Access to Health Care Improves COVID-19 Vaccination and Mitigates Health Disparities Among Medicare Beneficiaries.

BACKGROUND: COVID-19 disproportionately impacts the elderly, particularly racial/ethnic minorities and those with low socioeconomic status (SES). These latter groups may also have higher vaccine hesitancy. We aim to evaluate if access to care improves COVID-19 vaccination rates and improves health disparities. METHODS: We conducted a retrospective cohort study of Medicare patients receiving care in a high-touch capitated network across ten states. We collected type and date of COVID-19 vaccine and demographic and clinical data from the inpatient and outpatient electronic health records and socioeconomic status from the US census. Our primary outcome was completing vaccination using logistic regression. RESULTS: Our cohort included 93,224 patients enrolled in the network during the study period. Sixty nine percent of all enrolled patients completed full vaccination. Those who completed vaccination did it with Pfizer (46%), Moderna (49%), and Jannsen (4.6%) vaccines. In adjusted models, we found that the following characteristics increased the odds of being vaccinated: being male, increasing age, BMI, and comorbidities, being Black or Hispanic, having had the flu vaccine in 2020, and increasing number of office primary care visits. Living in a neighborhood with higher social deprivation and having dual Medicaid/Medicare enrollment decreased the odds of completing full vaccination. CONCLUSIONS: Increasing office visit in a high-touch primary care model is associated with higher vaccination rates among elderly populations who belong to racial/ethnic minorities or have low socioeconomic status. However, lower SES and Medicaid populations continue to have difficulty in completing vaccination. KEY POINTS: • High COVID-19 vaccination rates of minorities enrolled in Medicare can be achieved. • Lower socioeconomic status is associated with completing vaccination. • Increasing office visits can lead to higher vaccination rates.

Impact of Prediabetes on Cardiac Function Among Primary Care Patients.

Background: Prediabetes is a novel risk factor recently associated with changes in the left ventricle. Our aim is to determine if prediabetes is associated with heart failure (HF) and structural heart disease. Methods: We conducted a cross-sectional study and performed screening echocardiograms to consecutive primary care patients. We calculated the hemoglobin A1c (HbA1c) within 3 months of the echocardiogram and classified patients as having normal glucose, low-risk or high-risk prediabetes or diabetes. Our primary outcome was HF defined as an ejection fraction (EF) <50% and HF with preserved EF. Our secondary outcome was structural heart disease defined as having either a large atrium, left ventricular hypertrophy, or low EF. Results: We included 15,056 patients who underwent a screening echocardiogram and had a recorded HbA1c. Only 2794 patients had a normal blood glucose, 4201 had low-risk prediabetes, 2499 had high-risk prediabetes, and the remainder had diabetes. The adjusted odds ratio (ORs) of HF for low-risk prediabetes, high-risk prediabetes and diabetes were 1.38 [confidence interval (95% CI) 1.07-1.78] (P = 0.01), 1.47 (95% CI 1.05-2.01) (P = 0.01), and 1.60 (95% CI 1.16-2.01) (P < 0.01), respectively, when compared with normoglycemic patients. The adjusted OR of HF with preserved EF for low- and high-risk prediabetes and diabetes were 1.17 (95% CI 0.86-1.60) (P = 0.30), 1.60 (95% CI 1.15-2.21) (P < 0.01), and 1.63 (95% CI 1.24-2.13) (P < 0.01), respectively, when compared with normoglycemic patients. Conclusions: Prediabetes is a prevalent condition associated with structural heart disease and HF.

A case of COVID-19 Reinfection and Systematic Review of Patterns of Reinfection.

We present a case of a middle age Hispanic patient with COVID-19 reinfection. We conducted a systematic review of the literature of reinfection cases and found that women represent the majority of the cases and that reinfection usually presents with more severe disease, particularly among healthcare workers.

Erratum to "Prior cardiovascular risk and screening echocardiograms predict hospitalization and severity of coronavirus infection among elderly Medicare patients" [American Journal of Preventive Cardiology 3C (2020) 100090].

[This corrects the article DOI: 10.1016/j.ajpc.2020.100090.].

Metformin is associated with lower hospitalizations, mortality and severe coronavirus infection among elderly medicare minority patients in 8 states in USA.

