Hyunjee Kim

Does Becoming an ADL Spousal Caregiver Increase the Caregiver’s Depressive Symptoms?

This study investigated whether transitioning into the role of activities of daily living (ADL) spousal caregiver is associated with increased depressive symptoms for older husbands and wives among a sample of coresiding community-dwelling older couples. Using data from the Health and Retirement Study, we estimated a two-level linear model to examine the association between change in caregiver status and respondents’ depressive symptoms at follow-up, controlling for other factors identified in Pearlin’s stress process model (PSPM). Results indicate that both husbands and wives who become ADL caregivers have more follow-up depressive symptoms than noncaregivers. Furthermore, wives continuing as caregivers have more follow-up depressive symptoms than wives who do not provide care. Finally, the physical health of the spousal caregiver is related to depressive symptoms at follow-up. We conclude with policy and practice implications of these three main findings.

The CMS Comprehensive Care Model and Racial Disparity in Joint Replacement

In April 2016, the Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Care for Joint Replacement (CJR) model, an alternative payment model involving lower extremity joint (knee and hip) replacement. This program involves acute care hospitals in 67 randomly selected metropolitan statistical areas.1 Under the CJR model, hospitals will be held accountable for Medicare costs related to lower extremity joint replacement for 90 days after patient hospital discharge. Medicare will continue to reimburse hospitals and post–acute care clinicians and facilities on a feefor-service basis during the 90-day CJR episode. The model also sets a target payment rate for each hospital based on historical costs and regional averages. Eventually, by the fifth year, the target rate will be based entirely on the regional average. At the end of each year, if total payments during the CJR episode are lower than the target payment rate and a hospital meets all quality thresholds, the hospital would receive the difference between incurred costs and its target payment. Starting in the second year of the program, 2017, hospitals will be required to repay to Medicare any incurred costs beyond the target payment. The CJR program is an example of CMS’s efforts to transition half of all payments to value-based care models by 2018. The CJR encourages hospitals to work closely with physicians and post–acute care clinicians and facilities to reduce fragmentation of care, improve quality of care, and reduce costs. Medicare currently pays for different types of postoperative care services separately, giving clinicians and hospitals no financial incentive to pay attention to related care that patients receive in other settings. The CMS estimates that the new program will save

Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study

343 million over the 5 performance years of the CJR model,2 with most savings expected to be from reduced readmissions and use of post-acute care, such as skilled nursing facilities. Identifying lower extremity joint replacement for this alternative payment model as a way to reduce health care costs and improve care makes good sense. Utilization is projected to increase exponentially in the next decades as the prevalence of end-stage lower extremity osteoarthritis continues to increase. Some estimates suggest that demand for hip replacement could increase by 170% and demand for knee replacement could increase by more than 600%.3 For instance, in 2015, the number of total knee replacements performed in the United States exceeded 1 million,3 representing a 2-fold increase in total knee replacement operations over the past decade and making Medicare the single largest payer for these procedures. Nonetheless, as well-intentioned and appropriate as it might be, the CJR model unfolds in the setting of a well-documented disparity in health care. Arthritisrelated activity, work limitations, and severe pain (clinical indications for joint replacement) disproportionately affect African American patients compared with white patients.4 However, studies in the last 10 to 15 years have documented marked racial differences in utilization of elective joint replacement (41.5 per 10 000 for black patients vs 68.8 per 10 000 for white patients; P<.001).5 The reasons for this disparity are complex and involve patient-, clinician-, and system-level factors. Compared with white patients, African American patients are more likely to express lower preference for the treatment, which has been shown to be amenable to patient-centered educational interventions.6 There is also evidence to suggest that minority patients are more likely to receive joint replacement at low-volume or low-quality hospitals compared with nonminority patients and may have poorer surgical outcomes including higher rates of hospital readmission.7 African American patients also receive different types of rehabilitation care. In a sample of 129 522 patients who underwent elective total knee replacement in Pennsylvania between 2008 and 2012, patient race was significantly associated with discharge destination after surgery, even after adjusting for baseline comorbidity burden. Compared with white patients (n=121 449), African American patients (n=8073) had significantly higher odds of being admitted to a skilled nursing facility (odds ratio, 2.86 for age <65 years vs 2.19 for 65 years) or an inpatient rehabilitation facility (odds ratio, 2.04 for age <65 years vs 1.64 for age 65 years) for rehabilitation following surgery. In addition, admission to a skilled nursing or inpatient rehabilitation facility was associated with increased odds of all-cause 30-day readmission (odds ratio, 7.76 for inpatient rehabilitation facility and 2.01 for skilled nursing facility) to an acute care hospital.7 These readmissions can signal inadequate discharge planning or poor care continuity between acute care and post–acute care clinicians and settings. Therefore, the CJR model, in which hospitals are held financially responsible for post-acute care, might improve the quality of care provided for minority patients following joint replacement. The architects of the CJR model recognize the potential for unintended consequences such as shifting care outside of the episode, limiting some aspects of care, or even an increase in the number of episodes of care. But what is less appreciated is the potential effect of the model on racial disparity in joint replacement utilizaVIEWPOINT

