Background

Unhealthy alcohol use is a significant health issue for the US population. The US Preventive Services Task Force (USPSTF) recommends screening adults 18 years or older for unhealthy alcohol use during primary care visits.

Objectives

To evaluate alcohol screening among ambulatory visits made by US adult primary care patients and identify characteristics predictive of alcohol screening.

Design

A series of cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) data collected from 2014 to 2016 was used to examine US primary care providers' use of alcohol screening questionnaires and delivery of counseling on alcohol use.

Participants

A total of 19,213 visits made by patients aged 18 years or older to a US primary care physician trained in family medicine or internal medicine.

Main measures

Administration of a validated alcohol screening questionnaire and counseling/education on alcohol use. Variation in alcohol screening by patient demographic characteristics, reason for office visit, length of office visit, chronic medical conditions, evaluation by assigned primary care physician, new patient to practice, and region.

Key results

Alcohol screening with a validated questionnaire occurred during 2.6% (95% Cl: 0.9%, 4.3%) of visits. Alcohol counseling, provided either by the physician or by referral, was documented in 0.8% (95% Cl: 0.3%, 1.3%) of visits. Screening was significantly more likely if patients were seen by their assigned primary care physician (adjOR 4.38 (95% Cl: 1.41, 13.61)), a new patient to the practice (adjOR 4.18 (95% Cl: 2.30, 7.79)), or had several chronic medical conditions (adjOR 3.40 (95% Cl: 1.48, 7.78)). Patients' sex, race/ethnicity, age group, or length of appointment time was not associated with screening for unhealthy alcohol use.

Conclusions

Screening for unhealthy alcohol use using a validated questionnaire is uncommonly performed during US primary care visits. Interventions or incentives may be needed to increase uptake of USPSTF alcohol screening recommendations.

Context: Health plan disenrollment has been associated with higher mortality in patients with opioid use disorder. Insurance loss and health plan disenrollment might be downstream social consequences of opioid misuse and overdose that may heighten patient mortality risks during a period of heightened need for professional assistance. Objective: To test hypotheses that: 1) overdose events in patients prescribed long-term opioids are associated with subsequent health plan disenrollment; and 2) buprenorphine initiation after overdose would attenuate this association. Study Design: Retrospective cohort study. Setting and Dataset: Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages, ethnicities, and geographical regions across the United States. Population studied: Adults (aged ≥18 years) prescribed stable, opioid therapy for a 6-month baseline period (≥90% of days covered, <10% monthly fluctuation from 6-month average, average daily dose ≥10 morphine milligram equivalents). Outcome Measures: Health plan disenrollment during up to one year of follow-up. Negative binomial regression estimated adjusted incidence rate ratios of disenrollment by incident overdose and buprenorphine initiation after overdose. Results: We identified 556,676 patients who were followed up after 1,119,100 stable periods of opioid therapy. During follow-up, 17.5% of person-periods ended in health plan disenrollment. Overdose events during follow-up were associated with health plan disenrollment with a dose-response relationship [adjusted incidence rate ratio (aIRR) for 1 overdose event = 1.29 (95% CI: 1.24-1.35); aIRR for ≥2 overdose events = 1.51 (1.43-1.59)]. Among patients with overdose events, subsequent buprenorphine initiation was associated with substantially reduced risk of health plan disenrollment [aIRR 0.36 (0.17-0.74)]. Conclusions: Overdose events in patients prescribed long-term opioids may portend other social consequences, such as health insurance loss, which may exacerbate patient risk at a time of heightened need and vulnerability. Buprenorphine may mitigate the risk of health plan disenrollment in opioid-prescribed patients who overdose.

Quality assessment is critical for healthcare reform, but data sources are lacking for measurement of many important healthcare outcomes. With over 49 million people covered by Medicare as of 2010, Medicare claims data offer a potentially valuable source that could be used in targeted health care quality improvement efforts. However, little is known about the operating characteristics of provider profiling methods using claims-based outcome measures that may estimate provider performance with error. Motivated by the example of screening mammography performance, we compared approaches to identifying providers failing to meet guideline targets using Medicare claims data. We used data from the Breast Cancer Surveillance Consortium and linked Medicare claims to compare claims-based and clinical estimates of cancer detection rate. We then demonstrated the performance of claim-based estimates across a broad range of operating characteristics using simulation studies. We found that identification of poor performing providers was extremely sensitive to algorithm specificity, with no approach identifying more than 65% of poor performing providers when claims-based measures had specificity of 0.995 or less. We conclude that claims have the potential to contribute important information on healthcare outcomes to quality improvement efforts. However, to achieve this potential, development of highly accurate claims-based outcome measures should remain a priority.

