In 2021, an ad hoc committee of the United States (U.S.) National Academies of Science, Engineering, and Medicine (NASEM) affirmed that robust, relationship-centered primary care is the foundation of efficient, effective health care. Yet the ad hoc committee also noted primary care was “slowly dying,” due to chronic under-investment, ill-suited payment models, and inadequate workforce planning and development. Encouragingly, efforts to revitalize primary care are underway. To accelerate this movement by generating expert consensus recommendations on the highest priority actions to take in repairing the frayed U.S. primary care base, clinical scientists at the University of California Davis (UCD) School of Medicine convened the Summit to Revitalize Primary Care (Rev PC). Summit recommendations were generated in four closed working sessions of a national Expert Committee. Committee members were selected to ensure a breadth of perspectives (e.g., health plans, purchasers of insurance, regulatory agencies, health systems, clinicians, educators, researchers, economists) from the public and private sectors. Seven high priority recommendations emerged: (1) Increase the proportion of spending on primary care, coupled with initiatives to slow the growth in total health care spending; (2) Pay for primary care using models that support high quality, team-based, relationship-centered, equitable care; (3) Assist practices in transformation to advanced primary care models and assess the impacts on clinical teams, patients, and communities; (4) Maximize primary care’s potential to equitably advance health; (5) Advocate for training an appropriately large and diverse primary care physician workforce; (6) Expand research to address the most pressing issues in primary care; (7) Collaborate with a broad array of societal stakeholders in messaging the importance of robust primary care. These recommendations both overlap with and expand on those of the NASEM ad hoc committee and subsequent Standing Committee on Primary Care. Broad pursuit of the recommendations would catalyze sustained momentum toward appropriate primary care investment and workforce planning and development, enabling U.S. primary care to realize its yet-unfulfilled potential to improve population health and advance health equity while helping to control growth in total health care costs.

Early imaging for uncomplicated acute low back pain has no diagnostic benefit yet is completed after nearly one-quarter of primary care visits for acute back pain. This qualitative study examined patient and clinician perspectives on facilitators and barriers to deferring imaging for acute low back pain, including potential messages regarding a watchful waiting strategy without early imaging. Qualitative data derived from six patient focus groups (N = 30 patients with recent visits for acute low back pain) in Sacramento, CA and nine semi-structured physician interviews in 2020. Patients were asked about expectations regarding imaging, perceptions of care received for acute low back pain, and perspectives about potential messages encouraging a watchful waiting approach without early imaging. Clinicians were asked about facilitators and barriers to deferring low-value imaging. We used thematic analysis guided by grounded theory to identify and integrate themes. Over half of patients had received early imaging during their recent back pain episode. Patients expected physicians to provide a detailed rationale for ordering imaging or not. Patients were typically not persuaded by information on potential harms of imaging and sometimes thought discussion of imaging harms would undermine their trust in the clinician. Patients would be more willing to defer imaging if provided detailed and empathic guidance on pain management. Physicians expressed confidence in advocating a watchful waiting approach without imaging but acknowledged challenges in building patient trust during time-pressed visits, particularly when seeing patients for the first time. This qualitative study highlights several challenges to deferring early imaging in acute low back pain, as patients typically expect early imaging and were skeptical of clinician messaging about imaging harms. Physicians highlighted lack of a previously established, trustful relationship as a common structural barrier to deferring low-value spinal imaging.

