Provider patient-sharing networks and multiple-provider prescribing of benzodiazepines

Background: Prescription benzodiazepine overdose continues to cause significant morbidity and mortality in the US. Multiple-provider prescribing, due to either fragmented care or "doctor-shopping," contributes to the problem. Objective: To elucidate the effect of provider professional relationships on multiple-provider prescribing of benzodiazepines, using social network analytics. Design: A retrospective analysis of commercial healthcare claims spanning the years 2008 through 2011. Provider patient-sharing networks were modelled using social network analytics. Care team cohesion was measured using care density, defined as the ratio between the total number of patients shared by provider pairs within a patient's care team and the total number of provider pairs in the care team. Relationships within provider pairs were further quantified using a range of network metrics, including the number and proportion of patients or collaborators shared. Main measures: The relationship between patient-sharing network metrics and the likelihood of multiple prescribing of benzodiazepines. Participants: Patients between the ages of 18 and 64 years who received two or more benzodiazepine prescriptions from multiple providers, with overlapping coverage of more than 14 days. Results: A total of 5659 patients and 1448 provider pairs were included in our study. Among these, 1028 patients (18.2 %) received multiple prescriptions of benzodiazepines, involving 445 provider pairs (30.7 %). Patients whose providers rarely shared patients had a higher risk of being prescribed overlapping benzodiazepines; the median care density was 8.1 for patients who were prescribed overlapping benzodiazepines and 10.1 for those who were not (p < 0.0001). Provider pairs who shared a greater number of patients and collaborators were less likely to co-prescribe overlapping benzodiazepines. Conclusions: Our findings demonstrate the importance of care team cohesion in addressing multiple-provider prescribing of controlled substances. Furthermore, we illustrate the potential of the provider network as a surveillance tool to detect and prevent adverse events that could arise due to fragmentation of care. [an Erratum exists for this article and can be found at DOI: 10.1007/s11606-015-3533-x]8 page(s

Evaluation of optic neuritis following human papillomavirus vaccination

To assess the relationship between human papillomavirus (HPV) vaccination and occurrence of optic neuritis (ON) and to evaluate a claims-based algorithm for identification of ON. Females of 9–26 year olds in the HealthCore's Integrated Research Database (HIRDSM) with and without claims evidence of HPV vaccination between 2007 and 2012 were included in this study. Potential ON cases were identified using the claims-based algorithm, positive predictive value (PPV) was determined using medical chart review. For the claims analysis, two study designs, a self-controlled temporal scan statistic and a retrospective matched cohort analysis, were used. ON was defined based on an algorithm developed using diagnosis and procedure codes from the medical claims. The PPV for ON cases using charts that had enough information for reviewers to make a determination was 62.5% (95% CI: 49.5%–74.3%). With the self-controlled temporal scan statistic, the primary analysis restricting on recommended vaccination schedule timing showed an increased risk of potential ON after second dose (RR = 3.39; p = 0.03), this finding was not confirmed for any of the additional analyses performed for individual or combined doses. With the cohort design, there was no increased risk of potential ON following vaccination in either individual or combined dose analyses. The risk of potential ON was higher among participants with a history of prior autoimmune diseases. In conclusion, identifying confirmed ON cases through administrative claims data proved challenging. The claims-based analysis in this study did not provide evidence for an association of ON with HPV vaccination

Endocrine therapy initiation, discontinuation and adherence and breast imaging among 21-gene recurrence score assay-eligible women under age 65

Abstract Background Aside from chemotherapy utilization, limited data are available on the relationship between gene expression profiling (GEP) testing and breast cancer care. We assessed the relationship between GEP testing and additional variables and the outcomes of endocrine therapy initiation, discontinuation and adherence, and breast imaging exams in women under age 65 years. Methods Data from five state cancer registries were linked with claims data and GEP results. We assessed variables associated with survivorship care outcomes in an incident cohort of 5014 commercially insured women under age 65 years, newly diagnosed with stage I or II hormone-receptor-positive, human epidermal growth factor receptor 2 (HER2) non-positive breast cancer from 2006 to 2010. Results Among tested women, those with high Oncotype DX® Breast Recurrence Score® (RS) were significantly less likely to initiate endocrine therapy than women with low RS tumors (OR 0.40 (95% CI 0.20 to 0.81); P = 0.01). Among all test-eligible women, receipt of Oncotype DX testing was associated with a greater likelihood of endocrine therapy initiation (OR 2.48 (95% CI 2.03 to 3.04); P <0.0001). The odds of initiation were also significantly higher for tested vs. untested women among women who did not initiate chemotherapy within six months of diagnosis (OR 3.25 (95% CI 2.53 to 4.16)), with no effect in women who received chemotherapy. Discontinuation and adherence and breast imaging exams were unrelated to tested status or RS. Conclusions Lower endocrine therapy initiation rates among women with high RS tumors and among untested women not receiving chemotherapy are concerning, given its established efficacy. Additional research is needed to suggest mechanisms to close this gap

Validation of anaphylaxis in the Food and Drug Administration\u27s Mini-Sentinel

PURPOSE: We aim to develop and validate the positive predictive value (PPV) of an algorithm to identify anaphylaxis using health plan administrative and claims data. Previously published PPVs for anaphylaxis using International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) codes range from 52% to 57%. METHODS: We conducted a retrospective study using administrative and claims data from eight health plans. Using diagnosis and procedure codes, we developed an algorithm to identify potential cases of anaphylaxis from the Mini-Sentinel Distributed Database between January 2009 and December 2010. A random sample of medical charts (n = 150) was identified for chart abstraction. Two physician adjudicators reviewed each potential case. Using physician adjudicator judgments on whether the case met diagnostic criteria for anaphylaxis, we calculated a PPV for the algorithm. RESULTS: Of the 122 patients for whom complete charts were received, 77 were judged by physician adjudicators to have anaphylaxis. The PPV for the algorithm was 63.1% (95%CI: 53.9-71.7%), using the clinical criteria by Sampson as the gold standard. The PPV was highest for inpatient encounters with ICD-9-CM codes of 995.0 or 999.4. By combining only the top performing ICD-9-CM codes, we identified an algorithm with a PPV of 75.0%, but only 66% of cases of anaphylaxis were identified using this modified algorithm. CONCLUSIONS: The PPV for the ICD-9-CM-based algorithm for anaphylaxis was slightly higher than PPV estimates reported in prior studies, but remained low. We were able to identify an algorithm that optimized the PPV but demonstrated lower sensitivity for anaphylactic events