Publications

INTRODUCTION: Evidence suggests that U.S. dentists prescribe opioids excessively. There are limited national data on recent trends in opioid prescriptions by U.S. dentists. In this study, we examined trends in opioid prescribing by general dentists and dental specialists in the U.S. from 2012 to 2019.

METHODS: Dispensed prescriptions for oral opioid analgesics written by dentists were identified from IQVIA Longitudinal Prescription Data from January 2012 through December 2019. Autoregressive integrated moving average and joinpoint regression models described monthly population-based prescribing rates (prescriptions/100,000 individuals), dentist-based prescribing rates (prescriptions/1,000 dentists), and opioid dosages (mean daily morphine milligram equivalents/day). All analyses were performed in 2020.

RESULTS: Over the 8 years, dentists prescribed >87.2 million opioid prescriptions. Population- and dentist-based prescribing rates declined monthly by -1.97 prescriptions/100,000 individuals (95% CI= -9.98, -0.97) and -39.12 prescriptions/1,000 dentists (95% CI= -58.63, -17.65), respectively. Opioid dosages declined monthly by -0.08 morphine milligram equivalents/day (95% CI= -0.13, -0.04). Joinpoint regression identified 4 timepoints (February 2016, May 2017, December 2018, and March 2019) at which monthly prescribing rate trends were often decreasing in greater magnitude than those in the previous time segment.

CONCLUSIONS: Following national trends, dentists became more conservative in prescribing opioids. A greater magnitude of decline occurred post 2016 following the implementation of strategies aimed to further regulate opioid prescribing. Understanding the factors that influence prescribing trends can aid in development of tailored resources to encourage and support a conservative approach by dentists, to prescribing opioids.

BACKGROUND: Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians' baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians' (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios.

METHODS: As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients' expectations surrounding low-value prescribing.

RESULTS: We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients' well-being over satisfying their expectations.

CONCLUSIONS: When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

Although nonsteroidal anti inflammatory drugs are superior to opioids in dental pain management, opioids are still prescribed for dental pain in the United States. Little is known about the serious adverse outcomes of short-acting opioids within the context of dental prescribing. The objective of this study was to evaluate adverse outcomes and persistent opioid use (POU) after opioid prescriptions by dentists, based on whether opioids were overprescribed or within recommendations. A cross-sectional analysis of adults with a dental visit and corresponding opioid prescription (index) from 2011 to 2018 within a nationwide commercial claims database was conducted. Opioid overprescribing was defined as >120 morphine milligram equivalents per Centers for Disease Control and Prevention guidelines. Generalized estimating equation models were used to assess adverse outcomes (emergency department visits, hospitalizations, newly diagnosed substance use disorder, naloxone administration, or death within 30 days from index) and POU (≥1 prescription 4-90 days postindex). Predicted probabilities are reported. Of 633,387 visits, 2.6% experienced an adverse outcome and 16.6% had POU. Adverse outcome risk was not different whether opioids were overprescribed or within recommendations (predicted probability 9.0%, confidence interval [CI]: 8.0%-10.2% vs 9.1%, CI: 8.1-10.3), but POU was higher when opioids were overprescribed (predicted probability 27.4%, CI: 26.1%-28.8% vs 25.2%, CI: 24.0%-26.5%). Visits associated with mild pain and those with substance use disorders had the highest risk of both outcomes. Findings from this study demonstrate that dental prescribing of opioids was associated with adverse outcomes and POU, even when prescriptions were concordant with guidelines. Additional efforts are required to improve analgesic prescribing in dentistry, especially in groups at high risk of opioid-related adverse outcomes.

INTRODUCTION: Nonopioid analgesics are more effective for most oral pain, but data suggest that dental prescribing of opioids is excessive. This study evaluates the extent to which opioids exceed recommendations and the characteristics associated with opioid overprescribing by Veterans Health Administration dentists.

METHODS: This was a national cross-sectional study of Veterans' dental visits from 2015 to 2018. Overprescribing was defined per national guidelines as >120 morphine milligram equivalents (primary outcome). The association of dental visit and patient demographic and medical characteristics was modeled with overprescribing (defined as >120 morphine milligram equivalents) using Poisson regression with clustering by facility and patient. A secondary analysis assessed opioid prescriptions >3 days' supply. The dates of analysis were January 2020‒May 2021.

