Large Health Care Delivery System Research Articles

Examining Whether Patient Portal and Video Visit Use Differs by Race and Ethnicity Among Older Adults in a US Integrated Health Care Delivery System: Cross-Sectional Electronic Health Record and Survey-Based Study.

Health care systems are increasingly encouraging patients to use patient portals and participate in video visits. However, there is limited information about how portal use differs among older adults. This study aimed to understand how patient portal and video visit use differed by age, race, and ethnicity among older adult patients with access to the same digital health resources. This cross-sectional study used electronic health record and survey data for adults aged 65 to 85 years who were members of a large Northern California health care delivery system throughout 2019 and 2020. The electronic health record cohort (N=471,152) included 320,686 White, 35,892 Black, 44,922 Latino, 20,786 Chinese, 28,732 Filipino, 8473 South Asian, 6716 Japanese, 2930 Vietnamese, and 2015 Korean adults. Racial and ethnic group and age group (65 to 75 years vs 76 to 85 years) differences in having a patient portal account by December 2020, the performance of 2 portal activities (sending ≥1 message to a clinician in 2019 or 2020 and viewing ≥1 laboratory test result in 2020), and having ≥1 video visit during 2020 were examined. Modified log-Poisson regression was used to examine prevalence ratios for portal and video visit use, comparing racial and ethnic groups to White adults and Asian ethnic groups to Chinese adults after adjusting for sex and age. Data from a 2020 member survey were used to compare internet use factors among 2867 White, 306 Black, 343 Latino, 225 Chinese, and 242 Filipino adults. Black, Latino, and Filipino adults were less likely to have a patient portal account than White adults, and Filipino adults were less likely to have a patient portal account than Chinese adults. Black, Latino, Filipino, Korean, Vietnamese, and South Asian adults were less likely to have sent messages and viewed test results than White adults, while Chinese and Japanese adults' use of these features was similar to that of White adults. Filipino, Vietnamese, and Korean adults were less likely to have performed the aforementioned activities than Chinese adults. Video visit use was lower among Black and Latino adults and higher among Chinese and South Asian adults compared with White adults (aged 76 to 85 years) and lower among Filipino, Korean, and Vietnamese adults compared to Chinese adults. Survey data suggested that underlying differences in internet use may partially explain the lower use of messaging by Black, Latino, and Filipino adults compared with White and Chinese adults. Patient portal and video visit use differed by race, ethnicity, and age group among older adult patients with access to the same patient portal. Internet use factors may contribute to these differences. Differences in patient portal and video visit use across Asian subgroups underscore the importance of disaggregating use data by Asian ethnicity.

Clinical Use of Mental Health Digital Therapeutics in a Large Health Care Delivery System: Retrospective Patient Cohort Study and Provider Survey.

While the number of digital therapeutics (DTx) has proliferated, there is little real-world research on the characteristics of providers recommending DTx, their recommendation behaviors, or the characteristics of patients receiving recommendations in the clinical setting. The aim of this study was to characterize the clinical and demographic characteristics of patients receiving DTx recommendations and describe provider characteristics and behaviors regarding DTx. This retrospective cohort study used electronic health record data from a large, integrated health care delivery system. Demographic and clinical characteristics of adult patients recommended versus not recommended DTx by a mental health provider between May 2020 and December 2021 were examined. A cross-sectional survey of mental health providers providing these recommendations was conducted in December 2022 to assess the characteristics of providers and recommendation behaviors related to DTx. Parametric and nonparametric tests were used to examine statistical significance between groups. Of 335,250 patients with a mental health appointment, 53,546 (16%) received a DTx recommendation. Patients recommended to DTx were younger, were of Asian or Hispanic race or ethnicity, were female, were without medical comorbidities, and had commercial insurance compared to those without a DTx recommendation (P<.001). More patients receiving a DTx recommendation had anxiety or adjustment disorder diagnoses, but less had depression, bipolar, or psychotic disorder diagnoses (P<.001) versus matched controls not recommended to DTx. Overall, depression and anxiety symptom scores were lower in patients recommended to DTx compared to matched controls not receiving a recommendation, although female patients had a higher proportion of severe depression and anxiety scores compared to male patients. Provider survey results indicated a higher proportion of nonprescribers recommended DTx to patients compared to prescribers (P=.008). Of all providers, 29.4% (45/153) reported using the suggested internal electronic health record-based tools (eg, smart text) to recommend DTx, and of providers recommending DTx resources to patients, 64.1% (98/153) reported they follow up with patients to inquire on DTx benefits. Only 38.4% (58/151) of respondents report recommending specific DTx modules, and of those, 58.6% (34/58) report following up on the impact of these specific modules. DTx use in mental health was modest and varied by patient and provider characteristics. Providers do not appear to actively engage with these tools and integrate them into treatment plans. Providers, while expressing interest in potential benefits from DTx, may view DTx as a passive strategy to augment traditional treatment for select patients.

Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions

Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. ClinicalTrials.gov NCT05070338.

Gestational Exposure to Maternal Systemic Glucocorticoids and Childhood Risk of CKD

Background & ObjectivesThe potential effects of antenatal glucocorticoid exposure on the health of children are unclear. We examined the association of gestational exposure to maternal systemic glucocorticoids (SG) and the risk of developing chronic kidney disease (CKD) in childhood. Study designRetrospective cohort study. Setting & ParticipantsNewborns cared for at the largest healthcare delivery system in Taiwan between 2004 and 2018. ExposureMaternal prescriptions for SG between the last menstrual period and birth as a proxy for gestational exposure. OutcomeIncidence of childhood CKD, including congenital anomalies of the kidney and urinary tract (CAKUT) and other kidney diseases (non-CAKUT) over 10 years. Analytical ApproachCox proportional hazards models with stabilized inverse probability of treatment weighting and robust sandwich estimator were used to estimate the average association between SG and incident CKD after adjustment for offspring characteristics (aHR). ResultsAmong 23,363 singleton-born children, gestational SG exposure was significantly associated with a higher risk of childhood CKD (aHR, 1.69 [95% CI, 1.01–2.84]). Stratified analyses showed stronger associations between SG and childhood CKD within the strata of birth <37 weeks gestational age (aHR, 2.38 [95% CI, 1.19–4.78]), male sex (aHR, 1.89 [95% CI, 1.00–3.55]), gestational exposure in the second trimester (aHR, 6.70 [95% CI, 2.17–20.64]), and total dose >24 mg hydrocortisone equivalent (aHR, 1.91 [95% CI, 1.05–3.47). LimitationsStudy was limited to the Taiwan healthcare delivery system and childhood CKD events through age 10 years. ConclusionsThe findings of this study suggest that gestational exposure to systemic glucocorticoids is associated with the occurrence of kidney disease in childhood. If these findings are confirmed, they may inform clinicians who are considering prescribing SG during pregnancy.

Characterizing obesity in a large health care delivery system.

To characterize the prevalence of obesity and associated health care use within an integrated health care system in California. Cross-sectional study using electronic health records. Primary care patients 18 years and older receiving care at Sutter Health between 2015 and 2020 were included in the study. Obesity was classified and health care utilization was ascertained at index and during the follow-up periods. Differences in prevalence by demographic and clinical characteristics among patients with and without obesity were assessed. Logistic regression was used to estimate the relationship between obesity class and health care utilization (outpatient encounters). Of the 1,094,790 primary care patients included in the analysis, 35% were classified as having obesity, defined as a body mass index of 30 kg/m2 or more or 25 kg/m2 or more for Asian individuals. Obesity prevalence was greater in Hispanic patients (46%) than in non-Hispanic White patients (30%). Patients without obesity had fewer outpatient visits (mean [SD], 3.7 [3.8]) than those with class 1 (4.1 [4.0]), class 2 (4.6 [4.4]), and class 3 (5.2 [4.8]) obesity. In the fully adjusted regression model, the odds of being a high utilizer among patients with obesity were 1.1 (class 1), 1.2 (class 2), and 1.3 (class 3) times that of patients without obesity (P < .001). Obesity prevalence is high among patients in the Sutter Health system, varying by race/ethnicity, and was associated with increased outpatient visit utilization. There is a need for greater awareness of the impact of obesity and the specific patient populations affected by the disease.

Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement.

Promoting and maintaining patient safety in primary care requires different strategies and monitoring than utilized in large healthcare delivery systems. Maintenance of a culture of safety is key to providing patient safety but has been difficult to measure in primary care. This is particularly true in rural settings where practice size is a major barrier to measurement reliability. Primary care evaluates a wide range of patients, including those who are immunocompromised and others who have infectious diseases. Providing a safe environment with proper wearing of N95 masks, clean examination rooms, and adequate ventilation is important. Patients with infectious diseases should be separated from other patient populations. Primary care is often less bureaucratic than hospitals, but also has fewer resources to implement patient safety initiatives, along with detecting safety lapses and adverse events. However, monitoring the practice's safety practices and the culture of safety is of utmost importance and should be performed using both outcome and process measures. Because of the small size of many rural practices, effective monitoring of adverse events and maintenance of safety protocols should include patients. Patients are an important resource for reporting of adverse events and medical treatment outcomes. The aim of this manuscript is to underscore the importance of patient safety in primary care and to stimulate future research in developing a metric for the culture of safety in primary care, which also incorporates the patient perspective. Patients should be viewed not only as beneficiaries of patient safety but also as a critical component of its maintenance.

Asthma and COVID-19 Outcomes: A Prospective Study in a Large Health Care Delivery System.

Previous studies on the outcomes of asthma and COVID-19 have shown inconsistent results. This study aimed to elucidate the association between asthma and COVID-19 outcomes. We conducted a prospective study with a large health plan to compare the incidence of COVID-19 infection, hospitalization and ICU admission in a cohort of 41,282 patients with asthma and a 1:1 age-, sex-, and race-ethnicity-matched cohort without asthma across the following pandemic periods: pre-Delta (03/01/2020 to 05/31/2021), Delta (06/01/2021 to 12/31/2021), and Omicron (01/01/2022 to 08/13/2022). Demographic factors, comorbidities, COVID-19 test results, inpatient utilization, and COVID-19 vaccination status were collected from electronic health records. Subjects with asthma were more likely than controls to undergo COVID-19 testing during the three pandemic periods and were less likely to test positive in the Omicron period (fully adjusted odds ratio=0.92; 95% CI=0.86-0.98; p=0.01). Relative to controls, patients with asthma had an increased risk of hospitalization for COVID-19 (fully adjusted hazard ratio=1.33; 95% CI=1.08-1.64; p=0.01) and borderline significant (p=0.05) higher rates of ICU admissions in the pre-delta period but not during the delta or Omicron periods. The increased risk of COVID-19 hospitalization associated with asthma was more pronounced in patients with severe asthma and in women compared with men. None of the associations were significantly modified by vaccination status. Asthma was associated with a lower risk of COVID-19 infection but only during the Omicron period. Asthma was an independent risk factor for hospitalization for COVID-19 in the pre-delta period and this association was stronger for severe asthma and in women.

Guideline-Adherent Hypertension in Children and Adolescents: A Multi-Institutional Database Analysis from Taiwan.

Childhood-onset hypertension is associated with cardiovascular morbidity and adult mortality. This study aimed to assess guideline-adherent hypertension among Taiwanese youth and the agreement on hypertension between the 2017 American Academy of Pediatrics guidelines and the 2004 Fourth Report. In this cross-sectional study, we collected outpatient blood pressure (OBP) measurements obtained during routine care visits from a large healthcare delivery system between 2009 and 2018 to evaluate the rate of guideline-adherent hypertension and assess patient-related factors of pediatric hypertension. In total, 12,469 children and adolescents who underwent three separate ≥3 OBP measurements over 33,369 person-years with a total of 95,608 BP measurements in an outpatient setting were analyzed. According to the 2017 American Academy of Pediatrics (AAP) guidelines, the rate of pediatric hypertension in the study setting, which included participants aged 1 to 17 years, ranged from 0.78 to 5.95 per 1000 persons. Although there was perfect agreement between the thresholds of the two guidelines for defining hypertension in the age groups of 1-7, 8-12, and 13-17 years (all κ statistic ≥ 0.85), the use of the AAP threshold classified more adolescents as having hypertension. Children and adolescents with hypertension often had complex chronic diseases and required substantial healthcare services in outpatient, emergency, and inpatient settings. The present study provides evidence of guideline-adherent pediatric hypertension and highlights the importance of regularly monitoring blood pressure to identify and manage hypertension in children and adolescents. Further research is required to determine the impact of new thresholds on the detection of target organ damage at a pediatric age.

