Telehealth Utilization for Opioid Use Disorder: A Nationwide Analysis Before and After the COVID-19 Public Health Emergency Declaration.

Introduction: The COVID-19 pandemic has led to the rapid and widespread adoption of telehealth services. Telehealth may aid in bridging gaps in access to care. The specific impact of telehealth on opioid use disorder (OUD) and its treatment remains uncertain. Methods: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of(a) OUD treatments with and without telehealth support and (b) prescriptions for medications for opioid use disorder (MOUD) with and without telehealth support among individuals diagnosed with OUD. Results: In a study population of 1,340,506 individuals, OUD diagnosis rates were 5 per 1,000 in-person and 1 per 1,000 via telehealth. COVID-19 decreased in-person OUD diagnoses by 0.89 per 1,000, while telehealth diagnoses increased by 0.83 per 1,000. In-person MOUD treatment rates increased by 0.07 per 1,000 during COVID-19, while telehealth rates remained low. The onset of COVID-19 saw a 1.13 per 1,000 higher increase in telehealth-supported MOUD treatment compared to solely in-person treatment. Conclusions: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of (a) OUD treatments with and without telehealth support and (b) prescriptions for MOUD with and without telehealth support among individuals diagnosed with OUD.

The association between rurality, dual Medicare/Medicaid eligibility and chronic conditions with telehealth utilization: An analysis of 2019-2020 national Medicare claims.

INTRODUCTION: Telehealth services have the potential to increase healthcare access among underserved populations, such as rural residents and racial/ethnic minority groups. The COVID-19 public health emergency led to unprecedented growth in telehealth utilization, but evidence suggests the growth has not been equitable across all patient populations. This study aimed to explore whether telehealth utilization and expansion changed equitably from 2019 to 2020 among sub-groups of Medicare beneficiaries. METHODS: We conducted an analysis of telehealth utilization among a 20% random sample of 2019-2020 Medicare beneficiaries on a national level. We fit multivariable logistic regression models and calculated average marginal effects (AME) to assess the association between demographic and clinical characteristics on telehealth utilization. RESULTS: We found telehealth utilization was less likely among non-Hispanic Black/African-American (2019: adjusted odds ratio [aOR] = 0.77, AME = -0.15; 2020: aOR = 0.85, AME = -3.50) and Hispanic (2019: aOR = 0.79, AME = -0.13; 2020: aOR = 0.87, AME = -2.89) beneficiaries, relative to non-Hispanic White beneficiaries in both 2019 and 2020, with larger disparities in 2020. Rural beneficiaries were more likely to utilize telehealth than urban beneficiaries in 2019 (aOR = 2.62, AME = 0.84), but less likely in 2020 (aOR = 0.57, AME = -14.47). In both years, dually eligible Medicare/Medicaid beneficiaries were more likely than non-dually eligible beneficiaries to utilize telehealth (2019: aOR = 4.75, AME = 0.84; 2020: aOR = 1.34, AME = 2.25). However, the effects of dual eligibility and rurality changed in both models as the number of chronic conditions increased. DISCUSSION: We found evidence of increasing disparities in telehealth utilization among several Medicare beneficiary sub-groups in 2020 relative to 2019, including individuals of minority race/ethnicity, rural residents, and dually eligible beneficiaries, with disparities increasing among individuals with more chronic conditions. Although telehealth has the potential to address health inequities, our findings suggest that many of the patients in greatest need of healthcare are least likely to utilize telehealth services.

Opioid therapy trajectories of patients with chronic non-cancer pain over 1 year of follow-up after initiation of short-acting opioid formulations.

