Gellad, Walid F, Chester B Good, and David J Shulkin. (2017) 2017. “Addressing the Opioid Epidemic in the United States: Lessons From the Department of Veterans Affairs.”. JAMA Internal Medicine 177 (5): 611-12. https://doi.org/10.1001/jamainternmed.2017.0147.
Publications
2017
Cochran, Gerald, Adam J Gordon, Wei-Hsuan Lo-Ciganic, Walid F Gellad, Winfred Frazier, Carroline Lobo, Chung-Chou H Chang, Ping Zheng, and Julie M Donohue. (2017) 2017. “An Examination of Claims-Based Predictors of Overdose from a Large Medicaid Program.”. Medical Care 55 (3): 291-98. https://doi.org/10.1097/MLR.0000000000000676.
BACKGROUND: Health systems may play an important role in identification of patients at-risk of opioid medication overdose. However, standard measures for identifying overdose risk in administrative data do not exist.
OBJECTIVE: Examine the association between opioid medication overdose and 2 validated measures of nonmedical use of prescription opioids within claims data.
RESEARCH DESIGN: A longitudinal retrospective cohort study that estimated associations between overdose and nonmedical use.
SUBJECTS: Adult Pennsylvania Medicaid program 2007-2012 patients initiating opioid treatment who were: nondual eligible, without cancer diagnosis, and not in long-term care facilities or receiving hospice.
MEASURES: Overdose (International Classification of Disease, ninth edition, prescription opioid poisonings codes), opioid abuse (opioid use disorder diagnosis while possessing an opioid prescription), opioid misuse (a composite indicator of number of opioid prescribers, number of pharmacies, and days supplied), and dose exposure during opioid treatment episodes.
RESULTS: A total of 372,347 Medicaid enrollees with 583,013 new opioid treatment episodes were included in the cohort. Opioid overdose was higher among those with abuse (1.5%) compared with those without (0.2%, P<0.001). Overdose was higher among those with probable (1.8%) and possible (0.9%) misuse compared with those without (0.2%, P<0.001). Abuse [adjusted rate ratio (ARR), 1.52; 95% confidence interval (CI), 1.10-2.10), probable misuse (ARR, 1.98; 95% CI, 1.46-2.67), and possible misuse (ARR, 1.76; 95% CI, 1.48-2.09) were associated with significantly more events of opioid medication overdose compared with those without.
CONCLUSIONS: Claims-based measures can be used by health systems to identify individuals at-risk of overdose who can be targeted for restrictions on opioid prescribing, dispensing, or referral to treatment.
Kabiri, Mina, Jagpreet Chhatwal, Julie M Donohue, Mark S Roberts, Everette James, Michael A Dunn, and Walid F Gellad. (2017) 2017. “Long-Term Disease and Economic Outcomes of Prior Authorization Criteria for Hepatitis C Treatment in Pennsylvania Medicaid.”. Healthcare (Amsterdam, Netherlands) 5 (3): 105-11. https://doi.org/10.1016/j.hjdsi.2016.11.001.
BACKGROUND: Several highly effective but costly therapies for hepatitis C virus (HCV) are available. As a consequence of their high price, 36 state Medicaid programs limited treatment coverage to patients with more advanced HCV stages. States have only limited information available to predict the long-term impact of these decisions.
METHODS: We adapted a validated hepatitis C microsimulation model to the Pennsylvania Medicaid population to estimate the existing HCV prevalence in Pennsylvania Medicaid and estimate the impact of various HCV drug coverage policies on disease outcomes and costs. Outcome measures included rates of advanced-stage HCV outcomes and treatment and disease costs in both Medicaid and Medicare.
RESULTS: We estimated that 46,700 individuals in Pennsylvania Medicaid were infected with HCV in 2015, 33% of whom were still undiagnosed. By expanding treatment to include mild fibrosis stage (Metavir F2), Pennsylvania Medicaid will spend an additional $273 million on medications in the next decade with no substantial reduction in the incidence of liver cancer or liver-related death. Medicaid patients who are not eligible for treatment under restricted policies would get treatment once they transition to the Medicare program, which would incur 10% reduction in HCV-related costs due to early treatment in Medicaid. Further expanding treatment to patients with early fibrosis stages (F0 or F1) would cost Medicaid an additional $693 million during the next decade but would reduce the number of individuals in need of treatment in Medicare by 46% and decrease Medicare treatment costs by 23%. In some scenarios, outcomes could worsen with eligibility expansion if there is inadequate capacity to treat all patients.
CONCLUSIONS AND RELEVANCE: Expansion of HCV treatment coverage to less severe stages of liver disease may not substantially improve liver related outcomes for patients in Pennsylvania Medicaid in scenarios in which coverage through Medicare is widely available.
Stroupe, Kevin T, Bridget M Smith, Lauren Bailey, Jamal Adas, Walid F Gellad, Katie Suda, Zhiping Huo, Sean Tully, Muriel Burk, and Francesca Cunningham. (2017) 2017. “Medication Acquisition by Veterans Dually Eligible for Veterans Affairs and Medicare Part D Pharmacy Benefits.”. American Journal of Health-System Pharmacy : AJHP : Official Journal of the American Society of Health-System Pharmacists 74 (3): 140-50. https://doi.org/10.2146/ajhp150800.