Care trajectories for patients utilizing electronic visits for COVID-like symptoms in a large healthcare delivery system: May 2020–December 2021

Background There is limited information about how on-line screening tools developed by integrated systems facilitated management of COVID-like illness patients. Methods Using the Kaiser Permanente Northwest (KPNW) Electronic Health Record, we identified adult plan members who accessed online COVID-19 screening e-visits and enumerated their subsequent medical encounters, tests for SARS-CoV-2, and test outcomes. Results Between May 2020 and December 2021, members completed 55,139 e-visits, with disproportionate representation among females (65% vs. 53% in the overall membership) and members aged <45 years (61% vs. 39%). Thirty percent of patients (16,953) were managed entirely through e-visits and 70% received subsequent in-person care. The percent of SARS-CoV-2 positive individuals was highest among the 1055 individuals triaged to inpatient care (17.9%), compared to 9.5% among those escalated to additional ambulatory care. Conclusions The e-visit on-line screening tool helped KPNW assist thousands of patients with COVID-19 symptoms, avoid unnecessary in-person patient encounters, and preserved KPNW infection control and pandemic surge capacity.

The Relationship Between Limited English Proficiency and Discharge Opioid Prescription Among Patients Undergoing Operation

INTRODUCTION: Barriers to effective communication may negatively impact pain assessment and the decision to prescribe opioids. In this study, we examine the relationship between limited English proficiency (LEP) and postoperative opioid prescribing. METHODS: This is a cross-sectional study of patients undergoing operation across a large healthcare delivery system between 2016 and 2020. Discharge opioid prescription was converted to morphine milligram equivalents (MME). Odds of being prescribed an MME dose below the 25th percentile and above the 75th percentile were compared between English proficient (EP) and LEP patients using multivariable logistic regression. RESULTS: Among 89,383 patients included in this study (mean age 52.13 years, 51% female), 7.4% had LEP; 21.6% (95% CI 21.3% to 21.8%) of EP patients and 28.5% (95% CI 27.4% to 29.6%) of LEP patients were not prescribed opioids. Among those who had an opioid prescription, the median (interquartile range [IQR]) MME was lower in LEP compared with EP patients (150 [75 to 225] vs 180 [96 to 315]). Median MME at discharge varied across surgical specialties (Fig. 1). Patients with LEP had higher odds of being prescribed lowest quartile MME (odds ratio [OR] 1.32, 95% CI 1.21 to 1.43) and lower odds of being prescribed highest quartile MME (OR 0.66, 95% CI 0.59 to 0.73) compared with EP patients after adjustment for clinical characteristics and surgical specialty.CONCLUSION: No opioid prescribing and less opioid prescribing occurred more often in LEP patients. If these differences result in inadequate pain management, this may be an opportunity for performance improvement. Given that larger MME prescriptions can be problematic, the clinical impact of these differences remains to be determined.

Evaluating the effectiveness of email-based nudges to reduce postoperative opioid prescribing: study protocol of a randomised controlled trial

IntroductionSurgical patients are commonly prescribed more opioids at discharge than needed to manage their postoperative pain. These excess opioids increase the risks of new persistent opioid use, opioid-induced ventilatory impairment...

Comparative Adverse Kidney Outcomes in Women Receiving Raloxifene and Denosumab in a Real-World Setting.

