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Kilaru AS, Perrone J, Kelley D, et al. Participation in a Hospital Incentive Program for Follow-up Treatment for Opioid Use Disorder. JAMA Netw Open. 2020;3(1):e1918511. doi:10.1001/jamanetworkopen.2019.18511
Pennsylvania experienced an 80% increase in emergency department (ED) visits for opioid overdose from 2016 to 2017.1 The engagement of patients with opioid use disorder (OUD) in treatment after hospital discharge is a key strategy in preventing subsequent opioid overdose.2,3 The Pennsylvania Department of Human Services established an incentive program to improve the rate of OUD follow-up treatment among Medicaid recipients.4 In the Opioid Hospital Quality Improvement Program, hospitals earned payment for designing and attesting to 4 distinct clinical pathways: (1) ED initiation of buprenorphine treatment, (2) warm handoff to community resources, (3) referral and treatment for pregnant patients, and (4) inpatient initiation of medication treatment. Payment of the full incentive ($193 000) was contingent on participation and attestation of all 4 pathways, with smaller incentives for partial participation. We evaluated participation in this program among hospitals.
This study was deemed to be exempt from review by the institutional review board at the University of Pennsylvania. Because this study was done with publicly reported data, no informed consent was required by the institutional review board. We conducted a cross-sectional analysis of all hospitals with an ED in Pennsylvania. We excluded pediatric, federal, and specialty hospitals. Participation in the program was publicly reported in January 2019.4 We obtained publicly reported data on hospital characteristics from the Pennsylvania Department of Health and county-level data from the Pennsylvania Open Data Portal.5,6 We used a multivariable logistic regression model with robust SEs to compare differences in characteristics of hospitals that fully participated with those that declined or partially participated. We report adjusted risk differences (ARDs) and corresponding 95% CIs. A 2-sided P < .05 was deemed to be statistically significant. Analyses were conducted using Stata, version 14 (StataCorp LLC). This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Of 155 hospitals that met the inclusion criteria, 79 (51%) attested to all 4 pathways, 45 (29%) attested to fewer than 4 pathways, and 31 (20%) declined to attest to any pathway (Table 1). A total of 93 hospitals (60%) attested to the first pathway, 124 (80%) to the second pathway, 118 (76%) to the third pathway, and 93 (60%) to the fourth pathway. Fully participating hospitals had a mean (SD) bed size of 250 (242), and partial or nonparticipating hospitals had a mean (SD) bed size of 163 (125). In the adjusted model, larger hospitals were full participants more often than smaller hospitals (ARD, 5 percentage points; 95% CI, 0.2-10 percentage points; P = .04) (Table 2). Hospitals affiliated with health systems were full participants more often than independent hospitals (ARD, 22 percentage points; 95% CI, 4-42 percentage points; P = .02). Compared with hospitals in the southeast region of the state, hospitals in the northeast region were full participants less often (ARD, −34 percentage points; 95% CI, −56 to −12 percentage points; P = .01), and hospitals in the central and western regions were full participants more often (central: ARD, 27 percentage points; 95% CI, 12-43 percentage points; P = .004; western: ARD, 38 percentage points; 95% CI, 22-53 percentage points; P < .001). Hospitals in counties with higher overdose rates were more often full participants (ARD, 5 percentage points; 95% CI, 2-8 percentage points; P = .006).
Pennsylvania introduced the first statewide financial incentive to engage patients with OUD in treatment after hospital discharge. Although most hospitals participated in the program, more were willing to arrange warm handoffs to community treatment facilities rather than initiate medication treatment for OUD. Study limitations include the focus on pathway adoption rather than patient outcomes and not accounting for partnerships between hospitals and community treatment resources. In future years of the program, hospitals can earn payments for annual improvement in the rate of OUD follow-up treatment. Policies seeking to facilitate this transition among all hospitals and communities should consider local barriers to treatment initiation and follow-up.
Accepted for Publication: October 29, 2019.
Published: January 3, 2020. doi:10.1001/jamanetworkopen.2019.18511
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Kilaru AS et al. JAMA Network Open.
Corresponding Author: Austin S. Kilaru, MD, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 421 Guardian Dr, 1303 Blockley Hall, Philadelphia, PA 19104 (email@example.com).
Author Contributions: Dr Kilaru had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Kilaru, Perrone, Kelley, Siegel, Meisel.
Acquisition, analysis, or interpretation of data: Kilaru, Perrone, Siegel, Lubitz, Mitra, Meisel.
Drafting of the manuscript: Kilaru.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Kilaru, Siegel, Mitra.
Obtained funding: Kilaru, Meisel.
Administrative, technical, or material support: Kelley, Lubitz, Meisel.
Supervision: Kilaru, Perrone, Meisel.
Conflict of Interest Disclosures: Dr Meisel reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.
Funding/Support: This work was supported by pilot grant P50 MH113840 from the Penn ALACRITY Center. Research reported in this publication was partially funded through Patient-Centered Outcomes Research Institute Award CDR-1511-33496.
Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents of this article do not represent the views of the US Department of Veterans Affairs or the US government. The statements presented in this article are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its Board of Governors, or its Methodology Committee.
Additional Contributions: Sally A. Kozak, MHA, RN, Deputy Secretary, Office of Medical Assistance Programs, Department of Human Services, Commonwealth of Pennsylvania, provided guidance for this project and leadership of this program; she was not compensated for her contributions. The Hospital and Healthsystem Association of Pennsylvania provided support.
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