Low-Income Participants' Preference Between Financial Incentives for Behavioral Goals vs Weight Loss Targets and Associations With Behavioral Goal Adherence.

PURPOSE: Examine associations between whether participants' were matched to their preferred financial incentive design and behavioral goal adherence in a weight management intervention. DESIGN: Secondary quantitative analysis incorporating qualitative survey data. SETTING: Primary care clinics in socioeconomically disadvantaged communities in New York City and Los Angeles. SUBJECTS: 668 participants (mean age 47.7 years, 81.0% female, 72.6% Hispanic) with obesity were enrolled in the Financial Incentives foR Weight Reduction (FIReWoRk) intervention. MEASURES: We explored qualitatively participant's reasons for hypothetically choosing a behavioral goal-directed vs a weight loss outcome-based financial incentive program. Additionally, behavioral adherence to different goals was collected at the 6-month timepoint, categorized by match to preferred financial incentive design. ANALYSIS: Logistic regression was used to examine if participants with certain demographic and higher psychosocial factors were more likely to choose goal-directed over outcome-based incentives. Additionally, logistic regression was used to test for associations between preference and behavioral adherence, using incentive type as an interaction term. RESULTS: 60.2% of participants preferred the goal-directed incentive, with the majority stating that it was more structured. Married participants were more likely to prefer goal-directed incentives (OR = 1.57, CI = 1.06-2.33, P = .025). Moderation analysis revealed that participants who preferred goal-directed and were matched to goal-directed had greater rates of behavioral adherence for program attendance and self-weighing, but not dietary tracking and physical activity tracking, compared to those who preferred outcome-based and were matched to outcome-based. CONCLUSION: Receiving one's preferred incentive design may not play a strong role in behavioral goal adherence during financially incentivized weight loss interventions.

Statin use for cardiovascular disease prevention: perceptions among people living with HIV in the United States.

BACKGROUND: People living with HIV (PLWH) may be at heightened risk for cardiovascular disease (CVD). Statin use and lifestyle changes reduce the risk of CVD but remain under-prescribed among PLWH. The objective of this study was to characterize knowledge of CVD and statin use, current usage, barriers to taking statins, and information desired by PLWH to improve statin uptake among PLWH in Los Angeles, CA. METHODS: Between April 2019 and April 2020, we conducted four focus group discussions (n = 37) with patients across three public community health clinics that serve PLWH in Los Angeles County, California. All clinics participated in a larger study to improve statin prescribing for PLWH. We asked about knowledge of statins, willingness to take a statin, possible barriers to statin usage, preferred information sources for health information, and desired information about statins. We utilized standard qualitative content analysis methods to identify themes. RESULTS: We found a range in the awareness of statins, with some participants reporting never having heard of statins while others had a history of statin use. There were concerns about the potential long-term effect of statin use, but participants expressed willingness to use CVD medications generally and statins specifically, especially if recommended by their healthcare provider. Participants also expressed interest in potential alternatives to statin usage such as exercising regularly and nutritious eating. CONCLUSIONS: More interventions are needed to increase statin use among PLWH to improve CVD outcomes, which also has implications for HIV progression. Clinics should aim to increase patient and provider knowledge about CVD risk and statin use for PLWH and provide shared decision-making tools that are easy to use and culturally appropriate.

Cost-effectiveness of goal-directed and outcome-based financial incentives for weight loss in low-income populations: the FIReWoRk randomized clinical trial.

