The acute-to-chronic workload ratio:An inaccurate scaling index for an unnecessary normalisation process?

BACKGROUND: Problematic use of alcohol and other drugs (AOD) is highly prevalent among people living with the human immunodeficiency virus (PLWH), and untreated AOD use disorders have particularly detrimental effects on human immunodeficiency virus (HIV) outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement are important benchmarks for access to AOD use disorder treatment. To inform improved patient care, we compared HEDIS measures of AOD use disorder treatment initiation and engagement and health care utilization among PLWH and patients without an HIV diagnosis. METHODS: Patients with a new AOD use disorder diagnosis documented between October 1, 2014, and August 15, 2015, were identified using electronic health records (EHR) and insurance claims data from 7 health care systems in the United States. Demographic characteristics, clinical diagnoses, and health care utilization data were also obtained. AOD use disorder treatment initiation and engagement rates were calculated using HEDIS measure criteria. Factors associated with treatment initiation and engagement were examined using multivariable logistic regression models. RESULTS: There were 469 PLWH (93% male) and 86,096 patients without an HIV diagnosis (60% male) in the study cohort. AOD use disorder treatment initiation was similar in PLWH and patients without an HIV diagnosis (10% vs. 11%, respectively). Among those who initiated treatment, few engaged in treatment in both groups (9% PLWH vs. 12% patients without an HIV diagnosis). In multivariable analysis, HIV status was not significantly associated with either AOD use disorder treatment initiation or engagement. CONCLUSIONS: AOD use disorder treatment initiation and engagement rates were low in both PLWH and patients without an HIV diagnosis. Future studies need to focus on developing strategies to efficiently integrate AOD use disorder treatment with medical care for HIV

Development and implementation of a prescription opioid registry across diverse health systems

Objective: Develop and implement a prescription opioid registry in 10 diverse health systems across the US and describe trends in prescribed opioids between 2012 and 2018. Materials and Methods: Using electronic health record and claims data, we identified patients who had an outpatient fill for any prescription opioid, and/or an opioid use disorder diagnosis, between January 1, 2012 and December 31, 2018. The registry contains distributed files of prescription opioids, benzodiazepines and other select medications, opioid antagonists, clinical diagnoses, procedures, health services utilization, and health plan membership. Rates of outpatient opioid fills over the study period, standardized to health system demographic distributions, are described by age, gender, and race/ethnicity among members without cancer. Results: The registry includes 6 249 710 patients and over 40 million outpatient opioid fills. For the combined registry population, opioid fills declined from a high of 0.718 per member-year in 2013 to 0.478 in 2018, and morphine milligram equivalents (MMEs) per fill declined from 985 MMEs per fill in 2012 to 758 MMEs in 2018. MMEs per member declined from 692 MMEs per member in 2012 to 362 MMEs per member in 2018. Conclusion: This study established a population-based opioid registry across 10 diverse health systems that can be used to address questions related to opioid use. Initial analyses showed large reductions in overall opioid use per member among the combined health systems. The registry will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use

Impact of the change of copay policy in Medicare Part D on zoster vaccine uptake among Medicare beneficiaries in a managed care organization

Abstract Background Kaiser Permanente Southern California (KPSC) adopted the Medicare Part D Tier-6 with zero patient copay for zoster vaccination in 2012. We assessed the impact of the implementation on zoster vaccination rate (GSK study identifier: HO-13-14,182). Methods Zoster vaccination rate was examined among an open cohort of ≥65-year-old Medicare Part D beneficiaries during 01/01/2008–06/30/2014, compared to ≥65-year-old commercial health plan members and 60–64-year-old members. The demographics, vaccination records, and insurance and benefit type were confirmed through KPSC electronic medical record databases. Person-time based vaccination rate was calculated for each observation interval (calendar month or year). The changes in annual rates in one year pre- (2011) and post- (2012) Tier-6 implementation were compared in a difference-in-difference analysis. Linear spline Poisson regression models were fitted to compare the secular trend of monthly rates during pre and post Tier-6 implementation (01/2012). Results Zoster vaccination rate increased in Medicare Part D beneficiaries after the implementation of zero copay. The increase in annual vaccination rate from 2011 to 2012 was marginally higher in Medicare Part D beneficiaries but not statistically significant (difference in rate ratio [RR] = 0.04, p > 0.05) compared to commercial health plan members. Among non-Hispanic white members, the difference of RR was 0.09 (p = 0.020) between Medicare Part D beneficiaries and ≥65-year-old commercial plan members, and it was 0.08 (p = 0.034) compared to 60–64-year-old commercial plan members. In secular trend analysis, we did not observe significant increase in overall and race stratified zoster vaccination rate attributable to the implementation of the Tier-6. Conclusions The impact of Tier-6 on zoster vaccination was not substantial in elderly Medicare Part D beneficiaries in this population where a lower than average copay ($20 to$40) was applied prior to the Tier-6 implementation. Further research is necessary to explore the numerical relationship between vaccination and amount of copay. Trial registration GSK study identifier: HO-13-14,182

