PURPOSE:Clostridioides difficile infection (CDI) is a hospital-acquired infection commonly treated with oral vancomycin. An institutional policy aimed at reducing costs by substituting compounded liquid vancomycin for capsules may have the unintended consequence of having the liquid formulation prescribed at discharge, potentially delaying patients' access due to a lack of availability in pharmacies or lack of insurance coverage. This study aimed to evaluate hospital readmission rates of patients prescribed either vancomycin capsules or liquid upon discharge. METHODS:This was a retrospective cohort study conducted at an academic hospital using electronic health records data over a 6-year timeframe. The primary outcomes were all-cause and CDI-specific readmission rates within 30 days of discharge, and secondary outcomes included readmission rates within 60 and 90 days. Baseline characteristics were compared using chi-square or Mann-Whitney U tests. The hazard ratio (HR) for readmission was calculated using a Cox proportional hazards model, and readmission rates were analyzed using a Poisson regression model. All readmissions were confirmed by chart review. RESULTS:A total of 440 patients (61.3% female; median age, 58 years) were included; of these, 68% (n = 298) were prescribed vancomycin liquid and 32% (n = 142) a capsule form. Baseline characteristics were similar in the 2 groups, with the exception of the presence of inflammatory bowel disease (19.0% vs 6.4%, P < 0.0001) and median length of stay (6 days vs 8 days, P = 0.010). Patients prescribed vancomycin liquid were not more likely to be readmitted within 30 days relative to those prescribed capsule, with an adjusted HR for all-cause readmission of 1.58 (95% CI, 0.92-2.73) and an adjusted HR for CDI-specific readmission of 2.21 (95% CI, 0.72-6.76). However, patients prescribed liquid were more likely to be readmitted within 60 days, with an adjusted HR for all-cause readmission of 1.87 (95% CI, 1.19-2.94) and an adjusted HR for CDI-specific readmission of 2.84 (95% CI, 1.14-7.06). CONCLUSION:A hospital pharmacy practice implemented to reduce medication costs may impact vancomycin prescribing at discharge and, in turn, may negatively impact readmission rates for patients with CDI treated with oral vancomycin.

Background: This study evaluates the impact of Real-Time Prescription Benefits (RTPB), a tool integrated into electronic health records (EHRs), on patient out-of-pocket costs in an academic institution. RTPB provides prescribers with alternative, less expensive medications based on insurance plans. The primary measure was cost-savings, defined as the difference between the out-of-pocket cost of the prescribed medication and its alternative. Methods: A retrospective analysis of prescriptions from outpatient clinics in a university-based health system was conducted between May 2020 and July 2021. Prescriptions were analyzed at the 2nd level of the Anatomical Therapeutic Chemical (ATC) classification system. Costs were standardized to a 30-day supply. Standardized cost and total cost per prescription, and overall savings for the top 20 medication classes at the 2nd ATC level were calculated. The overall impact of RTPB was estimated based on selecting the least expensive alternative suggested by RTPB. Results: The study found that RTPB information was provided for 22% of prescriptions, with suggested alternatives for 1.26%. Among prescriptions with an alternative selected, the standardized average cost saving was $38.83. The study realized $15,416 in patient total cost savings. If the least expensive RTPB-suggested alternative were chosen for all prescriptions, an estimated $276,386 could have been saved. Psychoanaleptic and psycholeptic medications were the most prescribed with an alternative, with most savings in specialty drugs like anthelmintic and immunostimulant medications. Conclusion: The study highlights the importance of RTPB in reducing patient costs. It reports patient cost-savings with RTPB in prescribing decisions. Future research could explore the impact of RTPB on medication adherence using pharmacy claims data.

Quality improvement (QI) is based on a methodology of baseline measurement, intervention, and remeasurement/analysis, with iterative improvement cycles along the way. The accuracy of the data used for measuring and remeasuring quality is therefore paramount, which leads to the question: What if the data are not accurate?

Background: Florida House Bill 21 (HB21) was implemented in July 2018 to limit prescriptions of Schedule II opioids for acute pain patients, but it is unclear whether such restrictions have a collateral influence on the utilization of commonly prescribed adjuvant pain medications. Objective: The objective of this study was to assess whether this law was associated with a change in use patterns of gabapentinoids, benzodiazepines, and muscle relaxants. Methods: We obtained prescription claims for medications dispensed from January 1, 2015, to June 31, 2019, from a health plan serving a large Florida employer. Interrupted time series analyses were conducted to compare pre-HB21 and post-HB21 implementation changes in the mean monthly number of users and prescriptions for gabapentinoids, benzodiazepines, and muscle relaxants. Results: There was a 6% immediate increase (relative risk: 1.06; 95% confidence interval: 1.02, 1.11) in the monthly proportion of gabapentinoid users, and an 11% immediate increase in the monthly proportion of gabapentinoids prescriptions (relative risk: 1.11; 95% confidence interval: 1.04, 1.18) per 1000 patients following law implementation. However, after the law, we observed a significant reduction in trend for the monthly proportion of muscle relaxants and benzodiazepine users. Conclusions: An increased number of patients and prescriptions were observed for gabapentinoids, while fewer patients received benzodiazepines and muscle relaxants after HB21. In previous studies, opioid prescription restriction laws are shown to reduce opioids, but this work suggests that these laws may also have unintended consequences for the use of adjunctive medications that were not intended to be affected.