BACKGROUND: The Financial Incentives for Weight Reduction (FIReWoRk) clinical trial showed that financial incentive weight-loss strategies designed using behavioral economics were more effective than provision of weight-management resources only. We now evaluate cost-effectiveness. METHODS: Cost-effectiveness analysis of a multisite randomized trial enrolling 668 participants with obesity living in low-income neighborhoods. Participants were randomized to (1) goal-directed incentives (targeting behavioral goals), (2) outcome-based incentives (targeting weight-loss), and (3) resources only, which were provided to all participants and included a 1-year commercial weight-loss program membership, wearable activity monitor, food journal, and digital scale. We assessed program costs, time costs, quality of life, weight, and incremental cost-effectiveness in dollars-per-kilogram lost. RESULTS: Mean program costs at 12 months, based on weight loss program attendance, physical activity participation, food diary use, self-monitoring of weight, and incentive payments was $1271 in the goal-directed group, $1194 in the outcome-based group, and $834 in the resources-only group (difference, $437 [95% CI, 398 to 462] and $360 [95% CI, 341-363] for goal-directed or outcome-based vs resources-only, respectively; difference, $77 [95% CI, 58-130] for goal-directed vs outcome-based group). Quality of life did not differ significantly between the groups, but weight loss was substantially greater in the incentive groups (difference, 2.34 kg [95% CI, 0.53-4.14] and 1.79 kg [95% CI, -0.14 to 3.72] for goal-directed or outcome-based vs resources only, respectively; difference, 0.54 kg [95% CI, -1.29 to 2.38] for goal-directed vs outcome-based). Cost-effectiveness of incentive strategies based on program costs was $189/kg lost in the goal-directed group (95% CI, $124/kg to $383/kg) and $186/kg lost in the outcome-based group (95% CI, $113/kg to $530/kg). CONCLUSIONS: Goal-directed and outcome-based financial incentives were cost-effective strategies for helping low-income individuals with obesity lose weight. Their incremental cost per kilogram lost were comparable to other weight loss interventions.

Goal-directed versus outcome-based financial incentives for smoking cessation among low-income, hospitalised patients: rationale and design of the Financial Incentives for Smoking Treatment II (FIESTA II) randomised controlled trial.

INTRODUCTION: Smoking remains the leading preventable cause of death in the USA. Low utilisation of treatments for smoking cessation remains a major barrier for reducing smoking rates. Financial incentives represent an innovative approach to increasing use of therapies for smoking cessation. This paper will describe the rationale and design of the Financial Incentives for Smoking Treatment II (FIESTA II) study, a randomised controlled trial to evaluate the effectiveness and feasibility of goal-directed and outcome-based financial incentives to promote smoking cessation among hospitalised smokers. METHODS AND ANALYSIS: We are recruiting adult participants who smoked tobacco in the 30 days prior to initial interview and are contemplating quitting smoking. These participants will come from two hospitals in underserved communities in New York City and Los Angeles. They will be randomised into one of three arms. The first arm consists of goal-directed financial incentives plus enhanced usual care, which includes hospital-directed information about quitting smoking, nicotine replacement therapy and referral to a Quitline. The second arm involves outcome-based financial incentives plus enhanced usual care. The third arm consists of enhanced usual care alone. Multiple phone interviews with the participants will be completed after randomisation to assess smoking cessation. Participants will earn $20 for each follow-up interview completed and $30 for each smoking cessation test completed. Those who are randomised to the financial incentive groups can earn an additional $700. The participants in the outcome-based group will receive payments solely for exhibiting cessation, whereas the participants in the goal-based group are also eligible for receiving payments after meeting milestones such as speaking with a helpline coach. ETHICS: Human research protection committees at New York University School of Medicine and the University of California Los Angeles (UCLA) David Geffen School of Medicine granted ethics approval.Protocol number: IRB#19-000 084. TRIAL REGISTRATION NUMBER: NCT03979885.

Effectiveness of Goal-Directed and Outcome-Based Financial Incentives for Weight Loss in Primary Care Patients With Obesity Living in Socioeconomically Disadvantaged Neighborhoods: A Randomized Clinical Trial.

Importance: Financial incentives for weight management may increase use of evidence-based strategies while addressing obesity-related economic disparities in low-income populations. Objective: To examine the effects of 2 financial incentive strategies developed using behavioral economic theory when added to provision of weight management resources. Design, Setting, and Participants: Three-group, randomized clinical trial conducted from November 2017 to May 2021 at 3 hospital-based clinics in New York City, New York, and Los Angeles, California. A total of 1280 adults with obesity living in low-income neighborhoods were invited to participate, and 668 were enrolled. Interventions: Participants were randomly assigned to goal-directed incentives, outcome-based incentives, or a resources-only group. The resources-only group participants were given a 1-year commercial weight-loss program membership, self-monitoring tools (digital scale, food journal, and physical activity monitor), health education, and monthly one-on-one check-in visits. The goal-directed group included resources and linked financial incentives to evidence-based weight-loss behaviors. The outcome-based arm included resources and linked financial incentives to percentage of weight loss. Participants in the incentive groups could earn up to $750. Main Outcomes and Measures: Proportion of patients achieving 5% or greater weight loss at 6 months. Results: The mean (SD) age of the 668 participants enrolled was 47.7 (12.4) years; 541 (81.0%) were women, 485 (72.6%) were Hispanic, and 99 (14.8%) were Black. The mean (SD) weight at enrollment was 98.96 (20.54) kg, and the mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 37.95 (6.55). At 6 months, the adjusted proportion of patients who lost at least 5% of baseline weight was 22.1% in the resources-only group, 39.0% in the goal-directed group, and 49.1% in the outcome-based incentive group (difference, 10.08 percentage points [95% CI, 1.31-18.85] for outcome based vs goal directed; difference, 27.03 percentage points [95% CI, 18.20-35.86] and 16.95 percentage points [95% CI, 8.18-25.72] for outcome based or goal directed vs resources only, respectively). However, mean percentage of weight loss was similar in the incentive arms. Mean earned incentives was $440.44 in the goal-directed group and $303.56 in the outcome-based group, but incentives did not improve financial well-being. Conclusions and Relevance: In this randomized clinical trial, outcome-based and goal-directed financial incentives were similarly effective, and both strategies were more effective than providing resources only for clinically significant weight loss in low-income populations with obesity. Future studies should evaluate cost-effectiveness and long-term outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03157713.

