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Online First
Letter:
Pappas, Matthew A.
October 2019,
DOI:
1525-1497,10.1007/s11606-019-05322-x
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Online First
Original Article:
Lowenstein, Margaret
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Ashburn, Michael
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Hossain, Erik
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Delgado, M. Kit
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Perrone, Jeanmarie
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Grande, David
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Neuman, Mark D.
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Yang, Wei
October 2019,
DOI:
1525-1497,10.1007/s11606-019-05302-1
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BackgroundPrescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact.ObjectiveEvaluate implementation of a state prescribing limit law and health system electronic medical record (EMR) alert on characteristics of new opioid prescriptions, refill rates, and clinical encounters.DesignDifference-in-differences study comparing new opioid prescriptions from ambulatory practices in New Jersey (NJ) to controls in Pennsylvania (PA) from 1 year prior to the implementation of a NJ state prescribing limit (May 2016–May 2017) to 10 months after (May 2017–March 2018).ParticipantsAdults with new opioid prescriptions in an academic health system with practices in PA and NJ.InterventionsState 5-day opioid prescribing limit plus health system and health system EMR alert.Main MeasuresChanges in morphine milligram equivalents (MME) and tablet quantity per prescription, refills, and encounters, adjusted for patient and prescriber characteristics.Key ResultsThere were a total of 678 new prescriptions in NJ and 4638 in PA. Prior to the intervention, median MME/prescription was 225 mg in NJ and 150 mg in PA, and median quantity was 30 tablets in both. After implementation, median MME/prescription was 150 mg in both states, and median quantity was 20 in NJ and 30 in PA. In the adjusted model, there was a greater decrease in mean MME and tablet quantity in NJ relative to PA after implementation of the policy plus alert (-?82.99 MME/prescription, 95% CI -?148.15 to -?17.84 and -?10.41 tabs/prescription, 95% CI -?19.70 to -?1.13). There were no significant differences in rates of refills or encounters at 30 days based on exposure to the interventions.ConclusionsImplementation of a prescribing limit and EMR alert was associated with an approximately 22% greater decrease in opioid dose per new prescription in NJ compared with controls in PA. The combination of prescribing limits and alerts may be an effective strategy to influence prescriber behavior.
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Online First
Original Article:
Carr, John Jeffrey
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Cleveland, Erin R.
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VanWagner, Lisa B.
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Vos, Miriam B.
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Lloyd-Jones, Donald M.
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Rinella, Mary E.
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Ning, Hongyan
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Lewis, Cora E.
October 2019,
DOI:
1525-1497,10.1007/s11606-019-05340-9
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BackgroundNonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States, yet little is known about NAFLD awareness in individuals with incidental fatty liver on imaging.ObjectiveTo assess the level of awareness of imaging-defined NAFLD among individuals with and without metabolic risk factors.DesignCross-sectional analysis within a prospective longitudinal population-based cohort study conducted in four U.S. cities.ParticipantsAdults age 43 to 55 years enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study who underwent computed tomography and a personal health questionnaire at the year 25 exam (2010–2011, n?=?2788).Main MeasuresNAFLD was defined as liver attenuation =?51 Hounsfield units after exclusion of other causes of liver fat. Participants were considered “NAFLD aware” if they reported being told previously by a doctor or nurse that they had “fatty liver.”Key ResultsNAFLD prevalence was 23.9%. Only 16 of 667 (2.4%) participants with CT-defined NAFLD were aware of a NAFLD diagnosis. NAFLD aware participants were more likely to be white (81.3% vs. 53.5%, p?=?0.03) and have the metabolic syndrome (87.5% vs. 59.3%, p?=?0.02) and/or hypertension (75.0% vs. 50.2%, p?=?0.05). In multivariable analyses adjusted for demographics, metabolic syndrome and hypertension remained predictive of NAFLD awareness.ConclusionThere is low awareness of NAFLD among individuals with hepatic steatosis on imaging, even among those with metabolic risk factors. These findings highlight an opportunity to raise public and practitioner awareness of NAFLD with the goal of increasing diagnosis and implementing early treatment strategies.
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Online First
Original Article:
Weiser, Sheri D.
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Bibbins-Domingo, Kirsten
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Garber, Andrea K.
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Nagata, Jason M.
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Gooding, Holly C.
