Publications

BACKGROUND: Documentation of patient goals and preferences within medical records has the potential to align medication use with goals of care (GoC) and individualize medication appropriateness criteria. We characterized patient and surrogate-expressed GoC for older Veterans living with dementia and explored concordance with medication use during VA Community Living Center (CLC) (i.e., nursing home) stays.

METHODS: We conducted a cross-sectional analysis using the VA Residential History File, Minimum Data Set, Corporate Data Warehouse, and Medicare claims for Veterans with dementia admitted to VA CLCs from 4/2021 to 12/2021 for > 7 days. We extracted free text responses for "Veteran goals in own words" from a standardized GoC note. Two coders classified GoC topics using iterative coding. We examined bar code medication administration data for aspirin, benzodiazepines, opioids and antidementia medications within the 7 days following admission. We determined a schema for potential goal-concordant medication use (e.g., opioids for GoC focused on comfort) and assessed concordance of medication use with GoC topics.

RESULTS: Among 1000 VA CLC residents with dementia and GoC documented, 46.4% of responses were reported by the Veteran versus a surrogate. Common topics included comfort (44.6%), life-sustaining treatments (31.8%), function (13.7%), care setting/transitions (12.9%), and life prolongation (11.2%). Medications were seldom discussed. Opioid and benzodiazepine use was classified as goal-concordant for 56.7% and 72.2% of patients who used them. Aspirin and antidementia medication use was more commonly classified as goal-discordant (54.7% and 38.7%, respectively).

CONCLUSIONS: Goals elicited via an open-ended question provided only indirect information relevant to medication use, but in many cases could be used to refine judgments of appropriateness. Integration of patient goals into formal criteria evaluating medication appropriateness is a logical next step for medication optimization research. Future research should explore the utility of questions specific to medications in GoC conversations for individuals with dementia.

BACKGROUND: The Veterans Health Administration (VHA) launched VA Bug Alert (VABA) to identify admitted patients who are infected or colonized with multidrug-resistant organisms (MDROs) in real time and promote timely infection prevention measures. However, initial VABA adoption was suboptimal. The objective of this project was to compare the effectiveness of standard vs. enhanced implementation strategies for improving VABA adoption.

METHODS: 121 VA healthcare facilities were evaluated for adoption of VABA (at least 1 user registered at a facility) April 2021-September 2022. All facilities initially received standard implementation, which included: VABA revisions based on end-user feedback, education, and internal facilitation via monthly meetings with the MDRO Prevention Division of the VHA National Infectious Diseases Service. Surveys evaluated VABA perspectives among MDRO Prevention Coordinators (MPCs) and/or Infection Preventionists (IPs) before and after initial standard implementation. Facilities not registered for VABA following initial standard implementation (n = 31) were cluster-randomized to continue to receive standard implementation or enhanced implementation (audit and feedback reports and external facilitation via guided interviews to assess VABA use barriers). Percentages of facilities adopting VABA at baseline, after standard implementation (Follow-up 1), and after the enhanced vs. standard implementation trial period (Follow-up 2) were assessed and compared across time points using McNemar's test. VABA adoption was compared by trial condition using Fisher's exact test.

RESULTS: Before education, 25% of 167 MPC/IP survey respondents across 116 facilities reported no knowledge/use of VABA. After education, 82% of 92 survey respondents across 80 facilities reported intending to use VABA. At baseline, VABA registrations were 40%. Registrations significantly increased aft Follow-up 1(75%, p < 0.01) and at Follow-up 2 (89%, p < 0.01). Adoption did not significantly differ by assigned implementation condition but was higher among facilities that completed all components of enhanced implementation than those who did not (87.5% vs. 43.5%, p = 0.045). Guided interviews revealed key facilitators of VABA registration, which included perceived fit, implementation activities, and organizational context (e.g., staffing resources).

CONCLUSIONS: Implementation efforts dramatically increased VABA registrations. Incorporating interview feedback to increase VABA's fit with users' needs may increase its use and help reduce MDRO spread in VA.

BACKGROUND: Global shortages for 3 angiotensin receptor-II blockers (ARBs)-valsartan, losartan, and irbesartan-occurred in 2018-2019 after recalls due to ingredient impurities. Provider-level responses to the ARB shortages in the United States and spillovers to other antihypertensive classes are unknown.

OBJECTIVE: To estimate changes in provider-level prescribing for ARBs and non-ARB antihypertensives up to 18 months after the 2018-2019 recalls and shortages.

RESEARCH DESIGN: National cohort study of prescribers using all-payer pharmacy claims. Mixed interrupted time series models quantified changes in prescribing postshortages and heterogeneous changes by specialty, region, medical school graduation cohort, sex, and level of prerecall prescribing.