OBJECTIVE: This study compared opioid utilization trajectories of persons initiating tramadol, short-acting hydrocodone, or short-acting oxycodone, and it characterized opioid dose trajectories and type of opioid in persistent opioid therapy subsamples. METHODS: A retrospective cohort study of adults with chronic non-cancer pain who were initiating opioid therapy was conducted with the IQVIA PharMetrics® Plus for Academics data (2008-2018). Continuous enrollment was required for 6 months before ("baseline") and 12 months after ("follow-up") the first opioid prescription ("index date"). Opioid therapy measures were assessed every 7 days over follow-up. Group-based trajectory modeling (GBTM) was used to identify trajectories for any opioid and total morphine milligram equivalent measures, and longitudinal latent class analysis was used for opioid therapy type. RESULTS: A total of 40 276 tramadol, 141 023 hydrocodone, and 45 221 oxycodone initiators were included. GBTM on any opioid therapy identified 3 latent trajectories: early discontinuers (tramadol 39.0%, hydrocodone 54.1%, oxycodone 61.4%), late discontinuers (tramadol 37.9%, hydrocodone 39.4%, oxycodone 33.3%), and persistent therapy (tramadol 6.7%, hydrocodone 6.5%, oxycodone 5.3%). An additional fourth trajectory, intermittent therapy (tramadol 16.4%), was identified for tramadol initiators. Of those on persistent therapy, 2687 individuals were on persistent therapy with tramadol, 9169 with hydrocodone, and 2377 with oxycodone. GBTM on opioid dose resulted in 6 similar trajectory groups in each persistent therapy group. Longitudinal latent class analysis on opioid therapy type identified 6 latent classes for tramadol and oxycodone and 7 classes for hydrocodone. CONCLUSION: Opioid therapy patterns meaningfully differed by the initial opioid prescribed, notably the presence of intermittent therapy among tramadol initiators and higher morphine milligram equivalents and prescribing of long-acting opioids among oxycodone initiators.

Association of Remote Patient Monitoring with Mortality and Healthcare Utilization in Hypertensive Patients: a Medicare Claims-Based Study.

BACKGROUND: Hypertension management is complex in older adults. Recent advances in remote patient monitoring (RPM) have warranted evaluation of RPM use and patient outcomes. OBJECTIVE: To study associations of RPM use with mortality and healthcare utilization measures of hospitalizations, emergency department (ED) utilization, and outpatient visits. DESIGN: A retrospective cohort study. PATIENTS: Medicare beneficiaries aged ≥65 years with an outpatient hypertension diagnosis between July 2018 and September 2020. The first date of RPM use with a corresponding hypertension diagnosis was recorded (index date). RPM non-users were documented from those with an outpatient hypertension diagnosis; a random visit was selected as the index date. Six months prior continuous enrollment was required. MAIN MEASURES: Outcomes studied within 180 days of index date included (i) all-cause mortality, (ii) any hospitalization, (iii) cardiovascular-related hospitalization, (iv) non-cardiovascular-related hospitalization, (v) any ED, (vi) cardiovascular-related ED, (vii) non-cardiovascular-related ED, (viii) any outpatient, (ix) cardiovascular-related outpatient, and (x) non-cardiovascular-related outpatient. Patient demographics and clinical variables were collected from baseline and index date. Propensity score matching (1:4) and Cox regression were performed. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. KEY RESULTS: The matched sample had 16,339 and 63,333 users and non-users, respectively. Cumulative incidences of mortality outcome were 2.9% (RPM) and 4.3% (non-RPM), with a HR (95% CI) of 0.66 (0.60-0.74). RPM users had lower hazards of any [0.78 (0.75-0.82)], cardiovascular-related [0.79 (0.73-0.87)], and non-cardiovascular-related [0.79 (0.75-0.83)] hospitalizations. No significant association was observed between RPM use and the three ED measures. RPM users had higher hazards of any [1.10 (1.08-1.11)] and cardiovascular-related outpatient visits [2.17 (2.13-2.19)], while a slightly lower hazard of non-cardiovascular-related outpatient visits [0.94 (0.93-0.96)]. CONCLUSIONS: RPM use was associated with substantial reductions in hazards of mortality and hospitalization outcomes with an increase in cardiovascular-related outpatient visits.

Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies.

BACKGROUND: Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids. METHODS: We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose. INTERPRETATION: We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).

