Background: Hospitalization of patients with opioid use disorder (OUD) is increasing, yet little is known about opioid agonist therapy (OAT: methadone and buprenorphine) administration during admission. Objective: Describe and examine patient-and hospital-level characteristics associated with OAT receipt during hospitalization in the Veterans Health Administration (VHA). Participants: 12,407 unique patients, ≥ 18 years old, with an OUD-related ICD-10 diagnosis within 12 months prior to or during index hospitalization in fiscal year 2017 from 109 VHA hospitals in the continental United States. Main Measure: OAT received during hospitalization. Key Results: Few admissions received OAT (n = 1,914; 15%) and when provided it was most often for withdrawal management (n = 834; 7%). Among patients not on OAT prior to admission who survived hospitalization (n = 10,969), 2.0% (n = 203) were newly initiated on OAT with linkage to care after hospital discharge. Hospitals varied in the frequency of OAT delivery (range 0% to 43% of qualified admissions). Patients with pre-admission OAT (Adjusted Odds Ratio [AOR] = 15.30; 95% CI [13.2, 17.7]), acute OUD diagnosis (AOR = 2.3; 95% CI [1.99, 2.66]), and male gender (AOR 1.52; 95% CI [1.16, 2.01]) had increased odds of OAT receipt. Patients who received non-OAT opioids (AOR 0.53; 95 CI [0.46, 0.61]) or surgical procedures (AOR 0.75; 95 CI [0.57, 0.99]) had decreased odds of OAT receipt. Large (AOR = 2.0; 95% CI [1.39, 3.00]) and medium-sized (AOR = 1.9; 95% CI [1.33, 2.70]) hospitals were more likely to provide OAT. Conclusions: In a sample of VHA inpatient medical admissions, OAT delivery was infrequent, varied across the health system, and was associated with specific patient and hospital characteristics. Policy and educational interventions should promote hospital-based OAT delivery.

Objective The purpose of this study is to examine the extent to which Numeric Rating Scale (NRS) scores collected during usual care are associated with more robust and validated measures of pain, disability, mental health, and health related quality of life (HRQOL). Design We conducted a secondary analysis of data from a prospective cohort study. Subjects We included 186 patients with musculoskeletal pain who were prescribed long-term opioid therapy. Setting VA Portland Health Care System outpatient clinic. Methods All patients had been screened with the 0–10 NRS during routine outpatient visits. They also completed research visits that assessed pain, mental health and HRQOL every six months for two years. Accounting for non-independence of repeated measures data, we examined associations of NRS data obtained from the medical record with scores on standardized measures of pain and its related outcomes. Results NRS scores obtained in clinical practice were moderately associated with pain intensity scores (B’s = 0.53–0.59) and modestly associated with pain disability scores (B’s = 0.33–0.36) obtained by researchers. Associations between pain NRS scores and validated measures of depression, anxiety, and health related HRQOL were low (B’s = 0.09–0.26, with the preponderance of B’s < 0.20). Conclusions Standardized assessments of pain during usual care are moderately associated with research-administered measures of pain intensity and would be improved from the inclusion of more robust measures of pain-related function, mental health, and HRQOL.

We compared smoking status from Veterans Health Administration (VHA) structured data with text in electronic health record (EHR) to assess validity. We manually abstracted the smoking status of 5,610 VHA patients. Only those with a smoking status found in both EHR text data and VHA structured data were included (n=5,289). We calculated agreement and kappa statistics to compare structured data vs. manually abstracted EHR text smoking status. We found a kappa statistic of 0.70 and total agreement of 81.1% between EHR text data and structured data for Current, Former, and Never smoking categories. Comparing EHR text data and structured data between Never and Ever smokers revealed a kappa statistic of 0.62 and total agreement of 89.1%. For comparison between Current and Never/Former smokers, the kappa statistic was 0.80 and total agreement was 90.2%. We found substantial and significant agreement between smoking status in EHR text data and structured data that may aid in future research.

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Key PointsQuestionIs the implementation of an interprofessional education initiative in US Department of Veterans Affairs primary care clinics associated with changes in quality of care?FindingsIn this study using difference-in-differences analysis of Department of Veterans Affairs electronic health record data, patients cared for by resident clinicians who participated in a large, multisite, interprofessional education quality improvement initiative had modestly improved quality of care compared with patients cared for by resident clinicians at similar, nonparticipating Department of Veterans Affairs teaching clinics.MeaningIn this study, interprofessional education in primary care was associated with improvements in quality of care.

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Association between US norepinephrine shortage and mortality among patients with septic shock.

Objective: To assess the impact of direct acting anti-viral (DAA) therapy for hepatitis C virus (HCV) infection on changes in pain intensity and prescription opioid use among Veterans. Methods:We conducted a retrospective cohort study of Veterans with HCV who were seen in a rheumatology clinic at least once while receiving DAA therapy between January 1, 2010 and December 31st 2016. Demographic characteristics, HCV status, HCV treatment characteristics, numeric rating scale (NRS) pain scores and opioid prescription data were extracted from the electronic medical record. Pain scores were averaged over 6 months prior to HCV treatment and 6 months after completion of treatment. Prescription opioid dose was converted to a morphine equivalent daily dose (MEDD) and averaged across the two 6-month intervals.Generalized estimating equations were used to model the change in average pain and MEDD from pre-to post-HCV treatment. Effect size was assessed using Cohen's d. Results:A total of 121 Veterans, 91% male with average age of 59 were included.Average pre-treatment pain was 4.4 (SD 2.4). The average reduction in pain scores was 0.6 points (P = 0.02, Cohen's d = 0.22) after treatment. Among 67 patients prescribed chronic opioid therapy at baseline, average pre-treatment MEDD was 52.4 mg (SD = 62.5 mg) and post-DAA treatment average MEDD was 49.5 mg (SD = 69.3 mg), representing a decrease by 2.9 mg (P < 0.01, Cohen's d = 0.14). Opioid dose reduction was seen in 43/67 patients and 12 patients discontinued opioids entirely.Conclusion: Among US Veterans, subjective pain scores had modest improvement and opioid prescriptions were mildly reduced following treatment with DAA.