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Comment on National Quality Forum Framework to Measure Diagnostic Safety

A proposed measurement framework for diagnostic quality and safety developed by the National Quality Forum has been posted for public comment. Comments will inform recommendations for the development of priority measures to address measurement gaps in diagnostic accuracy. Public comment on this draft report and measurement framework is open through July 12. Please submit your comments on the project page or contact the NQF project team at diagnosticaccuracy@qualityforum.org with any questions.

Shining a Spotlight on the Opioid Crisis Through the Power of Data

By Anne Elixhauser, Ph.D.

As an AHRQ researcher, I get to dive into topics that matter to the American people using one of the most comprehensive health care databases—AHRQ's Healthcare Cost and Utilization Project, or HCUP. HCUP is the Nation’s most complete source of hospital-based data, including information on hospitalizations and emergency department (ED) visits for all patients, including those paid by government and private insurance as well as the uninsured.

Learning about data trends to help improve lives can mean swimming through very scary waters. Take the opioids crisis, for instance. There has been widespread attention given to opioid-related deaths in the media. A New York Times article recently estimated that nearly 60,000 people died from using an opioid drug in 2016 Link to Exit Disclaimer. On the other hand, the New York Times also wrote that opioid prescriptions have declined for the first time in two decades Link to Exit Disclaimer. These articles illustrate two very important aspects of the opioid crisis. But what about the people who don't die or are still being prescribed too many pills? And what about those who turn to heroin or other illicit opioids and overdose, but survive thanks to a visit to the hospital or emergency department (ED)?

It's hard to defeat a problem like the opioid epidemic until you know how bad the problem really is and what subgroups are affected disproportionately. That is what AHRQ is uniquely suited to provide—data on opioid hospitalizations and ED visits for specific population subgroups from our HCUP Fast Stats database. HCUP allows Secretary Price, other HHS agencies, policymakers, and frontline providers to best define the challenge, and ultimately, begin to measure how opioid addiction treatment and reduction efforts are working.

So what are the numbers? We highlighted some in a press release that is based on data in a new statistical brief on opioid-related hospitalizations and ED visits, by patient sex and age (PDF, 343 KB). The data are sobering:

  • Men and women were hospitalized at virtually the same rate nationwide in 2014—about 225 hospitalizations per 100,000 people. That's a 75 percent increase for women between 2005 and 2014, compared to only a 55 percent increase for men.
  • An infographic shows that in three-quarters of all States with available data, women had a higher rate of an opioid-related hospitalization than men in 2014.
  • However, men were still more likely to make opioid-related ED visits in 2014.
  • Individuals 25–44 years had the highest opioid-related ED visit rate in every State. But people 65 and older had the largest increases in opioid-related hospital stays and ED visits.

In July, we plan to release another statistical brief on opioid-related hospitalizations and ED visits by patient residence and income. This may also be a disturbing read, as the data will show, for example, that opioid-related ED visits increased the most in the lowest income communities from 2005 to 2014.

While none of these data are very encouraging, it is critical to have a better idea of why women are being hospitalized more than men or why 25–44 year-olds are visiting the ED more than other age groups, especially since we have 2015 and 2016 data for many States in the database and we are continuing to see the trend line for hospitalizations and ED visits going up.

That's why I am heartened by Secretary Price's request for additional funding for opioid abuse research. Recently, the Secretary awarded more than $70 million in grants to help prevent opioid overdose deaths. About $28 million of the grant money will go to medication-assisted treatment (MAT). AHRQ is investing about $12 million over 3 years in grants to explore how best to deliver MAT opioid abuse in rural areas and remove barriers to using MAT. Also, the recently enacted 21st Century Cures Act authorized the Substance Abuse and Mental Health Services Administration to award $485 million in grants for opioid abuse prevention, treatment, and recovery.

All these grants show HHS' dedication to halt the opioid epidemic. AHRQ will continue to play an important role monitoring the national and State data for opioid-related hospitalizations and ED visits—because that's our job.

Dr. Elixhauser is a Senior Researcher at AHRQ. She has worked with HCUP data for more than 20 years and is the author of more than 200 articles and reports.

CMS Releases 1991-2014 Health Care Spending by State

Data details health care spending for residents by service and major payer

Today, the Centers for Medicare & Medicaid Services’ (CMS) Office of the Actuary (OACT) released state-level health care spending data for the period 1991-2014. The data shows that while most states experienced faster growth in 2014 due to Medicaid expansion and enrollment in Exchange plans, per capita health spending in Medicaid expansion and non-expansion states grew at similar rates. The report also found that the most recent economic recession, which ended in 2009, and modest recovery since then, had a sustained impact on health spending and health insurance coverage. Every state experienced slower growth in per capita personal health care spending from 2010-2013 than experienced during the period 2004-2009.

