Suicide typologies among Medicaid beneficiaries, North Carolina 2014-2017.

BACKGROUND: There is a well-established need for population-based screening strategies to identify people at risk of suicide. Because only about half of suicide decedents are ever diagnosed with a behavioral health condition, it may be necessary for providers to consider life circumstances that may also put individuals at risk. This study described the alignment of medical diagnoses with life circumstances by identifying suicide typologies among decedents. Demographics, stressful life events, suicidal behavior, perceived and diagnosed health problems, and suicide method contributed to the typologies. METHODS: This study linked North Carolina Medicaid and North Carolina Violent Death Reporting System (NC-VDRS) data for analysis in 2020. For suicide decedents from 2014 to 2017 aged 25-54 years, we analyzed 12 indicators of life circumstances from NC-VDRS and 6 indicators from Medicaid claims, using a latent class model. Separate models were developed for men and women. RESULTS: Most decedents were White (88.3%), with a median age of 41, and over 70% had a health care visit in the 90 days prior to suicide. Two typologies were identified in both males (n = 175) and females (n = 153). Both typologies had similar profiles of life circumstances, but one had high probabilities of diagnosed behavioral health conditions (45% of men, 71% of women), compared to low probabilities in the other (55% of men, 29% of women). Black beneficiaries and men who died by firearm were over-represented in the less-diagnosed class, though estimates were imprecise (odds ratio for Black men: 3.1, 95% confidence interval: 0.8, 12.4; odds ratio for Black women: 5.0, 95% confidence interval: 0.9, 31.2; odds ratio for male firearm decedents: 1.6, 95% confidence interval: 0.7, 3.4). CONCLUSIONS: Nearly half of suicide decedents have a typology characterized by low probability of diagnosis of behavioral health conditions. Suicide screening could likely be enhanced using improved indicators of lived experience and behavioral health.

Association Between Medical Diagnoses and Suicide in a Medicaid Beneficiary Population, North Carolina 2014-2017.

BACKGROUND: Firearms are used in about half of U.S. suicides. This study investigated how various medical diagnoses are associated with firearm and nonfirearm suicide. METHODS: We used a case-control design including n = 691 North Carolina Medicaid beneficiaries who died from suicide between 1 January 2014 and 31 December 2017 as cases. We selected a total of n = 68,682 controls (~1:100 case-control ratio from North Carolina Medicaid member files using incidence density sampling methods). We linked Medicaid claims to the North Carolina Violent Death Reporting System to ascertain suicide and means (firearm or nonfirearm). We matched cases and controls on number of months covered by Medicaid over the past 36 months. Analyses adjusted for sex, race, age, Supplemental Security Income status, the Charlson Comorbidity Index, and frequency of health care encounters. RESULTS: The case-control odds ratios for any mental health disorder were 4.2 (95% confidence interval [CI]: 3.3, 5.2) for nonfirearm suicide and 2.2 (95% CI: 1.7, 2.9) for firearm suicide. There was effect measure modification by sex and race. Behavioral health diagnoses were more strongly associated with nonfirearm suicides than firearm suicide in men but did not differ substantially in women. The association of mental health and substance use diagnoses with suicides appeared to be weaker in Blacks (vs. non-Blacks), but the estimates were imprecise. CONCLUSION: Behavioral health diagnoses are important indicators of risk of suicide. However, these associations differ by means of suicide and sex, and associations for firearm-related suicide are weaker in men than women.

Improving Access to Cancer Testing and Treatment in Kenya.

