US Health System Research Articles

Organizational Intent, Organizational Structures, and Reviewer Mental Models Influence Mortality Review Processes

ObjectiveTo identify the factors that influence the mortality review process at health systems, including how mortality review is conducted, cases are adjudicated, and results are used. MethodsWe conducted a qualitative analysis of the mortality review processes of 6 US health systems from February 1, 2021 to June 31, 2021. The data sources included individual and small-group semi-structured interviews with mortality review team members and a content analysis of site artifacts (eg, guiding principles, chart abstraction forms, review workflows, and clinical pathways developed from past mortality reviews). We analyzed each site’s mortality review process, goals and incentives for mortality review, historical and evolving aspects of mortality review, personnel involved, and post-review use of findings. ResultsAcross the 6 systems, we interviewed a total of 24 mortality review experts and analyzed 26 site documents. We identified 3 thematic factors that influence mortality review processes: organizational intent, organizational structures for mortality review, and the mental models of individuals involved in the review process. Two subthemes emerged within organizational intent: (1) identifying preventable deaths to lower (clinical or financial) risk and (2) using death cases to guide system improvement. Sites varied in governance and decision rights concerning mortality review and adjudication, with 2 subthemes within organizational structures: (1) centralized-hierarchical and (2) decentralized or multidisciplinary. The analysis of mental models of participating reviewers revealed 2 themes: (1) confirmation of preventability and (2) identification of patterns or “signals.” ConclusionUnderstanding the factors that influence mortality review allows health systems to better leverage mortality review for institutional improvement and to develop training that builds shared mental models to enhance the review process.

Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study

ObjectiveTo characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health...

Incidence of Severe Adverse Drug Reactions to Ultrasound Enhancement Agents in a Contemporary Echocardiography Practice

Prior data indicate a very rare risk of serious adverse drug reaction (ADR) to ultrasound enhancement agents (UEAs). We sought to evaluate the frequency of ADR to UEA administration in contemporary practice. We retrospectively reviewed 4 US health systems to characterize the frequency and severity of ADR to UEA. Adverse drug reactions were considered severe when cardiopulmonary involvement was present and critical when there was loss of consciousness, loss of pulse, or ST-segment elevation. Rates of isolated back pain and headache were derived from the Mayo Clinic Rochester stress echocardiography database where systematic prospective reporting of ADR was performed. Among 26,539 Definity and 11,579 Lumason administrations in the Mayo Clinic Rochester stress echocardiography database, isolated back pain or headache was more frequent with Definity (0.49% vs 0.04%, P<.0001) but less common with Definity infusion versus bolus (0.08% vs 0.53%, P=.007). Among all sites there were 201,834 Definity and 84,943 Lumason administrations. Severe and critical ADR were more frequent with Lumason than with Definity (0.0848% vs 0.0114% and 0.0330% vs 0.0010%, respectively; P<.001 for each). Among the 3 health systems with >2,000 Lumason administrations, the frequency of severe ADR with Lumason ranged from 0.0755% to 0.1093% and the frequency of critical ADR ranged from 0.0293% to 0.0525%. Severe ADR rates with Definity were stable over time but increased in more recent years with Lumason (P=.02). Patients with an ADR to Lumason since the beginning of 2021 were more likely to have received a COVID-19 vaccination compared with matched controls (88% vs 75%; P=.05) and more likely to have received Moderna than Pfizer-Biotech (71% vs 26%, P<.001). Severe and critical ADR, while rare, were more frequent with Lumason, and the frequency has increased in more recent years. Additional work is needed to better understand factors, including associations with recently developed mRNA vaccines, which may be contributing to the increased rates of ADR to UEA since2021.

Association Between Hypertension and Diabetes Control and COVID-19 Severity: National Patient-Centered Clinical Research Network, United States, March 2020 to February 2022.

