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.

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.

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.

Background

Several cardiotoxic substances impact heart failure incidence. The burden of comorbid tobacco or substance use disorders among heart failure patients is under-characterized. We describe the burden of tobacco and substance use disorders among hospitalized heart failure patients in the United States.

Methods

We calculated the proportion of primary heart failure hospitalizations in the 2014 National Inpatient Sample with tobacco or substance use disorders accounting for demographic factors.

Results

Of 989,080 heart failure hospitalizations, 15.5% (n = 152,965) had documented tobacco (n = 119,285, 12.1%) or substance (n = 61,510, 6.2%) use disorder. Female sex was associated with lower rates of tobacco (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.70-0.74) and substance (OR 0.37; 95% CI, 0.36-0.39) use disorder. Tobacco and substance use disorder rates were highest for hospitalizations <55years of age. Native American race was associated with increased risk of alcohol use disorder (OR 1.67; 95% CI, 1.27-2.20) and black race with alcohol (OR 1.09; 95% CI, 1.02-1.16) or drug (OR 1.63; 95% CI, 1.53-1.74) use disorder. Medicaid insurance or income in the lowest quartile were associated with increased risk of tobacco and substance use disorders.

Conclusions

Tobacco and substance use disorders affect vulnerable heart failure populations, including those of male sex, younger age, lower socioeconomic status, and racial/ethnic minorities. Enhanced screening for tobacco and substance use disorders in hospitalized heart failure patients may reveal opportunities for treatment and secondary prevention.

BACKGROUND:Diagnosing obstructive coronary artery disease (CAD) is challenging in elderly adults, and current diagnostic approaches for CAD expose these individuals to risks from contrast dye and invasive procedures. DESIGN:A Registry to Evaluate Patterns of Care Associated with the Use of Corus CAD in Real World Clinical Care Settings (PRESET; NCT01677156), pragmatic clinical trial. SETTING:Community, 21 primary care practices. PARTICIPANTS:Of 566 stable, nonacute outpatients presenting with symptoms suggestive of obstructive CAD, the 176 who were aged 65 and older (median age 70, 61% female) were the current study participants. INTERVENTION:Blood-based precision medicine test, incorporating age, sex, and gene expression score (ASGES) to improve clinical decision-making and quality of care. MEASUREMENTS:Information on demographic characteristics, clinical factors, ASGES results (range 1-40; low (≤15), high (>15)), referral patterns to cardiology and advanced cardiac testing, and major adverse cardiac events (MACEs) was collected in a subgroup analysis of elderly adults in the PRESET Registry. Follow-up was for 1 year after ASGES testing. RESULTS:Median ASGES was 25, and 40 (23%) participants had a low score. Clinicians referred 12.5% of participants with a low ASGES and 49.3% with a high ASGES to cardiology or advanced cardiac testing (odds ratio for referral = 0.12, P < .001, adjusted for participants demographics and clinical covariates). Higher scores were associated with greater likelihood of posttest cardiac referral. At 1-year follow-up, the incidence of a MACE or revascularization was 10% (13/136) in the high ASGES group and 0% (0/40) in the low ASGES group (P = .04). CONCLUSION:The ASGES test showed potential clinical utility in the evaluation of elderly outpatients with symptoms suggestive of obstructive CAD. Test use may reduce unnecessary referrals and the risk of procedure-related complications in individuals with low ASGES, who are unlikely to benefit from further testing, while also identifying individuals who may benefit from further cardiac evaluation and management.

Purpose

The evaluation of obstructive coronary artery disease (CAD) is inefficient and costly. Previous studies of an age/sex/gene expression score (ASGES) in this diagnostic workup have shown a 96% negative predictive value, as well as an 85% decreased likelihood of cardiac referral among low-score outpatients at 45 days. The objective was to explore the one-year cost implications of ASGES use among symptomatic outpatients.

Design

A prospective PRESET Registry (NCT01677156) enrolled stable, nonacute adult patients presenting with symptoms suggestive of obstructive CAD at 21 U.S. primary care practices.

Methodology

Demographics, clinical factors, and ASGES (defined as low <=15 or elevated >15), as well as management plans post-ASGES, were collected. The economic endpoint analysis was based on the cost of cardiovascular-related tests, procedures, office visits, emergency room visits, and hospitalizations during one year after testing.