Both osteoporosis and kidney diseases are common and intercorrelate to increase morbidity and mortality in elderly women. This study aimed to compare adverse kidney outcome between women initiated with denosumab and a matched group of raloxifene initiators using propensity score matching methods in a large healthcare delivery system in Taiwan. The risks of adverse kidney outcomes were estimated using Cox proportional hazard regression and the change in kidney function over time was analyzed using the linear mixed model. A total of 9444 (4722 in each group) women were identified who matched the inclusion criteria between January 2003 and December, 2018. Denosumab use was significantly associated with higher risk of eGFR decline ≥ 30% from baseline than raloxifene use (aHR: 1.26; 95% CI: 1.16–1.36, p < 0.0001). The mean change in eGFR over time was 1.24 mL/min/1.73 m2 per year in the denosumab group and 0.45 mL/min/1.73 m2 per year in the raloxifene group (p = 0.0004). However, the risks of acute kidney injury (10.53%) and chronic dialysis (0.66%) in this study cohort were not significantly different for the two anti-osteoporosis treatments. Close monitoring of the residual kidney function and treatment effect is needed in those with denosumab.

FC039: Associations between Maternal Antenatal Systemic Glucocorticoids Usage and Childhood Chronic Kidney Disease

Abstract BACKGROUND AND AIMS The effect of antenatal glucocorticoid exposure on offspring health is currently unclear. Therefore, this study examined the association of maternal exposure to systemic glucocorticoids in the past and during pregnancy with the risk of chronic kidney disease (CKD) development in childhood. Methods A retrospective cohort study of maternal-child dyads was identified from the largest healthcare delivery system in Taiwan between 1 January 2004 and 31 December 2018. Primary analyses were used to compare past and gestational exposures with non-exposure to systemic glucocorticoid considering an inverse probability of treatment weight to adjust the hazard ratio of offspring CKD development in singleton child-matched pairs. Offspring birthweight, sex, gestational weeks stratified analyses and sibling-matched sensitivity analyses were performed to ensure the robustness of the primary study results. RESULTS In a cohort with 31 927 singleton born children, the cumulative incidence of CKD was 2.23% (n = 713), with 3.18% (n = 63) in the gestational glucocorticoid-exposed group, 1.91% (n = 58) in the past exposed group and 2.2% (n = 592) in the non-exposed group. Gestational exposure, compared with non-exposure, was significantly associated with a higher risk of childhood CKD (inverse probability therapeutic weighted hazard ratio [wHR], 1.42 [95% confidence interval (95% CI) 1.05–1.92] in Figure. 1A, but not past exposure (wHR: 0.89, 95% CI 0.67–1.18) (Figure. 1B). In male children, the risk of CKD was significantly higher among gestational-exposed children than among unexposed children (wHR: 1.72, 95% CI 1.21–2.43). The cohort with sibling matched children did not show a significantly increased risk of childhood CKD associated with gestational exposure (wHR: 1.31, 95% CI 0.79–2.18) (Figure. 1A). CONCLUSION Maternal gestational glucocorticoid treatment was found to be significantly associated with CKD development in children. These findings may support clinicians in performing benefit-risk assessment and in decision-making for systemic glucocorticoid treatment during pregnancy, in clinical settings.

Prediction and Clinically Important Factors of Acute Kidney Injury Non-recovery.

ObjectiveThis study aimed to identify phenotypic clinical features associated with acute kidney injury (AKI) to predict non-recovery from AKI at hospital discharge using electronic health record data.MethodsData for hospitalized patients in the AKI Recovery Evaluation Study were derived from a large healthcare delivery system in Taiwan between January 2011 and December 2017. Living patients with AKI non-recovery were used to derive and validate multiple predictive models. In total, 64 candidates variables, such as demographic characteristics, comorbidities, healthcare services utilization, laboratory values, and nephrotoxic medication use, were measured within 1 year before the index admission and during hospitalization for AKI.ResultsAmong the top 20 important features in the predictive model, 8 features had a positive effect on AKI non-recovery prediction: AKI during hospitalization, serum creatinine (SCr) level at admission, receipt of dialysis during hospitalization, baseline comorbidity of cancer, AKI at admission, baseline lymphocyte count, baseline potassium, and low-density lipoprotein cholesterol levels. The predicted AKI non-recovery risk model using the eXtreme Gradient Boosting (XGBoost) algorithm achieved an area under the receiver operating characteristic (AUROC) curve statistic of 0.807, discrimination with a sensitivity of 0.724, and a specificity of 0.738 in the temporal validation cohort.ConclusionThe machine learning model approach can accurately predict AKI non-recovery using routinely collected health data in clinical practice. These results suggest that multifactorial risk factors are involved in AKI non-recovery, requiring patient-centered risk assessments and promotion of post-discharge AKI care to prevent AKI complications.