Background Hypertension and diabetes are associated with increased COVID-19 severity. The association between level of control of these conditions and COVID-19 severity is less well understood. Methods and Results This retrospective cohort study identified adults with COVID-19, March 2020 to February 2022, in 43 US health systems in the National Patient-Centered Clinical Research Network. Hypertension control was categorized as blood pressure (BP) <130/80, 130 to 139/80 to 89, 140 to 159/90 to 99, or ≥160/100 mm Hg, and diabetes control as glycated hemoglobin <7%, 7% to <9%, ≥9%. Adjusted, pooled logistic regression assessed associations between hypertension and diabetes control and severe COVID-19 outcomes. Among 1 494 837 adults with COVID-19, 43% had hypertension and 12% had diabetes. Among patients with hypertension, the highest baseline BP was associated with greater odds of hospitalization (adjusted odds ratio [aOR], 1.30 [95% CI, 1.23-1.37] for BP ≥160/100 versus BP <130/80), critical care (aOR, 1.30 [95% CI, 1.21-1.40]), and mechanical ventilation (aOR, 1.32 [95% CI, 1.17-1.50]) but not mortality (aOR, 1.08 [95% CI, 0.98-1.12]). Among patients with diabetes, the highest glycated hemoglobin was associated with greater odds of hospitalization (aOR, 1.61 [95% CI, 1.47-1.76] for glycated hemoglobin ≥9% versus <7%), critical care (aOR, 1.42 [95% CI, 1.31-1.54]), mechanical ventilation (aOR, 1.12 [95% CI, 1.02-1.23]), and mortality (aOR, 1.18 [95% CI, 1.09-1.27]). Black and Hispanic adults were more likely than White adults to experience severe COVID-19 outcomes, independent of comorbidity score and control of hypertension or diabetes. Conclusions Among 1.5 million patients with COVID-19, higher BP and glycated hemoglobin were associated with more severe COVID-19 outcomes. Findings suggest that adults with poorest control of hypertension or diabetes might benefit from efforts to prevent and initiate early treatment of COVID-19.

Why Does the US Overly Rely on International Medical Graduates in Its Geriatric Psychiatric Workforce?

International medical graduates (IMGs) tend to choose careers in geriatric psychiatry likely because high-quality training and robust mentorship opportunities from other IMGs are available. Geriatric psychiatry offers stable career prospects and opportunities to express humanitarian impulses by working closely with elders. IMGs currently constitute almost a quarter of the psychiatry workforce and approximately 53% of the geriatric psychiatry work force in the United States. However, the number of IMGs entering psychiatry residencies-and, subsequently, geriatric psychiatry fellowships-has recently declined. Overreliance on IMGs in the US geriatric psychiatric workforce means these shortages will further burden an already-limited geriatric mental health care workforce and further compromise US health system capacity to meet its elders' needs.

Association of Provider Zip Code Sociodemographic Characteristics with Radiation Therapy Modality Use in the Medicare Population

Variations in healthcare delivery by provider and patient-level characteristics have been well studied in the US health system as a whole, though these patterns are not as well defined in radiation oncology. We evaluated the association of provider zip-code level sociodemographic characteristics with variations in radiation therapy (RT) modality use. We used the Centers for Medicare & Medicaid Services (CMS) Physician and Other Supplier Public Use File, CMS Physician Compare, and National Neighborhood Data Archive databases to link non-facility based radiation oncologists and their submitted Medicare charges in 2020 with sociodemographic information of the provider's zip code. We selected radiation oncologists who submitted for any of the following RT treatments: proton RT (PRT), stereotactic body RT (SBRT), intensity modulated RT (IMRT), 3D conformal RT (3DCRT), and brachytherapy (BT). Sociodemographic covariates included predominant race/ethnicity of area (Black, White, or Hispanic), percentage of population earning above $75,000 annually, provider rurality (metropolitan vs non-metropolitan), and predominant education level attained of area (Bachelor's degree vs no Bachelor's degree). We measured the association of these covariates with the use of different RT modalities with multivariable logistic regression. We identified 1,126 radiation oncologists for analysis. PRT was more likely to be used by providers in areas with a predominantly Black population compared with providers in areas with a predominantly White or Hispanic population (Black as reference, White odds ratio (OR) 0.11; 95% CI 0.05-0.24; Hispanic OR 0.23; 95% CI 0.08-0.56). IMRT was more likely to be used by providers in areas with a predominantly White or Hispanic population compared with providers in areas with a predominantly Black population (White OR 3.40; 95% CI 1.63-6.78; Hispanic OR 2.46; 95% CI 1.04-5.97). SBRT was less likely to be used in non-metro areas compared with metro areas (OR 0.28, 95% CI 0.12-0.56). The annual income measure was not associated with any RT modality. Providers in areas with predominantly Bachelor's degree attained were more likely to use PRT (Bachelor's degree as reference, OR 0.34; 95% CI 0.17-0.64) and less likely to use SBRT (OR 1.53; 95% CI 1.04-2.26), IMRT (OR 2.04; 95% CI 1.20-3.48), and 3DCRT (OR 1.52; 95% CI 1.04-2.22). No covariates were associated with BT use. We identified notable variations in RT delivery with multiple sociodemographic factors. A predominantly Black population was associated with a higher likelihood of PRT use, and BT use was not associated with any sociodemographic covariate. These findings might reflect reduced barriers to care afforded by the universal healthcare setting of Medicare or ongoing improvements in RT delivery with respect to previously identified health disparities. Additional work is needed to further elucidate these patterns of RT use and determine if they represent effective care.