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Palar, Kartika
October 2019,
DOI:
1525-1497,10.1007/s11606-019-05317-8
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BackgroundFood insecurity, or the limited or uncertain access to food resulting from inadequate financial resources, is associated with a higher prevalence of chronic disease in adulthood. Little is known about these relationships specifically in young adulthood, an important time for the development of chronic disease.ObjectiveTo determine the association between food insecurity and chronic disease including diabetes, hypertension, obesity, and obstructive airway disease in a nationally representative sample of US young adults.DesignCross-sectional nationally representative data collected from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health was analyzed using multiple logistic regression models.ParticipantsUS young adults ages 24–32 years oldMain MeasuresFood insecurity and general health; self-reported diabetes, hypertension, hyperlipidemia, “very overweight,” and obstructive airway disease; measured obesity derived from body mass index; and inadequate disease control (hemoglobin A1c =?7.0%, blood pressure =?140/90 mmHg) among those with reported diabetes and hypertension.Key ResultsOf the 14,786 young adults in the sample, 11% were food insecure. Food-insecure young adults had greater odds of self-reported poor health (2.63, 95% confidence interval (CI) 1.63–4.24), diabetes (1.67, 95% CI 1.18–2.37), hypertension (1.40, 95% CI 1.14–1.72), being “very overweight” (1.30, 95% CI 1.08–1.57), and obstructive airway disease (1.48, 95% CI 1.22–1.80) in adjusted models compared with young adults who were food secure. Food insecurity was not associated with inadequate disease control among those with diabetes or hypertension.ConclusionsFood insecurity is associated with several self-reported chronic diseases and obesity in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate. Future research should evaluate the impact of early interventions to combat food insecurity on the prevention of downstream health effects in later adulthood.
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Online First
Original Article:
Maxwell, Colleen J.
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Bell, Chaim M.
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Diong, Christina
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Quinn, Kieran L.
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Bronskill, Susan E.
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Morris, Andrew M.
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Stall, Nathan M.
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Jeffs, Lianne
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Detsky, Allan S.
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Campitelli, Michael A.
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Daneman, Nick
October 2019,
DOI:
1525-1497,10.1007/s11606-019-05333-8
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BackgroundPrescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician’s overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician’s current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown.ObjectiveTo examine the association between a physician’s rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults.DesignPopulation-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients.Participants1926 physicians who provided care among 128,979 physician-patient pairs in 2015.Main MeasuresLikelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics.Key ResultsCompared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11–1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17–1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27–1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90–13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers.ConclusionsThe intensity of a physician’s episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.
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Online First
Original Article:
Kim, Chong Y.
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Shin, Sherry Y. M.
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Funahashi, Tadashi T.
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Okike, Kanu
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Kanter, Michael H.
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Uhr, Natalie R.
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Xie, Kristal C.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05265-3
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BackgroundPhysician online ratings are ubiquitous and influential, but they also have their detractors. Given the lack of scientific survey methodology used in online ratings, some health systems have begun to publish their own internal patient-submitted ratings of physicians.ObjectiveThe purpose of this study was to compare online physician ratings with internal ratings from a large healthcare system.DesignRetrospective cohort study comparing online ratings with internal ratings from a large healthcare system.SettingKaiser Permanente, a large integrated healthcare delivery system.ParticipantsPhysicians in the Southern California region of Kaiser Permanente, including all specialties with ambulatory clinic visits.Main MeasuresThe primary outcome measure was correlation between online physician ratings and internal ratings from the integrated healthcare delivery system.ResultsOf 5438 physicians who met inclusion and exclusion criteria, 4191 (77.1%) were rated both online and internally. The online ratings were based on a mean of 3.5 patient reviews, while the internal ratings were based on a mean of 119 survey returns. The overall correlation between the online and internal ratings was weak (Spearman’s rho .23), but increased with the number of reviews used to formulate each online rating.ConclusionsPhysician online ratings did not correlate well with internal ratings from a large integrated healthcare delivery system, although the correlation increased with the number of reviews used to formulate each online rating. Given that many consumers are not aware of the statistical issues associated with small sample sizes, we would recommend that online rating websites refrain from displaying a physician’s rating until the sample size is sufficiently large (for example, at least 15 patient reviews). However, hospitals and health systems may be able to provide better information for patients by publishing the internal ratings of their physicians.
