Publications

PURPOSE: We compare trends in gabapentinoid and opioid utilization overall and by economic development category. We also sought to predict future trends and assess correlations in gabapentinoid and opioid utilization.

METHODS: We conducted a repeated cross-sectional analysis of retail prescriptions for 72 countries from Q1 2012 to Q3 2023. We measured standardized units/1000 population for gabapentinoid and opioid sales, stratified by development category, and used time-series models to predict trends for the following 3 years. Granger causality tests examined predictive relationships between gabapentinoid and opioid sales.

RESULTS: Global gabapentinoid annual sales rose by 114.5% from 2012 to 2022, with a higher increase in developing (180.9%) than developed economies (110.0%). In contrast, annual opioid sales declined globally by 25.4%, with a 27.9% decrease in developed and a 16.8% increase in developing economies. Assuming current trends persist over the following 3 years, gabapentinoid quarterly sales are forecasted to rise by 7.7% in developed and 18.6% in developing economies, while opioid quarterly sales are expected to decrease by 9.5% and increase by 15.1%, respectively. Granger causality tests indicated that gabapentinoids may predict opioid sales globally for the following year, but opioids did not predict gabapentinoid sales.

CONCLUSION: We evaluated the global trends in gabapentinoid and opioid sales, suggesting important differences in pain management practices across developed and developing economies. Our findings highlight the need to ensure the safe use of gabapentinoids and opioids while balancing proper pain management.

IMPORTANCE: Medicare beneficiaries with disabilities have excess opioid-related morbidity and mortality. A 2019 Medicare opioid safety policy was designed to address high-risk opioid prescribing and related harms by limiting the initial duration to 7 days and restricting high daily dosage across multiple prescribers.

OBJECTIVE: To evaluate the association of the 2019 Medicare opioid 7-day and 90-morphine milligram equivalence (MME) safety edits with opioid use among beneficiaries with disabilities.

DESIGN, SETTING, AND PARTICIPANTS: This interrupted time-series study used claims data from Optum's deidentified Clinformatics Data Mart database to assess changes in opioid prescriptions and use among Medicare Advantage beneficiaries (younger than 65 years) with disability entitlements from June 2016 to September 2021. The analysis compared opioid use outcomes before and after the safety policy was implemented in 2019 (including the COVID-19 pandemic) in 2 cohorts of patients (new to opioids vs long-term opioid use). Data analyses were performed from September 2023 to October 2024.

EXPOSURES: Implementation of the Medicare opioid 7-day and 90-MME safety edits in January 2019.

MAIN OUTCOMES AND MEASURES: Likelihood of an initial opioid prescription more than 7 days' supply and 30-day total MME; likelihood of development of long-term opioid use in a new-to-opioid cohort; the number of concurrent multiple-prescriber high-dosage episodes in a long-term opioid cohort.

RESULTS: The new-to-opioids cohort included 476 859 person-index months (mean [SD] age, 55.7 [7.8] years; 281 536 [59.0%] women). The long-term opioid cohort included 3 295 299 person-index months (mean [SD] age, 56.3 years [6.6]; 1 887 547 [57.3%] men and 1 407 752 [42.7%] women). The 7-day safety edit was associated with immediate and sustained reductions in the likelihood of an initial opioid prescription filled for more than 7 days' supply (start of the post-policy period: 46.7 % reduction; 99.5% CI, -48.3% to -45.2%; end of study period: 43.8% reduction; 99.5% CI, -45.7% to -41.9%). In contrast, moderate immediate reductions in the likelihood of development into long-term opioid use (13.8% reduction; 99.5% CI, -20.5% to -7.2%) diminished by the end of the study period (4.0% reduction; 99.5% CI, -10.4% to 2.4%). The 90-MME safety edit was associated with an immediate 36.1% reduction (99.5% CI, -42.8% to -29.4%) in the number of concurrent multiple-prescriber high-dosage episodes, which was reversed when the COVID-19 flexibility rolled back the 90-MME edit.

CONCLUSIONS AND RELEVANCE: The findings of this interrupted time-series study of Medicare Advantage beneficiaries younger than 65 years with disabilities show that the 2019 Medicare opioid safety policy was associated with shorter initial duration of opioid prescriptions and fewer concurrent multiple prescriber high-dosage prescriptions of opioids. Given that downstream reductions appeared to be transient, further interventions are needed to address the clinical and social risk factors for opioid misuse among beneficiaries with disabilities.

OBJECTIVES: Identifying people with possible dementia in health care systems is important to study outcomes and target improvements in care. This study sought to compare the performance of diagnostic codes and Minimum Data Set (MDS)-based measures for identifying dementia and cognitive impairment in older veteran nursing home residents.

DESIGN: Retrospective, cross-sectional analysis.

SETTING AND PARTICIPANTS: We used real-world health care data from the Veterans Affairs (VA) Residential History File, VA Corporate Data Warehouse (CDW), Medicare claims, and the MDS to assemble a cohort of VA Community Living Center (CLC) admissions over 2015 to 2021 for veterans aged ≥ 65 with dual VA and Medicare enrollment (n = 54,234).

