With Heart Failure and Reduced Ejection Fraction. J Am Heart Assoc 2021; 10:e020474. [PMID: 34612065 PMCID: PMC8751890 DOI: 10.1161/jaha.120.020474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Sacubitril/valsartan, a first‐in‐class angiotensin receptor neprilysin inhibitor, received US Food and Drug Administration approval in 2015 for heart failure with reduced ejection fraction (HFrEF). Our objective was to describe the sacubitril/valsartan initiation rate, associated characteristics, and 6‐month follow‐up dosing among veterans with HFrEF who are renin‐angiotensin‐aldosterone system inhibitor (RAASi) naïve. Methods and Results Retrospective cohort study of veterans with HFrEF who are RAASi naïve defined as left ventricular ejection fraction (LVEF) ≤40%; ≥1 in/outpatient heart failure visit, first RAASi (sacubitril/valsartan, angiotensin‐converting enzyme inhibitor [ACEI]), or angiotensin‐II receptor blocker [ARB]) fill from July 2015 to June 2019. Characteristics associated with sacubitril/valsartan initiation were identified using Poisson regression models. From July 2015 to June 2019, we identified 3458 sacubitril/valsartan and 29 367 ACEI or ARB initiators among veterans with HFrEF who are RAASi naïve. Sacubitril/valsartan initiation increased from 0% to 26.5%. Sacubitril/valsartan (versus ACEI or ARB) initiators were less likely to have histories of stroke, myocardial infarction, or hypertension and more likely to be older and have diabetes mellitus and lower LVEF. At 6‐month follow‐up, the prevalence of ≥50% target daily dose for sacubitril/valsartan, ACEI, and ARB initiators was 23.5%, 43.2%, and 47.1%, respectively. Conclusions Sacubitril/valsartan initiation for HFrEF in the Veterans Administration increased in the 4 years immediately following Food and Drug Administration approval. Sacubitril/valsartan (versus ACEI or ARB) initiators had fewer baseline cardiovascular comorbidities and the lowest proportion on ≥50% target daily dose at 6‐month follow‐up. Identifying the reasons for lower follow‐up dosing of sacubitril/valsartan could support guideline recommendations and quality improvement strategies for patients with HFrEF.
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Affiliation(s)
- April F Mohanty
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Emily B Levitan
- Department of Epidemiology University of Alabama at Birmingham School of Public Health Birmingham AL
| | - Jordan B King
- Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT.,Institute for Health Research Kaiser Permanente Colorado Aurora CO
| | - John A Dodson
- Leon H. Charney Division of Cardiology Department of Medicine New York University School of Medicine New York NY
| | - Orly Vardeny
- University of Minnesota Medical School Minneapolis MN
| | - James Cook
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Jennifer S Herrick
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Tao He
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Olga V Patterson
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Patrick R Alba
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Patricia A Russo
- US Health Economics & Outcomes Research Novartis Pharmaceuticals CorporationEast Hanover NJ
| | - Engels N Obi
- US Health Economics & Outcomes Research Novartis Pharmaceuticals CorporationEast Hanover NJ
| | | | - James C Fang
- Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Adam P Bress
- Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT
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10
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Davila H, Rosen AK, Stolzmann K, Zhang L, Linsky AM. Factors influencing providers' willingness to deprescribe medications. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Heather Davila
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
- Section of General Internal Medicine Boston University School of Medicine Boston Massachusetts USA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
- Department of Surgery Boston University School of Medicine Boston Massachusetts USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
| | - Libin Zhang
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
| | - Amy M. Linsky
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
- Section of General Internal Medicine Boston University School of Medicine Boston Massachusetts USA
- General Internal Medicine VA Boston Healthcare System Boston Massachusetts USA
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11
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Schleiden LJ, Zickmund SL, Roman KL, Kennedy K, Thorpe JM, Rossi MI, Niznik JD, Springer SP, Thorpe CT. Caregiver and provider perspectives on dual VA and Medicare Part D medication use in veterans with suspected dementia or cognitive impairment. Am J Health Syst Pharm 2021; 79:94-101. [PMID: 34453437 DOI: 10.1093/ajhp/zxab343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Many older veterans with dementia fill prescriptions through both Veterans Affairs (VA) and Medicare Part D benefits. Dual VA/Part D medication use may have unintended negative consequences on prescribing safety and quality. We aimed to characterize benefits and drawbacks of dual VA/Part D medication use in veterans with dementia or cognitive impairment from the perspectives of caregivers and providers. METHODS This was a qualitative study based on semistructured telephone interviews of 2 group: (1) informal caregivers accompanying veterans with suspected dementia or cognitive impairment to visits