Socioeconomic Determinants of Remote Patient Monitoring Implementation Among Rural and Urban Hospitals.

Introduction: Remote patient monitoring (RPM) is a form of telehealth that improves quality of care for chronic disease treatment and reduces hospital readmission rates. Geographical proximity to health care is important for individuals of low socioeconomic status (SES) who face additional financial and transportation barriers. The goal of this study was to assess the association between social determinants of health and adoption of RPM. Methods: This cross-sectional study analyzed data from hospitals that responded to the American Hospital Association's Annual Survey (2018) and spatially linked census tract-level environmental and social determinants of health obtained from the Social Vulnerability Index (2018). Results: A total of 4,206 hospitals (1,681 rural and 2,525 urban hospitals) met study criteria. Rural hospitals near households in the lower middle quartile SES were associated with a 33.5% lower likelihood of having adopted RPM for chronic care management compared with rural hospitals near households in the highest quartile SES (adjusted odds ratios [aOR] = 0.665; 95% confidence interval [CI]: 0.453-0.977). Urban hospitals near households in the lowest quartile SES were associated with a 41.9% lower likelihood of having adopted RPM for chronic care management compared with urban hospitals near households in the highest quartile SES (aOR = 0.581; 95% CI: 0.435-0.775). Similar trends in accessibility were found with RPM for postdischarge services among urban hospitals. Conclusion: Our findings highlight the importance of hospital responsibility and state and federal policy approaches toward ensuring equitable access to RPM services for patients characterized by lower SES.

Trends in Telehealth Visits During Pregnancy, 2018 to 2021.

This cross-sectional study examines trends of prenatal telehealth visits in pregnancy and explores patient characteristics associated with the number of prenatal telehealth visits.

Association between broadband capacity and telehealth utilization among Medicare Fee-for-service beneficiaries during the COVID-19 pandemic.

BACKGROUND: Telehealth is a rapidly growing modality for expanding healthcare access, especially in the post-COVID-19 era. However, telehealth requires high-quality broadband, thus making broadband a social determinant of health. The objective of this study was to evaluate the association between broadband access and telehealth utilization across the United States during the COVID-19 pandemic. METHODS: Using a cross-sectional, ecological study design, we merged county-level data on broadband capacity (Microsoft's Rural Broadband Initiative), telehealth utilization among Medicare Fee-for-Service beneficiaries from January through September 2020 (CareJourney), and county-level socioeconomic characteristics (Area Health Resources Files). Multivariable linear regression was used to estimate the association between broadband capacity, county-level characteristics, and telehealth utilization. RESULTS: Among the 3107 counties, those with the greatest broadband availability (quintile 5) had 47% higher telehealth utilization compared to counties with the least broadband availability (quintile 1). In the adjusted model, a 1 standard deviation (SD) increase in broadband access was associated with a 1.54 percentage point (pp) increase in telehealth utilization (P < 0.001). Rural county designation (-1.96 pp; P < 0.001) and 1 SD increases in average Medicare beneficiary age (-1.34 pp; P = 0.001), number of nursing home beds per 1000 individuals (-0.38 pp; P = 0.002), and proportion of Native Americans/Pacific Islanders (-0.59 pp; P < 0.001) were associated with decreased telehealth utilization. CONCLUSION: The association between broadband access and telehealth utilization and the decreased telehealth utilization in rural areas highlight the importance of broadband access for healthcare access and the need to continue investing in broadband infrastructure to promote equitable healthcare access across populations.

A State Profile of Disparities in Telehealth Utilization Among Medicare Beneficiaries: An Intersection Between Race/Ethnicity, Rurality, and Chronic Conditions-Arkansas, 2019.