Importance:Acute back pain is a common reason for primary care visits and often results in low-value spinal imaging. Objective:To evaluate the effect of a standardized patient-delivered intervention on rates of low-value spinal imaging among primary care patients with acute low back pain. Design, Setting, and Participants:In this randomized clinical trial, physicians or advanced practice clinicians were recruited from March 22 to August 5, 2021, from 10 adult primary care or urgent care clinics in Sacramento, California. The intervention period was from May 1, 2021, to March 30, 2022, with follow-up from October 28, 2021, to June 30, 2023. Analyses were performed from April 1 to June 25, 2024. Intervention:Clinicians were randomized 1:1 to intervention or control. Intervention clinicians received 3 simulated office visits, each with a standardized patient instructor (SPI) portraying a patient with acute uncomplicated back pain. At each visit, SPIs provided clinician feedback guided by a 3-step model: (1) set the stage for deferred imaging by building trust, (2) convey empathy, and (3) communicate optimism while advocating watchful waiting without imaging. Control clinicians received no intervention. Main Outcomes and Measures:The primary outcome was lumbar spinal imaging completion within 90 days of acute low back pain visits, with study clinicians assessed up to 18 months of follow-up. Secondary outcomes were cervical spine imaging completion after acute neck pain visits, any imaging completion after an adult visit, patient experience ratings of clinicians (scale range, 0-100), and use of targeted communication skills during an audio-recorded standardized patient evaluation visit at median follow-up of 16.8 months (range, 14.1-18.0 months). Results:The analysis included 53 clinicians; mean (SD) age was 46.7 (1.0) years, and 35 (66.0%) reported female gender. A total of 25 were in the intervention group and 28 in the control group. After adjustment for prerandomization rates, patients with acute low back pain who saw intervention and control clinicians during follow-up had similar rates of lumbar imaging (194 of 1234 clinic visits [15.7%] vs 226 of 1306 clinic visits [17.3%]; adjusted ratio of postintervention vs preintervention odds ratios [AORR], 1.00; 95% CI, 0.72-1.40). Adjusted follow-up rates of imaging for acute neck pain (AORR, 1.16; 95% CI, 0.83-1.63) and overall imaging (AORR, 1.07; 95% CI, 0.97-1.19) were not significantly different among patients of intervention and control clinicians. Intervention and control clinicians had similar mean (SD) patient experience ratings during follow-up (88.6 [28.7] vs 88.8 [28.3]; adjusted mean difference-in-differences, -1.0; 95% CI, -3.0 to 0.9). During audio-recorded standardized patient visits, intervention clinicians had significantly better ratings than controls on eliciting the patient's perspective (adjusted standardized difference [ASD], 0.62; 95% CI, 0.05-1.19) and conveying empathy (ASD, 1.16; 95% CI, 0.55-1.77). Conclusions and Relevance:In this randomized clinical trial of an educational intervention using simulated office visits to encourage a watchful waiting approach for acute low back pain, the intervention had no significant effect on low-value spinal imaging rates or patient experience ratings. Trial Registration:ClinicalTrials.gov Identifier: NCT04255199.

Background Patients with acute low back pain frequently request diagnostic imaging, and clinicians feel pressure to acquiesce to such requests to sustain patient trust and satisfaction. Spinal imaging in patients with acute low back pain poses risks from diagnostic evaluation of false-positive findings, patient labeling and anxiety, and unnecessary treatment (including spinal surgery). Watchful waiting advice has been an effective strategy to reduce some low-value treatments, and some evidence suggests a watchful waiting approach would be acceptable to many patients requesting diagnostic tests. Methods We will use key informant interviews of clinicians and focus groups with primary care patients to refine a theory-informed standardized patient-based intervention designed to teach clinicians how to advise watchful waiting when patients request low-value spinal imaging for low back pain. We will test the effectiveness of the intervention in a randomized clinical trial. We will recruit 8–10 primary care and urgent care clinics (~ 55 clinicians) in Sacramento, CA; clinicians will be randomized 1:1 to intervention and control groups. Over a 3- to 6-month period, clinicians in the intervention group will receive 3 visits with standardized patient instructors (SPIs) portraying patients with acute back pain; SPIs will instruct clinicians in a three-step model emphasizing establishing trust, empathic communication, and negotiation of a watchful waiting approach. Control physicians will receive no intervention. The primary outcome is the post-intervention rate of spinal imaging among actual patients with acute back pain seen by the clinicians adjusted for rate of imaging during a baseline period. Secondary outcomes are use of targeted communication techniques during a follow-up visit with an SP, clinician self-reported use of watchful waiting with actual low back pain patients, post-intervention rates of diagnostic imaging for other musculoskeletal pain syndromes (to test for generalization of intervention effects beyond back pain), and patient trust and satisfaction with physicians. Discussion This trial will determine whether standardized patient instructors can help clinicians develop skill in negotiating a watchful waiting approach with patients with acute low back pain, thereby reducing rates of low-value spinal imaging. The trial will also examine the possibility that intervention effects generalize to other diagnostic tests. Trial registration ClinicalTrials.gov NCT 04255199 . Registered on January 20, 2020

