Grant Ritter

Gender and Other Factors Associated with the Nonmedical Use of Abusable Prescription Drugs

Although there is extensive research on gender differences in the use of alcohol and illicit substances, few studies have examined gender differences in nonmedical prescription drug use. Using data from the 1991 National Household Survey on Drug Abuse (NHSDA), based on a sample of 3185 persons, logistic regression analysis is employed to determine how gender and other factors affect the likelihood of past-year nonmedical prescription drug use. Analysis revealed that women are significantly more likely than men to use any prescription drug, and that this gender difference is primarily driven by womens increased risk for narcotic analgesic and minor tranquilizer nonmedical use. Other factors, such as race, age, health status, and other substance use, also are significant predictors of nonmedical use. Findings from this study will enable researchers, policy makers, and providers to have a greater understanding of nonmedical drug use patterns and support greater gender sensitivity in the prevention, education, and treatment of nonmedical prescription drug use.

Use of Buprenorphine for Addiction Treatment: Perspectives of Addiction Specialists and General Psychiatrists

OBJECTIVE In 2002 buprenorphine (Suboxone or Subutex) was approved by the U.S. Food and Drug Administration for office-based treatment of opioid addiction. The goal of office-based pharmacotherapy is to bring more opiate-dependent people into treatment and to have more physicians address this problem. This study examined prescribing practices for buprenorphine, including facilitators and barriers, and the organizational settings that facilitate its being incorporated into treatment. METHODS Addiction specialists and other psychiatrists in four market areas were surveyed by mail and Internet in fall 2005 to examine prescribing practices for buprenorphine. Respondents included 271 addiction specialists (72% response rate) and 224 psychiatrists who were not listed as addiction specialists but who had patients with addictions in their practice (57% response rate). RESULTS Three years after approval of buprenorphine for office-based addiction treatment, nearly 90% of addiction specialists had been approved to prescribe it and two-thirds treated patients with buprenorphine. However, fewer than 10% of non-addiction specialist psychiatrists prescribed it. Regression-adjusted factors predicting prescribing of buprenorphine included support of training and use of buprenorphine by the physicians main affiliated organization, less time in general psychiatry compared with addictions treatment, more time in group practice rather than solo, ten or more opiate-dependent patients, belief that drugs play a large role in addiction treatment, and patient demand. CONCLUSIONS Office-based pharmacotherapy offers a promising path to improved access to addictions treatment, but prescribing has expanded little beyond the addiction specialist community.

Measuring Outcomes And Efficiency In Medicare Value-Based Purchasing

The Medicare program may soon adopt value-based purchasing (VBP), in which hospitals could receive incentives that are conditional on meeting specified performance objectives. The authors advocate for a market-oriented framework and direct measures of system-level value that are focused on better outcomes and lower total cost of care. They present a multidimensional framework for measuring outcomes of care and a method to adjust incentive payments based on efficiency. Incremental reforms based on VBP could provoke transformational changes in total patient care by linking payments to value related to the whole patient experience, recognizing shared accountability among providers.

The impact of employment counseling on substance user treatment participation and outcomes.

The nationally representative Alcohol and Drug Services Study (ADSS, 1996–1999) is used to examine employment counselings impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N = 988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.

Impact Of Health Plan Design And Management On Retirees' Prescription Drug Use And Spending, 2001

We examined 2001 prescription drug claims for a range of employer-based re- tiree plans administered by a national pharmacy benefit management firm, to understand how use and spending differ with various cost-sharing approaches and other drug use man- agement techniques among the elderly. In these plans, most of which had generous bene- fits and substantial use of mail order, more aggressive cost-sharing requirements com- bined with other management strategies were associated with greater member cost sharing, a shift to less costly medications (generic and mail order), and lower total prescrip- tion drug spending. Although we did not find lower rates of use in plans with aggressive cost sharing, this may be attributable in part to their higher drug use associated with mail-order incentives.

Evidence of spillover of illness among household members: EQ-5D scores from a US sample.

Background/Objectives: The effects of illness extend beyond the individual to caregivers and family members. This study identified evidence of spillover of illness onto household members’ health-related quality of life. Methods: Medical Expenditures Panel Survey (MEPS) data from 2000–2003 were analyzed using multivariable regression to identify spillover of household members’ chronic conditions onto individuals’ health-related quality of life as measured by the EuroQol-5D (EQ-5D) score (N = 24,188). Spillover was assessed by disease category, timing of occurrence (preexisting or new conditions), and age of the household member (adult or child). Results: Controlling for an individual’s own health conditions and other known predictors of EQ-5D scores, the authors found that the odds of an individual reporting full health (an EQ-5D score of 1.0, relative to <1.0) were lower with the presence of existing mental (odds ratio 0.71; 95% confidence interval, 0.64–0.79), respiratory (0.85; 0.75–0.97), and musculoskeletal (0.83; 0.75–0.93) conditions among adults and with mental (0.72; 0.62–0.82) and respiratory (0.80; 0.81–0.96) conditions among children in the household. The odds of an individual reporting full health were also lower for newly occurring chronic conditions in the household, including adults’ mental (0.79; 0.65–0.97), nervous/sensory system (0.76; 0.61–0.96), and musculoskeletal (0.78; 0.65–0.95) conditions and children’s mental conditions (0.64; 0.48–0.86). EQ-5D dimensions may be unsuited to fully capture spillover utility among household members, and MEPS lacks condition severity and caregiver status among household members. Conclusions: Evidence from a US sample suggests that individuals who live with chronically ill household members have lower EQ-5D scores than those who live either alone or with healthy household members. Averting spillover effects may confer substantial additional benefit at the population level for interventions that prevent or alleviate conditions that incur such effects.

