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Andriola C, Ellis RP, Siracuse JJ, Hoagland A, Kuo TC, Hsu HE, Walkey A, Lasser KE, Ash AS. A Novel Machine Learning Algorithm for Creating Risk-Adjusted Payment Formulas. JAMA Health Forum 2024; 5:e240625. [PMID: 38639980 PMCID: PMC11065160 DOI: 10.1001/jamahealthforum.2024.0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/25/2024] [Indexed: 04/20/2024] Open
Abstract
Importance Models predicting health care spending and other outcomes from administrative records are widely used to manage and pay for health care, despite well-documented deficiencies. New methods are needed that can incorporate more than 70 000 diagnoses without creating undesirable coding incentives. Objective To develop a machine learning (ML) algorithm, building on Diagnostic Item (DXI) categories and Diagnostic Cost Group (DCG) methods, that automates development of clinically credible and transparent predictive models for policymakers and clinicians. Design, Setting, and Participants DXIs were organized into disease hierarchies and assigned an Appropriateness to Include (ATI) score to reflect vagueness and gameability concerns. A novel automated DCG algorithm iteratively assigned DXIs in 1 or more disease hierarchies to DCGs, identifying sets of DXIs with the largest regression coefficient as dominant; presence of a previously identified dominating DXI removed lower-ranked ones before the next iteration. The Merative MarketScan Commercial Claims and Encounters Database for commercial health insurance enrollees 64 years and younger was used. Data from January 2016 through December 2018 were randomly split 90% to 10% for model development and validation, respectively. Deidentified claims and enrollment data were delivered by Merative the following November in each calendar year and analyzed from November 2020 to January 2024. Main Outcome and Measures Concurrent top-coded total health care cost. Model performance was assessed using validation sample weighted least-squares regression, mean absolute errors, and mean errors for rare and common diagnoses. Results This study included 35 245 586 commercial health insurance enrollees 64 years and younger (65 901 460 person-years) and relied on 19 clinicians who provided reviews in the base model. The algorithm implemented 218 clinician-specified hierarchies compared with the US Department of Health and Human Services (HHS) hierarchical condition category (HCC) model's 64 hierarchies. The base model that dropped vague and gameable DXIs reduced the number of parameters by 80% (1624 of 3150), achieved an R2 of 0.535, and kept mean predicted spending within 12% ($3843 of $31 313) of actual spending for the 3% of people with rare diseases. In contrast, the HHS HCC model had an R2 of 0.428 and underpaid this group by 33% ($10 354 of $31 313). Conclusions and Relevance In this study, by automating DXI clustering within clinically specified hierarchies, this algorithm built clinically interpretable risk models in large datasets while addressing diagnostic vagueness and gameability concerns.
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Affiliation(s)
- Corinne Andriola
- Center for Innovation in Population Health, College of Public Health, University of Kentucky, Lexington
| | - Randall P. Ellis
- Department of Economics, Boston University, Boston, Massachusetts
| | - Jeffrey J. Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Alex Hoagland
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Heather E. Hsu
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Allan Walkey
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester
| | - Karen E. Lasser
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
- Senior Editor, JAMA
| | - Arlene S. Ash
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester
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Cole MB, Strackman BW, Lasser KE, Lin MY, Paasche-Orlow MK, Hanchate AD. Medicaid Expansion and Preventable Emergency Department Use by Race/Ethnicity. Am J Prev Med 2024:S0749-3797(24)00041-2. [PMID: 38342480 DOI: 10.1016/j.amepre.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 02/02/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION This study aimed to examine changes in emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) among uninsured or Medicaid-covered Black, Hispanic, and White adults aged 26-64 in the first 5 years of the Affordable Care Act Medicaid expansion. METHODS Using 2010-2018 inpatient and ED discharge data from nine expansion and five nonexpansion states, an event study difference-in-differences regression model was used to estimate changes in number of annual ACSC ED visits per 100 adults ("ACSC ED rate") associated with the 2014 Medicaid expansion, overall and by race/ethnicity. A secondary outcome was the proportion of ACSC ED visits out of all ED visits ("ACSC ED share"). Analyses were conducted in 2022-2023. RESULTS Medicaid expansion was associated with no change in ACSC ED rates among all, Black, Hispanic, or White adults. When excluding California, where most counties expanded Medicaid before 2014, expansion was associated with a decrease in ACSC ED rate among all, Black, Hispanic, and White adults. Expansion was also associated with a decrease in ACSC ED share among all, Black, and White adults. White adults experienced the largest reductions in ACSC ED rate and share. CONCLUSIONS Medicaid expansion was associated with reductions in ACSC ED rates in some expansion states and reductions in ACSC ED share in all expansion states combined, with some heterogeneity by race/ethnicity. Expansion should be coupled with policy efforts to better link newly insured Black and Hispanic patients to non-ED outpatient care, alongside targeted outreach and expanded primary care capacity, which may reduce disparities in ACSC ED visits.
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Affiliation(s)
- Megan B Cole
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Braden W Strackman
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Karen E Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Meng-Yun Lin
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Amresh D Hanchate
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts.
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Rose SW, Strackman BW, Gilbert ON, Lasser KE, Paasche‐Orlow MK, Lin M, Saylor G, Hanchate AD. Disparities by Sex, Race, and Ethnicity in Use of Left Ventricular Assist Devices and Heart Transplants Among Patients With Heart Failure With Reduced Ejection Fraction. J Am Heart Assoc 2024; 13:e031021. [PMID: 38166429 PMCID: PMC10926796 DOI: 10.1161/jaha.123.031021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/11/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND The extent to which sex, racial, and ethnic groups receive advanced heart therapies equitably is unclear. We estimated the population rate of left ventricular assist device (LVAD) and heart transplant (HT) use among (non-Hispanic) White, Hispanic, and (non-Hispanic) Black men and women who have heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS We used a retrospective cohort design combining counts of LVAD and HT procedures from 19 state inpatient discharge databases from 2010 to 2018 with counts of adults with HFrEF. Our primary outcome measures were the number of LVAD and HT procedures per 1000 adults with HFrEF. The main exposures were sex, race, ethnicity, and age. We used Poisson regression models to estimate procedure rates adjusted for differences in age, sex, race, and ethnicity. In 2018, the estimated population of adults aged 35 to 84 years with HFrEF was 69 736, of whom 44% were women. Among men, the LVAD rate was 45.6, and the HT rate was 26.9. Relative to men, LVAD and HT rates were 72% and 62% lower among women (P<0.001). Relative to White men, LVAD and HT rates were 25% and 46% lower (P<0.001) among Black men. Among Hispanic men and women and Black women, LVAD and HT rates were similar (P>0.05) or higher (P<0.01) than among their White counterparts. CONCLUSIONS Among adults with HFrEF, the use of LVAD and HT is lower among women and Black men. Health systems and policymakers should identify and ameliorate sources of sex and racial inequities.
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Affiliation(s)
- Scott W. Rose
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Braden W. Strackman
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Olivia N. Gilbert
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Karen E. Lasser
- Section of General Internal MedicineBoston University School of MedicineBostonMAUSA
| | | | - Meng‐Yun Lin
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Georgia Saylor
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
- Section of General Internal MedicineBoston University School of MedicineBostonMAUSA
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Abstract
This JAMA Insights describes indications for naloxone use in preventing opioid overdoses and benefits vs barriers to its availability following FDA approval of its availability without a prescription.
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Affiliation(s)
- Jessica L Taylor
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Karen E Lasser
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
- Senior Editor, JAMA
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Liebschutz JM, Subramaniam GA, Stone R, Appleton N, Gelberg L, Lovejoy TI, Bunting AM, Cleland CM, Lasser KE, Beers D, Abrams C, McCormack J, Potter GE, Case A, Revoredo L, Jelstrom EM, Kline MM, Wu LT, McNeely J. Subthreshold opioid use disorder prevention (STOP) trial: a cluster randomized clinical trial: study design and methods. Addict Sci Clin Pract 2023; 18:70. [PMID: 37980494 PMCID: PMC10657560 DOI: 10.1186/s13722-023-00424-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/30/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Preventing progression to moderate or severe opioid use disorder (OUD) among people who exhibit risky opioid use behavior that does not meet criteria for treatment with opioid agonists or antagonists (subthreshold OUD) is poorly understood. The Subthreshold Opioid Use Disorder Prevention (STOP) Trial is designed to study the efficacy of a collaborative care intervention to reduce risky opioid use and to prevent progression to moderate or severe OUD in adult primary care patients with subthreshold OUD. METHODS The STOP trial is a cluster randomized controlled trial, randomized at the PCP level, conducted in 5 distinct geographic sites. STOP tests the efficacy of the STOP intervention in comparison to enhanced usual care (EUC) in adult primary care patients with risky opioid use that does not meet criteria for moderate-severe OUD. The STOP intervention consists of (1) a practice-embedded nurse care manager (NCM) who provides patient participant education and supports primary care providers (PCPs) in engaging and monitoring patient-participants; (2) brief advice, delivered to patient participants by their PCP and/or prerecorded video message, about health risks of opioid misuse; and (3) up to 6 sessions of telephone health coaching to motivate and support behavior change. EUC consists of primary care treatment as usual, plus printed overdose prevention educational materials and an educational video on cancer screening. The primary outcome measure is self-reported number of days of risky (illicit or nonmedical) opioid use over 180 days, assessed monthly via text message using items from the Addiction Severity Index and the Current Opioid Misuse Measure. Secondary outcomes assess other substance use, mental health, quality of life, and healthcare utilization as well as PCP prescribing and monitoring behaviors. A mixed effects negative binomial model with a log link will be fit to estimate the difference in means between treatment and control groups using an intent-to-treat population. DISCUSSION Given a growing interest in interventions for the management of patients with risky opioid use, and the need for primary care-based interventions, this study potentially offers a blueprint for a feasible and effective approach to improving outcomes in this population. TRIAL REGISTRATION Clinicaltrials.gov, identifier NCT04218201, January 6, 2020.
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Affiliation(s)
- Jane M Liebschutz
- Division of General Internal Medicine, Center for Research On Health Care, University of Pittsburgh, 200 Lothrop Street, Suite 933W, Pittsburgh, PA, 15213, USA.
| | | | - Rebecca Stone
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Noa Appleton
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Lillian Gelberg
- David Geffen School of Medicine at UCLA, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Travis I Lovejoy
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Amanda M Bunting
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Charles M Cleland
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- School of Public Health, Boston University, Boston, MA, USA
| | - Donna Beers
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | | | - Gail E Potter
- The Emmes Company, LLC, Rockville, MD, USA
- Biostatistics Research Branch, NIH/NIAID, Rockville, MD, USA
| | | | | | | | | | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer McNeely
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
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Hanchate AD, Abdelfattah L, Lin MY, Lasser KE, Paasche-Orlow MK. Affordable Care Act Medicaid Expansion was Associated With Reductions in the Proportion of Hospitalizations That are Potentially Preventable Among Hispanic and White Adults. Med Care 2023; 61:627-635. [PMID: 37582292 PMCID: PMC10894451 DOI: 10.1097/mlr.0000000000001902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
OBJECTIVE Using data on 5 years of postexpansion experience, we examined whether the coverage gains from Affordable Care Act Medicaid expansion among Black, Hispanic, and White individuals led to improvements in objective indicators of outpatient care adequacy and quality. RESEARCH DESIGN For the population of adults aged 45-64 with no insurance or Medicaid coverage, we obtained data on census population and hospitalizations for ambulatory care sensitive conditions (ACSCs) during 2010-2018 in 14 expansion and 7 nonexpansion states. Our primary outcome was the percentage share of hospitalizations due to ACSC out of all hospitalizations ("ACSC share") among uninsured and Medicaid-covered patients. Secondary outcomes were the population rate of ACSC and all hospitalizations. We used multivariate regression models with an event-study difference-in-differences specification to estimate the change in the outcome measures associated with expansion in each of the 5 postexpansion years among Hispanic, Black, and White adults. PRINCIPAL FINDINGS At baseline, ACSC share in the expansion states was 19.0%, 14.5%, and 14.3% among Black, Hispanic, and White adults. Over the 5 years after expansion, Medicaid expansion was associated with an annual reduction in ACSC share of 5.3% (95% CI, -7.4% to -3.1%) among Hispanic and 8.0% (95% CI, -11.3% to -4.5%) among White adults. Among Black adults, estimates were mixed and indicated either no change or a reduction in ACSC share. CONCLUSIONS After Medicaid expansion, low-income Hispanic and White adults experienced a decrease in the proportion of potentially preventable hospitalizations out of all hospitalizations.