Using prescription monitoring program data to characterize out‐of‐pocket payments for opioid prescriptions in a state Medicaid program

Study objective: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high‐performing, low‐performing, and high‐performance improving hospitals to reduce ED crowding. Methods: In this mixed‐methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case‐mix‐adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). Results: We engaged 4 high‐performing, 4 low‐performing, and 4 high‐performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length‐of‐stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data‐driven management, and performance accountability. Conclusion: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.

Effect of Automated Prescription Drug Monitoring Program Queries on Emergency Department Opioid Prescribing

Out‐of‐pocket payment for prescription opioids is believed to be an indicator of abuse or diversion, but few studies describe its epidemiology. Prescription drug monitoring programs (PDMPs) collect controlled substance prescription fill data regardless of payment source and thus can be used to study this phenomenon.

Effects of the Ten Percent Cap in Medicare Home Health Care on Treatment Intensity and Patient Discharge Status

Study objective: We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities. Methods: We performed a retrospective cohort study of ED visits by Medicaid beneficiaries. We assessed the staggered implementation (pre‐post) of automated prescription drug monitoring program queries at 86 EDs in Washington State from January 1, 2013, to September 30, 2015. The outcomes included any opioid prescribed within 1 day of the index ED visit and total dispensed morphine milligram equivalents. The exposure was the automated prescription drug monitoring program query intervention. We assessed program effects stratified by previous high‐risk opioid use. We performed multiple sensitivity analyses, including restriction to pain‐related visits, restriction to visits with a confirmed prescription drug monitoring program query, and assessment of 6 specific opioid high‐risk indicators. Results: The study included 1,187,237 qualifying ED visits (898,162 preintervention; 289,075 postintervention). Compared with the preintervention period, automated prescription drug monitoring program queries were not significantly associated with reductions in the proportion of visits with opioid prescribing (5.8 per 1,000 encounters; 95% confidence interval [CI] –0.11 to 11.8) or the amount of prescribed morphine milligram equivalents (difference 2.66; 95% CI –0.15 to 5.48). There was no evidence of selective reduction in patients with previous high‐risk opioid use (1.2 per 1,000 encounters, 95% CI –9.5 to 12.0; morphine milligram equivalents 1.22, 95% CI –3.39 to 5.82). The lack of a selective reduction in high‐risk patients was robust to all sensitivity analyses. Conclusion: An automated prescription drug monitoring program query intervention was not associated with reductions in ED opioid prescribing or quantities, even in patients with previous high‐risk opioid use.

