Prevalence of Psychotropic Polypharmacy and Associated Healthcare Resource Utilization during Initial Phase of Care among Adults with Cancer in USA

Background: The use of psychotropic medications is not uncommon among patients with newly diagnosed cancer. However, the impact of psychotropic polypharmacy on healthcare utilization during the initial phase of cancer care is largely unknown. Methods: We used a claims database to identify adults with incident breast, prostate, lung, and colorectal cancers diagnosed during 2011–12. Psychotropic polypharmacy was defined as concurrent use of two or more psychotropic medication classes for at least 90 days. A multivariable logistic regression was performed to identify significant predictors of psychotropic polypharmacy. Multivariable Poisson and negative binomial regressions were used to assess the associations between psychotropic polypharmacy and healthcare utilization. Results: Among 5604 patients included in the study, 52.6% had breast cancer, 30.6% had prostate cancer, 11.4% had colorectal cancer, and 5.5% had lung cancer. During the year following incident cancer diagnosis, psychotropic polypharmacy was reported in 7.4% of patients, with the highest prevalence among patients with lung cancer (14.4%). Compared with patients without psychotropic polypharmacy during the initial phase of care, patients with newly diagnosed cancer with psychotropic polypharmacy had a 30% higher rate of physician office visits, an 18% higher rate of hospitalization, and a 30% higher rate of outpatient visits. The rate of emergency room visits was similar between the two groups. Conclusion: Psychotropic polypharmacy during the initial phase of cancer care was associated with significantly increased healthcare resource utilization, and the proportion of patients receiving psychotropic polypharmacy differed by type of cancer. Impact: Findings emphasize the importance of evidence-based psychotropic prescribing and close surveillance of events causing increased healthcare utilization among patients with cancer receiving psychotropic polypharmacy

State Regulation of Policing: POST Commissions and Police Accountability

This Article examines the untapped potential of Peace Officer Standards and Training (POST) commissions to protect communities that experience police misconduct and discrimination. POST commissions, which are created by state laws and exist in all fifty states, have broad authority to regulate police officers and police departments. POST commissions determine eligibility and qualifications for police employment and regulate the content of training officers receive. Most POST commissions can also revoke certification of officers who commit serious misconduct or fail to meet continuing eligibility requirements set by the commissions. In some states, they can also impose statewide, compulsory reforms to policing policy. POST commissions have yet to fulfill their potential to protect the public from harmful police behaviors because (1) they lack clear legislative or organizational mandates to protect the public against unethical or unjust policing and (2) their membership tends to be dominated by law enforcement officials with little or no input from the communities that are most burdened by aggressive and discriminatory policing. If legislatures address these structural problems, POST commissions could regulate policing to protect communities from police abuse and misconduct

Estimating the Direct Costs of Outpatient Opioid Prescriptions: A Retrospective Analysis of Data from the Rhode Island Prescription Drug Monitoring Program

Background: Overuse and misuse of prescription opioids is associated with increased morbidity and mortality, and places a significant cost burden on health systems. Objective: To estimate annual state-wide spending for prescription opioids in Rhode Island. Methods: A cross-sectional study of opioids dispensed from retail pharmacies using data from the Rhode Island (R.I.) Prescription Drug Monitoring Program (PDMP) was performed. The study sample consisted of 651,227 opioid prescriptions dispensed to 197,062 patients between January 1, 2015 to December 31, 2015. The mean, median and total cost of opioid utilization was estimated using both prescription dispensings and patients as units of analysis. A generalized linear model with gamma distribution with an identity link function and separately with a log link function were used to estimate the annual adjusted average prescription opioid cost and to examine potential predictors of total annual expenditure, respectively. Results: The estimated annual expenditure for opioid prescriptions in R.I. for 2015 was $44,271,827. The average and median cost of an opioid prescription were$67.98 (standard deviation [SD] $210.91) and$21.08 (interquartile range [IQR]: $7.65,$47.51), respectively. Prescriptions for branded opioid products accounted for $17,380,279.05, which was about 39.3% of overall spending, although only 6% of all opioids dispensed were for brand-name drugs. On average, patients aged 45-54 and 55-64 years had overall adjusted spending for opioids that were 1.53 (95% confidence interval [CI]: 1.49, 1.57) and 1.75 (95% CI: 1.71, 1.80) times higher than patients age 65 years and older, respectively. Per patient Medicaid and Medicare average annual spending for opioid prescriptions were 1.19 (95% CI: 1.16, 1.22) and 2.01 (95% CI: 1.96, 2.06) times higher than commercial insurance spending, respectively. Annual opioid prescription spending was 2.01 (95% CI: 1.98, 2.04) and 1.50 (95% CI: 1.45, 1.55) times higher among patients who also had at least one benzodiazepine or sympathomimetic stimulant dispensing, respectively. Average total spending for prescription opioids per patient increased with the average daily dosage; from 3-fold for patients using 50-90 MME daily to 22-fold for those receiving 90 or more MME daily compared to those receiving less than 50 MME daily. Conclusion: This study provides the first estimate of the state-wide direct cost burden of prescription opioid use using PDMP data and standardized pricing benchmarks. Total annual cost increased with age up to 65 years, mean daily dose, and concurrent use of benzodiazepines or stimulants. Commercial insurance bears the majority of the cost of prescription opioid use but cost per patient is highest among Medicare beneficiaries. In addition to reducing harms associated with opioid overuse and misuse, substantial cost savings could be realized by reducing unnecessary opioid utilization especially among middle aged adults

