Evaluating the Effect of COVID-19 on Outpatient Opioid Utilization Among Health First Colorado Members and a National Non-Medicaid Cohort: An Interrupted Time Series Analysis.

Objective: COVID-19, coinciding with the opioid epidemic in the United States, has had significant impacts on health-care utilization. While mixed, early analyses signaled a potential resurgence in opioid use following the pandemic. The primary study objective was to assess the association of the COVID-19 pandemic with opioid utilization among Health First Colorado (Colorado's Medicaid Program) members and a non-Medicaid managed care cohort who did not have a diagnosis of cancer or sickle cell disease. Patients and Methods: Using an interrupted time series and segmented regression analysis, this population-level study assessed the association of the COVID-19 pandemic on prescribed utilization of long- and short-acting opioid analgesics among Health First Colorado members and a random sample of non-Medicaid managed care members. Pharmacy claims data for both cohorts were assessed between October 1, 2018, and September 30, 2021, with April 2020 identified as the interruption of interest. We evaluated the following monthly opioid use measures separately for short-acting and long-acting opioids: number of members filling an opioid, total fills, and total days supplied. Results: Short- and long-acting opioid utilization was significantly decreasing among Health First Colorado members in the 18 months prior to the start of COVID-19. After the onset of the pandemic, utilization stabilized and slopes were not significantly different from zero. Among the non-Medicaid managed care cohort, short- and long-acting opioid utilization significantly decreased in the 18 months leading up to the onset of the pandemic. After the onset of the pandemic, utilization of long-acting opioids stabilized, while utilization of short-acting opioids significantly increased. Conclusion: While we observed an increase in opioid utilization measures post-pandemic in the non-Medicaid managed care cohort, a similar increase was not observed in Health First Colorado members suggesting that thoughtful opioid policies put in place pre-pandemic may have been effective at controlling potential inappropriate opioid utilization.

Evaluation of an opioid pain teleconsultation service to address the opioid overdose epidemic in Colorado: A Health First Colorado demonstration project.

BACKGROUND: Since the mid-1990s, more than 500,000 deaths have been attributed to the opioid overdose epidemic, which has created a serious national crisis affecting public health and social and economic welfare. To mitigate these opioid-related overdoses and deaths, interventions targeted at both the patient and community level are needed. OBJECTIVE: This demonstration project sought to determine whether implementation of a provider-to-provider opioid pain teleconsultation service with a pain specialist was correlated with a reduction in inappropriate opioid use and improve health outcomes. METHODS: Individual-level claims data for Health First Colorado Medicaid members were collected between March 1, 2017, and September 30, 2021, for individuals who triggered a provider-to-provider pain management teleconsultation based on receipt of a prescription for an opioid where the member was receiving a high-dose opioid (n = 125) or was opioid-naive (n = 819). The primary outcome measures were a patient's opioid dose less than 200 morphine milligram equivalent (MME) by 6 months after the consult if consult was triggered for high-dose use or discontinuation of an opioid by 12 weeks after consult if the consult was triggered for opioid naivety. Secondary opioid-related health outcomes were also assessed. RESULTS: In the high-dose opioid cohort, 87% of the members had their monthly average MME reduced to less than 200 by 180 days after their consult. More than half of the opioid-naive group had discontinued their opioid by 90 days after their consult. CONCLUSION: Results indicate that provider-to-provider teleconsultation services with a pain specialist can be an effective intervention at reducing total inappropriate opioid use.

Assessment of Pharmacy Department Patient Safety Culture with the Use of Validated Work Environment Survey Indices.

CONTEXT: Patient safety culture (PSC) improvement is a strategy that can foster patient well-being. Measuring PSC without using a validated instrument has been proposed. OBJECTIVE: To assess the strengths of correlations between the Agency for Healthcare Research and Quality's validated Community Pharmacy Survey on Patient Safety Culture (CPSPSC) composites and nonvalidated People Pulse (PP) work environment indices. DESIGN: This was a cross-sectional, anonymous, voluntary survey. METHODS: This survey was conducted online in an ambulatory pharmacy department that had approximately 900 staff members within an integrated health care delivery system. All pharmacy department staff were asked to participate. CPSPSC composites and PP indices were calculated as percent-positive scores (PPS). Thirty-six correlations between PP index and CPSPSC composite PPS were assessed with the Pearson product-moment correlation coefficient. Correlation strengths were interpreted as very weak (± 0.00 to 0.19), weak (± 0.20 to 0.39), moderate (± 0.40 to 0.59), strong (± 0.60 to 0.79), and very strong (± 0.80 to 1.0). RESULTS: A total of 429 (47.4%) pharmacy staff participated. Overall, correlations between CPSPSC composites and PP indices' PPS varied widely. Although all correlations were positive and the majority of correlations were statistically significant, no correlations were identified as very strong. Ten correlations were strong, 16 were moderate, 4 were weak, and 3 were very weak. CONCLUSION: Although health care system personnel may prefer to measure PSC with a survey instrument that assesses a variety of workplace environment measures, these findings suggest that use of nonvalidated work environment indices will not provide accurate assessment of PSC in a pharmacy department.

Pharmacy Survey on Patient Safety Culture: Benchmarking Results.