Introduction: The COVID-19 pandemic brought about renewed interest and investment in telehealth, while also highlighting persistent health disparities in the Southern states. Little is known about the characteristics of those utilizing telehealth services in Arkansas, a rural Southern state. We sought to compare the characteristics of telehealth utilizers and nonutilizers among Medicare beneficiaries in Arkansas before the COVID-19 public health emergency to provide a baseline for future research investigating disparities in telehealth utilization. Methods: We used Arkansas Medicare beneficiary data (2018-2019) to model telehealth use. We included interactions to assess how the association between the number of chronic conditions and telehealth was moderated by race/ethnicity and rurality, adjusted for covariates. Results: Overall telehealth utilization in 2019 was low (n = 4,463; 1.1%). The adjusted odds of utilizing telehealth was higher for non-Hispanic Black/African Americans (vs. white, adjusted odds ratio [aOR] = 1.34, 95% confidence interval [CI] = 1.17-1.52), rural beneficiaries (aOR = 1.99, 95% CI = 1.79-2.21), and those with more chronic conditions (aOR = 1.23, 95% CI = 1.21-1.25). Race/ethnicity and rurality were significant moderators, such that the association between the number of chronic conditions and telehealth was strongest among white and among rural beneficiaries. Discussion: Among the 2019 Arkansas Medicare beneficiaries, having more chronic conditions was most strongly associated with telehealth use among white and rural individuals, while the effect was not as pronounced for Black/African American and urban individuals. Our findings suggest that advances in telehealth are not benefiting all Americans equally, with aging minoritized communities continuing to engage with more strained and underresourced health systems. Future research should investigate how upstream factors such as structural racism perpetuate poor health outcomes.

Using data analytics for telehealth utilization: A case study in Arkansas.

INTRODUCTION: Many patients used telehealth services during the COVID-19 pandemic. In this study, we evaluate how different factors have affected telehealth utilization in recent years. Decision makers at the federal and state levels can use the results of this study to inform their healthcare-related policy decisions. METHODS: We implemented data analytics techniques to determine the factors that explain the use of telehealth by developing a case study using data from Arkansas. Specifically, we built a random forest regression model which helps us identify the important factors in telehealth utilization. We evaluated how each factor impacts the number of telehealth patients in Arkansas counties. RESULTS: Of the 11 factors evaluated, five are demographic, and six are socioeconomic factors. Socioeconomic factors are relatively easier to influence in the short term. Based on our results, broadband subscription is the most important socioeconomic factor and population density is the most important demographic factor. These two factors were followed by education level, computer use, and disability in terms of their importance as it relates to telehealth use. DISCUSSION: Based on studies in the literature, telehealth has the potential to improve healthcare services by improving doctor utilization, reducing direct and indirect waiting times, and reducing costs. Thus, federal and state decision makers can influence the utilization of telehealth in specific locations by focusing on important factors. For example, investments can be made to increase broadband subscriptions, education levels, and computer use in targeted locations.

Comparative Study of Opioid Initiation With Tramadol, Short-acting Hydrocodone, or Short-acting Oxycodone on Opioid-related Adverse Outcomes Among Chronic Noncancer Pain Patients.

OBJECTIVE: To compare the safety profiles of low and high-dose tramadol, short-acting hydrocodone, and short-acting oxycodone therapies among chronic noncancer pain individuals. MATERIALS AND METHODS: A retrospective cohort study of individuals with back/neck pain/osteoarthritis with an initial opioid prescription for tramadol, hydrocodone, or oxycodone was conducted using IQVIA PharMetrics Plus claims for Academics database (2006 to 2020). Two cohorts were created for separately studying opioid-related adverse events (overdoses, accidents, self-inflicted injuries, and violence-related injuries) and substance use disorders (opioid and nonopioid). Patients were followed from the index date until an outcome event, end of enrollment, or data end. Time-varying exposure groups were constructed and Cox regression models were estimated. RESULTS: A total of 1,062,167 (tramadol [16.5%], hydrocodone [61.1%], and oxycodone [22.4%]) and 986,809 (tramadol [16.5%], hydrocodone [61.3%], and oxycodone [22.2%]) individuals were in the adverse event and substance use disorder cohorts. All high-dose groups had elevated risk of nearly all outcomes, compared with low-dose hydrocodone. Compared with low-dose hydrocodone, low-dose oxycodone was associated with a higher risk of opioid overdose (hazard ratio: 1.79 [1.37 to 2.33]). No difference in risk was observed between low-dose tramadol and low-dose hydrocodone (hazard ratio: 0.85 [0.64 to 1.13]). Low-dose oxycodone had higher risks of an opioid use disorder, and low-dose tramadol had a lower risk of accidents, self-inflicted injuries, and opioid use disorder compared with low-dose hydrocodone. DISCUSSION: Low-dose oxycodone had a higher risk of opioid-related adverse outcomes compared with low-dose tramadol and hydrocodone. This should be interpreted in conjunction with the benefits of pain control and functioning associated with oxycodone use in future research.