at a VA Geriatric Evaluation and Management clinic (n = 11) and (2) VA healthcare providers of veterans with dementia who obtained medications via VA and Part D (n = 12). We conducted semistructured telephone interviews with caregivers and providers about benefits and drawbacks of dual VA/Part D medication use. Interview transcripts were subjected to qualitative content analysis to identify key themes. RESULTS Caregivers and providers both described cost and convenience benefits to dual VA/Part D medication use. Caregivers reported drawbacks including poor communication between VA and non-VA providers and difficulty managing medications from multiple systems. Providers reported potential safety risks including communication barriers, conflicting care decisions, and drug interactions. CONCLUSION Results of this study allow for understanding of potential policy interventions to better manage dual VA/Part D medication use for older veterans with dementia or cognitive impairment at a time when VA is expanding access to non-VA care.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Susan L Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, and Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katie Lynn Roman
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Kayla Kennedy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle I Rossi
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Geriatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sydney P Springer
- University of New England School of Pharmacy Westbrook College of Health Professions, Portland, ME, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
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12
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Stroupe KT, Nazi K, Hogan TP, Poggensee L, Wakefield B, Martinez RN, Etingen B, Shimada S, Suda KJ, Huo Z, Cao L, Smith BM. Web-based patient portal use and medication overlap from VA and private-sector pharmacies among older veterans. J Manag Care Spec Pharm 2021; 27:983-994. [PMID: 34337984 PMCID: PMC10391010 DOI: 10.18553/jmcp.2021.27.8.983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: The availability of Medicare Part D pharmacy coverage may increase veterans' options for obtaining medications outside of the Department of Veterans Affairs (VA) pharmacies. However, availability of Part D coverage raises the potential that veterans may be receiving similar medications from VA and non-VA pharmacies. The VA's personal health record portal, My HealtheVet, allows veterans to self-enter the non-VA medications that they obtained from community-based pharmacies, including those reimbursed by Medicare Part D. The Blue Button medication view feature of My HealtheVet allows veterans to view and download their VA and self-entered non-VA medication history. OBJECTIVE: To examine whether the use by veterans of the Blue Button feature of My HealtheVet was associated with less acquisition of similar medications from VA and community-based pharmacies reimbursed by Medicare Part D. METHODS: This study included a national sample of veterans who were new My HealtheVet users during fiscal year 2013 (October 1, 2012-September 30, 2013) and who used the Blue Button medication view feature of My HealtheVet at least once (users). We compared these veterans with a random sample of veterans who were not registered to use My HealtheVet (nonusers). From these groups, we identified veterans who were enrolled in Part D. We used multiple logistic regression analysis to assess the association of Blue Button medication view use with obtaining medications from the same drug classes (with overlap of 7 or more days) from VA and Part D-reimbursed pharmacies. RESULTS: There were 7,973 My HealtheVet medication view users and 65,985 nonusers. During a 12-month period, medication view users received more 30-day supplies of medications (one 90-day supply equals three 30-day supplies) than nonusers, on average (152.1 vs 71.3, P < 0.001). A larger percentage of users than nonusers obtained medications from VA and Part D-reimbursed pharmacies with overlapping days supply from the same drug classes (30% vs 23%, P < 0.001). However, for veterans who obtained greater numbers of 30-day supplies (82 or more), a significantly smaller percentage of users than nonusers obtained overlapping medications from VA and Part D-reimbursed pharmacies. Moreover, controlling for the total number of 30-day supplies that veterans received, the odds of obtaining medications from VA and Part D-reimbursed pharmacies with days supply that overlapped by at least 7 days for the same drug classes was 18% lower for users than nonusers (P=0.002). CONCLUSIONS: Veterans who used the Blue Button medication view feature of My HealtheVet obtained a larger number of 30-day supplies of medications from VA pharmacies than nonusers. For veterans who obtained a larger number of 30-day supplies of medications, use of the Blue Button medication view feature of My HealtheVet was associated with less overlap in days supply of medication from the same drug class from VA and Part D-reimbursed pharmacies. DISCLOSURES: This study was funded by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service project IIR 14-041-2. The sponsor provided funding but was not involved in the development of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the Health Services Research and Development Service. All authors are employed in some capacity with the Department of Veterans Affairs and have no conflicts of interest to disclose.
