Roberts Eric T, Sileanu Florentina E, Li Yaming, Anderson Timothy S, Thorpe Carolyn T, Cashy John, Suda Katie J, Radomski Thomas R, Mor Maria K, Essien Utibe R, Vanneman Megan E, Fine Michael J, Gellad Walid F
Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, VA Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania, USA.
Health Serv Res. 2025 Jul 5:e70001. doi: 10.1111/1475-6773.70001.
To examine whether eligibility for Veterans Health Administration (VA) community care, which expanded Veterans' access to VA-funded care outside VA, increased the likelihood of Veterans concurrently filling prescriptions for opioids and central nervous system (CNS)-active medications.
We used a regression discontinuity design to analyze Veterans across a distance threshold for community care eligibility in the Veterans Choice Program, under which Veterans residing > 40 miles from the closest VA medical facility staffed by ≥ 1 full-time primary care physician qualified for community care. We used local linear regression to test whether exceeding this 40-mile threshold was associated with discontinuities in the probability of receiving overlapping supplies of opioids and another CNS medication (benzodiazepine, muscle relaxant, antiepileptic, or sleep aid) for ≥ 30 days per year.
We used VA pharmacy data for prescriptions filled at VA facilities, VA Program Integrity Tool files for prescriptions paid by VA and filled in community pharmacies, and Medicare and Medicaid data for prescriptions covered by those programs. Our analysis included annual cross-sectional samples of Veterans who filled ≥ 1 opioid prescription through VA, community care, Medicare, or Medicaid and lived 36-39 or 41-44 miles from the nearest VA facility during federal FYs 2016-2019 (n = 180,903 Veteran-year observations).
Among Veterans who filled an opioid prescription, 34.1% concurrently received another CNS medication for ≥ 30 days. Exceeding the threshold for community care eligibility was associated with a 1.14 percentage point (pp) increase (95% CI: 0.08, 2.20) in the probability of concurrently receiving an opioid and another CNS drug during 2016-2019. Discontinuities in overlap were larger among Veterans with a serious mental illness (2.7 pp.; 95% CI: 0.6, 4.9) during 2016-2019. During 2018-2019, discontinuities were larger in the overall sample (1.6 pp.; 0.0, 3.1) and among non-Hispanic Black Veterans (5.4 pp.; 95% CI: 0.5, 10.4).
Overall, VA community care eligibility was associated with a small increase in medication overlap involving opioids and other CNS-active medications. Increases in overlap were larger in certain Veteran subgroups and later study years, underscoring a need for continued monitoring of higher-risk co-prescribing in VA community care.
探讨退伍军人健康管理局（VA）社区护理资格（该资格扩大了退伍军人在VA以外获得VA资助护理的机会）是否增加了退伍军人同时开具阿片类药物和中枢神经系统（CNS）活性药物处方的可能性。
我们采用回归断点设计，分析退伍军人选择计划中社区护理资格距离阈值范围内的退伍军人。根据该计划，居住在距离配备至少1名全职初级保健医生的最近VA医疗设施超过40英里的退伍军人有资格获得社区护理。我们使用局部线性回归来测试超过这个40英里的阈值是否与每年至少30天同时接受阿片类药物和另一种CNS药物（苯二氮卓类、肌肉松弛剂、抗癫痫药或助眠药）重叠供应的概率不连续有关。
我们使用VA设施开具处方的VA药房数据、VA支付并在社区药房开具处方的VA项目完整性工具文件，以及这些项目涵盖的处方的医疗保险和医疗补助数据。我们的分析包括2016 - 2019财年通过VA、社区护理、医疗保险或医疗补助开具至少1张阿片类药物处方且居住在距离最近VA设施36 - 39英里或41 - 44英里的退伍军人年度横断面样本（n = 180,903退伍军人年观察值）。
在开具阿片类药物处方的退伍军人中，34.1%的人同时接受另一种CNS药物至少达30天。超过社区护理资格阈值与2016 - 2019年期间同时接受阿片类药物和另一种CNS药物治疗的概率增加1.14个百分点（pp）（95%CI：0.08，2.20）相关。2016 - 2019年期间，患有严重精神疾病的退伍军人重叠不连续情况更大（2.7 pp；95%CI：0.6，4.9）。在2018 - 2019年期间，总体样本（1.6 pp；0.0，3.1）和非西班牙裔黑人退伍军人（5.4 pp；95%CI：0.5，10.4）中的重叠不连续情况更大。
总体而言，VA社区护理资格与涉及阿片类药物和其他CNS活性药物的药物重叠略有增加有关。在某些退伍军人亚组和后期研究年份中，重叠增加幅度更大，这突出表明需要继续监测VA社区护理中高风险联合处方情况。