Analysis of Caregiver Burden Expressed in Social Media Discussions.

Almost 40% of US adults provide informal caregiving, yet research gaps remain around what burdens affect informal caregivers. This study uses a novel social media site, Reddit, to mine and better understand what online communities focus on as their caregiving burdens. These forums were accessed using an application programming interface, a machine learning classifier was developed to remove low information posts, and topic modeling was applied to the corpus. An expert panel summarized the forums' themes into ten categories. The largest theme extracted from Reddit's forums discussed the personal emotional toll of being a caregiver. This was followed by logistic issues while caregiving and caring for parents who have cancer. Smaller themes included approaches to end-of-life care, physical equipment needs when caregiving, and the use of wearables or technology to help monitor care recipients. The platform often discusses caregiving for parents which may reflect the age of Reddit's users. This study confirms that Reddit forums are used for caregivers to discuss the burdens associated with their role and the types of stress that can result from informal caregiving.

Implementation and Preliminary Effectiveness of a Multidisciplinary Telemedicine Pilot Initiative for Patients with Chronic Non-Cancer Pain in Rural and Underserved Areas at a Major Academic Medical Center.

Background: Arkansas lacks adequate access to high-quality pain care, as evidenced, in part, by it having the second highest opioid prescribing rate in the United States. To improve access to high-quality treatment of chronic pain, we developed the Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) Telemedicine Clinic, a multidisciplinary and interprofessional team of specialists who provide evidence-based pain management for patients with chronic pain. Methods: We conducted a single-arm pilot trial of the AR-IMPACT Telemedicine Clinic with rural, university-affiliated primary care clinics. We assessed the AR-IMPACT Telemedicine Clinic using an implementation framework and preliminary effectiveness measures. Specifically, we assessed 5 of the 8 implementation outcomes of the framework (ie, penetration, adoption, acceptability, appropriateness, and feasibility) using a mixed methods approach. To evaluate implementation outcomes, we used surveys, interviews, and administrative data. We used electronic health record data to measure preliminary effectiveness (ie, changes in average morphine milligram equivalents per day and pain and depression scores). Results: The AR-IMPACT team saw 23 patients that were referred by 13 primary care physicians from three rural, university-affiliated primary care clinics over one year. Of the 19 patients willing to participate in the pilot study, 12 identified as women, 31.6% identified as Black, and over 50% had less than a bachelor's level education. Patients rated the clinic positively with high overall satisfaction. Referring physicians indicated high levels of appropriateness, acceptability, and feasibility of the program. AR-IMPACT team members identified several barriers and facilitators to the feasibility of implementing the program. No changes in preliminary effectiveness measures were statistically significant. Conclusion: Overall, the AR-IMPACT Telemedicine Clinic obtained moderate penetration and adoption, was highly acceptable to patients, was highly acceptable and appropriate to providers, and was moderately feasible to providers and AR-IMPACT team members.

Utilization of Remote Patient Monitoring Within the United States Health Care System: A Scoping Review.

