Association Between Process-Based Quality Indicators and Mortality for Patients With Substance Use Disorders

OBJECTIVE

Substance use disorders (SUDs) are associated with elevated rates of mortality. Little is known about whether receiving appropriate care is associated with lower mortality for patients with SUDs. This study examined the association between the receipt of care for SUDs and subsequent 12- and 24-month mortality.

METHOD

This was a retrospective cohort study of veterans who received care for SUDs paid for by the Veterans Health Administration during October 2006- September 2007 (n = 339,966). Logistic regressions were used to examine the association between quality indicators measuring receipt of care and mortality while controlling for patient characteristics and facility service area.

RESULTS

There were four quality indicators: SUD treatment initiation, SUD treatment engagement, SUD-related psychosocial treatment, and SUD-related psychotherapy. Outcomes measured were mortality 12 and 24 months after the end of the observation period, through September 2009. Receipt of indicated care ranged from 26.5% to 58.6%, and 12- and 24-month mortality rates were 3% and 6%, respectively. Adjusted odds ratios [95% CI] of 12-month mortality by indicator were: initiation, 0.86 [0.79, 0.93]; engagement, 0.65 [0.58, 0.74]; psychosocial treatment, 0.88 [0.84, 0.92]; and psychotherapy, 0.84 [0.79, 0.89]. For the 24-month mortality outcome, adjusted odds ratios were: initiation, 0.88 [0.84, 0.93]; engagement, 0.78 [0.71, 0.85]; psychosocial treatment, 0.91 [0.88, 0.94]; and psychotherapy, 0.87 [0.83, 0.91]. Results were similar when controlling for facility service area.

CONCLUSIONS

Receiving appropriate care is associated with lower mortality for patients with SUDs. Significant overall and within-facility service area associations of quality indicators and mortality support their use in encouraging providers to deliver the indicated care. These indicators should be prioritized above others lacking comparably strong process-outcome associations.

Association Between Quality Measures and Perceptions of Care Among Patients With Substance Use Disorders

OBJECTIVE

This study evaluated whether eight quality measures assessing care for patients with a substance use disorder were associated with patient perceptions of their care, including perceived improvement and global rating of behavioral health care.

METHODS

Secondary data analyses were conducted of administrative and patient survey data collected as part of a national evaluation of Veterans Health Administration (VHA) mental health and substance use services. Data for patients who received care for substance use disorders during October 2006-September 2007 paid for by the VHA and who participated in a telephone interview about their care (N=2,074) were included. Measures of patient perceptions of care included perceived improvement and global rating of behavioral health care. Eight quality measures based on administrative data assessed initiation and engagement in substance use disorder care, receipt of psychotherapy or psychosocial treatment, and follow-up after hospitalization. Regression models were conducted in which each quality measure predicted each outcome, with analyses adjusting for patient characteristics and functioning.

RESULTS

Treatment engagement, two measures of psychotherapy receipt, and psychosocial treatment were significantly associated with perceived improvement, whereas treatment initiation and follow-up after hospitalization (seven and 30 days) were not. Psychotherapy receipt and follow-up after hospitalization (seven and 30 days) were significantly associated with global rating of behavioral health care.

CONCLUSIONS

Some quality measures assessing care for substance use disorders were significantly associated with patient perceptions of care. Results provide additional support for these quality measures and suggest that patient perceptions of care are an important outcome in assessing care.

Association between process measures and mortality in individuals with opioid use disorders

BACKGROUND

Individuals with opioid use disorders have high rates of mortality relative to the general population. The relationship between treatment process and mortality is unknown.

AIM

To examine the association between 7 process measures and 12- and 24-month mortality.

METHODS

Retrospective cohort study of patients with opioid use disorders who received care from the Veterans Administration between October 2006 and September 2007. Logistic regression models were used to examine the association between 12 and 24-month mortality and 7 patient-level process measures, while risk-adjusting for patient characteristics. Process measures included quarterly physician visits, any opioid use disorder pharmacotherapy, continuous pharmacotherapy, psychosocial treatment, Hepatitis B/C and HIV screening, and no prescriptions for benzodiazepines or opioids. We conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder.

