Geographic Variation of Inappropriate Prescription Opioid Use in - - PowerPoint PPT Presentation

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Geographic Variation of Inappropriate Prescription Opioid Use in Medicare W. Jenny Lo-Ciganic, MSPharm, MS, PhD University of Arizona, College of Pharmacy June 24, 2017 1 Research Team University of Arizona Drs. Jenny Lo-Ciganic, Kent

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Geographic Variation of Inappropriate Prescription Opioid Use in Medicare

  • W. Jenny Lo-Ciganic, MSPharm, MS, PhD

University of Arizona, College of Pharmacy

June 24, 2017

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Research Team

  • University of Arizona
  • Drs. Jenny Lo-Ciganic, Kent Kwoh, Daniel Malone, Sandipan Bhattacharjee, Jeannie

Lee, Melanie Bell, Ms. Lili Zhou and Mr. Westra Jordan

  • University of Pittsburgh
  • Drs. Walid Gellad & Julie Donohue
  • University of Wisconsin
  • Dr. Anne Roubal
  • Pharmacy Quality Alliance
  • Dr. Lisa Hines
  • ESRI Inc.
  • Mr. Jeremiah Lindemann

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Funding & Disclosure

  • Dr. Lo-Ciganic is supported by a University of Arizona Health

Sciences Career Development Award

  • Dr. Gellad is supported in part by VA HSR&D Merit Award I01

HX001765-01

  • Dr. Kwoh has received grant funding from Abbvie and EMD

Serono

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Overdose Deaths Involving Opioids, US 2000-2015

4

Deaths Per 100,000 population

Any Opioid

Commonly prescribed

  • pioids (natural & semi-

synthetic opioids and methadone)

Heroin Other synthetic

  • pioids (fentanyl,

tramadol)

Source: CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department

  • f Health and Human Services, CDC; 2016. https://wonder.cdc.gov/.
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Chronic Pain and Opioid Use in Medicare

  • Chronic pain conditions: 60%
  • Having ≥1 opioid prescription among

Part D enrollees: 35%

  • Having polypharmacy with

benzodiazepines: 25%

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Gaps in Research and Science

  • Current evidence focuses on opioid utilization
  • Medicaid fee-for-service
  • Medicare disabled enrollees
  • Medicare Part D opioid drug mapping tool
  • Little is known about geographic variations of

potentially inappropriate prescription opioid use

  • 1. Morden NE et al. Med Care 2014;52:852-859; 2. Zerzan JT et al. Med Care 2006;44:1005-1010
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Objective

To examine geographic variation of potentially inappropriate prescription opioid use among non-cancer Medicare beneficiaries

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Methods

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Study Design, Data Source, & Cohort

  • Cross-sectional study
  • 5% random sample of Medicare beneficiaries from 2011-2013
  • Exclusion criteria:
  • Not continuously enrolled in Part A, B, and D for 12 months
  • Medicare Advantage enrollees
  • Non-US residents
  • End-stage renal disease (ESRD) patients
  • Patients in hospice or with cancer
  • Had <2 opioid prescription fill
  • Had 2 prescription opioid fills but on the same day
  • Had <15 cumulative days of supplied opioids
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Sample Size Flow Chart in 2013

Total beneficiaries (5% sample; N= 2,972,192)

Of these, non-hospice and non-cancer patients were continuously enrolled and had complete health claims history (n= 1,394,393)

Excluded those who were (1) in Medicare Advantage program and not continuously enrolled in Part A, B, and D for 12 months (n=1,184,530), (2) non-US residents (n=27,343), (3) hospice patients (n=17,919), (4) ESRD patients (n=9,816); (5) cancers (except non-melanoma; n=338,191)

Of these, patients had ≥2 opioid filled on ≥2 separate days, and ≥15 cumulative days of supply (n= 292,641)

Excluded patients who had (1) no opioid prescriptions (n=902,952), (2) only 1 opioid fill (n=159,584), (3) only filled 2 opioid prescriptions on the same day (n=1,337), and (4) only had days supplied of opioids <15 cumulative days in 2013 (n=37,879).