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Affiliation(s)
- Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, and Department of Public Health Sciences, Loyola University Chicago, Maywood, IL
| | - Kim Nazi
- Independent Consultant, Veterans and Consumers Health Informatics Office, Office of Connected Care, Veterans Health Administration, US Department of Veterans Affairs, Coxsackie, NY
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, US Department of Veterans Affairs, Bedford, MA, and Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL
| | - Bonnie Wakefield
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, IA, and Sinclair School of Nursing, University of Missouri, Columbia
| | - Rachael N Martinez
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL
| | - Stephanie Shimada
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, US Department of Veterans Affairs, Bedford, MA, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, and Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Zhiping Huo
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL
| | - Bridget M Smith
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, US Department of Veterans Affairs, Hines, IL, and Feinberg School of Medicine, Northwestern University, Chicago, IL
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13
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Validation of a Subjective Caries Risk Assessment Tool. J Dent 2021; 113:103748. [PMID: 34274438 DOI: 10.1016/j.jdent.2021.103748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The objective was to evaluate the predictive validity of the American Dental Association's caries risk assessment (CRA) tool, adapted with permission, and used by the U.S. Department of Veterans Affairs dental services within their electronic dental record. METHODS This analytic epidemiologic study with a retrospective longitudinal design included Veterans who had a minimum of three years of available data. The primary outcome was caries-related treatment during the twelve-month predictive period following the CRA category identification. RESULTS The sample included 57,675 Veterans; 50.1% classified as low, 33.2% as moderate and 16.8% as high caries risk. During the twelve-month predictive period, both teeth/person and teeth with caries-related treatment rose sequentially from low to high CRA categories. However, poor sensitivity (0.34-0.58) and better specificity (0.53-0.78) values were observed. Similarly, better negative predictive values (0.72-0.79) compared to positive predictive values (0.28-0.34) were found. Adjusted logistic regression models showed that current treated caries (caries detected at the time of the CRA exam) was more strongly associated with future caries-related treatment than the subjective CRA determination. CONCLUSIONS The subjective CRA tool evaluated in this study is better at identifying patients at low risk of requiring future caries-related treatment versus those at higher risk. This makes it difficult to target the most caries susceptible patients with preventive measures. Furthermore, we found that the amount of caries treatment required at the time of the CRA exam had the strongest association with caries-related treatment during the subsequent twelve-month predictive period. CLINICAL SIGNIFICANCE The amount of caries-related treatment required at the time of the caries risk classification is the strongest predictor of future caries.
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14
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Rashdan S, Yang H, Le T, Selby C, Gerber DE, Alvarez CA. Prevalence and Significance of Potential Pharmacokinetic Drug-Drug Interactions Among Patients with Lung Cancer: Implications for Clinical Trials. Clin Drug Investig 2021; 41:161-167. [PMID: 33417195 DOI: 10.1007/s40261-020-00994-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The overall prevalence of potential drug-drug interactions (DDIs) among patients with lung cancer is unknown. OBJECTIVE The objective of this study was to determine the prevalence of potential DDIs and major DDIs among individuals newly diagnosed with lung cancer in a national cohort. PATIENTS AND METHODS We performed a retrospective cross-sectional study of adult patients in the United States Veterans' Affairs (VA) medical system diagnosed with lung cancer between 2003 and 2016. The primary endpoint was the prevalence of prescriptions for medications associated with any potential DDIs during the 3 months leading up to and including the date of lung cancer diagnosis. The secondary endpoint was the prevalence of prescriptions associated with major DDIs during the same time period. RESULTS Overall, 280,068 patients were included in the study; 55.9% of patients were prescribed medications associated with potential DDIs, while 5.3% received prescriptions for medications associated with major DDIs. Among the 20 most commonly prescribed drugs associated with potential DDIs, only two were associated with major DDIs. CONCLUSION Medications with potential DDIs are prescribed to the majority of patients with lung cancer; however, only about 5% of patients are prescribed medications with major DDIs that might be prohibited in certain clinical trials.