Objective

To develop and validate Medicare claims-based approaches for identifying abnormal screening mammography interpretation.

Data sources

Mammography data and linked Medicare claims for 387,709 mammograms performed from 1999 to 2005 within the Breast Cancer Surveillance Consortium (BCSC).

Study design

Split-sample validation of algorithms based on claims for breast imaging or biopsy following screening mammography.

Data extraction methods

Medicare claims and BCSC mammography data were pooled at a central Statistical Coordinating Center.

Principal findings

Presence of claims for subsequent imaging or biopsy had sensitivity of 74.9 percent (95 percent confidence interval [CI], 74.1-75.6) and specificity of 99.4 percent (95 percent CI, 99.4-99.5). A classification and regression tree improved sensitivity to 82.5 percent (95 percent CI, 81.9-83.2) but decreased specificity (96.6 percent, 95 percent CI, 96.6-96.8).

Conclusions

Medicare claims may be a feasible data source for research or quality improvement efforts addressing high rates of abnormal screening mammography.

Background

Existing guidelines for repeat screening and treatment monitoring intervals regarding the use of dual-energy x-ray absorptiometry (DXA) scans are conflicting or lacking. The Choosing Wisely campaign recommends against repeating DXA scans within 2 years of initial screening. It is unclear how frequently physicians order repeat scans and what clinical factors contribute to their use.

Objective

To estimate cumulative incidence and predictors of repeat DXA for screening or treatment monitoring in a regional health system.

Design

Retrospective longitudinal cohort study PARTICIPANTS: A total of 5992 women aged 40-84 years who received initial DXA screening from 2006 to 2011 within a regional health system in Sacramento, CA.

Main measures

Two- and five-year cumulative incidence and hazard rations (HR) of repeat DXA by initial screening result (classified into three groups: low or high risk of progression to osteoporosis, or osteoporosis) and whether women were prescribed osteoporosis drugs after initial DXA.

Key results

Among women not treated after initial DXA, 2-year cumulative incidence for low-risk, high-risk, and osteoporotic women was 8.0%, 13.8%, and 19.6%, respectively, increasing to 42.9%, 60.4%, and 57.4% by 5 years after initial screening. For treated women, median time to repeat DXA was over 3 years for all groups. Relative to women with low-risk initial DXA, high-risk initial DXA significantly predicted repeat screening for untreated women [adjusted HR 1.67 (95% CI 1.40-2.00)] but not within the treated group [HR 1.09 (95% CI 0.91-1.30)].

Conclusions

Repeat DXA screening was common in women both at low and high risk of progression to osteoporosis, with a substantial proportion of women receiving repeat scans within 2 years of initial screening. Conversely, only 60% of those at high-risk of progression to osteoporosis were re-screened within 5 years. Interventions are needed to help clinicians make higher-value decisions regarding repeat use of DXA scans.

Patients and physicians report that communication about chronic pain and opioids is often challenging, but there is little empirical research on whether patient-physician communication about pain affects patient and physician visit experience. This study video recorded 86 primary care visits involving 49 physicians and 86 patients taking long-term opioids for chronic musculoskeletal pain, systematically coded all pain-related utterances during these visits using a custom-designed coding system, and administered previsit and postvisit questionnaires. Multiple regression was used to identify communication behaviors and patient characteristics associated with patients' ratings of their visit experience, physicians' ratings of visit difficulty, or both. After adjusting for covariates, 2 communication variables-patient-physician disagreement and patient requests for opioid dose increases-were each significantly associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Patient desire for increased pain medicine was also significantly positively associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The association between patient requests for opioids and patient experience ratings was wholly driven by 2 visits involving intense conflict with patients demanding opioids. Patient-physician communication during visits is associated with patient and physician ratings of visit experience. Training programs focused on imparting communication skills that assist physicians in negotiating disagreements about pain management, including responding to patient requests for more opioids, likely have potential to improve visit experience ratings for both patients and physicians.

