Jake R. Morgan

Predictors of Frequent Emergency Room Visits among a Homeless Population

Background Homelessness, HIV, and substance use are interwoven problems. Furthermore, homeless individuals are frequent users of emergency services. The main purpose of this study was to identify risk factors for frequent emergency room (ER) visits and to examine the effects of housing status and HIV serostatus on ER utilization. The second purpose was to identify risk factors for frequent ER visits in patients with a history of illicit drug use. Methods A retrospective analysis was performed on 412 patients enrolled in a Boston-based health care for the homeless program (HCH). This study population was selected as a 2:1 HIV seronegative versus HIV seropositive match based on age, sex, and housing status. A subgroup analysis was performed on 287 patients with history of illicit drug use. Chart data were analyzed to compare demographics, health characteristics, and health service utilization. Results were stratified by housing status. Logistic models using generalized estimating equations were used to predict frequent ER visits. Results In homeless patients, hepatitis C was the only predictor of frequent ER visits (OR 4.49, p<0.01). HIV seropositivity was not predictive of frequent ER visits. In patients with history of illicit drug use, mental health (OR 2.53, 95% CI 1.07–5.95) and hepatitis C (OR 2.85, 95% CI 1.37–5.93) were predictors of frequent ER use. HIV seropositivity did not predict ER use (OR 0.45, 95% CI 0.21 – 0.97). Conclusions In a HCH population, hepatitis C predicted frequent ER visits in homeless patients. HIV seropositivity did not predict frequent ER visits, likely because HIV seropositive HCH patients are engaged in care. In patients with history of illicit drug use, hepatitis C and mental health disorders predicted frequent ER visits. Supportive housing for patients with mental health disorders and hepatitis C may help prevent unnecessary ER visits in this population.

Antibiotics for Respiratory Tract Infections: A Comparison of Prescribing in an Outpatient Setting

OBJECTIVE To examine inappropriate antibiotic prescribing for acute respiratory tract infections (RTIs) in ambulatory care to help target antimicrobial stewardship interventions. Design and Setting Retrospective analysis of RTI visits within general internal medicine (GIM) and family medicine (FM) ambulatory practices at an inner-city academic medical center from 2008 to 2010. METHODS Patient, physician, and practice characteristics were analyzed using multivariable logistic regression to determine factors predictive of inappropriate prescribing; physicians in the highest and lowest antibiotic-prescribing quartiles were compared using χ2 analysis. RESULTS Visits with FM providers, female gender, and self-reported race/ethnicity as white or Hispanic were significantly associated with inappropriate antibiotic prescribing. Physicians in the lowest quartile prescribed antibiotics for 5%-28% (mean, 21%) of RTI visits; physicians in the highest quartile prescribed antibiotics for 54%-85% (mean, 65%) of RTI visits. High prescribers had fewer African-American patients and more patients who were younger and privately insured. High prescribers had more patients with chronic lung disease. A GIM practice pod with a low prescriber was 3.0 times more likely to have a second low prescriber than other practice pods, whereas pods with a high prescriber were 1.3 times more likely to have a second high prescriber. CONCLUSIONS Medical specialty was the only physician factor predictive of inappropriate prescribing when patient gender, race, and comorbidities were taken into account. Possible disparities in care need further study. Stewardship education in medical school, enlisting low prescribers as physician leaders, and targeting interventions to the highest prescribers might be more effective approaches to antimicrobial stewardship.

Injectable naltrexone, oral naltrexone, and buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a United States commercially insured population

