Search

Depression among individuals who have been racially and ethnically minoritized in the United States can be vastly different from that of non-Hispanic White Americans. For example, African American adults who have depression rate their symptoms as more severe, have a longer course of illness, and experience more depression-associated disability. The purpose of this review was to conceptualize how structural racism and cumulative trauma can be fundamental drivers of the intergenerational transmission of depression. The authors propose that understanding risk factors for depression, particularly its intergenerational reach, requires accounting for structural racism. In light of the profoundly different experiences of African Americans who experience depression (i.e., a more persistent course of illness and greater disability), it is critical to examine whether an emerging explanation for some of these differences is the intergenerational transmission of this disorder due to structural racism.

Background Innovative program designs and strategies are needed to support the widespread uptake of cardiac rehabilitation (CR) programs in the post-COVID19 era. We combined user-centered design (UCD) and implementation science (ImS) principles to design a novel telehealth-enhanced hybrid (home and clinic-based) CR (THCR) program. Methods As part of a New York Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we designed a THCR program using an iterative 3 step UCD process informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research to: 1) identify user and contextual barriers to CR uptake (stakeholder interviews), 2) design an intervention prototype (design workshops and journey mapping), and 3) refine the prototype (usability testing). The process was optimized for usability and implementation outcomes. Results Step 1: Semi-structured interviews with stakeholders (n = 9) at 3 geographically diverse academic medical centers revealed behavioral (e.g., self-efficacy, knowledge) and contextual (e.g., social distancing guidelines, physical space, staffing, reimbursement) barriers to uptake. Step 2: Design workshops (n = 20) and journey-mapping sessions (n = 3) with multi-disciplinary NYPH stakeholders (e.g., digital health team, CR clinicians, creative director) yielded a THCR prototype that leveraged NYPH’s investment in their remote patient monitoring (RPM) platform to optimize feasibility of home-based CR sessions. Step 3: Usability testing with CR clinicians (n = 2) administering and CR patients (n = 3) participating in home-based sessions revealed usability challenges (e.g., RPM devices/exercise equipment usability; Wi-Fi/Bluetooth connectivity/syncing; patient safety/knowledge and protocol flexibility). Design workshops (n = 24) and journey-mapping sessions (n = 3) yielded design solutions (e.g., onboarding sessions, safety surveys, fully supervised remote sessions) and a refined THCR prototype. Conclusion Combining UCD and ImS methods while engaging multi-disciplinary stakeholders in an iterative process yielded a theory-informed telehealth-enhanced hybrid CR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process, and guidance for incorporating UCD and ImS methods in early-stage intervention development. THCR may shrink the evidence-to-practice gap in CR implementation. A future hybrid type I effectiveness-implementation trial will determine its feasibility, acceptability, and effectiveness.

Background: Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption. Methods: We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients. Results: We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support. Conclusions: We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

Background: In 2015, the US Preventive Services Task Force (USPSTF) updated its primary care screening guidelines to recommend out-of-office BP testing with ABPM or HBPM for confirming the diagnosis of hypertension (HTN) in adult patients with high office BP. Methods: We applied the Behavior Change Wheel framework to develop a theory-informed strategy for increasing the uptake of the USPSTF HTN screening guideline. We then conducted a 2-arm cluster randomized trial in which 8 primary care practices (154 clinicians) in an ambulatory care network serving vulnerable communities in New York City were randomized to receive the implementation strategy (4 practices) or a wait-list control (4 practices). The strategy was implemented from October 2017 to March 2018, and consisted of: 1) clinician education about HTN screening recommendations; 2) clinician information on how to order ABPM and HPBM; 3) patient information on ABPM and HBPM; 4) nurse training on how to teach patients to conduct HBPM; 5) access to an ABPM testing service; 6) clinician feedback on out-of-office BP test ordering; and 7) embedded tools in the EHR to facilitate ABPM and HBPM ordering. The primary outcome was change in the proportion of patients completing ABPM or HBPM in the year before versus year after implementation. Results: There were 1069 eligible patients (mean age 53±16 years, 67% women) with high office BP but no diagnosis or treatment for HTN. In implementation practices, the proportion of patients with out-of-office BP test ordering increased from 0.5% in the year before implementation to 4.0% in the year after implementation (p Conclusions: A theory-informed implementation strategy increased out-of-office BP testing in adult primary care patients being screened for HTN. Yet, out-of-office BP testing in the context of HTN screening remained low in both implementation and control practices, suggesting a need for more potent implementation strategies.