Toward Evaluation of Disseminated Effects of Medications for Opioid Use Disorder within Provider-Based Clusters Using Routinely-Collected Health Data

Routinely-collected health data can be employed to emulate a target trial when randomized trial data are not available. Patients within provider-based clusters likely exert and share influence on each other’s treatment preferences and subsequent health outcomes and this is known as dissemination or spillover. Extending a framework to replicate an idealized two-stage randomized trial using routinely-collected health data, an evaluation of disseminated effects within provider-based clusters is possible. In this paper, we propose a novel application of causal inference methods for dissemination to retrospective cohort studies in administrative claims data and evaluate the impact of the normality of the random effects distribution for the cluster-level propensity score on estimation of the causal parameters. An extensive simulation study was conducted to study the robustness of the methods under different distributions of the random effects. We applied these methods to evaluate baseline prescription for medications for opioid use disorder among a cohort of patients diagnosed opioid use disorder and adjust for baseline confounders using information obtained from an administrative claims database. We discuss future research directions in this setting to better address unmeasured confounding in the presence of disseminated effects

Recent advances in the application of stable isotope ratio analysis in forensic chemistry

This review paper updates the previous literature in relation to the continued and developing use of stable isotope ratio analysis in samples which are relevant to forensic science. Recent advances in the analysis of drug samples, explosive materials, and samples derived from human and animal samples are discussed. The paper also aims to put the use of isotope ratio mass spectrometry into a forensic context and discuss its evidential potential

Evaluation of the impact of telementoring using ECHO© technology on healthcare professionals' knowledge and self-efficacy in assessing and managing pain for people with advanced dementia nearing the end of life

Abstract Background Pain assessment and management in advanced and end-stage dementia are challenging; patients are at risk of under-diagnosis, under-assessment and under-treatment. Previous research has highlighted the importance of needs-driven training and development in this area for physicians, nurses and healthcare assistants (HCAs) across specialties, disciplines and care settings. This study used teleconferencing technology to connect healthcare professionals across multiple settings and disciplines in real-time clinics, based on the Project ECHO© model. This paper reports the evaluation of the clinics by physicians, nurses and HCAs, including their knowledge and self-efficacy in pain assessment and management for patients with advanced and end-stage dementia. Methods A mixed method evaluation comprising quantitative survey of self-reported knowledge and self-efficacy pre- and post-ECHO clinic participation, and qualitative exploration of experiences of the clinics using focus group interviews. A census approach to sampling was undertaken. Pre- and post-ECHO evaluations were administered electronically using Survey Monkey software. Mann-Whitney U tests were used to explore differences in knowledge and self-efficacy scores pre- and post-ECHO clinic participation. Statistical significance was set a-priori at p = 0.05. Focus groups were video- and audio-recorded, transcribed verbatim and analysed using Braun & Clarke’s model of thematic analysis. Results Eighteen healthcare professionals [HCPs] (physicians [n = 7], nurses [n = 10], HCA [n = 1]) and twenty HCPs (physicians [n = 10], nurses [n = 10]) completed pre- and post-ECHO evaluations respectively, reporting improvements in knowledge and self-efficacy on participation in ECHO clinics and perceived utility of the clinics. Seven HCPs (physicians [n = 2], nurses [n = 5]) participated in two focus groups. Four themes emerged: knowledge and skills development and dissemination; protected time; areas for improvement; and the future of ECHO. Conclusions Telementoring clinics for HCP education and training in pain assessment and management in advanced and end-stage dementia demonstrate a positive impact on knowledge and self-efficacy of HCPs and highlight the value of a cross-specialty network of practice which spans across disciplines/HCP types, care settings and geographical areas. Further development of ECHO services in this and in other clinical areas, shows significant potential to support delivery of high-quality care to complex patient populations

A specific group of genes respond to cold dehydration stress in cut Alstroemeria flowers whereas ambient dehydration stress accelerates developmental senescence expression patterns

Petal development and senescence entails a normally irreversible process. It starts with petal expansion and pigment production, and ends with nutrient remobilization and ultimately cell death. In many species this is accompanied by petal abscission. Post-harvest stress is an important factor in limiting petal longevity in cut flowers and accelerates some of the processes of senescence such as petal wilting and abscission. However, some of the effects of moderate stress in young flowers are reversible with appropriate treatments. Transcriptomic studies have shown that distinct gene sets are expressed during petal development and senescence. Despite this, the overlap in gene expression between developmental and stress-induced senescence in petals has not been fully investigated in any species. Here a custom-made cDNA microarray from Alstroemeria petals was used to investigate the overlap in gene expression between developmental changes (bud to first sign of senescence) and typical post-harvest stress treatments. Young flowers were stressed by cold or ambient temperatures without water followed by a recovery and rehydration period. Stressed flowers were still at the bud stage after stress treatments. Microarray analysis showed that ambient dehydration stress accelerates many of the changes in gene expression patterns that would normally occur during developmental senescence. However, a higher proportion of gene expression changes in response to cold stress were specific to this stimulus and not senescence related. The expression of 21 transcription factors was characterized, showing that overlapping sets of regulatory genes are activated during developmental senescence and by different stresses