Marijuana use disorder among adults with functional disabilities-A US population-based cross-sectional study.

BACKGROUND AND OBJECTIVES: Recent studies suggest a growing trend in marijuana use, compared to a stable prevalence of marijuana use disorder among US adults over the first 15 years of the 21st century. This study investigated the recent patterns of marijuana use disorder among people with disabilities (PWD). METHODS: We extracted a nationally representative sample (N = 209,058) from the 2015-2019 National Survey on Drug Use and Health data set and examined associations by functional disability status (any disability, disability by type, and number of disabling limitations) with marijuana use disorder using a series of independent multivariable logistic regression models. We also performed trend analyses during the study period. RESULTS: The prevalence of marijuana use disorder (from 1.7% to 2.3%) increased significantly among PWD between 2015 and 2019 (p-trend < .001). PWD were significantly more likely to report marijuana use disorder (odds ratio [OR], 1.37, 95% confidence interval [CI], 1.24-1.52) than people without disability (PWoD). Those with cognitive limitation only (OR, 1.78, 95% CI, 1.53-2.06) and ≥2 limitations (OR, 1.29, 95% CI, 1.10-1.51) were more likely to report marijuana use disorder than PWoD. DISCUSSION AND CONCLUSIONS: PWD had a consistently higher prevalence of marijuana use disorder than PWoD. Additionally, the level of risk for marijuana use disorder varied by disability type and number of disabling limitations. SCIENTIFIC SIGNIFICANCE: Our study provided new nuance on disparities in marijuana use disorder between PWD and PWoD and further revealed the varied risks for marijuana use disorder across different disability statuses.

Sociodemographic factors associated with major depressive episodes and suicidal ideation among emerging adults with diabetes in the U.S.

Background: Research focused on disparities related to mental health comorbidities, especially among emerging adults with diabetes, is limited. Identifying associated factors of disparities could inform policy decisions to make diabetes-related interdisciplinary care more accessible for vulnerable groups. Method: Using data from the National Survey on Drug Use and Health (2015-2019), we examined disparities in presence of major depressive episode (MDE) and suicidal ideation among emerging adults with diabetes. Survey design-adjusted bivariate and multivariable logistic regression models were used for statistical analyses. Results: The study included 1,125 emerging adults (18-25 years old), with a history of type 1 diabetes (T1D) or type 2 diabetes (T2D). After controlling for sociodemographic and health-related characteristics, we found lower odds of having past-year major MDE for non-Hispanic Black (AOR, 0.42, p=0.032) compared to their non-Hispanic White counterparts. Females were 3.02 times more likely to have past-year MDE than males (AOR, 3.02, p=0.004). The odds of having past-year MDE were 1.96 times higher among individuals who identified as LGB (lesbian, gay, bisexual) (AOR, 1.96, P=0.038). There were no statistically significant disparities in suicidal ideation related to race/ethnicity, sex, education, and family income. However, individuals who identified as LGB had significantly higher likelihood of suicidal ideation than their heterosexual counterparts (AOR, 2.47, P=0.004). Conclusion: Significant disparities related to MDE and suicidal ideation exist based on race/ethnicity, gender, and sexual orientation. Integration of a mental health professional into the multidisciplinary diabetes care team is critical for effective management of comorbid mental health conditions in younger patients with diabetes.

Telehealth Utilization During the COVID-19 Pandemic Among People With Functional Disabilities in the U.S.: A Preliminary Analysis of National Health Interview Survey 2020 Data.

Introduction: Telehealth has been widely promoted and adopted at multiple levels in the U.S. healthcare system during the COVID-19 pandemic. However, this rapid expansion of telehealth services may have further exacerbated health inequities among marginalized groups. Methods: Using the 2020 National Health Interview Survey, this study compared patterns of telehealth use between people with functional disabilities and people without disabilities during the first year of the pandemic. Results: In the multivariable-adjusted logistic regression models, respondents with moderate disabilities were significantly more likely to report telehealth use, not pandemic related (OR=1.25, 95% CI=1.03, 1.52) and telehealth use, pandemic related (OR=1.43, 95% CI=1.28, 1.60) than people without disabilities. Similarly, respondents with severe disabilities were significantly more likely to report telehealth use, not pandemic related (OR=1.46, 95% CI=1.07, 2.00) and telehealth use, pandemic related (OR=2.06, 95% CI=1.72, 2.46). In addition, telehealth use varied by the number of limitations and disability type. Conclusions: People with functional disabilities were more likely to report telehealth use than people without disabilities. Furthermore, these associations strengthened with increasing disability severity and number of limitations while varying by disability type. Additional studies are warranted to explore ways of providing patient-centered telehealth to responsively meet various healthcare needs of people with functional disabilities and improve their health outcomes.