Kidney bone disease and mortality in CKD: revisiting the role of vitamin D, calcimimetics, alkaline phosphatase, and minerals.

Recent evidence suggests that the traditional syndromes known as renal osteodystrophy, secondary hyperparathyroidism, and vitamin D deficiency are related to mortality in persons with moderate to advanced chronic kidney disease (CKD). The so-called 'kidney bone disease', also known as 'mineral and bone disorders', is defined to include bone disorders, mineral disarrays, and vascular calcification. We have identified 14 common and clinically relevant conditions of contemporary nature that are related to the kidney bone disease, including calcitriol (active vitamin D) deficiency, 25(OH)-vitamin D deficiency, biochemical hyperparathyroidism, relatively low parathyroid hormone (PTH) level, increased serum alkaline phosphatase (hyperphosphatasemia), elevated fibroblast growth factor (FGF)-23, high turnover bone disease, adynamic bone disease, uremic osteoporosis, vascular calcification, hyper- and hypophosphatemia, and hyper- and hypocalcemia. We present a critical review of these 14 conditions with emphasis on patient survival and other pertinent clinical outcomes. We also review unresolved controversies surrounding the management of these conditions by administration of nutritional vitamin D (ergocalciferol and cholecalciferol), vitamin D receptor activators (calcitriol, alphacalcidiol, doxercalciferol), D-mimetics (paricalcitol, maxacalcitol), calcimimetics (cinacalcet), recombinant PTH (teriparatide), and receptor activator of nuclear factor-kappaB ligand modulators (denosumab); compare mortality predictability of PTH and alkaline phosphatase; and examine potential risks of bone disorders and mineral disarrays in CKD patients

Kidney bone disease and mortality in CKD: revisiting the role of vitamin D, calcimimetics, alkaline phosphatase, and minerals.

Recent evidence suggests that the traditional syndromes known as renal osteodystrophy, secondary hyperparathyroidism, and vitamin D deficiency are related to mortality in persons with moderate to advanced chronic kidney disease (CKD). The so-called 'kidney bone disease', also known as 'mineral and bone disorders', is defined to include bone disorders, mineral disarrays, and vascular calcification. We have identified 14 common and clinically relevant conditions of contemporary nature that are related to the kidney bone disease, including calcitriol (active vitamin D) deficiency, 25(OH)-vitamin D deficiency, biochemical hyperparathyroidism, relatively low parathyroid hormone (PTH) level, increased serum alkaline phosphatase (hyperphosphatasemia), elevated fibroblast growth factor (FGF)-23, high turnover bone disease, adynamic bone disease, uremic osteoporosis, vascular calcification, hyper- and hypophosphatemia, and hyper- and hypocalcemia. We present a critical review of these 14 conditions with emphasis on patient survival and other pertinent clinical outcomes. We also review unresolved controversies surrounding the management of these conditions by administration of nutritional vitamin D (ergocalciferol and cholecalciferol), vitamin D receptor activators (calcitriol, alphacalcidiol, doxercalciferol), D-mimetics (paricalcitol, maxacalcitol), calcimimetics (cinacalcet), recombinant PTH (teriparatide), and receptor activator of nuclear factor-kappaB ligand modulators (denosumab); compare mortality predictability of PTH and alkaline phosphatase; and examine potential risks of bone disorders and mineral disarrays in CKD patients