Introduction: Hypertension (HTN) screening guidelines recommend using ambulatory blood pressure monitoring (ABPM) to exclude white coat HTN prior to newly diagnosing HTN. Yet, little is known about the impact of ABPM testing on HTN diagnosis decisions in primary care. Unfamiliarity with how to interpret ABPM results could lead to overtreatment or diagnostic inertia, the failure to diagnose a disease despite clinical evidence. Methods: We examined medical records of primary care patients with elevated office BP (≥140/90 mmHg) who were referred to an ABPM testing service. Patients were eligible for analysis if they were ≥18 years old, had elevated office BP without a HTN diagnosis and not prescribed BP medications, were referred by a primary care clinician from clinics affiliated with Columbia University Medical Center, and completed ABPM testing between 2016-2019. Using mean awake BP of 135/85 mmHg as the threshold for elevated ABPM, we compared the BP testing outcome (white coat HTN, in which only office BP was elevated, or sustained HTN, in which both office and ambulatory BP were elevated) to the physician’s action at the subsequent scheduled primary care visit (diagnosed or did not diagnose HTN per manual review of electronic medical records). Results: Overall, 111 patients with newly elevated office BP completed ABPM testing during the analysis period. Patients were referred by 60 physicians (50% trainees) from 6 clinics. Patients had a mean (SD) age of 53 (15) years; 73% were women. Fifty-nine patients (53%) had white coat HTN, and 52 (88%) were not diagnosed with HTN at their next primary care visit. The remaining 52 patients (47%) had sustained HTN, and 44 (85%) were diagnosed with HTN at their next visit. Medication was started for 31 of these 44 (70%). Overall, physicians diagnosed HTN concordantly with ABPM results for 96/111 patients (86%). Conclusions: More than half of primary care patients with elevated office BP referred for ABPM had white coat HTN. There was high concordance between ABPM results and physician HTN diagnoses, suggesting that ABPM reduces but does not eliminate overdiagnosis and diagnostic inertia in HTN. More research is needed to understand the reasons for discordance and how to optimize the implementation of ABPM testing into primary care.

Primary care has been dubbed the “de facto” mental health system of the United States since the 1970s. Since then, various forms of mental health delivery models for primary care have proven effective in improving patient outcomes and satisfaction and reducing costs. Despite increases in collaborative care implementation and reimbursement, prevalence rates of major depression in the United States remain unchanged while anxiety and suicide rates continue to climb. Meanwhile, primary care task forces in countries like the United Kingdom and Canada are recommending against depression screening in primary care altogether, citing lack of trials demonstrating improved outcomes in screened vs unscreened patients when the same treatment is available, high false-positive results, and small treatment effects. In this perspective, a primary care physician and two psychiatrists address the question of why we are not making headway in treating common mental health conditions in primary care. In addition, we propose systemic changes to improve the dissemination of mental health treatment in primary care.

Background: Few if any examples exist of how best to select and adapt sustainability strategies. We used a collaborative/integrated care use case to describe a novel, theory-informed, stakeholder engaged process for operationalizing sustainability strategies. Methods: Informed by the Behavior Change Wheel, we used mixed methods to identify key sustainability behaviors and determinants of sustainability before conducting a “sustainability mapping” phase to identify acceptable and equitable intervention functions and behavioral change techniques. Drawing on user centered design principles, we enlisted 22 national and local stakeholders to operationalize and adapt (e.g., content, functionality, workflow) a multi-level sustainability strategy to maximally target behavioral determinants of sustainability. Results: We identified ongoing provider treatment optimization and patient initiation as key sustainability behaviors in settings receiving external facilitation and fiscal implementation strategies. The most acceptable, equitable and feasible intervention functions included environmental restructuring, education, training, modeling, persuasion, and enablement. We determined that a waiting room delivered shared decision making and psychoeducation patient tool (DepCare) the results of which are delivered to providers as well as ongoing problem-solving/implementation team meetings with care managers would be the most acceptable and equitable multi-level strategy in diverse settings seeking to sustain CC programs. Key adaptations in response to contextual factors included expanding the DepCare tool to incorporate anxiety/suicide screening, triage support, multi-modal delivery, and patient activation (vs. shared decision making); pairing preference reports with decisional support as well as yearly onboarding/motivational provider and staff educational videos; shifting problem solving meetings from billing support to triage/reducing inappropriate referrals. Conclusion: We provide a roadmap for designing theory-informed, sustainability strategies and employing user centered design principles to adapt strategies to changing mental health landscapes.

