Trends in prevalent and incident opioid receipt: an observational study in Veterans Health Administration 2004-2012.

BACKGROUND: Improved understanding of temporal and regional trends may support safe and effective prescribing of opioids. OBJECTIVE: We describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012. DESIGN: Observational cohort study using Veterans Health Administration (VHA) administrative databases. PARTICIPANTS: All patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year. MAIN MEASURES: Prevalent and incident opioid receipt during each year of the study period. KEY RESULTS: The overall prevalence of opioid receipt increased from 18.9% of all veteran outpatients in FY2004 to 33.4% in FY2012, a 76.7% relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4% vs. 32.9%), and the youngest veterans (18-34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥ 80 years) (47.6% vs. 17.9%). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5%, and the highest of 50.8%. Annual incident opioid receipt increased from 8.8% in FY2004 to 10.2% in FY2011, with a decline to 9.8% in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame. CONCLUSIONS: Rates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.

Use of complementary and alternative medicine by older patients with arthritis: a population-based study.

OBJECTIVE: To determine the prevalence of complementary and alternative medicine (CAM) use and to identify factors associated with its use in older patients with arthritis. METHODS: A population-based telephone survey of 480 elderly patients with arthritis was conducted to determine demographics, comorbidities, health status, arthritis symptoms, and the use of CAM and traditional providers and treatments for arthritis. RESULTS: CAM provider use was reported by 28% of respondents, and 66% reported using one or more CAM treatments. Factors independently related to CAM provider use (P < 0.05) included podiatrist or orthotist use, physician visits for arthritis, and fair or poor self-reported health. For CAM treatments, independent associations were found with physical or occupational therapist use, physician visits for arthritis, chronic obstructive pulmonary disease, and alcohol abstinence. Rural residence, age, income, education, and health insurance type were unrelated to CAM use. CONCLUSION: Many older patients with arthritis reported seeing CAM providers, and most used CAM treatments. The use of CAM for arthritis was most common among those with poorer self-assessed health and higher use of traditional health care resources.

Length of stay as a source of bias in comparing performance in VA and private sector facilities: lessons learned from a regional evaluation of intensive care outcomes.

OBJECTIVES: Compare intensive care unit (ICU) mortality and length of stay (LOS) in a VA hospital and private sector hospitals and examine the impact of hospital utilization on mortality comparisons. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Consecutive ICU admissions to a VA hospital (n = 1,142) and 27 private sector hospitals (n = 51,249) serving the same health care market in 1994 to 1995. MEASURES: Mortality and ICU LOS were adjusted for severity of illness using a validated method that considers physiologic data from the first 24 hours of ICU admission. Mortality comparisons were made using two different multivariable techniques. RESULTS: Unadjusted in-hospital mortality was higher in VA patients (14.5% vs. 12.0%; P = 0.01), as was hospital (28.3 vs. 11.3 days; P <0.001) and ICU (4.3 vs. 3.9 days; P <0.001) LOS. Using logistic regression to adjust for severity, the odds of death was similar in VA patients, relative to private sector patients (OR 1.16, 95% CI 0.93-1.44; P = 0.18). However, a higher proportion of VA deaths occurred after 21 hospital days (33% vs. 13%; P <0.001). Using proportional hazards regression and censoring patients at hospital discharge, the risk for death was lower in VA patients (hazard ratio 0.70; 95% CI 0.59-0.82; P <0.001). After adjusting for severity, differences in ICU LOS were no longer significant (P = 0.19). CONCLUSIONS: Severity-adjusted mortality in ICU patients was lower in a VA hospital than in private sector hospitals in the same health care market, based on proportional hazards regression. This finding differed from logistic regression analysis, in which mortality was similar, suggesting that comparisons of hospital mortality between systems with different hospital utilization patterns may be biased if LOS is not considered. If generalizable to other markets, our findings further suggest that ICU outcomes are at least similar in VA hospitals.

Patient perceptions of the capabilities of internists: a multi-center survey.

PURPOSE: Surveys conducted by the American College of Physicians-American Society of Internal Medicine have shown that the public has varying opinions about the capabilities of internists. However, the perceptions of patients seeking care from internists remain uncertain. We wished to determine how patients visiting general internists perceived them and discover whether patients understood the differences between internists and other primary care physicians. SUBJECTS AND METHODS: We surveyed established adult patients visiting three general internal medicine clinics in Georgia, Iowa, and Vermont. Patients answered 11 questions about their perceptions of an internist's scope of care and selected which of 24 diseases, symptoms, or examination skills they thought an internist could manage. RESULTS: Patients completed 601 (66%) of the 911 surveys distributed. Nearly half of patients (45%) confused internists with family physicians and 39% thought internists could treat children. Patients with college education were more than twice as likely to know that internists were not interns (Odds ratio = 2.6, 95% confidence interval 1.8 to 3.8, P < 0.001) compared with patients having less education. Only 50% of patients thought an internist was trained in women's health. Significantly more (P < 0.001) patients demonstrated confidence in an internist's ability to treat symptoms (76%) than treat specific diseases (59%) or perform clinical examinations (54%). CONCLUSIONS: Established patients seeking care in internal medicine clinics lack consensus on the capabilities of internists, especially on how they differ from other specialties. Continued public education efforts should be considered to promote better understanding of the role of the internist as a specialist in adult medicine.