PURPOSE: In response to the increasing cancer burden in Kenya, this study identified barriers to patients seeking access to cancer testing and treatment and to clinicians in delivering these services. Policy recommendations based on findings are presented. METHODS: This qualitative study used semistructured key informant interviews. Purposive sampling was used to recruit 14 participants: seven oncology clinicians and seven support and advocacy leaders for patients with cancer. Qualitative analysis was used to identify themes. RESULTS: Seven barriers to cancer testing and treatment were identified: high cost of testing and treatment, low level of knowledge about cancer among population and clinicians, poor health-seeking behaviors among population, long distances to access diagnostic and treatment services, lack of decentralized diagnostic and treatment facilities, poor communication, and lack of better cancer policy development and implementation. CONCLUSION: Kenyans seeking cancer services face significant barriers that result in late presentation, misdiagnosis, interrupted treatment, stigma, and fear. Four policy recommendations to improve access for patients with cancer are (1) improve health insurance for patients with cancer; (2) establish testing and treatment facilities in all counties; (3) acquire diagnosis and treatment equipment and train health personnel to screen, diagnose, and treat cancer; and (4) increase public health awareness and education about cancer to improve diagnoses and treatment. Effective cancer testing and treatment options can be developed to address cancer in a resource-constrained environment like Kenya. An in-depth look at effective interventions and policies being implemented in countries facing similar challenges would provide valuable lessons to Kenya's health sector and policymakers.

"We Need to Deploy Them Very Thoughtfully and Carefully": Perceptions of Analytical Treatment Interruptions in HIV Cure Research in the United States-A Qualitative Inquiry.

Strategies to control HIV in the absence of antiretroviral therapy are needed to cure HIV. However, such strategies will require analytical treatment interruptions (ATIs) to determine their efficacy. We investigated how U.S. stakeholders involved in HIV cure research perceive ATIs. We conducted 36 in-depth interviews with three groups of stakeholders: 12 people living with HIV, 11 clinician-researchers, and 13 policy-makers/bioethicists. Qualitative data revealed several themes. First, there was little consensus on when ATIs would be ethically warranted. Second, the most frequent perceived hypothetical motivators for participating in research on ATIs were advancing science and contributing to society. Third, risks related to viral rebound were the most prevalent concerns related to ATIs. Stakeholders suggested ways to minimize the risks of ATIs in HIV cure research. Increased cooperation between scientists and local communities may be useful for minimizing risk. Further ethics research is necessary.

Perceptions of Equipoise, Risk-Benefit Ratios, and "Otherwise Healthy Volunteers" in the Context of Early-Phase HIV Cure Research in the United States: A Qualitative Inquiry.

Early-phase HIV cure research is conducted against a background of highly effective antiretroviral therapy, and involves risky interventions in individuals who enjoy an almost normal life expectancy. To explore perceptions of three ethical topics in the context of HIV cure research-(a) equipoise, (b) risk-benefit ratios, and (c) "otherwise healthy volunteers"-we conducted 36 in-depth interviews (IDIs) with three groups of purposively selected key informants: clinician-researchers ( n = 11), policy-makers and bioethicists ( n = 13), and people living with HIV (PLWHIV; n = 12). Our analysis revealed variability in perceptions of equipoise. Second, most key informants believed there was no clear measure of risk-benefit ratios in HIV cure research, due in part to the complexity of weighing (sometimes unknown) risks to participants and (sometimes speculative) benefits to science and society. Third, most clinician-researchers and policy-makers/bioethicists viewed potential HIV cure study participants as "otherwise healthy volunteers," but this perception was not shared among PLWHIV in our study.

Research on HIV cure: Mapping the ethics landscape.

In an essay, Karine Dubé and coauthors discuss the ethics of preclinical and clinical studies relevant to achieving an HIV cure.

Willingness to participate and take risks in HIV cure research: survey results from 400 people living with HIV in the US.