BACKGROUND AND AIMS: Metformin has antiviral and anti-inflammatory effects and several cohort studies have shown that metformin lower mortality in the COVID population in a majority white population. There is no data documenting the effect of metformin taken as an outpatient on COVID-19 related hospitalizations. Our aim was to evaluate if metformin decreases hospitalization and severe COVID-19 among minority Medicare patients who acquired the SARS-CoV2 virus. METHODS: We conducted a retrospective cohort study including elderly minority Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health records, demographic data, as well as clinical and echocardiographic data. We classified those using metformin as those patients who had a pharmacy claim for metformin and non-metformin users as those who were diabetics and did not use metformin as well as non-diabetic patients. Our primary outcome was hospitalization. Our secondary outcomes were mortality and acute respiratory distress syndrome (ARDS). RESULTS: We identified 1139 COVID-19 positive patients of whom 392 were metformin users. Metformin users had a higher comorbidity score than non-metformin users (p < 0.01). The adjusted relative hazard (RH) of those hospitalized for metformin users was 0.71; 95% CI 0.52-0.86. The RH of death for metformin users was 0.34; 95% CI 0.19-0.59. The RH of ARDS for metformin users was 0.32; 95% CI 0.22-0.45. Metformin users on 1000 mg daily had lower mortality, but similar hospitalization and ARDS rates when compared to those on 500-850 mg of metformin daily. CONCLUSIONS: Metformin is associated with lower hospitalization, mortality and ARDS among a minority COVID-19 population. Future randomized trials should confirm this finding and evaluate for a causative effect of the drug preventing disease.

Prior cardiovascular risk and screening echocardiograms predict hospitalization and severity of coronavirus infection among elderly medicare patients.

BACKGROUND: The COVID-19 pandemic has disproportionally impacted the elderly. In the United States and Europe the mortality rate of elderly patients with COVID-19 is greater than 30%. Our aim is to determine predictors of COVID-19 related hospitalization and severity of disease among elderly Medicare patients in the United States. METHODS: We conducted a retrospective cohort study including elderly Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health record, demographic, clinical and echocardiographic predictors. Our primary outcomes were hospitalization and adult respiratory distress syndrome (ARDS). Our secondary outcome was mortality. RESULTS: We identified 400 COVID-19 positive patients (incidence 5.2; (95% CI 4.7-5.7) per 1000 patients). The mean age of our patients was 72 â€‹± â€‹8, 60% were female, 82% were minorities and had a mean Charlson score of 2.9 â€‹± â€‹1.4. Two-hundred and forty-four patients were hospitalized due to COVID-19 (63%) and the mortality rate was 18%; 95% CI 14-22 with 1 patient still in the hospital. Age, socioeconomic status, Charlson score, systolic blood pressure, body mass index, grade 2 or 3 diastolic dysfunction, moderate or severe left ventricular hypertrophy were significant predictors of hospitalization and ARDS (p â€‹< â€‹0.05). CONCLUSIONS: Our study reports a lower incidence on a COVID-19 cohort than previously reported. Predictors of poor outcomes included socio-economic, cardiovascular risk and echocardiographic measures. High touch care with early cardiovascular risk factor modification could explain the low risk of events in our population.

Patients with elevated blood pressure or stage 1 hypertension have structural heart disease.

BACKGROUND: The 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations lower the hypertension threshold to 130/80 mmHg and recommends treatment for high-risk patients. Our aim is to determine whether the new blood pressure categories are associated with left ventricular (LV) structural changes and whether echocardiograms can provide risk stratification and help treatment initiation. METHODS: We conducted a cross-sectional study and performed screening echocardiograms to consecutive primary care patients. We calculated the Framingham score to identify patients with a low or intermediate score who had structural heart disease.We classified everyone as having normal, elevated blood pressure, stage 1 or stage 2 hypertension according to the 2017 ACC/AHA guidelines. We defined structural heart disease as having LV hypertrophy and an abnormal LV mass index. RESULTS: We included 16 650 patients who underwent a screening echocardiogram and had recorded blood pressure. Out of the 16 650 patients, 1465 patients had a normal blood pressure, 1382 had elevated blood pressure, 1333 had stage 1 hypertension, and the remainder had stage 2 hypertension. The adjusted odds ratios of having structural heart disease for elevated blood pressure and stage 1 hypertension were 1.30; 95% CI, 1.112-1.64; P < 0.01 and 1.69; 95% CI, 1.25-2.30; P < 0.01, respectively. We identified 542 patients with stage 1 hypertension who had a low or intermediate Framingham score and 19% (95% CI, 16-23%) had structural heart disease. CONCLUSION: A quarter of patients identified as having elevated blood pressure or stage 1 hypertension have structural heart disease. Screening echocardiograms may help to risk stratify those patients deemed ineligible for treatment.

The additive role of echocardiography in the screening for sudden death.