We investigated prescribing patterns for four opioid use disorder (OUD) medications: 1) injectable naltrexone, 2) oral naltrexone, 3) sublingual or oralmucosal buprenorphine/naloxone, and 4) sublingual buprenorphine as well as transdermal buprenorphine (which is approved for treating pain, but not OUD) in a nationally representative claims-based database (Truven Health MarketScan®) of commercially insured individuals in the United States. We calculated the prevalence of OUD in the database for each year from 2010 to 2014 and the proportion of diagnosed patient months on OUD medication. We compared characteristics of individuals diagnosed with OUD who did and did not receive these medications with bivariate descriptive statistics. Finally, we fit a Cox proportional hazards model of time to discontinuation of therapy as a function of therapy type, controlling for relevant confounders. From 2010 to 2014, the proportion of commercially insured individuals diagnosed with OUD grew by fourfold (0.12% to 0.48%), but the proportion of diagnosed patient-months on medication decreased from 25% in 2010 (0.05% injectable naltrexone, 0.4% oral naltrexone, 23.1% sublingual or oralmucosal buprenorphine/naloxone, 1.5% sublingual buprenorphine, and 0% transdermal buprenorphine) to 16% in 2014 (0.2% injectable naltrexone, 0.4% oral naltrexone, 13.8% sublingual or oralmucosal buprenorphine/naloxone, 1.4% sublingual buprenorphine, and 0.3% transdermal buprenorphine). Individuals who received medication therapy were more likely to be male, younger, and have an additional substance use disorder compared with those diagnosed with OUD who did not receive medication therapy. Those prescribed injectable naltrexone were more often male, younger, and diagnosed with additional substance use disorders compared with those prescribed other medications for opioid use disorder (MOUDs). At 30 days after initiation, 52% for individuals treated with injectable naltrexone, 70% for individuals treated with oral naltrexone, 31% for individuals treated with sublingual or oralmucosal buprenorphine/naloxone, 58% for individuals treated with sublingual buprenorphine, and 51% for individuals treated with transdermal buprenorphine discontinued treatment. In the Cox proportional hazard model, use of injectable naltrexone, oral naltrexone, sublingual buprenorphine, and transdermal buprenorphine were all associated with significantly greater hazard of discontinuing therapy beginning >30days after MOUD initiation (HR=2.17, 2.54, 1.15, and 2.21, respectively, 95% CIs 2.04-2.30, 2.45-2.64, 1.10-1.19, and 2.11-2.33), compared with the use of sublingual or oralmucosal buprenorphine/naloxone. This analysis demonstrates that the use of evidence-based medication therapies has not kept pace with increases in OUD diagnoses in commercially insured populations in the United States. Among those who have been treated, discontinuation rates >30days after initiation are high. The proportion treated with injectable naltrexone, oral naltrexone, and transdermal buprenorphine grew over time but remains small, and the discontinuation rates are higher among those treated with these medications compared with those treated with sublingual or oralmucosal buprenorphine/naloxone. In the face of the opioid overdose and addiction crisis, new efforts are needed at the provider, health system, and policy levels so that MOUD availability and uptake keep pace with new OUD diagnoses and OUD treatment discontinuation is minimized.

Cost Effectiveness and Cost Containment in the Era of Interferon-Free Therapies to Treat Hepatitis C Virus Genotype 1

Abstract Background Interferon-free regimens to treat hepatitis C virus (HCV) genotype 1 are effective but costly. At this time, payers in the United States use strategies to control costs including (1) limiting treatment to those with advanced disease and (2) negotiating price discounts in exchange for exclusivity. Methods We used Monte Carlo simulation to investigate budgetary impact and cost effectiveness of these treatment policies and to identify strategies that balance access with cost control. Outcomes included nondiscounted 5-year payer cost per 10000 HCV-infected patients and incremental cost-effectiveness ratios. Results We found that the budgetary impact of HCV treatment is high, with 5-year undiscounted costs of

Homelessness, HIV, and Incomplete Viral Suppression

1.0 billion to 2.3 billion per 10000 HCV-infected patients depending on regimen choices. Among noncirrhotic patients, using the least costly interferon-free regimen leads to the lowest payer costs with negligible difference in clinical outcomes, even when the lower cost regimen is less convenient and/or effective. Among cirrhotic patients, more effective but costly regimens remain cost effective. Controlling costs by restricting treatment to those with fibrosis stage 2 or greater disease was cost ineffective for any patient type compared with treating all patients. Conclusions Treatment strategies using interferon-free therapies to treat all HCV-infected persons are cost effective, but short-term cost is high. Among noncirrhotic patients, using the least costly interferon-free regimen, even if it is not single tablet or once daily, is the cost-control strategy that results in best outcomes. Restricting treatment to patients with more advanced disease often results in worse outcomes than treating all patients, and it is not preferred.

