Publications by authors named "Michael L Barnett"

106 Publications

Diabetes Care and Glycemic Control During the COVID-19 Pandemic in the United States.

JAMA Intern Med 2021 Jul 6. Epub 2021 Jul 6.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2021.3047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261690PMC
July 2021

Clinical Knowledge and Trends in Physicians' Prescribing of Opioids for New Onset Back Pain, 2009-2017.

JAMA Netw Open 2021 Jul 1;4(7):e2115328. Epub 2021 Jul 1.

Harvard School of Public Health, Boston, Massachusetts.

Importance: Opioid musculoskeletal pain overprescribing was widespread in the mid-2000s. The degree to which prescribing changed as awareness of the danger grew among physicians with different levels of clinical knowledge remains unstudied.

Objective: To compare the association of clinical knowledge with opioid prescribing from 2009 to 2011 when prescribing peaked nationally with 2015 to 2017 when guidelines shifted away from opioid prescribing.

Design, Setting, And Participants: This cross-sectional study included 10 246 midcareer general internal medicine physicians in the United States who saw patients who were Medicare beneficiaries with Part D enrollment from 2009 to 2017.

Main Outcomes And Measures: Any opioid prescription and high dosage or long duration (HDLD) (>7 days or >50 daily morphine milligram equivalents) opioid prescriptions filled within 7 days of applicable visits for new low back pain concerns. Associations between opioid prescribing for new low back pain concerns during outpatient visits and clinical knowledge measured by prior year American Board of Internal Medicine (ABIM) Maintenance of Certification examination performance were estimated using serial cross-sectional logit regressions. Regression covariates included yearly examination quartile (ie, knowledge quartile) interacted with 3-year group dummies (ie, early: 2009-2011; middle: 2012-2014; late: 2015-2017), state and year dummies, physician, practice, patient characteristics, and state opioid regulations.

Results: Of the 55 387 low back pain visits included in this study, 37 185 (67.1%) were visits with female patients, 41 978 (75.8%) were with White patients, and the mean (SE) age of patients was 76.2 (<0.01) years. The rate of opioid prescribing was 21.6% (11 978) for any opioid prescription and 17.6% (9759) for HDLD prescriptions. From 2009 to 2011, visits with physicians in the highest and lowest knowledge quartiles had similar adjusted opioid prescribing rates with a 0.5 (95% CI, -1.9 to 3.0) percentage point difference. By 2015 to 2017, visits with physicians in the highest knowledge quartile prescribed opioids less frequently that physicians in the lowest knowledge quartile (4.6 percentage point difference; 95% CI, -7.5 to -1.8 percentage points). Visits in which HDLD opioids were prescribed showed no difference in the early period but showed a difference in the late period when comparing physicians in the highest and lowest knowledge quartiles (early period: difference -0.1; 95% CI, -2.4 to 2.2 percentage points; late period difference: 4.8; 95% CI, -7.4 to -2.1 percentage points).

Conclusions And Relevance: In this cross-sectional study, when the standard of care shifted away from routine opioid prescribing, physicians who performed well on an ABIM examination were less likely to prescribe opioids for back pain than physicians who performed less well on the examination.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.15328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251502PMC
July 2021

Adverse Events And Emergency Department Opioid Prescriptions In Adolescents.

Health Aff (Millwood) 2021 06;40(6):970-978

Michael L. Barnett is an assistant professor in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an assistant professor of medicine at Harvard Medical School.

Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data. Using a regression discontinuity design, we exploited a discontinuous increase in opioid prescribing in the emergency department (ED) when adolescents transition from "child" to "adult" at age eighteen to estimate the effect of an ED opioid prescription on subsequent opioid-related adverse events. We found that adolescent patients just over age eighteen were similar to those just under age eighteen, but they were 9.7 percent more likely to be prescribed an opioid and 12.6 percent more likely to have an adverse opioid-related event, defined as overdose, diagnosis of opioid use disorder, or long-term opioid use, within one year. We estimated a 14.1 percent increased risk for an adverse outcome when "adults" just over age eighteen were prescribed opioids that would not have been prescribed if they were just under age eighteen and considered "children." Our results suggest that differences in care provided in pediatric versus adult care settings may be important to understanding prescribers' roles in the opioid epidemic.
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http://dx.doi.org/10.1377/hlthaff.2020.01762DOI Listing
June 2021

Coprescription of Opioids With Other Medications and Risk of Opioid Overdose.

