Supply of Primary Care Providers and Appointment Availability for Philadelphia\u27s Medicaid Population

This brief analyzes the supply of primary care providers serving the Medicaid population in Philadelphia, and the geographic variability of this measure across the city. It also examines important measures of access – appointment availability and wait time for an initial appointment – that highlight challenges faced by Medicaid patients

Declining Medicaid Fees and Primary Care Availability for New Medicaid Patients

Primary care appointment availability for new Medicaid patients declined when Medicaid fees for providers decreased after the ACA-mandated “fee bump” expired

Trends in Insurance Coverage for Acupuncture, 2010-2019.

This survey study examines US trends in insurance coverage for acupuncture from 2010 through 2019

Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

BackgroundAntiepileptics are commonly prescribed to nursing home residents with Alzheimer’s disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications.MethodsUsing the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long-term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain.ResultsOur study sample includes 973,074 persons living with ADRD who had a long-term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain.ConclusionsAntiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk–benefit for dementia care warrants further scrutiny.See related editorial by Carnahan et al. in this issue.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/175795/1/jgs18119.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/175795/2/jgs18119-sup-0001-TableS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/175795/3/jgs18119_am.pd

The Role of Schedule Volatility in Home Health Nursing Turnover

Despite considerable research on nursing turnover, few studies have considered turnover among nurses working in home health care. Using novel administrative data from one of the largest home health care organizations in the United States, this study examined turnover among home health nurses, focusing on the role of schedule volatility. We estimated separation rates among full-time and part-time registered nurses and licensed practical nurses and used daily visit logs to estimate schedule volatility, which was defined as the coefficient of variation of the number of daily visits in the prior four weeks. Between 2016 and 2019, the average annual separation rate of home health nurses was over 30%, with most separations occurring voluntarily. Schedule volatility and turnover were positively associated for full-time nurses, but not for part-time nurses. These results suggest that reducing schedule volatility for full-time nurses could mitigate nursing turnover in home health care

Evaluation of a behavioural intervention to reduce perioperative midazolam administration to older adults

Background: Older patients commonly receive benzodiazepines during anaesthesia despite guidelines recommending avoidance. Interventions to reduce perioperative benzodiazepine use are not well studied. We hypothesized an automated electronic medical record alert targeting anaesthesia providers would reduce administration of benzodiazepines to older adults undergoing general anaesthesia. Methods: We conducted a retrospective study of adults who underwent surgery at 5 hospitals within one US academic health system. One of the hospitals received an intervention consisting of provider education and an automated electronic medical record alert discouraging benzodiazepine administration to patients aged 70 years or older. We used difference-in-differences analysis to compare patterns of midazolam use 12-months before and after intervention at the intervention hospital, using the 4 non-intervention hospitals as contemporaneous comparators. Results: The primary analysis sample included 20,347 cases among patients aged 70 and older. At the intervention hospital, midazolam was administered in 454/4,240 (10.7%) cases pre-alert versus 250/3,750 (6.7%) post-alert (p<0.001). At comparator hospitals, respective rates were 3,186/6,366 (50.0%) versus 2,935/5,991 (49.0%) (p=0.24). After adjustment, the intervention was associated with a 3.2 percentage point (p.p.) reduction in the percentage of cases with midazolam administration (95% CI: (-5.2, -1.1); p=0.002). Midazolam dose was unaffected (adjusted mean difference -0.01 mg, 95% CI: (-0.20, 0.18); p=0.90). In 76,735 cases among patients aged 18–69, the percentage of cases with midazolam administration decreased by 6.9 p. p. (95% CI: (-8.0, -5.7); p<0.001). Conclusion: Provider-facing alerts in the intraoperative electronic medical record, coupled with education, can reduce midazolam administration to older patients presenting for surgery but may affect care of younger patients

Ending the Opioid and Overdose Crisis

The pandemic has worsened an existing drug overdose crisis that claimed the lives of more than 81,000 people in the U.S. from May 2019-June 2020. As the Biden-Harris administration firms up and implements its proposed response to the opioid epidemic, this brief provides evidence-based recommendations to consider.We focus our recommendations on the evidence and our experience in three areas: reducing the demand for opioids through policies that increase access to prevention, treatment, and recovery services; reducing the harms from opioid use through strategies that reduce morbidity and mortality; and reducing the supply of opioids through opioid stewardship that limits prescribing by the medical community and promotes adequate pain management. We also address the accountability of the pharmaceutical industry in contributing to the crisis and recommend ways to target settlement funds for maximal impact on the communities most affected