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Affiliation(s)
- Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Lindsey Abdelfattah
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Meng-Yun Lin
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Karen E. Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Michael K. Paasche-Orlow
- Division of General Internal Medicine, Department of Medicine, Tufts University School of Medicine, Boston, MA
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Hanchate AD, Strackman BW, Lin M, Paasche‐Orlow MK, Lasser KE, Cole MB. Medicaid expansion associated with no change in emergency department use across racial and ethnic groups. Health Serv Res 2023; 58:1014-1023. [PMID: 37202905 PMCID: PMC10480077 DOI: 10.1111/1475-6773.14171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE To estimate changes in the emergency department (ED) visit rate, hospitalization share of ED visits, and ED visit volumes associated with Medicaid expansion among Hispanic, Black, and White adults. DATA COLLECTION/EXTRACTION METHODS For the population of adults aged 26-64 with no insurance or Medicaid coverage, we obtained census population and ED visit counts during 2010-2018 in nine expansion and five nonexpansion states. MAIN OUTCOMES AND MEASURES The primary outcome was the annual number of ED visits per 100 adults ("ED rate"). The secondary outcomes were the share of ED visits leading to hospitalization, total number ("volumes") of all ED visits, ED visits leading to discharge ("treat-and-release") and ED visits leading to hospitalization ("transfer-to-inpatient"), and the share of the study population with Medicaid ("Medicaid share"). STUDY DESIGN An event-study difference in differences design that contrasts pre- versus post-expansion changes in outcomes in Medicaid expansion and nonexpansion states. PRINCIPAL FINDINGS In 2013, the ED rate was 92.6, 34.4, and 59.2 ED visits among Black, Hispanic, and White adults, respectively. The expansion was associated with no change in ED rate in all three groups in each of the five post-expansion years. We found that expansion was associated with no change in the hospitalization share of ED visits and the volume of all ED visits, treat-and-release ED visits, and transfer-to-inpatient ED visits. The expansion was associated with an 11.7% annual increase (95% CI, 2.7%-21.2%) in the Medicaid share of Hispanic adults, but no significant change among Black adults (3.8%; 95% CI, -0.04% to 7.7%). CONCLUSION ACA Medicaid expansion was associated with no changes in the rate of ED visits among Black, Hispanic, and White adults. Expanding Medicaid eligibility may not change ED use, including among Black and Hispanic subgroups.
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Affiliation(s)
- Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of Medicine, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | - Braden W. Strackman
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of Medicine, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | - Mengyun Lin
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of Medicine, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | | | - Karen E. Lasser
- Section of General Internal Medicine, Department of MedicineBoston University School of MedicineBostonMississippiUSA
| | - Megan B. Cole
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMississippiUSA
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Borden CG, Ashe EM, Buitron de la Vega P, Gast V, Saint-Phard T, Brody-Fialkin J, Power J, Wang N, Lasser KE. A novel pharmacy liaison program to address health-related social needs at an urban safety-net hospital. Am J Health Syst Pharm 2023; 80:1071-1081. [PMID: 37210728 DOI: 10.1093/ajhp/zxad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 05/23/2023] Open
Abstract
PURPOSE Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison-patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role. METHODS We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program. RESULTS Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non-English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support. CONCLUSION Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital.
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Affiliation(s)
- Caroline G Borden
- Boston Medical Center, Boston, MA
- Yale School of Medicine, New Haven, CT, USA
| | | | - Pablo Buitron de la Vega
- Section of General Internal Medicine, Boston Medical Center, Boston, MA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Vi Gast
- Takeda Pharmaceutical Company, Cambridge, MA, USA
| | | | | | - Julia Power
- Action for Boston Community Development, Inc., Boston, MA, USA
| | - Na Wang
- Boston University School of Public Health, Boston, MA, USA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, MA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Stulac SN, Costello E, Baker J, Elansary M, Reed K, Lasser KE. High Engagement in Care in a Pediatric Medical Home for Children Impacted By Parental Substance Use. Clin Pediatr (Phila) 2023:99228231189140. [PMID: 37515533 DOI: 10.1177/00099228231189140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
The opioid epidemic has heavily affected adults of childbearing age, leading to thousands of children impacted by parental substance use. Few programs provide longitudinal support to these children. This article describes an innovative pediatric medical home model for substance-impacted children and their families, at an urban safety-net hospital. The team-based program directly serves children, and also devotes significant resources to parental health and recovery. In the program's first 3 years, 95% of enrollees were engaged in care, meeting the American Academy of Pediatrics' recommended periodicity schedule for preventive health visits. On-time receipt of childhood vaccines ranged from 95% (pneumococcal conjugate) to 100% (human papilloma virus). The program's high engagement in care shows promise in engaging vulnerable families over time. Future work should explore how to engage children from more diverse backgrounds, and should examine whether the model impacts other indicators of health and well-being for children impacted by parental substance use.
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Affiliation(s)
- Sara N Stulac
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Eileen Costello
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Jill Baker
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Mei Elansary
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Kristin Reed
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Karen E Lasser
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Internal Medicine, Boston Medical Center, Boston, MA, USA
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Carroll JJ, Cushman PA, Lira MC, Colasanti JA, Del Rio C, Lasser KE, Parker V, Roy PJ, Samet JH, Liebschutz JM. Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies. J Gen Intern Med 2023; 38:1794-1801. [PMID: 36396881 PMCID: PMC10271994 DOI: 10.1007/s11606-022-07909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. OBJECTIVE This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. DESIGN We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. APPROACH We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. KEY RESULTS We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. CONCLUSION TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, North Carolina State University, Raleigh, NC, USA.
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
| | - Phoebe A Cushman
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Karen E Lasser
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Victoria Parker
- Department of Management, Peter. T. Paul College of Business & Economics, University of New Hampshire, Durham, NH, USA
| | - Payel J Roy
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Buitron de la Vega P, Ashe EM, Xuan Z, Gast V, Saint-Phard T, Brody-Fialkin J, Okonkwo F, Power J, Wang N, Lyons C, Silverstein M, Lasser KE. A Pharmacy Liaison-Patient Navigation Intervention to Reduce Inpatient and Emergency Department Utilization Among Primary Care Patients in a Medicaid Accountable Care Organization: A Nonrandomized Controlled Trial. JAMA Netw Open 2023; 6:e2250004. [PMID: 36622674 PMCID: PMC9856667 DOI: 10.1001/jamanetworkopen.2022.50004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Patients with unmet health-related social needs are at high risk for preventable health care utilization. Prior interventions to identify health-related social needs and provide navigation services with community resources have not taken place in pharmacy settings. OBJECTIVE To evaluate an enhancement of pharmacy care to reduce hospital admissions and emergency department (ED) visits among primary care patients in a Medicaid accountable care organization (ACO). DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled trial was conducted from May 1, 2019, through March 4, 2021, with 1 year of follow-up. Study allocation was determined by odd or even medical record number. The study was performed at a general internal medicine practice at a large safety-net hospital in Boston, Massachusetts. Patients who qualified for the hospital's pharmacy care program (aged 18-64 years and within the third to tenth percentile for health care utilization and cost among Medicaid ACO membership) who attended a visit with a primary care clinician were eligible. Of 770 eligible patients, 577 were approached, 127 declined, and 86 could not be contacted. INTERVENTIONS Patients in the control group received usual pharmacy care focused on medication adherence. Patients in the intervention group received enhanced pharmacy care with an additional focus on identification of and intervention for health-related social needs. The intervention took place for 1 year. MAIN OUTCOMES AND MEASURES The primary outcome was inpatient hospital admissions and ED visits (composite outcome) in the 12 months after enrollment during the intervention period. RESULTS Among 364 allocated patients (mean [SD] age, 50.1 [10.1] years; 216 women [59.3%]), 35 were Hispanic of any race (9.6%) and 214 were non-Hispanic Black (58.8%). All participants were included in the intention-to-treat analysis. In analyses controlling for baseline hospital admissions and ED visits the year prior to enrollment, the enhanced pharmacy care group was not associated with the odds of having any hospital admission or ED visit (adjusted odds ratio, 0.62 [95% CI, 0.23-1.62]; P = .32) among all patients and was not associated with the visit rates among those with any visit (adjusted rate ratio, 0.93 [95% CI, 0.71-1.22]; P = .62) relative to the usual pharmacy care group in the year following enrollment. CONCLUSIONS AND RELEVANCE The findings of this nonrandomized controlled trial suggest that inpatient and ED utilization among Medicaid ACO members at a safety-net hospital was not significantly different between groups at 1-year follow-up. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03919084.
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Affiliation(s)
- Pablo Buitron de la Vega
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Erin M. Ashe
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Ziming Xuan
- Boston University School of Public Health, Boston, Massachusetts
| | - Vi Gast
- Takeda Pharmaceutical Company, Cambridge, Massachusetts
| | - Tracey Saint-Phard
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | | | | | - Julia Power
- Action for Boston Community Development Inc, Boston, Massachusetts
| | - Na Wang
- Boston University School of Public Health, Boston, Massachusetts
| | - Chris Lyons
- Boston University School of Medicine, Boston, Massachusetts
| | | | - Karen E. Lasser
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
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12
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Jia J, Jenkins AJ, Quintiliani LM, Truong V, Lasser KE. Resilience and diabetes self-management among African-American men receiving primary care at an urban safety-net hospital: a cross-sectional survey. Ethn Health 2022; 27:1178-1187. [PMID: 33249921 DOI: 10.1080/13557858.2020.1849566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/02/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Resilience is the ability to adapt to adverse life events. Studies that explore diabetes self-management interventions integrating resilience in African-Americans with diabetes include few African-American men, who have higher diabetes-related mortality and complication rates compared to African-American women. DESIGN We conducted a cross-sectional study of African-American men with uncontrolled diabetes living in diabetes hotspots. We measured resilience levels using the General Self Efficacy Scale (GSES), adherence to diabetes self-management behaviors using the Diabetes Self-Management Questionnaire (DSMQ), and incarceration history by phone survey. We categorized participants as higher or lower resilience level and higher or lower adherence to diabetes self-management behaviors. Using multivariable logistic regression, we examined the relationship between resilience and adherence to diabetes self-management behaviors. Our model accounted for potential confounders, including age, incarceration history, and socioeconomic factors. RESULTS Of 234 patients contacted by mail and phone, 94 (40.2%) completed the survey. Mean age was 60.6 years, 59.5% reported an annual household income of less than $20,000, and 29.8% reported a history of incarceration. The mean unadjusted GSES score was 25.0 (sd 5.2; range: 0-30, higher scores indicate greater resilience), and the mean DSMQ score was 7.34 (sd 1.78; range: 0-10, higher scores indicate greater adherence to diabetes self-management behaviors). In multivariable analyses, higher levels of resilience were associated with higher adherence to diabetes self-management behaviors (aOR = 9.68, 95% CI 3.01, 31.12). History of incarceration was negatively associated with higher adherence to diabetes self-management behaviors (aOR = 0.23, 95% CI 0.06, 0.81). CONCLUSIONS Resilience and personal history of incarceration are associated with adherence to diabetes self-management behaviors among African-American men residing in diabetes hotspots. Future interventions should incorporate resilience training to improve diabetes self-management behaviors. At a societal level, social determinants of health that adversely affect African-American men, such as structural racism and mass incarceration, need to be eliminated.
