Publications

OBJECTIVE: The COVID-19 pandemic exacerbated health disparities and increased alcohol use and its health consequences. Although prepandemic research identified racial and ethnic disparities in receipt of alcohol use disorder treatment, few studies have described postpandemic disparities or have assessed the role social determinants of health (SDOHs) may play in these inequities. The authors examined how rates of treatment for alcohol use disorder differ by race and ethnicity, SDOHs, and at the intersection of both.

METHODS: In this cross-sectional analysis, the authors used a nationally representative sample of 5,785 U.S. adults with past-year alcohol use disorder from the 2023 National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression models were used to estimate the probability of any past-year alcohol use disorder treatment overall, by the intersection of race and ethnicity with 20 SDOH subcategories, and across treatment settings.

RESULTS: Only 9.6% of adults with alcohol use disorder in the NSDUH received any treatment in 2023. Compared with other racial and ethnic groups, non-Hispanic Black or African American adults had the lowest probability of receiving treatment for alcohol use disorder overall and in the stratified analyses of nine of 20 SDOH subcategories.

CONCLUSIONS: These findings highlight significant disparities in the receipt of treatment for alcohol use disorder among non-Hispanic Black or African American adults, generally concentrated within the more vulnerable SDOH categories. These results underscore a critical need for clinically and culturally nuanced policies and practices tailored to specific populations with health disparities.

RATIONALE: Sarcoidosis disproportionately affects U.S. military Veterans. Its rising incidence and prevalence among Veterans are higher than in civilians and vary by branch of service, suggesting a role for prior military exposures.

OBJECTIVES: To investigate whether estimated service-related exposure to inorganic dust is associated with increased risk of sarcoidosis.

METHODS: In a retrospective nested case-control study of Veterans enrolled in the Veterans Health Administration (VHA) who received VHA- or Medicare-covered care, sarcoidosis cases identified in electronic health records between 2002 and 2022 were each matched to five controls by propensity scores and incidence density sampling by calendar year. To estimate inorganic dust exposure, military occupational codes (MOCs) were linked to a job exposure matrix (JEM). Multivariable conditional logistic regression analyses were adjusted for demographics, geography, rurality, and service branch. The attributable fraction among the exposed was calculated. In secondary analyses, latency from service separation to diagnosis was assessed. In sensitivity analyses, exposure misclassification was assessed by using a modified JEM weighted for MOC coding precision and by examining only post-9/11 Veterans; service duration was also analyzed.

RESULTS: Among >16 million individuals evaluated, 3,019,636 Veterans had at least one MOC; 5,855 incident cases and 29,275 controls were analyzed. Inorganic dust exposure was associated with increased risk of sarcoidosis (conditional odds ratio [cOR]: 1.08; 95% confidence interval [CI], 1.003-1.170); the attributable fraction was 7.6%. Associations were stronger with a modified JEM score (cOR: 1.15; 95% CI 1.05-1.27) and when restricted to post-9/11 Veterans (cOR: 1.25; 95% CI 1.07-1.47). In latency analysis, sarcoidosis risk peaked 2-5 years post-service (cOR: 2.10; 95% CI: 1.20-3.58).

CONCLUSION: Occupational and environmental exposure to inorganic dust during military service was associated with increased risk of sarcoidosis among Veterans, carrying potential implications for prevention and surveillance.

The opioid crisis has remained a public health challenge in the US for more than two decades. After increasing from 2002 to 2012, opioid-related hospitalizations decreased from 2016 to 2019, but more recent trends are unknown. We sought to determine trends in incidence and outcomes of US opioid-related hospitalizations in recent years. We conducted a serial cross-sectional study of adult primary and secondary opioid-related hospitalizations, using the 2016-23 National Inpatient Survey and regression models, annual percent change, and z-tests to examine change during the study period. Measures included annual opioid-related hospitalizations, hospital stay outcomes, and sociodemographic characteristics. Among the 1.48 million opioid-related hospitalizations during 2016-23, survey-weighted to 7.42 million, 0.93 million were classified as primary and 6.49 million as secondary opioid-related hospitalizations. Hospitalizations decreased through 2023 for all groups except patients who were Hispanic or Native American, who reported Medicaid as their payer, or who were older than age sixty-five. The greatest decline occurred among people younger than age thirty-five. The proportion of hospitalizations ending in death and self-directed discharge increased by 0.58 percentage points and 2.68 percentage points, respectively. Overall, differential reductions in opioid-related hospitalizations and increasing mortality and self-directed discharge highlight opportunities for interventions.

OBJECTIVE: To investigate whether eligibility for Veterans Health Administration (VA)-purchased community care, which expanded Veterans' access to care outside VA, was associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans.

