Hilary Mosher

Association of health literacy with medication knowledge, adherence, and adverse drug events among elderly veterans.

Health literacy is an important priority in health care delivery, but its effect on clinical outcomes remains incompletely elucidated. This observational cohort study examined the association of health literacy with medication knowledge, adherence, and adverse drug events among cognitively intact veterans older than 65 years old who were taking 5 or more medications and who were enrolled in a Veterans Administration primary care clinic. Health literacy was determined by the Rapid Estimate of Adult Literacy in Medicine. Medication knowledge and adherence were assessed by clinical pharmacist interview and refill data. Adverse drug events were determined by interview and chart review at 3 and 12 months. The 310 subjects had a mean age of 74 years, 99% were White, and 97% were male. Percentage of medications known was 29% for the low health literacy group versus 49% (marginal) and 56% (adequate), p < .001. Known medication purposes were lower in the lower health literacy group (49% vs. 71% vs. 74%; p < .001). Health literacy was not associated with medication adherence: the low health literacy group took 84% of medications by label instructions compared with 80% (marginal) and 77% (adequate), p = .14; or with adverse drug events at 1 year (48% vs. 33% vs. 40%; p = .30). Patients with lower health literacy have poorer medication knowledge but not lower adherence or increased adverse drug events.

Trends in Prevalent and Incident Opioid Receipt: an Observational Study in Veterans Health Administration 2004–2012

ABSTRACTBackgroundImproved understanding of temporal and regional trends may support safe and effective prescribing of opioids.ObjectiveWe describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012.DesignObservational cohort study using Veterans Health Administration (VHA) administrative databases.ParticipantsAll patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year.Main MeasuresPrevalent and incident opioid receipt during each year of the study period.Key ResultsThe overall prevalence of opioid receipt increased from 18.9 % of all veteran outpatients in FY2004 to 33.4 % in FY2012, a 76.7 % relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4 % vs. 32.9 %), and the youngest veterans (18–34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥80 years) (47.6 % vs. 17.9 %). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5 %, and the highest of 50.8 %. Annual incident opioid receipt increased from 8.8 % in FY2004 to 10.2 % in FY2011, with a decline to 9.8 % in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame.ConclusionsRates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.

Prevalence and characteristics of hospitalized adults on chronic opioid therapy

BACKGROUND As chronic opioid therapy (COT) becomes more common, complexity of pain management in the inpatient setting increases; little is known about medical inpatients on COT. OBJECTIVE To determine the prevalence of COT among hospitalized patients and to compare outcomes among these patients relative to those not receiving COT. DESIGN Observational study of inpatient and outpatient administrative data. PARTICIPANTS All veterans with acute medical admissions to 129 Veterans Administration hospitals during fiscal years 2009 to 2011, residing in the community, and with outpatient pharmacy use. MEASUREMENTS We defined COT as 90 or more days of opioids prescribed in the 6 months prior to hospitalization. Patient characteristics included demographic variables and major comorbidities. Outcomes included 30-day readmission and death during hospitalization or within 30 days, with associations ascertained using multivariable logistic regression. RESULTS Of 122,794 hospitalized veterans, 31,802 (25.9%) received COT. These patients differed from comparators in age, sex, race, residence, and presence of chronic noncancer pain, chronic obstructive pulmonary disease, complicated diabetes, cancer, and mental health diagnoses including post-traumatic stress disorder. After adjustment for demographic factors, comorbidities, and admission diagnosis, COT was associated with hospital readmission (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.10-1.20) and death (OR: 1.19, 95% CI: 1.10-1.29). CONCLUSIONS COT is common among medical inpatients. Patients on COT differ from patients without COT beyond dissimilarities in pain and cancer diagnoses. Occasional and chronic opioid use are associated with increased risk of hospital readmission, and COT is associated with increased risk of death. Additional research relating COT to hospitalization outcomes is warranted.

Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine

Hospital-based clinicians frequently treat acute, noncancer pain. Although opioids may be beneficial in this setting, the benefits must be balanced with the risks of adverse events, including inadvertent overdose and prolonged opioid use, physical dependence, or development of opioid use disorder. In an era of epidemic opioid use and related harms, the Society of Hospital Medicine (SHM) convened a working group to develop a consensus statement on opioid use for adults hospitalized with acute, noncancer pain, outside of the palliative, end-of-life, and intensive care settings. The guidance is intended for clinicians practicing medicine in the inpatient setting (eg, hospitalists, primary care physicians, family physicians, nurse practitioners, and physician assistants). To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines, composed a draft Statement based on extracted recommendations, and obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies, and peer-reviewers. The iterative development process resulted in a final Consensus Statement consisting of 16 recommendations covering 1) whether to use opioids in the hospital, 2) how to improve the safety of opioid use during hospitalization, and 3) how to improve the safety of opioid prescribing at hospital discharge. As most guideline recommendations from which the Consensus Statement was derived were based on expert opinion alone, the working group identified key issues for future research to support evidence-based practice.