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Affiliation(s)
- Sawsan Rashdan
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hui Yang
- Pharmacy Practice, Texas Tech University Health Sciences Center, 5920 Forest Park Rd, Suite 400, Dallas, TX, 75235, USA.,Pharmacy and Research Services, Veterans Affairs North Texas HSC, Dallas, TX, USA
| | - Tri Le
- Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Christopher Selby
- Pharmacy Practice, Texas Tech University Health Sciences Center, 5920 Forest Park Rd, Suite 400, Dallas, TX, 75235, USA
| | - David E Gerber
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Internal Medicine, University of Texas Southwestern, Dallas, TX, USA.,Population and Data Sciences, University of Texas Southwestern, Dallas, TX, USA
| | - Carlos A Alvarez
- Pharmacy Practice, Texas Tech University Health Sciences Center, 5920 Forest Park Rd, Suite 400, Dallas, TX, 75235, USA. .,Population and Data Sciences, University of Texas Southwestern, Dallas, TX, USA. .,Pharmacy and Research Services, Veterans Affairs North Texas HSC, Dallas, TX, USA.
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15
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Peralta CA, Frigaard M, Rolon L, Seal K, Tuot D, Senyak J, Lo L, Powe N, Scherzer R, Chao S, Chiao P, Lui K, Shlipak MG, Rubinsky AD. Screening for CKD To Improve Processes of Care among Nondiabetic Veterans with Hypertension: A Pragmatic Cluster-Randomized Trial. Clin J Am Soc Nephrol 2020; 15:174-181. [PMID: 32034070 PMCID: PMC7015085 DOI: 10.2215/cjn.05050419] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES We conducted a pilot, pragmatic, cluster-randomized trial to evaluate feasibility and preliminary effectiveness of screening for CKD using a triple-marker approach (creatinine, cystatin C, and albumin/creatinine ratio), followed by education and guidance, to improve care of hypertensive veterans in primary care. We used the electronic health record for identification, enrollment, intervention delivery, and outcome ascertainment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We randomized 1819 veterans without diabetes but with hypertension (41 clusters) into three arms: (1) CKD screening followed by patient and provider education; (2) screening, education, plus pharmacist comanagement; or (3) usual care. The primary clinical outcome was BP change over 1 year. Implementation and process measures included proportion screened; CKD detection rate; and total and new use of renin-angiotensin system inhibitors, nonsteroidal anti-inflammatory drugs, and diuretics. RESULTS Median age was 68 years, 55% were white, 1658 (91%) had a prior creatinine measure, but only 172 (9%) had prior urine albumin/creatinine ratio, and 83 (5%) had a prior cystatin C measure. Among those in the intervention, 527 of 1215 (43%) were identified with upcoming appointments to have CKD screening. Of these, 367 (69%) completed testing. Among those tested, 77 (21%) persons had newly diagnosed CKD. After 1 year, change in systolic BP was -1 mm Hg (interquartile range, -11 to 11) in usual care, -2 mm Hg (-11 to 11) in the screen-educate arm, and -2 mm Hg (-13 to 10) in the screen-educate plus pharmacist arm; P=0.49. There were no significant differences in secondary outcomes in intention-to-treat analyses. In as-treated analyses, higher proportions of participants in the intervention arms initiated a renin-angiotensin system inhibitor (15% and 12% versus 7% in usual care, P=0.01) or diuretic (9% and 12% versus 4%, P=0.03). CONCLUSIONS The pragmatic design made identification, enrollment, and intervention delivery highly efficient. The limited ability to identify appointments resulted in inadequate between-arm differences in CKD testing rates to determine whether screening improves clinical outcomes.