Comparison of Adverse Kidney Outcomes With Empagliflozin and Linagliptin Use in Patients With Type 2 Diabetic Patients in a Real-World Setting.

Background: To compare the effects of empagliflozin and linagliptin use on kidney outcomes of type 2 diabetes mellitus (T2DM) patients in a real-world setting. Methods: The study involved a propensity score-matched cohort comprising new users of empagliflozin or linagliptin with T2DM between January 1, 2013 and December 31, 2018 from a large healthcare delivery system in Taiwan. Clinical outcomes assessed: acute kidney injury (AKI), post-AKI dialysis, and mortality. Cox proportional hazard model was used to estimate the relative risk of empagliflozin or linagliptin use; a linear mixed model was used to compare the average change in estimated glomerular filtration rate (eGFR) over time. Results: Of the 7,042 individuals, 67 of 3,521 (1.9%) in the empagliflozin group and 144 of 3,521 (4.1%) in the linagliptin group developed AKI during the 2 years follow-up. Patients in the empagliflozin group were at a 40% lower risk of developing AKI compared to those in the linagliptin group (adjusted hazard ratio [aHR], 0.60; 95% confidence interval [CI], 0.45–0.82, p = 0.001). Stratified analysis showed that empagliflozin users ≥65 years of age (aHR, 0.70; 95% CI, 0.43–1.13, p = 0.148), or with a baseline eGFR <60 ml/min/1.73 m2 (aHR, 0.97; 95% CI, 0.57–1.65, p = 0.899), or with a baseline glycohemoglobin ≦7% (aHR, 1.01; 95% CI, 0.51–2.00, p =0.973) experienced attenuated benefits with respect to AKI risk. A smaller decline in eGFR was observed in empagliflozin users compared to linagliptin users regardless of AKI occurrence (adjusted β = 1.51; 95% CI, 0.30–2.72 ml/min/1.73 m2, p = 0.014). Conclusion: Empagliflozin users were at a lower risk of developing AKI and exhibited a smaller eGFR decline than linagliptin users. Thus, empagliflozin may be a safer alternative to linagliptin for T2DM patients.

Renoprotective effect of SGLT-2 inhibitors among type 2 diabetes patients with different baseline kidney function: a multi-center study

BackgroundTo assess the effect of sodium glucose cotransporter-2 inhibitors (SGLT-2is) for type 2 diabetes on kidney outcomes stratified by patient baseline estimated glomerular filtration rate (eGFR) levels (i.e., eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 mL/min/1.73 m2).MethodsPatients from three large healthcare delivery systems in Taiwan who had initiated SGLT-2is or other glucose-lowering drugs (oGLDs) between May 2016 and December 2017 were included. Main outcomes were the times to 30%, 40%, and 50% eGFR reduction after treatment initiation. One-to-one propensity score matching in the overall study cohort and in each eGFR subgroup between SGLT-2i and oGLD users was applied to ensure between-group comparability in baseline characteristics.ResultsThere were 13,666 matched pairs of SGLT-2is and oGLD users in the overall cohort. While a sustained eGFR decline was revealed in oGLD-treated patients (mean values [standard errors] from 85.61 [0.43] to 82.49 [0.44] mL/min/1.73 m2 during the 12 months after treatment initiation), the mean eGFR values of SGLT-2i users decreased in the first 3 months (85.68 [0.37] to 79.71 [0.41] mL/min/1.73 m2) but then improved and sustained until the end of follow-up. There were 2300, 5705, and 5509 matched SGLT-2i and oGLD users in the eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 subgroups, respectively. Using SGLT-2is versus oGLDs was significantly associated with slower eGFR declines; hazard ratios (HRs) were 0.51 (95% CI 0.37–0.69), 0.51 (0.37–0.70), and 0.47 (0.31–0.71) for 40% eGFR reduction in the eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 subgroups, respectively. The renoprotective effect of SGLT-2is versus oGLDs was confirmed in the outcomes of 30% and 50% eGFR reduction across the three eGFR subgroups.ConclusionsThis study supports the renoprotective benefit of real-world SGLT-2i use irrespective of patient baseline kidney function.