BACKGROUND: A clinically based sudden cardiac death (SCD) risk score has predictive value. Echocardiographic parameters predict SCD. Our aim was to evaluate the effect of adding echocardiographic parameters to the clinical SCD risk score for the prediction of all-cause mortality. METHODS: We conducted a retrospective cohort of screening echocardiograms performed on primary care patients. We calculated the SCD risk score and added the left ventricular (LV) mass index, LV hypertrophy, diastolic dysfunction, and LV ejection fraction (EF). We calculated the c-statistic, net reclassification index (NRI), and Hosmer-Lemeshow chi-square for the SCD score alone or combined with each echocardiographic parameter in predicting all-cause mortality. RESULTS: We included 6447 primary care patients who underwent a screening echocardiogram and had a SCD score. The c-statistic of the SCD score for mortality was 0.61; 95% CI 0.58-0.62 and the c-statistic for the score combined with LV mass index increased to 0.64; 95% CI 0.63-0.65 and for the score combined with LVEF, the c-statistic was 0.64;95% CI 0.63-0.67. When diastolic dysfunction and LV hypertrophy were added to the SCD score, the c-statistic did not significantly change (P > 0.05). The NRI for the addition of LV mass index and LVEF was 0.52 ± 0.02, and the Hosmer-Lemeshow statistic was nonsignificant (P > 0.05). CONCLUSIONS: Adding LV mass index or LVEF to the SCD risk score improves the ability to predict mortality, but in the primary care setting, the improvement is small and underscores the challenge of SCD prediction and prevention in the community.

High-touch care leads to better outcomes and lower costs in a senior population.

OBJECTIVES: There are several models of primary care. A form of high-intensity care is a high-touch model that uses a high frequency of encounters to deliver preventive services. The aim of this study is to compare the healthcare utilization of patients receiving 2 models of primary care, ​1 with high-touch care and 1 without. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective cohort study of 2 models of care used among Medicare Advantage populations. Model 1 is a high-touch care model, and model 2 is a standard care model. Compared with model 2, model 1 has smaller panel sizes and a higher frequency of encounters. We compared patients' healthcare utilization and hospitalizations between both models using a propensity score-matched analysis, matching by Charlson Comorbidity Index (CCI) score, age, and gender. RESULTS: We included 17,711 unmatched Medicare Advantage primary care patients and matched 5695 patients from both models of care. CCI scores, age, and gender were similar between both matched groups (P >.05). The median total per member per month healthcare costs in model 1 were $87 (95% CI, $26-$278) compared with $121 (95% CI, $52-$284) in model 2 (P <.01). The mean number of hospital admissions was lower in model 1 (0.10 ± 0.40) compared with model 2 (0.20 ± 0.58). The number of primary care physician visits and preventive medication use were higher in model 1 (P <.05 for both). CONCLUSIONS: In a propensity-matched sample of Medicare Advantage patients, those receiving high-touch care had lower healthcare costs and fewer hospitalizations. Potential explanations are higher preventive medication use and more frequent visits.

A screening echocardiogram to identify diastolic dysfunction leads to better outcomes.

BACKGROUND: Diastolic dysfunction (DD) can lead to heart failure and higher mortality. Echocardiograms can detect DD but are not indicated for screening in older adults. Our aim was to evaluate the prevalence of DD and the impact of identifying it in seniors. METHODS: We performed screening echocardiograms in 5227 consecutive patients between January 2014 and March 2015 in 36 senior-focused value-based clinics across six states. We determined the presence of the grade of DD and defined stage B grade II/III (asymptomatic) and of stage C grade II/III (symptomatic) DD by the presence or absence of typical HF symptoms. We obtained prescribed medications from the electronic health record to determine absolute changes in HF therapy before and after the echocardiogram. RESULTS: We included a group with no DD (n=649), a group with grade 1 DD (n=2875), and those with grades 2 and 3 (n=1357) who had normal ejection fraction. The prevalence of grade 2 or 3 DD with preserved ejection fraction was 25%; 95% CI: 24-26. The absolute change of ace-inhibitor use before and after the echocardiogram increased by 14, 19, 23, 27 in patients without DD, those with grade 1, grade 2 or 3 asymptomatic and grade 2 or 3 symptomatic, respectively. The use of ß-blocker, statin, and diuretic had similar trends. CONCLUSIONS: Seniors without previously known stage B or stage C heart failure have moderate-to-severe DD, 27% of whom were stage C. Identifying seniors with DD leads to improvement in care.

Screening echocardiograms in a senior focused value based primary care improves systolic heart failure detection and clinical management.