RESULTS

Among individuals with opioid use disorders, not being prescribed opioids or benzodiazepines, receipt of any psychosocial treatment and quarterly physician visits were significantly associated with lower mortality at both 12 and 24 months, but Hepatitis and HIV screening, and measures related to opioid use disorder pharmacotherapy were not. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of the confounder, to render these findings non-significant.

CONCLUSIONS AND RELEVANCE

This is the first study to show an association between process measures and mortality in patients with opioid use disorders and provides initial evidence for their use as quality measures.

Protein intake distribution pattern does not affect anabolic response, lean body mass, muscle strength or function over 8 weeks in older adults: A randomized-controlled trial

BACKGROUND & AIMS

In our recent acute metabolic study, we found no differences in the anabolic response to differing patterns of dietary protein intake. To confirm this in a chronic study, we investigated the effects of protein distribution pattern on functional outcomes and protein kinetics in older adults over 8 weeks.

METHODS

To determine chronic effects of protein intake pattern at 1.1 g protein/kg/day in mixed meals on lean body mass (LBM), functional outcomes, whole body protein kinetics and muscle protein fractional synthesis rate (MPS) over 8-week respective dietary intervention, fourteen older subjects were randomly divided into either EVEN or UNVEN group. The UNEVEN group (n = 7) consumed the majority of dietary protein with dinner (UNEVEN, 15/20/65%; breakfast, lunch, dinner), while the EVEN group (n = 7) consumed dietary protein evenly throughout the day (EVEN: 33/33/33%).

RESULTS

We found no significant differences in LBM, muscle strength, and other functional outcomes between EVEN and UNEVEN before and after 8-week intervention. Consistent with these functional outcomes, we did not find significant differences in the 20-h integrated whole body protein kinetics [net protein balance (NB), protein synthesis (PS), and breakdown (PB)] above basal states and MPS between EVEN and UNEVEN intake patterns.

CONCLUSIONS

We conclude that over an 8-week intervention period, the protein intake distribution pattern in mixed meals does not play an important role in determining anabolic response, muscle strength, or functional outcomes. This trial is registered at https://ClinicalTrials.gov as NCT02787889.

Association Between Quality Measures and Mortality in Individuals With Co-Occurring Mental Health and Substance Use Disorders

IMPORTANCE

Individuals with co-occurring mental and substance use disorders have increased rates of mortality relative to the general population. The relationship between measures of treatment quality and mortality for these individuals is unknown.

OBJECTIVE

To examine the association between 5 quality measures and 12- and 24-month mortality.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study of patients with co-occurring mental illness (schizophrenia, bipolar disorder, post-traumatic stress disorder and major depression) and substance use disorders who received care for these disorders paid for by the Veterans Administration between October 2006 and September 2007. Logistic regression models were used to examine the association between 12 and 24-month mortality and 5 patient-level quality measures, while risk-adjusting for patient characteristics. Quality measures included receipt of psychosocial treatment, receipt of psychotherapy, treatment initiation and engagement, and a measure of continuity of care. We also examined the relationship between number of diagnosis-related outpatient visits and mortality, and conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder.

MAIN OUTCOMES MEASURE

Mortality 12 and 24 months after the end of the observation period.

RESULTS

All measures except for treatment engagement at 24 months were significantly associated with lower mortality at both 12 and 24 months. At 12 months, receiving any psychosocial treatment was associated with a 21% decrease in mortality; psychotherapy, a 22% decrease; treatment initiation, a 15% decrease, treatment engagement, a 31% decrease; and quarterly, diagnosis-related visits a 28% decrease. Increasing numbers of visits were associated with decreasing mortality. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of an unobserved confounder, to render these findings non-significant.

CONCLUSIONS AND RELEVANCE

This is the first study to show an association between process-based quality measures and mortality in patients with co-occurring mental and substance use disorders, and provides initial support for the predictive validity of the measures. By devising strategies to improve performance on these measures, health care systems may be able to decrease the mortality of this vulnerable population.