US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis.

OBJECTIVES: Nurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians. DESIGN, SETTING AND PARTICIPANTS: Using nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination. EXPOSURES: NPs/PAs. MAIN OUTCOME MEASURES: Use of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines. RESULTS: Before propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p<0.001) and worsening triage acuity scores (3.03, 2.85 and 2.67, p<0.001), respectively. After weighting, NPs/PAs-alone used fewer medications (2.62 vs 2.80, p=0.002), diagnostic tests (3.77 vs 4.66, p<0.001), procedures (0.67 vs 0.77, p<0.001), hospitalisations (OR 0.35 (95% CI 0.26 to 0.46)) and low-value CT/MRI studies (OR 0.65 (95% CI 0.53 to 0.80)) than physicians. Contrastingly, the NP/PA-physician combination used more medications (3.08 vs 2.80, p<0.001), diagnostic tests (5.07 vs 4.66, p<0.001), procedures (0.86 vs 0.77, p<0.001), hospitalisations OR 1.33 (95% CI 1.17 to 1.51) and low-value CT/MRI studies (OR 1.23 (95% CI 1.07 to 1.43)) than physicians-results were similar among EDs with >95% of NP/PA visits including the NP/PA-physician combination. CONCLUSIONS AND RELEVANCE: While U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

The National Heart Lung and Blood Institute Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Alliance.

OBJECTIVE: To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease. STUDY SETTING: NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma. STUDY DESIGN: The initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration. CONCLUSIONS: The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

Misperceptions of COVID-19 illness risk and preferences for business and school closures in the United States.

Misperceptions about COVID-19 health risks may be associated with preferences for school and business closures and fear of becoming seriously ill. We analyzed data from the Franklin Templeton-Gallup Economic of Recovery Study (July-December 2020, N = 35,068). Primary outcomes were whether a respondent favored closure of businesses or in-person schooling for elementary/secondary students. We also assessed respondents' fear of COVID-19 illness. We assessed risk misperceptions using respondents' estimates of the proportion of deaths from COVID-19 that occurred in persons under 55 years-old, the proportion of hospitalizations for COVID-19 that occurred in persons under 55 years-old, the mortality rate among patients hospitalized with COVID-19, and the rate of hospitalization for patients infected with COVID-19. The proportion of respondents who favored business closures ranged from 37% to 53%, and the proportion of respondents who favored school closures ranged from 38% to 44%. Most participants reported beliefs about COVID-19 health risks that were inaccurate, and overestimation of health risk was most common. For example, while deaths in persons younger than 55 years-old accounted for 7% of total U.S. deaths, respondents estimated that this population represented 43% of deaths. Overestimating COVID-19 health harms was associated with increased likelihood of fear of serious illness if infected, preferences for business closures, and preferences for school closures. U.S. survey respondents overestimated several COVID-19 risks, and overestimation was associated with increased fear of serious illness and stronger preferences for business/school lockdowns.

Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here.