Context: Tapering of long-term opioid therapy (LTOT) increased after publication of the 2016 CDC opioid guidelines, followed by anecdotal reports of exacerbated pain among tapered patients. However, two systematic reviews of limited evidence from multidisciplinary pain control programs found similar or better pain ratings after tapering versus baseline. Objective: To evaluate the association between opioid dose tapering and subsequent emergency (ED) visits, outpatient primary care visits and hospitalizations for pain among patients prescribed LTOT. Study Design: Retrospective cohort study. Dataset: 2015-2019 de-identified administrative data from the Optum Labs Data Warehouse, including medical and pharmacy claims and eligibility information for commercial and Medicare Advantage enrollees, representing a mixture of ages and geographical regions. Population: Adults ≥18 years old who were prescribed stable doses of LTOT ≥50 morphine milligram equivalents per day during a 12-month baseline period Outcome Measures: Monthly counts of ED visits, primary care visits, and hospitalizations for pain up to 12 months after cohort entry. Pain visits were defined by diagnostic codes for musculoskeletal or other specific chronic pain in the primary position on ED and hospitalization claims, or in any position for primary care visit claims. Analysis: Monthly counts were modeled using negative binomial regression as a function of tapering (≥15% relative dose reduction during 6 overlapping 60-day periods after cohort entry), total baseline pain and non-pain ED visits, primary care visits and hospitalizations, and adjusted for patient level-covariates (sociodemographics, comorbidities). Results: Among 51,361 patients prescribed stable LTOT, 14,331 patients (27.9%) tapered after cohort entry. Tapering was associated with more subsequent ED visits (adjusted incidence rate ratio [aIRR] 1.18, 95% CI: 1.11-1.27) and fewer subsequent primary care visits (aIRR 0.95, CI: 0.92-0.99) for pain. Hospitalizations for pain control were unchanged (aIRR 1.04, CI: 0.95-1.15). Conclusions: Among patients prescribed LTOT, opioid tapering was associated with subsequently more ED visits yet fewer primary care visits for pain, suggesting a shift in pain care from outpatient to the higher acuity emergency setting post-taper. The findings suggest tapering may have led to increased pain, disruption of primary care relationships, or some combination of these effects.

INTRODUCTION:National guidelines recommend that patients with chronic noncancer pain prescribed long-term opioid therapy (LTOT) undergo periodic urine drug testing (UDT), yet UDT is performed inconsistently, and little evidence supports the utility of this approach. We examined patient and prescriber factors associated with UDT.METHODS:A 1-year retrospective cohort study of 5690 patients prescribed LTOT by 689 clinicians in a network of 13 primary care and specialty clinics. Negative binomial regression examined patient and prescriber factors associated with the number of tests completed, and logistic regression examined prescriber and practice level testing likelihood. Analyses were adjusted for patient and clinician characteristics and accounted for patient clustering within prescribers.RESULTS:A total of 2256 patients (39.6%) had UDT completed at least once. More UDT completion was associated with Black patient race and receipt of more opioid prescriptions, as well as with clinician testing compliance.CONCLUSIONS:UDT was relatively infrequent in patients prescribed LTOT and associated with patient factors not known to confer greater opioid-related risk, such as race. In addition, there was significant clinician-driven variation in UDT. Given the uncertain clinical utility of such testing, these findings signal the need for strategies to address potential biases in the use of UDT.