Background and Purpose: Posttraumatic stress disorder (PTSD) symptoms are common after stroke/transient ischemic attack (TIA) and have been associated with medication nonadherence, potentially because medications serve as traumatic reminders of the prior stroke/TIA. This study examined associations between stroke/TIA-induced PTSD and aversive cognitions toward preventive medications. Methods: We enrolled a cohort of patients presenting to the emergency department with suspected stroke/TIA. One month posthospitalization, we assessed PTSD symptoms specific to the index stroke/TIA using the PTSD checklist specific and asked patients how often (1) did thinking about your stroke medication make you feel nervous or anxious?; (2) did thinking about your stroke medication make you think about your risk for future strokes?; and (3) did you skip or avoid taking your stroke medication so you would not have to think about your stroke? Logistic regression models tested the association between PTSD symptoms and each aversive cognition, adjusting for age, sex, ethnicity, and depression. Results: Among 408 included patients, 11.0% had elevated PTSD symptoms. These patients were more likely to report that thinking about their stroke medication made them feel nervous or anxious (37.8% versus 9.9%, P P P =0.009). In adjusted analyses, higher PTSD checklist specific scores were associated with increased nervousness/anxiety (odds ratio, 1.33 [95% CI, 1.18–1.50], P P P =0.06). Conclusions: Medications may serve as traumatic reminders after stroke/TIA-induced PTSD, potentially leading to medication nonadherence.

Introduction: Elevated depressive symptoms in coronary heart disease (CHD) patients increases the risk of recurrent cardiovascular events and mortality. Experts posit that behavioral determinants like physical inactivity, patient activation/healthcare engagement, and depression treatment uptake may mediate this relationship. Social determinants like access to high-resourced/integrated clinical settings have also emerged, independent of patient-level demographics/factors. We sought to examine the impact of social determinants on trends in behavioral risk factors among CHD patients. Methods: As part of a trial of an electronic shared decision-making tool in depressed CHD patients (iHeart DepCare), we recruited English and Spanish-speaking patients with upcoming internal medicine and cardiology clinic appointments in 8 geographically and socioeconomically diverse clusters of clinics in NY from April 2019 to August 2021. Eligible participants were aged ≥21 years with an ICD10 code for CHD and a Patient Health Questionnaire-9 ≥10 but not under psychiatric care. Baseline questionnaires included the patient activation measure, international physical activity questionnaire, and self-reported preferred mental health treatment. We used descriptive statistics and logistic regression to examine pre-post changes in behavioral risk factors (2020-2021 vs. 2019) overall and by system-level resources (6 commercial insured/extensively resourced clinics [high] vs. 2 Medicaid only/limited resources [low]). Results: Of the 627 screened patients, 96 (15.3%) of CHD patients had elevated depressive symptoms; 22.4% in low-resourced vs. 6.2% high-resourced clinics (p Conclusion: Over the last 2 years, patient activation, a key predictor of cardiovascular risk, worsened among depressed CHD patients. While social/system-level factors (i.e., lack of quality care) may contribute to depression burden, once depressed, CHD patients demonstrate suboptimal preventative behaviors, like physical activity, engagement/activation, and depression treatment-seeking, regardless of system-level resources. Future research should elucidate reasons for waning interest in cardiac rehab and therapy in this high-risk population, and consider activation interventions that meet patients in their communities or homes.

The 2018 American College of Cardiology/American Heart Association Guideline on the Management of Blood Cholesterol recommends statin therapy for eligible patients to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). We extracted electronic health record data for patients with at least one primary care or cardiology visit between October 2018 and January 2020 at an urban, academic medical center in New York City. Clinical and demographic data were used to identify patients eligible for primary prevention statin therapy. Statin prescription status was extracted from the electronic health record, and multivariate logistic regression was used to assess the association between statin prescription and age, gender, race, ethnicity, and other clinical and demographic covariables. In 7,550 patients eligible for primary prevention statin therapy, 3,994 (52.9%) were prescribed statins on at least 1 visit. Statin prescription was highest in patients with diabetes mellitus (73.6%) and with a 10-year ASCVD risk ≥20% (60.6%) and was lowest for those with a 10-year ASCVD risk between 5% and 7.5% (18.7%). Compared with those never prescribed statins, patients prescribed statins were less likely to be women, mainly driven by lower statin prescription rates for women with diabetes. In a fully adjusted model, women remained less likely to be prescribed statin therapy (adjusted odds ratios 0.79, 95% confidence interval 0.71 to 0.88). In conclusion, primary prevention statin therapy remains underutilized.