Sources of Low-Value Care Received by Medicare Beneficiaries and Associated Spending Within US Health Systems

This cross-sectional study examines referrals for low-value health care services and associated spending by ordering clinician among Medicare beneficiaries.

Impact of health system specialty pharmacies on total cost of care in cancer treatment, a multisite review.

Integrated delivery networks can use medically integrated dispensing of oral oncolytics on site through health system specialty pharmacies. There is little published research examining cost savings. Our objective was to demonstrate the financial value of health system specialty pharmacies among patients receiving oral oncolytics dispensed through fully, partially, and non-integrated dispensing strategies. This was a retrospective cohort study of adult patients from Symphony Health's Integrated Dataverse® repository who filled a prescription for an agent of interest from 7/1/16-6/30/20 that was written within 25 US health systems. Outcomes included costs, healthcare resource utilization, and duration of therapy. In total, 36,816 patients were included; 986 patients (2.7%) integrated, 1,822 (4.9%) partially integrated, and 34,008 (92.4%) non-integrated. Mean 6-month medical charge and oncolytic prescription costs were lower for the integrated group ($36,831; $55,786) than the partially integrated ($46,304, p = 0.053; $63,295, p = 0.071) and non-integrated groups ($54,261, p < 0.001; $65,005, p = 0.004). In most healthcare resource utilization categories, the integrated group had the lowest patient percentage utilizing medical care. Duration of therapy was lower on average by ∼3 months in the integrated vs non-integrated group, which may represent closer monitoring of patient medical records and need for fills vs autoship practices. Patients receiving oral oncolytics through medically integrated dispensing at health system specialty pharmacies may have lower medical and pharmacy costs and decreased healthcare resource utilization. This study adds to the growing body of literature supporting integrated delivery networks and integrated dispensing. Further research is needed to demonstrate the value of medically integrated dispensing through health system specialty pharmacies in the delivery of treatment to patients with cancer and other high-cost diseases.

The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation

One in three patients is affected by diagnosis-related communication failures. Only a few valid and reliable instruments that measure teamwork and communication exist, and none of those focus on improving diagnosis. The authors developed, refined, and psychometrically evaluated the TeamSTEPPSⓇ for Improving Diagnosis Team Assessment Tool (TAT), which assesses diagnostic teamwork and communication in five critical teamwork domains and can be used to identify strengths and opportunities for improvement and monitor performance. The TAT was administered as a cross-sectional survey to 360 health professionals across nine diverse US health systems. Content and construct validity were evaluated through pilot implementation and subject matter expert review. Reliability and internal consistency were assessed with Cronbach's alpha. To understand sources of variation in TAT scores and assess the tool's consistency across diverse health care organizations, generalizability theory (G-theory) was used. Best practices in screening for careless responding identified participants with random or nonvarying responses. Analyses indicated strong support for the tool. Content validity findings indicated that the TAT encompassed relevant diagnostic improvement teamwork and communication content. Construct validity, evaluated through pilot implementations, demonstrated the tool's effectiveness in assessing teamwork categories. Reliability analyses confirmed the TAT's internal consistency, with an overall Cronbach's alpha of 0.97. Each dimension of the TAT exhibited good reliability coefficients, ranging from 0.83 to 0.95. G-theory analysis showed that variations in TAT scores were primarily attributed to respondents (28.0%) and scale dimensions (59.6%); both are desirable facets of variation. Further, examination of careless respondents ensured the accuracy and quality of the results, enhancing the TAT's credibility as a valuable diagnostic improvement tool. Psychometric evaluation demonstrated that the TAT is a reliable and valid instrument for assessing teamwork and communication among and across diagnostic teams. The TAT adds a novel, evidence-based, psychometrically sound measurement tool to help advance diagnostic teamwork and communication to improve patient care and outcomes.

