Gaps in guideline-recommended anticoagulation in patients with atrial fibrillation and elevated thromboembolic risk within an integrated healthcare delivery system.

BACKGROUND: Atrial Fibrillation (AF) is the leading cause of stroke, which can be reduced by 70% with appropriate oral anticoagulation (OAC) therapy. Nationally, appropriate anticoagulation rates for patients with AF with elevated thromboembolic risk are as low as 50% even across the highest stroke risk cohorts. This study aims to evaluate the variability of appropriate anticoagulation rates among patients by sex, ethnicity, and socioeconomic status within the Kaiser Permanente Mid-Atlantic States (KPMAS). METHODS: This retrospective study investigated 9513 patients in KPMAS's AF registry with CHADS2 score ≥ 2 over a 6-month period in 2021. RESULTS: Appropriately anticoagulated patients had higher rates of diabetes, prior stroke, and congestive heart failure than patients who were not appropriately anticoagulated. There were no significant differences in anticoagulation rates between males and females (71.8% vs. 71.6%%, [OR] 1.01; 95% CI, 0.93-1.11; P = .76) nor by SES-SVI quartiles. There was a statistically significant difference between Black and White patients (70.8% vs. 73.1%, P = .03) and Asian and White patients (68.3% vs. 71.6%, P = .005). After adjusting for CHADS2, this difference persisted for Black and White participants with CHADS2 scores of ≤3 (62.6% vs. 70.6%, P < .001) and for Asian and White participants with CHADS2 scores > 5 (68.0% vs. 79.3%, P < .001). CONCLUSIONS: Black and Asian patients may have differing rates of appropriate anticoagulation when compared with White patients. Characterizing such disparities is the first step towards addressing treatment gaps in AF.

Patient Demographics and the Utilization of a Novel 3-Anatomic-Site Testing Panel Including Rectal Self-Collection as Compared With Usual Care Testing.

BACKGROUND: At Kaiser Permanente Mid-Atlantic States, we designed a 3-anatomic-site panel (urine, oropharynx, and rectum) with a self-collect feature for rectal sites. We compared the proportion tested at each anatomic site, demographic factors, and HIV status between those who received the 3-site panel versus usual care. METHODS: Patients entered our laboratories without a prior appointment and underwent urine (usual care [patient collected]), oropharynx (laboratory technician collected), and rectal site (patient collected) testing. Providers recommended the panel to their patients. Patients then had the choice to accept or to reject the panel. Multivariate and logistic regressions were conducted to explore the relationship of age, sex, race, and HIV status with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) test results as well as the type of testing (3-site panel vs. usual care testing) received. RESULTS: A total of 145,854 patients received usual care testing as compared with 9227 who received the panel. For those who underwent usual care testing, 4.0% tested positive for CT and 0.85% for GC. For those who received the panel, 9.1% tested positive for CT and 6.4% for GC. Those who received the 3-site panel were more likely to test positive for CT (odds ratio [OR], 2.70; confidence interval [CI], 2.46-2.97) and GC (OR, 4.00; CI, 3.59-4.64). White patients were the most likely to receive the panel compared with Black patients (OR, 3.14; CI, 2.96-3.33). Patients with HIV had greater odds of undergoing the panel (OR, 15.62; CI, 14.67-16.64) and of testing positive for CT (OR, 1.27; CI, 1.07-1.51) and GC (OR, 1.39; CI, 1.14-1.68). CONCLUSIONS: Patients who received the panel had higher odds of testing positive for CT and GC compared with patients with usual testing. Physician training may address the racial and sex differences observed in the panel enrollment and increase utilization. Self-collection for rectal sites should lead to higher detection of CT and GC.

Patient-to-physician messaging: volume nearly tripled as more patients joined system, but per capita rate plateaued.

Patients want to be able to communicate with their physicians by e-mail. However, physicians are often concerned about the impact that such communications will have on their time, productivity, and reimbursement. Typically, physicians are not reimbursed for time spent communicating with patients electronically. But under federal meaningful-use criteria for information technology, physicians can receive a modest incentive for such communications. Little is known about trends in secure e-mail messaging between physicians and patients. To understand these trends, we analyzed the volume of messages in a large academic health system's patient portal in the period 2001-10. At the end of 2010, 49,778 patients (22.7 percent of all patients seen within the system) had enrolled in the portal, and 36.9 percent of enrolled patients (8.4 percent of all patients) had sent at least one message to a physician. Physicians in the aggregate saw a near tripling of e-mail messages during the study period. However, the number of messages per hundred patients per month stabilized between 2005 and 2010, at an average of 18.9 messages. As physician reimbursement moves toward global payments, physicians' and patients' participation in secure messaging will likely increase, and electronic communication should be considered part of physicians' job descriptions.