BACKGROUND The United States is undergoing a crippling opioid epidemic, spurred in part by overuse of prescription opioids by adults 25 to 64 years of age. Of concern are long-duration and high-dose initial prescriptions, which place the patients and their friends and relatives at heightened risk for long-term opioid use, misuse, overdose, and death. METHODS We estimated the incidence of initial opioid prescriptions in each month between July 2012 and December 2017 using administrative-claims data from across the United States (accessed through Blue Cross–Blue Shield [BCBS] Axis); monthly incidence was estimated as the percentage of enrollees who received an initial opioid prescription among those who had not used opioids (i.e., no opioid pre-scription or a diagnosis of opioid use disorder in the 6 months before a given month). We then estimated the percentage of enrollees initiating opioid therapy who received a long-duration or high-dose initial opioid prescription in each month during this period. We also calculated the number of providers who initiated opioid therapy in any patient who had not used opioids in each month and examined monthly trends in the duration and dose of initial opioid prescriptions in prescriber and patient subgroups. Our study sample included 63,817,512 enrollees who had not used opioids (mean, 15,897,673 per month). RESULTS The monthly incidence of initial opioid prescriptions among enrollees who had not used opioids declined by 54%, from 1.63% in July 2012 to 0.75% in December 2017. This decline was accompanied by a decreasing number of providers (from 114,043 in July 2012 to 80,462 in December 2017) who initiated opioid therapy in any patient who had not used opioids. Nonetheless, among the shrinking sub-group of physicians who initiated opioid therapy in such patients, high-risk prescribing (i.e., prescriptions for more than a 3-day supply or for a dose of 50 morphine milligram equivalents per day or higher) persisted at a monthly rate of 115,378 prescriptions per 15,897,673 enrollees who had not used opioids. CONCLUSIONS As the opioid crisis progressed between July 2012 and December 2017, many providers stopped initiating opioid therapy. Although the number of initial opioid prescriptions declined, a subgroup of providers continued to write high-risk initial opioid prescriptions. (Funded by the National Institute on Aging and a gift from Owen and Linda Robinson.)
Abstract:Performance-based contracting is particularly challenging in health care, where multiple agents, information asymmetries and other market failures compound the critical contracting concern of multitasking. As performance-based contracting grows in developing countries, it is critical to better understand not only intended program impacts on rewarded outcomes, but also unintended program impacts such as multitasking and heterogeneous program effects in order to guide program design and scale-up. We use two waves of data from the Rwanda Demographic and Health Surveys collected before and after the quasi-experimental rollout of Rwanda's national pay-for-performance (P4P) program to analyze impacts on utilization of healthcare services, health outcomes and unintended consequences of P4P. We find that P4P improved some rewarded services, as well as some services that were not directly rewarded, but had no statistically significant impact on health outcomes. We do not find evidence that clearly suggests multitasking. We find that program effects vary by baseline levels of facility quality, with most improvements seen in the medium quality tier.We are grateful to
Background: Medical use of opioids has increased dramatically over the past 2 decades (1, 2), far exceeding increases in the prevalence of pain (3–5). This discrepancy may reflect efforts to address undertreatment of pain but has raised concerns about the appropriateness of physicians’ prescribing practices and whether patients’ medical indications justify opioid therapy. We therefore examined the indications associated with opioid prescriptions in ambulatory care between 2006 and 2015 to determine the proportion of prescriptions written for conditions causing pain. Objective: To determine the percentage of opioid prescriptions with a documented medical indication between 2006 and 2015, and to identify conditions commonly associated with opioid prescribing in ambulatory care. Methods and Findings: We used data from the National Ambulatory Medical Care Survey (NAMCS), an annual cross-sectional survey of visits to physician offices by insured and uninsured patients. For each visit, the NAMCS reports patient characteristics, prescribed medications, and up to 3 (between 2006 and 2013) or 5 (between 2014 and 2015) provider-assigned diagnoses denoting specific conditions discussed (recorded as International Classification of Diseases, Ninth Revision, codes).
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