Provider-level Characteristics Research Articles

Abstract 3451: Association of multi-level factors with cervical cancer screening in healthcare settings

Abstract Background- Few studies have examined the independent contribution of patient, clinician and system factors associated with completing cervical cancer screening. Methods- Using a large retrospective cohort created from electronic health record data, we examined the association of patient- and provider-level characteristics with cervical cancer screening among unknown- and average-risk, screen eligible women who entered the cohort at a primary care visit in 1 of 3 U.S. healthcare systems (Kaiser Permanente Washington, Parkland Health, Mass General Brigham) between 2010-2019. The outcome was time, in days, from cohort entry to screening. We fit piecewise exponential (PWE) survival models, nesting patients hierarchically within provider seen and the facility at the time of their analytic cohort entry visit. We excluded patients whose visit was with providers at their non-principal facility (principal defined as the facility that they saw most patients in 2010). The analysis was stratified by healthcare setting. Results- Median time from cohort entry until screening varied across settings (202-1063 days) and across providers and clinics (between cluster variance= 0.11-0.77, 0.06-1.18, respectively). Many patient-level characteristics (age, cohort entry year, race/ethnicity, number of comorbidities, smoking status, primary care visit within 12 months before cohort entry, and insurance), some of the provider-level characteristics (provider specialty and sex) and social determinants of health measures (Local Isolation Score Hispanic) were associated with time to screening. In the adjusted PWE models, for all three settings: a) Younger patients (21-49 years old) (vs older patients (50-65 years)); b) Hispanic and Non-Hispanic Asian/Pacific Islander (vs Non-Hispanic White); and c) patients seeing ob-gyn providers (vs family medicine providers) had shorter time to screening. Patients with a) higher (vs lower) comorbidity burden, and b) Medicare insurance (vs Commercial) were less likely to receive screened. Conclusion- By identifying characteristics at multiple levels that are associated with the outcome, our results help us identify targets for interventions to improve and increase timely cervical cancer screening in healthcare settings. Citation Format: Rutu Rathod, Ellen Hu, Sandi Pruitt, Jasmin A. Tiro, Jessica Chubak, Jennifer Haas, Steven J. Atlas, Gina Kruse, Amy E. Hughes. Association of multi-level factors with cervical cancer screening in healthcare settings [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3451.

Utilization of broad- versus narrow-spectrum antibiotics for the treatment of outpatient community-acquired pneumonia among adults in the United States.

To characterize antibiotic utilization for outpatient community-acquired pneumonia (CAP) in the United States. We conducted a cohort study among adults 18-64 years diagnosed with outpatient CAP and a same-day guideline-recommended oral antibiotic fill in the MarketScan® Commercial Database (2008-2019). We excluded patients coded for chronic lung disease or immunosuppressive disease; recent hospitalization or frequent healthcare exposure (e.g., home wound care, patients with cancer); recent antibiotics; or recent infection. We characterized utilization of broad-spectrum antibiotics (respiratory fluoroquinolone, β-lactam + macrolide, β-lactam + doxycycline) versus narrow-spectrum antibiotics (macrolide, doxycycline) overall and by patient- and provider-level characteristics. Per 2007 IDSA/ATS guidelines, we stratified analyses by otherwise healthy patients and patients with comorbidities (coded for diabetes; chronic heart, liver, or renal disease; etc.). Among 263 914 otherwise healthy CAP patients, 35% received broad-spectrum antibiotics (not recommended); among 37 161 CAP patients with comorbidities, 44% received broad-spectrum antibiotics (recommended). Ten-day antibiotic treatment durations were the most common for all antibiotic classes except macrolides. From 2008 to 2019, broad-spectrum antibiotic use substantially decreased from 45% to 19% in otherwise healthy patients (average annual percentage change [AAPC], -7.5% [95% CI -9.2%, -5.9%]), and from 55% to 29% in patients with comorbidities (AAPC, -5.8% [95% CI -8.8%, -2.6%]). In subgroup analyses, broad-spectrum antibiotic use varied by age, geographic region, provider specialty, and provider location. Real-world use of broad-spectrum antibiotics for outpatient CAP declined over time but remained common, irrespective of comorbidity status. Prolonged duration of therapy was common. Antimicrobial stewardship is needed to aid selection according to comorbidity status and to promote shorter courses.