PATIENTS AND METHODS: Active providers exposed to the 2018-2019 valsartan, irbesartan, and losartan shortages (defined as top-25th percentile for these drugs in 2017).

MEASURES: Within-class changes in prescribing for ARBs (recalled and nonrecalled). Between-class substitutions to non-ARB antihypertensives (ACE-Is, alpha- and beta-adrenergic blockers, calcium channel blockers, diuretics, and other agents).

RESULTS: Among 138,032 prescribers who met the inclusion criteria, per-prescriber fills for valsartan decreased by 57%-59% after it was recalled in July 2018. We observed concurrent increases for losartan and irbesartan fills and no change in overall ARB prescribing. There were no significant changes in fills for ACE-Is or for other antihypertensives. Absolute decreases in valsartan fills were greatest among providers with higher levels of prescribing at baseline. However, relative changes did not differ by prescriber characteristics.

CONCLUSIONS: In this prescriber level, national study, substitutions to other ARBs mitigated decreases in valsartan fills after it was recalled. There were no spillovers to non-ARB anti-hypertensives. The availability of close substitutes during drug shortages may mitigate gaps in access for prescribers and their patients.

We conducted an interrupted time series analysis to assess changes in antibiotic sales in 37 countries that implemented National Action Plans (NAPs) between 2013 and 2018. Overall, NAP implementation was not associated with changes in antibiotic sales two years later, with country-specific effects ranging from a 38.3% decrease to 65.3% increase.

Elevated blood pressure (BP) in the inpatient setting is frequently encountered by most healthcare providers. While there is general consensus on the management of acute BP elevations when associated with end-organ damage, these cases of true hypertensive emergency are relatively infrequent. In contrast, asymptomatic acute BP elevations are considerably more frequent, yet there is little consensus on their appropriate management. Contributing factors include concerns about missing true emergencies, the barriers affecting the accuracy of inpatient BP measurements and a lack of consistent data on the short- and long-term impact of inpatient BP elevations. Practice varies widely, even between departments within the same hospital, and includes observation, intravenous antihypertensives, oral agents and adjustments to existing regimens. Some clinicians also choose to discharge patients on intensified therapy based on inpatient BP values. However, despite the high prevalence of elevated BP in the inpatient setting, evidence remains heterogeneous and fragmented. This review aims to synthesise current knowledge and provide a practical, holistic framework for evaluating and managing elevated BP in the inpatient setting.

Background Persons experiencing homelessness bear high rates of morbidity, injury, and mortality. Medicaid offers an opportunity to provide support, but barriers persist to enrolling and maintaining enrollment among this vulnerable population. The objective of this study was to determine the initial and longer-term effects of the Affordable Care Act (ACA) Medicaid eligibility expansion on Medicaid enrollment among persons observed to be unhoused or housing insecure through recorded housing services utilization. Methods We applied interrupted time-series analyses of linked administrative data from two expansion states - New Jersey (NJ) and Pennsylvania (PA); Homeless Management Information System data were linked to monthly Medicaid enrollment files of non-elderly adults (aged 18-64) utilizing shelter, street outreach and other housing assistance from January 2011 to December 2016. The study outcome was a binary measure of Medicaid enrollment status in month of Homelessness Management Information System service exit overall and stratified by race/ethnicity. Results ACA Medicaid eligibility expansion was associated with a level change in the likelihood of enrollment of 7.5 percentage points (pp) in NJ and 8.5 pp in PA. The trend in enrollment post-expansion also increased by 0.6 pp/month in NJ. Compared to no homeless-related service use in the year, being recorded with one month with a shelter stay or other homelessness assistance services in the year was associated with a higher likelihood of Medicaid enrollment (14.8 pp higher in NJ and 6.9 pp higher in PA), and likelihood of enrollment was highest when two or more months with homelessness assistance services were used in the year (18.6 pp higher in NJ and 12.8 pp higher in PA). However, the effect of the policy change attenuated back to the pre-ACA trend in both states by the end of 2016. Results were similar across race/ethnicity stratifications. Conclusions We found significant increases in the likelihood of Medicaid enrollment after the ACA Medicaid expansions in the months immediately following the expansion. Additional months with homeless shelter stay or other housing services for unhoused persons were associated with a higher likelihood of Medicaid enrollment; this suggests the need for further investigation into the potential of leveraging staff-client relationships at homelessness assistance programs during future health policy initiatives.

BACKGROUND: Low-value health services adversely affect outcomes and unnecessarily increase the cost of care. Approximately 10% of Veterans receive at least one of 29 low-value services delivered or paid for by the Veterans Health Administration (VA) annually. However, determinants of and potential solutions to reduce low-value service delivery are poorly understood.