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Affiliation(s)
- Carmen A. Peralta
- Division of Nephrology
- Department of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Cricket Health, Inc., San Francisco, California; and
| | - Martin Frigaard
- University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Karen Seal
- Department of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Delphine Tuot
- Division of Nephrology
- Department of Medicine
- Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Josh Senyak
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Lowell Lo
- Division of Nephrology
- Department of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Neil Powe
- Department of Medicine
- Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Rebecca Scherzer
- Department of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Shirley Chao
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Phillip Chiao
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kimberly Lui
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Michael G. Shlipak
- Department of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Anna D. Rubinsky
- Department of Medicine
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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16
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Mohanty AF, Levitan EB, Dodson JA, Vardeny O, King JB, LaFleur J, He T, Patterson OV, Alba PR, Russo PA, Choi ME, Bress AP. Characteristics and Healthcare Utilization Among Veterans Treated for Heart Failure With Reduced Ejection Fraction Who Switched to Sacubitril/Valsartan. Circ Heart Fail 2019; 12:e005691. [DOI: 10.1161/circheartfailure.118.005691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background:
US guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF), who tolerate an ACEI (angiotensin-converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), be switched to sacubitril/valsartan to reduce morbidity and mortality. We compared characteristics and healthcare utilization between Veterans with HFrEF who were switched to sacubitril/valsartan versus maintained on an ACEI or ARB.
Methods:
retrospective cohort study of treated HFrEF (July 2015–June 2017) using Veterans Affairs data. The index date was the first fill for sacubitril/valsartan and if none, for an ACEI or ARB. Treated HFrEF was defined by (1) left ventricular ejection fraction ≤40%, (2) ≥1 in/outpatient HF encounter, and (3) ≥1 ACEI or ARB fill, all within 1-year preindex. Poisson regression models were used to compare baseline characteristics and 1:1 propensity score-matched adjusted 4-month follow-up healthcare utilization between sacubitril/valsartan switchers and ACEI or ARB maintainers.
Results:
Switchers (1612; 4.2%) were less likely than maintainers (37 065; 95.8%) to have a history of myocardial infarction or hypertension, and more likely to be black, have a lower left ventricular ejection fraction, and higher preindex healthcare utilization. Switchers were less likely to experience follow-up all-cause hospitalizations (11.2% versus 14.0%; risk ratio 0.80 [95% CI, 0.65–0.98],
P
value 0.035).
Conclusions:
Few Veterans with treated HFrEF were switched to sacubitril/valsartan within the first 2 years of Food and Drug Administration approval. Sacubitril/valsartan use was associated with a lower risk for all-cause hospitalizations at 4 months follow-up. Reasons for lack of guideline-recommended sacubitril/valsartan initiation warrant investigation and may reveal opportunities for HFrEF care optimization.
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Affiliation(s)
- April F. Mohanty
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama. (E.B.L.)
| | - John A. Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (J.A.D.)
| | - Orly Vardeny
- University of Minnesota Medical School and Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota (O.V.)
| | - Jordan B. King
- Department of Population Health Sciences (J.B.K., A.P.B.), University of Utah School of Medicine, Salt Lake City, UT
| | - Joanne LaFleur
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
- Department of Pharmacotherapy, University of UT College of Pharmacy, Salt Lake City, UT (J.L.)
| | - Tao He
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
| | - Olga V. Patterson
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Patrick R. Alba
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Patricia A. Russo
- US Health Economics & Outcomes Research, Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.A.R.)