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Affiliation(s)
- Jenny Jia
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Lisa M Quintiliani
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
| | - Ve Truong
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Karen E Lasser
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
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13
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Ellis RP, Hsu HE, Siracuse JJ, Walkey AJ, Lasser KE, Jacobson BC, Andriola C, Hoagland A, Liu Y, Song C, Kuo TC, Ash AS. Development and Assessment of a New Framework for Disease Surveillance, Prediction, and Risk Adjustment. JAMA Health Forum 2022; 3:e220276. [PMID: 35977291 PMCID: PMC8956982 DOI: 10.1001/jamahealthforum.2022.0276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/31/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Heather E. Hsu
- Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey J. Siracuse
- Boston University, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | | | | | | | - Ying Liu
- Government Accountability Office, Washington, DC
| | | | | | - Arlene S. Ash
- University of Massachusetts Medical School, Worcester
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14
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Hanchate AD, Qi D, Paasche-Orlow MK, Lasser KE, Liu Z, Lin M, Lewis KH. Examination of Elective Bariatric Surgery Rates Before and After US Affordable Care Act Medicaid Expansion. JAMA Health Forum 2021; 2:e213083. [PMID: 35977157 PMCID: PMC8727038 DOI: 10.1001/jamahealthforum.2021.3083] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023] Open
Abstract
Importance There is limited evidence on whether the Affordable Care Act Medicaid expansion beginning in 2014 improved access to elective procedures. Uninsured individuals are at higher risk of obesity and may have experienced improved uptake of bariatric surgery following Medicaid expansion. Objective To examine the association between Medicaid expansion and the receipt of inpatient elective bariatric surgery among Medicaid-covered and uninsured individuals aged 26 to 64 years. Design Setting and Participants This cohort study used difference-in-differences analysis of all-payer data (2010-2017) of 637 557 elective bariatric surgeries for patients aged 26 to 74 years from 11 Medicaid expansion states and 6 nonexpansion states. Nonexpansion states and individuals aged 65 to 74 years were control cohorts. Data analysis was performed from July 6, 2020, to July 23, 2021. Exposure Living in a Medicaid expansion state. Main Outcomes and Measures The main outcomes were the (1) number of elective bariatric surgeries, (2) population count, and (3) rate of bariatric surgery (number of surgeries per 10 000 population) among Medicaid-covered and uninsured individuals. Results Of the 600 798 elective bariatric surgeries in adults aged 26 to 64 years between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states. A total of 296 798 patients (78.9%) in expansion states were women vs 177 386 (78.9%) in nonexpansion states. Among individuals aged 26 to 64 years, the median age was 44 (IQR, 37-52) years. Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%. Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in nonexpansion states. Medicaid expansion was associated with a 36.6% annual increase (95% CI, 8.2% to 72.5%) in surgery volume, a 9.0% annual increase (95% CI, 3.8% to 14.5%) in the population, and a 25.5% change (95% CI, -1.3% to 59.4%) in the rate of bariatric surgery. By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic (28.9%; 95% CI, -24.4% to 119.8%) individuals. Conclusions and Relevance This cohort study found that Medicaid expansion was associated with increased rates of bariatric surgery among lower-income non-Hispanic White individuals, but not among Hispanic and non-Hispanic Black individuals.
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Affiliation(s)
- Amresh D. Hanchate
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | | | - Michael K. Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts,Department of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Karen E. Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts,Department of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Zhixiu Liu
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mengyun Lin
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kristina Henderson Lewis
- Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
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15
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Greco CM, Gaylord SA, Faurot K, Weinberg JM, Gardiner P, Roth I, Barnhill JL, Thomas HN, Dhamne SC, Lathren C, Baez JE, Lawrence S, Neogi T, Lasser KE, Castro MG, White AM, Simmons SJ, Ferrao C, Binda DD, Elhadidy N, Eason KM, McTigue KM, Morone NE. The design and methods of the OPTIMUM study: A multisite pragmatic randomized clinical trial of a telehealth group mindfulness program for persons with chronic low back pain. Contemp Clin Trials 2021; 109:106545. [PMID: 34455111 PMCID: PMC8691659 DOI: 10.1016/j.cct.2021.106545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 01/04/2023]
Abstract
Mindfulness-based stress reduction (MBSR) is an evidence-based non-pharmacological approach for chronic low back pain (cLBP), yet it is not readily available or reimbursable within primary care clinics. Primary care providers (PCPs) who wish to avoid prescribing opioids and other medications typically have few options for their cLBP patients. We present the protocol of a pragmatic clinical trial entitled OPTIMUM (Optimizing Pain Treatment In Medical settings Using Mindfulness). OPTIMUM is offered online via telehealth and includes medical group visits (MGV) with a PCP and a mindfulness meditation intervention modeled on MBSR for persons with cLBP. In diverse health-care settings in the US, such as a safety net hospital, federally qualified health centers, and a large academic health system, 450 patients will be assigned randomly to the MGV + MBSR or to usual PCP care alone. Participants will complete self-report surveys at baseline, following the 8-week program, and at 6- and 12-month follow-up. Health care utilization data will be obtained through electronic health records and via brief monthly surveys completed by participants. The primary outcome measure is the PEG (Pain, enjoyment, and general activity) at the 6-month follow-up. Additionally, we will assess psychological function, healthcare resource use, and opioid prescriptions. This trial, which is part of the NIH HEAL Initiative, has the potential to enhance primary care treatment of cLBP by combining PCP visits with a non-pharmacological treatment modeled on MBSR. Because it is offered online and integrated into primary care, it is expected to be scalable and accessible to underserved patients. Clinical Trials.gov: NCT04129450.
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Affiliation(s)
- Carol M Greco
- Department of Psychiatry and Physical Therapy, University of Pittsburgh School of Medicine and School of Health and Rehabilitation Sciences, PA, United States of America
| | - Susan A Gaylord
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Kim Faurot
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Janice M Weinberg
- Department of Biostatistics, Boston University School of Public Health, MA, United States of America
| | - Paula Gardiner
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Isabel Roth
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Jessica L Barnhill
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Holly N Thomas
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, PA, United States of America
| | - Sayali C Dhamne
- Boston University School of Public Health, Boston Medical Center, MA, United States of America
| | - Christine Lathren
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Jose E Baez
- General Internal Medicine, Boston Medical Center, MA, United States of America
| | - Suzanne Lawrence
- Department of Psychiatry, University of Pittsburgh, PA, United States of America
| | - Tuhina Neogi
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, United States of America
| | - Karen E Lasser
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States of America
| | - Maria Gabriela Castro
- Siler City Community Health Center, Piedmont Health Services, Department of Family Medicine, University of North Carolina at Chapel Hill, NC, United States of America
| | - Anna Marie White
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, PA, United States of America
| | | | - Cleopatra Ferrao
- General Internal Medicine, Boston Medical Center, MA, United States of America
| | - Dhanesh D Binda
- Boston University School of Medicine, Boston, MA, United States of America
| | - Nandie Elhadidy
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Kelly M Eason
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Kathleen M McTigue
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, PA, United States of America
| | - Natalia E Morone
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States of America.
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16
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Janeway MG, Sanchez SE, Rosen AK, Patts G, Allee LC, Lasser KE, Dechert TA. Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States. J Surg Res 2021; 266:373-382. [PMID: 34087621 DOI: 10.1016/j.jss.2021.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/18/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy. MATERIALS AND METHODS Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy. RESULTS Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals. CONCLUSIONS Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.
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Affiliation(s)
- Megan G Janeway
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Amy K Rosen
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Gregory Patts
- Boston University School of Public Health, Boston, Massachusetts
| | - Lisa C Allee
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Karen E Lasser
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Crosstown Center, Boston, Massachusetts
| | - Tracey A Dechert
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
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17
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Abstract
This cross-sectional study examines whether inpatient utilization among patients with lower socioeconomic status and among those who belong to racial/ethnic minority groups changed differentially in states that expanded Medicaid following the Patient Protection and Affordable Care Act (ACA).
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Affiliation(s)
- Karen E. Lasser
- Boston University School of Medicine, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Zhixiu Liu
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Meng-Yun Lin
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael K. Paasche-Orlow
- Boston University School of Medicine, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
| | - Amresh Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
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18
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Quintiliani LM, Kathuria H, Truong V, Murillo J, Borrelli B, Xuan Z, Lasser KE. Patient navigation among recently hospitalized smokers to promote tobacco treatment: Results from a randomized exploratory pilot study. Addict Behav 2021; 113:106659. [PMID: 33010473 PMCID: PMC7946867 DOI: 10.1016/j.addbeh.2020.106659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Adding screening for health-related social needs to tobacco treatment interventions initiated during hospitalizations may improve intervention effectiveness among vulnerable populations. Our objective was to examine the effect the acceptability and feasibility of a intervention in which a patient navigator screens for and addresses social needs to increase receipt of smoking cessation medication among recently hospitalized smokers at a safety-net hospital. METHODS In a two-group randomized exploratory pilot study, we assigned hospitalized smokers to either the Enhanced Traditional Control (ETC) group (list of smoking cessation resources) or ETC + Patient Navigation (up to 10 h of navigation over a 3-month period, in which a navigator screens for and addresses health-related social needs). We assessed socio-demographics, smoking-related variables, and process data. RESULTS Of 171 individuals screened, 44 (26%) were enrolled. Participants (mean age = 54.9 years, 61.4% non-Hispanic black, 68.2% high school education or less) smoked a mean of 11.4 cigarettes/day. 20 participants received a prescription for a cessation medication, 42.9% in the ETC group and 47.8% in the ETC + Patient Navigation group. 11 participants (47.8%) in the ETC + Patient Navigation group received the minimum intervention dose (completion of the social needs screener and at least one counseling session). Barriers to navigation were participants' medical illness and difficulty connecting with participants. CONCLUSIONS Although nearly half of hospitalized smokers receiving support from a patient navigator received a prescription for a smoking cessation medication, the percentage did not differ by study arm. Refinement of the protocol to coordinate with hospital-wide tobacco treatment and social needs screening initiatives is needed.
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Affiliation(s)
- Lisa M Quintiliani
- Boston University, School of Medicine, Boston Medical Center, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown 2, Boston, MA 02118, United States.
| | - Hasmeena Kathuria
- Boston University, School of Medicine, The Pulmonary Center, Boston Medical Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, 72 East Concord St., Boston, MA 02118, United States
| | - Ve Truong
- Boston Medical Center, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown 2, Boston, MA 02118, United States
| | - Jennifer Murillo
- Boston Medical Center, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown 2, Boston, MA 02118, United States
| | - Belinda Borrelli
- Boston University, Henry M. Goldman School of Dental Medicine, Center for Behavioral Science Research, 560 Harrison Ave., Boston, MA 02118, United States
| | - Ziming Xuan
- Boston University, School of Public Health, 801 Massachusetts Ave., Crosstown CT453, Boston, MA 02118, United States
| | - Karen E Lasser
- Boston University, School of Medicine, Boston Medical Center, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown 2, Boston, MA 02118, United States
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19
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Abstract
Efforts to engage young adults with substance use disorders in treatment often focus on the individual and do not consider the role that the family can play in the recovery process. In summarizing the proceedings of a longitudinal meeting on substance use among young adults, this special article outlines three key principles concerning the engagement of broader family units in substance use treatment: (1) care should involve family members (biological, extended, or chosen); (2) these family members should receive counseling on evidence-based approaches that can enhance their loved one's engagement in care; and (3) family members should receive counseling on evidence-based strategies that can improve their own health. For each principle, we provide an explanation of our guidance to practitioners, supportive evidence, and additional practice considerations.
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Affiliation(s)
- Sarah M Bagley
- Grayken Center for Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; .,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Alicia S Ventura
- Grayken Center for Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Karen E Lasser
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts; and
| | - Fred Muench
- Partnership to End Addiction, New York City, New York
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20
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Hsu HE, Ashe EM, Silverstein M, Hofman M, Lange SJ, Razzaghi H, Mishuris RG, Davidoff R, Parker EM, Penman-Aguilar A, Clarke KEN, Goldman A, James TL, Jacobson K, Lasser KE, Xuan Z, Peacock G, Dowling NF, Goodman AB. Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients with COVID-19 at an Urban Safety-Net Medical Center - Boston, Massachusetts, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:864-869. [PMID: 32644981 PMCID: PMC7727597 DOI: 10.15585/mmwr.mm6927a3] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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21
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Husain JM, LaRochelle M, Keosaian J, Xuan Z, Lasser KE, Liebschutz JM. Reasons for Opioid Discontinuation and Unintended Consequences Following Opioid Discontinuation Within the TOPCARE Trial. Pain Med 2020; 20:1330-1337. [PMID: 29955866 DOI: 10.1093/pm/pny124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To identify reasons for opioid discontinuation and post-discontinuation outcomes among patients in the Transforming Opioid Prescribing in Primary Care (TOPCARE) study. DESIGN In TOPCARE, an intervention to improve adherence to opioid prescribing guidelines, randomized intervention primary care providers (PCPs) received nurse care manager support, an electronic registry, academic detailing, and electronic tools, and control PCPs received electronic tools only. SETTING Four Boston safety net primary care practices. SUBJECTS Patients in both TOPCARE study arms who discontinued opioid therapy during the trial. METHODS Through chart review, we examined the reason for discontinuation and post-discontinuation outcomes: one or more PCP visits, one or more pain-related emergency department (ED) visits, evidence of opioid use disorder (OUD), and referral for OUD treatment. RESULTS Opioid discontinuations occurred in 83/586 (14.2%) intervention and 42/399 (10.5%) control patients (P = 0.09). Among patients who discontinued opioids, 81 (65%) discontinued for misuse, with no difference by group (P = 0.38). Aberrancy in monitoring (e.g., discordant urine drug test results) was the most common type of misuse prompting discontinuation (occurring in (51/83 [61%] of intervention patients vs 19/42 [45%, P = 0.08] of control patients). Intervention patients who discontinued opioids had less PCP follow-up (65% vs 88%, P < 0.01) compared with control patients. We found no differences between groups for pain-related ED visits, evidence of OUD, or OUD treatment referral following discontinuation. CONCLUSIONS The decreased follow-up among TOPCARE intervention patients who discontinued opioids highlights the need to understand unintended consequences of involuntary opioid discontinuations resulting from interventions to reduce opioid risk.