STUDY SETTING AND DESIGN: Regression discontinuity design, leveraging the distance threshold for community care eligibility (residing > 40 miles from the nearest VA facility with ≥ 1 or more full-time primary care physician), to examine the effects of community care eligibility on polypharmacy and potentially inappropriate medication use among Veterans aged ≥ 65 years.

DATA SOURCES AND ANALYTIC SAMPLE: VA pharmacy data for all prescriptions filled at VA facilities, VA Program Integrity Tool files for prescriptions paid by VA and filled in community pharmacies, and Medicare Part D data. Analyses included annual cross-sectional samples of Veterans 36-39 miles or 41-44 miles from their nearest VA facility during FY 2016-2019.

PRINCIPAL FINDINGS: The sample included 399,250 Veteran-year observations, of which 226,157 (56.6%) were 36-39 miles and 173,093 (43.4%) were 41-44 miles from the nearest eligible VA facility. Overall, we observed no discontinuities across the 40-mile threshold in the number of unique medications filled annually (-0.06 medications; 95% confidence interval [CI], -0.15 to 0.03). There were no discontinuities in proportions of Veterans filling ≥ 5 unique medications (-0.25 percentage points [pp]; 95% CI, -0.84 to 0.34), ≥ 10 medications (-0.55 pp.; 95% CI, -1.24 to 0.14), ≥ 1 medication on the Beers list (-0.02 pp.; 95% CI, -0.63 to 0.59), or ≥ 1 high-risk drug-drug interaction (-0.05 pp.; 95% CI, -0.17 to 0.07). Among Veterans with mental health conditions, exceeding the 40-mile threshold was associated with a higher likelihood of filling ≥ 10 unique medications annually (2.06 pp.; 95% CI, 0.42 to 3.70). We did not observe clinically or statistically significant discontinuities in other subgroups.

CONCLUSIONS: Overall, eligibility for VA-purchased community care was not associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans.

BACKGROUND: People with non-traumatic fractures typically qualify for antifracture medications to prevent recurrent fractures.

OBJECTIVE: To quantify the current osteoporosis care gap and determine factors that predict prescribing of antifracture medications following hospitalization for non-traumatic fracture.

DESIGN: Retrospective cohort study.

SETTING: Twenty hospitals from a large US health system.

PATIENTS: Patients aged 50 years and older presenting to the emergency department with a non-traumatic hip, pelvic, or vertebral fracture between 2017 and 2023.

MEASUREMENTS: In-hospital administration or outpatient prescription fill of antifracture medications within 180 days following hospital discharge. We estimated incident rate ratios (IRRs) using modified Poisson regression with robust standard errors to in order to determine factors associated with antifracture medication initiation.

RESULTS: The cohort included 9849 patients (median (IQR) age, 80 [70-87] years; 68% female) of which 9008 (91.4%) were antifracture medication naïve prior to hospital presentation. Of medication-naïve patients, 510 (5.7%) were prescribed antifracture medications, with 279 (3.1%) initiating treatment as an inpatient and 119 (1.3%) in the 180 days following discharge. Medication classes included bisphosphonate (N = 431, 85%), RANK ligand inhibitors and selective estrogen receptor modulators (N = 56, 11%), and anabolic therapies (N = 21, 4%). Female sex (IRR 1.93; 95% CI 1.41-2.64) and a pre-existing diagnosis of osteoporosis (IRR 1.76, 95% CI 1.47-2.11) were positively associated with medication receipt.

LIMITATIONS: Inability to measure reasons for treatment non-initiation.

CONCLUSIONS: This study found very few adults with a non-traumatic fracture received medical treatment for secondary osteoporosis fracture prevention. Expanded quality improvement efforts are needed to close the osteoporosis care gap.

Aggregated counts from electronic health records (EHRs) provide a rich source of real-world data for investigating critical medical conditions such as postpartum hemorrhage (PPH). We used the Evolve to Next-Gen Accrual to Clinical Trials (ENACT) network, a large, federated network of EHRs, to characterize national trends, risk factors, and comorbidities associated with PPH in a cohort of 705,120 women hospitalized for delivery from 2005 to 2022. During this period, there was a statistically significant increase in the incidence of PPH, consistent with previous studies. Asian women had the highest incidence of PPH (10.33%), followed by Black or African American (8.33%) and American Indian or Alaska Native (8.05%) women. In PPH deliveries, the top-ranked risk factor was severe eclampsia (18.51%), the top-ranked comorbidity was operative vaginal delivery (16.98%), and the commonest cause was uterine atony (83.06%). We demonstrated that a large federated EHR network such as ENACT can be used to generate population-level epidemiological findings, albeit with some limitations.