Suicide Ideation, Plans, and Attempts Among Military Veterans vs Nonveterans With Disability.

Importance: People with disability are at heightened risk for suicide ideation, planning, and attempt, with risk growing as the number of disabling limitations increases. Military veterans have higher rates of suicide deaths and disability relative to nonveterans. Objective: To evaluate whether veteran status is associated with greater risk for suicide in those with disability. Design, Setting, and Participants: This survey study used cross-sectional self-reported data from US adults who participated in the 2015-2020 National Survey on Drug Use and Health. Data were weighted to represent the population. Data analysis was conducted from July to August 2022. Main Outcomes and Measures: Suicide ideation, planning, and attempt served as primary outcomes. Disability status (present or absent) and number of disabling limitations (1, 2, or ≥3) served as factors. Veteran status was determined based on self-report (veteran or nonveteran). Multivariable logistic regression examined suicide ideation, planning, and attempt as a function of veteran status and disability variables. Results: Participants included 231 099 US veterans and nonveterans, representing 236 551 727 US adults, of whom 20.03% (weighted n = 47 397 876) reported a disabling limitation, 8.92% were veterans (weighted n = 21 111 727; 16.0% aged 35-49 years; 91.0% men; 6.7% Hispanic; 10.9% non-Hispanic Black; and 78.4% non-Hispanic White) and 91.08% were nonveterans (weighted n = 215 440 000; 25.4% aged 35-49 years; 44.0% male; 16.5% Hispanic; 11.7% non-Hispanic Black; and 63.3% non-Hispanic White). Overall, 4.39% reported suicide ideation, planning, or attempt (weighted n = 10 401 065). Among those with no disability, veteran status was associated with higher risk of suicide planning (adjusted odds ratio [AOR], 1.71; 95% CI, 1.17-2.49). Among those with 1 or 2 disabling limitations, being a veteran was associated with a lower risk of suicide planning (AOR, 0.57; 95% CI, 0.34-0.95) and history of attempt (AOR, 0.46; 95% CI, 0.24-0.88). Conclusions and Relevance: In this study of how suicide risk differs as a function of disability and veteran status, risk for death by suicide was lower among veterans with disability relative to nonveterans with disability. Veteran status may mitigate risk for suicide given increased receipt of more disability-related care through the Department of Veterans Affairs. Further research would extend this line of inquiry by examining the cause and type of disability as well as perceptions of disability on self-worth. It is possible that physical wounds of war are protective because of the meaning and value of service to one's country.

Drivers of Individual and Regional Variation in CMS Hierarchical Condition Categories Among Florida Beneficiaries.

Objective: To explore hierarchical condition categories (HCC) risk score variation among Florida Fee for Service (FFS) Medicare beneficiaries between 2016 and 2018. Data Sources: This study analyzed HCC risk score variation using Medicare claims data for Florida beneficiaries enrolled in Parts A & B between 2016 and 2018. Study Design: The CMS methodology analyzed HCC risk score variation using annual mean county- and beneficiary-level risk score changes. The association between variation and beneficiary characteristics, diagnoses, and geographic location was characterized using mixed-effects negative binomial regression models. Data Collection: Not applicable. Principal Findings: Counties in the Northeast [marginal effect (ME)=-0.003], Central (ME=-0.021), and Southwest (ME=-0.009) Florida have relatively lower mean risk scores. A higher number of lifetime (ME=0.246) and treatable (ME=0.288) conditions were associated with higher county-level risk scores, while more preventable conditions (ME=-0.249) were associated with lower risk scores. Counties with older beneficiaries (ME=0.015) and more Blacks (ME=0.070) have higher risk scores, while having female beneficiaries reduced risk scores (ME=-0.005). Individual risk scores did not vary by age (ME=0.000), but Blacks (ME=0.001) had higher rates of variation relative to Whites, while other races had comparatively lower variation (ME=-0.003). In addition, individuals diagnosed with more lifetime (ME=0.129), treatable (ME=0.235), and preventable (ME=0.001) conditions had higher risk score variation. Most condition-specific indicators showed small associations with risk score changes; however, metastatic cancer/acute leukemia, respirator dependence/tracheostomy, and pressure ulcers of the skin were significantly associated with both types of HCC risk score variation. Conclusion: Results showed demographics, HCC condition classifications (ie, lifetime, preventable, and treatable), and some specific conditions were associated with higher variation in mean county-level and individual risk scores. Results suggest consistent coding and reductions in the prevalence of certain treatable or preventable conditions could reduce the county and individual HCC risk score year-to-year change.