ImportanceOpioid tapering has been associated with negative consequences, such as increased overdoses and mental health needs. Tapering could also alter use of health care services and worsen care of comorbid conditions through disruption in primary care.ObjectiveTo evaluate tapering of stable long-term opioid therapy (LTOT) and subsequent health care service use and chronic condition care.Design, Setting, and ParticipantsA retrospective cohort study was conducted from January 1, 2008, to December 31, 2019. Data analysis was performed from July 9, 2020, to December 9, 2022. Data from the Optum Labs Data Warehouse, which contains deidentified retrospective administrative claims data and linked electronic health record data for commercial and Medicare Advantage enrollees, were used. Adults aged 18 years or older prescribed stable doses of LTOT at 50 morphine milligram equivalents or more per day during a 12-month baseline period were included, including subcohorts with hypertension or diabetes.ExposuresOpioid tapering, with 15% or more relative reduction in mean daily dose in 6 overlapping periods during 6 months.Main Outcomes and MeasuresEmergency department visits, hospitalizations, primary care and specialist visits, antihypertensive or antiglycemic medication adherence, and blood pressure and hemoglobin A1c levels during up to 12 months’ follow-up. Covariates included sociodemographic characteristics, comorbidities, health care use, and chronic condition control.ResultsAmong 113 604 patients (60 764 [53.5%] women; mean [SD] age, 58.1 [11.8] years) prescribed LTOT, 41 207 had hypertension and 23 335 had diabetes; in all cohorts, approximately half were women, and half were aged 50 to 65 years. In the overall cohort, tapering was associated with more emergency department visits (adjusted incidence rate ratio [aIRR], 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR, 1.16; 95% CI, 1.12-1.20), with similar magnitude associations in the hypertension and diabetes subcohorts. Tapering was associated with fewer primary care visits in the overall cohort (aIRR, 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR, 0.98; 95% CI, 0.97-0.99). For the hypertension or diabetes subcohorts, tapering was associated with reduced medication adherence (hypertension: aIRR, 0.60; 95% CI, 0.59-0.62; diabetes: aIRR, 0.69; 95% CI, 0.67-0.71) and small increases in diastolic blood pressure and hemoglobin A1c level.Conclusions and RelevanceIn this cohort study of patients prescribed LTOT, opioid tapering was associated with more emergency department visits and hospitalizations, fewer primary care visits, and reduced antihypertensive and antidiabetic medication adherence. These outcomes may represent unintended negative consequences of opioid tapering for policy makers and clinicians to consider.

Context: Acute back pain is a common reason for primary care visits and often results in low-value spinal imaging. Objective: To determine the effect of a standardized patient-based intervention on primary care clinician communication during visits with patients with acute low back pain. Study Design: Randomized clinical trial (NCT 04255199). Setting: 10 primary care clinics in Sacramento, CA. Population Studied: Primary care clinicians were randomized 1:1 to intervention or control groups (n=22 intervention and 28 control). Intervention: Intervention clinicians received 3 simulated office visits over with standardized patient instructors (SPIs) portraying patients with acute back pain. During visits, SPIs delivered feedback guided by a theory-informed intervention model, titled Watchful Waiting to Avoid Inappropriate Testing (WAIT). Control clinicians received no intervention. The three steps of WAIT are: 1) set the stage for deferred imaging by building trust, 2) convey empathy, and 3) communicate optimism while advocating a plan without imaging. Outcome measures: We report here on secondary outcomes of targeted communication behaviors during an audio-recorded standardized patient evaluation visit conducted at 9-12 months, which were independently coded using the Four Habits coding scheme: 1) Invest in the Beginning (of the Visit), 2) Elicit the Patient's Perspective, 3) Convey Empathy, and 4) Invest in the End. Results: During evaluation visits, intervention and control clinicians had similar mean ratings on Invest in the Beginning (7.1 vs. 6.7, p=0.37), Elicit the Patient's Perspective (10.2 vs. 9.3, p=0.26), and Invest in the End (22.1 vs. 22.1, p=0.98). Intervention and control clinicians did not differ significantly on the expression of optimism or recommending a watchful waiting approach without imaging. Intervention clinicians, however, had significantly higher mean ratings on the Convey Empathy scale (10.5 vs. 6.7, p<.001) with a Cohen's D of 0.95 (95% CI: 0.44-1.46). Intervention clinicians were rated significantly higher (p<.01) on each of the scale components: eliciting emotion, validating emotion, and identification of patients' feelings. Conclusions: A simulated office visit intervention substantially enhanced clinician empathic communication with patients with acute back pain. However, it did not improve other targeted communication behaviors including making recommendations for conservative approaches without imaging.

Introduction: Despite the pressing need for primary care-based suicide prevention initiatives and growing acknowledgement of recruitment difficulties and Institutional Review Board (IRB) challenges in suicide research, we are aware of no illustrative examples describing how IRB decisions in the design of a primary care trial can compound recruitment challenges.Methods: The CDC-funded trial (NCT02986113) of Men and Providers Preventing Suicide aimed to examine the effects of a tailored computer program encourage men with suicidal thoughts (n = 304, ages 35-64) to discuss suicide with a primary care clinician and accept treatment. Before a visit, participants viewed MAPS or a nontailored control video. Post-visit, both arms were offered telephone collaborative care, as mandated by the institutional review board (IRB). We previously showed that exposure to MAPs led to improvements in communication about suicide in a primary care visit. In this paper, we report data on the study's primary outcome, suicide preparatory behaviors.Results: After screening nearly 4100 men, 48 enrolled. Recruitment challenges, which were exacerabted by an IRB mandate narrowing post-intervention patient management differences between trial arms, limited detection of the effects of MAPS on suicide preparatory behaviors.Conclusions: While primary care settings are key sites for suicide prevention trials, issues such as recruitment difficulties and overly restrictive IRB requirements may limit their utility. Methodological innovation to improve recruitment and ethical guidance to inform IRB decision-making are needed.

