Publications

OBJECTIVE: Surveys are often used to assess intensive care unit (ICU) organizational characteristics for quality improvement. Typically these surveys target ICU nurse managers and/or physician directors. However, it is unclear whether these providers' assessments differ. We sought to determine whether differences existed in nurse- and physician-assessed ICU characteristics using a standardized survey.

DESIGN: We administered a previously developed survey to nurse managers and medical directors in adult ICUs within a single healthcare system in 2013. The survey asked about interprofessional staffing and evidence-based protocols. We examined differences between nurse managers' and medical directors' responses using McNemar's test and assessed concordance using the kappa statistic.

SETTING: Twenty-three ICUs in 10 hospitals in Southwestern Pennsylvania.

RESULTS: Sixteen (69%) were specialty ICUs. The median number of ICU beds was 34. Concordance was moderate for high- vs. low-intensity physician staffing (κ = 0.60) and almost perfect on questions related to interprofessional staffing (κ = 0.83 nurse practitioners/physician assistants; 1.0 respiratory therapists; 0.83 physical therapists). However, concordance was slight to fair with regard to the presence of these providers on rounds (κ = 0.20-0.21) and poor to slight for protocols for liberation from mechanical ventilation (κ = 0.19), sedation (κ = -0.03) and central line insertion (κ = -0.03).

CONCLUSIONS: Despite a standardized survey, we found substantial disagreement on ICU characteristics when assessed by the nurse manager or physician director. This study raises questions about the use of surveys to examine ICU organizational characteristics and suggests that differences in nurse managers' and medical directors' assessments could be helpful in guiding future ICU quality improvement projects.

BACKGROUND: Health insurance claims data may play an important role for health care systems and payers in monitoring the nonmedical use of prescription opioids (NMPO) among patients. However, these systems require valid methods for identifying NMPO if they are to target individuals for intervention. Limited efforts have been made to define NMPO using administrative data available to health systems and payers. We conducted a systematic review of publications that defined and measured NMPO within health insurance claims databases in order to describe definitions of NMPO and identify areas for improvement.

METHODS: We searched 8 electronic databases for articles that included terms related to NMPO and health insurance claims. A total of 2613 articles were identified in our search. Titles, abstracts, and article full texts were assessed according to predetermined inclusion/exclusion criteria. Following article selection, we extracted general information, conceptual and operational definitions of NMPO, methods used to validate operational definitions of NMPO, and rates of NMPO.

RESULTS: A total of 7 studies met all inclusion criteria. A range of conceptual NMPO definitions emerged, from concrete concepts of abuse to qualified definitions of probable misuse. Operational definitions also varied, ranging from variables that rely on diagnostic codes to those that rely on opioid dosage and/or filling patterns. Quantitative validation of NMPO definitions was reported in 3 studies (e.g., receiver operating curves or logistic regression), with each study indicating adequate validity. Three studies reported qualitative validation, using face and content validity. One study reported no validation efforts. Rates of NMPO among the studies' populations ranged from 0.75% to 10.32%.

CONCLUSIONS: Disparate definitions of NMPO emerged from the literature, with little uniformity in conceptualization and operationalization. Validation approaches were also limited, and rates of NMPO varied across studies. Future research should prospectively test and validate a construct of NMPO to disseminate to payers and health officials.

OBJECTIVES: To examine the association between statin use and objectively assessed decline in gait speed in community-dwelling older adults.

DESIGN: Longitudinal cohort study.

SETTING: Health, Aging and Body Composition (Health ABC) Study.

PARTICIPANTS: Two thousand five participants aged 70-79 at baseline with medication and gait speed data at 1998-99, 1999-2000, 2001-02, and 2002-03.

MEASUREMENTS: The independent variables were any statin use and their standardized daily doses (low, moderate, high) and lipophilicity. The primary outcome measure was decline in gait speed of 0.1 m/s or more in the following year of statin use. Multivariable generalized estimating equations were used, adjusting for demographic characteristics, health-related behaviors, health status, and access to health care.

RESULTS: Statin use increased from 16.2% in 1998-99 to 25.6% in 2002-03. The overall proportions of those with decline in gait speed of 0.1 m/s or more increased from 22.2% in 1998 to 23.9% in 2003. Statin use was not associated with decline in gait speed of 0.1 m/s or more (adjusted odds ratio (AOR) = 0.90, 95% confidence interval (CI) = 0.77-1.06). Similar nonsignificant trends were also seen with the use of hydrophilic or lipophilic statins. Users of low-dose statins were found to have a 22% lower risk of decline in gait speed than nonusers (AOR = 0.78, 95% CI = 0.61-0.99), which was mainly driven by the results from 1999-2000 follow-up.

CONCLUSION: These results suggest that statin use did not increase decline in gait speed in community-dwelling older adults.

Little is known about the health status of the 7.3 million Americans who enrolled in insurance plans through the Marketplaces established by the Affordable Care Act in 2014. Medication use may provide an early indicator of the health needs and access to care among Marketplace enrollees. We used data from January-September 2014 on more than one million Marketplace enrollees from Express Scripts, the largest pharmacy benefit management company in the United States. We compared the characteristics and medication use between early and late Marketplace enrollees and between all Marketplace enrollees and enrollees with employer-sponsored insurance. Among Marketplace enrollees, we found that those who enrolled earlier (October 2013-February 2014) were older and used more medication than later enrollees. Marketplace enrollees, as a whole, had lower average drug spending and were less likely to use most medication classes than the employer-sponsored comparison group. However, Marketplace enrollees were more likely to use medicines for hepatitis C and particularly for HIV.