BACKGROUND: Strategies to control coronavirus 2019 disease (COVID-19) have often been based on preliminary and limited data and have tended to be slow to evolve as new evidence emerges. Yet knowledge about COVID-19 has grown exponentially, and the expanding rollout of vaccines presents further opportunity to reassess the response to the pandemic more broadly. MAIN TEXT: We review the latest evidence concerning 10 key COVID-19 policy and strategic areas, specifically addressing: 1) the expansion of equitable vaccine distribution, 2) the need to ease restrictions as hospitalization and mortality rates eventually fall, 3) the advantages of emphasizing educational and harm reduction approaches over coercive and punitive measures, 4) the need to encourage outdoor activities, 5) the imperative to reopen schools, 6) the far-reaching and long-term economic and psychosocial consequences of sustained lockdowns, 7) the excessive focus on surface disinfection and other ineffective measures, 8) the importance of reassessing testing policies and practices, 9) the need for increasing access to outpatient therapies and prophylactics, and 10) the necessity to better prepare for future pandemics. CONCLUSIONS: While remarkably effective vaccines have engendered great hope, some widely held assumptions underlying current policy approaches call for an evidence-based reassessment. COVID-19 will require ongoing mitigation for the foreseeable future as it transforms from a pandemic into an endemic infection, but maintaining a constant state of emergency is not viable. A more realistic public health approach is to adjust current mitigation goals to be more data-driven and to minimize unintended harms associated with unfocused or ineffective control efforts. Based on the latest evidence, we therefore present recommendations for refining 10 key policy areas, and for applying lessons learned from COVID-19 to prevent and prepare for future pandemics.

Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges' into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery.

INTRODUCTION: Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory. METHODS AND ANALYSIS: This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings. ETHICS AND DISSEMINATION: The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT04104256.

Factors affecting statin uptake among people living with HIV: primary care provider perspectives.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of morbidity and mortality among people living with HIV (PLWH), but statin therapy, safe and effective for PLWH, is under-prescribed. This study examined clinic leadership and provider perceptions of factors associated with statin prescribing for PLWH receiving care in eight community health clinics across Los Angeles, California. METHODS: We conducted semi-structured telephone interviews with clinic leadership and providers across community health clinics participating in a larger study (INSPIRE) aimed at improving statin prescribing through education and feedback. Clinics included federally qualified health centers (N = 5), community clinics (N = 1) and county-run ambulatory care clinics (N = 2). Leadership and providers enrolled in INSPIRE (N = 39) were invited to participate in an interview. We used the Consolidated Framework for Implementation Research (CFIR) to structure our interview guide and analysis. We used standard qualitative content analysis methods to identify themes within CFIR categories; we also assessed current CVD risk assessment and statin-prescribing practices. RESULTS: Participants were clinic leaders (n = 6), primary care physicians with and without an HIV specialization (N = 6, N = 6, respectively), infectious diseases specialists (N = 12), nurse practitioners, physician assistants and registered nurses (N = 7). Ninety-five percent of providers from INSPIRE participated in an interview. We found that CVD risk assessment for PLWH is standard practice but that there is variation in risk assessment practices and that providers are unsure whether or how to adjust the risk threshold to account for HIV. Time, clinic and patient priorities impede ability to conduct CVD risk assessment with PLWH. CONCLUSIONS: Providers desire more data and standard practice guidance on prescribing statins for PLWH, including estimates of the effect of HIV on CVD, how to adjust the CVD risk threshold to account for HIV, which statins are best for people on antiretroviral therapy and on shared decision-making around prescribing statins to PLWH. While CVD risk assessment and statin prescribing fits within the mission and workflow of primary care, clinics may need to emphasize CVD risk assessment and statins as priorities in order to improve uptake.

Association of COVID-19 Risk Misperceptions With Household Isolation in the United States: Survey Study.

BACKGROUND: Adverse mental and emotional health outcomes are increasingly recognized as a public health challenge associated with the COVID-19 pandemic. OBJECTIVE: The goal of this study was to examine the association of COVID-19 risk misperceptions with self-reported household isolation, a potential risk factor for social isolation and loneliness. METHODS: We analyzed data from the Franklin Templeton-Gallup Economics of Recovery Study (July to December 2020) of 24,649 US adults. We also analyzed data from the Gallup Panel (March 2020 to February 2021), which included 123,516 observations about loneliness. The primary outcome was self-reported household isolation, which we defined as a respondent having no contact or very little contact with people outside their household, analogous to quarantining. RESULTS: From July to December 2020, 53% to 57% of respondents reported living in household isolation. Most participants reported beliefs about COVID-19 health risks that were inaccurate, and overestimation of health risk was most common. For example, while deaths in persons younger than 55 years old accounted for 7% of total US deaths, respondents estimated that this population represented 43% of deaths. Overestimating COVID-19 health risks was associated with increased self-reported household isolation, with percentage differences ranging from 5.6 to 11.8 (P<.001 at each time point). Characteristics associated with self-reported household isolation from the July and August 2020 surveys and persisting in the December 2020 survey included younger age (18 to 39 years), having a serious medical condition, having a household member with a serious medical condition, and identifying as a Democrat. In the Gallup Panel, self-reported household isolation was associated with a higher prevalence of loneliness. CONCLUSIONS: Pandemic-related harms to emotional and mental well-being may be attenuated by reducing risk overestimation and household isolation preferences that exceed public health guidelines.