RESULTS: Of the 196,595 visits, 28.7% exceeded 120 morphine milligram equivalents. Friday visits and people with chronic oral pain or substance misuse were associated with a higher prevalence of overprescribing. Women, older Veterans, and Black and Latinx Veterans were less likely to be overprescribed than men, younger Veterans, and White Veterans, respectively. Routine dental visits had a higher prevalence of opioid overprescribing than invasive visits. Opioid overprescribing decreased over time. White Veterans were more likely to receive oxycodone and hydrocodone, whereas people of Black race and Latinx ethnicity were more likely to receive codeine and tramadol. In the secondary analysis, 68.5% of opioid prescriptions exceeded a 3-day supply.

CONCLUSIONS: Nearly 1 in 3 opioids prescribed by Veterans Health Administration dentists exceed guidelines. Prescribing higher potency and quantities of opioids, especially on Fridays and to certain demographic groups, should be addressed as part of dental opioid stewardship programs.

Suicide is a leading cause of death in the US. Patients with pain conditions have higher suicidal risks. In a systematic review searching observational studies from multiple sources (e.g., MEDLINE) from 1 January 2000-12 September 2020, we evaluated existing suicide prediction models' (SPMs) performance and identified risk factors and their derived data sources among patients with pain conditions. The suicide-related outcomes included suicidal ideation, suicide attempts, suicide deaths, and suicide behaviors. Among the 87 studies included (with 8 SPM studies), 107 suicide risk factors (grouped into 27 categories) were identified. The most frequently occurring risk factor category was depression and their severity (33%). Approximately 20% of the risk factor categories would require identification from data sources beyond structured data (e.g., clinical notes). For 8 SPM studies (only 2 performing validation), the reported prediction metrics/performance varied: C-statistics (n = 3 studies) ranged 0.67-0.84, overall accuracy(n = 5): 0.78-0.96, sensitivity(n = 2): 0.65-0.91, and positive predictive values(n = 3): 0.01-0.43. Using the modified Quality in Prognosis Studies tool to assess the risk of biases, four SPM studies had moderate-to-high risk of biases. This systematic review identified a comprehensive list of risk factors that may improve predicting suicidal risks for patients with pain conditions. Future studies need to examine reasons for performance variations and SPM's clinical utility.

BACKGROUND: The Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard to assist in identifying Veterans at risk for adverse opioid overdose or suicide-related events. In 2018, a policy was implemented requiring VHA facilities to complete case reviews of Veterans identified by STORM as very high risk for adverse events. Nationally, facilities were randomized in STORM implementation to four arms based on required oversight and by the timing of an increase in the number of required case reviews. To help evaluate this policy intervention, we aimed to (1) identify barriers and facilitators to implementing case reviews; (2) assess variation across the four arms; and (3) evaluate associations between facility characteristics and implementation barriers and facilitators.

METHOD: Using the Consolidated Framework for Implementation Research (CFIR), we developed a semi-structured interview guide to examine barriers to and facilitators of implementing the STORM policy. A total of 78 staff from 39 purposefully selected facilities were invited to participate in telephone interviews. Interview transcripts were coded and then organized into memos, which were rated using the -2 to + 2 CFIR rating system. Descriptive statistics were used to evaluate the mean ratings on each CFIR construct, the associations between ratings and study arm, and three facility characteristics (size, rurality, and academic detailing) associated with CFIR ratings. We used the mean CFIR rating for each site to determine which constructs differed between the sites with highest and lowest overall CFIR scores, and these constructs were described in detail.

RESULTS: Two important CFIR constructs emerged as barriers to implementation: Access to knowledge and information and Evaluating and reflecting. Little time to complete the CASE reviews was a pervasive barrier. Sites with higher overall CFIR scores showed three important facilitators: Leadership engagement, Engaging, and Implementation climate. CFIR ratings were not significantly different between the four study arms, nor associated with facility characteristics.Plain Language Summary: The Veterans Health Administration (VHA) created a tool called the Stratification Tool for Opioid Risk Mitigation dashboard. This dashboard shows Veterans at risk for opioid overdose or suicide-related events. In 2018, a national policy required all VHA facilities to complete case reviews for Veterans who were at high risk for these events. To evaluate this policy implementation, 78 staff from 39 facilities were interviewed. The Consolidated Framework for Implementation Research (CFIR) implementation framework was used to create the interview. Interview transcripts were coded and organized into site memos. The site memos were rated using CFIR's -2 to +2 rating system. Ratings did not differ for four study arms related to oversight and timing. Ratings were not associated with facility characteristics. Leadership, engagement and implementation climate were the strongest facilitators for implementation. Lack of time, knowledge, and feedback were important barriers.