OBJECTIVE: This study's objective was to assess the patient safety culture in a large, integrated health delivery system's pharmacy department to allow for benchmarking with other health systems. METHODS: This was a cross-sectional survey conducted in a pharmacy department consisting of staff members who provide dispensing, clinical, and support services within an integrated health delivery system. The U.S. Agency for Healthcare Research and Quality's 11-composite, validated Pharmacy Survey on Patient Safety Culture questionnaire was transcribed into an online format. All departmental staff members were invited to participate in this anonymous survey. Cronbach α and overall results and contrasts between dispensing and clinical services staff and dispensing pharmacists and technicians/clerks as percentage positive scores (PPSs) are presented. Differences in contrasts were assessed with χ tests of association. RESULTS: Completed questionnaires were received from 598 (69.9%) of 855 employees. Cronbach α ranged from 0.55 to 0.90. Overall, the highest and lowest composite PPSs were for patient counseling (94.5%) and staffing and work pressure (44.7%), respectively. Compared with dispensing service, the clinical service participants had statistically higher PPSs for all composites except patient counseling, communication about mistakes, and staffing and work pressure (all P > 0.05). The technicians/clerks had a statistically higher PPS compared with the pharmacists for communication about mistakes (P = 0.007). All other composites were equivalent between groups. CONCLUSIONS: Patient counseling consistently had the highest PPS among composites measured, but opportunities existed for improvement in all aspects measured. Future research should identify and assess interventions targeted to improving the patient safety culture in pharmacy.

Clinical Outcomes of Continuation of Metformin Titration Instructions with Electronic Prescribing.

BACKGROUND: Anecdotal evidence suggests that metformin titration instructions are not being updated and refill requests are approved without modification of the titration instructions such that the titration instructions is continued for patients newly initiated on metformin. METHODS: This was a retrospective cohort analysis of adult patients who received newly initiated metformin pharmacotherapy. Patients were followed from their initial metformin purchase through two subsequent metformin refill purchases. Outcomes, including the 3-year incidence rate of patients with at least one set of continued titration instructions and proportions of patients with at least one gastrointestinal adverse effect (AE) and those with an elevated glucose measurement at follow-up, were assessed during the time period between patients' second and third metformin purchases. Analyses were performed comparing the exposure (i.e., patients with continued instructions) group to the control (i.e., patients without continued instructions) group. RESULTS: The exposure group had a higher mean age and chronic disease score but lower metformin starting dose than the control group (all p < 0.05). The 3-year incidence rate of patients with at least one continuation of titration instructions was 60.3 % (95 % CI 58.3-62.3). Gastrointestinal AEs were rare with equivalent proportions of patients in each group experiencing an event (p > 0.05). Control patients (48.7 % of patients with a measurement) were more likely to have had poorly controlled glucose than exposure patients (35.7 % of patients with a measurement) (p < 0.001). CONCLUSIONS: A high rate of continuation of titration instructions for patients newly initiated on metformin was observed; however, such continuation did not negatively affect clinical outcomes.

Assessment of the association between colchicine therapy and serious adverse events.

STUDY OBJECTIVE: As data that prompted a 2009 labeling change detailing contraindications, precautions, and dosing recommendations for the first branded colchicine product were limited to case reports of myotoxicity and blood dyscrasias ascribed to the drug, we sought to quantify the association of colchicine therapy with serious adverse outcomes in a cohort of insured patients. DESIGN: Case-control study. DATA SOURCE: Kaiser Permanente Colorado electronic data warehouses and electronic medical records. PATIENTS: Cases were patients with a creatine kinase (CK) level of at least 2000 U/L or who developed a clinically significant non-cancer-related blood dyscrasia (thrombocytopenia, neutropenia, leukopenia, aplastic anemia, or pancytopenia) between January 1, 2006, and June 30, 2009 (954 cases). Each case was matched to up to 10 controls by age, sex, and index date (date of the increased CK level or blood dyscrasia-supporting laboratory value). Controls were patients without elevated CK levels or blood dyscrasias who had a routine health maintenance examination during the same time period (index date was the date of their health maintenance examination [9007 controls]). MEASUREMENTS AND MAIN RESULTS: The primary study outcome was colchicine exposure, defined as a colchicine prescription purchase in the 100 days before the index date. The likelihood of colchicine exposure was examined with conditional logistic regression. Cases experienced a higher rate of previous colchicine exposure compared with controls (0.6% vs 0.2%, odds ratio 3.9, 95% confidence interval 1.4-10.7). In addition, cases had higher hospitalization rates (14.9% vs 5.0%, p<0.001), higher mean chronic disease scores (2.5 vs 0.0, p<0.001), and were more likely to have been exposed to drugs that may increase the risk of adverse events due to an interaction with a CYP3A4 inhibitor drug (6.9% vs 2.3%, p<0.001). CONCLUSION: Patients with confirmed elevations in CK level and/or blood dyscrasias had a higher rate of previous colchicine exposure, although low overall, and greater hospitalization rates and exposure to drugs that may increase the risk of adverse events compared with controls. These findings support the 2009 United States Food and Drug Administration labeling for the first branded colchicine product, cautioning use in patients with liver impairment or renal dysfunction and/or those receiving concurrent drugs that may increase risk of adverse events.