Publications

BACKGROUND: Cross-sectional studies have shown that antidepressants (ADs) and benzodiazepines (BZDs) are commonly co-prescribed for depression, potentially increasing the risk of falls and related injuries (FRI) compared to monotherapies. However, little is known about the longitudinal dosing patterns (i.e., trajectory) of ADs and BZDs and their associated FRI risk.

METHODS: This retrospective cohort study used group-based multi-trajectory models to identify AD-BZD trajectories among older Medicare fee-for-service beneficiaries with depression initiating ADs with/without BZDs. We measured the standardized daily doses of AD and BZD within 84 days after AD initiation and categorized them into negligible, very-low, low, moderate, high, or very-high levels with a discontinuing, declining, increasing, or stable trend. Then, we assessed the subsequent 12-month FRI risk associated with each trajectory.

RESULTS: Among 102,750 eligible beneficiaries, the mean age was 75.5 years (SD = 7.5); 67.0% were female, 81.2% were White, and 4.9% experienced an FRI. We identified 12 distinct AD/BZD trajectories, of which 79,424 patients received AD monotherapy, and 23,326 patients received both ADs and BZDs. Compared with Group A (low discontinuing AD; 17.3% of the cohort; FRI crude incidence rate = 99.7/1000 person-year), trajectories with a higher dose or a longer duration of AD use were associated with an increased FRI risk, regardless of BZD use. The hazard ratios (HR) and 95% confidence intervals (CI) for Groups B (low declining AD; 31.0% of the cohort), C (moderate increasing AD; 23.5%), and D (high increasing AD; 5.4%) were 1.11 (1.04-1.19), 1.24 (1.16-1.32), and 1.29 (1.16-1.42), respectively. Combining ADs and BZDs at very-low doses or with declining trends did not significantly alter FRI risk compared to AD monotherapy. However, FRI risk increased when BZDs were used at low doses (either with stable or increasing trends). The HR and 95%CI for Groups J (moderate increasing AD/low stable BZD, 1.3%) and L (very-high increasing AD/low-dose increasing BZD) were 1.71 (1.41, 2.08) and 1.96 (1.53, 2.49), respectively.

CONCLUSIONS: We observed a dose-response relationship between AD use and FRI risk, independent of BZD use, highlighting the importance of initiating ADs at the lowest effective dose and closely monitoring to prevent FRI.

Orthostatic hypotension (OH) is a common inpatient condition associated with falls, syncope, and mortality. However, standardized approaches for inpatient management of OH are lacking and may vary across clinical specialties. In this retrospective observational cohort study, we reviewed the electronic medical records of patients admitted to Beth Israel Deaconess Medical Center between April 1, 2015 and June 1, 2021 with a diagnosis of OH or medication-related hypotension. Variables of interest included admitting service, presenting symptoms, suspected etiology, and management. Among the 400 inpatients with OH, one-third had OH documented on admission. Dizziness and lightheadedness were the most common symptoms; medical patients experienced dizziness, falls, and other symptoms more frequently than surgical patients. Volume depletion and medications were the leading suspected causes of OH. Surgical patients were less likely to have medication-related OH and were more likely to lack an identified etiology. Cardiovascular disease was more frequently implicated in cardiology patients. Volume depletion, neurodegenerative disease, and other conditions were more often suspected among medical patients. Management commonly involved volume resuscitation and medication adjustment, though medication changes were less frequent in surgical patients. Nonpharmacologic interventions were more common among medical patients. By discharge, OH had resolved in only one-third of patients. In summary, inpatient OH was most often identified after admission, attributed to hypovolemia, treated with fluids, and unresolved at discharge, with differences in symptoms, etiology, and management between specialties. Prospective studies are needed to formalize diagnostic and treatment strategies for OH in the hospital setting.

OBJECTIVE: Determine whether a Medicare 7-day limit on initial opioid prescriptions (effective January 1, 2019) was associated with reductions in duration, dosage, and subsequent opioid fills among post-operative adults with disabilities.

BACKGROUND: Post-operative adults with disabilities are at increased risk for uncontrolled pain and extended opioid use.

METHODS: We identified adults with disability entitlement aged 18-64 from national Medicare Advantage health plan claims data who underwent common surgeries between July 2016-June 2021. We used a repeated cross-sectional interrupted time series design to examine changes in opioid prescribing associated with the 2019 7-day limit.

RESULTS: Sample included 24,910 member-index months (mean age [SD] 55.5 [8.0] years; 14,413 [57.9%] female) representing 24,283 members. The 7-day limit was associated with an 11.8 percentage point (pp) reduction (95% CI -13.3, -10.2) in the likelihood of an initial fill >7-day supply that remained lower than predicted (-5.7 pp, 95% CI -7.6, -3.7) by June 2021. Cumulative 30-day MME was lower than predicted (-35.9 MME, 95% CI -53.7, -18.1) in January 2019 but higher than predicted by June 2021 (95.2 MME, 95% CI 56.9, 133.6). The likelihood of ≥1 fills within 30-days of the initial fill was not significantly different in January 2019 but was 6.9 pp higher (95% CI 3.1, 10.7) than predicted by June 2021.

CONCLUSION: The 2019 Medicare 7-day limit was associated with immediate large reductions in initial opioid duration and dosage. Increased dosage observed in June 2021 may have been mediated by an increase in subsequent opioid prescriptions after the initial fill.