Context:Studies have shown certain risks associated with dose tapering and discontinuation among patients prescribed long-term, higher-dose opioid therapy. It is unknown whether these risks of overdose and mental health crisis are also associated with dose disruption in patients prescribed lower doses of opioid therapy.Objective:To determine associations between opioid dose disruption or discontinuation and rates of overdose and mental health crisis among patients prescribed long-term, low- to moderate- opioid therapy.Study Design:Retrospective cohort study.Setting:Data from the OptumLabs® Data Warehouse, years 2008-2019, which contains de-identified, longitudinally linkable administrative data, including medical and pharmacy claims and eligibility information as well as electronic health data for commercial and Medicare Advantage enrollees. Patients represent a diverse mix of ages, ethnicities and United States geographical regions.Population:US adults prescribed stable opioid therapy with average doses of 10-49 morphine milligram equivalents/day during one or more 6-month baseline period, with <10% monthly dose fluctuation compared to baseline dose (to establish eligibility), with 2-12 months of follow-up for each baseline period. Exposure: 50-100% relative reduction of average daily opioid dose during any one of six overlapping 60-day windows within the first 7 months of follow-up.Outcome Measures:Emergency or hospital encounters for all-drug overdose or mental health crisis (depression, anxiety, or suicide attempt) during up to 12 months follow-up. Negative binomial regression estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of time-varying dose disruption or discontinuation.Results:Among 369,085 patients with 658,756 baseline periods of stable opioid dosing, 9.6% of patients had a ≥50% dose reduction; 5.6% of patients completely discontinued opioids. In adjusted models, a ≥50% dose reduction (compared to continuing at baseline dose) was associated with an aIRR of 1.28 (95% CI: 1.14-1.44) for overdose and 1.57 (95% CI: 1.36-1.82) for mental health crisis. Discontinuing opioids was associated with an aIRR of 1.25 (95%CI: 1.08-1.45) for overdose and aIRR of 1.79 (1.46-2.20) for mental health crisis.Conclusions:Among patients prescribed stable, long-term lower dose opioid therapy, large relative dose reductions (50+%) were significantly associated with increased risk of overdose and mental health crisis.

Context: Opioid dose tapering has increased among patients prescribed long-term opioid therapy (LTOT). Concerns have been raised that tapering may disrupt the patient-physician relationship, which could negatively impact healthcare utilization and co-morbid chronic disease control. Objective: To evaluate the impact of opioid dose tapering on outpatient, emergency (ED), and hospitalization utilization among patients prescribed LTOT who have hypertension or diabetes. Study Design: Retrospective cohort study 2008-2019. Dataset: Data from the OptumLabs® Data Warehouse contains de-identified retrospective administrative claims data, including medical and pharmacy claims and eligibility information as well as electronic health record (EHR) data for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities and geographical regions. Population: Adults aged ≥18 years who were (1) prescribed stable doses of LTOT ≥50 morphine milligram equivalents (MME)/day during a 12-month baseline period and (2) had hypertension or diabetes treated with medication for ≥2 months/year. Outcomes: Monthly counts of primary care visits, specialty care visits, ED visits, and hospitalizations for up to 12 months after cohort entry. Visit counts were modeled using negative binomial regression as a function of tapering (≥15% relative dose reduction during 6 overlapping 60-day periods after cohort entry), and patient level-covariates (sociodemographics, comorbidities, chronic disease severity, and baseline utilization). Results: Among 41,213 patients with hypertension and 23,340 patients with diabetes prescribed stable LTOT, tapering was associated with fewer subsequent primary care visits among both hypertension and diabetes (adjusted incidence rate ratio [aIRR] 0.95, CI 0.93-0.96 and 0.96, 95% CI: 0.94-0.98, respectively), more ED visits (aIRR 1.10, CI: 1.07-1.14 and 1.09, CI 1.04-1.14), but no significant differences in specialty visits (aIRR 1.02, CI: 0.98-1.06 and 1.00, CI 0.96-1.05). Tapering was associated with a higher rate of hospitalization for hypertension (aIRR 1.16, CI: 1.08-1.24) but not diabetes (aIRR 1.08, CI 0.99-1.18). Conclusions: Among patients with hypertension or diabetes prescribed LTOT, opioid tapering was associated with subsequently lower primary care and higher ED utilization plus higher hospital utilization among patients with hypertension. The impacts of these utilization shifts on chronic disease control warrant study.