Real-World Depression Screening Practices Among Primary Care Providers Across Patient-Level and Provider-Level Characteristics.

This study examined primary care provider (PCP) alignment with guideline-based care for adolescent depression screening and identified factors associated with post-screening responses. A retrospective chart review was conducted across 17 primary care clinics. Logistical regressions were estimated across provider specialties, sociodemographic factors, and patient clinical histories. Significant differences in follow-up and identification of depression were found among patients with more severe depression presentation. Follow-up screening was also more likely to be completed among patients with private insurance and less likely to occur among Black patients. Patients with significant mental health history of a mood concern, history of being prescribed psychotropic medication, were currently on medications at the time of the screening, or had a history of an internal mental health referral had a higher predicted probability of being identified as depressed on the patient problem list.

Patient- And Provider-Level Predictors of Survival Among Patients With Metastatic Renal Cell Carcinoma Initiating Oral Anticancer Agents.

In an era of rapid expansion of FDA approvals for oral anticancer agents (OAAs), it is important to understand the factors associated with survival among real-world populations, which include groups not well-represented in pivotal clinical trials of OAAs, such as the elderly, racial minorities, and medically complex patients. Our objective was to evaluate patient- and provider-level characteristics' associations with mortality among a multi-payer cohort of metastatic renal cell carcinoma (mRCC) patients who initiated OAAs. This retrospective cohort study was conducted using data from the North Carolina state cancer registry linked to multi-payer claims data for the years 2004 to 2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. Included patients were individuals with mRCC who initiated an OAA and survived ≥90 days after beginning treatment. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox hazard models for associations between patient demographics, patient clinical characteristics, provider-level factors, and 2-year all-cause mortality. The cohort included 207 patients with mRCC who received OAAs. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, patients solely on Medicare had higher adjusted all-cause mortality compared with patients with any private insurance (HR: 2.35, 95% CL: 1.32-4.18). No provider-level covariates investigated were associated with all-cause mortality. Within a real-world population of mRCC patients taking OAAs, survival differed based on patient characteristics. In an era of rapid expansion of FDA approvals for OAAs, these real-world data underscore the continued importance of access to high-quality care, particularly for medically complex patients with limited resources.

Contingency Management in Canadian Addiction Treatment: Provider Attitudes and Use.

Contingency management (CM) is an evidence-based treatment for addictive disorders that is underused in clinical practice. The attitudes of staff are frequently reported as barriers to the uptake and use of evidence-based treatments, including CM. Understanding these barriers is an important step in implementation and could have an impact on an intervention's efficacy. We investigated Canadian addiction treatment providers' (ATPs) beliefs and use of CM. Managers of addictions treatment programs across Canada were contacted between March 2019 and February 2021 and asked to forward our survey to interested ATPs (N = 298 respondents; female = 210, male = 80, other = 8) who offered services to help clients reduce substance use in their program(s). Providers in 103 programs across all 10 Canadian provinces participated (26.2% response rate). Most were not familiar with CM and reported largely neutral attitudes toward it. Training-related barriers to CM were the most highly endorsed compared with other barriers. Most ATPs reported a desire for additional training in CM. Some denied wanting additional training because of concerns about CM, which was consistent with previous literature. Our findings suggest that successful implementation of evidence-based treatments requires consideration of provider-level characteristics including attitudes, knowledge, and concerns about the intervention. Results highlight the importance of integrating training with efforts to address systemic-level barriers to implementation.

