State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments - United States, 2018-2022.

The prevalence of cigarette smoking among U.S. adults enrolled in Medicaid is higher than among adults with private insurance; more than one in five adults enrolled in Medicaid smokes cigarettes. Smoking cessation reduces the risk for smoking-related disease and death. Effective treatments for smoking cessation are available, and comprehensive, barrier-free insurance coverage of these treatments can increase cessation. However, Medicaid treatment coverage and treatment access barriers vary by state. The American Lung Association collected and analyzed state-level information regarding coverage for nine tobacco cessation treatments and seven access barriers for standard Medicaid enrollees. As of December 31, 2022, a total of 20 state Medicaid programs provided comprehensive coverage (all nine treatments), an increase from 15 as of December 31, 2018. Only three states had zero access barriers, an increase from two; all three also had comprehensive coverage. Although states continue to improve smoking cessation treatment coverage and decrease access barriers for standard Medicaid enrollees, coverage gaps and access barriers remain in many states. State Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures by providing barrier-free coverage of all evidence-based cessation treatments and by promoting this coverage to enrollees and providers.

The Diagnostic Accuracy Of Procalcitonin for Urinary Tract Infection in Hospitalized Older Adults: a Prospective Study.

BACKGROUND: The diagnosis of urinary tract infection (UTI) is challenging among hospitalized older adults, particularly among those with altered mental status. OBJECTIVE: To determine the diagnostic accuracy of procalcitonin (PCT) for UTI in hospitalized older adults. DESIGN: We performed a prospective cohort study of older adults (≥65 years old) admitted to a single hospital with evidence of pyuria on urinalysis. PCT was tested on initial blood samples. The reference standard was a clinical definition that included the presence of a positive urine culture and any symptom or sign of infection referable to the genitourinary tract. We also surveyed the treating physicians for their clinical judgment and performed expert adjudication of cases for the determination of UTI. PARTICIPANTS: Two hundred twenty-nine study participants at a major academic medical center. MAIN MEASURES: We calculated the area under the receiver operating characteristic curve (AUC) of PCT for the diagnosis of UTI. KEY RESULTS: In this study cohort, 61 (27%) participants met clinical criteria for UTI. The median age of the overall cohort was 82.6 (IQR 74.9-89.7) years. The AUC of PCT for the diagnosis of UTI was 0.56 (95% CI, 0.46-0.65). A series of sensitivity analyses on UTI definition, which included using a decreased threshold for bacteriuria, the treating physicians' clinical judgment, and independent infectious disease specialist adjudication, confirmed the negative result. CONCLUSIONS: Our findings demonstrate that PCT has limited value in the diagnosis of UTI among hospitalized older adults. Clinicians should be cautious using PCT for the diagnosis of UTI in hospitalized older adults.

Barriers and facilitators for screening and treatment of hyperlipidemia among patients with inflammatory arthritis.

BACKGROUND: Patients with inflammatory arthritis (IA), defined as rheumatoid arthritis (RA) and psoriatic arthritis (PsA), are at increased risk for cardiovascular disease (CVD). The frequency of screening and treatment of hyperlipidemia, a modifiable CVD risk factor, is low in these patients. The reasons for low screening and treatment rates in this population are poorly understood. Our objective was to elicit the barriers and facilitators for screening and treatment of hyperlipidemia from the perspective of patients with IA. METHODS: We conducted a qualitative study using focus groups of patients with IA, guided by Bandura's Social Cognitive Theory. We recruited patients with IA aged 40 years and older from a single academic center. Data were analyzed thematically. RESULTS: We conducted three focus groups with 17 participants whose mean age was 56 (range 45-81) years; 15 were women. Four themes emerged as barriers: 1) need for more information about arthritis, prognosis, and IA medications prior to discussing additional topics like CVD risk; 2) lack of knowledge about how IA increases CVD risk; 3) lifestyle changes to reduce overall CVD risk rather than medications; and 4) the need to improve doctor-patient communication about IA, medications, and CVD risk. One theme emerged as a facilitator: 5) potential for peer coaches (patients with IA who are trained about concepts of CVD risk and IA) to help overcome barriers to screening and treatment of hyperlipidemia to lower CVD risk. CONCLUSION: Patients with IA identified educational needs about IA, increased CVD risk in IA and the need for improved doctor-patient communication about screening for hyperlipidemia and its treatment. Patients were receptive to working with peer coaches to facilitate achievement of these goals.