Introduction: Limited information exists on the landscape of studies and policies for remote patient monitoring (RPM) in the United States. Methods: We conducted a scoping review to assess (1) for which adult patient populations and health care needs is RPM being used and (2) the landscape of national- and state-level reimbursement policies for RPM. This study was guided by the Arksey and O'Malley methodological framework for scoping reviews and the Joanna Briggs Institute Manual for Evidence Synthesis. Results: A total of 399 articles were included in our final sample: 268 study articles and 131 articles of gray literature (e.g., websites, legislative bills). RPM-related articles rose drastically from 2015 to 2021, and the vast majority of articles were peer-reviewed journal articles. Of the study articles, prospective cohort studies were the most common study method, with m-health/smart watches being the most common RPM modality. RPM was found to be most commonly tested within patients with cardiovascular diseases, and the most common outcomes measured were usability and feasibility. Gray literature found 36 U.S. state Medicaid programs had reimbursement policies for RPM in 2021; however, 28 of those had at least one restriction on reimbursement (e.g., limited to specific providers). Conclusions: Despite the rapid growth in the literature on RPM and the adoption of reimbursement policies, retrospective, population-level studies, large randomized controlled trials, studies with a focus on additional favorable outcomes (e.g., quality of life), and studies evaluating trends in RPM reimbursement policies are lacking in the current literature.

Concordance of opioid exposure in all-payer claims databases with prescription drug monitoring program database using Arkansas as a case example.

OBJECTIVE: To assess the concordance between and benefit of adding prescription drug monitoring program (PDMP) data to all-payer claims database (APCD) data for identifying and classifying opioid exposure among insured individuals. DATA SOURCES AND STUDY SETTING: Arkansas APCD and PDMP. STUDY DESIGN: Enrollees in APCD were classified as (1) true positives: if they received opioids in both databases, (2) false positives: if they only received opioids in APCD, (3) true negatives: if they had no opioid exposure in both databases, (4) false negatives: if they only received opioids in the PDMP database. Specificity, sensitivity, negative, and positive predictive values were calculated using PDMP as the "gold standard" database source. Subjects were also categorized as those who received any opioid, chronic opioid, high-dose opioid, or high-risk opioid therapies. DATA COLLECTION/EXTRACTION METHODS: Arkansas residents continuously enrolled with pharmacy coverage in 2016 were included. APCD and PDMP were linked using an encrypted enrollee identifier, gender, and year of birth. PRINCIPAL FINDINGS: The degree of concordance in opioid exposure between the two databases among 1,411,565 enrollees was high (sensitivity = 92.67%, specificity = 96.13%, positive predictive value = 91.60%, negative predictive value = 96.65%). Enrollees classified as having any opioid (APCD: 31.64% vs. PDMP: 31.26% vs. APCD+PDMP: 33.93%), chronic opioid (APCD: 7.81% vs. PDMP: 7.54% vs. APCD+PDMP: 8.24%), high-dose opioid (APCD: 10.60% vs. PDMP: 9.62% vs. APCD+PDMP: 11.33%), or high-risk opioid (APCD: 5.28% vs. PDMP: 5.33% vs. APCD+PDMP: 6.20%) therapies, were similar using only APCD versus PDMP versus the combined APCD and PDMP data sources. CONCLUSIONS: Claims data sources, such as APCDs, are fairly accurate in identifying opioid exposure and the level of opioid exposure among persons with continuous pharmacy coverage.

Factors Associated with Remote Patient Monitoring Services Provision by Hospitals and Health Care Systems in the United States.

Purpose: To assess the factors associated with offering remote patient monitoring (RPM) services. Methods: We integrated three datasets: (1) 2019-2020 Area Health Resource Files, (2) 2019 American Community Survey, and (3) 2019 American Hospitals Association annual survey using county Federal Information Processing Standards code to evaluate associations between hospital characteristics and county-level demographic factors with provision of (1) post-discharge, (2) chronic care, (3) other RPM services, and (4) any of these three RPM service categories. These outcomes were analyzed using multi-level, mixed-effects multivariate logistic regression modeling to account for county-level clustering of hospitals. Findings: Among 3,381 hospitals, 1,354 (40.0%) provided any RPM services. Being part of a clinically integrated network (CIN) and private, non-profit (vs. public) ownership were respectively associated with 104.5% (95% confidence interval [CI]: 69.4-146.8%; p < 0.001) and 30.4% (95% CI: 2.5-66.0%; p = 0.031) higher odds of providing any RPM services. Critical access hospital (CAH) designation, for-profit (vs. public) ownership, and location in the South (vs. Northeast) were associated with significantly lowering odds of providing any RPM services by 36.2% (95% CI: 14.2-52.6%; p = 0.003), 70.1% (95% CI: 56.0-79.6%; p < 0.001), and 34.0% (95% CI: 2.8-55.1%; p = 0.035), respectively. Similar trends were found with the various RPM service categories. Conclusions: The factors most associated with provision of any RPM services were hospital-level factors. Specifically, being part of a CIN and private, non-profit ownership had the highest positive associations with offering RPM services whereas location in the South and CAH designation had the strongest negative associations. Further studies are needed to understand the reasons behind these associations.