Comparison of virtual to in-person academic detailing on naloxone prescribing rates at three U.S. Veterans Health Administration regional networks

IntroductionAcademic detailing, an educational outreach that promotes evidence-based practices to improve the quality of care for patients, has primarily been delivered using one-on-one in-person interactions. In 2018, the U.S. Department of Veterans Affairs (VA) Pharmacy Benefits Management implemented a pilot virtual academic detailing program to increase naloxone prescribing among veterans at risk for opioid overdose or death. The aim of this evaluation was to compare virtual and in-person academic detailing on naloxone prescribing rates at VA. MethodsA retrospective quasi-experimental pretest-posttest non-equivalent groups design was used to compare virtual academic detailing and in-person academic detailing on naloxone prescribing rates 12 months before and after providers received a naloxone-specific encounter at three VA regional networks between January 1, 2018 to May 31, 2020. Subgroup analysis was performed on rural providers. Generalized estimating equation models were constructed to compare the difference in naloxone prescribing rates before and after receiving virtual or in-person academic detailing controlling for provider-level characteristics. ResultsProviders who received virtual (N = 67) or in-person (N = 186) academic detailing had significant increases in naloxone prescribing, but the differences in the naloxone rates between the groups were not statistically significant (difference in changes in naloxone rates=+0.63; 95% CI: −2.23, 3.48). Similar findings were reported for rural providers. DiscussionProviders who received naloxone-related in-person or virtual academic detailing had increased naloxone prescribing rates; however, there were no differences between the two types of modalities. Virtual academic detailing is a viable alternative for delivering academic detailing and allows academic detailers to expand their reach to rural providers.

Health Service- and Provider-Level Factors Influencing Engagement in HIV Pre-Exposure Prophylaxis Care Among Male Sex Workers.

Multilevel barriers to pre-exposure prophylaxis (PrEP) care among male sex workers (MSW) include aspects of interactions with health services and providers. We examined relationships between health service- and provider-level factors and PrEP care among MSW. Between 2017 and 2019, we enrolled 111 MSW in the Northeast United States who were not on PrEP, but expressed interest in potentially using PrEP, in a behavioral intervention to promote PrEP uptake and adherence. Using baseline data, we examined whether having a primary care provider, past year frequency of medical visits, comfort discussing sexual practices with providers, and transportation difficulties to accessing general health care were associated with PrEP use self-efficacy, anticipated barriers to PrEP uptake, adherence, and retention (linear regression), and intention to initiate PrEP (logistic regression). Models adjusted for age, race/ethnicity, sexual identity, education, and income. Participants' mean age was 34.2 [standard deviation (SD) = 8.5], and 47% were non-White. Three-quarters (76%) intended to initiate PrEP within the next month. Comfort discussing sexual practices with providers was associated with PrEP use self-efficacy (b = 0.41, p = 0.008). Comfort discussing sexual practices with providers was negatively associated with anticipated barriers to PrEP uptake (b = -0.29, p = 0.006). Transportation difficulties to accessing general health care were associated with barriers to PrEP uptake (b = 0.30, p = 0.007) and barriers to PrEP adherence and retention (b = 0.57, p < 0.001). No health service- and provider-level characteristics were associated with intention to initiate PrEP. PrEP programs targeting MSW may benefit from interventions to foster communication between MSW and providers about sexual practices and should consider structural barriers to accessing care, including lack of access to transportation.

Exploring the heterogeneity of factors that may influence implementation of PrEP in family planning clinics: a latent profile analysis