Improving Engagement in Addiction Treatment: Translating Addiction Research Into Evidence-Based Practice

Background/Aims: Patient engagement is critical for the success of addiction treatment. We sought to evaluate the effectiveness of an innovative patient engagement enhancement system, Enhanced Engagement in Chemical Dependency (EECD), for improving patient engagement in addiction treatment. Methods: The EECD system promotes motivational interviewing/motivational enhancement therapy (MI/MET) and service matching approaches, an evidence-based practice that can improve engagement. It includes two components: 1) staff training in MI/MET, and 2) a standardized Web-based engagement assessment with real-time clinical and personalized patient reports and program-level management reports. We will roll out a staggered implementation in 12 outpatient addiction treatment programs at Kaiser Permanente Southern California, where about 8,000 new intakes were conducted per year. The analysis employs a stepped wedge design, in which all adults who have completed an intake in the 6 months prior to implementation will serve as internal baseline controls, while all adults who have completed an intake in the sites that have not yet implemented the system will serve as external controls for the implementation sites. We will evaluate the effectiveness of the EECD system on: 1) improving treatment engagement (attendance at two sessions within 30 days after the initial treatment visit); 2) authentic participation in outpatient treatment; 3) clinical outcomes (addiction severity index); 4) reducing treatment reentry within 6 months following the end of a treatment episode; 5) matching services to patient needs; and 6) sustained effectiveness in improving engagement. Generalized estimating equations will be used to test for significant differences in proportion of patients with favorable outcomes on binary variables. Linear mixed models will be used for continuous outcome variables. Results: Staff training and a staggered implementation of the EECD system will be rolled out in 12 sites during October 2014–April 2015, with two initial sites in phase I, five sites in phase II and five sites in Phase III. The results are forthcoming. Discussion: This systemic intervention project represents an important example of translating research into improving patient care in addiction treatment, through a multidisciplinary collaboration between researchers, providers and operational leaders. The findings from this project will facilitate adoption of evidence-based practices and innovative technologies in addiction treatment

Improving Engagement in Addiction Treatment: Translating Addiction Research Into Evidence-Based Practice

Background/Aims: Patient engagement is critical for the success of addiction treatment. We sought to evaluate the effectiveness of an innovative patient engagement enhancement system, Enhanced Engagement in Chemical Dependency (EECD), for improving patient engagement in addiction treatment. Methods: The EECD system promotes motivational interviewing/motivational enhancement therapy (MI/MET) and service matching approaches, an evidence-based practice that can improve engagement. It includes two components: 1) staff training in MI/MET, and 2) a standardized Web-based engagement assessment with real-time clinical and personalized patient reports and program-level management reports. We will roll out a staggered implementation in 12 outpatient addiction treatment programs at Kaiser Permanente Southern California, where about 8,000 new intakes were conducted per year. The analysis employs a stepped wedge design, in which all adults who have completed an intake in the 6 months prior to implementation will serve as internal baseline controls, while all adults who have completed an intake in the sites that have not yet implemented the system will serve as external controls for the implementation sites. We will evaluate the effectiveness of the EECD system on: 1) improving treatment engagement (attendance at two sessions within 30 days after the initial treatment visit); 2) authentic participation in outpatient treatment; 3) clinical outcomes (addiction severity index); 4) reducing treatment reentry within 6 months following the end of a treatment episode; 5) matching services to patient needs; and 6) sustained effectiveness in improving engagement. Generalized estimating equations will be used to test for significant differences in proportion of patients with favorable outcomes on binary variables. Linear mixed models will be used for continuous outcome variables. Results: Staff training and a staggered implementation of the EECD system will be rolled out in 12 sites during October 2014–April 2015, with two initial sites in phase I, five sites in phase II and five sites in Phase III. The results are forthcoming. Discussion: This systemic intervention project represents an important example of translating research into improving patient care in addiction treatment, through a multidisciplinary collaboration between researchers, providers and operational leaders. The findings from this project will facilitate adoption of evidence-based practices and innovative technologies in addiction treatment