Individuals Eligible for Lung Cancer Screening Less Likely to Receive Screening When Enrolled in Health Plans With Deductibles.

BACKGROUND: In 2015, the Centers for Medicare & Medicaid Services and commercial insurance plans began covering lung cancer screening (LCS) without patient cost-sharing for all plans. We explore the impact of enrolling into a deductible plan on the utilization of LCS services despite having no out-of-pocket cost requirement. METHODS: This retrospective study analyzed data from the Population-based Research to Optimize the Screening Process Lung Consortium. Our cohort included non-Medicare LCS-eligible individuals enrolled in managed care organizations between February 5, 2015, and February 28, 2019. We estimate a series of sequential logistic regression models examining utilization across the sequence of events required for baseline LCS. We report the marginal effects of enrollment into deductible plans compared with enrollment in no-deductible plans. RESULTS: The total effect of deductible plan enrollment was a 1.8 percentage-point (PP) decrease in baseline LCS. Sequential logistic regression results that explore each transition separately indicate deductible plan enrollment was associated with a 4.3 PP decrease in receipt of clinician visit, a 1.7 PP decrease in receipt of LCS order, and a 7.0 PP decrease in receipt of baseline LCS. Reductions persisted across all observable races and ethnicities. CONCLUSIONS: These findings suggest individuals enrolled in deductible plans are more likely to forgo preventive LCS services despite requiring no out-of-pocket costs. This result may indicate that increased cost-sharing is associated with suboptimal choices to forgo recommended LCS. Alternatively, this effect may indicate individuals enrolling into deductible plans prefer less health care utilization. Patient outreach interventions at the health plan level may improve LCS.

Monitoring vaccine safety using the vaccine safety Datalink: Assessing capacity to integrate data from Immunization Information systems.

BACKGROUND: The Vaccine Safety Datalink (VSD) uses vaccination data from electronic health records (EHR) at eight integrated health systems to monitor vaccine safety. Accurate capture of data from vaccines administered outside of the health system is critical for vaccine safety research, especially for COVID-19 vaccines, where many are administered in non-traditional settings. However, timely access and inclusion of data from Immunization Information Systems (IIS) into VSD safety assessments is not well understood. METHODS: We surveyed the eight data-contributing VSD sites to assess: 1) status of sending data to IIS; 2) status of receiving data from IIS; and 3) integration of IIS data into the site EHR. Sites reported separately for COVID-19 vaccination to capture any differences in capacity to receive and integrate data on COVID-19 vaccines versus other vaccines. RESULTS: All VSD sites send data to and receive data from their state IIS. All eight sites (100%) routinely integrate IIS data for COVID-19 vaccines into VSD research studies. Six sites (75%) also routinely integrate all other vaccination data; two sites integrate data from IIS following a reconciliation process, which can result in delays to integration into VSD datasets. CONCLUSIONS: COVID-19 vaccines are being administered in a variety of non-traditional settings, where IIS are commonly used as centralized reporting systems. All eight VSD sites receive and integrate COVID-19 vaccine data from IIS, which positions the VSD well for conducting quality assessments of vaccine safety. Efforts to improve the timely receipt of all vaccination data will improve capacity to conduct vaccine safety assessments within the VSD.

Development and validation of a prediction model for opioid use disorder among youth.

BACKGROUND: Youth are vulnerable to opioid use initiation and its complications. With growing rates of opioid overdose, strategies to identify youth at risk of opioid use disorder (OUD) to efficiently focus prevention interventions are needed. This study developed and validated a prediction model of OUD in youth aged 14-18 years. METHODS: The model was developed in a Colorado healthcare system (derivation site) using Cox proportional hazards regression analysis. Model predictors and outcomes were identified using electronic health record data. The model was externally validated in a separate Denver safety net health system (validation site). Youth were followed for up to 3.5 years. We evaluated internal and external validity using discrimination and calibration. RESULTS: The derivation cohort included 76,603 youth, of whom 108 developed an OUD diagnosis. The model contained 3 predictors (smoking status, mental health diagnosis, and non-opioid substance use or disorder) and demonstrated good calibration (p = 0.90) and discrimination (bootstrap-corrected C-statistic = 0.76: 95 % CI = 0.70, 0.82). Sensitivity and specificity were 57 % and 84 % respectively with a positive predictive value (PPV) of 0.49 %. The validation cohort included 45,790 youth of whom, 74 developed an OUD diagnoses. The model demonstrated poorer calibration (p < 0.001) but good discrimination (C-statistic = 0.89; 95 % CI = 0.84, 0.95), sensitivity of 87.8 % specificity of 68.6 %, and PPV of 0.45 %. CONCLUSIONS: In two Colorado healthcare systems, the prediction model identified 57-88 % of subsequent OUD diagnoses in youth. However, PPV < 1% suggests universal prevention strategies for opioid use in youth may be the best health system approach.

Integration of data from a safety net health care system into the Vaccine Safety Datalink.