Results

The analysis included 566 patients, 51% of whom were women and the median age was 56. Forty-five percent had a low ASGES. The mean cost of cardiovascular care for patients in the year following ASGES was $1,647 for patients with a low ASGES versus $2,709 for those with an elevated score (39% reduction, P=.03 by Wilcoxon rank test). This relationship remained after multivariate analysis that adjusted for patient demographics and clinical covariates (P<.001).

Conclusion

The ASGES helped identify patients with low current likelihood of obstructive CAD. These patients had lower costs of cardiovascular care during one year of follow-up. Early reductions in cardiac referrals at 45 days among these patients persisted at one year.

Importance

Recent increases in US opioid-related deaths underscore the need to understand drivers of fatal overdose. The initial prescription of opioids represents a critical juncture because it increases the risk of future opioid use disorder and is preventable.

Objective

To examine new opioid prescribing patterns in US patients at increased risk of overdose from benzodiazepine use.

Design, setting, and participants

This study used publicly available data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from January 1, 2005, through December 31, 2015, to identify adults 20 years or older receiving new opioid prescriptions and concurrently using a benzodiazepine.

Main outcomes and measures

Population-based rates of new opioid prescriptions stratified by use of benzodiazepines.

Results

This study analyzed 13 146 visits, representing 214 million visits nationally, with a new opioid prescription. Rates of new opioid prescriptions among adults using a benzodiazepine increased from 189 to 351 per 1000 persons between 2005 and 2010 (rate difference, 162; 95% CI, 29-295; P = .02) and decreased to 172 per 1000 persons by 2015 (rate difference, -179; 95% CI, -310 to -48; P = .008). New opioid prescriptions in the general population not using benzodiazepines increased nonsignificantly from 78 to 93 per 1000 US persons between 2005 and 2010 (rate difference, 15; 95% CI, -3 to 33; P = .10) and decreased nonsignificantly to 79 per 1000 persons by 2015 (rate difference, -14; 95% CI, -38 to 11; P = .28). The likelihood of receiving a new opioid prescription during an ambulatory visit remained higher for patients concurrently using benzodiazepines compared with the general population after adjusting for demographic characteristics, comorbidities, and diagnoses associated with pain (adjusted relative risk, 1.83; 95% CI, 1.56-2.15; P < .001). Naloxone was coprescribed in less than 1% of visits when a patient concurrently used a benzodiazepine.

Conclusions and relevance

In 2010, new opioid prescriptions for US adults stopped increasing and began to decrease among higher-risk patients who used benzodiazepines. These patterns suggest that the recent increase in opioid-related deaths may be associated with factors other than physicians writing new opioid prescriptions. Nevertheless, prescribing among higher-risk patients still occurred at rates higher than rates in the general population, representing an important opportunity to improve quality of care for patients experiencing pain.

Background

Cardiovascular disease is emerging as a major cause of morbidity and mortality among patients with HIV. We compared use of national guideline-recommended cardiovascular care during office visits among HIV-infected versus HIV-uninfected adults.

Methods and results

We analyzed data from a nationally representative sample of HIV-infected and HIV-uninfected patients aged 40 to 79 years in the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2006 to 2013. The outcome was provision of guideline-recommended cardiovascular care. Logistic regressions with propensity score weighting adjusted for clinical and demographic factors. We identified 1631 visits by HIV-infected patients and 226 862 visits by HIV-uninfected patients with cardiovascular risk factors, representing ≈2.2 million and 602 million visits per year in the United States, respectively. The proportion of visits by HIV-infected versus HIV-uninfected adults with aspirin/antiplatelet therapy when patients met guideline-recommended criteria for primary prevention or had cardiovascular disease was 5.1% versus 13.8% (P=0.03); the proportion of visits with statin therapy when patients had diabetes mellitus, cardiovascular disease, or dyslipidemia was 23.6% versus 35.8% (P<0.01). There were no differences in antihypertensive medication therapy (53.4% versus 58.6%), diet/exercise counseling (14.9% versus 16.9%), or smoking cessation advice/pharmacotherapy (18.8% versus 22.4%) between HIV-infected versus HIV-uninfected patients, respectively.

Conclusions

Physicians generally underused guideline-recommended cardiovascular care and were less likely to prescribe aspirin and statins to HIV-infected patients at increased risk-findings that may partially explain higher rates of adverse cardiovascular events among patients with HIV. US policymakers and professional societies should focus on improving the quality of cardiovascular care that HIV-infected patients receive.