Economic outcomes of depression screening after acute coronary syndromes: The CODIACS-QoL randomized clinical trial.

OBJECTIVE: To evaluate the cost-effectiveness of screening for depression in patients with acute coronary syndrome (ACS) and no history of depression. METHODS: Cost-effectiveness analysis of a randomized trial enrolling 1500 patients with ACS between 2013 and 2017. Patients were randomized to no screening, screening and notifying the primary care provider (PCP), and screening, notifying the PCP, and providing enhanced depression treatment. Outcomes measured were Healthcare utilization, costs, and incremental cost-effectiveness ratios. RESULTS: 7.1% of patients screened positive for depressive symptoms. There was no significant difference in usage of mental health services, cardiovascular tests and procedures, and medications. Mean total costs in No Screen group ($7440), in Screen, Notify, and Treat group ($6745), and in Screen and Notify group ($6204). The difference was only significant in the Screen and Notify group versus the No Screen group (-$1236, 95% confidence interval -$2388 to -$96). Because mean QALYs were higher (+0.003 QALY in Screen and Notify; +0.004 QALYs in Screen, Notify, and Treat) and mean total costs were lower in both intervention groups, these interventions were cost-effective. There was substantial uncertainty because confidence intervals around cost differences were wide and QALY effects were small. CONCLUSION: Depression screening strategies for patients with ACS may be modestly cost-effective.

The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016.

BACKGROUND: Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed. OBJECTIVE: To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries. DESIGN: We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services. SETTING/PARTICIPANTS: NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees. MAIN MEASURES: We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources. KEY RESULTS: During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study. CONCLUSIONS: US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.

Patient-Reported Reasons for Not Using Primary Prevention Statin Therapy.

Almost half of patients who meet American College of Cardiology/American Heart Association (ACC/AHA) criteria for statin therapy are untreated. We aimed to evaluate patient-reported reasons for not using guideline-recommended statin therapy in a public healthcare system. Achieving this goal is key to addressing gaps in care and reducing preventable cardiovascular morbidity. We surveyed patients who met 2013 ACC/AHA guidelines for statin therapy but were not using statins. The survey probed domains of patient knowledge regarding cardiovascular health and benefits of statins, barriers to use, physician trust, and interest in cardiovascular care. Among 71 patients eligible for guideline-recommended statin therapy but not currently taking statins, 49 (69%) had a high school education or lower, 41 (58%) reported that they were unaware they should be prescribed a statin and 49 (69%) were unaware of the benefits of statins. Almost all patients, 70 (99%), reported caring about their cardiovascular health, 61 (86%) reported that they had a high level of trust in their physician, and 51 (72%) reported a willingness to follow their physician's advice. Despite interest in cardiovascular health, awareness of benefits of statin therapy was low and knowledge of recommended statin therapy was low. Increasing patients' awareness of their eligibility through systematic testing and linkage to statin therapy, along with education, may increase statin use among patients recommended for therapy.

Guideline-Based Statin Eligibility, Coronary Artery Stenosis and Cardiovascular Events in Patients with Stable Chest Pain: A Secondary Analysis of the PROMISE Randomized Clinical Trial.