PURPOSE: The patterns of medication acquisition for veterans dually eligible for pharmacy benefits from the Department of Veterans Affairs (VA) and Medicare Part D-reimbursed pharmacies were examined.
METHODS: The characteristics of veterans who used pharmacies reimbursed by (1) VA only, (2) both VA and Part D-reimbursed, and (3) Part D-reimbursed only pharmacies in 2009 were compared and their medication types and sources examined. Pharmacy usage was measured as the number of 30-day medication supplies and the number of different drug classes that veterans received from VA and Part D-reimbursed pharmacies. Chi-square testing and analysis of variance were used to compare unadjusted patient characteristics and healthcare utilization.
RESULTS: A total of 145,899 veterans with any VA or Part D-reimbursed pharmacy use were included in the study: 69.6% used VA pharmacies only, 9.9% used VA and Part D-reimbursed pharmacies, and 20.5% used Part D-reimbursed pharmacies only. Veterans who lived in rural areas, were non-Black, had VA medication copayments, or were dual or Medicare-only outpatient users were more likely to be dual or Part D-reimbursed only pharmacy users (p < 0.001). Dual pharmacy users received more 30-day supplies than did the other two pharmacy-use groups (p < 0.001).
CONCLUSION: Nearly one third of VA users received medications from Part D-reimbursed pharmacies, either alone or together with VA pharmacies. Among dual pharmacy users, over half received medications from the same drug class from both VA and Part D-reimbursed pharmacies for which the days' supplies overlapped by more than seven days.
Radomski, Thomas R, Xinhua Zhao, Carolyn T Thorpe, Joshua M Thorpe, Jennifer G Naples, Maria K Mor, Chester B Good, Michael J Fine, and Walid F Gellad. (2017) 2017. “The Impact of Medication-Based Risk Adjustment on the Association Between Veteran Health Outcomes and Dual Health System Use.”. Journal of General Internal Medicine 32 (9): 967-73. https://doi.org/10.1007/s11606-017-4064-4.
BACKGROUND: Veterans commonly receive care from both Veterans Health Administration (VA) and non-VA sources (i.e., dual use). A major challenge in comparing health outcomes between dual users and VA-predominant users is applying an accurate method of risk adjustment.
OBJECTIVE: To determine how different comorbidity indices affect the association between patterns of dual use and health outcomes.
DESIGN: Retrospective cohort.
PARTICIPANTS: A total of 316,775 community-dwelling Veterans (≥65 years) with type 2 diabetes who were enrolled in VA and fee-for-service Medicare from 2008 to 2010.
METHODS: We determined the associations between dual use and death or diabetes-related hospitalization in FY 2010 using multivariable models incorporating claims-based (Elixhauser) or medication-based (RxRisk-V) risk adjustment. Dual use was classified using four previously identified groups of health services users: 1) VA-predominant, 2) VA + Medicare visits and labs, 3) VA + Medicare test strips, and 4) VA + Medicare medications.
KEY RESULTS: Controlling for Elixhauser comorbidities, dual-use groups 2-4 had significantly decreased odds of death or hospitalization compared to VA-predominant users. Controlling for RxRisk-V comorbidities, groups 2-4 had increased odds of death compared to VA-predominant users, but variable odds of hospitalization, with group 2 having increased odds (OR 1.06, CI 1.04-1.09), while groups 3 (OR 0.96, CI 0.94-0.99) and 4 (OR 0.93, CI 0.89-0.97) had decreased odds.
CONCLUSIONS: The method of risk adjustment drastically influences the direction of effect in health outcomes among dual users of VA and Medicare. These findings underscore the need for standardized and reliable risk adjustment methods that are not susceptible to measurement differences across different health systems.
Thorpe, Joshua M, Carolyn T Thorpe, Walid F Gellad, Chester B Good, Joseph T Hanlon, Maria K Mor, John R Pleis, Loren J Schleiden, and Courtney Harold Van Houtven. (2017) 2017. “Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study.”. Annals of Internal Medicine 166 (3): 157-63. https://doi.org/10.7326/M16-0551.
BACKGROUND: Recent federal policy changes attempt to expand veterans' access to providers outside the Department of Veterans Affairs (VA). Receipt of prescription medications across unconnected systems of care may increase the risk for unsafe prescribing, particularly in persons with dementia.
OBJECTIVE: To investigate the association between dual health care system use and potentially unsafe medication (PUM) prescribing.
DESIGN: Retrospective cohort study.
SETTING: National VA outpatient care facilities in 2010.
PARTICIPANTS: 75 829 veterans with dementia who were continuously enrolled in Medicare from 2007 to 2010; 80% were VA-only users, and 20% were VA-Medicare Part D (dual) users.
MEASUREMENTS: Augmented inverse propensity weighting was used to estimate the effect of dual-system versus VA-only prescribing on 4 indicators of PUM prescribing in 2010: any exposure to Healthcare Effectiveness Data and Information Set (HEDIS) high-risk medication in older adults (PUM-HEDIS), any daily exposure to prescriptions with a cumulative Anticholinergic Cognitive Burden (ACB) score of 3 or higher (PUM-ACB), any antipsychotic prescription (PUM-antipsychotic), and any PUM exposure (any-PUM). The annual number of days of each PUM exposure was also examined.