Clin Pharmacol Ther 2021 May 28. Epub 2021 May 28.

Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Polypharmacy is common among patients taking prescription opioids long-term, and the codispensing of interacting medications may further increase opioid overdose risk. To identify nonopioid medications that may increase opioid overdose risk in this population, we conducted a case-crossover-based screening of electronic claims data from IBM MarketScan and Optum Clinformatics Data Mart spanning 2003 through 2019. Eligible patients were 18 years of age or older and had at least 180 days of continuous enrollment and 90 days of prescription opioid use immediately before an opioid overdose resulting in an emergency room visit or hospitalization. The main analysis quantified the odds ratio (OR) between opioid overdose and each nonopioid medication dispensed in the 90 days immediately before the opioid overdose date after adjustment for prescription opioid dosage and benzodiazepine codispensing. Additional analyses restricted to patients without cancer diagnoses and individuals who used only oxycodone for 90 days immediately before the opioid overdose date. The false discovery rate (FDR) was used to account for multiple testing. We identified 24,866 individuals who experienced opioid overdose. Baclofen (OR 1.56; FDR < 0.01; 95% confidence interval (CI), 1.29 to 1.89), lorazepam (OR 1.53; FDR < 0.01; 95% CI, 1.25 to 1.88), and gabapentin (OR 1.16; FDR = 0.09; 95% CI, 1.04 to 1.28), among other nonopioid medications, were associated with opioid overdose. Similar patterns were observed in noncancer patients and individuals who used only oxycodone. Interventions may focus on prescribing safer alternatives when a potential for interaction exists.
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http://dx.doi.org/10.1002/cpt.2314DOI Listing
May 2021

Coprescription of Opioids With Other Medications and Risk of Opioid Overdose.

Clin Pharmacol Ther 2021 May 28. Epub 2021 May 28.

Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Polypharmacy is common among patients taking prescription opioids long-term, and the codispensing of interacting medications may further increase opioid overdose risk. To identify nonopioid medications that may increase opioid overdose risk in this population, we conducted a case-crossover-based screening of electronic claims data from IBM MarketScan and Optum Clinformatics Data Mart spanning 2003 through 2019. Eligible patients were 18 years of age or older and had at least 180 days of continuous enrollment and 90 days of prescription opioid use immediately before an opioid overdose resulting in an emergency room visit or hospitalization. The main analysis quantified the odds ratio (OR) between opioid overdose and each nonopioid medication dispensed in the 90 days immediately before the opioid overdose date after adjustment for prescription opioid dosage and benzodiazepine codispensing. Additional analyses restricted to patients without cancer diagnoses and individuals who used only oxycodone for 90 days immediately before the opioid overdose date. The false discovery rate (FDR) was used to account for multiple testing. We identified 24,866 individuals who experienced opioid overdose. Baclofen (OR 1.56; FDR < 0.01; 95% confidence interval (CI), 1.29 to 1.89), lorazepam (OR 1.53; FDR < 0.01; 95% CI, 1.25 to 1.88), and gabapentin (OR 1.16; FDR = 0.09; 95% CI, 1.04 to 1.28), among other nonopioid medications, were associated with opioid overdose. Similar patterns were observed in noncancer patients and individuals who used only oxycodone. Interventions may focus on prescribing safer alternatives when a potential for interaction exists.
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http://dx.doi.org/10.1002/cpt.2314DOI Listing
May 2021

Community Factors Associated With Telemedicine Use During the COVID-19 Pandemic.

JAMA Netw Open 2021 05 3;4(5):e2110330. Epub 2021 May 3.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.10330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132134PMC
May 2021

Hospital Responses to Incentives in Episode-Based Payment for Joint Surgery: A Controlled Population-Based Study.

JAMA Intern Med 2021 Jul;181(7):932-940

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Importance: Medicare's Comprehensive Care for Joint Replacement (CJR) model, initiated in 2016, is a national episode-based payment model for lower-extremity joint replacement (LEJR). Metropolitan statistical areas (MSAs) were randomly assigned to participation. In the third year of the program, Medicare made hospital participation voluntary in half of the MSAs and enabled LEJRs for knees to be performed in the outpatient setting without being subject to episode-based payment. How these changes affected program savings is unclear.

Objective: To estimate savings from the CJR program over time and assess how responses by hospitals to changing incentives were associated with those savings.

