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The American Journal of Managed Care March 2020
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Medication Nonadherence, Mental Health, Opioid Use, and Inpatient and Emergency Department Use in Super-Utilizers
Satya Surbhi, PhD, MS, BPharm; Ilana Graetz, PhD; Jim Y. Wan, PhD, MPhil; Justin Gatwood, PhD, MPH; and James E. Bailey, MD, MPH

Medication Nonadherence, Mental Health, Opioid Use, and Inpatient and Emergency Department Use in Super-Utilizers

Satya Surbhi, PhD, MS, BPharm; Ilana Graetz, PhD; Jim Y. Wan, PhD, MPhil; Justin Gatwood, PhD, MPH; and James E. Bailey, MD, MPH
Nonadherence to essential chronic medications and mental health diagnosis were associated with higher hospitalizations and emergency department use among Medicare super-utilizers.
ABSTRACT

Objectives: To examine whether mental health conditions, opioid use, and medication nonadherence are associated with inpatient and emergency department (ED) use among Medicare super-utilizers from medically underserved areas.

Study Design: Retrospective panel study.

Methods: The study included Medicare super-utilizers (≥3 hospitalizations or ≥2 hospitalizations with ≥2 ED visits in 6 months) served by a health system in a medically underserved area in the South from February 2013 to December 2014 with at least 1 filled prescription for hypertension, type 2 diabetes, cardiovascular, and/or chronic obstructive pulmonary disease/asthma medications. We used random effects negative binomial models to assess whether mental health diagnosis, opioid use, and medication nonadherence were associated with preventable and overall hospitalizations and ED visits stratified by age (18-64 vs ≥65 years).

Results: Overall chronic disease medication nonadherence was associated with more frequent hospitalizations and ED visits for both younger (hospitalizations: incidence rate ratio [IRR], 1.31; 95% CI, 1.16-1.47; ED visits: IRR, 1.33; 95% CI, 1.14-1.55) and older (hospitalizations: IRR, 1.34; 95% CI, 1.20-1.49; ED visits: IRR, 1.18; 95% CI, 1.02-1.38) beneficiaries. Mental health diagnosis was significantly associated with higher hospitalizations and ED visits among both age groups. Although associations between opioid medication use and inpatient and ED use were inconsistent and not significant in most cases, we found that 7 or more days’ supply of opioids was associated with lower preventable hospitalizations in Medicare beneficiaries 65 years or older.

Conclusions: The study findings highlight the importance of improving medication adherence and addressing behavioral health needs in Medicare super-utilizers.

Am J Manag Care. 2020;26(3):e98-e103. https://doi.org/10.37765/ajmc.2020.42642
Takeaway Points

Nonadherence to essential chronic medications and mental health diagnosis were associated with higher hospitalizations and emergency department use among Medicare super-utilizers.
  • This study builds on previous research conducted among Medicare patients by focusing on a more vulnerable Medicare population from a medically underserved metropolitan area in the South with patients who are predominantly African American, younger, disabled, and super-utilizing.
  • This study has important implications for policy makers and institutions involved in improving the quality of care and reducing costs for super-utilizers.
  • The study findings highlight the importance of improving medication adherence and addressing behavioral health needs in Medicare super-utilizers.
Optimal adherence to essential prescription medications is critical for the treatment of chronic conditions.1-3 Medication nonadherence is a major barrier to achieving treatment goals, especially among high-risk patient populations.4 These include so-called super-utilizers—patients with disproportionately high inpatient and emergency department (ED) use—who generally have multiple chronic conditions and use multiple concurrent medications to treat these conditions.5-8 The cost of caring for super-utilizers is high, with estimates that they represent only 3% to 5% of the US population but account for 30% to 50% of total spending.5,9

Findings of previous studies conducted among Medicare beneficiaries have shown that optimal medication adherence is associated with lower inpatient and ED use.10,11 Evidence shows that depression is associated with higher incidence of hospitalizations among patients who are high utilizers of medical care, and our previous studies have highlighted high rates of chronic pain and opioid use in this vulnerable population.12-14 However, the impact of these factors on healthcare utilization among medically underserved communities is not well understood. This study builds on previous research by focusing on more vulnerable Medicare beneficiaries from a medically underserved metropolitan area in the South who are predominantly African American, younger, and disabled.13

This study was conducted using baseline data from the SafeMed Program, a care transitions program focusing on medication management and funded by the CMS Health Care Innovation Awards (HCIA).6 SafeMed targeted super-utilizers from medically underserved areas (MUAs) with ambulatory care–sensitive chronic conditions (hypertension, type 2 diabetes, congestive heart failure [CHF], coronary artery disease [CAD], chronic obstructive pulmonary disease [COPD], or asthma) for which outpatient care improvements can reduce inpatient utilization.15-18 Using longitudinal 2-year Medicare data for the period prior to the SafeMed intervention, we examined whether medication nonadherence, mental health diagnosis, and opioid medication use were associated with inpatient and ED use in super-utilizers. We also examined whether tobacco use disorder, polypharmacy, number of prescribers, and access to outpatient care were associated with hospitalizations and ED visits in this vulnerable population.

METHODS

Design and Setting

This study was a retrospective panel analysis of the baseline data for Medicare beneficiaries from a MUA served by a hospital system in Memphis, Tennessee, and meeting the SafeMed Program eligibility criteria during the enrollment period from February 2013 to December 2014.6 For each patient, we reviewed 2 years of data prior to SafeMed enrollment. The dates of this 2-year baseline period varied for each patient based on their enrollment date for the SafeMed Program. For instance, if a patient was enrolled in the SafeMed Program in February 2013, the 2-year evaluation period was from February 2011 to February 2013. The data for each patient were divided into four 6-month patient-periods, with the last 6-month period serving as the qualifying period for the SafeMed Program.6 The panel design enabled us to examine changes in hospitalizations, ED visits, and nonadherence over time. eAppendix Figure 1 (eAppendix available at ajmc.com) shows the study design.

Data

The study used Chronic Conditions Data Warehouse files including pharmacy and medical claims for all fee-for-service Medicare beneficiaries with parts A, B, and D coverage. Data on hospitalizations were obtained using Medicare Provider Analysis and Review files. Data on observation stays and ED visits were obtained using Medicare outpatient revenue center files. Part D drug event files were used to assess medication nonadherence, and diagnosis codes present in the inpatient, outpatient, or Part B claims were used to assess chronic conditions. Medicare beneficiary summary files (parts A, B, and D) were used to assess demographic factors. Patient identifier and claim identifier were used as linking variables.

Study Population

The final study sample (N = 1092) included adult super-utilizers (≥3 hospitalizations or ≥2 hospitalizations with ≥2 ED visits in 6 months) with a diagnosis of at least 1 of the previously mentioned ambulatory care–sensitive conditions, with continuous eligibility for Medicare parts A, B, and D and who had filled at least 1 of 17 type 2 diabetes, cardiovascular, or COPD/asthma drug classes during the 2-year period. The list of therapy classes is presented in eAppendix Table 1. The study sample was divided into 2 groups: (1) Medicare beneficiaries aged 18 to 64 years who are eligible due to their disability19 and (2) Medicare beneficiaries 65 years or older. The study excluded patients with insulin fills because adherence cannot be reliably calculated using claims data.20


 
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