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Online First
Original Article:
Bero, Lisa
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Chiu, Kellia
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Grundy, Quinn
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05214-0
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BackgroundDevelopers of medicines-related apps collect a variety of technical, health-related, and identifying user information to improve and tailor services. User data may also be used for promotional purposes. Apps, for example, may be used to skirt regulation of direct-to-consumer advertising of medicines. Researchers have documented routine and extensive sharing of user data with third parties for commercial purposes, but little is known about the ways that app developers or “first” parties employ user data.ObjectiveWe aimed to investigate the nature of user data collection and commercialization by developers of medicines-related apps.ApproachWe conducted a content analysis of apps’ store descriptions, linked websites, policies, and sponsorship prospectuses for prominent medicines-related apps found in the USA, Canada, Australia, and UK Google Play stores in late 2017. Apps were included if they pertained to the prescribing, administration, or use of medicines, and were interactive. Two independent coders extracted data from documents using a structured, open-ended instrument. We performed open, inductive coding to identify the range of promotional strategies involving user data for commercial purposes and wrote descriptive memos to refine and detail these codes.Key ResultsTen of 24 apps primarily provided medication adherence services; 14 primarily provided medicines information. The majority (71%, 17/24) outlined at least one promotional strategy involving users’ data for commercial purposes which included personalized marketing of the developer’s related products and services, highly tailored advertising, third-party sponsorship of targeted content or messaging, and sale of aggregated customer insights to stakeholders.ConclusionsApp developers may employ users’ data in a feedback loop to deliver highly targeted promotional messages from developers, and commercial sponsors, including the pharmaceutical industry. These practices call into question developers’ claims about the trustworthiness and independence of purportedly evidenced-based medicines information and may create a risk for mis- or overtreatment.
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Online First
Editorial:
Asch, Steven M.
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Fischer, Michael A.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05324-9
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Online First
Original Article:
Tillisch, Kirsten
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Sandbrink, Friedhelm
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Sall, James
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Pangarkar, Sanjog S.
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Konitzer, Lisa
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Bevevino, Adam
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Kang, Daniel G.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05086-4
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DescriptionIn September 2017, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved the joint Clinical Practice Guideline (CPG) for Diagnosis and Management of Low Back Pain. This CPG was intended to provide healthcare providers a framework by which to evaluate, treat, and manage patients with low back pain (LBP).MethodsThe VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine’s tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through September 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. A patient focus group was also convened to ensure patient values and perspectives were considered when formulating preferences and shared decision making in the guideline.RecommendationsThe VA/DOD LBP CPG provides evidence-based recommendations for the diagnostic approach, education and self-care, non-pharmacologic and non-invasive therapy, pharmacologic therapy, dietary supplements, non-surgical invasive therapy, and team approach to treatment of low back pain.
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Online First
Original Article:
Chen, Julius L.
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Chernew, Michael E.
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Fendrick, A. Mark
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Thompson, Joseph W.
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Rose, Sherri
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05318-7
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BackgroundEpisode-based payment (EBP) is gaining traction among payers as an alternative to fee-for-service reimbursement. However, there is concern that EBP could influence the number of episodes.ObjectiveTo examine how procedure volume changed after the introduction of EBP in 2013 and 2014 under the Arkansas Health Care Payment Improvement Initiative.DesignUsing 2011–2016 commercial claims data, we estimate a difference-in-differences model to assess the impact of EBP on the probability of a beneficiary having an episode for four procedures that were reimbursed under EBP in Arkansas: total joint replacement, cholecystectomy, colonoscopy, and tonsillectomy.ParticipantsCommercially insured beneficiaries in Arkansas serve as our treatment group, while commercially insured beneficiaries in neighboring states serve as our comparison group.InterventionsStatewide implementation of EBP for various clinical conditions by two of Arkansas’ largest commercial insurers.Main MeasuresFor a given procedure type, the primary outcomes are the annual rate of procedures (number of procedures per 1000 beneficiaries) and the probability of a beneficiary undergoing that procedure in a given quarter.Key ResultsThe relationship between EBP and procedure volume varies across procedures. After EBP was implemented, the probability of undergoing colonoscopy increased by 17.2% (point estimate, 2.63; 95% CI, 1.18 to 4.08; p?
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Original Article:
Singer, Phillip M.
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Nelson, Daniel B.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05051-1
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Since 2017, four states have successfully adopted the Medicaid expansion through ballot initiative. We analyze how states could potentially use ballot initiatives to implement these programs. We find there are serious legal and political challenges to expansion by initiative. Only six non-expansion states allow for a ballot initiative to pass and implement the Medicaid expansion. Amongst those states, there are challenges that limit the development, scope, and implementation of an initiative. Whether a state adopts the Medicaid expansion has important implications for health care providers.