Decline in Prescription Opioids Attributable to Decreases in Long-Term Use: A Retrospective Study in the Veterans Health Administration 2010–2016

BackgroundImproved understanding of temporal trends in short- and long-term opioid prescribing may inform efforts to curb the opioid epidemic.ObjectiveTo characterize the prevalence of short- and long-term opioid prescribing in the Veterans Health Administration (VHA) from 2010 to 2016.DesignObservational cohort study using VHA databases.ParticipantsAll patients receiving at least one outpatient prescription through the VHA during calendar years 2010 through 2016.Main MeasuresPrevalence of opioid use from 2010 through 2016, stratified by short-term, intermediate-term, and long-term use. Temporal trends in discontinuation among existing long-term users and initiation of new long-term use and the net impact on rates of long-term opioid use. Relative likelihood of transitioning to long-term opioid use contrasted with use patterns in the prior year.Key ResultsThe prevalence of opioid prescribing was 20.8% in 2010, peaked at 21.2% in 2012, and declined annually to 16.1% in 2016. Between 2010 and 2016, reductions in long-term opioid prescribing accounted for 83% of the overall decline in opioid prescription fills. Comparing data from 2010–2011 to data from 2015–2016, declining rates in new long-term use accounted for more than 90% of the decreasing prevalence of long-term opioid use in the VHA, whereas increases in cessation among existing long-term users accounted for less than 10%. The relative risk of transitioning to long-term use during 2016 was 6.5 (95% CI: 6.4, 6.7) among short-term users and 35.5 (95% CI: 34.8, 36.3) among intermediate users, relative to patients with no opioid prescriptions filled during 2015.ConclusionsOpioid prescribing trends followed similar trajectories in VHA and non-VHA settings, peaking around 2012 and subsequently declining. However, changes in long-term opioid prescribing accounted for most of the decline in the VHA. Recent VA opioid initiatives may be preventing patients from initiating long-term use. This may offer valuable lessons generalizable to other healthcare systems.

Using balanced metrics and mixed methods to better understand QI interventions

Improving quality while maintaining or reducing costs requires balancing competing demands to bring value to healthcare. High-value reporting of quality improvement (QI) initiatives similarly requires balancing descriptions of improvements achieved with assessments of potential costs and unintended consequences. Using balanced QI metrics allows simultaneous measurement of intended improvements (eg, reduced length of stay (LOS)) and of processes or outcomes that might worsen as a result of a given intervention (eg, mortality, hospital readmission). In their initiative to improve the efficiency of inpatient care without compromising safety at a large teaching hospital in Edmonton, Alberta in Canada, McAlister et al 1 report balanced measures, use a methodologically evaluative QI design, and describe the local contextual factors that influenced their success, thus creating generalisable knowledge. Their intervention bundles a number of plausible improvements on inpatient units: daily interdisciplinary care rounds, geographical cohorting of patients—that is, placing general medicine patients and their doctors at one place in the hospital, strategies to optimise care transitions (eg, medication reconciliation) and use of best practice through care maps, order sets and decision support tools. Many would regard these changes as components of high-quality inpatient care and appropriate to all patients. In reality, limited evidence supports these interventions individually and the magnitude of their benefits (at least on their own) is probably not large. Hence, the reason for a multifaceted or bundled intervention—we do not know which component will generate important improvements, and, it is possible all are needed. Some components may even have synergistic effects. Such bundled interventions will be increasingly important to deal with highly complex healthcare problems, which typically have no single ‘magic bullet’ solution. On the one hand, a bundled approach aims at the QI target quickly (as opposed to testing each component in turn or trying different combinations of possibly synergistic components). …

Predictors of Long-Term Opioid Use After Opioid Initiation at Discharge From Medical and Surgical Hospitalizations

Opioid analgesics may be initiated following surgical and medical hospitalization or in ambulatory settings; rates of subsequent long-term opioid (LTO) use have not been directly compared. This retrospective cohort study of the Veterans Health Administration (VHA) included all patients receiving a new outpatient opioid prescription from a VHA provider in fiscal year 2011. If a new outpatient prescription was filled within 2 days following hospital discharge, the initiation was considered a discharge prescription. LTO use was defined as an episode of continuous opioid supply lasting a minimum of 90 days and beginning within 30 days of the initial prescription. We performed bivariate and multivariate analyses to identify the factors associated with LTO use following surgical and medical discharges. Following incident prescription, 5.3% of discharged surgical patients, 15.2% of discharged medical patients, and 19.3% of outpatient opioid initiators received opioids long term. Medical and surgical patients differed; surgical patients were more likely to receive shorter prescription durations. Predictors of LTO use were similar in medical and surgical patients; the most robust predictor in both groups was the number of days’ supply of the initial prescription (odds ratio [OR] = 1.24 and 95% confidence interval [CI], 1.12–1.37 for 8–14 days; OR = 1.56 and 95% CI, 1.39–1.76 for 15–29 days; and OR = 2.59 and 95% CI, 2.35–2.86 for >30 days) compared with the reference group receiving ⩽7days. Rates of subsequent LTO use are higher among discharged medical patients than among surgical patients. Characteristics of opioid prescribing within the initial 30 days, including initial dose and days prescribed, were strongly associated with LTO use.

