Receiving opioids for the first time while hospitalized doubles the risk of continued use

1. Receiving opioids for the first time while hospitalized doubles the risk of continued use

Notes: HD video soundbites of the authors discussing the paper are available to download at http://www.dssimon.com/MM/ACP-opioids.
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2864
Editorial: http://annals.org/aim/article/doi/10.7326/M19-1394
URLs go live when the embargo lifts

People who received opioids for the first time while hospitalized had double the risk of continuing to receive opioids for months after discharge, compared with their hospitalized peers who were not given opioids. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Previous studies have shown that some surgical and medical patients who fill opioid prescriptions immediately after leaving the hospital go on to have chronic opioid use. However, little was known about how and if those patients were being introduced to the opioids while in the hospital.

Researchers at the University of Pittsburgh Graduate School of Public Health and School of Medicine colleagues reviewed the electronic health records of 191,249 hospital admissions of patients who had not been prescribed opioids in the prior year and were admitted to a community or academic hospital in Pennsylvania between 2010 and 2014. Opioids were prescribed in 48 percent of the admissions, with those patients being given opioids for a little more than two-thirds of their hospital stay, on average. Almost 6 percent of patients receiving opioids during their hospital stay were still being prescribed opioids three months later, compared with 3 percent of those without inpatient opioid use. Non-opioid painkillers and anti-inflammatory medications, such as ibuprofen, aspirin or naproxen, were rarely tried before an opioid was administered - as little as 7.9 percent of the time for some conditions.

The authors of an accompanying editorial from Boston Medical Center and Boston University suggest that any interaction between patients and the health care system that may involve pain presents the opportunity for a first opioid prescription and avoiding this first prescription in opioid-naïve patients could be important for reducing incident long-term use and associated harms. The authors suggest the development of a protocol to pursue nonopioid analgesic use before opioid use during hospitalizations. But if they have to be used, they should be used in the lowest dosage and for the least amount of days possible.

Notes and media contacts: For an embargoed PDF or to speak with the editor of Annals of Internal Medicine, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Julie M. Donohue, PhD, please contact Allison Hydzik at hydzikam@upmc.edu.

2. Climate change may have brought flesh-eating infection to previously unaffected waters

Abstract: http://annals.org/aim/article/doi/10.7326/L19-0133
URLs go live when the embargo lifts

Rising water temperatures in the Delaware Bay may be to blame for cases of Vibrio vulnificus, a flesh-eating infection that can occur after handling or consumption of seafood, seen in the area. Findings from a case report are published in Annals of Internal Medicine.

V vulnificus is endemic to the southeastern U.S. coast. Cases have also been reported from the Chesapeake Bay but are rarely reported from the Delaware Bay, which is farther north and slightly cooler. Wound infections occur through breaks in the skin, and intestinal infections occur after consumption of seafood. Either route can lead to bloodstream infections, and the mortality rate is high.

Researchers from Cooper University Hospital describe five cases of V vulnificus necrotizing fasciitis that occurred during the summer months of 2017 and 2018 after water exposure and/or consumption of crabs in the Delaware Bay. All of the patients received prompt medical attention and surgical management, and four survived. The study authors suggest that these cases should serve as an alert to clinicians that V vulnificus infections are occurring more frequently outside traditional geographic areas.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at Laevans@acponline.org. To speak with authors, Katherine Doktor, MD or Madeline King, PharmD, please contact Would Wendy Marano at marano-wendy@cooperhealth.edu.

3. Savings associated with Medicare Shared Savings Program may be overstated

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2539
URLs go live when the embargo lifts

Participation in the Medicare Shared Savings Program (MSSP) was not associated with improvements in spending, quality of care, or outcomes. Selection effects - including exit of high-cost clinicians - may contribute to overstated estimates of savings. Findings from an instrumental variable analysis are published in Annals of Internal Medicine.

The MSSP is a program where groups of clinicians, hospitals and other providers voluntarily assume responsibility for the spending and quality outcomes of a defined population of free-for-service Medicare beneficiaries. Accountable care organizations (ACOs) in the MSSP are associated with modest improvements in spending and quality. However, estimates of these savings may be overstated if high-cost physicians exit the program.

Researchers from the University of Michigan School of Public Health used national Medicare data to evaluate changes in spending and quality performance while accounting for selection effects in the MSSP. The authors used adjusted longitudinal models that accounted for secular trends, market-level factors, and observed differences across MSSP participants and local control beneficiaries. To account for clinicians' nonrandom entry and exit from the MSSP, the number of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as the falsification outcome.

The researchers found that participation in MSSP was not associated with improvements in spending, quality, or hip fracture (the falsification outcome). Before the start of the MSSP, spending trends differed between beneficiaries who did and did not enter the program. Supplemental analyses found that high-cost clinicians and beneficiaries were disproportionately likely to exit MSSP ACOs, suggesting that improved quality and spending performance in MSSP may have been driven by nonrandom exit of clinicians and their patients.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Andrew M. Ryan, PhD, please contact Andrea LaFerle at alaferle@umich.edu.

4. ACP partners with TIME'S UP Healthcare to assure gender safety and equity in the workplace

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0229
URLs go live when the embargo lifts

The American College of Physicians (ACP) has partnered with TIME'S UP Healthcare to launch an initiative aimed at assuring safety, equity, and inclusion in the workplace for women in medicine. While TIME'S UP gained international attention through high-profile support from the entertainment industry, issues of sexual and gender harassment and gender inequity are all too common in all fields and industries. Healthcare is no exception, according to a commentary published in Annals of Internal Medicine by Darilyn Moyer, MD, Executive Vice President/CEO of ACP and Lynn E. Fiellin, MD, from the Yale School of Medicine.

A recent report found that up to 50 percent of female medical students reported sexual harassment from faculty or staff. Later in their careers, many of these female physicians recounted subsequent severe depression, recurrent troubling memories, and diminished interest in their medical studies, and considered leaving medicine altogether. In its position paper, "Achieving Gender Equity in Physician Compensation and Career Advancement," ACP outlined many of the problems faced by women in medicine and offered remedies. The ACP-TIME'S UP Healthcare partnership is a natural progression towards bringing those remedies to fruition.

Through this partnership, ACP and TIME'S UP Healthcare will coordinate efforts, share best practices, and provide support for each organization's educational and advocacy work. ACP will designate a representative to work directly with TIME'S UP Healthcare with the goal of becoming "the recognized leader in quality patient care, advocacy, education and enhancing career satisfaction for internal medicine and its subspecialties." According to the commentary authors, the need to implement the goals of TIME'S UP Healthcare is urgent, and the time for action is now.

Notes and media contacts: For an embargoed PDF, or to speak with Darilyn Moyer, MD, Executive Vice President/CEO of ACP, please contact Angela Collom at acollom@acponline.org. To speak with the commentary lead author, Lynn E. Fiellin, MD, from Yale School of Medicine, please contact Ziba Kashef at ziba.kashef@yale.edu.

Also New in this issue:

Inpatient Notes: Four "GEMS"--Geriatric Evaluation and Management Strategies When Admitting an Acutely Ill Older Adult to the Hospital
Lillian Min, MD, MSHS; Lona Mody, MD, MSc
Hospitalist Commentary
Abstract: http://annals.org/aim/article/doi/10.7326/M19-1372

###