Design, Participants, And Setting: This controlled population-based study used Medicare claims data from January 1, 2014, to December 31, 2019, to analyze the spending for beneficiaries who received LEJR in 171 MSAs randomized to CJR vs typical payment. One-quarter of beneficiaries before and after the April 1, 2016, start date were excluded as a 6-month washout period (January 1 to June 30, 2016) to allow time in the evaluation period for hospitals to respond to the program rules.

Main Outcomes And Measures: The main outcomes were episode spending and, starting in year 3 of the program, the hospitals' decision to no longer participate in CJR and perform LEJRs in the outpatient setting.

Results: Data from 1 087 177 patients (mean [SD] age, 74.4 [8.4] years; 692 604 women [63.7%]; 980 635 non-Hispanic White patients [90.2%]) were analyzed. Over the first 4 years of CJR, 321 038 LEJR episodes were performed at 702 CJR hospitals, and 456 792 episodes were performed at 826 control hospitals. From the second to the fourth year of the program, savings in CJR vs control MSAs diminished from -$976 per LEJR episode (95% CI, -$1340 to -$612) to -$331 (95% CI, -$792 to $130). In MSAs where hospital participation was made voluntary in the third year, more hospitals in the highest quartile of baseline spending dropped out compared with the lowest quartile (56 of 60 [93.3%] vs 29 of 56 [51.8%]). In MSAs where participation remained mandatory, CJR hospitals shifted fewer knee replacements to the outpatient setting in years 3 to 4 than controls (12 571 of 59 182 [21.2%] vs 21 650 of 68 722 [31.5%] of knee LEJRs). In these mandatory MSAs, 75% of the reduction in savings per episode from years 1 to 2 to years 3 to 4 of the program ($455; 95% CI, $137-$722) was attributable to CJR hospitals' decision on which patients would undergo surgery or whether the surgical procedure would occur in the outpatient setting.

Conclusions And Relevance: This controlled population-based study found that savings observed in the second year of CJR largely dissipated by the fourth year owing to a combination of responses among hospitals to changes in the program. These results suggest a need for caution regarding the design of new alternative payment models.
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http://dx.doi.org/10.1001/jamainternmed.2021.1897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8129900PMC
July 2021

Childhood Respiratory Outpatient Visits Correlate With Socioeconomic Status and Drive Geographic Patterns in Antibiotic Prescribing.

J Infect Dis 2021 Jun;223(12):2029-2037

Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.

Background: Reducing geographic disparities in antibiotic prescribing is a central public health priority to combat antibiotic resistance, but drivers of this variation have been unclear.

Methods: We measured how variation in outpatient visit rates (observed disease) and antibiotic prescribing rates per visit (prescribing practices) contributed to geographic variation in per capita antibiotic prescribing in Massachusetts residents younger than 65 years between 2011 and 2015.

Results: Of the difference in per capita antibiotic prescribing between high- and low-prescribing census tracts in Massachusetts, 45.2% was attributable to variation in outpatient visit rates, while 25.8% was explained by prescribing practices. Outpatient visits for sinusitis, pharyngitis, and suppurative otitis media accounted for 30.3% of the gap in prescribing, with most of the variation in visit rates concentrated in children younger than 10 years. Outpatient visits for these conditions were less frequent in census tracts with high social deprivation index.

Conclusions: Interventions aimed at reducing geographic disparities in antibiotic prescribing should target the drivers of outpatient visits for respiratory illness and should account for possible underutilization of health services in areas with the lowest antibiotic consumption. Our findings challenge the conventional wisdom that prescribing practices are the main driver of geographic disparities in antibiotic use.
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http://dx.doi.org/10.1093/infdis/jiab218DOI Listing
June 2021

Changes in Stress and Workplace Shortages Reported by U.S. Critical Care Physicians Treating Coronavirus Disease 2019 Patients.

Crit Care Med 2021 07;49(7):1068-1082

Harvard Medical School, Boston, MA.

Objectives: Eleven months into the coronavirus disease 2019 pandemic, the country faces accelerating rates of infections, hospitalizations, and deaths. Little is known about the experiences of critical care physicians caring for the sickest coronavirus disease 2019 patients. Our goal is to understand how high stress levels and shortages faced by these physicians during Spring 2020 have evolved.

Design: We surveyed (October 23, 2020 to November 16, 2020) U.S. critical care physicians treating coronavirus disease 2019 patients who participated in a National survey earlier in the pandemic (April 23, 2020 to May 3, 2020) regarding their stress and shortages they faced.