Background Multimorbidity is common, and care is impacted by patient life context. Effective, efficient interventions to improve patient-centered outcomes such as perceived treatment burden are limited. There is a need for interventions that integrate patient contextual information into primary care encounters to improve such outcomes. Patient life context is a multitude of factors that influence a patient’s life and healthcare, including social determinants of health and broader elements such as family and work demands. Methods This pilot randomized controlled trial (RCT) protocol will compare standard pre-visit planning to context-informed pre-visit planning that incorporates the patient’s life context, for patients with diabetes plus other chronic comorbid conditions. Primary outcomes include measures of trial protocol and intervention feasibility and acceptability: physician study and visit perceived burden, patient satisfaction, and patient, physician and staff experience with the trial. Additional measurements of intervention impact include: initial estimates of effect size on patient treatment burden and other patient-oriented outcomes, change in glycemic control, and other intermediate medical outcomes. Discussion This intervention is novel as it collects patient life context information using a direct person-to-person approach, allows physicians to review the information prior to patient arrival at the clinic and, where appropriate, incorporate it when negotiating treatment plans, and is longitudinal, summarizing evolving contextual information over time. This pilot RCT has the potential to demonstrate trial protocol and intervention feasibility and acceptability, and estimate effect size on patient and provider outcomes, to inform for a future, definitive RCT. Trial Registration: This trial was registered at ClinicalTrials.gov prior to patient enrollment: NCT04568382

Studies employing data collected over 15 years ago suggested salutary effects of postbaccalaureate (PB) premedical coursework on medical school class diversity, academic performance, and primary care training. The studies may have limited current applicability given changes in medical school admissions paradigms and population demographics. Using data from interviewees at >1 of 5 California public medical schools between 2011-2013 (N=3805), we examined associations of PB premedical coursework with underrepresented race/ethnicity; academic performance (United States Medical Licensing Examination Step 1 and Step 2 scores, clerkship Honors); and primary care residency. Adjusting for age, sex, and year, PB coursework was associated with underrepresented race/ethnicity, but not after further adjustment for self-designated disadvantage (SDA). PB coursework was not associated with academic performance or primary care residency. Holistic consideration of SDA and UIM status in admissions coupled with robust matriculant support may merit exploration as an alternative to PB coursework for increasing medical school diversity.

Importance Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis. Objective To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids. Design, Setting, and Participants Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion. Exposures Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period. Main Outcomes and Measures Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity. Results The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21). Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

Opioid-related mortality continues to rise. Though risks of prescription opioid misuse and abuse are well known, short-term mortality across a range of prescription opioid exposure is unclear. This study was conducted in order to assess the short-term mortality associated with quantity of reported opioid prescriptions, An observational analysis was performed using data from the Medical Expenditure Panel Survey, years 2005–2015, a population-based, nationally representative household survey. This study included adults (age 18+) with prescription data and death status reported during their 2-year survey participation. Key exposure is the number of opioid prescriptions (0, 1–5, 6 or more) in year 1 of survey participation. The main outcome is all-cause mortality reported during the 2-year survey participation. Of 90,622 participants, 14% reported at least 1 opioid prescription. There were 774 (0.9%) deaths during the survey period, 551 (0.7%) among those not reporting opioids, 127 (1.2%) among those reporting 1–5 opioid prescriptions, and 96 (3.9%) among those reporting 6 or more opioid prescriptions. After adjusting for sociodemographics, health status, and utilization, there was no significant association between category of opioid prescriptions and death during the study period; adjusted odds ratios = 0.86 (95% CI = 0.66, 1.22, p = 0.27) and 0.99 (95% CI = 0.74, 1.34, p = 0.96), respectively, for 1–5 prescriptions and 6 or more prescriptions. In a nationally representative sample, opioid prescriptions were associated with increased short-term mortality only without adjustment for sociodemographics, health status, or utilization. The relationship between prescription opioid use and mortality risk is more complex than previously reported, meriting further examination.