OBJECTIVE: To characterize the drivers of and approaches to reduce low-value service delivery across VA Medical Centers (VAMCs) from the perspective of VA clinicians.

DESIGN: Qualitative study using semi-structured interviews conducted from October 2022 to November 2023.

PARTICIPANTS: 65 VA clinicians, including 32 generalists and 33 medical and surgical specialists, at 46 VAMCs.

APPROACH: We used deductive analysis based on a priori categories and definitions structured by the Theoretical Domains Framework to identify predominant themes related to drivers of low-value service delivery. We used inductive analysis to identify clinician-suggested approaches to reduce low-value services.

KEY RESULTS: We identified three overarching domains as drivers of low-value service delivery at VA: 1) environmental context and resources; 2) social influence; and 3) belief about consequences. Regarding key subthemes, social pressure from Veterans emerged among generalists and specialists. Generalists were more likely to identify referral parameters or requirements compared to specialists, while specialists were more like to identify negative consequences compared to generalists. We identified four overarching domains as approaches to reduce low-value service delivery at VA, which were consistently identified by both generalists and specialists: 1) improving quality and access to VA health care; 2) dissemination of best practices; 3) optimizing use of the electronic health record; and 4) instilling an organizational culture on value.

CONCLUSIONS: We identified the most salient drivers of and approaches to reduce low-value services from the perspective of VA clinicians. These findings may inform the design of future de-implementation interventions and policy to reduce VA-delivered low-value services.

BACKGROUND: Opioid exposure during cancer therapy may increase long-term unsafe opioid prescribing. This study sought to determine the rates of coprescription of benzodiazepine and opioid medications and new persistent opioid use after surgical treatment of early-stage cancer.

METHODS: A retrospective cohort study was conducted among a US veteran population via the Veterans Affairs Corporate Data Warehouse database. Participants were opioid-naive persons aged ≥21 years with a new diagnosis of stage 0-III cancer between January 1, 2015, and December 31, 2016. Outcomes were days of coprescription of benzodiazepines and opioids in the 13 months posttreatment and new persistent opioid use. The exposure was total morphine milligram equivalents (MMEs) attributed to treatment and prescribed from 30 days before through 14 days after the index surgical procedure.

RESULTS: Among 9213 veterans, coprescription of benzodiazepines and opioids occurred in 366 patients (4.0%) and new persistent opioid use in 981 patients (10.6%). In a linear model adjusting for patient, clinical, and geographic factors, persons in the highest quartile compared to no opioid exposure had increased days with coprescription of benzodiazepines and opioids (mean difference, 1.0; 95% CI, 0.3-1.7). In a discrete time survival analysis, persons in the highest quartile of MME exposure compared to none had a greater risk of new persistent opioid use (hazard ratio, 1.6; 95% CI, 1.3-1.9).

CONCLUSIONS: More than one of 10 opioid-naive veterans undergoing curative-intent surgical treatment for cancer developed new persistent opioid use. Optimizing cancer treatment pain management strategies to mitigate long-term opioid-related health risks is crucial.

BACKGROUND: Twelve state Medicaid programs limit the monthly number of covered prescriptions. Such cap policies may force enrollees to forego essential medications with important health consequences. We aimed to determine the impact of cap policies on acute care use and all-cause mortality among enrollees with opioid use disorder (OUD).

METHODS: Using 2016-2019 T-MSIS Analytical Files, we propensity-score matched enrollees with OUD in 12 states with cap policies and 26 states without cap policies. Outcomes measured over 12 months included emergency department (ED) visits, hospitalization, and all-cause mortality and were analyzed via generalized linear regression models. We conducted subgroup analyses by use of medications for OUD (MOUD) and comorbidity level and sensitivity analyses to examine the role of cap policy characteristics.

RESULTS: Unadjusted risks were 64.0 % vs. 62.5 % for ED visits, 27.6 % vs. 27.5 % for hospitalizations, and 3.2 % vs. 2.7 % for mortality in cap states and non-cap states, respectively. After adjustment, hospitalization risk was higher (RR=1.89, 99.5 %CI:1.13,3.16) in cap states than non-cap states whereas ED visits and mortality did not differ. There were largely no outcome differences by cap status in subgroups. Strict prescription limits allowing 3-4 prescriptions monthly (RR=1.90, 95 %CI:1.09,3.30) and lack of MOUD exemptions (RR=2.23, 95 %CI:1.32,3.78) were associated with increased hospitalization risk relative to non-cap states.

CONCLUSIONS: Medicaid prescription cap policies were associated with increased hospitalization risk, but there were no differences in ED use or all-cause mortality. Cap policies may undermine the health of individuals with OUD and could be counterproductive to state efforts to curb Medicaid spending.