Effect of a High Dosage Opioid Prior Authorization Policy on Prescription Opioid Use, Misuse, and Overdose Outcomes

OBJECTIVE To estimate the effect of the 10 percent cap introduced to Medicare home health care on treatment intensity and patient discharge status. DATA SOURCES Medicare Denominator, Medicare Home Health Claims, and Medicare Provider of Services Files from 2008 through 2010. STUDY DESIGN We used agency-level variation in the proportion of outlier payments prior to the implementation of the 10 percent cap to identify how home health agencies adjusted the number of home health visits and patient discharge status under the new law. PRINCIPAL FINDINGS Under the 10 percent cap, agencies dramatically decreased the number of service visits. Agencies also dropped relatively healthy patients and sent sicker patients to nursing homes. CONCLUSIONS The drastic reduction in the number of service visits and discontinuation of relatively healthy patients from home health care suggest that the 10 percent cap improved the efficiency of home health services as intended. However, the 10 percent cap increased other types of health care expenditures by pushing sicker patients to use more expensive health services.

Does Prescription Opioid Shopping Increase Overdose Rates in Medicaid Beneficiaries

ABSTRACT Background: High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes. Methods: Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy. Results: Following implementation of Oregons high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills < 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy. Conclusions: Oregons prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.

Opioid Prescribing Practices for Pediatric Headache

Study objective: The link between prescription opioid shopping and overdose events is poorly understood. We test the hypothesis that a history of prescription opioid shopping is associated with increased risk of overdose events. Methods: This is a secondary analysis of a linked claims and controlled substance dispense database. We studied adult Medicaid beneficiaries in 2014 with prescription opioid use in the 6 months before an ambulatory care or emergency department visit with a pain‐related diagnosis. The primary outcome was a nonfatal overdose event within 6 months of the cohort entry date. The exposure of interest (opioid shopping) was defined as having opioid prescriptions by different prescribers with greater than or equal to 1‐day overlap and filled at 3 or more pharmacies in the 6 months before cohort entry. We used a propensity score to match shoppers with nonshoppers in a 1:1 ratio. We calculated the absolute difference in outcome rates between shoppers and nonshoppers. Results: We studied 66,328 patients, including 2,571 opioid shoppers (3.9%). There were 290 patients (0.4%) in the overall cohort who experienced a nonfatal overdose. In unadjusted analyses, shoppers had higher event rates than nonshoppers (rate difference of 4.4 events per 1,000; 95% confidence interval 0.8 to 7.9). After propensity score matching, there were no outcome differences between shoppers and nonshoppers (rate difference of 0.4 events per 1,000; 95% confidence interval –4.7 to 5.5). These findings were robust to various definitions of opioid shoppers and look‐back periods. Conclusion: Prescription opioid shopping is not independently associated with increased risk of overdose events.

Variations in prescription drug monitoring program use by prescriber specialty

Objectives To characterize the frequency of opioid prescribing for pediatric headache in both ambulatory and emergency department (ED) settings, including prescribing rates by provider type. Study design A retrospective cohort study of Washington State Medicaid beneficiaries, aged 7‐17 years, with an ambulatory care or ED visit for headache between January 1, 2012, and September 30, 2015. The primary outcome was any opioid prescribed within 1 day of the visit. Results A total of 51 720 visits were included, 83% outpatient and 17% ED. There was a predominance of female (63.2%) and adolescent (59.4%) patients, and 30.5% of encounters involved a pediatrician. An opioid was prescribed in 3.9% of ED and 1.0% of ambulatory care visits (P < .001). Pediatricians were less likely to prescribe opioids in both ED (‐2.70 percentage point; 95% CI, ‐3.53 to ‐1.88) and ambulatory settings (‐0.31 percentage point; 95% CI, ‐0.54 to ‐0.08; P < .001). Conclusions Opioid prescribing rates for pediatric headache were low, but significant variation was observed by setting and provider specialty. We identified opioid prescribing by nonpediatricians as a potential target for quality improvement efforts.