Sepsis Prediction Model for Determining Sepsis vs SIRS, qSOFA, and SOFA

The Sepsis Prediction Model (SPM) is a proprietary decision support tool created by Epic Systems; it generates a predicting sepsis score (PSS). The model has not undergone validation against existing sepsis prediction tools, such as Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), or quick Sepsis-Related Organ Failure Asessement (qSOFA). To assess the validity and timeliness of the SPM compared with SIRS, qSOFA, and SOFA. This retrospective cohort study included all adults admitted to 5 acute care hospitals in a single US health system between June 5, 2019, and December 31, 2020. Data analysis was conducted from March 2021 to February 2023. A sepsis event was defined as receipt of 4 or more days of antimicrobials, blood cultures collected within ±48 hours of initial antimicrobial, and at least 1 organ dysfunction as defined by the organ dysfunction criteria optimized for the electronic health record (eSOFA). Time zero was defined as 15 minutes prior to qualifying antimicrobial or blood culture order. Of 60 507 total admissions, 1663 (2.7%) met sepsis criteria, with 1324 electronic health record-confirmed sepsis (699 [52.8%] male patients; 298 [22.5%] Black patients; 46 [3.5%] Hispanic/Latinx patients; 945 [71.4%] White patients), 339 COVID-19 sepsis (183 [54.0%] male patients; 98 [28.9%] Black patients; 36 [10.6%] Hispanic/Latinx patients; and 189 [55.8%] White patients), and 58 844 (97.3%; 26 632 [45.2%] male patients; 12 698 [21.6%] Black patients; 3367 [5.7%] Hispanic/Latinx patients; 40 491 White patients) did not meet sepsis criteria. The median (IQR) age was 63 (51 to 73) years for electronic health record-confirmed sepsis, 69 (60 to 77) years for COVID-19 sepsis, and 60 (42 to 72) years for nonsepsis admissions. Within the vendor recommended threshold PSS range of 5 to 8, PSS of 8 or greater had the highest balanced accuracy for classifying a sepsis admission at 0.79 (95% CI, 0.78 to 0.80). Change in SOFA score of 2 or more had the highest sensitivity, at 0.97 (95% CI, 0.97 to 0.98). At a PSS of 8 or greater, median (IQR) time to score positivity from time zero was 68.00 (6.75 to 605.75) minutes. For SIRS, qSOFA, and SOFA, median (IQR) time to score positivity was 7.00 (-105.00 to 08.00) minutes, 74.00 (-22.25 to 599.25) minutes, and 28.00 (-108.50 to 134.00) minutes, respectively. In this cohort study of hospital admissions, balanced accuracy of the SPM outperformed other models at higher threshold PSS; however, application of the SPM in a clinical setting was limited by poor timeliness as a sepsis screening tool as compared to SIRS and SOFA.

Hepatocellular Carcinoma Surveillance Patterns and Outcomes in Patients With Cirrhosis