BACKGROUND: For atrial fibrillation (AF) patients, oral anticoagulants (OACs) can reduce the risk of stroke by 60%; however, nearly 50% of patients recommended to receive OACs do not receive therapy. Integrated insurers that cover pharmacy and medical benefits may be incentivized to improve OAC use and adherence because they benefit from offsets in medical costs associated with prevented strokes. OBJECTIVE: To compare OAC use and adherence between AF patients enrolled in Medicare stand-alone prescription drug plans (PDPs), which only cover pharmacy benefits, and those enrolled in Medicare Advantage prescription drug (MAPD) plans, which cover medical and pharmacy benefits. METHODS: This was a retrospective cohort study, conducted using 2014-2016 Medicare claims data from the Centers for Medicare & Medicaid Services and a large regional health plan in Pennsylvania. Primary outcomes included OAC use and OAC adherence. OAC use was measured as filling at least 1 prescription for an OAC after AF diagnosis. OAC adherence was defined as having greater than or equal to 80% of days covered with an OAC. We constructed conditional logistic regression models in propensity score-matched samples to test the association between enrollment in PDPs or MAPD plans and outcomes. RESULTS: There were 2,551 AF patients enrolled in PDPs and 4,502 in MAPD plans before propensity score matching. The propensity score-matched sample included 2,537 patients in each group. OAC use was higher among MAPD beneficiaries (74%-76%) compared with PDP beneficiaries (70%; P < 0.001), and 41%-42% of MAPD beneficiaries were adherent to OACs, compared with 34% of PDP beneficiaries (P < 0.001). In adjusted analyses among propensity score-matched samples, PDP enrollment was associated with lower odds of OAC use (OR = 0.67, 95% CI = 0.56-0.81) and adherence (OR = 0.68, 95% CI = 0.59-0.78) compared with MAPD enrollment. CONCLUSIONS: AF patients enrolled in MAPD plans were more likely to use and adhere to OACs compared with PDP enrollees. These results may reflect the financial incentives of MAPD plans to improve guideline-recommended OAC use, since MAPD insurers bear the risk of pharmacy and medical costs and thus may benefit from cost savings associated with averted stroke events. As efforts to improve use and adherence of OACs in AF patients increase, focus should be given to how insurance benefit designs can affect medication use. DISCLOSURES: No outside funding supported this study. Hernandez has received personal fees from BMS and Pfizer, unrelated to this study. The other authors have nothing to disclose.

BACKGROUND: Oral anticoagulants (OAC) is indicated for stroke prevention in patients with atrial fibrillation (AF) with a moderate or high risk of stroke. Despite the benefits of stroke prevention, only 50%-60% of Americans with nonvalvular AF and a moderate or high risk of stroke receive OAC medication. OBJECTIVE: To understand the extent to which low OAC use by patients with AF is attributed to underprescribing or underfilling once the medication is prescribed. METHODS: This is a retrospective cohort study that used linked claims data and electronic health records from Optum Integrated data. Participants were adults (aged ≥ 18 years) with first AF between January 2013 and June 2017. The outcomes included (1) being prescribed OACs within 180 days of AF diagnosis or not and (2) filling an OAC prescription or not among patients with AF who were prescribed an OAC within 150 days of AF diagnosis. Multivariable logistic regression models were constructed to determine factors associated with underprescribing and underfilling. RESULTS: Of the 6,141 individuals in the study cohort, 51% were not prescribed OACs within 6 months of their AF diagnosis. Of the 2,956 patients who were prescribed, 19% did not fill it at the pharmacy. In the final adjusted model, younger age, location (Northeast and South), a low CHA2DS2-VASc score, and a high HAS-BLED score were associated with a lower likelihood of being prescribed OACs. Among patients who were prescribed, Medicare enrollment (odds ratio [OR] [95% CI] = 2.2 [1.3-3.7]) and having a direct oral anticoagulant prescription (1.5 [1.2-1.9]) were associated with a lower likelihood of filling the prescription. CONCLUSIONS: Both underprescribing and underfilling are major drivers of low OAC use among patients with AF, and solutions to increase OAC use must address both prescribing and filling. DISCLOSURES: Research reported in this study was supported by the National Heart, Lung and Blood Institute (K01HL142847 and R01HL157051). Dr Guo is supported by the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK133465), PhMRA Foundation Research Starter Award, and the University of Florida Research Opportunity Seed Fund. Dr Hernandez reports scientific advisory board fees from Pfizer and Bristol Myers Squibb, outside of the submitted work.