Setting: ICU.

Patients: Coronavirus disease 2019 patients.

Intervention: Irrelevant.

Measurement: Physician emotional distress/physical exhaustion: low (not at all/not much), moderate, or high (a lot/extreme). Shortage indicators: insufficient ICU-trained staff and shortages in medication, equipment, or personal protective equipment requiring protocol changes.

Main Results: Of 2,375 U.S. critical care attending physicians who responded to the initial survey, we received responses from 1,356 (57.1% response rate), 97% of whom (1,278) recently treated coronavirus disease 2019 patients. Two thirds of physicians (67.6% [864]) reported moderate or high levels of emotional distress in the Spring versus 50.7% (763) in the Fall. Reports of staffing shortages persisted with 46.5% of Fall respondents (594) reporting a staff shortage versus 48.3% (617) in the Spring. Meaningful shortages of medication and equipment reported in the Spring were largely alleviated. Although personal protective equipment shortages declined by half, they remained substantial.

Conclusions: Stress, staffing, and, to a lesser degree, personal protective equipment shortages faced by U.S. critical care physicians remain high. Stress levels were higher among women. Considering the persistence of these findings, rising levels of infection nationally raise concerns about the capacity of the U.S. critical care system to meet ongoing and future demands.
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http://dx.doi.org/10.1097/CCM.0000000000004974DOI Listing
July 2021

The hidden costs of moving care home.

Am J Manag Care 2021 03 1;27(3):e64-e65. Epub 2021 Mar 1.

Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 407, Boston, MA 02115. Email:

As home-based care utilization rises, an exploration of potential unintended consequences is necessary. The authors focus on support gaps, informal caregiving, and failure to meaningfully engage clinicians.
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http://dx.doi.org/10.37765/ajmc.2021.88521DOI Listing
March 2021

Persistent challenges of COVID-19 in skilled nursing facilities: The administrator perspective.

J Am Geriatr Soc 2021 04 21;69(4):875-878. Epub 2021 Feb 21.

Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1111/jgs.17062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014766PMC
April 2021

Abrupt Discontinuation of Long-term Opioid Therapy Among Medicare Beneficiaries, 2012-2017.

J Gen Intern Med 2021 06 29;36(6):1576-1583. Epub 2021 Jan 29.

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA.

Background: With mounting pressure to reduce opioid use, concerns exist about abrupt withdrawal of treatment for the millions of Americans using long-term opioid therapy (LTOT). However, little is known about how patients are tapered from LTOT nationally.

Objective: Measure national patterns of LTOT discontinuation and adherence to recommended tapering speed.

Design: Observational study of Medicare Part D from 2012 to 2017.

Participants: Using claims for a 20% sample of Medicare beneficiaries, we included patients on LTOT for 1 year or more, defined as those with ≥ 4 consecutive quarters with > 60 days of opioids supplied in each quarter.

Main Measures: Our primary outcome was discontinuation of LTOT, defined as at least 60 consecutive days without opioids supplied. We additionally examined whether discontinuation of LTOT was "tapered" or "abrupt" by comparing LTOT users' daily MME dose in the last month of therapy to their average daily dose in a baseline period of 7 to 12 months before discontinuation. By the last month of therapy, patients with "abrupt" discontinuation had a < 50% reduction in their average daily dose at baseline.

Key Results: From 2012 to 2017, there were 258,988 LTOT users, 17,617 of whom discontinued therapy. Adjusted rates of LTOT discontinuation increased from 5.7% of users in 2012 to 8.5% in 2017, a 49% relative increase (p < 0.001). There was a similar increase in annual discontinuation rate for LTOT users on lower (26-90 MME, 5.8% to 8.7%, p < 0.001) vs. higher doses (> 90 MME, 5.3% to 7.7%, p < 0.001). The majority of LTOT discontinuations were stopped abruptly, and increased over time (70.1% to 81.2%, 2012-2017, p < 0.001).

Conclusions: Medicare beneficiaries on LTOT were increasingly likely to have their therapy discontinued from 2012 to 2017. The vast majority of discontinuing users, even those on high doses, had less than 50% reduction in dose, which is inconsistent with existing guidelines.
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http://dx.doi.org/10.1007/s11606-020-06402-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175547PMC
June 2021

Changes in Health Care Use and Outcomes After Turnover in Primary Care.