| | | | - Adam P. Bress
- Department of Population Health Sciences (J.B.K., A.P.B.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
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17
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Miller LB, Sjoberg H, Mayberry A, McCreight MS, Ayele RA, Battaglia C. The advanced care coordination program: a protocol for improving transitions of care for dual-use veterans from community emergency departments back to the Veterans Health Administration (VA) primary care. BMC Health Serv Res 2019; 19:734. [PMID: 31640673 PMCID: PMC6805730 DOI: 10.1186/s12913-019-4582-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Veterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Gaps in transitions of care between VA and non-VA systems are common. The Advanced Care Coordination (ACC) quality improvement program aims to address these gaps by implementing a comprehensive longitudinal care coordination intervention with a focus on Veterans' social determinants of health (SDOH) to facilitate Veterans' transitions of care back to the Eastern Colorado Health Care System (ECHCS) for follow-up care. METHODS The ACC program is an ongoing quality improvement study that will enroll dual-use Veterans after discharge from non-VA emergency department (EDs), and will provide Veterans with social worker-led longitudinal care coordination addressing SDOH and providing linkage to resources. The ACC social worker will complete biopsychosocial assessments to identify Veteran needs, conduct regular in-person and phone visits, and connect Veterans back to their VA care teams. We will identify non-VA EDs in the Denver, Colorado metro area that will provide the most effective partnership based on location and Veteran need. Veterans will be enrolled into the ACC program when they visit one of our selected non-VA EDs without being hospitalized. We will develop a program database to allow for continuous evaluation. Continuing education and outreach including the development of a resource guide, Veteran Care Cards, and program newsletters will generate program buy-in and bridge communication. We will evaluate our program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, supported by the Practical, Robust Implementation and Sustainability Model, Theoretical Domains Framework, and process mapping. DISCUSSION The ACC program will improve care coordination for dual-use Veterans by implementing social-work led longitudinal care coordination addressing Veterans' SDOH. This intervention will provide an essential service for effective care coordination.
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Affiliation(s)
- Lindsay B Miller
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Heidi Sjoberg
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Ashlea Mayberry
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Marina S McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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18
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Anderson TS, Jing B, Wray CM, Ngo S, Xu E, Fung K, Steinman MA. Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use. Med Care 2019; 57:836-842. [PMID: 31464843 PMCID: PMC6742560 DOI: 10.1097/mlr.0000000000001188] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance. OBJECTIVES The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use. RESEARCH DESIGN Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications. RESULTS The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care. CONCLUSION Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Charlie M. Wray
- Department of Medicine, University of California San Francisco, San Francisco, CA California, USA
| | - Sarah Ngo
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Edison Xu
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Kathy Fung
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Michael A. Steinman
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
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19
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The Relationship of Self-Report and Medication Possession With Glaucoma Medication Administration Success. J Glaucoma 2019; 28:e46-e48. [DOI: 10.1097/ijg.0000000000001136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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20
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Jurasic MM, Gibson G, Wehler CJ, Orner MB, Jones JA. Caries prevalence and associations with medications and medical comorbidities. J Public Health Dent 2018; 79:34-43. [DOI: 10.1111/jphd.12292] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 09/17/2018] [Indexed: 12/21/2022]
Affiliation(s)
- M. Marianne Jurasic
- Boston University Henry M. Goldman School of Dental Medicine Boston MA USA
- VA Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital Bedford MA USA
| | - Gretchen Gibson
- Veterans Health Care System of the Ozarks Fayetteville AR USA
| | - Carolyn J. Wehler
- VA Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital Bedford MA USA
- Boston University Henry M. Goldman School of Dental Medicine Boston MA USA
| | - Michelle B. Orner
- VA Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital Bedford MA USA
| | - Judith A. Jones
- VA Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital Bedford MA USA
- University of Detroit Mercy School of Dentistry Detroit MI USA
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21
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Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausmann LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Patterns of opioid prescriptions received prior to unintentional prescription opioid overdose death among Veterans. Res Social Adm Pharm 2018; 15:1007-1013. [PMID: 30385111 DOI: 10.1016/j.sapharm.2018.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/24/2018] [Accepted: 10/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans. OBJECTIVES To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans. METHODS In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008-2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012-2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only. RESULTS Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death. CONCLUSIONS Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.