Background Many states have implemented opioid days’ supply restriction policies, leading to reductions in opioid prescribing. Although research within certain provider types exist, no study has evaluated a restriction policy by various provider types. Objective To evaluate changes in opioid utilization following a days’ supply restriction policy stratified by provider type: surgery, emergency medicine, primary care, specialty care, and dentistry. Design Interrupted time series (ITS) Participants Opioid prescription claims of patients in a private health plan serving a large Florida employer from 1/1/2015 to 3/31/2019. Provider types were determined using the Healthcare Provider Taxonomy Code associated with the national provider identifier (NPI). Interventions Florida’s opioid restriction policy implemented on July 1, 2018. Main Measures Changes in mean morphine milligram equivalent (MMEs), mean days’ supply, and mean number of units dispensed per opioid prescription before and after policy implementation. Key Results There were 10,583 opioid initial prescriptions dispensed. Treating providers were classified as surgery (16.4%; n = 1732), emergency care (14.3%; n = 1516), primary care (21.2%; n = 2241), specialty care (11.4%; n = 1207), and dentistry providers (23.7%; n = 2511). Significant reductions in mean days’ supply were observed across most provider types ranging from 14% reduction for dentistry providers to 41% reduction for specialty care providers. Significant changes were observed for emergency care and specialty care providers with a 30% (p = 0.001)and 29% (p < 0.001) reduction in mean MME, respectively, and a 27% (p = 0.040) reduction in mean number of units dispensed in emergency care providers, after implementation. Pre-implementation trends in opioid prescribing varied by provider type impacting the effects of the opioid days’ supply restriction policy. Conclusions Pre-policy opioid prescribing varied by provider type with a differential impact on mean MMEs, mean days’ supply, and mean number of units dispensed per prescription following implementation.

BACKGROUND:Florida House Bill 21 (HB21) was implemented in July 2018 to limit Schedule II opioids prescriptions for patients with acute pain to a 3-day supply. Little is known about the potential unintended effects that such opioid restriction policies may have on chronic pain patients, who are exempt from the law.OBJECTIVE:We aimed to evaluate the effect of HB21 on opioid utilization measures among a cohort of chronic opioid therapy (COT) patients.STUDY DESIGN:A quasi-experimental design with interrupted time series analyses.SETTING:Pharmacy claims from January 1, 2015 to June 31, 2019 from a large employer-based health plan in Florida.METHODS:COT patients were those who received a ≥ 70 days' supply of opioids in the prior 90 days, representing 15,310 patients. Interrupted time series analyses were conducted to compare the following monthly measures among COT patients before and after HB21 implementation: 1) number of COT patients, 2) daily Morphine Milligram Equivalents [MMEs], 3) days' supply of prescriptions.RESULTS:There was a significant 25% reduction in the trend (pre-HB21 RR: 0.95, 95% CI: 0.93, 0.96 versus post-HB21 RR: 0.70, 95% CI: 0.65, 0.76) and an 8% immediate decrease (RR: 0.92, 95% CI: 0.88, 0.97) in the monthly prevalence of COT patients after HB21 implementation. However, no significant change was observed in trends for monthly number of days supplied per prescription, monthly MMEs per COT patient-day, or total MMEs per prescription.LIMITATIONS:Our study used data from employer-based private health insurance and did not include a longer post-policy period to adjust for implementation lag.CONCLUSION:Fewer patients received COT after HB21; however, patients who continued to receive COT experienced no significant changes in their regimen. The study did not assess whether COT patients were appropriately tapered or if therapeutic alternatives were initiated for new chronic pain patients.

PURPOSE: The distribution and vaccination of COVID-19 vaccines to billions of people worldwide will likely be one of the biggest public health undertakings in history. There has been a large focus on identifying processes to safely, efficiently, and effectively vaccinate large populations. We aimed to describe the development and operationalization of a drive-in COVID-19 vaccine site in a parking garage adjacent to outpatient clinics at University of Florida (UF) Health Physicians and how it was informed by the roll-out of SARS-CoV-2 testing and administration of respiratory vaccinations. DESIGN/METHODOLOGY/APPROACH: A technical description and analysis of a drive-in COVID-19 vaccine site. FINDINGS: We incrementally increased the number of vaccines performed per day from 300 in the first 2 weeks to 700 an additional 2 weeks later. By the end of January, we completed nearly 14 000 vaccinations. At this capacity, we estimate the site could performed 5000 vaccinations per week. PRACTICAL IMPLICATIONS: This manuscript provides step-by-step guidance how to develop, operationalize, and implement a sustainable drive-in COVID-19 vaccination site. ORIGINALITY/VALUE: To our knowledge, this is the first description of a drive-in approach to COVID-19 vaccination. Our findings can help inform other health entities as they develop or expand vaccination efforts that may serve as a template for other sites to adapt.