Hepatocellular carcinoma (HCC) surveillance is associated with improved early detection and reduced mortality, although practice patterns and effectiveness vary in clinical practice. We aimed to characterize HCC surveillance patterns in a large, diverse cohort of patients with HCC. We conducted a retrospective cohort study of patients diagnosed with HCC between January 2008 and December 2022 at 2 large US health systems. We recorded imaging receipt in the year before HCC diagnosis: ultrasound plus α-fetoprotein (AFP), ultrasound alone, multiphasic contrast-enhanced computed tomography (CT)/magnetic resonance imaging (MRI), and no liver imaging. We used multivariable logistic and Cox regression analysis to compare early tumor detection, curative treatment receipt, and overall survival between surveillance strategies. Among 2028 patients with HCC (46.7% Barcelona Clinic Liver Cancer stage A), 703 (34.7%) had ultrasound plus AFP, 293 (14.5%) had ultrasound alone, 326 (16.1%) had multiphasic CT/MRI, and 706 (34.8%) had no imaging in the year before HCC diagnosis. Over the study period, proportions without imaging were stable, whereas use of CT/MRI increased. Compared with no imaging, CT/MRI and ultrasound plus AFP, but not ultrasound alone, were associated with early stage HCC detection and curative treatment. Compared with ultrasound alone, CT/MRI and ultrasound plus AFP were associated with increased early stage detection. HCC surveillance patterns vary in clinical practice and are associated with differing clinical outcomes. While awaiting data to determine if CT or MRI surveillance can be performed in a cost-effective manner in selected patients, AFP has a complementary role to ultrasound-based surveillance, supporting its adoption in practice guidelines.

Who's Accountable? Low-Value Care Received By Medicare Beneficiaries Outside Of Their Attributed Health Systems.

Policy makers and payers increasingly hold health systems accountable for spending and quality for their attributed beneficiaries. Low-value care-medical services that offer little or no benefit and have the potential for harm in specific clinical scenarios-received outside of these systems could threaten success on both fronts. Using national Medicare data for fee-for-service beneficiaries ages sixty-five and older and attributed to 595 US health systems, we describe where and from whom they received forty low-value services during 2017-18 and identify factors associated with out-of-system receipt. Forty-three percent of low-value services received by attributed beneficiaries originated from out-of-system clinicians: 38percent from specialists, 4percent from primary care physicians, and 1percent from advanced practice clinicians. Recipients of low-value care were more likely to obtain that care out of system if age 75 or older (versus ages 65-74), male (versus female), non-Hispanic White (versus other races or ethnicities), rural dwelling (versus metropolitan dwelling), more medically complex, or experiencing lower continuity of care. However, out-of-system service receipt was not associated with recipients' health systems' accountable care organization status. Health systems might improve quality and reduce spending for their attributed beneficiaries by addressing out-of-system receipt of low-value care-for example, by improving continuity.

Gaps in Guideline-Based Lipid-Lowering Therapy for Secondary Prevention in the United States: A Retrospective Cohort Study of 322 153 Patients.

Many patients with atherosclerotic cardiovascular disease (ASCVD) are not on guideline-recommended statin therapy. We evaluated utilization of statins and other lipid-lowering therapy (LLT), and changes in low-density lipoprotein cholesterol (LDL-C), among patients with ASCVD over a 1-year period. LLT and LDL-C levels at the first outpatient visit (January 1, 2017-December 31, 2018) and 1-year follow-up were evaluated using data from Cerner Real-World Data, an electronic health record-derived data set from 92 US health systems. Logistic regression was used to evaluate factors associated with high-intensity statin use. We identified 322 153 patients with ASCVD (median age 69 years, 58.8% men, 81.8% White). Overall, 76.1% of patients were on statins, with only 39.4% on high-intensity statins. Men were more likely to receive high-intensity statins than women (multivariable-adjusted odds ratio, 1.34 [95% CI, 1.30-1.38]). Increasing age was associated with lower odds of statin use (odds ratio, 0.79 per 5-year increase at 60 years [95% CI, 0.78-0.81]). Patients with peripheral artery disease (odds ratio, 0.40 [95% CI, 0.37-0.42]) and cerebrovascular disease (odds ratio, 0.75 [95% CI, 0.70-0.80]) had lower odds of using high-intensity statins than those with coronary artery disease. At baseline, most patients (61.3%) had elevated LDL-C (≥70 mg/dL), including 59.8% of those on low/moderate-intensity statins and 76.1% on no statin; only 45.3% achieved an LDL-C <70 mg/dL at 1 year. Nonstatin LLT use was low (ezetimibe, 4.4%; proprotein convertase subtilisin/kexin type 9 inhibitors, 0.7%). Among patients on no statin or low/moderate-intensity statin at baseline, 14.8% and 13.4%, respectively, were on high-intensity statins at 1 year. Among patients with ASCVD in routine care, high-intensity statins are underutilized, and uptitration and use of nonstatin therapy are uncommon. Women, older adults, and individuals with noncardiac ASCVD are particularly undertreated. Concerted efforts are needed to address therapeutic inertia for lipid management in patients with ASCVD.