Risk for Prolonged Opioid Use Following Total Knee Arthroplasty in Veterans

BACKGROUND Patients undergoing total knee arthroplasty (TKA) may be at risk for prolonged postsurgical opioid use due to a high prevalence of persistent postsurgical pain (20%) and high rates of presurgical opioid use. METHODS The current study uses a Veterans Health Administration sample of 6653 Veterans who underwent TKA in the fiscal year 2014 that did not require surgical revision during the subsequent year. RESULTS Sixty percent of the sample had used an opioid in the year prior to surgery, including 20% who were on long-term opioid use at the time of surgery (defined as 90+ days of continuous use) and 40% with any other opioid use in the year prior to surgery. In patients on long-term opioids at the time of surgery, 69% received opioids for at least 6 months and 57% for at least 12 months after TKA. In patients not on long-term opioids at the time of TKA, only 4% received opioids for at least 6 months and 2% for at least 12 months after TKA. Differing risk factors for prolonged opioid use 12 months after TKA were identified in these 2 cohorts (ie, those who were and were not receiving long-term opioids at TKA). CONCLUSION These findings suggest that the greatest risk for prolonged opioid use after TKA is preoperative opioid use.

Between the guidelines: SQUIRE 2.0 and advances in healthcare improvement practice and reporting

The practice and reporting of healthcare improvement has matured significantly since its origin early this century. Most initial improvement reports were akin to management reports or case studies. They often lacked the specificity and details needed to communicate the design, performance and findings with enough precision, accuracy and thoroughness to allow readers to assess validity of the design and execution of the work. Prevention of central line-associated bloodstream infection (CLABSI) has yielded some of the fields most informative ‘foundation stories,’ illustrating the successes and challenges of identifying interventions that work, why they work and how to make them work in different settings.1 ,2 An important lesson learned from attempts to replicate potentially generalisable successes, such as checklists for CLABSI,3 was that the behaviours, attitudes, alliances and cultural shifts that occasion, and are occasioned by, the act of improvement are more complex4 and more powerful than what might be termed the ‘hardware’ of the improvement—the checklist, template or scripted procedure itself. The article by Dandoy et al 5 adds an additional chapter to the developing story of healthcare improvement practice and reporting by relating one groups response to an observed failure of a previously successfully CLABSI-prevention bundle. The description of this highly developed groups investigation and rapid-cycle improvement response to changes in previously stable CLABSI rates suggests potentially translatable improvement ‘hardware,’ such as requiring two people for dressing changes or requiring baths, oral care and out-of-bed activities. However, the mechanisms by which these components may have led to the measured outcomes remain unclear: did the components lead to improvement, or were they just part of the complex solution generated by a culture of improvement? …

Sedative Prescriptions Are Common at Opioid Initiation: An Observational Study in the Veterans Health Administration

Background Concurrent use of sedatives, especially anxiolytics, and opioids is associated with increased risk of medication-related harms. To the extent that multiple prescribers are involved, approaches to influence patterns of coprescribing will differ from those to influence prescribing within a single drug class. Objectives Describe the proportion of new opioid recipients with concurrent sedative medications at opioid initiation and determine whether these medications were prescribed by the same prescriber. Methods We used national Department of Veterans Affairs (VA) outpatient pharmacy administration data to identify veterans who received a new opioid prescription between October 20, 2010, and September 1, 2011 (FY 2011), preceded by a 365-day opioid-free period. Concurrent sedative use was defined as a skeletal muscle relaxant, benzodiazepine, atypical antipsychotic, or hypnotic filled on the opioid start date or before and after the opioid start date with a gap of less than twice the day supply of the prior fill. Results Concurrent sedative use at opioid initiation was 21.4% (112,408/526,499) in FY 2011. The proportion of concurrent recipients who received at least one concurrent sedative prescribed by a provider other than the opioid prescriber was 61.4% (69,002/112,408). The proportion of recipients who received a sedative concurrent with opioid initiation from the same prescriber varied across sedative class. Benzodiazepines and opioids were prescribed by the same provider in 41.1% (15,520/37,750) of concurrent users. Conclusion One in five patients newly prescribed opioids also had a sedative prescription. Less than half of patients with concurrent opioid and benzodiazepine prescriptions received these from the same provider. Efforts to reduce concurrent opioid and sedative prescribing will require addressing care coordination.