JAMA Intern Med 2021 Feb;181(2):186-194

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: Disruptions of continuity of care may harm patient outcomes, but existing studies of continuity disruption are limited by an inability to separate the association of continuity disruption from that of other physician-related factors.

Objectives: To examine changes in health care use and outcomes among patients whose primary care physician (PCP) exited the workforce and to directly measure the association of this primary care turnover with patients' health care use and outcomes.

Design, Setting, And Participants: This cohort study used nationally representative Medicare billing claims for a random sample of 359 470 Medicare fee-for-service beneficiaries with at least 1 PCP evaluation and management visit from January 1, 2008, to December 31, 2017. Primary care physicians who stopped practicing were identified and matched with PCPs who remained in practice. A difference-in-differences analysis compared health care use and clinical outcomes for patients who did lose PCPs with those who did not lose PCPs using subgroup analyses by practice size. Subgroup analyses were done on visits from January 1, 2008, to December 31, 2017.

Exposure: Patients' loss of a PCP.

Main Outcomes And Measures: Primary care, specialty care, urgent care, emergency department, and inpatient visits, as well as overall spending for patients, were the primary outcomes. Receipt of appropriate preventive care and prescription fills were also examined.

Results: During the study period, 9491 of 90 953 PCPs (10.4%) exited Medicare. We matched 169 870 beneficiaries whose PCP exited (37.2% women; mean [SD] age, 71.4 [6.1] years) with 189 600 beneficiaries whose PCP did not exit (36.9% women; mean [SD] age, 72.0 [5.0] years). The year after PCP exit, beneficiaries whose PCP exited had 18.4% (95% CI, -19.8% to -16.9%) fewer primary care visits and 6.2% (95% CI, 5.4%-7.0%) more specialty care visits compared with beneficiaries who did not lose a PCP. This outcome persisted 2 years after PCP exit. Beneficiaries whose PCP exited also had 17.8% (95% CI, 6.0%-29.7%) more urgent care visits, 3.1% (95% CI, 1.6%-4.6%) more emergency department visits, and greater spending ($189 [95% CI, $30-$347]) per beneficiary-year after PCP exit. These shifts were most pronounced for patients of exiting PCPs in solo practice, whose beneficiaries had 21.5% (95% CI, -23.8% to -19.3%) fewer primary care visits, 8.8% (95% CI, 7.6%-10.0%) more specialty care visits, 4.4% more emergency department visits (95% CI, 2.1%-6.7%), and $260 (95% CI, $12-$509) in increased spending.

Conclusions And Relevance: Loss of a PCP was associated with lower use of primary care and increased use of specialty, urgent, and emergency care among Medicare beneficiaries. Interrupting primary care relationships may negatively impact health outcomes and future engagement with primary care.
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http://dx.doi.org/10.1001/jamainternmed.2020.6288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670398PMC
February 2021

Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US.

JAMA Intern Med 2021 03;181(3):388-391

Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2020.5928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670397PMC
March 2021

Association of Skilled Nursing Facility Participation in a Bundled Payment Model With Institutional Spending for Joint Replacement Surgery.

JAMA 2020 11;324(18):1869-1877

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: Medicare recently concluded a national voluntary payment demonstration, Bundled Payments for Care Improvement (BPCI) model 3, in which skilled nursing facilities (SNFs) assumed accountability for patients' Medicare spending for 90 days from initial SNF admission. There is little evidence on outcomes associated with this novel payment model.

Objective: To evaluate the association of BPCI model 3 with spending, health care utilization, and patient outcomes for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR).

Design, Setting, And Participants: Observational difference-in-difference analysis using Medicare claims from 2013-2017 to evaluate the association of BPCI model 3 with outcomes for 80 648 patients undergoing LEJR. The preintervention period was from January 2013 through September 2013, which was 9 months prior to enrollment of the first BPCI cohort. The postintervention period extended from 3 months post-BPCI enrollment for each SNF through December 2017. BPCI SNFs were matched with control SNFs using propensity score matching on 2013 SNF characteristics.

Exposures: Admission to a BPCI model 3-participating SNF.

Main Outcomes And Measures: The primary outcome was institutional spending, a combination of postacute care and hospital Medicare-allowed payments. Additional outcomes included other categories of spending, changes in case mix, admission volume, home health use, length of stay, and hospital use within 90 days of SNF admission.