David Lassman, the lead author of the report noted that, “recent economic and health sector factors have had clear impacts by state, both by payer and in the rates of overall per capita personal health care expenditure growth; however, during the 2009 to 2014 period, the variation in spending between the lowest and highest states was virtually unchanged.”

The report, published as a web first in Health Affairs, offers vital context for understanding how health spending varies across states. The analysis updates previous estimates published in 2011 and examines personal health care spending (or the health care goods and services consumed) through a resident-based view. These estimates are also presented both by type of goods and services (such as hospital services and retail prescription drugs) and by major payer (including Medicare, Medicaid, and private health insurance) for the individuals who reside in a state.

The topline findings from the report include:

  • Considerable regional variation on personal health care spending:
    • In 2014, the New England and Mideast regions had the highest levels of total per capita personal health care spending ($10,119 and $9,370, respectively), or 26 and 16 percent higher than the national average ($8,045).
    • In contrast, the Rocky Mountain and Southwest regions had the lowest levels of total personal health care spending per capita in 2014 ($6,814 and $6,978, respectively) with average spending roughly 15 percent lower than the national average.
  • Similar growth in Medicaid expansion and non-expansion states: While most states experienced faster growth in 2014 compared to 2013 due to Medicaid expansion and enrollment in Health Insurance Exchange plans, per capita health spending in Medicaid expansion and non-expansion states grew at similar rates, 4.4 and 4.5 percent respectively. The similar growth in per capita spending for expansion and non-expansion states was due largely to two effects:
    • Faster growth in the use of healthcare goods and services in expansion states relative to non-expansion states due to a larger increase in the percent of people insured in those states.
    • Faster growth in spending per insured person in non-expansion states relative to expansion states.
  • Impact of recent economic recession and recovery: The most recent economic recession, which ended in 2009, and modest recovery since then, had a sustained impact on health spending and health insurance coverage.
    • For 2010-2013, per capita personal health spending grew at a rate of 2.8 percent per year on average, substantially slower than during 2004-2009, when spending averaged 5.2 percent growth per year.
    • During 2010-2013, every state experienced slower growth in per capita personal health care spending with an average deceleration of just over two percentage points compared to the 2004-2009 period.
  • Three Major Payers:
    • Medicare: States with above average per enrollee Medicare spending were generally located in the eastern United States while states with the lowest spending were generally in the western United States.
      • The State with the highest per enrollee Medicare spending in 2014 was New Jersey ($12,614) with spending levels roughly 15 percent above the national average ($10,986).
      • In 2014, Montana was the State with the lowest per enrollee Medicare spending, at $8,238 per enrollee (25 percent below the national average per enrollee).
    • Medicaid: The recent trends in per enrollee spending were driven by the Medicaid coverage expansion, which increased the share of relatively less expensive enrollees relative to the previous Medicaid beneficiary population mix in expansion states.
      • Total Medicaid spending increased 12.3 percent from 2013 to 2014 for states that expanded Medicaid, compared with 6.2 percent for states that did not expand Medicaid.
      • However, on a per enrollee basis Medicaid spending declined considerably for the expansion states (-5.1 percent) in 2014, because of the enrollment of relatively less expensive enrollees, whereas per enrollee Medicaid spending in the non-expansion states increased 5.1 percent.
    • Private Health Insurance: Per enrollee private health insurance spending was $4,551 in 2014, an average annual increase of 3.3 percent since 2009 ($3,872).
      • Total private health insurance spending grew more rapidly in states that did not expand Medicaid eligibility by 2014 than in states that did expand eligibility, at rates of 6.8 percent and 4.6 percent, respectively.
      • A majority of this difference reflects faster private health insurance enrollment growth in non-expansion states (3.2 percent) compared to that for expansion states (1.9 percent).

The OACT data and analysis will appear at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html

An article about the study also being published by Health Affairs here: http://content.healthaffairs.org/lookup/doi/10.1377/hlthaff.2017.0416

NOW AVAILABLE: Driving Action and Progress on Obesity Prevention and Treatment: Proceedings of a Workshop

Driving Action and Progress on Obesity Prevention and Treatment: Proceedings of a Workshop

After decades of increases in the obesity rate among U.S. adults and children, the rate recently has dropped among some populations, particularly young children. What are the factors responsible for these changes? How can promising trends be accelerated? What else needs to be known to end the epidemic of obesity in the United States?

To examine these and other pressing questions, the Roundtable on Obesity Solutions, of the National Academies of Sciences, Engineering, and Medicine, ...

Read More

New Documentary on Difficulties Faced by Patients With Chronic Pain

Dr. Lynn Webster of Utah recently produced a documentary about pain treatment. The documentary, “The Painful Truth,” can be found online and on public television stations across the country and provides insight into the difficulties patients run into when trying to find effective treatment for chronic pain.