Validation of EHR medication fill data obtained through electronic linkage with pharmacies.

BACKGROUND: Recent linkages between electronic health records (EHRs) and pharmacy data hold opportunity for up-to-date assessment of medication adherence at the point of care. OBJECTIVE: To validate linked EHR-pharmacy data, which can be used for point-of-care interventions for concordance with insurance claims data for patients in a large health care delivery system. METHODS: We performed a retrospective cohort study of adult patients with an active antihypertensive medication order and seen as outpatients between August 25, 2019, and August 31, 2019. Pharmacy fill information was obtained from the EHR via linkages with Surescripts pharmacy and pharmacy benefit manager data, as well as from insurance claims available at our institution. We matched antihypertensive medication fills observed in the linked EHR-pharmacy database with available fills in the insurance claims database and calculated the percentage of medication fills that were available in each database. We estimated medication adherence using proportion of days covered in the linked EHR-pharmacy database and in the insurance claims database. RESULTS: Of 26,679 patients with hypertension, 23,348 (87.5%) had at least 1 antihypertensive medication fill recorded in the linked EHR-pharmacy database. Of 1,501 patients matched with the insurance database and with a documented medication fill, a fill was present for 1,484 (98.9%) and 1,259 (83.9%) patients in the linked EHR-pharmacy and insurance databases, respectively. Of 12,109 medication fills recorded in the insurance data, we found an overlap of 11,060 (91.3%) fills with the linked EHR-pharmacy database. The linked EHR-pharmacy database also contained 18,232 of 19,281 (94.6%) medication fills present in either database. Measured medication adherence was higher for patients when based on linked EHR-pharmacy data compared with insurance claims data (42% vs 30%, P < 0.001). CONCLUSIONS: Linked EHR-pharmacy data captured medication fills for the vast majority of patients and resulted in higher estimates of adherence than insurance claims. Our results suggest that pharmacy fill data available in the EHR have sufficient reliability to be used for point-of-care assessment of medication adherence. DISCLOSURES: This study was supported by grant R01HL155149 from the National Heart, Lung, and Blood Institute. Allen Thorpe provided funding for the NYU Langone Health Learning Health System Program, which helped fund this project. The authors have nothing to disclose.

Nudge me: tailoring text messages for prescription adherence through N-of-1 interviews.

Almost 50% of patients with cardiovascular diseases face challenges in taking medications and increased morbidity and mortality. Text messaging may impact medication refill behavior and can be delivered at scale to patients by texting mobile phones. To obtain feedback from persons with chronic conditions on the design of interactive text messages and determine language of message for making messages that can motivate patients to refill medications on time. We purposively sampled 35 English and Spanish speaking patients with at least one chronic condition from three large healthcare delivery systems to participate in N-of-1 video-based synchronous interviews. Research assistants shared ideas for theory-informed text messages with content intended to persuade patients to refill their medication. We transcribed recorded interviews and conducted a content analysis to identify strategies to employ generating a dynamic interactive text message library intended to increase medication refill. Those interviewed were of diverse age and race/ethnicity and typical of persons with multiple chronic conditions. Several participants emphasized that personally tailored and positively framed messages would be more persuasive than generic and/or negative messages. Some patients appreciated humor and messages that could evoke a sense of social support from their providers and rejected the use of emojis. Messages to remind patients to refill medications may facilitate improvements in adherence, which in turn can improve chronic care. Designing messages that are persuasive and can prompt action is feasible and should be considered given the ease with which such messages can be delivered automatically at scale.