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Affiliation(s)
- Jawad M Husain
- Department of Psychiatry.,Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston, Massachusetts
| | - Marc LaRochelle
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston, Massachusetts
| | - Julia Keosaian
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston, Massachusetts
| | - Ziming Xuan
- Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston, Massachusetts.,Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston, Massachusetts.,Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Jane M Liebschutz
- Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston, Massachusetts.,Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Lasser KE, Buitron de la Vega P, Ashe EM, Xuan Z, Alva S, Battisti L, Losi S, Sieber C, Richards C, Sullivan P, Triscari L, Brody L, Roth MT, LeBlanc A, Silverstein M. A pharmacy liaison-patient navigation intervention to reduce inpatient and emergency department utilization among primary care patients in a Medicaid accountable care organization: A pragmatic trial protocol. Contemp Clin Trials 2020; 94:106046. [PMID: 32485325 DOI: 10.1016/j.cct.2020.106046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 05/18/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine whether employing the services of a pharmacy liaison to promote medication adherence (usual care), relative to a pharmacy liaison with training in motivational interviewing and as a patient navigator who systematically screens for health-related social needs and provides targeted navigation services to connect patients with appropriate community resources in partnership with a community-based organization (enhanced usual care), will reduce inpatient hospital admissions and emergency department visits among patients who are members of a Medicaid ACO and receive primary care at a large urban safety-net hospital. BACKGROUND Prior studies have demonstrated only modest effects in reducing utilization among safety-net patient populations. Interventions that address health-related social needs have the potential to reduce utilization in these populations. DESIGN/METHODS Assignment to treatment condition is by medical record number (odd vs. even) and is unblinded (NCT03919084). Adults age 18-64 within the 3rd to 10th percentile for health care utilization and cost among Medicaid Accountable Care Organization membership attending a primary care visit in the general internal medicine practice at Boston Medical Center enrolled. DISCUSSION Our study will advance the field in two ways: 1) by providing evidence about the effectiveness of pharmacy liaisons who also function as patient navigators; and 2) by de-implementing patient navigators. Patients in the enhanced usual care arm will no longer receive the services of a clinic-based patient navigator. In addition, our study includes a novel collaboration with a community-based organization, and focuses on an intermediate-cost patient population, rather than the most costly patient population.
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Affiliation(s)
- Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Ave, 6th Floor, Boston, MA 02119, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA; Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA; Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA.
| | - Pablo Buitron de la Vega
- Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Ave, 6th Floor, Boston, MA 02119, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA; Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA.
| | - Erin M Ashe
- Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA.
| | - Ziming Xuan
- Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA.
| | - Sonia Alva
- Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA.
| | - Leandra Battisti
- Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA.
| | - Stephanie Losi
- Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA.
| | - Christina Sieber
- Action for Boston Community Development Inc., 178 Tremont St, Boston, MA 02111, USA.
| | - Carla Richards
- Action for Boston Community Development Inc., 178 Tremont St, Boston, MA 02111, USA.
| | - Patricia Sullivan
- Action for Boston Community Development Inc., 178 Tremont St, Boston, MA 02111, USA.
| | - Leah Triscari
- Action for Boston Community Development Inc., 178 Tremont St, Boston, MA 02111, USA.
| | - Lauren Brody
- Action for Boston Community Development Inc., 178 Tremont St, Boston, MA 02111, USA.
| | - Mary-Tara Roth
- Clinical Research Resources Office, Boston Medical Center, Boston University Medical Campus, 75 E Newton St, Evans Building, 7(th) Floor, Boston, MA 02118, USA.
| | - Alison LeBlanc
- Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA.
| | - Michael Silverstein
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA; Section of General Academic Pediatrics, Boston Medical Center, 72 East Concord St, Vose Building, 3(rd) Floor, Boston, MA 02118, USA.
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23
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Stokes A, Lundberg DJ, Sheridan B, Hempstead K, Morone NE, Lasser KE, Trinquart L, Neogi T. Association of Obesity With Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US. JAMA Netw Open 2020; 3:e202012. [PMID: 32239222 PMCID: PMC7118518 DOI: 10.1001/jamanetworkopen.2020.2012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Prior studies have identified an association between obesity and prescription opioid use in the US. However, the pain conditions that are factors in this association remain unestablished. OBJECTIVE To investigate the association between obesity and pain diagnoses recorded by primary care clinicians as reasons for prescription of opioids. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study including 565 930 patients aged 35 to 64 years with a body mass index (BMI) measurement recorded in 2016 was conducted. Electronic health records of patients seen by primary care clinicians in the US in the multipayer athenahealth network from January 1, 2015, to December 31, 2017, were reviewed, and data were analyzed from March 1 to September 15, 2019. MAIN OUTCOMES AND MEASURES Any prescription of opioids in the 365 days before or after the first BMI measurement in 2016 were identified. All International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, claims within 7 days before each opioid prescription were captured and classified using a pain diagnosis typologic system. Weight was categorized as underweight (BMI, 18.5-19.9), normal weight (BMI, 20.0-24.9), overweight (BMI, 25.0-29.9), obese I (BMI, 30-34.9), obese II (BMI, 35.0-39.9), obese III (BMI, 40.0-49.9), and obese IV (BMI, 50.0-80.0). RESULTS Among 565 930 patients, 329 083 (58.1%) were women. A total of 125 093 patients (22.1%) were aged 35 to 44 years, 199 384 patients (35.2%) were 45 to 54 years, and 241 453 patients (42.7%) were 55 to 64 years. A total of 177 631 patients (31.4%) were overweight and 273 135 patients (48.2%) were obese at baseline. Over 2 years, 93 954 patients (16.6%) were prescribed opioids. The risk of receiving prescription opioids increased progressively with BMI (adjusted relative risk for overweight: 1.08; 95% CI, 1.06-1.10; obese I: 1.24; 95% CI, 1.22-1.26; obese II: 1.33; 95% CI, 1.30-1.36; obese III: 1.48; 95% CI, 1.45-1.51; and obese IV, 1.71; 95% CI, 1.65-1.77). The percentage of patients with opioid prescriptions attributable to an overweight or obese BMI was 16.2% (95% CI, 15.0%-17.4%). Prescription opioids for management of osteoarthritis (relative risk for obese vs normal weight, 1.90; 95% CI, 1.77-2.05) and other joint disorders (relative risk, 1.63; 95% CI, 1.55-1.72) both had stronger associations with obesity than the mean for any pain diagnosis (relative risk, 1.33; 95% CI, 1.31-1.36). Osteoarthritis, other joint disorders, and other back disorders comprised a combined 53.4% of the absolute difference in prescription of opioids by obesity. CONCLUSIONS AND RELEVANCE Joint and back disorders appear to be the most important diagnoses in explaining the increased receipt of opioid prescriptions among patients with obesity. Addressing the opioid crisis will require attention to underlying sources of demand for prescription opioids, including obesity, through its associations with pain.
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Affiliation(s)
- Andrew Stokes
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Dielle J. Lundberg
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | | | | | - Natalia E. Morone
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Karen E. Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Ludovic Trinquart
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Tuhina Neogi
- Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
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Kathuria H, Koppelman E, Borrelli B, Slatore CG, Clark JA, Lasser KE, Wiener RS. Patient-Physician Discussions on Lung Cancer Screening: A Missed Teachable Moment to Promote Smoking Cessation. Nicotine Tob Res 2020; 22:431-439. [PMID: 30476209 PMCID: PMC7297104 DOI: 10.1093/ntr/nty254] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 11/21/2018] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Little is known about whether patients and physicians perceive lung cancer screening (LCS) as a teachable moment to promote smoking cessation or the degree to which physicians in "real world" settings link LCS discussions with smoking cessation counseling. We sought to characterize patient and physician perspectives of discussions about smoking cessation during LCS. METHODS We conducted a qualitative study (interviews and focus groups) with 21 physicians and 28 smokers screened in four diverse hospitals. Transcripts were analyzed for characteristics of communication about smoking cessation and LCS, the perceived effect on motivation to quit smoking, the degree to which physicians leverage LCS as a teachable moment to promote smoking cessation, and suggestions to improve patient-physician communication about smoking cessation in the context of LCS. RESULTS Patients reported that LCS made them more cognizant of the health consequences of smoking, priming them for a teachable moment. While physicians and patients both acknowledged that smoking cessation counseling was frequent, they described little connection between their discussions regarding LCS and smoking cessation counseling. Physicians identified several barriers to integrating discussions on smoking cessation and LCS. They volunteered communication strategies by which LCS could be leveraged to promote smoking cessation. CONCLUSIONS LCS highlights the harms of smoking to patients who are chronic, heavy smokers and thus may serve as a teachable moment for promoting smoking cessation. However, this opportunity is typically missed in clinical practice. IMPLICATIONS LCS highlights the harms of smoking to heavily addicted smokers. Yet both physicians and patients reported little connection between LCS and tobacco treatment discussions due to multiple barriers. On-site tobacco treatment programs and post-screening messaging tailored to the LCS results are needed to maximize the health outcomes of LCS, including smoking quit rates and longer-term smoking-related morbidity and mortality.
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Affiliation(s)
- Hasmeena Kathuria
- The Pulmonary Center, Boston University School of Medicine, Boston, MA
| | - Elisa Koppelman
- Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Bedford, MA
- Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Belinda Borrelli
- Henry M. Goldman School of Dental Medicine, Boston University, Boston, MA
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
| | - Jack A Clark
- Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Bedford, MA
- Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, MA
- Community Health Sciences, Boston University School of Public Health, Boston, MA
| | - Renda Soylemez Wiener
- The Pulmonary Center, Boston University School of Medicine, Boston, MA
- Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Bedford, MA
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25
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Lee KS, Quintiliani L, Heinz A, Johnson NL, Xuan Z, Truong V, Lasser KE. A financial incentive program to improve appointment attendance at a safety-net hospital-based primary care hepatitis C treatment program. PLoS One 2020; 15:e0228767. [PMID: 32045447 PMCID: PMC7012423 DOI: 10.1371/journal.pone.0228767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 01/23/2020] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Hepatitis C (HCV) infection is a significant health threat, with increasing incidence rates in the setting of the opioid crisis. Many patients miss appointments and cannot initiate treatment. We implemented financial incentives to improve appointment attendance in a primary care-based HCV treatment setting. METHODS We conducted a systems-level financial incentives intervention at the Adult Primary Care HCV Treatment Program at Boston Medical Center which provides care to many patients with substance use disorders. From April 1 to June 30, 2017, we provided a $15 gift card to patients who attended appointments with an HCV treatment provider. We evaluated the effectiveness of the incentives by 1) conducting a monthly interrupted time series analysis to assess trends in attendance January 2016-September 2017; and 2) comparing the proportion of attended appointments during the intervention to a historical comparison group in the previous year, April 1 to June 30, 2016. RESULTS 327 visits were scheduled over the study period; 198 during the intervention and 129 during the control period. Of patient visits in the intervention group, 72.7% were attended relative to 61.2% of comparison group visits (p = 0.03). Appointments in the intervention group were more likely to be attended (adjusted odds ratio 1.94, 95% confidence interval 1.16-3.24). Interrupted time series analysis showed that the intervention was associated with an average increase of 15.4 attended visits per 100 appointments scheduled, compared to the period prior to the intervention (p = 0.01). CONCLUSIONS Implementation of a financial incentive program was associated with improved appointment attendance at a safety-net hospital-based primary care HCV treatment program. A randomized trial to establish efficacy and broader implementation potential is warranted.