Background: Physician denial of patient requests is associated with lower patient satisfaction. Our objective was to explore factors that influence physician request denial and patient satisfaction after request denial. Methods: Cross-sectional observational study of 1141 adult patients seen during 1319 outpatient visits with 56 primary care physicians. We measured patients' postvisit self-report of requests and request fulfillment, visit satisfaction, sociodemographics, health status, symptom burden, life satisfaction, medical skepticism, and whether patients saw their usual physician and a faculty or resident physician. We used mixed-effects regression analyses to identify predictors of request denial and visit satisfaction among patients who had a request denied. Results: Patients made at least 1 request at 867 visits (65.7%) with at least 1 denied request reported at 182 visits (21.0%). Patients who saw their usual physician were less likely to report a request denial (adjusted Odds Ratio [aOR], 0.61; 95% CI, 0.42 to 0.88), and patients with the highest symptom burden (aOR, 2.21; 95% CI, 1.38 to 3.55) or greater medical skepticism (aOR, 1.35; 95% CI, 1.03 to 1.78) were more likely to report request denials. After request denials, patients seeing their usual physicians reported significantly greater visit satisfaction compared with not seeing their usual physician (adjusted percentile rank in visit satisfaction: 12.4%; 95% CI, 3.5% to 21.2%). Conclusions: Approximately one fifth of visits in primary care have a denied request. Having an office visit with one's usual physician is associated with reduced likelihood of request denial and may mitigate the adverse impacts of request denial on patient visit satisfaction.

BACKGROUND:Prior studies examining the association of opioid prescriptions with satisfaction with care involved limited, selected samples with mixed findings. We examined this issue, of relevance to reducing discretionary opioid prescribing, in a US representative sample. METHODS:We performed an observational study of adults (N = 69,985) enrolled in the 2005 to 2015 US Medical Expenditure Panel Surveys. We examined the association of high (top quartile) satisfaction with receipt of 0, 1 to 5, or ≥6 opioid prescriptions per year. The base model adjusted for demographics and year; the full model added adjustment for health status (12-item Short Form Survey). A sensitivity analysis further adjusted for outpatient visits. RESULTS:In the base model, respondents who received 1 to 5 or ≥6 opioid prescriptions were each less likely to have high satisfaction than those who received no opioid prescriptions (adjusted odds ratios [AORs] [95% CIs] 0.83 [0.79-0.88] and 0.70 [0.63-0.79], respectively). After adding health status adjustment, compared with respondents receiving no opioid prescriptions, those receiving 1 to 5 were similarly likely and those reporting ≥6 were more likely to have high satisfaction (AORs [95% CIs] 1.00 [0.94-1.06] and 1.44 [1.27-1.63], respectively). The findings were not substantively affected by further adjustment for outpatient visits. DISCUSSION:In a US national sample, individuals who received ≥6 opioid prescriptions in a year were more likely to have top quartile satisfaction than those receiving fewer or no opioid prescriptions after accounting for health status. Whether the high satisfaction among such individuals was driven by the prescriptions themselves or by other personal characteristics requires study, as do the effects of deprescribing.

As medical schools seek to address the growing disparity between the socioeconomic makeup of their students and the general population, it is important to understand the academic trajectory of disadvantaged students. We used a locally-developed multicomponent socioeconomic disadvantage (SED) measure and the self-designated disadvantaged (SDA) question ["yes" (+) or "no" (-)] from the American Medical College Application Service application to examine academic performance of students from three disadvantaged categories (high SED/SDA+, high SED/SDA-, and low SED/SDA+); with low SED/SDA-as the reference group across five California schools. Compared with reference, the DA+ subgroups scored lower on USMLE Step 1 and Step 2 Clinical Knowledge examinations and received fewer clerkship Honors. After adjustment for academic metrics and sociodemographic variables, high SED subgroups performed similarly to reference, but performance gaps for low SED/SDA+ students persisted. Medical schools must better understand the institutional and other drivers of academic success in disadvantaged students.