Of these, disabled beneficiaries (n=135,252; 46.2%) Of these, non-disabled beneficiaries (n=157,389; 53.8%)

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Main Independent Variable

  • Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR)
  • 3,436 health service areas were assigned to 306 HRR regions

where the greatest proportion of major procedures were performed

  • Each HRR has at least one city where major cardiovascular

surgery and neurosurgery are performed

  • 1. http://www.dartmouthatlas.org/data/region/; 2. Donohue JM et al. N Eng J Med 2012;366: 530-538
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Primary Outcomes of Interest:

Pharmacy Quality Alliance (PQA) Measures

  • Among disabled Medicare opioid users (≥ 2 prescriptions with total

days supply ≥15 days) by HRR each year, % of beneficiaries with

  • High-dose: daily dosage >120 morphine milligram equivalent

(MME) for ≥90 consecutive days

  • Multiple providers: opioid prescriptions from ≥4 prescribers

and ≥4 pharmacies

  • Concurrent benzodiazepine use for ≥30 cumulative days
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Covariates

Sociodemographics

  • Age
  • Sex
  • Race/ethnicity
  • Low-income

subsidy status

  • Dual Medicaid

eligibility Health status factors

  • Prescription

Hierarchical Clinical Conditions (RxHCC)

  • Musculoskeletal

disorders

  • Depression
  • Other serious

mental illness Regional/access-to- care factors

  • Rural vs urban

geographic location

  • No. hospitals with

pain management programs

  • No. hospitals with

physical therapy programs

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Statistical Analyses

  • Multivariable logistic regression at the individual level
  • Categorical regional HRR indicator
  • Adjust for sociodemographics, health status, regional/access-to-care covariates
  • Using marginal effect models to obtain the predicted probabilities of

inappropriate prescription opioid use measures in each HRR

  • SAS 9.4, Stata 14.0, ArcGIS 10.4.1
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Results

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Potentially Inappropriate Prescription Opioid Use in Disabled Medicare, 2011-2013

8.9 8.8 8.6

5.1 5.2 4.6 32.9 5 10 15 20 25 30 35 2011 (N=114,696) 2012 (N=124,929) 2013 (N=135,252) % of disabled beneficiaries having inappropriate opioid use

Calendar Year (Number of Disabled Beneficiaries)

High-dose Multiple providers Concurrent benzodiazepine use*

*Centers for Medicare & Medicaid Services (CMS) began coverage for benzodiazepines in 2013

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Potentially Inappropriate Prescription Opioid Use in Non-disabled Medicare, 2011-2013

1.28 1.27 1.25

0.76 0.77 0.81

16.98 2 4 6 8 10 12 14 16 18 2011 (N=132,654) 2012 (N=141,632) 2013 (N=157,389) % of disabled beneficiaries having inappropriate opioid use

Calendar Year (Number of Disabled Beneficiaries)

High-dose Multiple providers Concurrent benzodiazepine use*

*Centers for Medicare & Medicaid Services (CMS) began coverage for benzodiazepines in 2013

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Selected Characteristics, Disabled Beneficiaries, 2013

All cohort High dose Multiple providers Concurrent benzodiazepine N 135,252 11,691 6,149 44,458 Age ≥65, % 28.9 12.2 9.6 23.3 Female, % 59.2 50.6 61.2 64.8 Race/ethnicity, % White 75.0 85.8 68.8 83.6 Black 19.1 9.9 25.8 12.0 Hispanic/others 5.9 3.3 5.5 4.4 Low-income subsidy, % 66.8 70.4 83.8 70.0 Dual eligibility, % 57.6 57.0 75.6 60.3 Musculoskeletal disorders, % 61.3 68.1 73.8 65.4 Depression, % 26.4 29.5 41.8 36.6 Other mental illness, % 9.0 7.9 19.4 13.8

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2012

High-dose, 2011-2013

2011 2013

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High dose, Top 10 HRRs

2011 Adjusted rates, % Sarasota, FL 22.6 Pueblo, CO 18.9 Fort Lauderdale, FL 18.9 Ridgewood, NJ 16.9 Hudson, FL 16.9 Clearwater, FL 16.8 New Brunswick, NJ 16.3 Morristown, NJ 16.3 Salisbury, MD 16.1 Paterson, NJ 15.6 2012 Adjusted rates, % Sarasota, FL 21.0 Ridgewood, NJ 18.2 Pueblo, CO 16.9 Sun City, AZ 16.8 Fort Lauderdale, FL 16.8 Hudson, FL 15.9 New Brunswick, NJ 15.7 Salisbury, MD 14.8 Clearwater, FL 14.5 Medford, OR 14.5 2013 Adjusted rates, % Sun City, AZ 16.6 Sarasota, FL 16.2 Lawton, OK 15.5 Pueblo, CO 15.5 New Brunswick, NJ 14.8 Clearwater, FL 14.5 Napa, CA 14.3 Fort Lauderdale, FL 14.0 Mesa, AZ 13.7 Knoxville, TN 13.6

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Multiple Providers, 2011-2013