BACKGROUND: Recommendations for preventive statin treatment in patients with stable chest pain may be difficult as symptoms can be unspecific. It is unclear if coronary CT angiography (CTA)-detected coronary artery disease (CAD) can optimize statin prescription. METHODS: In stable chest pain patients randomized to CTA in the PROMISE trial, statin eligibility was defined per 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Primary outcome was a composite of death, myocardial infarction or unstable angina over 26 months median follow-up. Hazard ratios (HR) of non-obstructive (1-69% stenosis) and obstructive (≥70% stenosis) CAD for events were determined using Cox proportional hazard models. Calculated HR were then incorporated into the ACC/AHA pooled cohort equation (PCE) to revised ASCVD risk and assess re-classification of statin eligibility. RESULTS: Among 3986 patients (60.5 ± 8.2 years; 51% female), 72.9% (2904/3986) were statin eligible. Event rates in statin-eligible vs. ineligible patients were 3.3% vs. 2.3% (HR = 1.4 (95% CI 0.9-2.2), p = 0.142). Although the proportion of statin-eligible patients increased with CAD severity, 54% without CAD were statin eligible. Incorporating information on CAD into PCE reclassified 12.7% of patients (1.3% towards statin, 11.4% towards no statin). Similar results were found in stratified analysis of statin naïve patients (reclassification of 13.9%, 1.0% towards statin, and 12.9% towards no statin). As a result, revised ASCVD risk improved model discrimination in all patients (c-statistic: 0.59 (95 %CI 0.55-0.62) vs. 0.52 (95 %CI 0.49-0.56); p 0.001), while reducing statin use by 10.1% (62.7% vs. 72.9% statin eligible, p 0.001). CONCLUSION: In stable chest pain patients, integration of CAD into guideline recommendations was associated with greater accuracy to reclassify those at increased risk for incident events and a more efficient use of statins.

Differences in Cardiovascular Care Between Adults With and Without Opioid Prescriptions in the United States.

Background Patients prescribed opioids often have chronic conditions that increase their risk of adverse cardiovascular outcomes, but little is known about the primary preventive cardiovascular care these patients receive. Methods and Results We analyzed data from the 2014 to 2016 National Ambulatory Medical Care Survey to evaluate physicians' provision of primary preventive cardiovascular care to adults with and without opioid prescriptions. We included all visits made by adults 40 to 79 years old with at least 1 cardiovascular risk factor but no existing atherosclerotic cardiovascular disease. There were ≈32 million visits by adults who were prescribed opioids and ≈167 million visits by adults not prescribed opioids on an annual basis. The prevalence of primary preventive care was modest in patients with versus those without opioid prescriptions, respectively: (1) statins for patients with dyslipidemia (52.1% versus 46.3%); (2) statins for patients with diabetes mellitus (49.1% versus 37.9%); (3) antihypertensive agents for patients with hypertension (76.5% versus 65.8%); (4) diet/exercise counseling (40.5% versus 45.3%); and (5) smoking cessation therapy (25.3% versus 19.3%). In multivariate analyses, opioid use was associated with higher rates of statin therapy in patients with diabetes mellitus (adjusted relative risk [aRR], 1.25; 95% CI, 1.06-1.47; P=0.007) and antihypertensive medication in patients with hypertension (aRR 1.14; 95% CI, 1.06-1.22; P<0.001). Conclusions Overall adherence to guideline-recommended primary preventive cardiovascular care during ambulatory visits was suboptimal. Findings show that patients prescribed opioids versus those without opioid prescriptions were more likely to receive statin therapy and antihypertensive agents in the setting of diabetes mellitus and hypertension, respectively. Ongoing efforts to bridge these gaps in primary prevention of cardiovascular disease remain a high priority.

ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research.

Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.

Reducing cardiovascular risk among people living with HIV: Rationale and design of the INcreasing Statin Prescribing in HIV Behavioral Economics REsearch (INSPIRE) randomized controlled trial.

Cardiovascular disease (CVD) is a major cause of morbidity among people living with HIV (PLWH). Statins can safely and effectively reduce CVD risk in PLWH, but evidence-based statin therapy is under-prescribed in PLWH. Developed using an implementation science framework, INcreasing Statin Prescribing in HIV Behavioral Economics REsearch (INSPIRE) is a stepped-wedge cluster randomized trial that addresses organization-, clinician- and patient-level barriers to statin uptake in Los Angeles community health clinics serving racially and ethnically diverse PLWH. After assessing knowledge about statins and barriers to clinician prescribing and patient uptake, we will design, implement and measure the effectiveness of (1) educational interventions targeting leadership, clinicians, and patients, followed by (2) behavioral economics-informed clinician feedback on statin uptake. In addition, we will assess implementation outcomes, including changes in clinician acceptability of statin prescribing for PLWH, clinician acceptability of the education and feedback interventions, and cost of implementation.