Background: Telemedicine use vastly expanded during the Covid-19 pandemic, with uncertain impact on cardiovascular care. quality. Objectives: To examine the association between telemedicine use and blood pressure (BP) control. Methods: This is a retrospective cohort study of 32,727 adult patients with hypertension (HTN) seen in primary care and cardiology clinics at an urban, academic medical center from February to December, 2020. The primary outcome was poor BP control, defined as having no BP recorded OR if the last recorded BP was ≥140/90 mmHg. Multivariable logistic regression was used to assess the association between telemedicine use during the study period (none, 1 telemedicine visit, 2+ telemedicine visits) and poor BP control, adjusting for demographic and clinical characteristics. Results: During the study period, no BP was recorded for 486/20,745 (2.3%) patients with in-person visits only, for 1,863/6,878 (27.1%) patients with 1 telemedicine visit, and for 1,277/5,104 (25.0%) patients with 2+ telemedicine visits. After adjustment, telemedicine use was associated with poor BP control (odds ratio [OR], 2.06, 95% confidence interval [CI] 1.94 to 2.18, p Conclusions: BP is less likely to be recorded during telemedicine visits, but telemedicine use does not negatively impact BP control when BP is recorded.

Racial and ethnic differences in blood pressure (BP), regardless of antihypertensive medication use, contribute to cardiovascular disease disparities. We analyzed systolic BP (SBP) data from US adults in the National Health and Nutrition Examination Survey from 1999 to 2002 through 2015 to 2018 (n=51 743) to determine if racial and ethnicity disparities have changed over time. Among US adults not taking antihypertensive medication, the mean age-adjusted SBP (95% CI), mm Hg, in 1999 to 2002 and 2015 to 2018 was 119.6 (118.7–120.5) and 119.4 (118.7–120.1) for non-Hispanic White adults, 124.7 (123.7–125.7) and 124.9 (123.8–125.9) for non-Hispanic Black adults and 120.4 (118.6–122.2) and 120.4 (119.7–121.2) for Hispanic adults. The mean multivariable-adjusted SBP was 4.1 mm Hg (2.7–5.4) higher in 1999 to 2002 and 3.8 mm Hg (2.6–5.0) higher in 2015 to 2018 among non-Hispanic Black adults compared with non-Hispanic White adults, while there was no evidence of a difference between Hispanic adults and non-Hispanic White adults in 1999 to 2002 (−0.2 mm Hg [95% CI, −1.9 to 1.5]) or 2015 to 2018 (−0.8 mm Hg [95% CI, −1.8 to 0.1]). Among US adults taking antihypertensive medication, the mean age-adjusted SBP (95% CI), mm Hg, in 1999 to 2002 and 2015 to 2018 was 129.6 (126.7–132.4) and 127.1 (125.6–128.6) for non-Hispanic White adults, 136.9 (133.8–140.0) and 135.3 (132.5–138.1) for non-Hispanic Black adults and 133.9 (128.0–139.7) and 131.8 (127.6–136.0) for Hispanic adults. After multivariable adjustment, in 1999 to 2002 and 2015 to 2018, mean SBP was 4.8 mm Hg (1.8–7.8) and 6.5 mm Hg (4.5–8.4) higher, respectively, among non-Hispanic Black adults versus White adults, and 2.4 mm Hg (−2.6 to 7.3) and 3.6 mm Hg (0.8 to 6.4) higher, respectively, among Hispanic adults versus non-Hispanic White adults. In the United States, non-Hispanic Black adults continue to have higher SBP levels compared with non-Hispanic White adults.

Background There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. Methods This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. Results Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening. Conclusions Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Background Telemedicine visit use vastly expanded during the COVID-19 pandemic, and this has had an uncertain impact on cardiovascular care quality. Objective We sought to examine the association between telemedicine visits and the failure to meet the Controlling High Blood Pressure (BP) quality measure from the Centers for Medicare & Medicaid Services. Methods This was a retrospective cohort study of 32,727 adult patients with hypertension who were seen in primary care and cardiology clinics at an urban, academic medical center from February to December 2020. The primary outcome was a failure to meet the Controlling High Blood Pressure quality measure, which was defined as having no BP recorded or having a last recorded BP of ≥140/90 mm Hg (ie, poor BP control). Multivariable logistic regression was used to assess the association between telemedicine visit use during the study period (none, 1 telemedicine visit, or ≥2 telemedicine visits) and poor BP control; we adjusted for demographic and clinical characteristics. Results During the study period, no BP was recorded for 2.3% (486/20,745) of patients with in-person visits only, 27.1% (1863/6878) of patients with 1 telemedicine visit, and 25% (1277/5104) of patients with ≥2 telemedicine visits. After adjustment, telemedicine use was associated with poor BP control (1 telemedicine visit: odds ratio [OR] 2.06, 95% CI 1.94-2.18; P Conclusions Increased telemedicine visit use is associated with poorer performance on the Controlling High Blood Pressure quality measure. However, telemedicine visit use may not negatively impact BP control when BP is recorded.