Results: There were 448 BPCI SNFs with 18 870 LEJR episodes among 16 837 patients (mean [SD] age, 77.5 [9.4] years; 12 173 [72.3%] women) matched with 1958 control SNFs with 72 005 LEJR episodes among 63 811 patients (mean [SD] age, 77.6 [9.4] years; 46 072 [72.2%] women) in the preintervention and postintervention periods. Seventy-nine percent of matched BPCI SNFs were for-profit facilities, 85% were located in an urban area, and 85% were part of a larger corporate chain. There were no systematic changes in patient case mix or episode volume between BPCI-participating SNFs and controls during the program. Institutional spending decreased from $17 956 to $15 746 in BPCI SNFs and from $17 765 to $16 563 in matched controls, a differential decrease of 5.6% (-$1008 [95% CI, -$1603 to -$414]; P < .001). This decrease was related to a decline in SNF days per beneficiary (from 26.2 to 21.3 days in BPCI SNFs and from 26.3 to 23.4 days in matched controls; differential change, -2.0 days [95% CI, -2.9 to -1.1]). There was no significant change in mortality or 90-day readmissions.

Conclusions And Relevance: Among Medicare patients undergoing lower extremity joint replacement from 2013-2017, the BPCI model 3 was significantly associated with a decrease in mean institutional spending on episodes initiated by admission to SNFs. Further research is needed to assess bundled payments in other clinical contexts.
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http://dx.doi.org/10.1001/jama.2020.19181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656279PMC
November 2020

Classifying Electronic Consults for Triage Status and Question Type.

Proc Conf Assoc Comput Linguist Meet 2020 Jul;2020:1-6

Boston Children's Hospital, Boston, MA.

Electronic consult (eConsult) systems allow specialists more flexibility to respond to referrals more efficiently, thereby increasing access in under-resourced healthcare settings like safety net systems. Understanding the usage patterns of eConsult system is an important part of improving specialist efficiency. In this work, we develop and apply classifiers to a dataset of eConsult questions from primary care providers to specialists, classifying the messages for how they were triaged by the specialist office, and the underlying type of clinical question posed by the primary care provider. We show that pre-trained transformer models are strong baselines, with improving performance from domain-specific training and shared representations.
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http://dx.doi.org/10.18653/v1/2020.nlpmc-1.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603636PMC
July 2020

COVID-19 Test Result Turnaround Time for Residents and Staff in US Nursing Homes.

JAMA Intern Med 2021 04;181(4):556-559

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2020.7330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600050PMC
April 2021

Association of Peer Comparison Emails With Electronic Health Record Documentation of Cancer Stage by Oncologists.

JAMA Netw Open 2020 10 1;3(10):e2015935. Epub 2020 Oct 1.

Division of Hematology and Oncology, Department of Medicine, General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts.

Importance: Systematically capturing cancer stage is essential for any serious effort by health systems to monitor outcomes and quality of care in oncology. However, oncologists do not routinely record cancer stage in machine-readable structured fields in electronic health records (EHRs).

Objective: To evaluate whether a peer comparison email intervention that communicates an oncologist's performance on documenting cancer stage relative to that of peer physicians was associated with increased likelihood that stage was documented in the EHR.

Design, Setting, And Participants: This 12-month, randomized quality improvement pilot study aimed to increase oncologist staging documentation in the EHR. The pilot study was performed at Massachusetts General Hospital Cancer Center from October 1, 2018, to September 30, 2019. Participants included 56 oncologists across 3 practice sites who treated patients in the ambulatory setting and focused on diseases that use standardized staging systems. Data were analyzed from July 2, 2019, to March 5, 2020.

Interventions: Peer comparison intervention with as many as 3 emails to oncologists during 6 months that displayed the oncologist's staging documentation rate relative to all oncologists in the study sample.

Main Outcomes And Measures: The primary outcome was patient-level documentation of cancer stage, defined as the likelihood that a patient's stage of disease was documented in the EHR after the patient's first (eg, index) ambulatory visit during the pilot period.