Hearing Impairment, Mental Health Services Use, and Perceived Unmet Needs Among Adults With Serious Mental Illness: A Cross-Sectional Study.

PURPOSE: Individuals with hearing impairment have higher risks of mental illnesses. We sought to develop a richer understanding of how the presence of any hearing impairment affects three types (prescription medication, outpatient services, and inpatient services) of mental health services utilization (MHSU) and perceived unmet needs for mental health care; also, we aimed to identify sociodemographic factors associated with outpatient mental health services use among those with hearing impairment and discuss potential implications under the U.S. health care system. METHOD: Using secondary data from the 2015-2019 National Survey on Drug Use and Health, our study included U.S. adults aged ≥ 18 years who reported serious mental illnesses (SMIs) in the past year. Multivariable logistic regression was used to examine associations of hearing impairment with MHSU and perceived unmet mental health care needs. RESULTS: The study sample comprised 12,541 adults with SMIs. Prevalence of MHSU (medication: 55.5% vs. 57.5%; outpatient: 37.1% vs. 44.2%; inpatient: 6.6% vs.7.1%) and unmet needs for mental health care (47.5% vs. 43.3%) were estimated among survey respondents who reported hearing impairment and those who did not, respectively. Those with hearing impairment were significantly less likely to report outpatient MHSU (OR = 0.73, 95% CI [0.60, 0.90]). CONCLUSIONS: MHSU was low while perceived unmet needs for mental health care were high among individuals with SMIs, regardless of hearing status. In addition, patients with hearing impairment were significantly less likely to report outpatient MHSU than their counterparts. Enhancing communication is essential to improve access to mental health care for those with hearing impairment.

Opioid Use Behaviors Among People With Disability in the United States: An Analysis of the National Survey on Drug Use and Health.

OBJECTIVE: People with disability (PWD) often experience chronic pain, and opioid is widely used prescription medication. However, population-based evidence of opioid use behaviors among PWD is lacking. This study examined the prevalence of opioid use behaviors by sociodemographic and health-related characteristics among PWD compared with people without disability (PWoD). METHODS: This cross-sectional study used data from 2015-2019 National Survey on Drug Use and Health. Three types of opioid use behaviors (any use, misuse, and use disorder) were defined and compared by disability status. Five self-reported disability types were measured, including hearing, vision, cognitive, mobility, and complex activity limitations. Complex survey design-adjusted descriptive and logistic regression models were used for statistical analysis. RESULTS: Of 201,376 respondents aged 18 years or older, 34.6% reported any opioid use, 4.2% opioid misuse, and 0.8% opioid use disorder. Compared with PWoD, PWD had higher prevalence of any opioid use (49.7% vs 30.7%), misuse (6.2% vs 3.7%), and use disorder (1.7% vs 0.8%). In adjusted analysis, PWD with mobility limitation (odds ratio [OR], 1.95; 95% confidence interval, 1.81-2.11) or multiple limitations (OR, 1.92; 95% CI, 1.83-2.02) were almost 2 times more likely to report any opioid use than PWoD. The likelihood of reporting any opioid use (ORs, 1.42-2.50), misuse (ORs, 1.24-2.41), and disorder (ORs, 1.38-2.54) increased as the number of limitations increased. CONCLUSIONS: People with vision, cognitive, or multiple limitations had higher rates of opioid misuse and disorder than PWoD. Development of more inclusive opioid abuse prevention strategies for PWD is warranted.

People With Functional Disability and Access to Health Care During the COVID-19 Pandemic: A US Population-based Study.