Views of primary care physicians and rheumatologists regarding screening and treatment of hyperlipidemia among patients with rheumatoid arthritis.

BACKGROUND: Despite high risk for cardiovascular disease (CVD) mortality, screening and treatment of hyperlipidemia in patients with rheumatoid arthritis (RA) is suboptimal. We asked primary care physicians (PCPs) and rheumatologists to identify barriers to screening and treatment for hyperlipidemia among patients with RA. METHODS: We recruited rheumatologists and PCPs nationally to participate in separate moderated structured group teleconference discussions using the nominal group technique. Participants in each group generated lists of barriers to screening and treatment for hyperlipidemia in patients with RA, then each selected the three most important barriers from this list. The resulting barriers were organized into physician-, patient- and system-level barriers, informed by the socioecological framework. RESULTS: Twenty-seven rheumatologists participated in a total of 3 groups (group size ranged from 7 to 11) and twenty PCPs participated in a total of 3 groups (group size ranged from 4 to 9). Rheumatologists prioritized physician level barriers (e.g. 'ownership' of hyperlipidemia screening and treatment), whereas PCPs prioritized patient-level barriers (e.g. complexity of RA and its treatments). CONCLUSION: Rheumatologists were conflicted about whether treatment of CVD risk among patients with RA should fall within the role of the rheumatologist or the PCP. All participating PCPs agreed that CVD risk reduction was within their role. Factors that influenced PCPs' decisions for screening and treatment for CVD risk in patients with RA were mainly related to their concern about how treatment for CVD risk could influence RA symptomatology (myalgia from statins) or how inflammation from RA and RA medications influences lipid profiles.

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments - United States, 2008-2018.

The prevalence of current cigarette smoking is approximately twice as high among adults enrolled in Medicaid (23.9%) as among privately insured adults (10.5%), placing Medicaid enrollees at increased risk for smoking-related disease and death (1). Medicaid spends approximately $39 billion annually on treating smoking-related diseases (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications* are effective in helping tobacco users quit (3). Comprehensive, barrier-free, widely promoted coverage of these treatments increases use of cessation treatments and quit rates and is cost-effective (3). To monitor changes in state Medicaid cessation coverage for traditional Medicaid enrollees† over the past decade, the American Lung Association collected data on coverage of nine cessation treatments by state Medicaid programs during December 31, 2008-December 31, 2018: individual counseling, group counseling, and the seven FDA-approved cessation medications§; states that cover all nine of these treatments are considered to have comprehensive coverage. The American Lung Association also collected data on seven barriers to accessing covered treatments.¶ As of December 31, 2018, 15 states covered all nine cessation treatments for all enrollees, up from six states as of December 31, 2008. Of these 15 states, Kentucky and Missouri were the only ones to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers could reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (3-7).

Tobacco-Free Pharmacies and U.S. Adult Smoking Behavior: Evidence From CVS Health's Removal of Tobacco Sales.

INTRODUCTION: Beginning September 3, 2014, CVS Health stopped selling tobacco products in all of its retail stores nationwide. This study assessed the impact of removing tobacco sales from CVS Health on cigarette smoking behaviors among U.S. adult smokers. METHODS: CVS Health retail location data (2012-2016) were linked with data from the Behavioral Risk Factor Surveillance System, a phone-based survey of the non-institutionalized civilian population aged ≥18 years. Using a difference-in-differences regression model, quit attempts and daily versus nondaily smoking were compared between smokers living in counties with CVS stores and counties without CVS stores, before and after CVS's removal of tobacco sales. Control variables included individuals' sociodemographic and health-related variables, state tobacco control variables, and urban status of counties. Analyses were conducted in 2018. RESULTS: During the 2-year period following the removal of tobacco sales from CVS Health, smokers living in counties with high CVS density (≥3.5 CVS stores per 100,000 people) had a 2.21% (95% CI=0.08, 4.33) increase in their quit attempt rates compared with smokers living in counties without CVS stores. This effect was greater in urban areas (marginal effect: 3.03%, 95% CI=0.81, 5.25); however, there was no statistically significant impact in rural areas. Additionally, there was no impact on daily versus nondaily smoking in either urban or rural areas. CONCLUSIONS: Removing tobacco sales in retail pharmacies could help support cessation among U.S. adults who are attempting to quit smoking, particularly in urban areas.