INTRODUCTION: Participation in early-phase HIV cure studies includes clinical risks with little to no likelihood of clinical benefit. Examining the willingness of people living with HIV to participate is important to guide study design and informed consent. Our study examined the overall willingness of people living with HIV to participate in HIV cure research in the US, focusing on perceived risks and benefits of participation. METHODS: We undertook an online survey of adults living with HIV in the US. Survey questions were developed based on previous research and a scoping review of the literature. We quantitatively assessed individuals' perceived risks and benefits of HIV cure-related research and respondents' willingness to participate in different modalities of HIV cure studies. RESULTS: We recruited 409 study participants of whom 400 were eligible for the study and were included in the analysis (nine were not eligible due to self-declared HIV-negative status). We found >50% willingness to participate in 14 different types of HIV cure studies. Perceived clinical benefits and social benefits were important motivators, while personal clinical risks appeared to deter potential participation. Roughly two-thirds of survey respondents (68%) indicated that they were somewhat willing to stop treatment as part of HIV cure research. In the bivariate models, females, African Americans/blacks, Hispanics, individuals in the lowest income bracket, people living with HIV for longer periods of their lives, and people who were self-perceived 'very healthy' were less willing to participate in certain types of HIV cure studies than others. Multivariate results showed the perceived benefits (adjusted odds ratios >1) and perceived risks (adjusted odds ratios <1) acted as potential motivators and deterrents to participation, respectively. CONCLUSION: Our study is the first attempt to quantify potential motivators and deterrents of participation in HIV cure research in the US using perceived risks and benefits. The results offer guidance to HIV cure researchers and developers of interventions about the beneficial and detrimental characteristics of HIV cure strategies that are most meaningful to people living with HIV. The study also highlights new potential lines of inquiry for further social science and ethics research.

'Well, It's the Risk of the Unknown Right?': A Qualitative Study of Perceived Risks and Benefits of HIV Cure Research in the United States.

INTRODUCTION: Biomedical research towards an HIV cure is advancing in the United States and elsewhere, yet little is known about perceptions of risks and benefits among potential study participants and other stakeholders. We conducted a qualitative study to explore perceived risks and benefits of investigational HIV cure research among people living with HIV (PLWHIV), biomedical HIV cure researchers, policy-makers and bioethicists. METHODS: We conducted a qualitative research study using in-depth interviews with a purposive sample of PLWHIV, biomedical HIV cure researchers, policy-makers and bioethicists in 2015-2016. We analysed interview transcripts using thematic analysis anchored in grounded theory. RESULTS: We conducted and analyzed 36 key informant interviews. Qualitative analysis revealed four main findings. 1) Potential HIV cure study volunteers noted needing more information and education about the potential risks of HIV cure research. 2) Biomedical HIV cure researchers, policy-makers and bioethicists showed less awareness of social and financial risks of HIV cure research than PLWHIV. 3) Most respondents across the different categories of informants identified some risks that were too great to be acceptable in HIV cure research, although a subset of PLWHIV did not place an upper limit on acceptable risk. 4) PLWHIV showed a better awareness of potential psychological benefits of participating in HIV cure research than other groups of stakeholders. CONCLUSION: Our research suggests that PLWHIV have a variable understanding of the individual risks, sometimes substantial, associated with participating in biomedical HIV cure research studies. Community engagement and increased research literacy may help improve community understanding. Intensive informed consent procedures will be necessary for ethical study implementation. The current state of HIV cure research offers greater potential benefits to society than to participants. There is likely to be disagreement among regulators, researchers, clinicians, and potential participants about what constitutes acceptable risk for HIV cure studies.

Correlates of women's intentions to be screened for human papillomavirus for cervical cancer screening with an extended interval.

