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Key Points Question How does the risk of overdose change with the number of days with concurrent opioid and benzodiazepine use? Findings In this cohort study of US Medicare data, the overdose risk associated with concurrent benzodiazepine use changed over time. Concurrent benzodiazepine use was associated with a 5-fold increase in the risk of opioid-related overdose during the initial 90 days and an increase of 1.87 times on days 91 to 180. Meaning Policy interventions should focus on preventing concurrent opioid and benzodiazepine use in the first place instead of reducing the length of concurrent use. Patients using both medications should be closely monitored, particularly during the first days of concurrent use.

Background Only 50% of atrial fibrillation ( AF ) patients recommended for oral anticoagulation ( OAC ) use these medications, and less than half of them adhere to OAC . In a cohort of Medicare beneficiaries newly diagnosed with AF , we identified groups of patients with similar trajectories of OAC use and adherence, and evaluated patient characteristics affecting group membership. Methods and Results We selected continuously enrolled Medicare Part D beneficiaries with first AF diagnosis in 2014 to 2015 (n=34 898). We calculated the proportion of days covered with OAC over the first 12 months after diagnosis and identified OAC adherence trajectories using group‐based trajectory models. We constructed multinomial logistic regression models to evaluate how demographics, system‐level factors, and clinical characteristics were associated with group membership. We identified 4 trajectories of OAC adherence: patients who never used OAC (43.8%), late OAC initiators (7.6%), early OAC discontinuers (8.9%), and continuously adherent patients (40.1%). Predictors such as sex, black race, residence in the South, or HAS ‐ BLED score were associated with not only OAC use, but also the timing of initiation and the likelihood of discontinuation. For example, HAS ‐ BLED score ≥4 was associated with a higher likelihood of not using OAC (odds ratio 1.35; 95% CI , 1.14–1.62), of late initiation (1.55; 95% CI , 1.11–2.05), and of early discontinuation (odds ratio 1.35; 95% CI , 1.01–1.84). Conclusions We identified 4 distinct trajectories of OAC adherence after first AF diagnosis, with <45% of newly diagnosed AF patients belonging to the trajectory group characterized by continuous OAC adherence. Trajectories were associated not only with demographic and clinical characteristics but also with regional factors.

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BACKGROUND/OBJECTIVE Uncertainty regarding benefits and risks associated with acetylcholinesterase inhibitors (AChEIs) in severe dementia means providers do not know if and when to deprescribe. We sought to identify which patient‐, provider‐, and system‐level characteristics are associated with AChEI discontinuation. DESIGN Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS), version 3.0, Area Health Resource File, and Nursing Home Compare. Cox‐proportional hazards models with time‐varying covariates were used to identify patient‐, provider‐, and system‐level factors associated with AChEI discontinuation (30‐day or more gap in supply). SETTING US Medicare–certified nursing homes (NHs). PARTICIPANTS Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106). RESULTS The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). The most commonly prescribed AChEIs were donepezil (77.8%), followed by transdermal rivastigmine (14.6%). The cumulative incidence of AChEI discontinuation was 29.7% at the end of follow‐up (330 days), with mean follow‐up times of 194 days for continuous users of AChEIs and 105 days for those who discontinued. Factors associated with increased likelihood of discontinuation were new admission, older age, difficulty being understood, aggressive behavior, poor appetite, weight loss, mechanically altered diet, limited prognosis designation, hospitalization in 90 days prior, and northeastern region. Factors associated with decreased likelihood of discontinuation included memantine use, use of strong anticholinergics, polypharmacy, rurality, and primary care prescriber vs geriatric specialist. CONCLUSION Among NH residents with severe dementia being treated with AChEIs, the cumulative incidence of AChEI discontinuation was just under 30% at 1 year of follow‐up. Our findings provide insight into potential drivers of deprescribing AChEIs, identify system‐level barriers to deprescribing, and help to inform covariates that are needed to address potential confounding in studies evaluating the potential risks and benefits associated with deprescribing. J Am Geriatr Soc 67:1871–1879, 2019