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Affiliation(s)
- Patience Moyo
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie M Donohue
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA; Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA; Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Value Based Pharmaceutical Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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22
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Thorpe CT, Gellad WF, Mor MK, Cashy JP, Pleis JR, Van Houtven CH, Schleiden LJ, Hanlon JT, Niznik JD, Carico RL, Good CB, Thorpe JM. Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia. Health Serv Res 2018; 53 Suppl 3:5375-5401. [PMID: 30328097 DOI: 10.1111/1475-6773.13055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. DATA SOURCES/STUDY SETTING National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. STUDY DESIGN We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. DATA COLLECTION/EXTRACTION METHODS Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. PRINCIPAL FINDINGS Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. CONCLUSIONS Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,School of Medicine and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - John R Pleis
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Courtney H Van Houtven
- Durham Veterans Affairs Health Care System, VA Medical Center (152), Durham, NC.,Duke University School of Medicine, VA Medical Center (152), Durham, NC
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ronald L Carico
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Center for High Value Pharmaceutical Purchasing, UPMC Health Plan, Pittsburgh, PA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
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23
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Axon RN, Gebregziabher M, Everett CJ, Heidenreich P, Hunt KJ. Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk. J Am Heart Assoc 2018; 7:e009054. [PMID: 30371248 PMCID: PMC6201461 DOI: 10.1161/jaha.118.009054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/11/2018] [Indexed: 01/04/2023]
Abstract
Background Individuals receiving cross-system care (dual users) have higher rates of healthcare utilization and worse outcomes for heart failure ( HF ) and other conditions. Individuals can be dual users or single-system users at different times, though, and little is known about utilization and mortality within discrete episodes of care. Methods and Results A retrospective cohort of 3439 patients with 5231 discrete episodes of HF exacerbation were identified between 2007 and 2011. Episodes encompassed the period from 2 weeks before an initial HF emergency department ( ED ) visit or hospitalization, included any acute care visits within 30 days after initial visit, and ended 30 days after the last acute care visit in the episode chain. All-cause and HF -specific ED visits and hospitalization within 30 days of index visit were analyzed using generalized estimating equations with robust variance. Hazard for death within episodes of acute illness was analyzed using Cox proportional hazards models. In adjusted analyses, dual use acute HF episodes were associated with higher odds of all-cause ED visits (odds ratio 1.61, 95% confidence interval [ CI ], 1.33, 1.95), HF -specific ED visits, (odds ratio 1.54, 95% CI , 1.12, 2.13), all-cause hospitalization (odds ratio 1.89, 95% CI , 1.50, 2.38), and HF -specific hospitalization (odds ratio 1.62, 95% CI , 1.15-2.30) as compared with Veterans Health Administration-only episodes of acute HF care. Dual use episodes of care were associated with higher hazard for mortality (hazard ratio=1.52, 95% CI 1.07, 2.16) as compared with all-Veterans Health Administration episodes of care. Conclusions Episodes of acute HF care spanning across healthcare systems appear to be associated with higher risk of subsequent ED visits, hospitalization, and mortality.
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Affiliation(s)
- R. Neal Axon
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Division of General Internal MedicineDepartment of MedicineThe Medical University of South CarolinaCharlestonSC
| | - Mulugeta Gebregziabher
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
| | - Charles J. Everett
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
| | - Paul Heidenreich
- Division of CardiologyVA Palo Alto Healthcare SystemStanford University Medical CenterPalo AltoCA
| | - Kelly J. Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
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24
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Hatch MN, Raad J, Suda K, Stroupe KT, Hon AJ, Smith BM. Evaluating the Use of Medicare Part D in the Veteran Population With Spinal Cord Injury/Disorder. Arch Phys Med Rehabil 2018; 99:1099-1107. [PMID: 29425699 DOI: 10.1016/j.apmr.2017.12.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/05/2017] [Accepted: 12/22/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the different sources of medications, the most common drug classes filled, and the characteristics associated with Medicare Part D pharmacy use in veterans with spinal cord injury/disorder (SCI/D). DESIGN Retrospective, cross-sectional, observational study. SETTING Outpatient clinics and pharmacies. PARTICIPANTS Veterans (N=13,442) with SCI/D using Medicare or Veteran Affairs pharmacy benefits. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Characteristics and top 10 most common drug classes were examined in veterans who (1) used VA pharmacies only; (2) used both VA and Medicare Part D pharmacies; or (3) used Part D pharmacies only. Chi-square tests and multinomial logistic regression analyses were used to determine associations between various patient variables and source of medications. Patient level frequencies were used to determine the most common drug classes. RESULTS A total of 13,442 veterans with SCI/D were analyzed in this study: 11,788 (87.7%) used VA pharmacies only, 1281 (9.5%) used both VA and Part D pharmacies, and 373 (2.8%) used Part D pharmacies only. Veterans older than 50 years were more likely to use Part D pharmacies, whereas those with traumatic injury, or secondary conditions, were less associated with the use of Part D pharmacies. Opioids were the most frequently filled drug class across all groups. Other frequently used drug classes included skeletal muscle relaxants, gastric medications, antidepressants (other category), anticonvulsants, and antilipemics. CONCLUSIONS Approximately 12% of veterans with SCI/D are receiving medication outside the VA system. Polypharmacy in this population of veterans is relatively high, emphasizing the importance of health information exchange between systems for improved care for this medically complex population.