BACKGROUND: High-risk HPV DNA testing has been proposed as a primary tool for cervical cancer screening (HPV-CCS) as an alternative to the Papanicolaou cytology- method. This study describes factors associated with women's intentions to attend cervical cancer screening if high-risk HPV DNA testing (HPV-CCS) was implemented as a primary screening tool, and if screening were conducted every 4 years starting after age 25. METHODS: This online survey was designed using the Theory of Planned Behaviour to assess factors that impact women's intentions to attend HPV-CCS among women aged 25-69 upon exit of the HPV FOCAL trial. Univariate and regression analyses were performed to compare the demographic, sexual history, and smoking characteristics between women willing and unwilling to screen, and scales for intention to attend HPV-CCS. A qualitative analysis was performed by compiling and coding the comments section of the survey. RESULTS: Of the 981 women who completed the survey in full, only 51.4 % responded that they intended to attend HPV-CCS with a delayed start age and extended screening interval. Women who intended to screen were more likely to have higher education (AOR 0.59, 95 % CI [0.37, 0.93]), while both positive attitudes (AOR 1.26, 95 % CI [1.23, 1.30]) and perceived behavior control (AOR 1.06, 95 % CI [1.02, 1.10]) were significant predictors of intention to screen. Among women who provided comments in the survey, a large number of women expressed fears about not being checked more than every 4 years, but 12 % stated that these fears may be alleviated by having more information. CONCLUSIONS: Acceptability of increased screening intervals and starting age could be improved through enhanced education of benefits. Program planners should consider measures to assess and improve women's knowledge, attitudes and beliefs prior to the implementation of new screening programs to avoid unintended consequences.

The business case for pediatric asthma quality improvement in low-income populations: examining a provider-based pay-for-reporting intervention.

OBJECTIVE: To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State. DESIGN: Practice-level, randomized prospective evaluation. SETTING: Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan). PARTICIPANTS: Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices). INTERVENTION: For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. After each chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care. MAIN OUTCOME MEASURES: Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis). RESULTS: The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization for children in treatment relative to control practices. CONCLUSIONS: A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years.

Women's intentions to self-collect samples for human papillomavirus testing in an organized cervical cancer screening program.

BACKGROUND: Mounting evidence affirms HPV testing as an effective cervical cancer screening tool, and many organized screening programs are considering adopting it as primary testing. HPV self-collection has comparable sensitivity to clinician collected specimens and is considered a feasible option in hard-to-reach women. We explored women's intentions to HPV self-collect for cervical cancer screening from a cohort participating in a Canadian randomized controlled cervical cancer screening trial. METHODS: Women aged 25-65 were invited to complete an online survey assessing intentions to be screened with HPV testing instead of the Pap smear. The survey was based in the Theory of Planned Behaviour and questions were included to assess women's intentions to self-collect for HPV. Demographic characteristics of women who intended to self-collect were compared with those who did not. Demographic and scale variables achieving a p-value <0.1 in the univariate and bivariate analyses were included in the stepwise logistic regression model. The final model was created to predict factors associated with women's intentions to self-collect an HPV specimen for cervical cancer. Odds ratios were calculated with 95% confidence intervals to identify variables associated with a woman's intention to self-collect for cervical cancer screening. RESULTS: The overall survey response rate was 63.8% (981/1538) with 447 (45.6%) reporting they intended to self-collect, versus 534 (54.4%) reporting they did not. In the univariate analysis, women with more than high school education were more likely to self-collect. Women who intended to receive HPV testing versus the Pap smear were 1.94 times as likely to be in favour of self-collection and those who intended to self-collect had significantly higher attitudinal scores towards HPV self-collection. The adjusted odds ratio and 95% confidence interval from the multivariate analysis demonstrated attitude towards self-collection was the only significant variable predicting a woman's intention to self-collect (OR 1.25; 95% CI: 1.22, 1.29). CONCLUSIONS: The primary predictor of a woman's intention to HPV self-collect for cervical cancer screening was her attitude towards the procedure. From a program planning perspective, these results indicate that education and awareness may be significant contributing factors to improving acceptance of self-collection and subsequently, improving screening attendance rates.

A non-experimental study of oral anticoagulation therapy initiation before and after national patient safety goals.