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Affiliation(s)
- Kristen S. Lee
- Boston University School of Medicine, Boston, Massachusetts, United States of America
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
| | - Lisa Quintiliani
- Boston University School of Medicine, Boston, Massachusetts, United States of America
- Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Alexandra Heinz
- Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Natrina L. Johnson
- Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Ziming Xuan
- Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Ve Truong
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Karen E. Lasser
- Boston University School of Medicine, Boston, Massachusetts, United States of America
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, United States of America
- Boston University School of Public Health, Boston, Massachusetts, United States of America
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26
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Jones EA, Linas BP, Truong V, Burgess JF, Lasser KE. Budgetary impact analysis of a primary care-based hepatitis C treatment program: Effects of 340B Drug Pricing Program. PLoS One 2019; 14:e0213745. [PMID: 30870475 PMCID: PMC6417774 DOI: 10.1371/journal.pone.0213745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/27/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Safety-net health systems, which serve a disproportionate share of patients at high risk for hepatitis C virus (HCV) infection, may use revenue generated by the federal drug discount pricing program, known as 340B, to support multidisciplinary care. Budgetary impacts of repealing the drug-pricing program are unknown. Our objective was to conduct a budgetary impact analysis of a multidisciplinary primary care-based HCV treatment program, with and without 340B support. METHODS We conducted a budgetary impact analysis from the perspective of a large safety-net medical center in Boston, Massachusetts. Participants included 302 HCV-infected patients (mean age 45, 75% male, 53% white, 77% Medicaid) referred to the primary care-based HCV treatment program from 2015-2016. Main measures included costs and revenues associated with the treatment program. Our main outcomes were net cost with and without 340B Drug Pricing support. RESULTS Total program costs were $942,770, while revenues totaled $1.2 million. With the 340B Drug Pricing Program the hospital received a net revenue of $930 per patient referred to the HCV treatment program. In the absence of the 340B program, the hospital would lose $370 per patient referred. Ninety-seven percent (68/70) of patients who initiated treatment in the program achieved a sustained virologic response (SVR) at a net cost of $4,150 each, among this patient subset. CONCLUSIONS The 340B Drug Pricing Program enabled a safety-net hospital to deliver effective primary care-based HCV treatment using a multidisciplinary care team. Efforts to sustain the 340B program could enable dissemination of similar HCV treatment models elsewhere.
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Affiliation(s)
- Eric A. Jones
- Boston University, School of Public Health, Boston, MA, United States of America
| | - Benjamin P. Linas
- Boston University, School of Medicine, Boston, MA, United States of America
| | - Ve Truong
- Boston Medical Center, Section of General Internal Medicine, Boston, MA, United States of America
| | - James F. Burgess
- Boston University, School of Public Health, Boston, MA, United States of America
| | - Karen E. Lasser
- Boston University, School of Medicine, Boston, MA, United States of America
- Boston Medical Center, Section of General Internal Medicine, Boston, MA, United States of America
- * E-mail:
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Jia J, Quintiliani L, Truong V, Jean C, Branch J, Lasser KE. A community-based diabetes group pilot incorporating a community health worker and photovoice methodology in an urban primary care practice. Cogent Medicine 2019. [DOI: 10.1080/2331205x.2019.1567973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Jenny Jia
- General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Lisa Quintiliani
- General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Ve Truong
- General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Cheryl Jean
- General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Jerome Branch
- General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Karen E. Lasser
- General Internal Medicine, Boston Medical Center, Boston, MA, USA
- School of Public Health, Boston University, Boston, MA, USA
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28
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Mickle K, Lasser KE, Hoch JS, Cipriano LE, Dreitlein WB, Pearson SD. The Effectiveness and Value of Patisiran and Inotersen for Hereditary Transthyretin Amyloidosis. J Manag Care Spec Pharm 2019; 25:10-15. [PMID: 30589627 PMCID: PMC10398025 DOI: 10.18553/jmcp.2019.25.1.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES Funding for this summary was contributed by the Laura and John Arnold Foundation, Blue Shield of California, and California Health Care Foundation to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, AHIP, Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, Cambia Health Solutions, United Healthcare, Kaiser Permanente, Premera Blue Cross, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Prime Therapeutics, Sanofi, Spark Therapeutics, Health Care Service Corporation, Editas, Alnylam, Regeneron, Mallinkrodt, Biogen, HealthPartners, and Novartis. Mickle, Dreitlein, and Pearson are ICER employees. Lasser, Cipriano, and Hoch have nothing to disclose.
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Affiliation(s)
- Kristin Mickle
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | | | - Jeffrey S. Hoch
- Center for Healthcare Policy and Research, University of California, Davis
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Essien UR, Molina RL, Lasser KE. Strengthening the postpartum transition of care to address racial disparities in maternal health. J Natl Med Assoc 2018; 111:349-351. [PMID: 30503575 DOI: 10.1016/j.jnma.2018.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/15/2018] [Accepted: 10/29/2018] [Indexed: 11/29/2022]
Abstract
Maternal morbidity and mortality, important indicators of healthcare quality both nationally and internationally, have gained increasing public attention in the United States (U.S.). The U.S. has the highest rate of maternal mortality among high-income countries; notably, this rate has more than doubled since 1990. Black women in the U.S. die at three to four times the rate of white women from pregnancy-related complications, one of the widest of all racial disparities in women's health. Medical complications, including cardiovascular disease and hypertensive disorders in pregnancy, remain leading contributors to disparities in maternal outcomes including pregnancy-related deaths. However, an under-explored opportunity for improvement is the failure to transition from obstetrical to primary care, which limits optimizing postpartum health. Health system approaches, community-based interventions, and policy solutions that facilitate transitions of care may be critical to eliminating persistent disparities in maternal outcomes.
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Affiliation(s)
- Utibe R Essien
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Rose L Molina
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, MA, USA
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Pace CA, Gergen-Barnett K, Veidis A, D'Afflitti J, Worcester J, Fernandez P, Lasser KE. Warm Handoffs and Attendance at Initial Integrated Behavioral Health Appointments. Ann Fam Med 2018; 16:346-348. [PMID: 29987084 PMCID: PMC6037516 DOI: 10.1370/afm.2263] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/26/2018] [Accepted: 04/06/2018] [Indexed: 11/09/2022] Open
Abstract
Though integrated behavioral health programs often encourage primary care physicians to refer patients by means of a personal introduction (warm handoff), data are limited regarding the benefits of warm handoffs. We conducted a retrospective study of adult primary care patients referred to behavioral health clinicians in an urban, safety-net hospital to investigate the association between warm handoffs and attendance rates at subsequent initial behavioral health appointments. In multivariable analyses, patients referred via warm handoffs were not more likely to attend initial appointments (OR = 0.96; 95% CI, 0.79-1.18; P = .71). A prospective study is necessary to confirm the role of warm handoffs.
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Affiliation(s)
- Christine A Pace
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Katherine Gergen-Barnett
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Alysa Veidis
- Commonwealth Care Alliance, Boston, Massachusetts
| | - Joanna D'Afflitti
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Jason Worcester
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Pedro Fernandez
- Department of Psychiatry, University of Texas Southwestern, Dallas, Texas
| | - Karen E Lasser
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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31
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Wiener RS, Koppelman E, Bolton R, Lasser KE, Borrelli B, Au DH, Slatore CG, Clark JA, Kathuria H. Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study. J Gen Intern Med 2018; 33:1035-1042. [PMID: 29468601 PMCID: PMC6025674 DOI: 10.1007/s11606-018-4350-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/29/2017] [Accepted: 01/18/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Guidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings. OBJECTIVE To characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making. DESIGN Qualitative study entailing semi-structured interviews and focus groups. PARTICIPANTS We enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net). APPROACH Using content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making. KEY RESULTS Clinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making. CONCLUSIONS Due to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening's rationale, trade-offs, and process.
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Affiliation(s)
- Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA. .,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.
| | - Elisa Koppelman
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Rendelle Bolton
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA.,The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Karen E Lasser
- Boston University School of Public Health, Boston, MA, USA.,Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Belinda Borrelli
- Henry M. Goldman School of Dental Medicine, Boston University, Boston, MA, USA
| | - David H Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jack A Clark
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Hasmeena Kathuria
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
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Lasser KE, Hanchate AD, McCormick D, Walley AY, Saitz R, Lin M, Kressin NR. Massachusetts Health Reform's Effect on Hospitalizations with Substance Use Disorder-Related Diagnoses. Health Serv Res 2018; 53:1727-1744. [PMID: 28523674 PMCID: PMC5980373 DOI: 10.1111/1475-6773.12710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine whether Massachusetts (MA) health reform affected substance (alcohol or drug) use disorder (SUD)-related hospitalizations in acute care hospitals. DATA/STUDY SETTING 2004-2010 MA inpatient discharge data. DESIGN Difference-in-differences analysis to identify pre- to postreform changes in age- and sex-standardized population-based rates of SUD-related medical and surgical hospitalizations, adjusting for secular trends. DATA EXTRACTION METHODS We identified 373,751 discharges where a SUD-related diagnosis was a primary or secondary discharge diagnosis. FINDINGS Adjusted for age and sex, the rates of drug use-related and alcohol use-related hospitalizations prereform were 7.21 and 8.87 (per 1,000 population), respectively, in high-uninsurance counties, and 8.58 and 9.63, respectively, in low-uninsurance counties. Both SUD-related rates increased after health reform in high- and low-uninsurance counties. Adjusting for secular trends in the high- and low-uninsurance counties, health reform was associated with no change in drug- or alcohol-related hospitalizations. CONCLUSIONS Massachusetts health reform was not associated with any changes in substance use disorder-related hospitalizations. Further research is needed to determine how to reduce substance use disorder-related hospitalizations, beyond expanding insurance coverage.
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Affiliation(s)
- Karen E. Lasser
- Section of General Internal MedicineBoston University School of MedicineBostonMA
- Department of Community Health SciencesBoston University School of Public HealthBostonMA
| | - Amresh D. Hanchate
- Section of General Internal MedicineBoston University School of MedicineBostonMA
- VA Boston Healthcare SystemBostonMA
| | - Danny McCormick
- Harvard Medical SchoolDepartment of MedicineCambridge Health AllianceCambridgeMA
| | - Alexander Y. Walley
- Section of General Internal MedicineBoston University School of MedicineBostonMA
| | - Richard Saitz
- Section of General Internal MedicineBoston University School of MedicineBostonMA
- Department of Community Health SciencesBoston University School of Public HealthBostonMA
| | - Meng‐Yun Lin
- Section of General Internal MedicineBoston University School of MedicineBostonMA
- Department of Health Law, Policy & ManagementBoston University School of Public HealthBostonMA
| | - Nancy R. Kressin
- Section of General Internal MedicineBoston University School of MedicineBostonMA
- VA Boston Healthcare SystemBostonMA
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Lasser KE, Lunze K, Cheng DM, Blokhina E, Walley AY, Tindle HA, Quinn E, Gnatienko N, Krupitsky E, Samet JH. Depression and smoking characteristics among HIV-positive smokers in Russia: A cross-sectional study. PLoS One 2018; 13:e0189207. [PMID: 29408935 PMCID: PMC5800551 DOI: 10.1371/journal.pone.0189207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 11/21/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Globally, persons with HIV infection, depression and substance use disorders have a higher smoking prevalence and smoke more heavily than other populations. These associations have not been explored among Russian smokers with HIV infection and substance use disorders. The purpose of this study was to examine the relationship between the presence of depressive symptoms and smoking outcomes in an HIV-positive cohort of Russian smokers with a history of substance use disorders (alcohol and/or drug use disorders). METHODS We performed a cross-sectional secondary data analysis of a cohort of HIV-positive regular smokers with a history of substance use disorders recruited in St. Petersburg, Russia in 2012-2015. The primary outcome was heavy smoking, defined as smoking > 20 cigarettes per day. Nicotine dependence (moderate-very high) was a secondary outcome. The main independent variable was a high level of depressive symptoms in the past 7 days (defined as CES-D > = 24). We used multivariable logistic regression to examine associations between depressive symptoms and the outcomes, controlling for age, sex, education, income, running out of money for housing/food, injection drug use, and alcohol use measured by the AUDIT. RESULTS Among 309 regular smokers, 79 participants (25.6%) had high levels of depressive symptoms, and 65 participants (21.0%) were heavy smokers. High levels of depressive symptoms were not significantly associated with heavy smoking (adjusted odds ratio [aOR] 1.50, 95% CI 0.78-2.89) or with moderate-very high levels of nicotine dependence (aOR 1.35, 95% CI 0.75-2.41). CONCLUSIONS This study did not detect an association between depressive symptoms and smoking outcomes among HIV-positive regular smokers in Russia.