BACKGROUND: In 2013 the Institute of Medicine suggested that the Vaccine Safety DataLink (VSD) should broaden its population by including data of more patients from low income and racially and ethnically diverse backgrounds. In response, Kaiser Permanente Colorado (KPCO) partnered with Denver Health (DH), an integrated safety net health care system, to explore the integration of DH data. METHODS: We compared three different methods (reference date of September 1, 2013): "Empanelment" (any patient who has had a primary care visit in the past 18months), "Proxy-enrollment" (two health care visits in 3years separated by 90days), and "Enrollment" in a managed care plan. For each of these methods, we compared cohort size, vaccination rates, socio-demographic characteristics, and health care utilization. RESULTS: The empaneled population at DH provided the best comparison to KPCO. DH's empaneled population was 111,330 (57,173 adults; 54,157 children), while KPCO had 436,290 empaneled patients (336,462 adults; 99,828 children). Vaccination rates in both health care systems for empaneled patients were comparable. Two year-old up-to-date coverage rates were 83.2% (KPCO) and 86.9% (DH); rates for adolescent Tdap and MCV4 were 85.5% (KPCO) and 90.6% (DH). There were significant differences in the two populations in age, gender, race, preferred language, and % Federal Poverty Level (FPL) (DH 70.7%<100% FPL; KPCO 17.4%), as well as in healthcare utilization - for example pediatric emergency department utilization was twice as high at DH. CONCLUSIONS: Using a cohort of "empaneled" patients, it is possible to integrate data from a safety net health care system that does not have a uniform managed care population into the VSD, and to compare vaccination rates, socio-demographic characteristics, and health care utilization across the two systems. The KPCO-DH collaboration may serve as a model for incorporating data from a safety net healthcare system into the VSD.

Vaccine adverse events in a safety net healthcare system and a managed care organization.

BACKGROUND: The Institute of Medicine, in a 2013 report, recommended that the Vaccine Safety Datalink (VSD) expand collaborations to include more diversity in the study population. Kaiser Permanente Colorado (KPCO), an established VSD site, partnered with Denver Health (DH), an integrated safety net healthcare system, to demonstrate the feasibility of integrating DH data within the VSD. Prior to incorporating the data, we examined the identification of specific vaccine associated adverse events (VAEs) in these two distinct healthcare systems. METHODS: We conducted retrospective cohort analyses within KPCO and DH to compare select VAEs between the two populations. We examined the following associations between January 1, 2004 and December 31, 2013: Measles, Mumps, and Rubella (MMR) vaccine and febrile seizures in children 2years and younger, intussusception after rotavirus vaccine in infants 4-34weeks, syncope after adolescent vaccines (Tetanus, Diphtheria, acellular Pertussis; Meningococcal and Human Papillomavirus) in adolescents 13-17years and medically attended local reactions after pneumococcal polysaccharide (PPSV23) vaccine in adults 65years and older. Both sites used similar data procurement methods and chart review processes. RESULTS: For seizures after MMR vaccine (KPCO - 3.15vs. DH - 2.97/10,000 doses) and syncope after all adolescent vaccines (KPCO - 3.0vs. DH - 2.37/10,000 doses), the chart confirmed rates were comparable at the two sites. However, for medically attended local reactions after PPSV23, there were differences in chart confirmed rates between the sites (KPCO - 31.65vs. DH - 14.90/10,000 doses). For intussusception after rotavirus vaccine, the number of cases was too low to make a valid comparison (KPCO - 0vs. DH - 0.13/10,000 doses). CONCLUSION: We demonstrated that data on important targeted VAEs can be captured at DH and rates appear similar to those at KPCO. Work is ongoing on the optimal approach to assimilate DH data as a potential safety net healthcare system in the VSD.

Screening for and Diagnosis of Depression Among Adolescents in a Large Health Maintenance Organization.

OBJECTIVE: The aim of this analysis was to determine changes in patterns of depression screening and diagnosis over three years in primary and specialty mental health care in a large health maintenance organization (HMO) as part of a project to develop quality measures for adolescent depression treatment. METHODS: Two series of aggregate data (2010-2012) were gathered from the electronic health records of the HMO for 44,342 unique adolescents (ages 12 to 21) who had visits in primary and mental health care. Chi square tests assessed the significance of changes in frequency and departmental location of Patient Health Questionnaire-9 (PHQ-9) administration, incidence of depression symptoms, and depression diagnoses. RESULTS: There was a significant increase in PHQ-9 use, predominantly in primary care, consistent with internally generated organizational recommendations to increase screening with the PHQ-9. The increase in PHQ-9 use led to an increase in depression diagnoses in primary care and a shift in the location of some diagnoses from specialty mental health care to primary care. The increase in PHQ-9 use was also linked to a decrease in the proportion of positive PHQ-9 results that led to formal depression diagnoses. CONCLUSIONS: The rate of depression screening in primary care increased over the study period. This increase corresponded to an increase in the number of depression diagnoses made in primary care and a shift in the location in which depression diagnoses were made, from the mental health department to primary care. The frequency of positive PHQ-9 administrations not associated with depression diagnoses also increased.