Results: Among the 56 oncologists participating (32 men [57%]), receipt of emails with peer comparison data was associated with increased likelihood of documentation of cancer stage using the structured field in the EHR (23.2% vs 13.0% of patient index visits). In adjusted analyses, this difference represented an increase of 9.0 (95% CI, 4.4-13.5) percentage points (P = .002) in the probability that a patient's cancer stage was documented, a relative increase of 69% compared with oncologists who did not receive peer comparison emails. The association increased with each email that was sent, ranging from a nonsignificant 4.0 (95% CI, -0.8 to 8.8) percentage points (P = .09) after the first email to a statistically significant 11.2 (95% CI, 4.9-17.4) percentage points (P = .003) after the third email . The association was concentrated among an oncologist's new patients (increase of 11.8 [95% CI, 6.2-17.4] percentage points; P = .001) compared with established patients (increase of 1.6 [95% CI, -2.9 to 6.1] percentage points; P = .44) and persisted for 7 months after the email communications stopped.

Conclusions And Relevance: In a quality improvement pilot trial, peer comparison emails were associated with a substantial increase in oncologist use of the structured field in the EHR to document stage of disease.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.15935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539129PMC
October 2020

Clinical Risk Factors for COVID-19 Among People With Substance Use Disorders.

Psychiatr Serv 2020 12 6;71(12):1308. Epub 2020 Oct 6.

Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston (Wen); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (Saloner). Tami L. Mark, Ph.D., and Alexander J. Cowell, Ph.D., are editors of this column.

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http://dx.doi.org/10.1176/appi.ps.202000215DOI Listing
December 2020

Suddenly Becoming a "Virtual Doctor": Experiences of Psychiatrists Transitioning to Telemedicine During the COVID-19 Pandemic.

Psychiatr Serv 2020 11 16;71(11):1143-1150. Epub 2020 Sep 16.

RAND Corporation, Arlington, Virginia (Uscher-Pines), and Boston (Sousa); Greater Los Angeles Department of Veterans Affairs Medical Center, Los Angeles (Raja); Department of Health Care Policy, Harvard Medical School, Boston (Mehrotra, Huskamp); Beth Israel Deaconess Medical Center, Boston (Mehrotra); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett).

Objective: In response to the COVID-19 pandemic, many psychiatrists have rapidly transitioned to telemedicine. This qualitative study sought to understand how this dramatic change in delivery has affected mental health care, including modes of telemedicine psychiatrists used, barriers encountered, and future plans. The aim was to inform the ongoing COVID-19 response and pass on lessons learned to psychiatrists who are starting to offer telemedicine.

Methods: From March 31 to April 9, 2020, semistructured interviews were conducted with 20 outpatient psychiatrists practicing in five U.S. states with significant early COVID-19 activity. Inductive and deductive approaches were used to develop interview summaries, and a matrix analysis was conducted to identify and refine themes.

Results: At the time of the interviews, all 20 psychiatrists had been using telemedicine for 2-4 weeks. Telemedicine encompassed video visits, phone visits, or both. Although many continued to prefer in-person care and planned to return to it after the pandemic, psychiatrists largely perceived the transition positively. However, several noted challenges affecting the quality of provider-patient interactions, such as decreased clinical data for assessment, diminished patient privacy, and increased distractions in the patient's home setting. Several psychiatrists noted that their disadvantaged patients lacked reliable access to a smartphone, computer, or the Internet. Participants identified several strategies that helped them improve telemedicine visit quality.

Conclusions: The COVID-19 pandemic has driven a dramatic shift in how psychiatrists deliver care. Findings highlight that although psychiatrists expressed some concerns about the quality of these encounters, the transition has been largely positive for both patients and physicians.
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http://dx.doi.org/10.1176/appi.ps.202000250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606640PMC
November 2020

Therapies Offered at Residential Addiction Treatment Programs in the United States.

JAMA 2020 Aug;324(8):804-806

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.8969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7448823PMC
August 2020

Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic.

Health Aff (Millwood) 2020 10 20;39(10):1812-1821. Epub 2020 Aug 20.

Michael L. Barnett is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts.

The coronavirus disease 2019 (COVID-19) pandemic continues to devastate US nursing homes. Adequate personal protective equipment (PPE) and staffing levels are critical to protect nursing home residents and staff. Despite the importance of these basic measures, few national data are available concerning the state of nursing homes with respect to these resources. This article presents results from a new national database containing data from 98 percent of US nursing homes. We find that more than one in five nursing homes reports a severe shortage of PPE and any shortage of staff. Rates of both staff and PPE shortages did not meaningfully improve from May to July 2020. Facilities with COVID-19 cases among residents and staff, as well as those serving more Medicaid recipients and those with lower quality scores, were more likely to report shortages. Policies aimed at providing resources to obtain additional direct care staff and PPE for these vulnerable nursing homes, particularly in areas with rising community COVID-19 case rates, are needed to reduce the national COVID-19 death toll.
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http://dx.doi.org/10.1377/hlthaff.2020.01269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598889PMC
October 2020

Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs).

