Brown University School of Public Health, Providence, Rhode Island (P.M.).
VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.).
Ann Intern Med. 2019 Apr 2;170(7):433-442. doi: 10.7326/M18-2574. Epub 2019 Mar 12.
More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems.
To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose.
Nested case-control study.
VA and Medicare Part D.
Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions.
The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications.
Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005).
Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems.
Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety.
U.S. Department of Veterans Affairs.
在美国退伍军人事务部（VA）登记的患者中，有一半以上的人还同时参加了医疗保险，他们可以选择从 VA 或 Medicare 参与方提供者那里获得处方。如果这两个系统中的提供者不能协调护理，或者如果处方使用情况没有在系统之间进行跟踪，那么这种双重系统的护理可能会导致不安全的阿片类药物使用。
评估双重系统开阿片类药物处方与处方类阿片类药物过量死亡之间的关系。
嵌套病例对照研究。
VA 和 Medicare 部分 D。
从同时参加 VA 和 Medicare 部分 D 的所有退伍军人中确定病例和对照患者，这些患者至少从这两个系统中的一个系统开了一份阿片类药物处方。2012 年或 2013 年死于处方类阿片类药物过量的 215 例病例患者根据死亡日期（即索引日期）与 833 例存活对照患者进行了匹配（最多 1:4），匹配因素包括年龄、性别、种族/民族、残疾、是否参加医疗补助或低收入补贴、管理式医疗参保情况、居住地区和农村程度以及基于药物的合并症衡量标准。
暴露是指索引日期前 6 个月内阿片类药物处方的来源，分为 VA 专用、Part D 专用或 VA 和 Part D（即双重使用）。结果是从国家死亡索引中确定的非故意或原因不明的处方类阿片类药物过量死亡。使用条件逻辑回归，根据年龄、婚姻状况、处方药物监测计划和其他药物的使用情况，调整了与该结果之间的关联。
在病例患者中，平均年龄为 57.3 岁（SD，9.1），194 名（90%）为男性，181 名（84%）为非西班牙裔白人。总体而言，60 例病例患者（28%）和 117 例对照患者（14%）接受了双重阿片类药物处方。与仅接受 VA 阿片类药物（比值比[OR]，3.53[95%CI，2.17 至 5.75]；P<0.001）或仅接受 Part D 阿片类药物（OR，1.83[CI，1.20 至 2.77]；P=0.005）的患者相比，双重使用者死于处方类阿片类药物过量的几率显著更高。
数据来自 2012 年至 2013 年，无法捕捉到退伍军人事务部或 Medicare 部分 D 系统之外获得的处方。
在同时参加 VA 和 Medicare 部分 D 的退伍军人中，双重使用阿片类药物处方与处方类阿片类药物过量死亡独立相关。这种退伍军人致命过量的危险因素强调了跨医疗保健系统进行护理协调以提高阿片类药物处方安全性的重要性。
美国退伍军人事务部。