Background There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. Methods This explanatory, sequential, mixed-methods study collected survey data (n = 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥ 70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n = 19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n = 5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. Results Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not experience overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may be reasons for overuse. Providers identified potential strategies including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may no longer benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop a standard process of care around mammography screening. Conclusions Multi-level factors contributing to mammography overuse are dynamic and reinforced. To ensure equitable de-implementation, there is a need for more refined theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Background Hypertension guidelines recommend screening and treatment for masked hypertension (MHT). Yet, few primary care providers (PCPs) screen for MHT, and little is known about PCP awareness, knowledge, and attitudes toward MHT. Methods Three focus groups involving 30 PCPs from 3 medical centers in New York were conducted. Focus group transcripts were analyzed using thematic content analysis. Results Awareness of MHT varied, and only 2 providers had diagnosed MHT. There was also low knowledge about the prevalence and impact of MHT. While some PCPs were receptive to MHT screening after learning about its significance, others viewed the current evidence as insufficient to change practice. Providers were discomforted by labeling patients with nonelevated office blood pressure (BP) as hypertensive and reluctant to add another screening test to their workload without stronger evidence. There was distrust in the accuracy of home BP monitoring to screen for MHT. There was more confidence in ambulatory BP monitoring (ABPM) for MHT screening, but ABPM was viewed as largely inaccessible. There was broad agreement with lifestyle changes for MHT. There were concerns that antihypertensive medication lacked evidence from randomized trials and could induce harmful side effects. Conclusions Limited PCP knowledge about MHT, concerns about the accuracy and accessibility of screening tests, overloaded PCPs, and insufficient evidence were major barriers to screening and treatment for MHT. Prior to broad uptake by PCPs, randomized trials demonstrating the net benefits of MHT screening and treatment may be needed, along with increased dissemination of knowledge about MHT and improved access to ABPM.

Background Depressive symptoms are associated with mortality. Data regarding moderation of this effect by age and sex are inconsistent, however. We aimed to identify whether age and sex modify the association between depressive symptoms and all‐cause and cardiovascular disease (CVD) mortality. Methods and Results The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective cohort of Black and White individuals recruited between 2003 and 2007. Associations between time‐varying depressive symptoms (Center for Epidemiologic Studies Depression scale score ≥4 versus P =0.05; CVD: age 45–64 years aHR, 1.17; 95% CI, 0.90–1.53 versus age ≥65 years aHR, 1.26; 95% CI, 1.06–1.50; P =0.54; all‐cause: males aHR, 1.46; 95% CI, 1.29–1.64 versus female aHR, 1.34; 95% CI, 1.19–1.50; P =0.35; CVD: male aHR, 1.32; 95% CI, 1.08–1.62 versus female aHR, 1.22; 95% CI, 1.00–1.47; P =0.64). Similar results were observed when stratified by self‐reported health status. Conclusions Depressive symptoms confer mortality risk regardless of age and sex, including individuals who report excellent/very good health.

Introduction: The coronavirus disease 2019 (COVID19) pandemic required strict social distancing to curb transmission. Unfortunately, these measures severely limited healthcare access and chronic disease management. In response, many health organizations rapidly developed or expanded telemedicine to provide care directly to patients at home. Little has been reported about the impact of such interventions on clinical outcomes during COVID19. We examined whether enrollment in a remote patient monitoring (RPM) program for hypertension (HTN) prior to COVID19 was associated with improved blood pressure during the pandemic. Methods: We developed an RPM program that tracked vital signs, medication side effects, and treatment adherence patterns outside of the clinic. Patients were referred by their primary care doctor for uncontrolled HTN or suspected white coat HTN. Patients received a two-way tablet, blood pressure cuff, and virtual nursing support via scheduled video visits. Those referred for uncontrolled HTN who had at least two weeks of data both before and after the onset of COVID19 (defined as the first two weeks of March 2020) were included in the study. A mixed-models analysis that adjusted for serial autocorrelation was used to compare mean systolic blood pressure (SBP) and mean diastolic blood pressure (DBP) in the pre-/post-COVID19 periods. Results: Of 94 patients enrolled in the RPM program to date, 46 had at least two weeks of data both pre-COVID19 and post-COVID19. Mean age was 69.0 ± 10.9 years, 69.6% (32 of 46) were women, 78.3% (36 of 46) were Hispanic, and 63.0% (29 of 46) were Spanish-speaking. Pre-COVID, mean SBP was 132.31 ± 13.99 mmHg, mean DBP was 77.10 ± 9.87 mmHg, and 70% (32 of 46) of patients had uncontrolled BP (>130/80 mmHg per AHA guidelines). Post-COVID, mean SBP was 129.57 ± 13.29 mmHg, mean DBP was 76.00 ± 9.16 mmHg, and 57% (26 of 46) of patients had uncontrolled BP. There was a significant reduction in both mean SBP (β = –2.74, 95% CI –5.21, –0.26, p = 0.03) and mean DBP (β = –1.10, 95% CI –2.22, 0.02, p = 0.05) post-COVID vs. pre-COVID. Discussion: Despite the stress and social isolation associated with COVID19, participation in an RPM program that combines home BP monitoring with virtual nursing support can help maintain and even mildly decrease BP.