Otolaryngol Head Neck Surg 2021 04 18;164(4):712-719. Epub 2020 Aug 18.

Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Objective: To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), "Opioid Prescribing for Analgesia After Common Otolaryngology Operations," presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib.

Data Sources: National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT.

Review Methods: AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials.

Conclusion: NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects.

Implications For Practice: The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.
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http://dx.doi.org/10.1177/0194599820947013DOI Listing
April 2021

Association of a clinician's antibiotic prescribing rate with patients' future likelihood of seeking care and receipt of antibiotics.

Clin Infect Dis 2020 Aug 10. Epub 2020 Aug 10.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.

Background: One underexplored driver of inappropriate antibiotic prescribing for acute respiratory illnesses (ARI) is patients' prior care experiences. When patients receive antibiotics for an ARI, patients may attribute their clinical improvement to the antibiotics, regardless of their true benefit. These experiences, and experiences of family members, may drive whether patients seek care or request antibiotics when they have subsequent ARIs.

Methods: Using encounter data from a national United States insurer, we identified patients <65 years old with an index ARI urgent care center (UCC) visit. We categorized clinicians within each UCC into quartiles based on their ARI antibiotic prescribing rate. Exploiting the quasi-random assignment of patients to a clinician within an UCC, we examined the association between the clinician's antibiotic prescribing rate to the patients' rates of ARI antibiotic receipt as well as their spouses' rate of antibiotic receipt in the subsequent year.

Results: Across 232,256 visits at 736 UCCs, ARI antibiotic prescribing rates were 42.1% and 80.2% in the lowest and highest quartile of clinicians, respectively. Patient characteristics were similar across the four quartiles. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics (+3.0 fills/100 patients (a 14.6% difference), 95% CI 2.2-3.8, p<0.001,) versus those seen by the lowest-prescribing clinicians. The increase in antibiotics was also observed among the patients' spouses. The increase in patient ARI antibiotic prescriptions was largely driven by an increased number of ARI visits (+5.6 ARI visits/100 patients, 95% CI 3.6-7.7, p<0.001), rather than a higher antibiotic prescribing rate during those subsequent ARI visits.

Conclusions: Receipt of antibiotics for an ARI increases the likelihood that patients and their family members will receive antibiotics for future ARIs.
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http://dx.doi.org/10.1093/cid/ciaa1173DOI Listing
August 2020

Medicare's Care Management Codes Might Not Support Primary Care As Expected.

Health Aff (Millwood) 2020 05;39(5):828-836

Bruce E. Landon is a professor in the Departments of Health Care Policy and of Medicine and a faculty member in the Center for Primary Care, all at Harvard Medical School.

To enhance compensation for primary care activities that occur outside of face-to-face visits, the Centers for Medicare and Medicaid Services recently introduced new billing codes for transitional care management (TCM) and chronic care management (CCM) services. Overall, rates of adoption of these codes have been low. To understand the patterns of adoption, we compared characteristics of the practices that billed for these services to those of the practices that did not and determined the extent to which a practice other than the beneficiary's usual primary care practice billed for the services. Larger practices and those using other novel billing codes were more likely to adopt TCM or CCM. Over a fifth of all TCM claims and nearly a quarter of all CCM claims were billed by a practice that was not the beneficiary's assigned primary care practice. Our results raise concerns about whether these codes are supporting primary care as originally expected.
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http://dx.doi.org/10.1377/hlthaff.2019.00329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490751PMC
May 2020

Addiction Treatment: The Authors Reply.

Health Aff (Millwood) 2020 04;39(4):722

Harvard Medical School Boston, Massachusetts.

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http://dx.doi.org/10.1377/hlthaff.2020.00247DOI Listing
April 2020

The Role of the Household in Prescription Opioid Safety.

JAMA Netw Open 2020 03 2;3(3):e201108. Epub 2020 Mar 2.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.1108DOI Listing
March 2020

Opioid Prescribing in the Midst of Crisis - Myths and Realities.

N Engl J Med 2020 Mar;382(12):1086-1088

From the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, and the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital - both in Boston.

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http://dx.doi.org/10.1056/NEJMp1914257DOI Listing
March 2020
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