Association Between Broadband Capacity and Social Vulnerability Factors in the United States: A County-Level Spatial Analysis.

This study evaluated relationships between county-level social vulnerability and broadband access using spatial clustering and regression approaches. County-level broadband availability (Federal Communications Commission [FCC] and Microsoft; 2019-2020), social vulnerability (COVID-19 Community Vulnerability Index [CCVI]; 2020), and primary care access (Area Health Resource File; 2019-2020) data sets were used. Two measures of broadband availability were considered: (1) Microsoft system-reported proportion of county population with broadband and (2) difference in FCC-reported and Microsoft-reported proportions of county population with broadband. Cluster maps were constructed using local Moran's I, and spatial Durbin models were estimated using primary care shortage designation and CCVI themes (socioeconomic status, minority status, housing/transportation/disability, epidemiological risk, health care system, high-risk environment, and population density). Among 3102 counties, county-level broadband coverage varied widely between Microsoft (0.39) and FCC (0.84), with greater coverage in the East and West, and larger discrepancies between FCC and Microsoft data in the South and Appalachia. In spatial regressions, a one-point increase in socioeconomic status vulnerability (0-least; 10-most vulnerable), was associated with a 2.0 percentage point (pp) reduction in broadband access (P < 0.001). Similar inverse relationships were observed with housing, epidemiological, and health care system variables. There were greater divergences between FCC and Microsoft measures with each one-point increase in socioeconomic status (1.4 pp), epidemiological risk (0.6 pp), and health care system (0.7 pp) vulnerability. More vulnerable counties had lower broadband and larger divergences between FCC and Microsoft data. Broadband is necessary for utilizing telehealth services; careful considerations in measuring broadband access can facilitate policies that improve equitable access to care.

Development of a potential opioid misuse measure from administrative dispensing data and contrasting opioid misuse among individuals on long-term tramadol, long-term short-acting hydrocodone or long-term short-acting oxycodone therapy in Arkansas.

OBJECTIVE: This study sought to: (1) construct and validate a composite potential opioid misuse score; and (2) compare potential opioid misuse among individuals prescribed long-term therapy on tramadol, short-acting hydrocodone or short-acting oxycodone. METHODS: A retrospective cohort study was conducted using Arkansas All-Payer Claims Database (APCD; 2013-2018) linked to Arkansas Prescription Drug Monitoring Program (PDMP; 2014-2017) and state death certificate data (2013-2018). The study subjects were ambulatory, cancer-free adults with incident long-term therapy on tramadol, short-acting hydrocodone or short-acting oxycodone. The number of opioid prescribers/pharmacies, cash payment for opioid prescriptions, overlapping prescribers/pharmacies and a composite misuse score (derived from opioid prescribers/pharmacies and cash payment) were assessed in two 180 day windows as potential measures of misuse. The composite score was developed based on associations observed with opioid overdose and opioid-related injuries. RESULTS: A total of 17,816 (tramadol), 23,660 (hydrocodone) and 4799 (oxycodone) persons were included. The composite score had modest discrimination for overdose (c-index = 0.65). In the first 180 day period, the average composite misuse scores were 1.28 (tramadol), 1.93 (hydrocodone) and 2.18 (oxycodone). Compared to long-term hydrocodone, long-term tramadol had lower misuse (IRR [95% CI]: 0.75 [0.73-0.76]), and long-term oxycodone had higher misuse (1.09 [1.07-1.11]) in adjusted analyses. Qualitatively similar associations were observed for nearly all individual component measures of misuse. CONCLUSION: A composite measure of potential opioid misuse had modest levels of discrimination in detecting overdose. In comparison to long-term hydrocodone therapy, long-term oxycodone had higher and tramadol had lower risk of potential opioid misuse.