BackgroundTitle X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention. However, PrEP has not been widely integrated into family planning services, especially in the Southern US, and data suggest there may be significant implementation challenges in this setting. Because Title X clinics vary greatly in provider-, organizational-, and systems-level characteristics, there is likely variation in capacity to implement PrEP across clinics.MethodsWe conducted a survey from February to June 2018 among providers and administrators of non-PrEP-providing Title X-funded clinics across 18 southern states. Survey items were designed using the Consolidated Framework for Implementation Research (CFIR) to assess constructs relevant to PrEP implementation. To explore the heterogeneity of CFIR-related implementation determinants and identify distinct sub-groups of Title X clinics, a latent profile analysis was conducted using nine CFIR constructs: complexity, relative advantage, cost, attitudes, implementation climate, compatibility, leadership engagement, available resources, and cosmopolitanism. We then conducted a multi-level analysis (accounting for nesting of participants within clinics) to test whether group membership was associated with readiness for implementation of PrEP, controlling for key sociodemographic characteristics.ResultsFour hundred and fourteen healthcare providers/administrators from 227 non-PrEP-providing Title X clinics participated in the study. We identified six sub-groups of clinics that each had distinct patterns of PrEP implementation determinants. Clinic sub-groups included “Highest Capacity for Implementation”, “Favorable Conditions for Implementation”, “Mixed Implementation Context”, “Neutral Implementation Context”, “Incompatible Setting for Implementation”, and “Resource-Strained Setting”. Group membership was related to numerous provider-level (i.e., ability to prescribe medication) and clinic-level (i.e., provision of primary care) characteristics. In comparison to the “Neutral” group (which held neutral perceptions across the implementation determinants), the “Highest Capacity” and “Favorable Conditions” groups had significantly higher levels of implementation readiness, and the “Resource-Strained” group had a significantly lower level of implementation readiness.ConclusionsLatent profile analyses can help researchers understand how implementation readiness varies across healthcare settings, promoting tailoring of implementation strategies to unique contexts.

Lessons From the Free-Text Epidemic: Opportunities to Optimize Deployment of Imaging Clinical Decision Support.

The Protecting Access to Medicare Act of 2014 requires clinicians to consult Appropriate Use Criteria (AUC) when ordering advanced imaging procedures. Free-text order indications are available when there is no applicable structured indication but are unscored by the AUC. We determined the proportion of free-text indications among all advanced imaging orders and the proportion of free-text indications that could be mapped to a single structured indication. All outpatient advanced diagnostic imaging orders placed in a large multisite health system were recorded after initial AUC deployment (November 20, 2017, to December 19, 2017). Clinicians were prompted upon order entry to select a structured indication or enter a free-text indication. We manually reviewed the two imaging examinations with the highest rate of free-text indications: enhanced CT abdomen/pelvis and unenhanced CT head. Regression analysis examined differences in patient-, imaging-, context-, and provider-level characteristics between scored and unscored examinations. Among all 39,533 orders for advanced imaging procedures, 59% (23,267 of 39,533) were unscored by the system. The regression model c-statistic (0.50-0.55) demonstrated poor model fit to evaluate for differences between scored and unscored examinations. Free-text indications were found in 71% (16,440 of 23,267) of unscored examinations and 42% (16,440 of 39,533) of all examinations. Manual review of all 1,693 CT abdomen/pelvis and 1,527 CT head examinations with free-text indications revealed that 3,132 free-text indications (97%) could be mapped to a single existing structured indication. Of all initially placed outpatient advanced imaging procedure orders, 42% included free-text indications and 97% of manually reviewed free-text indications could be mapped to a single structured indication.

Rural-urban differences in antibiotic prescribing for uncomplicated urinary tract infection.

To examine rural-urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI). Observational cohort study. Using the IBM MarketScan Commercial Database (2010-2015), we identified US commercially insured women aged 18-44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural-urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural-urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural-urban status. Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10-1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural-urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty. Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.