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Letter:
Sharp, Christopher
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Chen, Yi-Ren
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Hom, Jason
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Tan, Marilyn
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Chen, Doris
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Wang, Suwei
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Chin, Kuo-Kai
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05057-9
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Original Article:
Winston, Lisa G.
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Henderson, Mark C.
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Williams, Donna M.
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Aronowitz, Paul B.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05053-z
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Letter:
Possin, Katherine L.
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Miller, Bruce L.
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Steele, Natasha Z. R.
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Bernstein, Alissa
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Rogers, Kirsten M.
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Ritchie, Christine S.
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Rankin, Katherine P.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05013-7
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Original Article:
Thomas, Marie
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Boyd, Michele
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Carroll, Jennifer K.
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Holder, Tameir
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Overa, Cleo Clarize
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Cassells, Andrea
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Fine, Steven M.
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Cross, Wendi
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Sanders, Mechelle
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Fiscella, Kevin
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Tobin, Jonathan N.
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Luque, Amneris
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Farah, Subrina
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05102-7
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BackgroundLittle is known about strategies to improve patient activation, particularly among persons living with HIV (PLWH).ObjectiveTo assess the impact of a group intervention and individual coaching on patient activation for PLWH.DesignPragmatic randomized controlled trial.SitesEight practices in New York and two in New Jersey serving PLWH.ParticipantsThree hundred sixty PLWH who received care at participating practices and had at least limited English proficiency and basic literacy.InterventionSix 90-min group training sessions covering use of an ePersonal Health Record loaded onto a handheld mobile device and a single 20–30 min individual pre-visit coaching session.Main MeasuresThe primary outcome was change in Patient Activation Measure (PAM). Secondary outcomes were changes in eHealth literacy (eHEALS), Decision Self-efficacy (DSES), Perceived Involvement in Care Scale (PICS), health (SF-12), receipt of HIV-related care, and change in HIV viral load (VL).Key ResultsThe intervention group showed significantly greater improvement than the control group in the primary outcome, the PAM (difference 2.82: 95% confidence interval [CI] 0.32–5.32). Effects were largest among participants with lowest quartile PAM at baseline (p?
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Original Article:
Becker, William C.
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Fuller, William S.
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Oldfield, Benjamin J.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05016-4
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Original Article:
Santos, Michael A.
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Foulke, Galen
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05178-1
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Letter:
Lu, Na
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Walensky, Rochelle P.
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Zhang, Yuqing
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Blumenthal, Kimberly G.
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Choi, Hyon K.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-04991-y
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Letter:
Bian, John
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Rockey, Don C.
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Schreiner, Andrew D.
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05172-7
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Original Article:
Lasserson, Daniel
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Seccombe, Adam
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McCluskey, Lauren
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Sapey, Elizabeth
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Moorey, Hannah
September 2019,
DOI:
1525-1497,10.1007/s11606-019-05073-9
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BackgroundFluid resuscitation is a widely used intervention that is mandated in the management of sepsis. While its use can be life-saving, its overuse is associated with harm. Despite this, the best means of assessing a need for fluid resuscitation in an acute medical setting is unclear.ObjectiveTo assess studies of diagnostic tests that identify the need for fluid resuscitation in adults with sepsis, as defined by the presence of fluid responsiveness.DesignProtocol registration was performed in advance (PROSPERO:CRD42017048651). Research database searches were performed alongside additional searches to identify grey literature. Diagnostic test accuracy studies that assessed any fluid assessment tool were identified independently by two authors, before data extraction and quality assessments were performed.ParticipantsAdults with sepsis, without intensive care organ support, who would be appropriate for admission to an acute medical unit.Key ResultsOf the 26,841 articles that were screened, 14 studies were identified for inclusion, involving a combined total of 594 patients. Five categories of index test were identified: inferior vena cava collapsibility index (IVCCI), haemodynamic change with passive leg raise, haemodynamic change with respiration, haemodynamic change with intravenous fluid administration, and static assessment tools. Due to the high level of clinical heterogeneity affecting all aspects of study design, quantitative analysis was not feasible. There was a lack of consensus on reference tests to determine fluid responsiveness.ConclusionWhile fluid resuscitation is considered a key part of the management of sepsis, evidence to support fluid assessment in awake adults is lacking. This review has highlighted a number of research recommendations that should be addressed as a matter of urgency if patient harm is to be avoided.
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