METHODS: We defined 3 measures of possible dementia: (1) claims/CDW diagnoses using Chronic Conditions Warehouse (CCW) algorithms for Alzheimer's disease or non-Alzheimer's dementia; (2) MDS active diagnosis items for Alzheimer's disease and non-Alzheimer's dementia; and (3) MDS Cognitive Function Scale (CFS) assessment indicating at least mild cognitive impairment. We calculated proportions identified with each definition, and sensitivity, specificity, and positive predictive value of claims/CDW diagnoses and MDS indicators for dementia for identifying CFS impairment.

RESULTS: Among VA CLC residents, 61.4% met at least 1 criterion for possible dementia (38.6% claims/CDW, 23.3% MDS active diagnosis, 50.8% CFS). Diagnoses from claims/CDW had 56.5% sensitivity and 80.0% specificity for identifying veterans with CFS cognitive impairment. Active diagnoses from the MDS exhibited poorer sensitivity (38.1%), but higher specificity (92.0%) identifying veterans with cognitive impairment on the CFS.

CONCLUSIONS AND IMPLICATIONS: Consistent with what has been reported in Medicare nursing home residents, we observed only partial overlap between indicators of possible dementia across diagnosis codes and other indicators vs cognitive assessments in MDS. Our findings support the utility of these measures for identifying individuals with possible dementia across different systems, but further work is needed to understand implications when using diagnosis codes or cognitive assessments.

BACKGROUND: One of the largest-ever retail drug shortages began in 2018 when several angiotensin II receptor blockers (ARBs) for treating hypertension, heart failure, and chronic kidney disease-valsartan, losartan, and irbesartan-were recalled for carcinogenic impurities. The long-term consequences of the ARB shortages and whether certain groups experienced more adverse outcomes is unknown.

OBJECTIVE: To evaluate changes in adherence and health outcomes after ARB recalls and to identify patients who experienced greater changes in access and adverse clinical outcomes.

METHODS: Using an integrated claims and electronic health record dataset and a difference-in-differences design, we evaluated changes in the proportion of days covered (PDC) for ARBs and similar drugs (angiotensin-converting enzyme inhibitors [ACE-Is]), uncontrolled blood pressure, major cardiovascular event (MACE)-related acute care visits, and all-cause ambulatory care visits in the 12 months before vs 18 months after recalls for valsartan, losartan, and irbesartan users vs patients taking similar, nonrecalled drugs (ACE-Is, nonrecalled ARBs). Triple-difference models characterized heterogeneous associations by pre-recall patient demographic (race, ethnicity, age), clinical (baseline indication, mental health conditions), and adherence variables.

RESULTS: Adjusting for pre-recall patient characteristics, we observed no significant changes in PDC for ARBs and ACE-Is (combined), uncontrolled blood pressure, or ambulatory care visits among 86,507 recalled ARB users vs 123,583 comparison drug users in the 18 months after the recalls. Following the recalls, medication switches increased on average by an additional 2.08 percentage points (p.p.) per quarter (95% CI = 2.01-2.15) for recalled ARB vs comparison drug users, a 195.9% relative increase. We observed the most switches in the 90-day period immediately after valsartan's recall (difference-in-difference: 9.48 p.p.; 95% CI = 9.36-9.59; relative change = 892%). Cumulatively, 55.2% of valsartan, 7.6% of losartan, and 18.9% of irbesartan users switched medications after 18 months. We observed an increase in the proportion of recalled ARB vs comparison patients who experienced medication gaps exceeding 30 days (1.13 p.p. per quarter on average; 95% CI = 0.97-1.30), which was most apparent after approximately 15 months (5 quarters). Although MACE-related acute care visits did not change in the quarter (90 days) immediately after valsartan's recall, we observed an increase of 1.40 additional visits per 1,000 recalled ARB vs comparison drug patients in each subsequent quarter, a 9.3% relative increase. Results were similar across most subgroups.

CONCLUSIONS: The 2018 ARB recalls were associated with immediate changes in antihypertension medication use. Many patients transitioned to alternative medications. Although overall impacts on clinical outcomes were minimal and not statistically significant, small increases in medication gaps and MACE-related acute care visits among some patients occurred after more than 1 year. The ARB recalls may have been associated with fewer adverse events than other recent shortages owing to the widespread availability of alternative treatments in the same or similar drug class.

IMPORTANCE: Monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) or its receptor (anti-CGRP mAbs) offer effective migraine-specific preventive treatment. However, concerns exist about their potential cardiovascular risks due to CGRP blockade.