INTRODUCTION: The COVID-19 pandemic and nationwide restriction measures have disrupted health care delivery and access for the general population. There is limited evidence about access to care issues (delayed and forgone care) due to the pandemic among people with disability (PWD). METHODS: This study used the 2020 National Health Interview Survey data. Disability status was defined by disability severity (moderate and severe disability), type, and the number of disabling limitations. Descriptive analysis and multivariate logistic regression (adjusted for sociodemographic and health-related characteristics) were conducted to estimate delayed/forgone care (yes/no) between PWD and people without disability (PWoD). RESULTS: Among 17,528 US adults, 40.7% reported living with disability. A higher proportion of respondents with severe and moderate disability reported delaying care than PWoD (severe=33.2%; moderate=27.5%; PWoD=20.0%, P <0.001). The same was true for forgone medical care (severe=26.6%; moderate=19.0%; PWoD=12.2%, P <0.001). Respondents with a moderate disability {delayed [odds ratio (OR)=1.33, 95% confidence interval (CI)=1.19, 1.49]; forgone [OR=1.46, 95% CI=1.28, 1.67]} and a severe disability [delayed (OR=1.52, 95% CI=1.27, 1.83); forgone (OR=1.84, 95% CI=1.49, 2.27)] were more likely to report delayed medical care and forgone medical care compared with PWoD. These findings were consistent across the models using disability type and the number of limitations. CONCLUSIONS: PWD were more likely to experience COVID-19-related delays in or forgone medical care compared with PWoD. The more severe and higher frequency of disabling limitations were associated with higher degrees of delayed and forgone medical care. Policymakers need to develop disability-inclusive responses to public health emergencies and postpandemic care provision among PWD.

Association between functional disability type and suicide-related outcomes among U.S. adults with disabilities in the National Survey on Drug Use and Health, 2015-2019.

While research on suicidal behavior for people with disability (PWD) suggests they experience higher risk than people without disability, less is known about variations among individuals with different disability types. This nationally representative, cross-sectional study compared differences in suicide-related outcomes (ideation, planning, attempts) among PWD by functional disability type (hearing, vision, cognitive, mobility, complex activity) and number. Secondary analysis of adult PWD in the 2015-2019 National Survey on Drug Use and Health (unweighted N = 35,544; representing 47,723,378 PWD, weighted) was used to estimate relationships between suicide-related outcomes and disability type and number. Most respondents were female (55.9%), and 36.0% were aged ≥65 years. Adjusted odds ratios (AORs) from multivariable logistic regression indicated that suicidal ideation and suicide attempt, respectively, were significantly more likely among individuals with cognitive (AOR = 1.71, 95% CI = 1.24-2.35; AOR = 2.54, 95% CI = 1.31-4.91), complex activity (AOR = 1.96, 95% CI = 1.37-2.81; AOR = 2.67, 95% CI = 1.32-5.41), and ≥2 limitations (AOR = 2.02, 95% CI = 1.52-2.69; AOR = 3.46, 95% CI = 1.84-6.50) than hearing limitation. Also, relative to other disability types, suicide-related outcomes were significantly more likely among individuals with cognitive limitation and complex activity limitation (p < 0.001). Additionally, suicide-related outcomes elevated in likelihood as the number of limitations increased, with the largest associations among those with ≥5 limitations for suicidal ideation (AOR = 2.31, 95% CI = 1.46-3.66), suicide planning (AOR = 3.34, 95% CI = 1.97-5.68), and suicide attempt (AOR = 6.37, 95% CI = 3.76-10.79). Subgroup analyses showed that presence of cognitive limitation and multiple limitations differentiated between suicidal ideators and suicide attempters. Further research is needed to identify causes of these risks and develop suicide prevention efforts for these particularly vulnerable groups.

Association of functional disability and treatment modalities with perceived effectiveness of treatment among adults with depression: a cross-sectional study.

BACKGROUND: Approximately 17.3 million US adults had at least one major depressive episode (MDE) in 2017. Of those, about two-thirds received mental health services from health professionals. Persons with disabilities (PWD) have higher risks of depression and may face more challenges in seeking treatment. OBJECTIVE: Examined whether the presence of disabilities affected the perceived effectiveness of treatment for people with MDE who received outpatient mental health care. METHODS: We obtained MDE status, functional disability, modality of treatment (i.e., medication only, counseling only, medication plus counseling), self-reported effectiveness of treatment, and covariates from a nationally representative sample of US adults aged ≥18 years in the 2015-2019 National Survey on Drug Use and Health. We used multivariable logistic regression models with recommended survey weighting to examine associations between disability and perceived effectiveness of treatment. RESULTS: The study population comprised 9992 respondents, representing 9.53 million US adults who had MDE and received outpatient mental health care in the past year. Overall, 58.9% had at least one functional limitation. A higher proportion of PWDs received medication plus counseling treatment compared to persons without disabilities (79.2% vs. 67.9%, P < .001). PWDs were significantly less likely to rate treatment as effective (OR = 0.77; 95% CI: 0.66-0.91). Odds ratios decreased as the number of limitations increased, and this association was moderated by treatment modality. CONCLUSION: PWDs have poorer perceived outcomes of outpatient mental health care for depression, especially for treatment modalities involving counseling. These findings call for focused attention to depression treatment efforts for PWD that accommodate their needs.

