Publications

BACKGROUND & AIMS: Despite increased risks for adverse effects in patients with cirrhosis, little is known about opioid prescriptions for this population. We aimed to assess time trends in opioid prescribing and factors associated with receiving opioids among patients with cirrhosis.

METHODS: Among Veterans with cirrhosis, identified using national Veterans Health Administration data (2005-2014), we assessed characteristics of patients and their prescriptions for opioids. We calculated the annual proportion of patients receiving any opioid prescription. Among opioid recipients, we assessed prescriptions that were long-term (>90 days' supply), for high doses (>100 MME/day), or involved combinations of opioids and acetaminophen or benzodiazepine. We evaluated patient characteristics independently associated with long-term and any opioid prescriptions using mixed-effects regression models.

RESULTS: Among 127,239 Veterans with cirrhosis, 97,974 (77.0%) received a prescription for an opioid. Annual opioid prescriptions increased from 36% in 2005 to 47% in 2014 (P < .01). Among recipients of opioids, the proportions of those receiving long-term prescriptions increased from 47% in 2005 to 54% in 2014 (P < .01), and19%-21% received prescriptions for high-dose opioids. Prescriptions for combinations of opioids and acetaminophen decreased from 68% in 2005 to 50% in 2014 (P < .01) and for combinations of opioids and benzodiazepines decreased from 24% to 19% over this time (P < .01). Greater probability of long-term opioid prescriptions was independently associated with younger age, female sex, white race, hepatitis C, prior hepatic decompensation, hepatocellular carcinoma, mental health disorders, nicotine use disorders, medical comorbidities, surgery, and pain-related conditions.

CONCLUSION: Among Veterans with cirrhosis, 36%-47% were prescribed opioids in each year. Mental health disorders and hepatic decompensation were independently associated with long-term opioid prescriptions.

This study uses Medicaid drug utilization data to describe reimbursement and market share of long-acting insulins before and after approval of new insulin products and to estimate savings associated with a “biosimilar” for insulin glargine approved in 2015.

BACKGROUND: More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems.

OBJECTIVE: To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose.

DESIGN: Nested case-control study.

SETTING: VA and Medicare Part D.

PARTICIPANTS: Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions.

MEASUREMENTS: The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications.

RESULTS: Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005).

LIMITATION: Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems.

CONCLUSION: Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety.

PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.

INTRODUCTION: Value-based contracts (VBCs) that link drug payments to disease-related performance metrics aim to increase the value and lower the cost of medications by aligning incentives and sharing risk between payers and pharmaceutical manufacturers. This study sought to identify outcome measures that are meaningful to key stakeholders to inform VBCs for coronary artery disease (CAD) medications.

METHODS: We administered a modified Delphi survey to gather expert opinion from a diverse panel of patients (n = 9), cardiologists (n = 4), primary care physicians (n = 5), payers (n = 2), pharmacy benefits managers (n = 3), and pharmaceutical company representatives (n = 2). A list of 16 CAD-associated clinical indicators was generated from the literature and expert consultation. Delphi participants rated the importance of each outcome on a five-point Likert scale, and selected the three most meaningful outcomes. We defined consensus as ≥ 75% agreement on the importance of an outcome (Likert scores 4 or 5 or selection of an outcome as most meaningful).

RESULTS: Eleven of 13 outcomes reached consensus for importance on the Likert scale. "Preventing heart attacks" was selected as the most meaningful outcome (80%) while "preventing death" ranked second (76%).

CONCLUSIONS: Our study results verify the utility of a widely used clinical CAD outcome measure, myocardial infarction events, for the purpose of pharmaceutical value-based contracting.

BACKGROUND: Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes.

OBJECTIVE: To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia.

METHODS: Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids.

RESULTS: Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%).

CONCLUSIONS: Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.

This study uses wholesale medication acquisition costs and Medicare claims data to assess how prices of existing tumor necrosis factor inhibitors changed in response to the market entry of new tumor necrosis factor inhibitors.

BACKGROUND: Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans.

OBJECTIVES: To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans.

METHODS: In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008-2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012-2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only.

RESULTS: Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death.

CONCLUSIONS: Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.