241. Rural-urban differences in antibiotic prescribing for uncomplicated urinary tract infections

BackgroundIdentification of inappropriate antibiotic prescribing patterns is critical for designing antimicrobial stewardship programs. We sought to examine whether the risk of receipt of an inappropriate outpatient antibiotic prescription varied by rural-urban status among women with an uncomplicated urinary tract infection (UTI).MethodsUsing the IBM MarketScan Commercial Database, we identified U.S. women 18–44 years diagnosed with a new uncomplicated UTI and prescribed an oral antibiotic with activity against common uropathogens from April 2011 through June 2015. We classified first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin) as appropriate, non-first-line agents (fluoroquinolones and β-lactams) as inappropriate, and antibiotic duration as appropriate when the days’ supply was consistent with Infectious Diseases Society of America 2011 guidelines. Rural-urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural-urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics.ResultsOf 670,450 women with uncomplicated UTI, 46.7% of antibiotic prescriptions were written for inappropriate agents and 76.1% for inappropriate durations (Figures 1 and 2). Use of inappropriate agents or durations did not change appreciably over the study period (2011–2013 vs. 2014–2015). Of 507,737 prescriptions with inappropriate duration, 501,496 (98.8%) were written for a days’ supply longer than recommended. Compared to urban women, rural women had similar risk of receipt of an inappropriate agent (adjusted risk ratio 0.99, 95% CI, 0.98–1.00) but were more likely to receive a prescription for an inappropriate duration (adjusted risk ratio 1.10, 95% CI, 1.09–1.11).Figure 1. Distribution of antibiotic agent by rural-urban status Figure 2. Distribution of the antibiotic prescription days’ supply by antibiotic agent and rural-urban status ConclusionRegardless of rural-urban status, the majority of antibiotic prescriptions for uncomplicated UTI were written for inappropriate agents and durations. Rural women were more likely to receive prescriptions with inappropriately long durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and reduce unnecessary exposure to antibiotics, particularly in rural settings.Disclosures Margaret A. Olsen, PhD, MPH, Merck (Grant/Research Support)Pfizer (Consultant, Grant/Research Support)

1351. Pediatric Antibioitic Use in the North Carolina Medicaid Population

BackgroundAntimicrobial resistance is increasing in the United States, with antibiotic use as the main driver. The majority of antibiotic use occurs in the outpatient setting. 6 of the 7 highest prescribing states are located in the Appalachian region of the country. Overall, the state of North Carolina (NC) has prescribing rates that are at the national average, but the geographic, patient and provider-level characteristics associated with antibiotic prescribing within the state are unknown.MethodsWe used NC Medicaid claims from 2013-2018 to identify oral antibiotics prescribed to children, defined as individuals < 21 years. Antibiotics were identified using National Drug Codes. Overall rates of antibiotic prescribing were reported as the number of prescriptions per 1000 children overall and stratified by age, sex, race/ethnicity and residence in a metropolitan area. Provider characteristics and setting type were identified using existing variables in the Medicaid dataset. A geographic information system was used to graphically depict rates of antibiotic use by county.ResultsRates of prescribing decreased from 724/1000 children in 2013 to 578/1000 children in 2018. Across all study years there were differences in prescribing rates by sex, race/ethnicity, age and residence in a metropolitan area. (Table) Prescriptions were more common in children who were younger (0-2), white non-Hispanic, female and living in non-metropolitan areas. Prescribing rates were geographically heterogeneous, with the highest rates in the western mountain region and declining across a west to east gradient. (Figure) Most (62%) antibiotic prescriptions were written in the primary care setting. Pediatricians prescribed 48% of all antibiotic courses.Antibiotic Prescriptions Per 1000 Children, by Demographic Group (2013-2018) Antibiotic Prescriptions per 1000 Children, by County (2013-2018) ConclusionAlthough NC is not a high-prescribing state in general, we found notable difference in prescribing based on key demographic characteristics. These results are consistent with prior reports from other Appalachian states including Kentucky, West Virginia and Tennessee. Rates of prescription were highest in non-metropolitan areas overall but GIS mapping revealed a marked west-east gradient. These data suggest that specific Appalachian characteristics, rather than rurality alone, may be associated with excessive antibiotic prescribing.DisclosuresMichael J. Smith, MD, MSC.E, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support)

Patient and provider-level factors associated with changes in utilization of treatments in response to evidence on ineffectiveness or harm