Association of functional disability with mental health services use and perceived unmet needs for mental health care among adults with serious mental illness.

BACKGROUND: Approximately 13.1 million U.S. adults experienced serious mental illness (SMI) in 2019. Persons with disability (PWD) have higher risks of SMI. Ensuring adequate access to mental health (MH) services for PWD is imperative to ameliorate this burden. METHODS: Using the 2015-2019 National Survey on Drug Use and Health, we obtained study variables for U.S. adults with SMI in the past year and used multivariable logistic regression models to examine the association of disability with MH services and perceived unmet needs. RESULTS: The sample comprised 12,532 respondents, representing 11,143,650 U.S. adults with SMI. Overall, PWD had higher proportions of using prescription medications (64.7% vs. 46.2%), outpatient treatment (48.4% vs. 36.5%) and inpatient treatment (8.6% vs. 4.7%) compared to persons without disability; however, the prevalence of perceived unmet MH service needs was also higher (46.3% vs. 39.4%) among PWD. Multivariable logistic regression models showed presence of any disability, cognitive and ≥2 limitations were significantly associated with MH services use (all p<0.01). However, PWD were significantly more likely to report perceived unmet MH service needs (p<0.01 for any disability as well as cognitive, complex activity, and ≥2 limitations). LIMITATIONS: Due to data limitations, disability status and SMI may be misclassified for some respondents, and the results may not be generalized to all individuals with SMI. CONCLUSION: While PWD were more likely to use MH services, they also had higher odds of unmet MH needs. These results call for more effective and tailored mental health services for PWD.

Association Between Disability and Suicide-Related Outcomes Among U.S. Adults.

INTRODUCTION: Although research has analyzed the sociodemographic and socioeconomic risks for suicide, only recently has suicide risk for people with disabilities been examined. This study investigates the associations between disability and distinct suicide-related outcomes, including suicidal ideation, suicide planning, and suicide attempt. METHODS: This nationally representative, cross-sectional study comprised secondary analyses of the 2015-2019 National Survey on Drug Use and Health conducted in 2020 (N=198,640, representing 229,556,289 U.S. adults). Disability status comprised the presence of any disability; hearing, vision, mobility, cognitive, complex activity, or ≥2 limitations; and 1, 2, 3, 4, or ≥5 limitations. Suicide-related outcomes in the past year included none, suicidal ideation only, suicide planning, and suicide attempt. Multivariable logistic regression was applied to estimate the AORs. RESULTS: Overall, 19.8% reported any disability. Results showed that people with disabilities were significantly more likely than those without disabilities to report suicidal ideation (AOR=2.13, 95% CI=1.93, 2.36), suicide planning (AOR=2.66, 95% CI=2.27, 3.11), and suicide attempt (AOR=2.47, 95% CI=2.05, 2.98). Furthermore, individuals within each limitation count group were significantly more likely than people without disabilities to report suicide-related outcomes (p<0.001), with the largest magnitudes among those with ≥5 limitations for suicidal ideation (AOR=3.80, 95% CI=2.32, 6.23), suicide planning (AOR=6.45, 95% CI=3.52, 11.80), and suicide attempt (AOR=8.19, 95% CI=4.45, 15.07). CONCLUSIONS: People with various types of functional disabilities had an elevated risk for suicide-related outcomes, compared with people without disabilities. The more limitations a person had progressively increased their risk. These findings call for focused attention to the mental health of people with disabilities, including suicide prevention efforts that accommodate their needs.

Factors associated with persistently high-cost health care utilization for musculoskeletal pain.