The Effect of Shorter Treatment Regimens for Hepatitis C on Population Health and Under Fixed Budgets

Background. The importance of HIV viral suppression is widely known, however few studies have examined the effects of homelessness on HIV viral suppression. Methods. The study included HIV-seropositive patients in a health care for the homeless program (HCH). Electronic medical record data for 138 patients were analyzed to compare demographic characteristics, health characteristics, and utilization by housing status. For the 95 individuals with available HIV viral loads, multivariable logistic analysis was performed to examine factors associated with incomplete viral suppression. Results. The adjusted odds ratio of incomplete HIV viral load suppression was 3.84 times higher in homeless compared with housed (95% CI 1.36–10.36) individuals. Illicit drug use and combined antiretrovirals (cART) were associated with HIV viral suppression. Conclusions. Homelessness predicted incomplete HIV viral suppression. Stable housing may improve viral suppression and access to cART. Drug use was associated with viral suppression, likely because of patient engagement with on-site addiction services.

Evaluating Quality of Care for Sexually Transmitted Infections in Different Clinical Settings.

Abstract Background Direct acting antiviral hepatitis C virus (HCV) therapies are highly effective but costly. Wider adoption of an 8-week ledipasvir/sofosbuvir treatment regimen could result in significant savings, but may be less efficacious compared with a 12-week regimen. We evaluated outcomes under a constrained budget and cost-effectiveness of 8 vs 12 weeks of therapy in treatment-naïve, noncirrhotic, genotype 1 HCV-infected black and nonblack individuals and considered scenarios of IL28B and NS5A resistance testing to determine treatment duration in sensitivity analyses. Methods We developed a decision tree to use in conjunction with Monte Carlo simulation to investigate the cost-effectiveness of recommended treatment durations and the population health effect of these strategies given a constrained budget. Outcomes included the total number of individuals treated and attaining sustained virologic response (SVR) given a constrained budget and incremental cost-effectiveness ratios. Results We found that treating eligible (treatment-naïve, noncirrhotic, HCV-RNA <6 million copies) individuals with 8 weeks rather than 12 weeks of therapy was cost-effective and allowed for 50% more individuals to attain SVR given a constrained budget among both black and nonblack individuals, and our results suggested that NS5A resistance testing is cost-effective. Conclusions Eight-week therapy provides good value, and wider adoption of shorter treatment could allow more individuals to attain SVR on the population level given a constrained budget. This analysis provides an evidence base to justify movement of the 8-week regimen to the preferred regimen list for appropriate patients in the HCV treatment guidelines and suggests expanding that recommendation to black patients in settings where cost and relapse trade-offs are considered.

Capsule Commentary on Tannenbaum et al., Nudging Physician Prescription Decisions by Partitioning the Order Set: Results of a Vignette-Based Study

Background We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge. Methods Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards. Results Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment. Conclusions An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

An interrupted continuum of care? What are the risk factors and comorbidities related to long-term engagement and retention in HIV care?