RESULTS: Compared with VA-only users, dual users had more than double the odds of exposure to any-PUM (odds ratio [OR], 2.2 [95% CI, 2.2 to 2.3]), PUM-HEDIS (OR, 2.4 [CI, 2.2 to 2.8]), and PUM-ACB (OR, 2.1 [CI, 2.0 to 2.2]). The odds of PUM-antipsychotic exposure were also greater in dual users (OR, 1.5 [CI, 1.4 to 1.6]). Dual users had an adjusted average of 44.1 additional days of any-PUM exposure (CI, 37.2 to 45.0 days).
LIMITATION: Observational study design of veteran outpatients only.
CONCLUSION: Among veterans with dementia, rates of PUM prescribing are significantly higher among dual-system users than with VA-only users.
PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.
Gellad, Walid F, Xinhua Zhao, Carolyn T Thorpe, Joshua M Thorpe, Florentina E Sileanu, John P Cashy, Maria Mor, et al. (2017) 2017. “Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions Among Veterans Dually Enrolled in Department of Veterans Affairs and Medicare Part D.”. Substance Abuse 38 (1): 22-25. https://doi.org/10.1080/08897077.2016.1267071.
BACKGROUND: Buprenorphine is a key tool in the management of opioid use disorder, but there are growing concerns about abuse, diversion, and safety. These concerns are amplified for the Department of Veterans Affairs (VA), whose patients may receive care concurrently from multiple prescribers within and outside VA. To illustrate the extent of this challenge, we examined overlapping prescriptions for buprenorphine, opioids, and benzodiazepines among veterans dually enrolled in VA and Medicare Part D.
METHODS: We constructed a cohort of all veterans dually enrolled in VA and Part D who filled an opioid prescription in 2012. We identified patients who received tablet or film buprenorphine products from either source. We calculated the proportion of buprenorphine recipients with any overlapping prescription (based on days supply) for a nonbuprenorphine opioid or benzodiazepine, focusing on veterans who received overlapping prescriptions from a different system than their buprenorphine prescription (Part D buprenorphine recipients receiving overlapping opioids or benzodiazepines from VA and vice versa).
RESULTS: There were 1790 dually enrolled veterans with buprenorphine prescriptions, including 760 (43%) from VA and 1091 (61%) from Part D (61 veterans with buprenorphine from both systems were included in each group). Among VA buprenorphine recipients, 199 (26%) received an overlapping opioid prescription and 11 (1%) received an overlapping benzodiazepine prescription from Part D. Among Part D buprenorphine recipients, 208 (19%) received an overlapping opioid prescription and 178 (16%) received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients with cross-system opioid overlap, 25% (49/199) and 35% (72/208), respectively, had >90 days of overlap.
CONCLUSIONS: Many buprenorphine recipients receive overlapping prescriptions for opioids and benzodiazepines from a different health care system than the one in which their buprenorphine was filled. These findings highlight a previously undocumented safety risk for veterans dually enrolled in VA and Medicare.
Stroupe, Kevin T, Lauren Bailey, Walid F Gellad, Katie Suda, Zhiping Huo, Rachael Martinez, Muriel Burk, Francesca Cunningham, and Bridget M Smith. (2017) 2017. “Veterans’ Pharmacy and Health Care Utilization Following Implementation of the Medicare Part D Pharmacy Benefit.”. Medical Care Research and Review : MCRR 74 (3): 328-44. https://doi.org/10.1177/1077558716643887.
We examined associations between enrollment in Medicare Part D pharmacy benefits and changes in medication acquisition from Department of Veterans Affairs (VA) pharmacies. We included all women and a random 10% sample of men who were VA enrollees, ≥65 years old as of January 1, 2004, and alive through December 2007. We used difference-in-differences models with propensity score weighting to examine changes in medication acquisition between 2005 (before Part D was implemented) and 2007 (after Part D implementation) for veterans who were or were not Part D enrolled. Of 231,716 veterans meeting inclusion criteria, 49,881 (21.5%) were enrolled. While 30-day medication supplies decreased from 26.2 to 23.4 for enrolled veterans, they increased from 36.6 to 37.4 for nonenrolled veterans (difference-in-differences: -4.0, p < .001). Reductions in 30-day supplies were greater among veterans who were required to pay VA copayments for some or all medications and who used VA and Medicare outpatient services.
Gellad, Walid F, Carolyn T Thorpe, John F Steiner, and Corrine I Voils. (2017) 2017. “The Myths of Medication Adherence.”. Pharmacoepidemiology and Drug Safety 26 (12): 1437-41. https://doi.org/10.1002/pds.4334.
Marcum, Zachary A, and Walid F Gellad. (2017) 2017. “Improving Medication Adherence: Keep Your Eyes on the Prize.”. Journal of General Internal Medicine 32 (3): 236-37. https://doi.org/10.1007/s11606-016-3927-4.