BACKGROUND: Musculoskeletal pain conditions incur high costs and produce significant personal and public health consequences, including disability and opioid-related mortality. Persistence of high-cost health care utilization for musculoskeletal pain may help identify system inefficiencies that could limit value of care. The objective of this study was to identify factors associated with persistent high-cost utilization among individuals seeking health care for musculoskeletal pain. METHODS: This was a retrospective cohort study of Medical Expenditure Panel Survey data (2008-2013) that included a non-institutionalized, population-based sample of individuals seeking health care for a musculoskeletal pain condition (n = 12,985). Expenditures associated with musculoskeletal pain conditions over two consecutive years were analyzed from prescribed medicine, office-based medical provider visits, outpatient department visits, emergency room visits, inpatient hospital stays, and home health visits. Persistent high-cost utilization was defined as being in the top 15th percentile for annual musculoskeletal pain-related expenditures over 2 consecutive years. We used multinomial regression to determine which modifiable and non-modifiable sociodemographic, health, and pain-related variables were associated with persistent high-cost utilization. RESULTS: Approximately 35% of direct costs for musculoskeletal pain were concentrated among the 4% defined as persistent high-cost utilizers. Non-modifiable variables associated with expenditure group classification included age, race, poverty level, geographic region, insurance status, diagnosis type and total number of musculoskeletal pain diagnoses. Modifiable variables associated with increased risk of high expenditure classification were higher number of missed work days, greater pain interference, and higher use of prescription medication for pain, while higher self-reported physical and mental health were associated with lower risk of high expenditure classification. CONCLUSIONS: Health care delivery models that prospectively identify these potentially modifiable factors may improve the costs and value of care for individuals with musculoskeletal pain prone to risk for high-cost care episodes.

Patient-provider communication quality for persons with disabilities: A cross-sectional analysis of the Health Information National Trends Survey.

BACKGROUND: It is unclear how perceived patient-provider communication quality (PPPCQ) varies according to disability status. Lack of adequate patient-provider communication may prevent providers from considering healthcare issues that are relevant and important to persons with disabilities (PWD), potentially contributing to poorer health outcomes. OBJECTIVE/HYPOTHESIS: To examine PPPCQ by disability status using current U.S. Department of Health and Human Services standards for surveillance of functional disabilities. METHODS: This cross-sectional study used nationally-representative data from the 2012-2013 Health Information National Trends Survey (HINTS). Participants were categorized as having any disability (hearing, vision, mobility, cognitive, self-care, and/or independent living limitations). PPPCQ was assessed using seven HINTS questions about communication with healthcare professionals. Linear regression was used to estimate mean differences in composite PPPCQ scores, and logistic regression was used to estimate odds ratios (OR) for a provider "always or usually" performing PPPCQ. RESULTS: The study population comprised 5301 participants, representing 180,442,731 U.S. adults. Overall, 22.1% (weighted) reported any disability. Adjusted mean PPPCQ scores were significantly lower for PWD (72.8, 95% CI: 68.2-77.4) than persons without disability (78.3, 95% CI: 76.5-80.2), p = 0.021. More specifically, PWD were significantly less likely to be given attention needed to address feelings and emotions (OR = 0.6, 95% CI: 0.4, 0.9, p = 0.017), to have next steps understood (OR = 0.4, 95% CI: 0.2, 0.8, p = 0.019), and to receive a clear explanation (OR = 0.3, 95% CI: 0.1, 0.8, p = 0.018). CONCLUSIONS: PWD are less likely to report key elements of effective patient-provider communication. Implementing patient-centered care may improve patient-provider communication for this vulnerable population.

Comorbidity Subgroups Among Medicare Beneficiaries Seeking Health Care for Musculoskeletal Pain.

BACKGROUND: Treatment of musculoskeletal pain in older adults may be more effective if it incorporates integrated management of comorbid health conditions. The purpose of this study was to define empirically derived comorbidity subgroups among Medicare beneficiaries with an index condition of osteoarthritis (OA) or low back pain (LBP) as a precursor to the development of comorbidity-specific pain treatment pathways. METHODS: This study included Medicare beneficiaries participating in the Medicare Current Beneficiary Survey (MCBS) and seeking care for OA (n = 723) or LBP (n = 617) with data available for 3 years after entry into the survey. We identified 30 comorbidity diagnoses using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes in claims data during beneficiaries' first year in the survey. Latent class analysis defined comorbidity subgroups, and posterior probabilities were used to assign subgroup classification. Self-reported disability was compared over three consecutive years for each subgroup. RESULTS: We identified similar comorbidity subgroups for OA and LBP. The subgroups included (range of percent prevalence) low comorbidity (47.6%-54.4%), nonvascular (21.8%-28.6%), diabetes (12.2%-15.0%), renal disease with complicated hypertension (5.5%-5.8%), and complex cardiac disease/high comorbidity (3.3%-5.8%). OA and LBP subgroups with more complex comorbidity burden generally demonstrated higher disability over 3 years. CONCLUSIONS: Five comorbidity subgroups were identified, with a large proportion of older adults classified into the subgroup defined by a low probability of most comorbidities. These findings provide direction for the development of pain treatment pathways that are tailored to address common comorbidity profiles among older adults.