Retrospective comparison of traditional and artificial intelligence-based heart failure phenotyping in a US health system to enable real-world evidence

ObjectiveQuantitatively evaluate the quality of data underlying real-world evidence (RWE) in heart failure (HF).DesignRetrospective comparison of accuracy in identifying patients with HF and phenotypic information was made using traditional (ie,...

A "sludge audit" for health system colorectal cancer screening services.

"Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services. Mixed methods sludge audit. We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes. Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients. Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

Prenatal Health Care Outcomes Before and During the COVID-19 Pandemic Among Pregnant Individuals and Their Newborns in an Integrated US Health System

The COVID-19 pandemic accelerated the use of telemedicine. However, data on the integration of telemedicine in prenatal health care and health outcomes are sparse. To evaluate a multimodal model of in-office and telemedicine prenatal health care implemented during the COVID-19 pandemic and its association with maternal and newborn health outcomes. This cohort study of pregnant individuals using longitudinal electronic health record data was conducted at Kaiser Permanente Northern California, an integrated health care system serving a population of 4.5 million people. Individuals who delivered a live birth or stillbirth between July 1, 2018, and October 21, 2021, were included in the study. Data were analyzed from January 2022 to May 2023. Exposure levels to the multimodal prenatal health care model were separated into 3 intervals: unexposed (T1, birth delivery between July 1, 2018, and February 29, 2020), partially exposed (T2, birth delivery between March 1, 2020, and December 5, 2020), and fully exposed (T3, birth delivery between December 6, 2020, and October 31, 2021). Primary outcomes included rates of preeclampsia and eclampsia, severe maternal morbidity, cesarean delivery, preterm birth, and neonatal intensive care unit (NICU) admission. The distributions of demographic and clinical characteristics, care processes, and health outcomes for birth deliveries within each of the 3 intervals of interest were assessed with standardized mean differences calculated for between-interval contrasts. Interrupted time series analyses were used to examine changes in rates of perinatal outcomes and its association with the multimodal prenatal health care model. Secondary outcomes included gestational hypertension, gestational diabetes, depression, venous thromboembolism, newborn Apgar score, transient tachypnea, and birth weight. The cohort included 151 464 individuals (mean [SD] age, 31.3 [5.3] years) who delivered a live birth or stillbirth. The mean (SD) number of total prenatal visits was similar in T1 (9.41 [4.75] visits), T2 (9.17 [4.50] visits), and T3 (9.15 [4.66] visits), whereas the proportion of telemedicine visits increased from 11.1% (79 214 visits) in T1 to 20.9% (66 726 visits) in T2 and 21.3% (79 518 visits) in T3. NICU admission rates were 9.2% (7014 admissions) in T1, 8.3% (2905 admissions) in T2, and 8.6% (3615 admissions) in T3. Interrupted time series analysis showed no change in NICU admission risk during T1 (change per 4-week interval, -0.22%; 95% CI, -0.53% to 0.09%), a decrease in risk during T2 (change per 4-week interval, -0.91%; 95% CI, -1.77% to -0.03%), and an increase in risk during T3 (change per 4-week interval, 1.75%; 95% CI, 0.49% to 3.02%). There were no clinically relevant changes between T1, T2, and T3 in the rates of risk of preeclampsia and eclampsia (change per 4-week interval, 0.76% [95% CI, 0.39% to 1.14%] for T1; -0.19% [95% CI, -1.19% to 0.81%] for T2; and -0.80% [95% CI, -2.13% to 0.55%] for T3), severe maternal morbidity (change per 4-week interval , 0.12% [95% CI, 0.40% to 0.63%] for T1; -0.39% [95% CI, -1.00% to 1.80%] for T2; and 0.99% [95% CI, -0.88% to 2.90%] for T3), cesarean delivery (change per 4-week interval, 0.06% [95% CI, -0.11% to 0.23%] for T1; -0.03% [95% CI, -0.49% to 0.44%] for T2; and -0.05% [95% CI, -0.68% to 0.59%] for T3), preterm birth (change per 4-week interval, 0.23% [95% CI, -0.11% to 0.57%] for T1; -0.37% [95% CI, -1.29% to 0.55%] for T2; and -0.15% [95% CI, -1.41% to 1.13%] for T3), or secondary outcomes. These findings suggest that a multimodal prenatal health care model combining in-office and telemedicine visits performed adequately compared with in-office only prenatal health care, supporting its continued use after the pandemic.