Background Patient portals are now widely available and increasingly adopted by patients and providers. Despite the growing research interest in patient portal adoption, there is a lack of follow-up studies describing the following: whether patients use portals actively; how frequently they use distinct portal functions; and, consequently, what the effects of using them are, the understanding of which is paramount to maximizing the potential of patient portals to enhance care delivery. Objective To investigate the characteristics of primary care patients using different patient portal functions and the impact of various portal usage behaviors on patients’ primary care service utilization and appointment adherence. Methods A retrospective, observational study using a large dataset of 46,544 primary care patients from University of Florida Health was conducted. Patient portal users were defined as patients who adopted a portal, and adoption was defined as the status that a portal account was opened and kept activated during the study period. Then, users were further classified into different user subgroups based on their portal usage of messaging, laboratory, appointment, and medication functions. The intervention outcomes were the rates of primary care office visits categorized as arrived, telephone encounters, cancellations, and no-shows per quarter as the measures of primary care service utilization and appointment adherence. Generalized linear models with a panel difference-in-differences study design were then developed to estimate the rate ratios between the users and the matched nonusers of the four measurements with an observational window of up to 10 quarters after portal adoption. Results Interestingly, a high propensity to adopt patient portals does not necessarily imply more frequent use of portals. In particular, the number of active health problems one had was significantly negatively associated with portal adoption (odds ratios [ORs] 0.57-0.86, 95% CIs 0.51-0.94, all P<.001) but was positively associated with portal usage (ORs 1.37-1.76, 95% CIs 1.11-2.22, all P≤.01). The same was true for being enrolled in Medicare for portal adoption (OR 0.47, 95% CI 0.41-0.54, P<.001) and message usage (OR 1.44, 95% CI 1.03-2.03, P=.04). On the impact of portal usage, the effects were time-dependent and specific to the user subgroup. The most salient change was the improvement in appointment adherence, and patients who used messaging and laboratory functions more often exhibited a larger reduction in no-shows compared to other user subgroups. Conclusions Patients differ in their portal adoption and usage behaviors, and the portal usage effects are heterogeneous and dynamic. However, there exists a lack of match in the patient portal market where patients who benefit the most from patient portals are not active portal adopters. Our findings suggest that health care delivery planners and administrators should remove the barriers of adoption for the portal beneficiaries; in addition, they should incorporate the impact of portal usage into care coordination and workflow design, ultimately aligning patients’ and providers’ needs and functionalities to effectively deliver patient-centric care.

BackgroundThe objective of this study was to investigate the impact of patient portal adoption on patients' primary care utilization and appointment adherence.MethodsWe conducted a retrospective observational study using a panel difference-in-differences (DID) framework to investigate the use of primary care services by patients, adjusting for their disease burden and allowing for time-dependent portal effect. A large dataset with 46,544 patients of University of Florida (UF) Health during the study period July 2013 - June 2016 was used. The main outcome measures are disease burden adjusted rates of office visits arrived, no-show, and cancellation to primary care physicians (PCPs) per quarter between patient portal adopters (denoted as users) and non-users.ResultsAt the time of adoption, the quarterly PCP office visit rate ratio (RR) of patient portal users to non-users was 1.33 (95% CI, 1.27-1.39; p<0.001). The RRs were between 0.94 to 0.99 up to four quarters after portal adoption (p=0.749, 0.100, 0.131, and 0.091, respectively), and were significantly less than one at the seventh (RR =0.82; 95% CI, 0.73-0.91; p<0.001) and the eighth (RR=0.80; 95% CI, 0.70-0.90; p<0.001) quarters post adoption. The quarterly no-show rates of the users were significantly smaller (RRs were between 0.60 and 0.83) except for the seventh, eighth and tenth quarters post adoption. In these three quarters, the no-show rates were not significantly changed (p=0.645, 0.295, and 0.436, respectively). Quarterly cancellation rates were not significantly affected by portal adoption (p>0.05 for all cases).ConclusionsPatient portal users' disease burden adjusted PCP office visit rate was significantly reduced in one and a half year and thereafter post portal adoption. PCP appointment no-show rate was also significantly reduced and cancellation rate was not affected, implying improved care engagement of patients.

The financial success of a malpractice insurance program is directly influenced by how effectively the covered providers respond to risk. This article describes a University Self-Insurance Program partnership to provide small grants to providers who have the expertise and passion for a specific risk reduction activity that is cost effective and measurable and has a high probability of improving patient care and reducing claims or lawsuits. Implementation of this small grant concept can be tailored to become operational in virtually any setting from an independent medical practice to a multistate healthcare system.

Both affiliation with an academic medical center and implementation of service line management may be effective management strategies for community health care organizations. The authors describe the design, implementation, and performance of a unique combination of these two distinct strategies for cardiovascular program development in the affiliation of the University of Florida Health Science Center with Health First, a regional community-based integrated delivery system.