OBJECTIVES: The Joint Commission revised its National Patient Safety Goals (NPSGs) to include oral anticoagulation therapy (OAT) in 2008. We sought to examine the effect of including OAT in The Joint Commission's NPSGs on historically low rates of OAT initiation for individuals with incident atrial fibrillation (AF). SETTING: Southeastern state in the USA. PARTICIPANTS: North Carolina State Health Plan claims data from 944 500 individuals enrolled between 1 January 2006 and 31 December 2010, supplemented with data from the Area Resource File and Online Survey, Certification and Reporting data network. We evaluated OAT initiation before and after the 2008 NPSGs revisions in a retrospective cohort new user design with an AF intervention group and two control groups: a positive control-patients estimated to be at very high risk of thromboembolism (mechanical heart valve and pulmonary embolism); and a negative control-patients with very low perceived risk of thromboembolism (paroxysmal AF). We developed multivariable models using a difference-in-difference parameterisation. Effects were estimated with generalised estimating equations. PRIMARY OUTCOME MEASURE: OAT initiation, a binary outcome defined as having a prescription drug claim for warfarin within 30 days of the index claim. RESULTS: OAT initiation was low (26.8%) for eligible individuals with incident AF in 2006-2008 but increased after NPSGs implementation (31.7%, p=0.022). OAT initiation was high but decreased in the positive control group (67.5% vs 62.0%, p=0.003). Multivariate analysis resulted in a relative 11% (95% CI (4% to 18%), p<0.01) increase in OAT initiation for incident AF patients. CONCLUSIONS: We document a substantial increase in guideline concordant OAT initiation in incident AF after the establishment of NPSGs, suggesting that regulatory healthcare agency initiatives can influence clinical practice.

Patient-centered medical homes and oral anticoagulation therapy initiation.

Despite evidence-based guidelines, oral anticoagulation therapy (OAT) initiation is low among incident atrial fibrillation (AF) patients. Patient-centered medical homes (PCMHs) may increase access, quality, and value through coordinating care. As such, PCMHs hold potential for improving OAT initiation among AF patients. We estimated the effect of receiving care in accredited PCMHs on OAT initiation for incident AF patients compared with those not receiving care in accredited PCMHs. Our study, a retrospective cohort new user design, included privately insured patients in North Carolina during years 2006 to 2010. We developed propensity scores for PCMH exposure, performed inverse probability of treatment weighting, and estimated effects with generalized estimating equations. We found a positive association between PCMH exposure and OAT initiation in unadjusted (6.78%; p < .001) and adjusted (6.25%; p < .001) models. Greater implementation and optimization of PCMH model principles may enhance this association, reducing AF-related stroke morbidity and mortality.

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.

Appropriate and safe use of medications is an important aspect of quality of care in nursing home patients. Because of their complex medication use process, anticoagulants are prone to medication errors in the frail elderly. Therefore, we designed this study to characterize anticoagulant medication errors and to evaluate their association with patient harm using individual medication error incidents reported by all North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Characteristics, causes, and specific outcomes of harmful anticoagulant medication errors were reported as frequencies and proportions and compared between anticoagulant errors and other medication errors using chi-square tests. A multivariate logistic regression model explored the relationship between anticoagulant medication errors and patient harm, controlling for patient- and error-related factors.

Women's intentions to receive cervical cancer screening with primary human papillomavirus testing.

We explored the potential impact of human papillomavirus (HPV) testing on women's intentions to be screened for cervical cancer in a cohort of Canadian women. Participants aged 25-65 years from an ongoing trial were sent a questionnaire to assess women's intentions to be screened for cervical cancer with HPV testing instead of Pap smears and to be screened every 4 years or after 25 years of age. We created scales for attitudes about HPV testing, perceived behavioral control, and direct and indirect subjective norms. Demographic data and scales that were significantly different (p < 0.1) between women who intended to be screened with HPV and those who did not intend were included in a stepwise logistic regression model. Of the 2,016 invitations emailed, 1,538 were received, and 981 completed surveys for a response rate of 63% (981/1,538). Eighty-four percent of women (826/981) responded that they intended to attend for HPV-based cervical cancer screening, which decreased to 54.2% when the screening interval was extended, and decreased further to 51.4% when screening start was delayed to age of 25. Predictors of intentions to undergo screening were attitudes (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.15, 1.30), indirect subjective norms (OR: 1.02; 95% CI: 1.01, 1.03) and perceived behavioral control (OR: 1.16; 95% CI: 1.10; 1.22). Intentions to be screened for cervical cancer with HPV testing decreased substantially when the screening interval was extended and screening started at age of 25. Use of primary HPV testing may optimize the screening paradigm, but programs should ensure robust planning and education to mitigate any negative impact on screening attendance rates.