MO359ASSOCIATIONS BETWEEN RENAL FUNCTION TRAJECTORIES AFTER 3 MONTHS ACUTE KIDNEY INJURY AND LONG-TERM RENAL OUTCOMES

Abstract Background and Aims Renal function recovery after acute kidney injury (AKI) is associated with patient outcomes. The study objectives were to assess the patterns of AKI recovery within 6 months following discharge for AKI and subsequent incidence of chronic dialysis. Method A retrospective cohort of 234,867 hospitalized adult patients was examined for AKI between January 1, 2010, and December 31, 2017 in the largest healthcare delivery system in Taiwan. Renal function recovery at 3- and 6-month post discharge, incident chronic kidney disease and chronic dialysis initiation were analyzed over 7 years of follow-up. Renal recovery was defined by &amp;lt; 1.5× baseline SCr (prior to the hospitalization). Independent associations between renal function recovery patterns and renal outcomes was assessed by Cox proportional hazard model controlling for potential confounders, and subdistribution hazard ratio (SHR) with [95% CI] was analysed for competing risk of early death. Results Among 3 months AKI survivors (n=24,132), 14.28% (n=3,430) did not recovery back to baseline, and 16% of recovery did not sustain. Three distinct renal function recovery continuums at 6 months post hospital discharge were: persistent non-recovery (10.18%), non-recovery (14.33%), and recovery (75.5%). Comparing to survivors without AKI (n=50,387), the impact of renal recovery continuum on chronic dialysis initiation varied by patient’s baseline renal disease (SHR was 2.82 [95%CI, 2.42-3.28] in CKD, and 0.8 [95%CI, 0.27-2.38] for non-CKD. Persistent non-recovery was significantly associated with a greater increased risk of chronic dialysis than non-recovery in any patients with AKI. Comparing to patients with sustained AKI recovery, risk of CKD onset increased 5-fold in persistent non-recovery and 3-fold risk in non-recovery. Conclusion The continuum of AKI recovery post 6 months is associated with increased risk of chronic dialysis, particularly in patients with baseline CKD. These study results suggested that patients ever with AKI should receive close renal function monitoring for post-discharge management.

Treatment patterns for patients with metastatic or recurrent head and neck cancer in a large integrated health-care system.

e18015 Background: Since publication of the landmark KEYNOTE-048 Trial, pembrolizumab alone or with platinum-based chemotherapy and 5-fluorouracil (5FU) was established as a standard of care for the frontline treatment of patients with recurrent or metastatic head and neck squamous cell cancer (HNSCC), replacing the EXTREME regimen of Cetuximab with platinum and 5FU. In clinical practice, some clinicians modify the KEYNOTE-048 regimen by substituting a taxane for 5FU (i.e., Paclitaxel + Carboplatin + Pembrolizumab, PCT). Within the Kaiser Permanente Northern California (KPNCAL) network, we identified a cohort of 123 patients who received palliative first-line therapy for metastatic HNSCC to identify practice patterns in a real-world setting within a large health care delivery system. Methods: This is a data-only cohort study of all adult KPNCAL members diagnosed with metastatic HNSCC treated with palliative combination chemotherapy and/or immunotherapy between January 1, 2018 and July 31, 2020. Results: Among a cohort of 123 patients, 28 patients received the EXTREME regimen (platinum + 5FU + cetuximab), 10 received modified EXTREME (platinum + taxane + cetuximab), 14 received platinum + 5FU + pembrolizumab, 9 received platinum + taxane + pembrolizumab and 62 received single agent immunotherapy. From 2018 through mid-2020, there was an apparent shift away from cetuximab based regimens and a concurrent rise in immunotherapy-based regimens. By mid-2020, the majority of patients received an immunotherapy-based regimen (28 patients), while only 5 patients received a cetuximab based regimen (Table). Conclusions: Data from our cohort reported clinical practice patterns within a large multispecialty integrated health-care system in Northern California. Our findings highlight the marked variability in practice patterns within a single health care system for first-line metastatic therapy. While we identified trends away from cetuximab based therapy and toward immunotherapy-based therapy in clinical practice there remained wide practice variations among clinical oncologist treating patients with newly diagnosed metastatic HNSCC. This further emphasizes the need for prospective clinical trials to identify the optimal regimen or to confirm clinical equipoise between regimens among patients with metastatic or recurrent head and neck cancer. [Table: see text]