Risk for Medication Nonadherence Among Medicaid Enrollees With Fibromyalgia: Development of a Validated Risk Prediction Tool.

OBJECTIVE: To develop and validate a risk assessment tool called the Prescription Medication Non-Adherence Prediction Tool (Rx-NAPT) to predict medication nonadherence in patients with fibromyalgia. METHODS: This was a retrospective cohort study using claims data from South Carolina Medicaid. Patients with fibromyalgia who were ≥18 years old and who had filled at least 1 prescription medication for pregabalin, duloxetine, or milnacipran from January 1, 2005, through June 30, 2011 were included. Medication possession ratios (MPRs) were calculated to classify patients as adherent (MPR ≥ 80%) or nonadherent (MPR < 80%). Multivariable logistic models using 100 bootstrap replications (with replacement) were used to identify factors associated with medication nonadherence, including age, gender, race, days' supply, medication type, and fibromyalgia-related comorbidity score. Weighted ß coefficients of the predictors were used to create the Rx-NAPT. Youden's J statistic was used to classify nonadherent patients into different levels of risk. RESULTS: The study sample comprised 6,626 patients with fibromyalgia, where 4,804 (72.50%) were non-adherent and 1,822 (27.50%) were adherent to their prescribed medication(s). Logistic regression models showed that 7 predictors (gender, age, race, fibromyalgia-related comorbidity score, medication type, health maintenance organization coverage, emergency room visit) were statistically significant in ≥50% of the bootstrapped samples. The final model demonstrated reasonable discrimination (area under the curve [AUC] = 0.6224) and calibration (Hosmer-Lemeshow goodness-of-fit; P > 0.05) statistics and was validated internally (AUC = 0.6372). CONCLUSION: Poor adherence with medication remains an important barrier to providing optimal care. Our risk prediction model provides an easy tool to help clinicians better identify patients with fibromyalgia who may not take their medications as prescribed.

Impact of Provider Participation in ACO Programs on Preventive Care Services, Patient Experiences, and Health Care Expenditures in US Adults Aged 18-64.

BACKGROUND: Little is known about the impact of accountable care organization (ACO) on US adults aged 18-64. OBJECTIVES: To examine whether having a usual source of care (USC) provider participating in an ACO affects receipt of preventive care services, patient experiences, and health care expenditures among nonelderly Americans. RESEARCH DESIGN: A cross-sectional analysis of the 2015 Medical Organizations Survey linked with the Medical Expenditure Panel Survey. SUBJECTS: Survey respondents aged 18-64 with an identified USC and continuous health insurance coverage during 2015. MEASURES: Preventative care services (routine checkup, flu vaccination, and cancer screening), patient experiences with health care (access to care, interaction quality with providers, and global satisfaction), and health care expenditures (total and out-of-pocket expenditures) for respondents with USC by ACO and non-ACO provider groups. RESULTS: Among 1563, nonelderly Americans having a USC, we found that nearly 62.7% [95% confidence interval (CI), 58.6%-66.7%; representing 15,722,208 Americans] were cared for by ACO providers. Our analysis showed no significant differences in preventive care services or patient experiences between ACO and non-ACO groups. Adjusted mean total health expenditures were slightly higher for the ACO than non-ACO group [$7016 (95% CI, $4949-$9914) vs. $6796 (95% CI, $4724-$9892)]; however, this difference was not statistically significant (P=0.250). CONCLUSIONS: Our findings suggest that having a USC provider participating in an ACO is not associated with preventive care services use, patient experiences, or health care expenditures among a nonelderly population.

Benchmarking Implications: Analysis of Medicare Accountable Care Organizations Spending Level and Quality of Care.