Abstract 267: Demographic differences in patients diagnosed with breast neoplasms living in Arkansas counties that have a history of a high percentage of crop land

Cancer is the second leading cause of death in Arkansas, and obesity is a significant co-morbidity. Understanding how obesity interacts with environmental exposures to influence cancer rates is critical to the health of Arkansans. Agriculture is the largest industry in Arkansas, and positive associations between BMI, pesticide exposure and breast cancer incidence in pesticide applicators have been reported, possibly due to perturbations in hormones and oxidative stress. The primary goal of the current study is to explore the roles of BMI and county of residence in women with breast neoplasm diagnoses utilizing the UAMS Data Warehouse dataset (a collection of data on patients treated at a University of Arkansas for Medical Sciences facility [1999-2012]). This case-case study identified Arkansas counties with either a high or low percentage of cropland in 1987. Eighteen counties were pair-matched within each group based on population and cancer cases, with 272 and 271 patients residing in high and low percentage of cropland respectively who had malignant breast neoplasm diagnoses. Adjusted odds ratios were calculated using logistic regression. With percentage of cropland (high vs. low) as the response variable and independent variables of race, age and BMI, Caucasians [OR 3.461; CI (1.954, 6.129)] were significantly higher within the low cropland than the high cropland, and age at diagnosis [OR 0.979; (0.963, 0.995)] was significantly lower within the high cropland than the low cropland. When the model was stratified by race (Caucasian and non-Caucasians), age at diagnosis [OR 0.977; CI (0.959, 0.995)] was significantly lower within the high cropland than the low cropland for Caucasians. No significant differences were found among non-Caucasians between high and low of cropland. When the model was stratified by BMI (normal/underweight and overweight/obese), Caucasians [OR 4.222; CI (2.114, 8.436)] were significantly higher within low cropland than the high cropland for overweight/obese patients and age at diagnosis [OR 0.972; CI (0.947, 0.998)] was significantly lower within the high cropland than the low cropland for normal/underweight patients. Within the high cropland population, using race as a response variable, BMI (OR 0.427; CI 0.28, 0.66) was significantly higher and age at diagnosis (OR 1.17; CI 1.04, 1.32) was significantly lower for non-Caucasians. These data demonstrate a difference in breast cancer patients both between high and low cropland counties, and within the high cropland counties in Arkansas. Thus, BMI and environmental exposures could interact to influence breast cancer risk in agricultural communities. With the growing obesity epidemic, understanding how these factors are related are critical in the design of cancer prevention strategies.

Citation Format: Rosalind B. Penney, Bryant Phelan, Amy M. Schrader, Page Moore, Susan A. Kadlubar. Demographic differences in patients diagnosed with breast neoplasms living in Arkansas counties that have a history of a high percentage of crop land. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 267. doi:10.1158/1538-7445.AM2014-267

Reversible regulation of P2Y(2) nucleotide receptor expression in the duct-ligated rat submandibular gland

Ligation of the main excretory duct of the rat submandibular gland (SMG) produces a pronounced atrophy that is reversed upon ligature removal. Based on previous studies by our group and others suggesting that P2Y(2) nucleotide receptors are upregulated in response to tissue damage, we hypothesized that P2Y(2) receptor activity and mRNA levels would increase after duct ligation and return to control levels after ligature removal. Our results support this hypothesis. Intracellular Ca(2+) mobilization in response to the P2Y(2) receptor agonist UTP in SMG cells was increased significantly after ligation periods of 1.5 to 7 days, whereas no significant response was observed in the contralateral, nonligated gland. P2Y(2) receptor mRNA, as measured by semiquantitative RT-PCR, increased about 15-fold after 3 days of ligation. These increases reverted to control levels by 14 days after ligature removal. In situ hybridization revealed that the changes in P2Y(2) receptor mRNA abundance occurred mostly in acinar cells, which also were more adversely affected by ligation, including an increase in the appearance of apoptotic bodies. These findings support the idea that P2Y(2) receptor upregulation may be an important component of the response to injury in SMG and that recovery of normal physiological function may signal a decreased requirement for P2Y(2) receptors.

Twenty years of the Journal of Homosexuality: a bibliometric examination of the first 24 volumes, 1974-1993

This study examines and evaluates the contents of the first 24 volumes of Journal of Homosexuality (JH), from 1974 to 1993. Data from each issue of JH, in terms of source articles and contributing authors, were collected and analyzed. JH is shown to be a scholarly journal, with high rates of citations per article, high levels of author education, a prevalence of scholarly methodological approaches, and a low rate of self-citation. Articles that disseminated the findings of empirical research noticeably decreased over time, while articles focusing on historical analysis noticeably increased. This trend was consonant with the change over time of JH's mission statement and editorial policy.