High-quality health care not only includes timely access to effective new therapies but timely abandonment of therapies when they are found to be ineffective or unsafe. Little is known about changes in use of medications after they are shown to be ineffective or unsafe. In this study, we examine changes in use of two medications: fenofibrate, which was found to be ineffective when used with statins among patients with Type 2 diabetes (ACCORD lipid trial); and dronedarone, which was found to be unsafe in patients with permanent atrial fibrillation (PALLAS trial). We examine the patient and provider characteristics associated with a decline in use of these medications. Using Medicare fee-for-service claims from 2008 to 2013, we identified two cohorts: patients with Type 2 diabetes using statins (7 million patient-quarters), and patients with permanent atrial fibrillation (83 thousand patient-quarters). We used interrupted time-series regression models to identify the patient- and provider-level characteristics associated with changes in medication use after new evidence emerged for each case. After new evidence of ineffectiveness emerged, fenofibrate use declined by 0.01 percentage points per quarter (95% CI - 0.02 to - 0.01) from a baseline of 6.9 percent of all diabetes patients receiving fenofibrate; dronedarone use declined by 0.13 percentage points per quarter (95% CI - 0.15 to - 0.10) from a baseline of 3.8 percent of permanent atrial fibrillation patients receiving dronedarone. For dronedarone, use declined more quickly among patients dually-enrolled in Medicare and Medicaid compared to Medicare-only patients (P < 0.001), among patients seen by male providers compared to female providers (P = 0.01), and among patients seen by cardiologists compared to primary care providers (P < 0.001).

Determinants of Food Insecurity Among Congregate Meal Participants: A Cross-Sectional Study Using Participant Information Matched to Geographic and Service Provider Data.

As people age, they are more likely to face financial, medical, and mobility related challenges that can put them at risk of food insecurity. This is a serious public health concern that has been associated with many adverse health outcomes. This study examined factors associated with food insecurity among older adults who receive congregate meals from the Administration on Aging's Nutrition Services Program. Combining participant, geographic, and provider data allowed for a more detailed assessment of older adult food insecurity than is typically possible using other national surveys. A cross-sectional study. We conducted a cross-sectional data analysis using national survey data from the Administration on Aging's Nutrition Services Program Outcomes Survey, conducted from 2015 to 2016. The data were linked to provider data from the meal site where participants ate. Logistic regression analysis was conducted to estimate the associations between food insecurity and demographic, household, geographic, and provider-level characteristics and circumstances. Interviews with congregate meal participants were conducted in person at congregate meal sites or another preferred place. A total of 520 older adults were included as study participants. All older adults were participating in the Nutrition Services Program and receiving congregate meals at the time of the survey interview. All participants were at least 67 years old. This study used a 6-item food security measure as the dependent variable. Older adults who answered at least 3 of the 6 questions affirmatively were considered food insecure. Food security was assessed over a 30-day recall period. 18% of congregate meal participants lived in food insecure households. Among congregate meal participants, having low income, difficulty reaching family and friends, past military service, and mobility challenges, and attending a site that provided nutrition counseling were associated with increased food insecurity (most odds ratios ranged from 1.1 to 2.6). Older age, geographic access to food, certain chronic health conditions, and provider-offered nutrition screening and social activities reduced the odds of experiencing food insecurity (most odds ratios ranged from 0.2 to 0.4). Although the Nutrition Services Program helps to alleviate food insecurity, a nontrivial percentage of participants remain food insecure. Nutrition programs can help address clients' food access limitations by broadening nutrition screenings at meal sites to include more comprehensive assessments based on non-traditional risk factors for food insecurity.

Characteristics of Office-Based Buprenorphine Prescribers for Medicare Patients

Opioid use disorder (OUD) is a major and growing public health concern, and Medicare patients have nearly double the proportion of OUD prevalence compared with those with commercial insurance. This study examines provider-level characteristics to delineate the wide variation behind buprenorphine provision, which is the mainstay of medication-assisted treatment for OUD. Using Medicare Part D Public Use Files claims data from 2013 to 2016 in all states, we assessed prescribing patterns of buprenorphine formulations for the specialties of family medicine, internal medicine, psychiatry, and general practice. We incorporated data from 2013 to 2016 American Medical Association Physician Masterfile to model various provider- and area-level characteristics as predictors of buprenorphine prescriber status. Family medicine and internal medicine comprise nearly two-thirds of the outpatient buprenorphine prescriber population for Medicare beneficiaries. Yet, both specialties also have the lowest proportion of active buprenorphine prescribers compared with psychiatrists and general practitioners. Additional characteristics associated with buprenorphine provision include male sex, osteopathic training, Northeast region, US undergraduate medical education, more years in practice, and a higher proportion of dual-eligible patients. Primary care specialties, such as family medicine and internal medicine, currently comprise a significant majority of the US buprenorphine prescriber population for Medicare beneficiaries. Future policies should target specific demographics to enable greater patient access from physicians who are characteristically less likely to prescribe buprenorphine to increase overall capacity.