Early evidence has shown that Accountable Care Organizations (ACOs) have achieved some success in improving the quality of care and reducing Medicare costs. However, it has been argued that the ACO rewarding model may disproportionately affect relatively low-spending (LS; considered as efficient) organizations that have fewer options to cut unnecessary services compared with high-spending (HS; inefficient) organizations. We conducted a cross-sectional retrospective study to compare ACO financial and quality of care performance between HS-ACO and LS-ACO. After adjusting for ACO organizational factors and beneficiary characteristics, we found that HS-ACOs generated greater savings per beneficiary than LS-ACOs ($501 vs. -$108, p < .001); however, HS-ACOs had a lower quality of care performance (48.79 vs. 53.29, p = .002). Specifically, LS-ACOs had better quality performance than HS-ACOs in patient experience/satisfaction (p = .02), preventive care services (p = .004), and hospitalization management (p = .001), whereas HS-ACOs better performed in routine checkup/follow-up (p < .001) and risk population management (p = .048). Our findings indicated that Medicare ACO rewarding model seems to be advantageous for HS-ACOs regardless of the overall quality of care performance.

Healthcare Costs and Medication Adherence Among Patients with Fibromyalgia: Combination Medication vs. Duloxetine, Milnacipran, Venlafaxine, and Pregabalin Initiators.

OBJECTIVE: To examine medication adherence and healthcare costs for combination prescription initiators (duloxetine/milnacipran/venlafaxine with pregabalin) vs. monotherapy initiators (duloxetine, milnacipran, venlafaxine, and pregabalin) among patients with fibromyalgia syndrome (FMS). METHODS: Our retrospective cohort study used claims data for the South Carolina Blue Cross Blue Shield State Health Plan (SHP). Patients with FMS ≥ 18 years of age, with prescription initiation from July 1, 2007, through June 30, 2010, and SHP enrollment for 12 months pre- and post-index periods were included (combination: n = 100; pregabalin: n = 665; duloxetine: n = 713; milnacipran: n = 131; venlafaxine: n = 272). Medication adherence measures included high adherence (medication possession ratio ≥ 80%) and total supply days. Healthcare costs comprised direct medical expenditures. Propensity score methods of inverse probability of treatment weights were used to control for selection bias due to differing pre-index characteristics. RESULTS: Odds ratios for high adherence were significantly increased (P < 0.05) among the combination cohort vs. the venlafaxine (2.15), duloxetine (1.39), and pregabalin (2.20) cohorts. Rate ratios for total supply days were significantly higher (P < 0.05) for combination vs. venlafaxine (1.23), duloxetine (1.08), and pregabalin (1.32) cohorts. Expenditures for total health care were significantly higher (P < 0.05) for combination vs. duloxetine ($26,291 vs. $17,190), milnacipran ($33,638 vs. $22,886), and venlafaxine ($26,586 vs. $16,857) cohorts. CONCLUSIONS: Medication adherence was considerably better for combination prescription initiators; however, expenditures for total health care were higher. Still, our findings suggest important clinical benefits with the use of combination prescription therapy, and prospective studies of medication adherence are warranted to examine causal relationships with outcomes not captured by healthcare claims databases.

Association between race/ethnicity and disability status and receipt of vaccines among older adults in Florida.

BACKGROUND: Individuals living with a disability or are a member of a certain racial/ethnic group may be at heightened risk for not receiving important vaccinations. OBJECTIVE: This study examined whether race/ethnicity and disability status are associated with the receipt of two vaccines (influenza and pneumococcal) among older adults living in Florida. METHODS: Using the 2011-2015 Florida Behavioral Risk Factor Surveillance System, a cross-sectional survey, we ran bivariate and multivariate analyses to determine the associations for race/ethnicity and disability status with receipt of vaccinations among individuals 65 years and older. Interactions between race/ethnicity and disability status were tested in each model. RESULTS: Among our study sample, 68% received the pneumococcal vaccine in their lifetime and 54% of them received influenza vaccine in the past 12 months. Multivariate logistic regression indicated that Non-Hispanic Blacks and Hispanics were less likely to receive both vaccines compared to Non-Hispanic Whites. Older adults with a disability were more likely to receive influenza and pneumococcal vaccines compared to those without. A significant interaction was observed between race/ethnicity and disability status for predicting pneumococcal vaccination receipt. CONCLUSIONS: Large proportions of older adults in Florida continue to go without needed vaccinations. Although race/ethnicity and disability status were shown to have some association with receipt of vaccines, having a regular source of care, employment and income also were shown to be important predictors.