Objective The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic. Methods This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th–April 24th 2020) at a large medical center in NYC (n = 657). Results Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest. Conclusions NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.

BACKGROUND Guidelines recommend that patients with newly elevated office blood pressure undergo ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to rule-out white coat hypertension before being diagnosed with hypertension. We explored patients’ perspectives of the barriers and facilitators to undergoing ABPM or HBPM. METHODS Focus groups were conducted with twenty English- and Spanish-speaking individuals from underserved communities in New York City. Two researchers analyzed transcripts using a conventional content analysis to identify barriers and facilitators to participation in ABPM and HBPM. RESULTS Participants described favorable attitudes toward testing including readily understanding white coat hypertension, agreeing with the rationale for out-of-office testing, and believing that testing would benefit patients. Regarding ABPM, participants expressed concerns over the representativeness of the day the test was performed and the intrusiveness of the frequent readings. Regarding HBPM, participants expressed concerns over the validity of the monitoring method and the reliability of home blood pressure devices. For both tests, participants noted that out-of-pocket costs may deter patient participation and felt that patients would require detailed information about the test itself before deciding to participate. Participants overwhelmingly believed that out-of-office testing benefits outweighed testing barriers, were confident that they could successfully complete either testing if recommended by their provider, and described the rationale for their testing preference. CONCLUSIONS Participants identified dominant barriers and facilitators to ABPM and HBPM testing, articulated testing preferences, and believed that they could successfully complete out-of-office testing if recommended by their provider.

In 2015, the US Preventive Services Task Force updated their hypertension recommendations to advise that adults with elevated office blood pressure (BP) undergo out-of-office BP measurement to exclude white coat hypertension before diagnosis. Our goal was to determine the most important barriers to primary care providers' ordering ambulatory and home BP monitoring in the United States. We enrolled 63 primary care providers into nominal group panels in which participants iteratively listed and ranked barriers to ambulatory and home BP monitoring. Top-ranked barriers to ambulatory BP monitoring were challenges in accessing testing, costs of testing, concerns about the willingness or ability of patients to successfully complete tests, and concerns about the accuracy and benefits of testing. Top-ranked barriers to home BP monitoring were concerns about compliance with the correct test protocol, accuracy of tests results, out-of-pocket costs of home BP devices, and time needed to instruct patients on home BP monitoring protocol. Efforts to increase the use of ambulatory and home BP monitoring by primary care providers in the United States should prioritize increasing the financial and personnel resources available for testing and addressing provider concerns about patients' ability to conduct high-quality tests.