Association Between the 10-Year ASCVD Risk Score and COVID-19 Complications Among Healthy Adults (Analysis from the National Cohort COVID Collaborative)

COVID-19 complications have been linked to worse outcomes among patients with established atherosclerotic cardiovascular disease (ASCVD). Less is known about the cumulative consequences of multiple ASCVD risk factors on COVID-19 outcomes. We evaluated the dose-response associations between 10-year ASCVD risk scores and COVID-19 complications. The National COVID-19 Cohort Collaborative collects electronic health record data from over 70 US health systems. Our analysis was limited to patients with positive COVID-19 tests without documented ASCVD events at the time of the first positive test. We evaluated the dose-response associations between 10-year ASCVD risk scores, categorized into categorized as low (<7.5%), intermediate (7.5% to 20.0%), or high (>20.0%), and COVID-19 complications, including hospitalizations and mortality. We reported the outcomes using multivariable-adjusted hazard ratios and 95% confidence intervals (CIs). Our cohort included 120,335 patients with documented positive COVID-19 test results who were free of ASCVD events. The mean age was 51.9 ± 16.1years, 59.4% were women, 15.3% were Black, and 13.7% were Hispanic/Latino. Overall, 15,363 patients (12.8%) were hospitalized and 2,058 (1.7%) died. Patients at intermediate risk of developing ASCVD were had a 1.49 (95% CI 1.41 to 1.56) increased risk of hospitalization and 1.77 (95% CI 1.76 to 1.79) increased risk of mortality compared with patients at low risk. Patients at high risk had a 2.23 (95% CI 2.10 to 2.38) increased risk of hospitalization and a 5.98 (95% CI 5.93 to 6.03) increased risk of mortality. In conclusion, patients in this nationwide cohort at high risk of developing ASCVD are at substantially greater risk of COVID-19 complications. COVID-19 mitigation efforts should focus on these patient populations.

‘You just emotionally break’: understanding COVID-19 narratives through public health humanities

News reports that feature the experiences of healthcare workers have shaped public conversations about the pandemic from its earliest days. For many, stories of the pandemic have been an introduction...

Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System

Tailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems. To assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP. This parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022. Risk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants' general practitioners and may have included a referral to physiotherapy. The primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group. Analysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, -0.75 points; 95% CI -2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, -1.66 to 1.76 points). In this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care. ClinicalTrials.gov Identifier: NCT03127826.

Organization of Cancer Specialists in US Physician Practices and Health Systems.

To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers. Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physicians providing cancer care. We stratified physicians by discipline (adult/pediatric medical oncologists, radiation oncologists, surgical/gynecologic oncologists, other surgeons performing cancer surgeries, or palliative care physicians), system type (National Cancer Institute [NCI] Cancer Center system, non-NCI academic system, nonacademic system, or nonsystem/independent practice), practice size, and composition (single disciplinary oncology, multidisciplinary oncology, or multispecialty). We computed the density of cancer specialists by county and calculated distances to the nearest NCI Cancer Center. More than half of all cancer specialists (57.8%) practiced in health systems, but 55.0% of cancer-related visits occurred in independent practices. Most system-based physicians were in large practices with more than 100 physicians, while those in independent practices were in smaller practices. Practices in NCI Cancer Center systems (95.2%), non-NCI academic systems (95.0%), and nonacademic systems (94.3%) were primarily multispecialty, while fewer independent practices (44.8%) were. Cancer specialist density was sparse in many rural areas, where the median travel distance to an NCI Cancer Center was 98.7 miles. Distances to NCI Cancer Centers were shorter for individuals living in high-income areas than in low-income areas, even for individuals in suburban and urban areas. Although many cancer specialists practiced in multispecialty health systems, many also worked in smaller-sized independent practices where most patients were treated. Access to cancer specialists and cancer centers was limited in many areas, particularly in rural and low-income areas.