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Affiliation(s)
- Karen E. Lasser
- Department of Medicine, Section of General Internal Medicine, Boston University Schools of Medicine and Public Health/Boston Medical Center, Boston, Massachusetts, United States of America
| | - Karsten Lunze
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, United States of America
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Elena Blokhina
- First St. Petersburg Pavlov State Medical University, St. Petersburg, Russian Federation
| | - Alexander Y. Walley
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, United States of America
| | - Hilary A. Tindle
- The Vanderbilt Center for Tobacco, Addiction, and Lifestyle, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Emily Quinn
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Natalia Gnatienko
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction and Research Education Unit, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Evgeny Krupitsky
- First St. Petersburg Pavlov State Medical University, St. Petersburg, Russian Federation
- St. Petersburg Bekhterev Research Psychoneurological Institute, St. Petersburg, Russian Federation
| | - Jeffrey H. Samet
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, United States of America
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Liebschutz JM, Lange AV, Heymann OD, Lasser KE, Corey P, Shanahan CW, Kopinski HS, Husain JM, Cushman PA, Parker VA. Communication between nurse care managers and patients who take opioids for chronic pain: Strategies for exploring aberrant behavior. J Opioid Manag 2018; 14:191-202. [PMID: 30044484 DOI: 10.5055/jom.2018.0449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE One approach to potential misuse of prescription opioids by patients with chronic pain is team-based collaborative primary care, with primary care visits complemented by frequent visits with nurse care managers (NCMs) specializing in addiction care. However, little is known about the communication strategies NCMs employ in these visits. This study aimed to describe strategies NCMs used with patients when discussing aberrancies encountered during opioid monitoring. DESIGN Observational study of NCM-patient interactions. Patients' primary care providers had been randomized to the treatment arm of a study evaluating an intervention, of which NCM visits were part, to change opioid prescribing patterns. The overall intervention was found to be successful. SETTING Four primary care settings. PARTICIPANTS Two NCMs and 41 patients. MAIN OUTCOME MEASURE Forty one interactions between two NCMs and 41 unique patients were directly observed, and the detailed field notes coded for strategies using conventional content analysis. RESULTS Five themes describing strategies that NCMs use to navigate aberrant patient behavior emerged: (1) NCM develops therapeutic relationship with patient; (2) NCM encourages adherence to monitoring strategies by contextualizing intensive opioid management for patient; (3) NCM inquires into discrepancies between patient's narrative and objective data to further understand aberrancy; (4) NCM assesses patient's medication use and pain to obtain more information about aberrancy and determine risk for opioid misuse; and (5) NCM educates patient and makes recommendations to guide appropriate medication use. CONCLUSIONS These findings provide a potential model for the replication of intensive care management strategies utilizing NCMs in primary care.
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Affiliation(s)
- Jane M Liebschutz
- Visiting Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Associate Professor of Medicine, Department of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts
| | - Allison V Lange
- Resident, Department of Internal Medicine, UTSouthwestern Medical Center, San Antonio, Texas
| | - Orlaith D Heymann
- Doctoral Student, Department of Sociology, University of Cincinnati, Cincinnati, Ohio
| | - Karen E Lasser
- Associate Professor of Medicine, Department of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts; Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Pamela Corey
- Nurse Educator, Department of Nursing, Boston Medical Center, Boston, Massachusetts
| | - Christopher W Shanahan
- Assistant Professor of Medicine, Department of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts
| | | | - Jawad M Husain
- Resident, Department of Psychiatry, Boston Medical Center, Boston, Massachusetts
| | - Phoebe A Cushman
- Assistant Professor of Medicine, Division of General Internal Medicine, UMass Memorial Health Care, Worcester, Massachusetts
| | - Victoria A Parker
- Associate Professor of Management, Department of Management, Peter T. Paul College of Business and Economics, University of New Hampshire, Durham, New Hampshire
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Fleurant M, Lasser KE, Quintiliani LM, Liebschutz J. Group Self-Reflection to Address Burnout: A Facilitator's Guide. MedEdPORTAL 2017; 13:10663. [PMID: 30800863 PMCID: PMC6338134 DOI: 10.15766/mep_2374-8265.10663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/10/2017] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Inadequately supported clinicians risk burnout, which is prevalent among them. Balint-like groups can be utilized to address clinician stressors and augment interpersonal skills by exploring the clinician-patient relationship. METHODS In January 2012, we initiated the Clinical Case Discussion Group (CCDG), based on Michael Balint's Balint group, at the Boston University School of Medicine Section of General Internal Medicine. The CCDG is an interprofessional group discussion founded on self-reflection of patient cases designed to tease out ethical, psychosocial, and medical issues that impact the clinician-patient relationship. The format consists of a facilitator-led small group session including 5-10 minutes of case discussion followed by open group discussion. In April 2014, we conducted a cross-sectional survey of clinicians who participated in the CCDG to evaluate the group's ability to foster skills in self-reflection, empathy, response to patient challenges, personal awareness, and tolerance of uncertainty, and to address clinicians' personal and professional stressors. RESULTS More than 75% of clinicians surveyed agreed that participation fostered skills in tolerating uncertainty, increasing empathy, and navigating difficult patient relationships. All respondents agreed the group developed skills in self-reflection. At least 40% of clinicians reported some degree of isolation, professional stress, and personal stress; group participation addressed these issues at least 70% of the time. DISCUSSION This self-reflection case discussion group, incorporated into academic clinical practice, supports the professional development of a broad cadre of clinicians and addresses both personal and professional stressors. Clinical departments should consider systematically implementing similar groups in practice.
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Affiliation(s)
- Marshall Fleurant
- Assistant Professor of Medicine, Grady Section, Department of General Medicine and Geriatrics, Emory University School of Medicine
- Assistant Professor of Medicine, Grady Memorial Hospital
| | - Karen E. Lasser
- Associate Professor of Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine
- Associate Professor of Medicine, Boston Medical Center
- Associate Professor of Medicine, Boston University School of Public Health
| | - Lisa M. Quintiliani
- Assistant Professor of Medicine, Department of Community Health Sciences, Boston University School of Public Health
| | - Jane Liebschutz
- Associate Professor of Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine
- Associate Professor of Medicine, Boston Medical Center
- Associate Professor of Medicine, Boston University School of Public Health
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Lasser KE, Quintiliani LM, Truong V, Xuan Z, Murillo J, Jean C, Pbert L. Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:1798-1807. [PMID: 29084312 PMCID: PMC5820724 DOI: 10.1001/jamainternmed.2017.4372] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE While the proportion of adults who smoke cigarettes has declined substantially in the past decade, socioeconomic disparities in cigarette smoking remain. Few interventions have targeted low socioeconomic status (SES) and minority smokers in primary care settings. OBJECTIVE To evaluate a multicomponent intervention to promote smoking cessation among low-SES and minority smokers. DESIGN, SETTING, AND PARTICIPANTS For this prospective, unblinded, randomized clinical trial conducted between May 1, 2015, and September 4, 2017, adults 18 years and older who spoke English, smoked 10 or more cigarettes per day in the past week, were contemplating or preparing to quit smoking, and had a primary care clinician were recruited from general internal medicine and family medicine practices at 1 large safety-net hospital in Boston, Massachusetts. INTERVENTIONS Patients were randomized to a control group that received an enhancement of usual care (n = 175 participants) or to an intervention group that received up to 4 hours of patient navigation delivered over 6 months in addition to usual care, as well as financial incentives for biochemically confirmed smoking cessation at 6 and 12 months following enrollment (n = 177 participants). MAIN OUTCOMES AND MEASURES The primary outcome determined a priori was biochemically confirmed smoking cessation at 12 months. RESULTS Among 352 patients who were randomized (mean [SD] age, 50.0 [11.0] years; 191 women [54.3%]; 197 participants who identified as non-Hispanic black [56.0%]; 40 participants who identified as Hispanic of any race [11.4%]), all were included in the intention-to-treat analysis. At 12 months following enrollment, 21 participants [11.9%] in the navigation and incentives group, compared with 4 participants [2.3%] in the control group, had quit smoking (odds ratio, 5.8; 95% CI, 1.9-17.1; number needed to treat, 10.4; P < .001). In prespecified subgroup analyses, the intervention was particularly beneficial for older participants (19 [19.8%] vs 1 [1.0%]; P < .001), women (17 [16.8%] vs 2 [2.2%]; P < .001), participants with household yearly income of $20 000 or less (15 [15.5%] vs 3 [3.1%]; P = .003), and nonwhite participants (21 [15.2%] vs 4 [3.0%]; P < .001). CONCLUSIONS AND RELEVANCE In this study of adult daily smokers at 1 large urban safety-net hospital, patient navigation and financial incentives for smoking cessation significantly increased the rates of smoking cessation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02351609.
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Affiliation(s)
- Karen E Lasser
- Boston University, School of Medicine, Section of General Internal Medicine, Crosstown Center, Boston, Massachusetts.,Boston University, School of Public Health, Department of Community Health Sciences, Crosstown Center, Boston, Massachusetts.,Boston Medical Center, Section of General Internal Medicine, Crosstown Center, Boston, Massachusetts
| | - Lisa M Quintiliani
- Boston University, School of Medicine, Section of General Internal Medicine, Crosstown Center, Boston, Massachusetts.,Boston University, School of Public Health, Department of Community Health Sciences, Crosstown Center, Boston, Massachusetts
| | - Ve Truong
- Boston Medical Center, Section of General Internal Medicine, Crosstown Center, Boston, Massachusetts
| | - Ziming Xuan
- Boston University, School of Public Health, Department of Community Health Sciences, Crosstown Center, Boston, Massachusetts
| | - Jennifer Murillo
- Boston Medical Center, Section of General Internal Medicine, Crosstown Center, Boston, Massachusetts
| | - Cheryl Jean
- Bridge Over Troubled Waters, Boston, Massachusetts
| | - Lori Pbert
- University of Massachusetts Medical School, Division of Preventive and Behavioral Medicine, Department of Medicine, Worcester
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37
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Affiliation(s)
- Karen E Lasser
- From Boston Medical Center and Boston University School of Medicine and School of Public Health, Boston, Massachusetts
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38
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Liebschutz JM, Xuan Z, Shanahan CW, LaRochelle M, Keosaian J, Beers D, Guara G, O'Connor K, Alford DP, Parker V, Weiss RD, Samet JH, Crosson J, Cushman PA, Lasser KE. Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial. JAMA Intern Med 2017; 177:1265-1272. [PMID: 28715535 PMCID: PMC5710574 DOI: 10.1001/jamainternmed.2017.2468] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. OBJECTIVE To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices. INTERVENTIONS Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. MAIN OUTCOMES AND MEASURES Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language. RESULTS Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). CONCLUSIONS AND RELEVANCE A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01909076.
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Affiliation(s)
- Jane M Liebschutz
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Ziming Xuan
- Boston University School of Public Health, Boston, Massachusetts
| | - Christopher W Shanahan
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Marc LaRochelle
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Julia Keosaian
- Boston University School of Public Health, Boston, Massachusetts
| | - Donna Beers
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - George Guara
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Kristen O'Connor
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Daniel P Alford
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Victoria Parker
- Boston University School of Public Health, Boston, Massachusetts
| | - Roger D Weiss
- McLean Hospital, Belmont, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jeffrey H Samet
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
| | - Julie Crosson
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Dorchester House Community Health Center, Boston, Massachusetts
| | - Phoebe A Cushman
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
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Lasser KE, Heinz A, Battisti L, Akoumianakis A, Truong V, Tsui J, Ruiz G, Samet JH. A Hepatitis C Treatment Program Based in a Safety-Net Hospital Patient-Centered Medical Home. Ann Fam Med 2017; 15:258-261. [PMID: 28483892 PMCID: PMC5422088 DOI: 10.1370/afm.2069] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/12/2016] [Accepted: 12/30/2016] [Indexed: 11/09/2022] Open
Abstract
Hepatitis C virus (HCV) infection is a major public health problem. Urban safety-net hospitals are a prime location for HCV treatment delivery. Showing that physicians in primary care settings can deliver HCV infection care is important to expand treatment; models doing so in the era of newer oral HCV medications are needed. This article describes an innovative and successful HCV primary care treatment program in a patient-centered medical home based at an urban, safety-net hospital. The program is public health oriented in that a central team member is a public health social worker who performs population management and addresses underlying social determinants of health to facilitate engagement in HCV treatment. Other team members include general internists trained to treat HCV infections, a pharmacist, and a pharmacy technician. The program is funded with revenue generated by the 340b drug discount program, which allows providers to generate revenue when patients fill prescriptions at pharmacies in safety-net settings, as insurance reimbursements for medications exceed the cost at which safety-net providers purchase medications. During the course of 1 year, the program received 302 referrals. Of these approximately 23% have received treatment.