Analgesic medication errors in North Carolina nursing homes.

The objective of this study was to characterize analgesic medication errors and to evaluate their association with patient harm. The authors conducted a cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Bivariate associations between analgesic medication errors with patient factors, error-related factors, and impact on patients were tested with chi-square tests. A multivariate logistic regression model explored the relationship between type of analgesic medication errors and patient harm, controlling for patient- and error-related factors. A total of 32,176 individual medication error incidents were reported over a 2-year period in North Carolina nursing homes, 12.3% (n = 3949) of which were analgesic medication errors. Of these analgesic medication errors, opioid and nonopioid analgesics were involved in 3105 and 844 errors, respectively. Opioid errors were more likely to be wrong drug errors, wrong dose errors, and administration errors compared with nonopioid errors (P < .0001 for all comparisons). In the multivariate model, opioid errors were found to have higher odds of patient harm compared with nonopioid errors (odds ratio [OR] = 3, 95% confodence interval [CI]: 1.1-7.8). The authors conclude that opioid analgesics represent the majority of analgesic error reports, and these error reports reflect an increased likelihood of patient harm compared with nonopioid analgesics.

Exploratory evaluation of medication classes most commonly involved in nursing home errors.

BACKGROUND: Medication errors may potentially pose significant risk of harmful outcomes in vulnerable nursing home residents. Current literature lacks data regarding the drug classes most frequently involved in errors in this population and their risk relative to underlying drug class utilization rates. OBJECTIVES: This study (1) describes the frequency and error characteristics for the drug classes most commonly involved in medication errors in nursing homes, and (2) examines the correlation between drug class utilization rates and their involvement in medication errors in nursing home residents. DESIGN: A cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2010 to 2011 was conducted. PARTICIPANTS: All nursing home residents in the state of North Carolina. MAIN MEASURES: The 10 drug classes most frequently involved in medication errors were identified. Characteristics and patient impact of these medication errors were further examined as frequencies and proportions within each drug class. Medication error data were combined with data from the 2004 National Nursing Home Survey to capture nationally representative estimates of medication use by drug class in nursing home patients. The correlation between medication utilization and error involvement was assessed. RESULTS: There were 32,176 individual medication errors reported to Medication Error Quality Initiative in years 2010-2011. The 10 drug classes most commonly involved in medication errors were analgesics (12.27%), anxiolytics/sedative/hypnotics (8.39%), antidiabetic agents (5.86%), anticoagulants (5.04%), anticonvulsants (4.05%), antidepressants (4.05%), laxatives (3.13%), ophthalmic preparations (2.77%), antipsychotics (2.47%), and diuretics (2.34%). The correlation between utilization and medication error involvement was not statistically significant (P value for spearman correlation coefficient = .88), suggesting certain drug classes are more likely to be involved in medication errors in nursing home patients regardless of the extent of their use. CONCLUSIONS: The drug classes frequently and disproportionately involved in errors in nursing homes include anxiolytics/sedatives/hypnotics, antidiabetic agents, anticoagulants, anticonvulsants, and ophthalmic preparations. Better understanding of the causes and prevention strategies to reduce these errors may improve nursing home patient safety.

Shortcomings in public and private insurance coverage of diabetes self-management education and support.

