Full length articleAssociation between process measures and mortality in individuals with opioid use disorders
Introduction
Opioid use disorders (OUDs), including both heroin and prescription opioid use disorders, are associated with high rates of mortality both in the United States and worldwide (Degenhardt et al., 2011, Degenhardt et al., 2014a, Gomes et al., 2014, Martins et al., 2015, Rudd et al., 2016b). Mortality risks for individuals with opioid use disorders range from 6 to 20 times higher than the general population, and opioid-related mortality has increased dramatically during the past two decades, particularly with the increasing misuse of prescription opioids (Centers for Disease Control and Prevention (CDC), 2011, Frenk et al., 2015, Rudd et al., 2016a, Rudd et al., 2016b). Younger individuals are disproportionately affected and bear the greatest burden of premature mortality. In addition to being associated with medical illnesses such as endocarditis and hepatitis, OUDs complicate the treatment of other conditions (e.g., acute and chronic pain, conditions requiring surgical intervention) and are associated with higher costs (Birnbaum et al., 2011, Meyer et al., 2014, Ronan and Herzig, 2016).
Reducing the mortality associated with OUDs is an ongoing public health challenge and an important goal for health care systems. While health care systems have little ability to decrease some causes of premature mortality, such as injuries and homicides, they may influence mortality through the quality of the care they deliver. Health care providers can decrease the mortality risk of patients with OUDs through recognition and treatment of worsening chronic health problems, preventing iatrogenic causes of mortality or through influencing patients’ drug use and subsequent risk behaviors by providing effective treatment (Davoli et al., 2007, Gaither et al., 2016a, Gaither et al., 2016b, Grossbard et al., 2014).
Understanding the relationship between the quality of care provided and mortality can help health care systems reduce the increased mortality experienced by persons with OUDs. Quality of care is commonly examined using either measures of process, which assess the care provided to the patient, or outcomes, which assess the impact of the care on the patient’s health or functioning. While improved patient outcomes are the gold standard for measuring quality, using outcome-based quality measures is challenging. Outcome data can be expensive and difficult to obtain; do not identify which care processes need to be improved; and outcome measures require risk adjustment. In contrast, process-based measures are more easily operationalized from electronic health records and can provide information about where performance is variable and quality improvement efforts should be targeted. Furthermore, administrative-data based process measures can be reported in real-time, allowing health care systems to take timely corrective action.
While the rationale for specific quality measures usually comes from practice guidelines and/or a synthesis of the literature, process measures should have demonstrated reliability and validity before being used as quality measures to improve performance. There are no reliable and valid quality measures for individuals with OUDs, and measures that have been developed and validated for use in substance use disorders more generally have not been specifically tested in opioid dependent populations (Garnick et al., 2002, Garnick et al., 2009, Harris et al., 2010). This is an important limitation, because disease-specific measures, when they draw attention to specific clinical processes, may be more actionable than generic measures for quality improvement efforts. However, unless process measures are associated with clinically meaningful outcomes, using them to monitor and improve performance will not result in the expected improvements.
Given the importance of mortality as a clinical outcome, we examined the association of 7 process-based measures with 12- and 24-month mortality among persons with OUDs. If these measures are associated with lower mortality, it would provide initial evidence that they could be used by health care systems as part of specific strategies to improve the care provided to individuals with OUDs and to decrease mortality. It would also provide initial evidence for the predictive validity of the measures.
Section snippets
Overview
This study was approved by the Institutional Review Boards of the Central Arkansas Veterans Healthcare Center and the University of Arkansas for Medical Sciences. The boards waived the requirement for informed consent as it was a minimal risk study. Administrative data was obtained from the Veterans Administration (VA) Medical SAS data sets. Mortality through September 30, 2009 was obtained from the VA Vital Status Mini File.
Study population
We identified all veterans with OUDs using the International
Results
In FY2007, 32,422 patients with OUDs accessed services provided or paid for by the VA. Table 1 shows their demographic and descriptive characteristics; 96% were male and the average age was 52 (SD = 9). Sixty-eight percent had at least one new SUD treatment episode; 23% had co-occurring PTSD. The unadjusted mortality rate was 3.7% at 12 months (1165 individuals) and 7.2% at 24 months (2272).
Adherence to the process measures ranged from a high of 79% (any psychosocial treatment) to a low of 12%
Discussion
Among individuals with OUDs, receiving 3 of the 7 process measures was associated with lower 12- and 24-month mortality and provides initial evidence for their use as quality measures. Not being prescribed either prescription opioids or benzodiazepines, use of psychosocial treatment and quarterly physician visits were all associated with lower mortality at 12 and 24 months. It is important to note that while the population was at least minimally engaged with VA care, nearly 17% did not receive
Conclusions
At a time when health care systems are increasingly focused on measuring, assessing, and providing incentives to improve quality (Glied et al., 2015, Patel et al., 2015), the lag in the development of behavioral health measures as compared to physical health measures is concerning (Institute of Medicine, 2006). Our findings of an association between three of our seven process measures and mortality provide support for the predictive validity of these measures and for their use as quality
Role of funding source
Nothing declared.
Contributors
Each author has contributed significantly to the work and agrees to the submission. Katherine E. Watkins obtained funding, designed the study, developed quality measures, interpreted data, and drafted and edited the article. Susan M. Paddock specified statistical models, led analyses, reviewed results, and reviewed and edited the manuscript. Teresa J. Hudson oversaw the IRB review and obtaining data, reviewed results, and reviewed and edited the manuscript. Songthip Ounpraseuth conducted
Conflict of interest
No conflict declared.
Acknowledgements
This material is the result of work supported with resources and the use of facilities at the Central Arkansas Veteran Healthcare Center, Little Rock, AR. Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R01DA033953. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The sponsors had no role in the
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