Background The US Preventive Services Task Force (USPSTF) recommends out-of-office blood pressure (BP) testing to exclude white coat hypertension prior to hypertension diagnosis. Despite improved availability and coverage of home and 24-h ambulatory BP monitoring (HBPM, ABPM), both are infrequently used to confirm diagnoses. We used the Behavior Change Wheel (BCW) framework, a multi-step process for mapping barriers to theory-informed behavior change techniques, to develop a multi-component implementation strategy for increasing out-of-office BP testing for hypertension diagnosis. Informed by geographically diverse provider focus groups (n = 63) exploring barriers to out-of-office testing and key informant interviews (n = 12), a multi-disciplinary team (medicine, psychology, nursing) used rigorous mixed methods to develop, refine, locally adapt, and finalize intervention components. The purpose of this report is to describe the protocol of the Effects of a Multi-faceted intervention on Blood pRessure Actions in the primary Care Environment (EMBRACE) trial, a cluster randomized control trial evaluating whether a theory-informed multi-component strategy increased out-of-office testing for hypertension diagnosis. Methods/design The EMBRACE Trial patient sample will include all adults ≥ 18 years of age with a newly elevated office BP (≥ 140/90 mmHg) at a scheduled visit with a primary care provider from a study clinic. All providers with scheduled visits with adult primary care patients at enrolled ACN primary care clinics were included. We determined that the most feasible, effective implementation strategy would include delivering education about out-of-office testing, demonstration/instruction on how to perform out-of-office HBPM and ABPM testing, feedback on completion rates of out-of-office testing, environmental prompts/cues via computerized clinical decision support (CDS) tool, and a culturally tailored, locally accessible ABPM testing service. We are currently comparing the effect of this locally adapted multi-component strategy with usual care on the change in the proportion of eligible patients who complete out-of-office BP testing in a 1:1 cluster randomized trial across 8 socioeconomically diverse clinics. Conclusions The EMBRACE trial is the first trial to test an implementation strategy for improving out-of-office testing for hypertension diagnosis. It will elucidate the degree to which targeting provider behavior via education, reminders, and decision support in addition to providing an ABPM testing service will improve referral to and completion of ABPM and HBPMs. Trial registration Clinicaltrials.gov, NCT03480217, Registered on 29 March 2018

PURPOSE: Depressive symptoms relapse and remit over time, perhaps differentially by race and income. Few studies have examined whether time-varying depressive symptoms (TVDS) differentially predict mortality. We sought to determine whether race (white/black) and income (

Background Elevated depressive symptoms among survivors of acute coronary syndromes (ACS) confer recurrent cardiovascular events and mortality, worse quality of life, and higher healthcare costs. While multiple scientific groups advise routine depression screening for ACS survivors, no randomized trials exist to inform this screening recommendation. We aimed to assess the effect of screening for depression on change in quality of life over 18 months among ACS patients. Methods The Comparison of Depression Identification after Acute Coronary Syndrome on Quality of Life and Cost Outcomes (CODIACS-QoL) trial is a pragmatic, 3-arm trial that randomized ACS patients to 1) systematic depression screening using the 8-item Patient Health Questionnaire (PHQ-8) and if positive screen (PHQ-8 ≥ 10), notification of primary care providers (PCPs) and invitation to participate in centralized, patient-preference, stepped depression care (Screen, Notify, and Treat, N = 499); 2) systematic depression screening and PCP notification only (Screen and Notify, N = 501); and 3) usual care (No Screen, N = 500). Adults hospitalized for ACS in the previous 2–12 months without prior history of depression were eligible for participation. Key outcomes will be quality-adjusted life years (primary), cost of health care utilization, and depression-free days across 18 months. Results A total of 1500 patients were randomized in the CODIACS-QOL trial (28.3% women; 16.3% Hispanic; mean age 65.9 (11.5) years). Only 7% of ACS survivors had elevated depressive symptoms. Conclusions Using a novel randomization schema and pragmatic design principles, the CODIACS-QoL trial achieved its enrollment target. Eventual results of this trial will inform future depression screening recommendations in cardiac patients. Trial registration: ClinicalTrials.gov (NCT 01993017).