INTRODUCTION: A 2019 Medicare opioid safety policy limited initial opioid duration to 7 days and long-term daily dosage to 90 morphine milligram equivalence (MME). Because effective pain management may vary by rurality, this study examined whether the policy differentially affected opioid prescribing among rural versus urban beneficiaries with disabilities.

METHODS: Deidentified claims data was used to gather a rolling cohort of Medicare Advantage beneficiaries with disabilities ages 18 to 64 from 2016 to 2021. Comparative interrupted time series were used in 2025 to analyze rural-urban differences in the duration and dosages of opioid fills for new-to-opioid beneficiaries, the target of the 7-day limit (N = 526,019 person-months), and the number of high-dosage episodes for long-term opioid beneficiaries, the target of the 90-MME limit (N = 3,312,161 person-months).

RESULTS: Despite significant reductions in initial opioid duration for both groups, the 7-day limit effect on initial opioid duration weakened over time (trend change: 0.17 [98.75% CI 0.04 to 0.30]) in the rural relative to the urban group. By the end of the study period, the rural group experienced 3.8 percentage points more initial opioid fills exceeding the 7-day limit (95% CI 0.4 to 7.3) than the urban group. Furthermore, the total dosage prescribed in subsequent fills among rural beneficiaries was 27.97 MME (95% CI -52.19 to -3.75) less than urban beneficiaries by the end of the study period. The rural and urban groups responded similarly to the 90-MME limitation.

CONCLUSIONS: Rural relative to urban new-to-opioid beneficiaries with disabilities experienced a weakened effect on initial opioid duration after Medicare's 7-day limit, while receiving declining dosage in follow-up opioid fills, suggesting potential disparities in access to follow-up opioid prescriptions for rural versus urban beneficiaries with disabilities. Policymakers may consider more flexible opioid regulations and attention to alternative pain management for rural Medicare beneficiaries.

BACKGROUND: Despite limited evidence of efficacy and well-established risks, long-term benzodiazepine use remains common. In July 2016, the Oregon Medicaid program introduced a prior authorization policy limiting benzodiazepine prescriptions to 4 weeks.

OBJECTIVES: To evaluate the impact of Oregon's benzodiazepine policy on medication utilization and health outcomes.

RESEARCH DESIGN: Interrupted time series regressions from January 2015-December 2017 (18 mo pre vs. post-policy).

SUBJECTS: Rolling cohorts of adult benzodiazepine recipients with 6 months of continuous enrollment before and after each month of observation.

MEASURES: Benzodiazepine utilization included monthly measures of overall, prevalent long-term, and incident long-term medication use. Harms included a composite measure of emergency department or inpatient admissions for overdose, self-harm, acute withdrawal, or acute psychiatric events, and were compared with patients using similar medications that were not affected by the policy.

RESULTS: The study population included 69,143 benzodiazepine recipients; 68% were female, and the average age was 41 years or older. Following policy implementation, there was a significant segment decrease (-​​​29.82 recipients/1000 patients; 95% CI: -​​​33.75 to -​​​25.89) in incident long-term benzodiazepine use and a 1.17 recipients/1000 patients/month (95% CI: 0.82-1.52) increase in trend. Trends in prevalent long-term (-1.16 recipients/1000 patients/month: 95% CI: -1.32 to -0.99) benzodiazepine use also declined. Modest trend decreases in harm were observed among all cohorts.

CONCLUSIONS: A policy to limit benzodiazepine duration was associated with a substantial reduction in progression to longer-term use and modest declines in the trend for potential harms.

Medicaid is the largest insurer for patients with opioid use disorder (OUD) and finances a disproportionate share of medication treatment for OUD (MOUD). Within Medicaid, initiation and continuity of MOUD are associated with improved outcomes, but substantial inequities across populations and care settings remain. The Medicaid Outcomes Distributed Research Network (MODRN) has supported Medicaid agency efforts to improve MOUD receipt and continuity of care. In the context of MODRN-Examining Quality Improvement for Medicaid Programs, the Behavioral Health Treatment Engagement and Retention Learning Collaborative (BHTER) will implement and evaluate interventions focused on improving quality and reducing variation in process and clinical outcomes in Medicaid patients with OUD. BHTER's aims are to (1) estimate the effects of a quality improvement intervention on receipt and continuity of MOUD in intervention practices relative to comparison practices, (2) examine whether a quality improvement intervention narrows racial gaps in rates and continuity of MOUD in intervention relative to comparison practices, (3) examine provider perspectives on the quality improvement intervention, with a focus on practice and process changes that resulted in improvement, and factors that impede or facilitate delivery of high-quality MOUD care. In this protocol paper, we describe the rationale, methods, and impact of BHTER.