BACKGROUND: Screening echocardiograms are not indicated. Our aim is to evaluate the impact of screening echocardiograms on improving clinical management among older adults. METHODS: We performed screening echocardiograms for all consecutive patients and defined incident systolic heart failure (HF) as an ejection fraction of less than 50% among patients without a previous HF diagnosis. We reviewed medical record data to determine if the new cases where Stage B or C. We obtained prescribed medications and vital signs from the electronic health record to determine absolute changes before and after the echocardiogram. RESULTS: We performed an echocardiogram in 6,417 patients with a mean age of 71.4±6. The echocardiogram identified 292 seniors with new cases of systolic HF (5.34%; 95% CI: 4.7-5.9) and 239 were stage B HF. The increase in the use of ace-inhibitor, beta blocker when comparing the pre and post echocardiogram periods was highest in those with Stage C and those with ejection fraction lower than 40%. Systolic blood pressure (SBP) decreased from 140±19 to 136±15 (P<0.01) and low density lipoprotein (LDL) from 105±36 to 97±33 (P<0.01). CONCLUSIONS: Performing echocardiograms in senior-focused value-based primary care improves evidence-based cardiovascular treatment and short-term clinical outcomes, including lowering SBP and LDL.

Noninvasive differentiation of pulmonary arterial and venous hypertension using conventional and Doppler tissue imaging echocardiography.

To determine whether pulmonary arterial hypertension (PAH) and pulmonary venous hypertension (PVH) can be differentiated noninvasively, we reviewed data on 44 patients with pulmonary artery systolic pressure greater than or equal to 40 mm Hg by echocardiography and cardiac catheterization performed within 7 days of each other. Based on left ventricular end-diastolic pressure or pulmonary capillary wedge pressure, 20 patients were classified as having PVH and 24 as having PAH. Early (E) and late (A) diastolic mitral inflow velocities, deceleration time, early diastolic mitral annular velocity (E'), and E/A and E/E' ratios were remeasured in the two groups. Compared with patients with PAH, those with PVH had significantly higher E (107.8 +/- 27.3 vs 65.0 +/- 24.0 cm/s, P < .001), E/A (2.4 +/- 1.0 vs 0.9 +/- 0.4, P < .001), and E/E' (14.3 +/- 4.3 vs 5.1 +/- 1.9, P < .001), and significantly lower A (55.5 +/- 33.5 vs 74.1 +/- 20.8 cm/s, P < .001), E' (8.0 +/- 2.5 vs 13.1 +/- 3.6 cm/s, P = .001), and deceleration time (148.5 +/- 49.0 vs 192.3 +/- 41.9 milliseconds, P = .003). The area under receiver operating characteristic curve was 97% for E/E' and 91% for E/A. Optimal cutoff for diagnosing PVH was 9.2 for E/E' (sensitivity 95%, specificity 96%) and 1.7 for E/A (sensitivity 75%, specificity 91%). PAH and PVH may be differentiated by readily obtainable conventional and tissue Doppler parameters.

Postprandial hypertriglyceridemia increases circulating levels of endothelial cell microparticles.

BACKGROUND: This study evaluated a possible relationship between levels of endothelial microparticles (EMPs), known to be a sensitive indicator of endothelial disturbance, and changes in postprandial lipid levels in healthy volunteers after a low- or high-fat meal. METHODS AND RESULTS: Eighteen healthy subjects without known cardiovascular risk factors were evaluated. Lipid and EMP levels were measured before and 1 and 3 hours after a single low- or high-fat isocaloric meal. The low-fat meal had no significant postprandial effect on EMPs or lipids compared with fasting levels. In contrast, a single high-fat meal significantly increased EMP levels after 1 and 3 hours, from 389+/-54 (thousands per milliliter) when fasting to 541+/-139 (P=0.0002) and 677+/-159 (P<0.0001), respectively, and correlated with a postprandial elevation in serum triglycerides. CONCLUSIONS: A single high-fat meal led to a significant elevation of plasma EMP levels in healthy, normolipidemic subjects and correlated with a postprandial elevation of serum triglycerides. EMPs may be an indirect marker of endothelial dysfunction or injury induced by postprandial triglyceride-rich lipoproteins.

The complications of hypertension

Hypertension causes multisystem end-organ damage if left uncontrolled. Physicians should aim for good primary care - i.e. achieving target blood pressure control, patient compliance, and education; supported by regular clinical examination, and the use of appropriate laboratory services. Good primary care in preventing the complications is far more cost effective than treating the complications (AU)