Objectives Depression frequently co-occurs with multiple chronic diseases in complex, costly, and dangerous patterns of multimorbidity. The field of health psychology may benefit from evaluating the temporal characteristics of depression's associations with common diseases, and from determining whether depression is a central connector in multimorbid disease clusters. The present review addresses these issues by focusing on 4 of the most prevalent diseases: hypertension, ischemic heart disease, arthritis, and diabetes. Method Study 1 assessed how prior chronic disease diagnoses were associated with current depression in a large, cross-sectional, population-based study. It assessed depression's centrality using network analysis accounting for disease prevalence. Study 2 presents a systematic scoping review evaluating the extent to which depression was prospectively associated with the onset of the 4 prevalent chronic diseases. Results In Study 1 depression had the fourth highest betweenness centrality ranking of 26 network nodes and centrally connected many existing diseases and unhealthy behaviors. In Study 2 depression was associated with subsequent incidence of ischemic heart disease and diabetes across multiple meta-analyses. Insufficient information was available about depression's prospective associations with incident hypertension and arthritis. Conclusions Depression is central in patterns of multimorbidity and is associated with incident disease for several of the most common chronic diseases, justifying the focus on screening and treatment of depression in those at risk for developing chronic disease. Future research should investigate the mediating and moderating roles of health behaviors in the association between depression and the staggered emergence over time of clusters of multimorbid chronic diseases. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective Shared decision-making (SDM) is increasingly promoted in the primary care setting, but depressive symptoms, which are associated with cognitive changes, may influence decision-making preferences. We sought to assess whether elevated depressive symptoms are associated with decision-making preference in patients with comorbid chronic illness. Methods We enrolled 195 patients ≥ 18 years old with uncontrolled hypertension from two urban, academic primary care clinics. Depressive symptoms were assessed using the 8-item Patient Health Questionnaire. Clinician-directed decision-making preference was assessed according to the Control Preference Scale. The impact of depressive symptoms on decision-making preference was assessed using generalized linear mixed models adjusted for age, gender, race, ethnicity, education, Medicaid status, Charlson Comorbidity Index, partner status, and clustering within clinicians. Results The mean age was 64.2 years; 72% were women, 77% Hispanic, 38% Black, and 33% had elevated depressive symptoms. Overall, 35% of patients preferred clinician-directed decision-making, 19% mostly clinician-directed, 39% shared, and 7% some or little clinician-input. Patients with (vs. without) elevated depressive symptoms were more likely to prefer clinician-directed decision-making (46% versus 29%; p = 0.02; AOR 2.51, 95% CI 1.30–4.85, p = 0.005). Remitted depressive symptoms (vs. never depressed) were not associated with preference. Conclusions Elevated depressive symptoms are associated with preference for clinician-directed decision-making. We suggest that clinicians should be aware of this effect when incorporating preference into their communication styles and take an active role in eliciting patient values and exchanging information about treatment choice, all important components of shared decision-making, particularly when patients are depressed.

Depression may adversely affect health outcomes by influencing doctor-patient communication. We aimed to determine the association between depressive symptoms and doctor-patient communication among patients presenting to the emergency department (ED) with a suspected acute coronary syndrome (ACS).We enrolled a consecutive sample of 500 patients evaluated for ACS symptoms from the ED of an urban medical center. Depressive symptoms (8-item Patient Health Questionnaire, PHQ-8) and doctor-patient communication in the ED (Interpersonal Processes of Care) were assessed during hospitalization. Logistic regression was used to determine the association between depressive symptoms and doctor-patient communication, adjusting for age, sex, race, ethnicity, education, language, health insurance status and comorbidities.Compared to nondepressed patients, depressed patients (PHQ-8≥10) were more likely (P.05) to report suboptimal communication on five of seven communication domains: clarity, elicitation of concerns, explanations, patient-centered decision making and discrimination. A greater proportion of depressed versus nondepressed patients reported suboptimal overall communication (39.8% versus 22.9%, P.001). In adjusted analyses, depressed patients remained more likely to report suboptimal doctor-patient communication (adjusted odds ratio 2.42, 95% confidence interval 1.52-3.87; P.001).Depressed patients with ACS symptoms reported less optimal doctor-patient communication in the ED than nondepressed patients. Research is needed to determine whether subjectively rated differences in communication are accompanied by observable differences.

BACKGROUND: We compared the cost-effectiveness of hypertension treatment in non-Hispanic blacks and non-Hispanic whites according to 2014 US hypertension treatment guidelines. METHODS: The cardiovascular disease (CVD) policy model simulated CVD events, quality-adjusted life years (QALYs), and treatment costs in 35- to 74-year-old adults with untreated hypertension. CVD incidence, mortality, and risk factor levels were obtained from cohort studies, hospital registries, vital statistics, and national surveys. Stage 1 hypertension was defined as blood pressure 140-149/90-99mm Hg; stage 2 hypertension as ≥150/100mm Hg. Probabilistic input distribution sampling informed 95% uncertainty intervals (UIs). Incremental cost-effectiveness ratios (ICERs) < $50,000/QALY gained were considered cost-effective. RESULTS: Treating 0.7 million hypertensive non-Hispanic black adults would prevent about 8,000 CVD events annually; treating 3.4 million non-Hispanic whites would prevent about 35,000 events. Overall 2014 guideline implementation would be cost saving in both groups compared with no treatment. For stage 1 hypertension but without diabetes or chronic kidney disease, cost savings extended to non-Hispanic black males ages 35-44 but not same-aged non-Hispanic white males (ICER $57,000/QALY; 95% UI $15,000-$100,000) and cost-effectiveness extended to non-Hispanic black females ages 35-44 (ICER $46,000/QALY; $17,000-$76,000) but not same-aged non-Hispanic white females (ICER $181,000/QALY; $111,000-$235,000). CONCLUSIONS: Compared with non-Hispanic whites, cost-effectiveness of implementing hypertension guidelines would extend to a larger proportion of non-Hispanic black hypertensive patients.