2011 2012

2013

2013

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Multiple Providers, Top 10 HRRs

2011 Adjusted rates, % Arlington, VA 10.7 Lake Charles, LA 9.6 Takoma Park, MD 8.6 Chattanooga, TN 8.2 Metairie, LA 8.2 Sun City, AZ 7.9 Dubuque, IA 7.1 Temple, TX 6.9 Fort Myers, FL 6.8 Honolulu, HI 6.5 2012 Adjusted rates, % Minot, ND 10.8 Sun City, AZ 9.7 Provo, UT 9.0 Paterson, NJ 8.9 Arlington, VA 8.3 Washington, DC 7.4 Norfolk, VA 7.3 Fort Wayne, IN 7.0 Honolulu, HI 7.0 Newport News, VA 6.9 2013 Adjusted rates, % Arlington, VA 11.2

  • St. Cloud, MN

7.7 Pueblo, CO 7.3 Anchorage, AK 7.2

  • St. Paul, MN

6.9 Phoenix, AZ 6.8 Provo, UT 6.8 Lake Charles, LA 6.4 San Jose, CA 6.3 Jacksonville, FL 6.1

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Concurrent Benzodiazepine Use, 2013

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Concurrent Benzodiazepine Use, Top 10 HRRs

2013 Adjusted rates, % Slidell, LA 49.8 Miami, FL 49.5 Clearwater, FL 47.3 Detroit, MI 46.1 Paterson, NJ 46.0 Panama City, FL 45.5 Dearborn, MI 44.8 Hudson, FL 44.6 Lake Charles, LA 44.0 Spartanburg, SC 43.7

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Discussion

  • Substantial HRR-level variation exists
  • Concurrent opioid and benzodiazepine use was common
  • Implications: Potential target interventions
  • Verification of appropriate diagnoses and treatment monitoring
  • Consultation with mental health or pain specialists
  • Prior authorization of long-term use
  • Pharmacy lock-in program
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Limitations

  • Lack of socio-behavioral and other information (e.g.,

reason for use)

  • Uncertainty if the medications were actually taken by the

patients

  • Substance use disorders claims were redacted by CMS
  • Limited generalizability to other populations
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Thank you for your attention!

Jenny Lo-Ciganic MSPharm, MS, PhD, lociganic@pharmacy.arizona.edu

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High dose of >120mg daily MME ≥90 consecutive days

2013 Disabled OR (95%CI) P value Age 0.97 (0.97, 0.97) <0.0001 Male (ref=female) 1.38 (1.33, 1.44) <0.0001 Race (ref=white) Black 0.42 (0.39, 0.45) <0.0001 Hispanic 0.43 (0.38, 0.50) <0.0001 Others 0.61 (0.54, 0.69) <0.0001 Metropolitan residents 1.17 (1.10, 1.23) <0.0001 Low income subsidy 1.43 (1.34, 1.53) <0.0001 Dual eligibility 0.65 (0.61, 0.69) <0.0001 RxHCC index 0.96 (0.92, 1.00) 0.05 Musculoskeletal disorders 1.50 (1.43, 1.58) <0.0001 Depression 1.05 (1.00, 1.11) 0.06 Other mental illness 0.63 (0.59, 0.68) <0.0001 # Hospitals with physical therapy 0.98 (0.97, 1.00) 0.01 # Hospitals with pain management programs 0.96 (0.92, 1.00) 0.02

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Sensitivity analysis results on using different thresholds for high-dose

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2012

High-dose >120mg MME for cumulative 90 days (disabled)

2011 2013

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2012

High-dose >90mg MME for consecutive 90 days (disabled)

2011 2013

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2012

High-dose >90mg MME for cumulative 90 days (disabled)

2011 2013

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Maps and Hot-Spot Analysis: Non-disabled beneficiaries

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2011

High-dose, 2011-2013 (non-disabled)

2012 2013

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Non-disabled: High dose, Top 12 HRRs

2011 Adjusted rates Anchorage, AK 4.4% Wichita Falls, TX 4.3% Redding, CA 3.7% Medford, OR 3.6% Chico, CA 3.5% Wilmington, DE 3.4% Youngstown, OH 3.2% Kalamazoo, MI 3.0% Madison, WI 2.9% Missoula, MT 2.7% Tampa, FL 2.6% Lebanon, NH 2.6% 2012 Adjusted rates Traverse City, MI 3.9% Redding, CA 3.8% Johnstown, PA 3.7% Boulder, CO 3.5% Anchorage, AK 3.5% Napa, CA 3.5% Great Falls, MT 3.3% Kalamazoo, MI 3.3% Chico, CA 3.1% Youngstown, OH 2.9% Salisbury, MD 2.9% Wilkes-Barre, PA 2.7% 2013 Adjusted rates Great Falls, MT 4.5% Boulder, CO 4.1% Johnstown, PA 3.3% Medford, OR 3.1% Provo, UT 2.8% Bismarck, ND 2.7% Gulfport, MS 2.7% Las Vegas, NV 2.4% Hudson, FL 2.4% La Crosse, WI 2.4% San Francisco, CA 2.4% Kalamazoo, MI 2.3%

