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Objective. To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes. Data Sources/Setting. Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012. Study Design. Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence. Data Collection. Adherence and OOP costs were based on pharmacy dispensing records and benefits. Principal Findings. Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost [greater than or equal to]$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence ([greater than or equal to]20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months). Conclusions. Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control. Key Words. Adherence, medical expenditures, pharmacy benefits, out-of-pocket costs, As a strategy to control expenditures and excessive use of services, insurers and health care delivery systems typically require patients to bear an out-of-pocket (OOP) cost (in the form of [...]

IMPORTANCE: The risk of adverse events from ascending thoracic aorta aneurysm (TAA) is poorly understood but drives clinical decision-making. OBJECTIVE: To evaluate the association of TAA size with outcomes in nonsyndromic patients in a large non–referral-based health care delivery system. DESIGN, SETTING, AND PARTICIPANTS: The Kaiser Permanente Thoracic Aortic Aneurysm (KP-TAA) cohort study was a retrospective cohort study at Kaiser Permanente Northern California, a fully integrated health care delivery system insuring and providing care for more than 4.5 million persons. Nonsyndromic patients from a regional TAA safety net tracking system were included. Imaging data including maximum TAA size were merged with electronic health record (EHR) and comprehensive death data to obtain demographic characteristics, comorbidities, medications, laboratory values, vital signs, and subsequent outcomes. Unadjusted rates were calculated and the association of TAA size with outcomes was evaluated in multivariable competing risk models that categorized TAA size as a baseline and time-updated variable and accounted for potential confounders. Data were analyzed from January 2018 to August 2021. EXPOSURES: TAA size. MAIN OUTCOMES AND MEASURES: Aortic dissection (AD), all-cause death, and elective aortic surgery. RESULTS: Of 6372 patients with TAA identified between 2000 and 2016 (mean [SD] age, 68.6 [13.0] years; 2050 female individuals [32.2%] and 4322 male individuals [67.8%]), mean (SD) initial TAA size was 4.4 (0.5) cm (828 individuals [13.0% of cohort] had initial TAA size 5.0 cm or larger and 280 [4.4%] 5.5 cm or larger). Rates of AD were low across a mean (SD) 3.7 (2.5) years of follow-up (44 individuals [0.7% of cohort]; incidence 0.22 events per 100 person-years). Larger initial aortic size was associated with higher risk of AD and all-cause death in multivariable models, with an inflection point in risk at 6.0 cm. Estimated adjusted risks of AD within 5 years were 0.3% (95% CI, 0.3-0.7), 0.6% (95% CI, 0.4-1.3), 1.5% (95% CI, 1.2-3.9), 3.6% (95% CI, 1.8-12.8), and 10.5% (95% CI, 2.7-44.3) in patients with TAA size of 4.0 to 4.4 cm, 4.5 to 4.9 cm, 5.0 to 5.4 cm, 5.5 to 5.9 cm, and 6.0 cm or larger, respectively, in time-updated models. Rates of the composite outcome of AD and all-cause death were higher than for AD alone, but a similar inflection point for increased risk was observed at 6.0 cm. CONCLUSIONS AND RELEVANCE: In a large sociodemographically diverse cohort of patients with TAA, absolute risk of aortic dissection was low but increased with larger aortic sizes after adjustment for potential confounders and competing risks. Our data support current consensus guidelines recommending prophylactic surgery in nonsyndromic individuals with TAA at a 5.5-cm threshold.

Background. The specialist&apos;s role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential. Objective. To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). Subjects/Study Setting. A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices. Study Design. We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction. Principal Findings. Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction. Conclusions. Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction. Key Words. Satisfaction, quality of care, managed care, financial incentives Patient satisfaction with medical care is an important component in assessing the quality of care. Studies have found that satisfaction is associated with patient compliance with provider recommendations, willingness to initiate malpractice litigation, switching providers and health plans, and medical care utilization (Sherbourne et al. 1992; Vaccarino 1977; Marquis, Davies, and Ware 1983; Newcomer, Preston, and Harrington 1996; Zastowny, Roghmann, and Cafferata 1989)., The published literature suggests that practice characteristics, including practice size, provider capitation, and certain forms of utilization review, are associated with patient satisfaction with primary care (Rubin et al. 1993; [...]

The American Heart Association Life's Simple 7 schema can be used to categorize patients’ cardiovascular health status as poor, intermediate, or ideal on the basis of smoking, BMI, physical activity, dietary patterns, blood pressure, cholesterol, and fasting blood sugar. This study examined the association between cardiovascular health status and subsequent healthcare utilization.