Procalcitonin utilization in the real world: An observational study of antibiotic prescribing practices.

OBJECTIVES: This study aims to better understand and describe antibiotic prescribing practices and adherence to a procalcitonin (PCT)-guided algorithm in patients undergoing serum PCT testing in adult hospitalized patients. METHODS: We performed an observational, retrospective study of 201 randomly selected patients who are aged ≥18 years, admitted to the general medicine floors or step-down unit between 1 January 2017 and 31 December 2017, and had serum PCT testing. Physician adherence to a PCT-guided algorithm was assessed through chart review. RESULTS: We found an overall adherence of 64.7%. Adherence was highest for PCT values above 0.25 ng/mL (82.8% for 0.25-0.50 ng/mL and 83.6% for >0.50 ng/mL). Adherence was lower for PCT values less than 0.25 ng/mL (59% for <0.1 ng/mL and 38% for 0.1-0.24 ng/mL). Serial testing was performed in 10% of patients. CONCLUSIONS: Hospital-based providers are more likely to overrule the algorithm and either initiate or continue antibiotics when guidelines encourage discontinuing antibiotics. These findings have important implications for antimicrobial stewardship and patient care and suggest that hospital-based providers may benefit from targeted didactics regarding the interpretation of the serum PCT assay.

Evaluation of the Patient Activated Learning System (PALS) to improve knowledge acquisition, retention, and medication decision making among hypertensive adults: Results of a pilot randomized controlled trial.

BACKGROUND: There are few engaging, patient centered, and reliable e-Health sources, particularly for patients with low health literacy. OBJECTIVES: We tested the Patient Activated Learning System (PALS) against WebMD. We hypothesized that participants using PALS would have higher knowledge scores, greater perceived learning, comfort, and trust than participants using WebMD. METHODS: Participants with hypertension from an urban Internal Medicine practice were randomized to view 5 web pages in PALS orWebMD containing information about chlorthalidone. We assessed knowledge, learning perceptions, comfort, and trust through surveys immediately and one week following the intervention. RESULTS: 104 participants completed both survey sets (PALS = 51,WebMD = 53). Immediate post intervention mean knowledge scores were higher for the PALS participants [(4.33 vs. 3.62 (P = .003)]. A greater proportion of PALS participants answered ≥4/5 questions correctly (82% vs. 57%; IRR 1.46 [95% CI 1.13-1.89]). A greater proportion of PALS participants agreed they would feel comfortable taking chlorthalidone if prescribed to them (73% vs. 55%; IRR 1.38 [95% CI 1.04-1.84]). One-week recall and trust were similar in the two groups. CONCLUSIONS: PALS may have advantages overWebMD for immediate knowledge acquisition, perceived learning, and comfort. IMPLICATIONS: PALS is a promising new approach to eHealth patient education. ClinicalTrials.gov registration identifier: NCT03156634.

State-Specific Cessation Behaviors Among Adult Cigarette Smokers - United States, 2014-2015.

This study assessed state-specific smoking cessation behaviors among US adult cigarette smokers aged 18 years or older. Estimates came from the 2014-2015 Tobacco Use Supplement to the Current Population Survey (N = 163,920). Prevalence of interest in quitting ranged from 68.9% (Kentucky) to 85.7% (Connecticut); prevalence of making a quit attempt in the past year ranged from 42.7% (Delaware) to 62.1% (Alaska); prevalence of recently quitting smoking ranged from 3.9% (West Virginia) to 11.1% (District of Columbia); and prevalence of receiving quit advice from a medical doctor in the past year ranged from 59.4% (Nevada) to 81.7% (Wisconsin). These findings suggest that opportunities exist to encourage and help more smokers to quit.

Tobacco Cessation Interventions and Smoke-Free Policies in Mental Health and Substance Abuse Treatment Facilities - United States, 2016.