Factors associated with telehealth use among adults in the United States: Findings from the 2020 National Health Interview Survey.

INTRODUCTION: During the COVID-19 pandemic, health care shifted to virtual interactions with health professionals. The aim of this study was to examine the determinants of telehealth use in a nationally representative sample of the United States adult population. METHODS: The study used data from the 2020 National Health Interview Survey of 17,582 respondents aged ≥18. Andersen's model of health services utilization was employed to examine predisposing, enabling, and needs factors associated with past-year telehealth use. Multivariable logistic regression was conducted to examine statistical associations. RESULTS: 32.5% of adults (n = 6402; mean age 51.6, SE = 0.4) reported telehealth use. Predisposing factors: Women and married/partnered adults and those with higher levels of education had greater odds of using telehealth. Adults living in Midwest and South and adults living in medium-small and non-metropolitan areas had decreased odds of using telehealth. Enabling factors: Income and having a usual source of care were positively associated with telehealth use. A negative association was found for those with no insurance and telehealth use, whereas a positive association was found for military insurance. Needs factors: Odds of using telehealth were increased for adults who had well-visits and ER visits in the past 12 months. Mental health services quadrupled the odds of telehealth use. Odds of using telehealth increased with each additional chronic disease, including COVID-19. CONCLUSION: There are disparities in telehealth use according to sex, education, rurality, access to care, and health needs. Tackling these disparities is pivotal to ensure barriers to telehealth use are not exacerbated post-pandemic.

Association between opioid therapy trajectories and potential opioid-related adverse health events.

PURPOSE: We identified associations between membership in seven group-based trajectories based on supply of filled opioid prescriptions and potential opioid-related adverse health events over a 720-day window. METHODS: We identified two veteran cohorts with chronic non-cancer pain who initiated treatment with long-term opioid therapy between 2008 and 2015, excluding those with prior substance use disorder (n = 373 941) or non-SUD, opioid-related adverse outcome (n = 405 631) diagnoses. Outcomes of interest included opioid use disorder, non-opioid drug use disorder, and alcohol use disorder for the first cohort; or accidents resulting in wounds or injuries, self-inflicted injuries, opioid-related accidents and overdoses, alcohol and non-opioid drug-related accidents and overdoses, and violence-related injuries for the second cohort. Using a cross-sectional design, Veterans were followed until the specific outcome of interest was diagnosed, they died, the study ended, or they were lost to follow up. Accelerated failure time models were estimated for each outcome. RESULTS: Membership in persistent moderate days covered and persistent modest days covered trajectories was associated with decreased risk of opioid use disorder (Moderate: θ = 0.59, 95%CI:0.54, 0.64; Modest: θ = 0.54, 95%CI:0.50, 0.59) and opioid overdose (Moderate: θ = 0.67,95%CI: 0.57, 0.79; Modest: θ = 0.72, 95%CI:0.61, 0.85) versus higher-utilizing persistent users. Rapid discontinuation was associated with decreased risk of opioid use disorder (θ = 0.86, 95% CI:0.77, 0.95) and opioid overdose (θ = 0.54, 95%CI:0.41, 0.71), but increased risk of alcohol use disorder (θ = 1.07, 95%CI:1.00, 1.15) and other substance use disorders. Delayed discontinuation or delayed reduction was associated with increased risk for most opioid related adverse health events. CONCLUSION: Persistent use trajectories with low levels of opioid utilization were associated with lower risks of potential opioid-related adverse health events.