Expansion coverage and preferential utilization of cancer surgery among racial and ethnic minorities and low-income groups

BackgroundThe Affordable Care Act Medicaid expansion demonstrated inconsistent effects on cancer surgery utilization rates among racial and ethnic minorities and low-income Americans. This quasi-experimental study examines whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid programs. MethodsA cohort of more than 81,000 patients 18 to 64 years of age who underwent cancer surgery were examined in Medicaid expansion versus nonexpansion states. This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File for the years 2012 to 2015. Poisson interrupted time series analysis were performed to examine the impact of Medicaid expansion on the utilization of cancer surgery for the uninsured overall, low-income persons, and racial minorities, adjusting for age, sex, Elixhauser comorbidity score, population-level characteristics, and provider-level characteristics. ResultsFor persons from low-income ZIP codes, Medicaid expansion was associated with an immediate 24% increase in utilization (P = .002) relative to no significant change in nonexpansion states. No significant trends, however, were observed after the Affordable Care Act expansion for racial and ethnic minorities in expansion versus nonexpansion states. ConclusionMedicaid expansion was associated with greater utilization of cancer surgery by low-income Americans but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these findings highlight the need for additional investigation to uncover other factors that contribute to race-ethnic disparities in surgical cancer care.

Identification of High-Yield Targets for Antimicrobial Stewardship Program Efforts Within a Nonfreestanding Children's Hospital.

Identify diagnoses with the highest likelihood of prompting antimicrobial stewardship program (ASP) recommendations and lowest probability of recommendation acceptance, investigate the impact of provider years in practice on recommendation receipt and acceptance, and simultaneously assess the influence of patient and provider-level variables associated with recommendations within a nonfreestanding children's hospital. Retrospective cohort study of antibiotic courses reviewed by the ASP staff from December 1, 2014 to November 30, 2016. Poisson regression was used to detect associations between diagnoses, provider years in practice, and the probability of recommendation receipt and acceptance. Multivariable logistic regression was used to simultaneously examine the influence of patient and provider-level characteristics on recommendation probability. A total of 938 inpatient encounters and 1170 antibiotic courses were included. Diagnoses were associated with provider receipt (P < .001) and acceptance (P < .001) of recommendations, with ear, nose, and throat and/or sinopulmonary diagnoses most likely to prompt recommendations (56%; 95% confidence interval [CI], 48-64) and recommendations for neonatal and/or infant diagnoses accepted least often (67%; 95% CI, 58-76). No associations were initially found between provider experience and recommendation receipt or acceptance, although multivariable analysis revealed a trend between increasing years in practice and recommendation likelihood (P = .001). Vancomycin usage (64%; 95% CI, 56-72) and ear, nose, and throat and/or sinopulmonary diagnoses (56%; 95% CI, 47-65) had the highest probability of a recommendation. Sensitivity analyses revealed that use of diagnosis-related clinical practice guidelines decreased recommendations and increased acceptance rates, especially for the surgery diagnosis category. High-yield targets for ASP activities at our nonfreestanding children's hospital were identified. Clinical practice guidelines have the potential to decrease ASP workload, and their development should be particularly encouraged for ASPs with limited resources.