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2012 2011

Multiple Providers, 2011-2013 (non-disabled)

2013

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Non-disabled: Multiple Providers, Top 12 HRRs

2011 Adjusted rates San Mateo County, CA 2.4% Great Falls, MT 2.2% Salem, OR 2.1% Alameda County, CA 2.0% Lafayette, IN 2.0% Panama City, FL 2.0% Contra Costa County, CA 2.0% Kalamazoo, MI 2.0% Detroit, MI 1.8% Colorado Springs, CO 1.8% Greeley, CO 1.8% Waterloo, IA 1.7% 2012 Adjusted rates Bradenton, FL 3.0% Muncie, IN 2.8% Petoskey, MI 2.7% Gulfport, MS 2.6% Idaho Falls, ID 2.5% Metairie, LA 2.5% Arlington, VA 2.4% Contra Costa County, CA 2.1% Marshfield, WI 1.9% York, PA 1.8% Greeley, CO 1.8% Davenport, IA 1.8% 2013 Adjusted rates Pueblo, CO 3.7% Anchorage, AK 2.3% Colorado Springs, CO 2.0% Muncie, IN 2.0% San Jose, CA 2.0% Victoria, TX 2.0% Dearborn, MI 1.8% Gulfport, MS 1.8% Ann Arbor, MI 1.7% San Mateo County, CA 1.7% Marshfield, WI 1.7% Traverse City, MI 1.7%

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High-Dose AND Multiple Providers, 2011-2013 (non-disabled)

2011 2012 2013

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Non-disabled: High-Dose AND Multiple Providers, Top 12 HRRs

2011 Adjusted rates Elmira, NY 0.50% Panama City, FL 0.36% Ventura, CA 0.29% Salisbury, MD 0.28% Huntington, WV 0.24% Worcester, MA 0.22% Fort Myers, FL 0.22% White Plains, NY 0.22% Joliet, IL 0.21% Boise, ID 0.18% Kalamazoo, MI 0.17% Detroit, MI 0.16% 2012 Adjusted rates Olympia, WA 0.49% Columbus, GA 0.36% Roanoke, VA 0.36% Salisbury, MD 0.32% Wilmington, DE 0.31% Morgantown, WV 0.29% Everett, WA 0.28% Colorado Springs, CO 0.28% Redding, CA 0.28% Charlottesville, VA 0.26% Worcester, MA 0.25% New Haven, CT 0.25% 2013 Adjusted rates Muncie, IN 0.88% Victoria, TX 0.76% Boulder, CO 0.62% Gulfport, MS 0.62% Burlington, VT 0.37% Morgantown, WV 0.36% Newport News, VA 0.31% Akron, OH 0.30% Davenport, IA 0.28% Spartanburg, SC 0.25% Tucson, AZ 0.22% Medford, OR 0.21%

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Concurrent Benzodiazepine Use, 2013 (non-disabled)

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Non-disabled: Concurrent Benzodiazepine Use, Top 12 HRRs

2013 Adjusted rates Miami, FL 32.6% Spartanburg, SC 31.8% Johnson City, TN 30.5% Alexandria, LA 28.1% Jonesboro, AR 26.6% Charleston, WV 25.3% Montgomery, AL 25.3% Kingsport, TN 24.7% Jackson, TN 24.7% Greenville, SC 24.2% Morgantown, WV 24.1% Hickory, NC 23.9%

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Compare with other maps

http://urbanobservatory.maps.arcgis.com/apps/Casc ade/index.html?appid=f86499d99e4340b68229eacc fb02b29f&utm_source=homepage&utm_medium= website&utm_term=esri&utm_content=block&utm_ campaign=gis_in_health Opioid Prescription Claims in Part D, 2013 Drug Poisoning Deaths, 2013

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https://www.cdc.gov/drugoverdose/data/prescribing.html

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Trust for America's Health - The Facts Hurt: A State by State Injury Prevention Policy Report 2015; http://healthyamericans.org/assets/files/TFAH-2015-InjuryRpt-FINAL.pdf