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Affiliation(s)
- Maya N Hatch
- Spinal Cord Injury and Disorders Center, Long Beach Veterans Affairs Medical Center, Long Beach, CA
| | - Jason Raad
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL
| | - Katie Suda
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL
| | - Kevin T Stroupe
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL
| | - Alice J Hon
- Spinal Cord Injury and Disorders Center, Long Beach Veterans Affairs Medical Center, Long Beach, CA
| | - Bridget M Smith
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL; Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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25
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Cancino RS, Jack BW, Jarvis J, Cummings AK, Cooper E, Cremieux PY, Burgess JF. Health Services Utilization Among Fee-for-Service Medicare and Medicaid Patients Under Age 65 with Behavioral Health Illness at an Urban Safety Net Hospital. J Manag Care Spec Pharm 2017. [PMID: 28650248 PMCID: PMC10397911 DOI: 10.18553/jmcp.2017.23.7.781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In 2011, fee-for-service patients with both Medicare and Medicaid (dual eligible) sustained $319.5 billion in health care costs. OBJECTIVE To describe the emergency department (ED) use and hospital admissions of adult dual eligible patients aged under 65 years who used an urban safety net hospital. METHODS This was a retrospective database analysis of patients aged between 18 and 65 years with Medicare and Medicaid, who used an urban safety net academic health center between January 1, 2011, and December 31, 2011. We compared patients with and without behavioral health illness. The main outcome measures were hospital admission and ED use. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity score matching was used to control for confounding factors. Rate ratios (RR) and 95% confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching. RESULTS In 2011, 10% of all fee-for-service dual eligible patients aged less than 65 years in Massachusetts were seen at Boston Medical Center. Data before propensity score matching showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score between patients with and without behavioral health illness. Analysis after propensity score matching found significant differences in sex, Hispanic race, and other education and employment status. Compared with patients without behavioral health illness, patients with behavioral health illness had a higher RR for hospital admissions (RR = 2.07; 95% CI = 1.81-2.38; P < 0.001) and ED use (RR = 1.61; 95% CI = 1.46-1.77; P < 0.001). Results were robust after adjusting for characteristics that remained statistically significantly different after propensity score matching. CONCLUSIONS Adult dual eligible patients aged less than 65 years with behavioral health illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population. DISCLOSURES This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.
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Affiliation(s)
- Ramon S Cancino
- 1 Department of Family & Community Medicine, University of Texas Health Science Center at San Antonio, Joe R. & Teresa Lozano Long School of Medicine
| | - Brian W Jack
- 2 Department of Family Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts
| | | | | | | | | | - James F Burgess
- 4 Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, and Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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26
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Suda KJ, Smith BM, Bailey L, Gellad WF, Huo Z, Burk M, Cunningham F, Stroupe KT. Opioid dispensing and overlap in veterans with non-cancer pain eligible for Medicare Part D. J Am Pharm Assoc (2003) 2017; 57:333-340.e3. [DOI: 10.1016/j.japh.2017.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/12/2017] [Accepted: 02/13/2017] [Indexed: 10/19/2022]
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