Health Care Savings with the Patient-Centered Medical Home: Community Care of North Carolina's Experience

This study evaluated the financial impact of integrating a systemic care management intervention program (Community Care of North Carolina) with person-centered medical homes throughout North Carolina for non-elderly Medicaid recipients with disabilities during almost 5 years of program history. It examined Medicaid claims for 169,676 non-elderly Medicaid recipients with disabilities from January 2007 through third quarter 2011. Two models were used to estimate the programs impact on cost, within each year. The first employed a mixed model comparing member experiences in enrolled versus unenrolled months, accounting for regional differences as fixed effects and within physician group experience as random effects. The second was a pre-post, intervention/comparison group, difference-in-differences mixed model, which directly matched cohort samples of enrolled and unenrolled members on strata of preenrollment pharmacy use, race, age, year, months in pre-post periods, health status, and behavioral health history. The study team found significant cost avoidance associated with program enrollment for the non-elderly disabled population after the first years, savings that increased with length of time in the program. The impact of the program was greater in persons with multiple chronic disease conditions. By providing targeted care management interventions, aligned with person-centered medical homes, the Community Care of North Carolina program achieved significant savings for a high-risk population in the North Carolina Medicaid program.

Evidence of Spillover of Illness among Household Members

Background/Objectives: The effects of illness extend beyond the individual to caregivers and family members. This study identified evidence of spillover of illness onto household members’ health-related quality of life. Methods: Medical Expenditures Panel Survey (MEPS) data from 2000–2003 were analyzed using multivariable regression to identify spillover of household members’ chronic conditions onto individuals’ health-related quality of life as measured by the EuroQol-5D (EQ-5D) score (N = 24,188). Spillover was assessed by disease category, timing of occurrence (preexisting or new conditions), and age of the household member (adult or child). Results: Controlling for an individual’s own health conditions and other known predictors of EQ-5D scores, the authors found that the odds of an individual reporting full health (an EQ-5D score of 1.0, relative to <1.0) were lower with the presence of existing mental (odds ratio 0.71; 95% confidence interval, 0.64–0.79), respiratory (0.85; 0.75–0.97), and musculoskeletal (0.83; 0.75–0.93) conditions among adults and with mental (0.72; 0.62–0.82) and respiratory (0.80; 0.81–0.96) conditions among children in the household. The odds of an individual reporting full health were also lower for newly occurring chronic conditions in the household, including adults’ mental (0.79; 0.65–0.97), nervous/sensory system (0.76; 0.61–0.96), and musculoskeletal (0.78; 0.65–0.95) conditions and children’s mental conditions (0.64; 0.48–0.86). EQ-5D dimensions may be unsuited to fully capture spillover utility among household members, and MEPS lacks condition severity and caregiver status among household members. Conclusions: Evidence from a US sample suggests that individuals who live with chronically ill household members have lower EQ-5D scores than those who live either alone or with healthy household members. Averting spillover effects may confer substantial additional benefit at the population level for interventions that prevent or alleviate conditions that incur such effects.

Engagement in Outpatient Substance Abuse Treatment and Employment Outcomes

This study, a collaboration between an academic research center and Washington State’s health, employment, and correction departments, investigates the extent to which treatment engagement, a widely adopted performance measure, is associated with employment, an important outcome for individuals receiving treatment for substance use disorders. Two-stage Heckman probit regressions were conducted using 2008 administrative data for 7,570 adults receiving publicly funded treatment. The first stage predicted employment in the year following the first treatment visit, and three separate second-stage models predicted the number of quarters employed, wages, and hours worked. Engagement as a main effect was not significant for any of the employment outcomes. However, for clients with prior criminal justice involvement, engagement was associated with both employment and higher wages following treatment. Clients with criminal justice involvement face greater challenge regarding employment, so the identification of any actionable step which increases the likelihood of employment or wages is an important result.

Organizational and Financial Issues in the Delivery of Substance Abuse Treatment Services

Examination of organizational and financial characteristics of the specialty substance abuse treatment system allows an understanding of how to meet the needs of clients in the system. Further, this assessment may afford insights into how the specialty sector may adapt in the changing environment of managed care. Data from Phase I of the Alcohol and Drug Services Study (ADSS) describe the specialty substance abuse treatment system in terms of type of care, setting, level of affiliation, licensure/accreditation, ownership, revenue sources, client referral sources, clients primary substance of abuse, and managed care. Although the system is largely outpatient and remains substantially two tiered in terms of public/private funding mix, it varies along a number of organizational and financial dimensions which have implications for system structure and facility viability in the changing environment of substance abuse treatment service delivery.