INTRODUCTION: Early detection and intervention are crucial for reducing the impacts of depression and associated healthcare costs. Few studies have used electronic health records (EHR) and machine learning (ML) with a longitudinal design to predict depression onset. We developed and validated ML algorithms using EHR to identify patients at high risk for the onset of diagnosis-based major depressive disorder (MDD) in primary care settings.

METHODS: Using a prognostic modeling approach with retrospective cohort study design, we identified patient visits in primary care settings for individuals aged ≥18 years from the Accelerating Data Value Across a National Community Health Center Network Clinical Research Network 2015-2021 data. We measured 267 features at six-month intervals starting six months prior to the first encounter. We developed algorithms using Least Absolute Shrinkage and Selection Operator (LASSO), random forest, and XGBoost with 10-fold cross validation. Using hold-out testing data, we measured prediction performance (e.g., C-statistics), stratified patients into decile risk subgroups, and assessed model biases.

RESULTS: Among eligible 1,965,399 individuals (mean age = 43.52 ± 16.04 years; male = 35%; African American = 20%) with 4,985,280 person-periods, the MDD onset rate was 1% during the study period. XGBoost performed similarly to other models and had the fewest predictors, (C-statistic = 0.763, 95% CI = [0.760, 0.767]). XGBoost had a 66.78% sensitivity, 74.19% specificity, and 2.55% positive predictive value at the balanced threshold identified using Youdan Index. The top three risk decile subgroups captured ∼70% of MDD cases, without significant racial or sex biases.

CONCLUSIONS: An ML algorithm using EHR data can effectively identify individuals at high risk of depression onset within the subsequent six months, without exacerbating racial or sex biases, providing a valuable tool for targeted early interventions.

In February 2017, the Department of Veterans Affairs (VA) restructured outpatient medication copayments, creating three medication tiers comparable with private-sector value-based insurance designs (with copayments: US$5, US$8, US$11 per 30-day supply for Tiers 1-3, respectively); however, Veteran medication management experiences have not been assessed following this change. We invited a random sample of Veterans with chronic conditions (e.g., diabetes, hypertension) who utilized VA services to complete a mailed survey about VA and non-VA pharmacy use and medication management experiences following this restructuring. There were 2,884 respondents (29% response rate). Veterans with the lowest proportion of medications from Tier 1 after the restructuring had the highest predicted probability of non-VA pharmacy use from regression analyses. Among respondents subject to VA copayments, 27% reported being better able to afford medications after the restructuring. However, 29% reported worrying about paying for medications, and 18% reported making tradeoffs (e.g., spending less on utilities, food) to pay for prescriptions.

IMPORTANCE: The utilization of elective surgical procedures is lower for patients enrolled in Medicare Advantage (MA) than in traditional Medicare (TM), but it remains unclear whether surgical episode costs differ between MA and TM for comparable patients.

OBJECTIVE: To compare the estimated costs, markers of resource use (eg, length of stay and location of surgery), and outcomes of surgical episodes for similar patients enrolled in MA and TM.

DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, 2019 Medicare claims and encounters data were analyzed to compare differences in surgical episode costs for beneficiaries with MA vs TM who underwent common elective surgical procedures across 11 categories. Procedures performed in either inpatient or outpatient settings were included in the analysis. Data were analyzed from January 2023 to March 2025.

EXPOSURES: Enrollment in MA or TM.

MAIN OUTCOMES AND MEASURES: The primary outcomes were estimated 30-day costs of surgical episodes and factors affecting costs and/or outcomes, including share of inpatient procedures, length of stay, share of patients discharged home, and 30-day readmission rates. A secondary outcome explored potential facility selection and patient steering by estimating the distance traveled to surgery. Multivariable linear regression models adjusted for the type of surgical procedure, patient characteristics, and their Elixhauser Comorbidity Index were used to compare outcomes of surgical episodes in patients with MA vs TM within hospital referral regions.

RESULTS: The analysis included 1 177 700 surgical procedures among 1 110 263 Medicare beneficiaries (mean [SD] age, 73.42 [5.8] years; 686 708 females [58.3%]). The overall rate of surgery utilization was lower among MA patients vs TM patients (difference in rate, -4.4%; 95% CI, -4.8% to -4.1%), with variation found across surgical categories. Across procedures, 30-day surgical episode costs for MA patients vs TM patients were, on average, $671 (95% CI, $639-$702) lower. The share of procedures billed at the higher inpatient rate was 5.41 (95% CI, 5.23-5.58) percentage points (pp) lower for MA patients than for TM patients, and the mean length of inpatient stay was 0.27 (95% CI, 0.26-0.29) days shorter. The share of patients discharged home was higher for those with MA vs TM (3.82 [95% CI, 3.65-3.99] pp). MA patients traveled a mean of 2.32 (95% CI, 1.62-3.01) miles farther for surgery. Readmission rates were lower for patients with MA (-0.70 [95% CI, -0.83 to -0.58] pp).

CONCLUSIONS AND RELEVANCE: This study found that in addition to lower utilization of common elective surgical procedures, the costs of surgical episodes were lower for patients enrolled in MA than those enrolled in TM. MA plans had lower costs because more procedures were performed in outpatient settings, required shorter lengths of stay, and less expensive postacute care, with no apparent harm to overall quality. Physician and surgical facility selection and patient steering likely contributed to these cost differences. These findings highlight potential mechanisms by which MA plans may achieve cost savings compared with TM plans.