Background

The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with dual-energy x-ray absorptiometry (DXA) for women aged ≥ 65 years and younger women with increased risk. "Choosing Wisely" initiatives advise avoiding DXA screening in women younger than 65 years without osteoporosis risk factors.

Objective

We aimed to determine the extent to which DXA screening is used in accordance with USPSTF recommendations within a regional health system.

Design

This was a retrospective longitudinal cohort study within 13 primary care clinics in the Sacramento, CA region.

Patients

The study included 50,995 women aged 40-85 years without prior osteoporosis screening, diagnosis, or treatment attending primary care visits from 2006 to 2012, observed for a mean of 4.4 years.

Main measures

We examined incidence of DXA screening. Covariates included age, race/ethnicity, and osteoporosis risk factors (body mass index < 20, glucocorticoid use, secondary osteoporosis, prior high-risk facture, rheumatoid arthritis, alcohol abuse, and current smoking).

Key results

Among previously unscreened women for whom the USPSTF recommends screening, 7-year cumulative incidence of DXA screening was 58.8 % among women aged 60-64 years with ≥ 1 risk factor (95 % CI: 51.9-65.8 %), 57.8 % for women aged 65-74 years (95 % CI: 55.6-60.0 %), and 42.7 % for women aged ≥ 75 years (95 % CI: 38.7-46.7 %). Among women for whom the USPSTF does not recommend screening, 7-year cumulative incidence was 45.5 % among women aged 50-59 years (95 % CI 44.1-46.9 %) and 58.6 % among women aged 60-64 years without risk factors (95 % CI 55.9-61.4 %).

Conclusions

DXA screening was underused in women at increased fracture risk, including women aged ≥ 65 years. Meanwhile, DXA screening was common among women at low fracture risk, such as younger women without osteoporosis risk factors. Interventions may be needed to augment the value of population screening for osteoporosis.

Background

The exponential growth of the biomedical literature necessitates investigating strategies to reduce systematic reviewer burden while maintaining the high standards of systematic review validity and comprehensiveness.

Methods

We compared the traditional systematic review screening process with (1) a review-of-reviews (ROR) screening approach and (2) a semi-automation screening approach using two publicly available tools (RobotAnalyst and AbstrackR) and different types of training sets (randomly selected citations subjected to dual-review at the title-abstract stage, highly curated citations dually reviewed at the full-text stage, and a combination of the two). We evaluated performance measures of sensitivity, specificity, missed citations, and workload burden RESULTS: The ROR approach for treatments of early-stage prostate cancer had a poor sensitivity (0.54) and studies missed by the ROR approach tended to be of head-to-head comparisons of active treatments, observational studies, and outcomes of physical harms and quality of life. Title and abstract screening incorporating semi-automation only resulted in a sensitivity of 100% at high levels of reviewer burden (review of 99% of citations). A highly curated, smaller-sized, training set (n = 125) performed similarly to a larger training set of random citations (n = 938).

Conclusion

Two approaches to rapidly update SRs-review-of-reviews and semi-automation-failed to demonstrate reduced workload burden while maintaining an acceptable level of sensitivity. We suggest careful evaluation of the ROR approach through comparison of inclusion criteria and targeted searches to fill evidence gaps as well as further research of semi-automation use, including more study of highly curated training sets.

A diverse physician workforce is needed to increase access to care for underserved populations, particularly as the Affordable Care Act expands insurance coverage. Yet legal restrictions constrain the extent to which medical schools may use race/ethnicity in admissions decisions. We conducted simulations using academic metrics and socioeconomic data from applicants to a California public medical school from 2011 to 2013. The simulations systematically adjusted medical school applicants' academic metrics for socioeconomic disadvantage. We found that socioeconomic and under-represented minority disparities in admissions could be eliminated while maintaining academic readiness. Adjusting applicant academic metrics using socioeconomic information on medical school applications may be a race-neutral means of increasing the socioeconomic and racial/ethnic diversity of the physician workforce.