IMPORTANCE: A deceleration in the rate of decrease of heart disease (HD) mortality between 2011 and 2014 has been reported. In the context of the rapid increase in the population of adults aged 65 years and older, extending the examination of HD mortality through 2017 has potentially important implications for public health and medical care. OBJECTIVE: To examine changes in the age-adjusted mortality rate and the number of deaths within subcategories of HD from 2011 to 2017 in conjunction with the change in the size of the US population during the same period. DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data set was used to identify national changes in the US population aged 65 years and older and in the age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, coronary heart disease (CHD), heart failure, and other HDs from January 1, 2011, to December 31, 2017. MAIN OUTCOMES AND MEASURES: Changes from 2011 to 2017 in the US population and in age-adjusted mortality rates and number of deaths that were listed with an underlying cause of HD, CHD, heart failure (both as an underlying and a contributing cause), and other HDs overall, by sex and race/ethnicity. RESULTS: The total size of this population of US adults aged 65 years and older increased 22.9% from 41.4 million to 50.9 million between January 1, 2011, and December 31, 2017, while the population of adults younger than 65 years increased by only 1.7%. During this period, the age-adjusted mortality rate decreased 5.0% for HD and 14.9% for CHD while increasing 20.7% for heart failure and 8.4% for other HDs. The number of deaths increased 8.5% for HD, 38.0% for heart failure, and 23.4% for other HDs while decreasing 2.5% for CHD. A total of 80% of HD deaths occurred in the group of adults aged 65 years and older. CONCLUSIONS AND RELEVANCE: The substantial increase in the growth rate of the group of adults aged 65 years and older who have the highest risk of HD was associated with an increase in the number of HD deaths in this group despite a slowly declining HD mortality rate in the general population. With the number of adults aged 65 years and older projected to increase an additional 44% from 2017 to 2030, innovative and effective approaches to prevent and treat HD, particularly the substantially increasing rates of heart failure, are needed.

Transcatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR.

IMPORTANCE: Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. OBJECTIVE: To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. EXPOSURES: The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. MAIN OUTCOMES AND MEASURES: Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. RESULTS: Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. CONCLUSIONS AND RELEVANCE: A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.

The eligibility and potential benefit of transcatheter edge-to-edge repair (TEER) in addition to guideline-directed medical therapy to treat moderate-severe or severe secondary mitral regurgitation (MR) has not been reported in a contemporary heart failure (HF) population. In this study 50,841 adults with HF identified between 2013-2018 were screened for TEER eligibility based on the Food and Drug Administration (FDA) labeling. After applying the FDA eligibility criteria, 2,461 of these patients (4.8%) qualified for TEER (FDA+). These patients had higher natriuretic peptide levels and were more likely to have had a prior 1-year HF hospitalization. The estimated number needed to treat to prevent or postpone all-cause hospitalization was 4.4, 8.8 for HF hospitalization, and 5.3 for all-cause death at 24 months. The low prevalence of FDA eligibility for TEER treatment was primarily due to absence of moderate-severe or severe MR. Additional research is necessary to validate the scope of eligibility and comparative effectiveness of TEER.

Aim:To assess, through a systematic review, evidence for the effects of antiarrhythmic drugs (AADs) on cardiovascular (CV) hospitalization and mortality. Materials & methods:English language articles were identified using MEDLINE, EMBASE and the Cochrane Clinical Trial Registry and were screened for study applicability and methodological quality. Results:Out of 3526 identified studies, 38 were selected for analysis (19 evaluated individual AADs, 13 compared rate- versus rhythm-control strategies, and 6 evaluated multiple AADs but did not report outcomes for individual agents). None of the studies examining individual AADs employed the CV hospitalization end point used in ATHENA (the reference trial). There were no head-to-head comparisons of individual AADs on CV hospitalization. Most high-quality studies used multidrug rate- versus rhythm-control strategies. Conclusion:Assessment of the comparative effectiveness of individual AADs on CV hospitalization and mortality end points is not possible with the current evidence.

Systematic case identification is critical to improving population health, but widely used diagnosis code-based approaches for conditions like valvular heart disease are inaccurate and lack specificity.

Introduction:Administrative claims data are often used for population management and quality reporting, but diagnosis codes for conditions such as valvular heart disease can be inaccurate and vary across health systems. Echocardiography (echo) data contain detailed clinical information but are generally unstructured and not feasible to extract manually in large scale.Methods:We developed and validated natural language processing (NLP) algorithms to identify aortic stenosis (AS) from echo reports in Kaiser Permanente Northern California (KPNC) and compared AS identification using NLP vs. administrative codes. Using NLP software (Linguamatics i2e), we initially developed algorithms to identify AS from a development set of >100 echo reports manually confirmed with AS, with iterative refinement using additional development sets (>100 echo reports each) until the NLP algorithm achieved positive and negative predictive values (PPV and NPV) of >95%. We then applied the NLP algorithm to all 2008-2018 echo reports (transthoracic, transesophageal or stress) in KPNC adults and compared results to ICD-9/10 diagnostic code-based definitions from 14 days before to 6 months after the echo date.Results:The NLP algorithm was developed and refined among >500 echo reports to achieve >95% PPV and NPV. Application of NLP to 957,505 echo reports (N=522,653 patients with mean age 63.3 years, 51% women, 8.5% black, 13.5% Asian/Pacific Islander, 12.9% Hispanic and median [interquartile range] 1 [1 to 2] echoes per person) yielded 104,090 echoes (10.9%) with AS (N=53,791 patients). Among echoes identified by NLP as positive for AS, 36,070 (34.7%) had diagnosis codes for AS between 14 days prior and 6 months after echo. Among echo?s without AS via NLP, 12,626 (1.5%) had diagnosis codes for AS between 14 days before to 6 months after the echo.Conclusions:An NLP algorithm applied to a large echo database was more accurate than using diagnosis codes for identifying AS and can facilitate more effective individual and population management than relying on administrative data alone. Future NLP development to characterize AS severity will further advance personalized and population-based care strategies for surveillance and treatment.