OBJECTIVE: To compare the incidence of cardiovascular disease (CVD) between Medicare beneficiaries with migraine who initiated anti-CGRP-mAbs vs onabotulinumtoxinA in the US.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective, sequential cohort study was conducted among a nationally representative population-based sample of Medicare claims from May 2018 through December 2020. Data analysis was performed from August to December 2023. This study included fee-for-service Medicare beneficiaries aged 18 years or older with migraine who initiated either anti-CGRP mAbs or onabotulinumtoxinA. Beneficiaries who had a history of myocardial infarction (MI), stroke, cluster headache, malignant cancer, or hospice service within a 1-year baseline period prior to treatment initiation were excluded. To minimize channeling bias from new drug introductions and time-related bias due to the COVID-19 pandemic, 5 cohorts were established, representing sequential 6-month calendar intervals based on the initial prescription or date of index anti-CGRP mAbs or onabotulinumtoxinA use.

EXPOSURE: Anti-CGRP mAbs vs onabotulinumtoxinA.

MAIN OUTCOMES AND MEASURES: The primary outcome was time to first MI or stroke. Secondary outcomes included hypertensive crisis, peripheral revascularization, and Raynaud phenomenon. The inverse probability of treatment-weighted Cox proportional hazards models were used to compare outcomes between the 2 treatment groups.

RESULTS: Among 266 848 eligible patients with migraine, 5153 patients initiated anti-CGRP mAbs (mean [SD] age, 57.8 [14.0] years; 4308 female patients [83.6%]) and 4000 patients initiated onabotulinumtoxinA (mean [SD] age, 61.9 [13.7] years; 3353 female patients [83.8%]). Use of anti-CGRP mAbs was not associated with an increased risk of composite CVD events (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.44-1.77), hypertensive crisis (aHR, 0.46; 95% CI, 0.14-1.55), peripheral revascularization (aHR, 1.50; 95% CI, 0.48-4.73), or Raynaud phenomenon (aHR, 0.75; 95% CI, 0.45-1.24) compared with onabotulinumtoxinA. Subgroup analyses by age group and presence of established non-MI or stroke CVD showed similar findings.

CONCLUSIONS AND RELEVANCE: In this cohort study, despite initial concerns regarding the cardiovascular effects of CGRP blockade, anti-CGRP mAbs were not associated with an increased risk of CVD compared with onabotulinumtoxinA among adult Medicare beneficiaries with migraine, who were predominantly older adults or individuals with disability. Future studies with longer follow-up periods and in other populations are needed to confirm these findings.

OBJECTIVES: To highlight the often overlooked role of user interface (UI) design in mitigating bias in artificial intelligence (AI)-based clinical decision support (CDS).

MATERIALS AND METHODS: This perspective paper discusses the interdependency between AI-based algorithm development and UI design and proposes strategies for increasing the safety and efficacy of CDS.

RESULTS: The role of design in biasing user behavior is well documented in behavioral economics and other disciplines. We offer an example of how UI designs play a role in how bias manifests in our machine learning-based CDS development.

DISCUSSION: Much discussion on bias in AI revolves around data quality and algorithm design; less attention is given to how UI design can exacerbate or mitigate limitations of AI-based applications.

CONCLUSION: This work highlights important considerations including the role of UI design in reinforcing/mitigating bias, human factors methods for identifying issues before an application is released, and risk communication strategies.

BACKGROUND: Ischemic stroke is a leading cause of death and disability. Society guidelines recommend pharmacotherapies for secondary stroke prevention. However, the role of sex differences in prescription and adherence to guideline-directed medical therapies (GDMT) after ischemic stroke remains understudied. The aim of this study was to examine sex differences in prescription patterns and adherence to GDMT at 1 year after ischemic stroke in a cohort of commercially insured patients.

METHODS: Using the Truven Health MarketScan database from 2016 to 2020, we identified patients admitted with ischemic stroke. GDMT was defined as any statin, antihypertensive agents, or oral anticoagulant prescription within 30 days after discharge. Medication adherence was estimated using the proportion of days covered at 1 year. The proportion of days covered <0.80 was used to define nonadherence. A multivariable model adjusting for covariates was performed to identify the factors associated with nonadherence at 1 year. This analysis was restricted to new users of GDMT.

RESULTS: Among 155 220 patients admitted with acute ischemic stroke during the study period, 15 919 met the inclusion criteria. The mean age was 55.7 years, and 8218 (51.7%) were women. Women were less likely to be prescribed statins (58.0% versus 71.8%) and antihypertensive agents (27.7% versus 41.8%). In this subset of patients with atrial flutter/fibrillation, women were also less likely to be prescribed oral anticoagulants (41.2% versus 45.0%). Women were more likely to be nonadherent (ie, proportion of days covered <0.80) to statins (47.3% versus 41.6%; P<0.0001), antihypertensives (33.3% versus 32.2%; P=0.005), and the combination of both (49.6% versus 45.0%; P=0.003). On multivariable analysis, women were likely to be nonadherent to statins and antihypertensive agents at 1 year (odds ratio, 1.23 [95% CI, 1.08-1.41]).

CONCLUSIONS: In this real-world analysis of commercially insured patients with ischemic stroke, women were less likely initiated on GDMT within 30 days after discharge. Women were more likely to be nonadherent to statins and antihypertensive agents at 1 year. Future efforts and novel interventions are needed to understand the reasons and minimize these disparities.