The patients featured in “The Painful Truth” include some who are fearful of losing access to opioid treatment, as well as those who say some doctors have refused to treat them and pharmacies have balked at filling their prescriptions. The apprehension among some pain patients that they won’t be able to get opioids has been reported in several media outlets, including STAT.

Webster acknowledged that several of the patients in his documentary are “miserable” even while taking opioids, and the documentary makes the point that better treatments are desperately needed. For now, however, he said opioid medications are often the best of several flawed options.

“With all of the focus on opioid addiction, we are forgetting many people with pain who have benefited,” he said. “It’s the only thing that keeps them from suicide.”

Critical Article from STAT

I was a fan of the author David Armstrong when he wrote for Wall Street Journal. However, his recent article on Lynn Webster’s documentary starts out with guilt by association. Roughly a year ago, Lynn called me and asked for advice on how to promote this documentary. At that time, he was passionate about the way pain management patients and their physicians are being unfairly shunned by society.

Armstrong notes that Dr. Webster and several of the experts he quotes in the program have long-standing financial relationships with pain medicine makers. When asked why these relationships are not disclosed to viewers, Webster told STAT that he did not receive any drug industry funding for the documentary. He said it was funded entirely by himself and his wife.

“I am cognizant of that issue, but I think I dealt with it as carefully as I could,” he said in an interview. If viewers want to know whether any of the individual doctors associated with the documentary have financial relationships with pharmaceutical makers, Webster said they can search for that information on the web.

Dr. Webster Paid for the Documentary Himself

I encourage the media to call Lynn and hear why he did this documentary and paid for it out of his own pocket.  Yes, Lynn worked for industry but that is by no means his primary motivation to do this documentary. Go spend some time in a pain clinic and meet some patients who are truly in pain, this is by no means a binary issue.

“There are dozens of important stories about people with opioid addiction almost daily but rarely is there a story about people in pain,” Webster said in an email to STAT.

Does the Media Own Some Part of the Opioid Crisis?

It hit me recently that the Media needs to take some responsibility for the Opioid crisis, in 2004 when the Cox 2 inhibitors were slammed as “unsafe” there was no thought to what other alternative therapies that were available to alleviate pain.  Had the media or the medical community for that matter, paid just a little attention and thought, the best Cox 2 inhibitors would have been hugely successful and companies would have reaped the benefit, but the opioid crisis might never have happened.

Comments from Tom Fogarty, MD

We reached out to Tom Fogarty, Founder of the Fogarty Institute and inventor of the catheter, who stated,

Opioid addiction is a serious and worldwide problem that is ever increasing. The reasons are multi-factorial, unfortunately a minority of physicians are responsible for this. A doctor’s sole purpose is to relieve pain and suffering and the vast majority adhere to that doctrine. The minority who knowingly do not, should be investigated and corrected. Continued excessive use of opioid prescriptions (easily documented) should be followed by fines and some other forms of punishment imposed upon the responsible physician. Chronic addiction to opioids and other drugs should be handled by specialists in the field of pain management. Dr. Lynn Webster and others should be looked to for resolution of these problems. The majority should not be punished, that is our patients, by inappropriate laws or recommendations.

Viewpoints Should Not Be Discounted Because of Past Work History

It always bothers me when I see someone’s viewpoints discounted simply because they have worked for industry in the past. The author is capable of doing better work.

Further, Aaron Pruitt, director of content at MontanaPBS, said he was “not aware” of any financial connections between Webster and companies that make opioid pain relievers. “If there is some evidence of that, I have seen nothing,” he said. After being directed to public disclosures of those relationships, Pruitt wrote in an email, “As far as I can tell, he has been working with companies to find safer, less addictive treatments for patients.”

In a pitch to television stations offered the documentary, the distributors write that “NETA and MontanaPBS have carefully reviewed The Painful Truth, and the credentials of Dr. Webster. We have found Dr. Webster to be one of the country’s experts on pain treatment, a past president of the American Academy of Pain Medicine, and an advocate for the safe prescription of opioids.”

Disclosure: the company I own, Rockpointe, receives grants from pharmaceutical and device manufacturers for accredited educational programs.

AHRQ Works: Building Bridges Between Research and Practice

Accelerating learning and innovation in health care delivery is what AHRQ does—every day. AHRQ tools take the "what" and translate it into the “how” by providing research-backed, practical tools that doctors and nurses can use to improve care.

Read More: AHRQ Works: Building Bridges Between Research and Practice

Read and share this infographic about forgetfulness

Many people worry about becoming forgetful as they age. They think it is the first sign of Alzheimer’s disease. But forgetfulness can be a normal part of aging. Check out this infographic to see examples of mild forgetfulness versus signs of serious memory problems, like Alzheimer’s disease. Be sure to talk to your doctor if you have concerns.