Adjunct clinical interventions that influence vaginal birth after cesarean rates: systematic review

BackgroundRates of cesarean deliveries have been increasing, and contributes to the rising number of elective cesarean deliveries in subsequent pregnancies with associated maternal and neonatal risks. Multiple guidelines recommend that women be offered a trial of labor after a cesarean (TOLAC). The objective of the study is to systematically review the literature on adjunct clinical interventions that influence vaginal birth after cesarean (VBAC) rates.MethodsWe searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any adjunct clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting changes in TOLAC or VBAC rates. One reviewer extracted data and a second reviewer verified for accuracy. Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT).ResultsTwenty-three studies of overall moderate to good methodological quality examined adjunct clinical interventions affecting TOLAC and/or VBAC rates: system-level interventions (three studies), provider-level interventions (three studies), guidelines or information for providers (seven studies), provider characteristics (four studies), and patient-level interventions (six studies). Provider-level interventions (opinion leader education, laborist, and obstetrician second opinion for cesarean sections) and provider characteristics (midwifery antenatal care, physicians on night float call schedules, and deliveries by family physicians) were associated with increased rates of VBAC. Few studies employing heterogeneous designs, sample sizes, interventions and comparators limited confidence in the effects. Studies of system-level and patient-level interventions, and guidelines/information for providers reported mixed findings.ConclusionsLimited evidence indicates some provider-level interventions and provider characteristics may increase rates of attempted and successful TOLACs and/or VBACs, whereas other adjunct clinical interventions such as system-level interventions, patient-level interventions, and guidelines/information for healthcare providers show mixed findings.

Multi-level Influences on Breast Cancer Screening in Primary Care.

Use of breast cancer screening is influenced by factors associated with patients, primary care providers, practices, and health systems. We examined the relative effects of these nested levels on four breast cancer screening metrics. A web-based survey was completed at 15 primary care practices within two health systems representing 306 primary care providers (PCPs) serving 46,944 women with a primary care visit between 1/2011-9/2014. Analyses occurred between 1/2017 and 5/2017. Across four nested levels (patient, PCP, primary care practice, and health system), frequency distributions and adjusted rates of primary care practice characteristics and survey results for four breast screening metrics (percent screened overall, and percent screened age 40-49, 50-74, and 75+) were reported. We used hierarchical multi-level mixed and random effects analysis to assess the relative influences of PCP, primary care practice, and health system on the breast screening metrics. Overall, the proportion of women undergoing breast cancer screening was 73.1% (73.4% for ages 40-49, 76.5% for 50-74, and 51.1% for 75+). Patient ethnicity and number of primary care visits were strongly associated with screening rates. After adjusting for woman-level factors, 24% of the overall variation among PCPs was attributable to the primary care practice level, 35% to the health system level, and 41% to the residual variation among PCPs within practice. No specific provider-level characteristics were found to be statistically significant determinants of screening rates. After accounting for woman-level characteristics, the remaining variation in breast cancer screening was largely due to provider and health system variation.

Provider Adherence to Nutrition and Physical Activity Best Practices Within Early Care and Education Settings in Minnesota, Helping to Reduce Early Childhood Health Disparities.

Licensed child care providers, and the early care and education settings in which they operate, are uniquely situated to influence children's healthy eating and physical activity through practices, attitudes, and supportive physical and social environments. However, preliminary research indicates that child-, family-, and provider-level characteristics affect adherence to best practices across early care and education settings. The current article used survey data ( n = 618) to characterize differences in child care providers' adherence to nutrition, physical activity, and mealtime best practices, based on child-, family- and provider-level characteristics, and to describe secular trends in adherence to nutrition and physical activity best practices between 2010 and 2016. Results indicate that differences exist across certain characteristics, including child race/ethnicity, family's use of child care assistance, language spoken at home, and provider educational attainment; however, it is notable that in most cases providers serving children of minority race and children in low-income families have a higher rate of compliance with the nutrition and physical activity best practices studied. Additionally, the comparison of adherence to best practices from 2010 to 2016 suggests that, while there was an increase in mean adherence from 2010 to 2016, overall trends in adherence across child-, family- and provider-level characteristics have been consistent across time. Public health professionals should continue to advocate for opportunities for providers to learn how to best incorporate best practices within their setting (e.g., education and training opportunities) as well as for the development and adoption of systems-level changes (e.g., expansion of food assistance programs) to reduce barriers to adherence to best practices.