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Affiliation(s)
- Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts .,Boston University Schools of Medicine and Public Health, Boston, Massachusetts.,Boston Medical Center, Boston, Massachusetts
| | | | | | | | - Ve Truong
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Judith Tsui
- Division of General Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | | | - Jeffrey H Samet
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University Schools of Medicine and Public Health, Boston, Massachusetts.,Boston Medical Center, Boston, Massachusetts
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40
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Tikkanen RS, Woolhandler S, Himmelstein DU, Kressin NR, Hanchate A, Lin MY, McCormick D, Lasser KE. Hospital Payer and Racial/Ethnic Mix at Private Academic Medical Centers in Boston and New York City. Int J Health Serv 2017; 47:460-476. [PMID: 28152644 DOI: 10.1177/0020731416689549] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Academic medical centers (AMCs) are widely perceived as providing the highest-quality medical care. To investigate disparities in access to such care, we studied the racial/ethnic and payer mixes at private AMCs of New York City (NYC) and Boston, two cities where these prestigious institutions play a dominant role in the health care system. We used individual-level inpatient discharge data for acute care hospitals to examine the degree of hospital racial/ethnic and insurance segregation in both cities using the Index of Dissimilarity, together with recent changes in patterns of care in NYC. In multivariable logistic regression analyses, black patients in NYC were two to three times less likely than whites, and uninsured patients approximately five times less likely than privately insured patients, to be discharged from AMCs. In Boston, minorities were overrepresented at AMCs relative to other hospitals. NYC hospitals were more segregated overall according to race/ethnicity and insurance than Boston hospitals, and insurance segregation became more pronounced in NYC after the Affordable Care Act. Although health reform improved access to insurance, access to AMCs remains limited for disadvantaged populations, which may undermine the quality of care available to these groups.
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Affiliation(s)
| | - Steffie Woolhandler
- 1 Hunter College, City University of New York, New York, USA.,6 Harvard Medical School, Boston, Massachusetts, USA.,7 Cambridge Health Alliance, Cambridge, Massachusetts, USA
| | - David U Himmelstein
- 1 Hunter College, City University of New York, New York, USA.,6 Harvard Medical School, Boston, Massachusetts, USA.,7 Cambridge Health Alliance, Cambridge, Massachusetts, USA
| | - Nancy R Kressin
- 2 Boston Medical Center, Crosstown Center, Boston, Massachusetts, USA.,3 Boston University School of Medicine, Boston, Massachusetts, USA.,4 Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA
| | - Amresh Hanchate
- 3 Boston University School of Medicine, Boston, Massachusetts, USA.,4 Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA
| | - Meng-Yun Lin
- 2 Boston Medical Center, Crosstown Center, Boston, Massachusetts, USA.,5 Boston University School of Public Health, Boston, Massachusetts, USA
| | - Danny McCormick
- 6 Harvard Medical School, Boston, Massachusetts, USA.,7 Cambridge Health Alliance, Cambridge, Massachusetts, USA
| | - Karen E Lasser
- 2 Boston Medical Center, Crosstown Center, Boston, Massachusetts, USA.,3 Boston University School of Medicine, Boston, Massachusetts, USA
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Calderwood AH, Lasser KE, Roy HK. Colon adenoma features and their impact on risk of future advanced adenomas and colorectal cancer. World J Gastrointest Oncol 2016; 8:826-834. [PMID: 28035253 PMCID: PMC5156849 DOI: 10.4251/wjgo.v8.i12.826] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 11/02/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To review the evidence on the association between specific colon adenoma features and the risk of future colonic neoplasia [adenomas and colorectal cancer (CRC)].
METHODS We performed a literature search using the National Library of Medicine through PubMed from 1/1/2003 to 5/30/2015. Specific Medical Subject Headings terms (colon, colon polyps, adenomatous polyps, epidemiology, natural history, growth, cancer screening, colonoscopy, CRC) were used in conjunction with subject headings/key words (surveillance, adenoma surveillance, polypectomy surveillance, and serrated adenoma). We defined non-advanced adenomas as 1-2 adenomas each < 10 mm in size and advanced adenomas as any adenoma ≥ 10 mm size or with > 25% villous histology or high-grade dysplasia. A combined endpoint of advanced neoplasia included advanced adenomas and invasive CRC.
RESULTS Our search strategy identified 592 candidate articles of which 8 met inclusion criteria and were relevant for assessment of histology (low grade vs high grade dysplasia, villous features) and adenoma size. Six of these studies met the accepted quality indicator threshold for overall adenoma detection rate > 25% among study patients. We found 254 articles of which 7 met inclusion criteria for the evaluation of multiple adenomas. Lastly, our search revealed 222 candidate articles of which 6 met inclusion criteria for evaluation of serrated polyps. Our review found that villous features, high grade dysplasia, larger adenoma size, and having ≥ 3 adenomas at baseline are associated with an increased risk of future colonic neoplasia in some but not all studies. Serrated polyps in the proximal colon are associated with an increased risk of future colonic neoplasia, comparable to having a baseline advanced adenoma.
CONCLUSION Data on adenoma features and risk of future adenomas and CRC are compelling yet modest in absolute effect size. Future research should refine this risk stratification.
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Florian J, Roy NMSO, Quintiliani LM, Truong V, Feng Y, Bloch PP, Russinova ZL, Lasser KE. Using Photovoice and Asset Mapping to Inform a Community-Based Diabetes Intervention, Boston, Massachusetts, 2015. Prev Chronic Dis 2016; 13:E107. [PMID: 27513998 PMCID: PMC4993113 DOI: 10.5888/pcd13.160160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Introduction Diabetes self-management takes place within a complex social and environmental context. This study’s objective was to examine the perceived and actual presence of community assets that may aid in diabetes control. Methods We conducted one 6-hour photovoice session with 11 adults with poorly controlled diabetes in Boston, Massachusetts. Participants were recruited from census tracts with high numbers of people with poorly controlled diabetes (diabetes “hot spots”). We coded the discussions and identified relevant themes. We further explored themes related to the built environment through community asset mapping. Through walking surveys, we evaluated 5 diabetes hot spots related to physical activity resources, walking environment, and availability of food choices in restaurants and food stores. Results Community themes from the photovoice session were access to healthy food, restaurants, and prepared foods; food assistance programs; exercise facilities; and church. Asset mapping identified 114 community assets including 22 food stores, 22 restaurants, and 5 exercise facilities. Each diabetes hot spot contained at least 1 food store with 5 to 9 varieties of fruits and vegetables. Only 1 of the exercise facilities had signage regarding hours or services. Memberships ranged from free to $9.95 per month. Overall, these findings were inconsistent with participants’ reports in the photovoice group. Conclusion We identified a mismatch between perceptions of community assets and built environment and the objective reality of that environment. Incorporating photovoice and community asset mapping into a community-based diabetes intervention may bring awareness to underused neighborhood resources that can help people control their diabetes.
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Affiliation(s)
- Jana Florian
- Boston Medical Center, Section of General Internal Medicine, 801 Massachusetts Ave, Crosstown No. 2094, Boston, MA 02119.
| | - Nicole M St Omer Roy
- Boston Medical Center, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Lisa M Quintiliani
- Boston Medical Center, Section of General Internal Medicine, Boston, Massachusetts
| | - Ve Truong
- Boston Medical Center, Section of General Internal Medicine, Boston, Massachusetts
| | - Yi Feng
- Boston Medical Center, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Philippe P Bloch
- Boston University, Center for Psychiatric Rehabilitation, Boston, Massachusetts
| | - Zlatka L Russinova
- Boston University, Center for Psychiatric Rehabilitation, Boston, Massachusetts
| | - Karen E Lasser
- Boston Medical Center, Section of General Internal Medicine, Boston, Massachusetts
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Hanchate AD, McCormick D, Lasser KE, Feng C, Manze MG, Kressin NR. Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net? Health Serv Res 2016; 52:1647-1666. [PMID: 27500666 DOI: 10.1111/1475-6773.12542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety-net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if Massachusetts health reform was associated with shifts in the volume of inpatient care from safety-net to non-safety-net hospitals overall, or among other vulnerable sociodemographic (racial/ethnic minority, low socioeconomic status, high uninsured rate area) and clinical subpopulations (emergent status, diagnosis). DATA SOURCES/STUDY SETTING Discharge records for adults discharged from all nonfederal acute care hospitals in Massachusetts, New Jersey, New York, and Pennsylvania 2004-2010. STUDY DESIGN Using a difference-in-differences design, we compared pre-/post-reform changes in safety-net and non-safety-net hospital discharge outcomes in Massachusetts among adults 18-64 with corresponding changes in comparisons states with no reform, overall, and by subpopulations. PRINCIPAL FINDINGS Reform was not associated with changes in inpatient care use at safety-net and non-safety-net hospitals across all discharges or in most subpopulations examined. CONCLUSIONS Demand for inpatient care at safety-net hospitals may not decrease following insurance expansion. Whether this is due to other access barriers or patient preference needs to be explored.
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Affiliation(s)
- Amresh D Hanchate
- VA Boston Healthcare System, Boston, MA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Danny McCormick
- Harvard Medical School, Department of Medicine, Cambridge Health Alliance, Cambridge, MA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Chen Feng
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Meredith G Manze
- City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, NY
| | - Nancy R Kressin
- VA Boston Healthcare System, Boston, MA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
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Woolhandler S, Himmelstein DU, Distajo R, Lasser KE, McCormick D, Bor DH, Wolfe SM. America's Neglected Veterans: 1.7 Million Who Served Have No Health Coverage. Int J Health Serv 2016; 35:313-23. [PMID: 15932009 DOI: 10.2190/upbq-c3rh-d367-5h9d] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Many U.S. military veterans lack health insurance and are ineligible for care in Veterans Administration health care facilities. Using two recently released national government surveys—the 2004 Current Population Survey and the 2002 National Health Interview Survey—the authors examined how many veterans are uninsured (lacking health insurance coverage and not receiving care from the VA) and whether uninsured veterans have problems in access to care. In 2003, 1.69 million military veterans neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics; the number of uninsured veterans increased by 235,159 since 2000. The proportion of nonelderly veterans who were uninsured rose from 9.9 percent in 2000 to 11.9 percent in 2003. An additional 3.90 million members of veterans' households were also uninsured and ineligible for VHA care. Medicare covered virtually all Korean War and World War II veterans, but 681,808 Vietnam-era veterans were uninsured (8.7 percent of the 7.85 million Vietnam-era vets). Among the 8.27 million veterans who served during “other eras” (including the Persian Gulf War), 12.1 percent (999,548) lacked health coverage. A disturbingly high number of veterans reported problems in obtaining needed medical care. By almost any measure, uninsured veterans had as much trouble getting medical care as other uninsured persons. Thus millions of U.S. veterans and their family members are uninsured and face grave difficulties in gaining access to even the most basic medical care.
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Park TW, Saitz R, Nelson KP, Xuan Z, Liebschutz JM, Lasser KE. The association between benzodiazepine prescription and aberrant drug-related behaviors in primary care patients receiving opioids for chronic pain. Subst Abus 2016; 37:516-520. [PMID: 27092738 DOI: 10.1080/08897077.2016.1179242] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Benzodiazepine use has been associated with addiction-related risks, but little is known about its association with aberrant drug-related behaviors in patients receiving opioids for chronic pain. The authors examined the association between receipt of a benzodiazepine prescription and 2 aberrant drug-related behaviors, early opioid refills and illicit drug (cocaine) use in patients receiving opioids for noncancer chronic pain. METHODS This was a retrospective cohort study of 847 patients with ≥1 visit to either a hospital-based primary care clinic or one of two community health centers between September 1, 2011, and August 31, 2012. All patients received ≥3 opioid prescriptions written at least 21 days apart within 6 months, and ≥1 urine drug screen during the study period. A Cox proportional hazards model estimated the hazard of a second early opioid refill, defined as an opioid prescription written 7-25 days after the previous prescription for the same drug, as a function of time-varying benzodiazepine prescription. A logistic regression model examined the relationship between benzodiazepine prescription and a positive urine test for cocaine. Models were adjusted for demographics and mental/substance use disorder diagnoses. RESULTS Twenty-three percent (n = 196) of patients received ≥1 benzodiazepine prescription during the study period. Twenty-two percent (n = 183) of patients had ≥2 early opioid refills, and 11% (n = 93) had ≥1 positive urine drug tests for cocaine. Receipt of benzodiazepine prescription was associated with an increased hazard of having a second early opioid refill, adjusted hazard ratio = 1.54 (95% confidence interval [CI]: 1.09-2.18), but not associated with a positive cocaine test, adjusted odds ratio = 1.07 (95% CI: 0.55-2.23). CONCLUSIONS Among primary care patients receiving chronic opioid therapy, benzodiazepine prescription was associated with early opioid refills but not with cocaine use. Further research should better elucidate the risks and benefits of prescribing benzodiazepines to patients receiving opioids for chronic pain.