Persons with mental or substance use disorders or both are more than twice as likely to smoke cigarettes as persons without such disorders and are more likely to die from smoking-related illness than from their behavioral health conditions (1,2). However, many persons with behavioral health conditions want to and are able to quit smoking, although they might require more intensive treatment (2,3). Smoking cessation reduces smoking-related disease risk and could improve mental health and drug and alcohol recovery outcomes (1,3,4). To assess tobacco-related policies and practices in mental health and substance abuse treatment facilities (i.e., behavioral health treatment facilities) in the United States (including Puerto Rico), CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA) analyzed data from the 2016 National Mental Health Services Survey (N-MHSS) and the 2016 National Survey of Substance Abuse Treatment Services (N-SSATS). In 2016, among mental health treatment facilities, 48.9% reported screening patients for tobacco use, 37.6% offered tobacco cessation counseling, 25.2% offered nicotine replacement therapy (NRT), 21.5% offered non-nicotine tobacco cessation medications, and 48.6% prohibited smoking in all indoor and outdoor locations (i.e., smoke-free campus). In 2016, among substance abuse treatment facilities, 64.0% reported screening patients for tobacco use, 47.4% offered tobacco cessation counseling, 26.2% offered NRT, 20.3% offered non-nicotine tobacco cessation medications, and 34.5% had smoke-free campuses. Full integration of tobacco cessation interventions into behavioral health treatment, coupled with implementation of tobacco-free campus policies in behavioral health treatment settings, could decrease tobacco use and tobacco-related disease and could improve behavioral health outcomes among persons with mental and substance use disorders (1-4).

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments - United States, 2015-2017.

Cigarette smoking prevalence among Medicaid enrollees (25.3%) is approximately twice that of privately insured Americans (11.8%), placing Medicaid enrollees at increased risk for smoking-related disease and death (1). Medicaid spends approximately $39 billion annually on treating smoking-related diseases (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications* are effective in helping tobacco users quit (3). Although state Medicaid coverage of tobacco cessation treatments improved during 2014-2015, coverage was still limited in most states (4). To monitor recent changes in state Medicaid cessation coverage for traditional (i.e., nonexpansion) Medicaid enrollees, the American Lung Association collected data on coverage of a total of nine cessation treatments: individual counseling, group counseling, and seven FDA-approved cessation medications† in state Medicaid programs during July 1, 2015-June 30, 2017. The American Lung Association also collected data on seven barriers to accessing covered treatments, such as copayments and prior authorization. As of June 30, 2017, 10 states covered all nine of these treatments for all enrollees, up from nine states as of June 30, 2015; of these 10 states, Missouri was the only state to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers would be expected to reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (5-7).

State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage - United States, 2016.

In 2015, 27.8% of adult Medicaid enrollees were current cigarette smokers, compared with 11.1% of adults with private health insurance, placing Medicaid enrollees at increased risk for smoking-related disease and death (1). In addition, smoking-related diseases are a major contributor to Medicaid costs, accounting for about 15% (>$39 billion) of annual Medicaid spending during 2006-2010 (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications are effective treatments for helping tobacco users quit (3). Insurance coverage for tobacco cessation treatments is associated with increased quit attempts, use of cessation treatments, and successful smoking cessation (3); this coverage has the potential to reduce Medicaid costs (4). However, barriers such as requiring copayments and prior authorization for treatment can impede access to cessation treatments (3,5). As of July 1, 2016, 32 states (including the District of Columbia) have expanded Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA),*,† which has increased access to health care services, including cessation treatments (5). CDC used data from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES) and the Behavioral Risk Factor Surveillance System (BRFSS) to estimate the number of adult smokers enrolled in Medicaid expansion coverage. To assess cessation coverage among Medicaid expansion enrollees, the American Lung Association collected data on coverage of, and barriers to accessing, evidence-based cessation treatments. As of December 2015, approximately 2.3 million adult smokers were newly enrolled in Medicaid because of Medicaid expansion. As of July 1, 2016, all 32 states that have expanded Medicaid eligibility under ACA covered some cessation treatments for all Medicaid expansion enrollees, with nine states covering all nine cessation treatments for all Medicaid expansion enrollees. All 32 states imposed one or more barriers on at least one cessation treatment for at least some enrollees. Providing barrier-free access to cessation treatments and promoting their use can increase use of these treatments and reduce smoking and smoking-related disease, death, and health care costs among Medicaid enrollees (4,6-8).