The objective of this study is to present preliminary data to characterize public and private insurance coverage for diabetes self-management education (DSM Education) and diabetes self-management support (DSM Support). Representatives from Medicaid and 2 private insurance providers in 10 states provided coverage information for their insurance plans. Two states (the most populous state from the East and West coasts) were sampled purposively and 8 additional states from 4 geographic regions (northeast, southeast, northwest, southwest) were sampled at random. Representatives from each private insurer described both a premium and basic coverage plan. Thus, 10 Medicaid programs and 40 private insurance plans were represented. Information about Medicare coverage was accessed from publicly available documents. Restricted by physician certification of patient eligibility, Medicare coverage included 10 hours of DSM Education plus 3 hours of medical nutrition therapy (MNT) within a continuous 12-month period, and 4 hours of follow-up (2 hours DSM Education and 2 hours MNT) for each subsequent year. Only 22 of 40 sampled private insurance and 5 of 10 Medicaid plans covered DSM Education, which ranged from 7 to 20 hours of education per year. Medicaid and private plans often limited the amount of DSM Education or required patients to obtain a physician certification of eligibility. Other than on-demand access features, coverage of DSM Support was minimal. Public and private insurance coverage of DSM Education was neither widespread nor uniform, while coverage of DSM Support was scarce.

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

BACKGROUND: Patients transitioning to a nursing home from their home or other facility are at high risk for medication errors. OBJECTIVE: Our aim was to describe characteristics of medication errors occurring during transitions to nursing homes, to compare characteristics of transition errors with errors not involving a transition, and to evaluate the impact of these errors on patient harm. METHODS: This was a cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2007 through 2009. Bivariate associations between errors in transition with patient factors, error-related factors, reported causes of errors, and impact on patients were tested using a χ(2) test. Multivariate logistic regression explored whether medication errors during transitions were more harmful than errors not occurring during transitions. Patient-related factors included in the model were age, sex, and cognitive ability. Error-related factors were primary type of error, process phase when error began, primary personnel involved, and an indicator for repeat error. RESULTS: A total of 27,759 individual medication error incidents were reported over a 3-year period in North Carolina nursing homes. Of these errors, 2919 incidents (11%) involved a patient transitioning to a nursing home. Errors involved in transitions were found to have higher odds of patient harm compared with errors not involved in transitions (odds ratio = 1.85; 95% CI, 1.30-2.63). Staff communication, order transcription, medication availability, pharmacy issues, and name confusion were particularly important contributors to medication errors during transitions (P < 0.05 for comparison with nontransition errors). CONCLUSIONS: Transitions across care settings introduce risk for patient harm, and medication errors are an important area for improvement during transitions.

Online medication error graphic reports: a pilot in North Carolina nursing homes.

OBJECTIVES: Since 2003, North Carolina nursing homes have been required by state law to report all medication errors, but the nursing homes have not had usable and timely access to their own error data. We created and pilot tested a new online graphic reporting feature to give homes practical and timely reports on their own reported errors for use in improving medication processes. METHODS: The new graphic reports feature was added to the existing online reporting system and provides immediate access to a set of tables and graphs on all submitted errors. Fifteen nursing homes were recruited to participate in a pilot test of the graphic reports. Key informant interviews were conducted to gather in-depth qualitative information on the use of the reports. RESULTS: The reports were used primarily for providing information to members of the quality assurance committee and for staff training. Sites had very few technical problems accessing or printing the reports and were able to view them on existing computer systems. Sites with significant numbers of submitted errors in the system reported greater usefulness of the graphics than sites with few errors. Staff turnover at the director of nursing position was the most common reason for low participation at some sites. CONCLUSIONS: The online graphic reports are a positive, user-friendly next step in providing information to the nursing homes to use in improving patient safety. The information is deemed by the users to be the right content, professional in appearance, and accessible to the nursing home.