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Affiliation(s)
- Tae Woo Park
- a Division of General Internal Medicine, Department of Medicine, Alpert Medical School and Rhode Island Hospital , Providence , Rhode Island , USA.,b Department of Psychiatry and Human Behavior , Alpert Medical School and Rhode Island Hospital , Providence , Rhode Island , USA
| | - Richard Saitz
- c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA.,d Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston , Massachusetts , USA
| | - Kerrie P Nelson
- e Department of Biostatistics , Boston University School of Public Health , Boston , Massachusetts , USA
| | - Ziming Xuan
- c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA
| | - Jane M Liebschutz
- d Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston , Massachusetts , USA
| | - Karen E Lasser
- c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA.,d Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston , Massachusetts , USA
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Quintiliani LM, Russinova ZL, Bloch PP, Truong V, Xuan Z, Pbert L, Lasser KE. Patient navigation and financial incentives to promote smoking cessation in an underserved primary care population: A randomized controlled trial protocol. Contemp Clin Trials 2015; 45:449-457. [PMID: 26362691 DOI: 10.1016/j.cct.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
Abstract
Despite the high risk of tobacco-related morbidity and mortality among low-income persons, few studies have connected low-income smokers to evidence-based treatments. We will examine a smoking cessation intervention integrated into primary care. To begin, we completed qualitative formative research to refine an intervention utilizing the services of a patient navigator trained to promote smoking cessation. Next, we will conduct a randomized controlled trial combining two interventions: patient navigation and financial incentives. The goal of the intervention is to promote smoking cessation among patients who receive primary care in a large urban safety-net hospital. Our intervention will encourage patients to utilize existing smoking cessation resources (e.g., quit lines, smoking cessation groups, discussing smoking cessation with their primary care providers). To test our intervention, we will conduct a randomized controlled trial, randomizing 352 patients to the intervention condition (patient navigation and financial incentives) or an enhanced traditional care control condition. We will perform follow-up at 6, 12, and 18 months following the start of the intervention. Evaluation of the intervention will target several implementation variables: reach (participation rate and representativeness), effectiveness (smoking cessation at 12 months [primary outcome]), unintended consequences (e.g., purchase of illicit substances with incentive money), adoption (use of intervention across primary care suites), implementation (delivery of intervention), and maintenance (smoking cessation after conclusion of intervention). Improving the implementation of smoking cessation interventions in primary care settings serving large underserved populations could have substantial public health impact, reducing cancer-related morbidity/mortality and associated health disparities.
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Affiliation(s)
- Lisa M Quintiliani
- Boston University, School of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown Center, 2nd Floor, Boston, MA 02118, USA; Boston University, School of Public Health, Department of Community Health Sciences, 801 Massachusetts Ave. Crosstown Center, 4th Floor, Boston, MA 02118, USA.
| | - Zlatka L Russinova
- Boston University, Center for Psychiatric Rehabilitation, 940 Commonwealth Ave., West, Boston, MA 02215, USA.
| | - Philippe P Bloch
- Boston University, Center for Psychiatric Rehabilitation, 940 Commonwealth Ave., West, Boston, MA 02215, USA.
| | - Ve Truong
- Boston University, School of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown Center, 2nd Floor, Boston, MA 02118, USA.
| | - Ziming Xuan
- Boston University, School of Public Health, Department of Community Health Sciences, 801 Massachusetts Ave. Crosstown Center, 4th Floor, Boston, MA 02118, USA.
| | - Lori Pbert
- University of Massachusetts Medical School, Department of Medicine, Division of Preventive and Behavioral Medicine, 55 Lake Ave. North, Worcester, MA 01655, USA.
| | - Karen E Lasser
- Boston University, School of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown Center, 2nd Floor, Boston, MA 02118, USA; Boston University, School of Public Health, Department of Community Health Sciences, 801 Massachusetts Ave. Crosstown Center, 4th Floor, Boston, MA 02118, USA.
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Lasser KE, Shanahan C, Parker V, Beers D, Xuan Z, Heymann O, Lange A, Liebschutz JM. A Multicomponent Intervention to Improve Primary Care Provider Adherence to Chronic Opioid Therapy Guidelines and Reduce Opioid Misuse: A Cluster Randomized Controlled Trial Protocol. J Subst Abuse Treat 2015; 60:101-9. [PMID: 26256769 DOI: 10.1016/j.jsat.2015.06.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/25/2015] [Accepted: 06/29/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prescription opioid misuse is a significant public health problem as well as a patient safety concern. Primary care providers (PCPs) are the leading prescribers of opioids for chronic pain, yet few PCPs follow standard practice guidelines regarding assessment and monitoring. This cluster randomized controlled trial will determine whether four implementation strategies; nurse care management, use of a patient registry, academic detailing, and electronic tools, will increase PCP adherence to chronic opioid therapy guidelines and reduce opioid misuse among patients, relative to electronic tools alone. The implementation strategies and intervention content are based on the chronic care model. METHODS We include 53 PCPs from three Boston-area community health centers and one urban safety-net hospital-based primary care practice who have at least four patients meeting the following inclusion criteria: 1) age≥18; 2) one or more completed visits to the primary care practice in the past year; 3) long-term opioid treatment defined as three or more opioid prescriptions written at least 21days apart within 6months and 4) an inpatient or outpatient ICD-9-CM diagnosis for musculoskeletal or neuropathic pain. We consider PCPs to be study subjects, and obtained a waiver of informed consent for patients because the study is promoting an established standard of care. We enrolled participants (PCPs) from December 2012 through March 2015. PCPs were randomized to receive the intervention, which includes four components: 1) nurse care management, 2) use of a patient registry, 3) academic detailing, and 4) electronic tools, or a control condition, which includes only the use of the electronic tools. The intervention PCPs receive the services of a nurse-managed registry for planning individual patient care and conducting population-based care for patients receiving opioids for chronic pain. In academic detailing visits, trained co-investigators provide intervention PCPs with individualized education to change prescribing practice. Electronic tools, located on a web site external to the EMR, www.mytopcare.org, include validated instruments to assess patient status, and management resources to facilitate PCP adherence to suggested monitoring. Electronic tools are available to PCPs in both study arms. The primary outcomes are PCP adherence to chronic opioid therapy guidelines and patient opioid misuse. Secondary outcomes include measures of substance abuse, possible opioid diversion, and level of opioid risk among patients. We will follow PCPs and their estimated 1200 chronic pain patients for 1year after study enrollment. To determine whether the intervention condition achieves greater adherence to guidelines and reduced opioid misuse after 1year compared to the control condition, we will compare the baseline and follow-up measures of the individual patients, stratifying by intervention status and noting differences that are statistically significant at the p=0.05 level. Analyses will be based on intent-to-treat. RESULTS Randomization resulted in groups with similar baseline characteristics. The ages of PCPs are evenly distributed, with inclusion of both PCPs who have recently completed training and those who have been in practice for more than 20years. Two-thirds of enrolled PCPs are women, and one-third are non-white. DISCUSSION The study will determine the impact of this multicomponent intervention on improving PCP adherence to guidelines and reducing opioid misuse among patients.
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Affiliation(s)
- Karen E Lasser
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA; Department of Community Health Sciences, Boston University School of Public Health.
| | - Christopher Shanahan
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Victoria Parker
- Department of Health Policy and Management, Boston University School of Public Health
| | - Donna Beers
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health
| | - Orlaith Heymann
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Allison Lange
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Jane M Liebschutz
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
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McCormick D, Hanchate AD, Lasser KE, Manze MG, Lin M, Chu C, Kressin NR. Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics. BMJ 2015; 350:h1480. [PMID: 25833157 PMCID: PMC4382709 DOI: 10.1136/bmj.h1480] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states. DESIGN Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform. SETTING Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States. PARTICIPANTS Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007). MAIN OUTCOME MEASURES Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs. RESULTS After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval -1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (-1.9%, -8.5% to 5.1%) or white and Hispanic people (2.0%, -7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, -2.3% to 5.3%). CONCLUSIONS Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions.
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Affiliation(s)
- Danny McCormick
- Harvard Medical School, Department of Medicine, Cambridge Health Alliance, 1493 Cambridge, MA 02139, USA
| | - Amresh D Hanchate
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Meredith G Manze
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Mengyun Lin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Chieh Chu
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Nancy R Kressin
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
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Hanchate AD, Kapoor A, Katz JN, McCormick D, Lasser KE, Feng C, Manze MG, Kressin NR. Massachusetts health reform and disparities in joint replacement use: difference in differences study. BMJ 2015; 350:h440. [PMID: 25700849 PMCID: PMC4353277 DOI: 10.1136/bmj.h440] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To estimate the impact of the insurance expansion in 2006 on use of knee and hip replacement procedures by race/ethnicity, area income, and the use of hospitals that predominantly serve poor people ("safety net hospitals"). DESIGN Quasi-experimental difference in differences study examining change after reform in the share of procedures performed in safety net hospitals by race/ethnicity and area income, with adjustment for patients' residence, demographics, and comorbidity. SETTING State of Massachusetts, United States. PARTICIPANTS Massachusetts residents aged 40-64 as the target beneficiaries of reform and similarly aged residents of New Jersey, New York, and Pennsylvania as the comparison (control) population. MAIN OUTCOMES MEASURES Number of knee and hip replacement procedures per 10 000 population and use of safety net hospitals. Procedure counts from state discharge data for 2.5 years before and after reform, and multivariate difference in differences. Poisson regression was used to adjust for demographics, economic conditions, secular time, and geographic factors to estimate the change in procedure rate associated with health reform by race/ethnicity and area income. RESULTS Before reform, the number of procedures (/10 000) in Massachusetts was lower among Hispanic people (12.9, P<0.001) than black people (28.1) and white people (30.1). Overall, procedure use increased 22.4% during the 2.5 years after insurance expansion; reform in Massachusetts was associated with a 4.7% increase. The increase associated with reform was significantly higher among Hispanic people (37.9%, P<0.001) and black people (11.4%, P<0.05) than among white people (2.8%). Lower income was not associated with larger increases in procedure use. The share of knee and hip replacement procedures performed in safety net hospitals in Massachusetts decreased by 1.0% from a level of 12.7% before reform. The reduction was larger among Hispanic people (-6.4%, P<0.001) than white people (-1.0%), and among low income residents (-3.9%, p<0.001) than high income residents (0%). CONCLUSIONS Insurance expansion can help reduce disparities by race/ethnicity but not by income in access to elective surgical care and could shift some elective surgical care away from safety net hospitals.
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Affiliation(s)
- Amresh D Hanchate
- VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
| | - Alok Kapoor
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Jeffrey N Katz
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA USA
| | - Danny McCormick
- Cambridge Health Alliance and Harvard Medical School, Cambridge, MA, USA
| | - Karen E Lasser
- Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Chen Feng
- Boston Medical Center, Boston, MA, USA
| | - Meredith G Manze
- City University of New York, School of Public Health, New York, NY, USA
| | - Nancy R Kressin
- VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
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Khalid L, Liebschutz JM, Xuan Z, Dossabhoy S, Kim Y, Crooks D, Shanahan C, Lange A, Heymann O, Lasser KE. Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med 2014; 16:480-7. [PMID: 25529863 DOI: 10.1111/pme.12602] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to compare adherence to opioid prescribing guidelines and potential opioid misuse in patients of resident vs attending physicians. DESIGN Retrospective cross-sectional study. SETTING Large primary care practice at a safety net hospital in New England. SUBJECTS Patients 18-89 years old, with at least one visit to the primary care clinic within the past year and were prescribed long-term opioid treatment for chronic noncancer pain. METHODS Data were abstracted from the electronic medical record by a trained data analyst through a clinical data warehouse. The primary outcomes were adherence to any one of two American Pain Society Guidelines: (1) documentation of at least one opioid agreement (contract) ever and (2) any urine drug testing in the past year, and evidence of potential prescription misuse defined as ≥2 early refills. We employed logistic regression analysis to assess whether patients' physician status predicts guideline adherence and/or potential opioid misuse. RESULTS Similar proportions of resident and attending patients had a controlled substance agreement (45.1% of resident patients vs. 42.4% of attending patient, P = 0.47) or urine drug testing (58.6% of resident patients vs. 63.6% of attending patients, P = 0.16). Resident patients were more likely to have two or more early refills in the past year relative to attending patients (42.8% vs. 32.5%; P = 0.004). In the adjusted regression analysis, resident patients were more likely to receive early refills (odds ratio 1.82, 95% confidence interval 1.26-2.62) than attending patients. CONCLUSIONS With some variability, residents and attending physicians were only partly compliant with national guidelines. Residents were more likely to manage patients with a higher likelihood of opioid misuse.
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Affiliation(s)
- Laila Khalid
- Section of General Internal Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, Massachusetts, USA
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