T annenbaum et al. 1 use vignettes to explore the effect of the order that information is provided in computerized provider order entry (CPOE) on policy-critical practices, such as use of antibiotics. With the proliferation of CPOE systems, a number of advantages associated with their use have been revealed: reducing errors caused by misreading handwriting, reducing duplicate or incorrect doses or tests, and alerting providers to potential medication interactions. In this value-focused environment, administrators have become much more highly capable and willing to make design and implementation decisions that may affect clinical practice. This process change is attractive in its relative ease of implementation and dissemination, given the difficulty in changing antibiotic prescribing behavior. However, success will depend on effective integration into existing workflow. Clinicians are known to alter quality and safety measures in order to expedite treatment or address patient concerns. These “workarounds” have been studied in the context of healthcare administration safeguards, and their effect on the subversion of medication safety measures illustrates likely challenges to EMR design changes motivated by this work. The problems of workarounds as well as shortcuts reflect underlying forces behind the change in the behavior studied. CPOE users employ a variety of “shortcuts” to increase efficiency and reduce search costs. The authors suggest that new ordering could be a shortcut for signaling which choices are “common or appropriate”. Future research on inappropriate use should grapple directly with when and why providers employ shortcuts. The shortcut may dictate that it is “safer” to prescribe, given uncertainty, that it is easier to quiet a demanding patient with a prescription, or that it is faster to write a script and move to the next appointment. Understanding how to increase the perceived “cost” of overprescribing such that risks are stark and framing guidelines as worthwhile investments of time is critical. If CPOE modifications are not matched with parallel alterations in underlying clinician knowledge, attitudes, and behaviors, the effects may be temporary and may fall short of the goal of significant and long-lasting reductions in inappropriate antibiotic utilization. The inclusion of user input in CPOE design and the study of the impact on work practices of prescribing providers warrants more effort and attention.Tannenbaum et al.1 use vignettes to explore the effect of the order that information is provided in computerized provider order entry (CPOE) on policy-critical practices, such as use of antibiotics. With the proliferation of CPOE systems, a number of advantages associated with their use have been revealed: reducing errors caused by misreading handwriting, reducing duplicate or incorrect doses or tests, and alerting providers to potential medication interactions. In this value-focused environment, administrators have become much more highly capable and willing to make design and implementation decisions that may affect clinical practice. This process change is attractive in its relative ease of implementation and dissemination, given the difficulty in changing antibiotic prescribing behavior. However, success will depend on effective integration into existing workflow. Clinicians are known to alter quality and safety measures in order to expedite treatment or address patient concerns. These “workarounds” have been studied in the context of healthcare administration safeguards,2 and their effect on the subversion of medication safety measures illustrates likely challenges to EMR design changes motivated by this work. The problems of workarounds as well as shortcuts reflect underlying forces behind the change in the behavior studied. CPOE users employ a variety of “shortcuts” to increase efficiency and reduce search costs. The authors suggest that new ordering could be a shortcut for signaling which choices are “common or appropriate”.1 Future research on inappropriate use should grapple directly with when and why providers employ shortcuts. The shortcut may dictate that it is “safer” to prescribe, given uncertainty, that it is easier to quiet a demanding patient with a prescription, or that it is faster to write a script and move to the next appointment. Understanding how to increase the perceived “cost” of overprescribing such that risks are stark3 and framing guidelines as worthwhile investments of time is critical. If CPOE modifications are not matched with parallel alterations in underlying clinician knowledge, attitudes, and behaviors, the effects may be temporary and may fall short of the goal of significant and long-lasting reductions in inappropriate antibiotic utilization. The inclusion of user input in CPOE design and the study of the impact on work practices of prescribing providers warrants more effort and attention.

Using Medical Claims for Policy Effectiveness Surveillance: Reimbursement and Utilization of Abdomen/Pelvis Computed Tomography Scans.

Despite the importance of continuous care, a large proportion of persons with HIV are not engaged or retained in care at any one time, leading to poor outcomes. Identifying the risk factors associated with lack of engagement and retention in HIV care is needed in order to target patients for interventions. While both engagement and retention in care have been studied using multiple measures, the observation period for the majority of studies is less than one year, few studies have examined both initial engagement and retention, and the effect of comorbidities has typically not been included. This study extends the literature by examining how comorbidities, in addition to demographics, HIV clinical indicators and transmission risk factors, were associated with engagement and retention in a cohort study of 485 HIV-infected persons seen for an initial HIV visit at an urban safety-net hospital. Using the electronic medical record, demographic, risk factor, health status and comorbidity data were gathered at the time of initial visits. To measure engagement and retention, appointment data were obtained for a 24-month period following the initial visit. Key findings were that unknown HIV transmission risk factor and being homeless at initial visit were associated with both lack of engagement and retention. Conversely being diagnosed with a psychiatric disorder was predictive of retention. Our findings have important implications for program structure, including the integration of care, as well as regarding key components to be addressed holistically in early clinic visits.