Nontuberculous mycobacteria (NTMs) are environmental microorganisms that can cause infections in humans, primarily in the lung and soft tissue. The prevalence of NTM-associated diseases is increasing in the United States. Exposure to NTMs occurs primarily through human interactions with water (especially aerosolized). Potable water from sites across the U.S. was collected to investigate the presence of NTM. Water from 68 taps was sampled 4 times over the course of 2 years. In total, 272 water samples were examined for NTM using a membrane filtration, culture method. Identification of NTM isolates was accomplished by polymerase chain reaction (PCR) amplification of the 16S rRNA and hsp65 genes. NTMs were detected in 78% of the water samples. The NTM species detected most frequently were: Mycobacterium mucogenicum (52%), Mycobacterium avium (30%), and Mycobacterium gordonae (25%). Of the taps that were repeatedly positive for NTMs, the species M. avium, M. mucogenicum, and Mycobacterium abscessus were found to persist most frequently. This study also observed statistically significant higher levels of NTM in chloraminated water than in chlorinated water.

BACKGROUND: Academic medical centers (AMCs) have increasingly adopted conflict of interest policies governing physician-industry relationships; it is unclear how policies impact prescribing.

OBJECTIVES: To determine whether 9 American Association of Medical Colleges (AAMC)-recommended policies influence psychiatrists' antipsychotic prescribing and compare prescribing between academic and nonacademic psychiatrists.

RESEARCH DESIGN: We measured number of prescriptions for 10 heavily promoted and 9 newly introduced/reformulated antipsychotics between 2008 and 2011 among 2464 academic psychiatrists at 101 AMCs and 11,201 nonacademic psychiatrists. We measured AMC compliance with 9 AAMC recommendations. Difference-in-difference analyses compared changes in antipsychotic prescribing between 2008 and 2011 among psychiatrists in AMCs compliant with ≥ 7/9 recommendations, those whose institutions had lesser compliance, and nonacademic psychiatrists.

RESULTS: Ten centers were AAMC compliant in 2008, 30 attained compliance by 2011, and 61 were never compliant. Share of prescriptions for heavily promoted antipsychotics was stable and comparable between academic and nonacademic psychiatrists (63.0%-65.8% in 2008 and 62.7%-64.4% in 2011). Psychiatrists in AAMC-compliant centers were slightly less likely to prescribe these antipsychotics compared with those in never-compliant centers (relative odds ratio, 0.95; 95% CI, 0.94-0.97; P < 0.0001). Share of prescriptions for new/reformulated antipsychotics grew from 5.3% in 2008 to 11.1% in 2011. Psychiatrists in AAMC-compliant centers actually increased prescribing of new/reformulated antipsychotics relative to those in never-compliant centers (relative odds ratio, 1.39; 95% CI, 1.35-1.44; P < 0.0001), a relative increase of 1.1% in probability.

CONCLUSIONS: Psychiatrists exposed to strict conflict of interest policies prescribed heavily promoted antipsychotics at rates similar to academic psychiatrists and nonacademic psychiatrists exposed to less strict or no policies.

OBJECTIVE: The study examined changes in French general practitioners' (GPs) antipsychotic preferences between 2003 and 2010, a period when evidence challenging the superiority and safety of second-generation antipsychotics was introduced.

METHODS: Data from the IMS Health Disease Analyzer database for a cohort of 347 GPs (with 12 or more antipsychotic prescriptions in 2003 and in 2010) were used. For each year and GP, preferred antipsychotic was defined as the drug most frequently prescribed at the patient level. Trends in mean number of prescriptions, preferred drug, and changes in preferred antipsychotic class were documented.

RESULTS: The mean annual number of antipsychotic prescriptions increased over the period (p<.001). The percentage of GPs who preferred a second-generation antipsychotic tripled, from 16% in 2003 to 50% in 2010. In 2010, 42% of GPs who preferred first-generation antipsychotics in 2003 had switched their preference to second-generation antipsychotics.

CONCLUSIONS: GPs' preferences for antipsychotics changed dramatically between 2003 and 2010.

OBJECTIVES: Use of buprenorphine - an effective treatment for opioid use disorders (OUDs) - has increased rapidly in recent years and is often financed by Medicaid. We investigated predictors of buprenorphine treatment, patterns of care, and quality of care in a large state Medicaid program.

METHODS: Data from Pennsylvania Medicaid from 2007 to 2012 provided information regarding diagnoses, demographic characteristics, enrollment, and use of inpatient and outpatient services, and prescription drugs. We identified adult enrollees using buprenorphine, and examined prevalence of OUD diagnosis and patterns of use (duration and dose) and quality of care (physician visits, receipt of behavioral health counseling, urine drug screens, and other prescription drug use). We use a mixed logistic regression model to examine enrollee characteristics associated with buprenorphine use.

RESULTS: The share of enrollees with OUD filling prescriptions for buprenorphine increased from 2985 (9.8%) to 12,691 (25.2%) from 2007 to 2012. Between 26.2 and 32.0% of enrollees using buprenorphine had no diagnosis of OUD, depending on the year. Only 60.1% of enrollees with buprenorphine use received at least one urine drug screen, 41.0% had behavioral health counseling services, and 34.7 and 38.0% had other opioid and benzodiazepine claims, respectively, concomitant with buprenorphine use. Quality of care was lower among those with no OUD diagnosis recorded. The mean daily doses of buprenorphine decreased over time. We found wide variation in likelihood of buprenorphine use among those with OUD based upon age, sex, and race.

CONCLUSIONS: Increases in buprenorphine treatment in a Medicaid population were observed across time; however, increases varied by age, sex, and rate, and the quality of care received seemed to be generally poor. The quality of the provision of buprenorphine treatment occurring in Medicaid populations should be further explored.