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BackgroundStudies assessing the impact of built environments on body weight are often limited by modest power to detect residential effects that are small for individuals but may nonetheless comprise large attributable risks. ObjectiveWe used data extracted from electronic health records to construct a large retrospective cohort of patients. This cohort will be used to explore both the impact of moving between environments and the long-term impact of changing neighborhood environments. MethodsWe identified members with at least 12 months of Kaiser Permanente Washington (KPWA) membership and at least one weight measurement in their records during a period between January 2005 and April 2017 in which they lived in King County, Washington. Information on member demographics, address history, diagnoses, and clinical visits data (including weight) was extracted. This paper describes the characteristics of the adult (aged 18-89 years) cohort constructed from these data. ResultsWe identified 229,755 adults representing nearly 1.2 million person-years of follow-up. The mean age at baseline was 45 years, and 58.0% (133,326/229,755) were female. Nearly one-fourth of people (55,150/229,755) moved within King County at least once during the follow-up, representing 84,698 total moves. Members tended to move to new neighborhoods matching their origin neighborhoods on residential density and property values. ConclusionsData were available in the KPWA database to construct a very large cohort based in King County, Washington. Future analyses will directly examine associations between neighborhood conditions and longitudinal changes in body weight and diabetes as well as other health conditions. International Registered Report Identifier (IRRID)DERR1-10.2196/16787

Background Patient-shared electronic health records provide opportunities for care outside of office visits. However, those who might benefit may be unable to or choose not to use these resources, while others might not need them. Objective Electronic Communications and Home Blood Pressure Monitoring (e-BP) was a randomized trial that demonstrated that Web-based pharmacist care led to improved blood pressure (BP) control. During recruitment we attempted to contact all patients with hypertension from 10 clinics to determine whether they were eligible and willing to participate. We wanted to know whether particular subgroups, particularly those from vulnerable populations, were less willing to participate or unable to because they lacked computer access. Methods From 2005 to 2006, we sent invitation letters to and attempted to recruit 9298 patients with hypertension. Eligibility to participate in the trial included access to a computer and the Internet, an email address, and uncontrolled BP (BP ≥ 140/90 mmHg). Generalized linear models within a modified Poisson regression framework were used to estimate the relative risk (RR) of ineligibility due to lack of computer access and of having uncontrolled BP. Results We were able to contact 95.1% (8840/9298) of patients. Those refusing participation (3032/8840, 34.3%) were significantly more likely (P < .05) to be female, be nonwhite, have lower levels of education, and have Medicaid insurance. Among patients who answered survey questions, 22.8% (1673/7354) did not have computer access. Older age, minority race, and lower levels of education were risk factors for lack of computer access, with education as the strongest predictor (RR 2.63, 95% CI 2.30-3.01 for those with a high school degree compared to a college education). Among hypertensive patients with computer access who were willing to participate, African American race (RR 1.22, 95% CI 1.06-1.40), male sex (RR 1.28, 95% CI 1.18-1.38), and obesity (RR 1.53, 95% CI 1.31-1.79) were risk factors for uncontrolled BP. Conclusion Older age, lower socioeconomic status, and lower levels of education were associated with decreased access to and willingness to participate in a Web-based intervention to improve hypertension control. Failure to ameliorate this may worsen health care disparities. Trial Registration Clinicaltrials.gov NCT00158639; http://www.clinicaltrials.gov/ct2/show/NCT00158639 (Archived by WebCite at http://www.webcitation.org/5v1jnHaeo)

PurposeThis study aims to determine whether radiologists who perform well in screening also perform well in interpreting diagnostic mammography.Materials and methodsWe evaluated the accuracy of 468 radiologists interpreting 2,234,947 screening and 196,164 diagnostic mammograms. Adjusting for site, radiologist, and patient characteristics, we identified radiologists with performance in the highest tertile and compared to those with lower performance.ResultsA moderate correlation was noted for radiologists' accuracy when interpreting screening versus their accuracy on diagnostic examinations: sensitivity (rspearman=0.51, 95% CI: 0.22, 0.80; P=.0006) and specificity (rspearman=0.40, 95% CI: 0.30, 0.49; P

BackgroundPharmacist- or nurse-led team care decreases patient blood pressure (BP) and cardiovascular disease (CVD) risk.PurposeTo evaluate whether a Web-based dietitian-led (WD) team care intervention was feasible and resulted in decreased BP, CVD risk, and weight compared to usual care (UC).MethodsElectronic health record (EHR) data identified patients aged 30-69 years with BMI >26, elevated BP, and 10%-25% 10-year Framingham CVD risk who were registered patient website users. Patients with uncontrolled BP at screening were randomized to UC or WD, which included a home BP monitor, scale, and dietitian team care. WD participants had a single in-person dietitian visit to obtain baseline information and create a plan to reduce CVD risk. Planned follow-up occurred via secure messaging to report BP, weight, and fruit and vegetable intake and receive ongoing feedback. If needed, dietitians encouraged patients and their physicians to intensify antihypertensive and lipid-lowering medications. Primary outcomes were change in systolic BP and weight loss ≥4 kg at 6 months. Feasibility outcomes included intervention utilization and satisfaction.ResultsBetween 2010 and 2011, a total of 90 of 101 participants completed 6-month follow-ups. The WD group had higher rates of secure messaging utilization and patient satisfaction. The WD group lost significantly more weight than the UC group (adjusted net difference=-3.2 kg, 95% CI=-5.0, -1.5, p

Generalized linear mixed models (GLMM) are commonly used to analyze clustered data, but when the number of clusters is small to moderate, standard statistical tests may produce elevated type I error rates. Small‐sample corrections have been proposed for continuous or binary outcomes without covariate adjustment. However, appropriate tests to use for count outcomes or under covariate‐adjusted models remains unknown. An important setting in which this issue arises is in cluster‐randomized trials (CRTs). Because many CRTs have just a few clusters (eg, clinics or health systems), covariate adjustment is particularly critical to address potential chance imbalance and/or low power (eg, adjustment following stratified randomization or for the baseline value of the outcome). We conducted simulations to evaluate GLMM‐based tests of the treatment effect that account for the small (10) or moderate (20) number of clusters under a parallel‐group CRT setting across scenarios of covariate adjustment (including adjustment for one or more person‐level or cluster‐level covariates) for both binary and count outcomes. We find that when the intraclass correlation is non‐negligible (≥$$ \ge $$0.01) and the number of covariates is small (≤$$ \le $$2), likelihood ratio tests with a between‐within denominator degree of freedom have type I error rates close to the nominal level. When the number of covariates is moderate (≥$$ \ge $$5), across our simulation scenarios, the relative performance of the tests varied considerably and no method performed uniformly well. Therefore, we recommend adjusting for no more than a few covariates and using likelihood ratio tests with a between‐within denominator degree of freedom. [ABSTRACT FROM AUTHOR]

PURPOSE We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. METHODS Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. RESULTS Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). CONCLUSIONS Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation. Key words: primary health care; cardiovascular disease; quality improvement; chronic illness; prevention; health promotion; quantitative methods; health services; organizational change; practice-based research, INTRODUCTION Past efforts to transform primary care have included practice redesign based on medical home principles and adoption of electronic health records. (1-4) More recently, primary care practices face increasing [...]

BackgroundWeb-based collaborative approaches to managing chronic illness show promise for both improving health outcomes and increasing the efficiency of the healthcare system.ObjectiveAnalyze the cost-effectiveness of the Electronic Communications and Home Blood Pressure Monitoring to Improve Blood Pressure Control (e-BP) study, a randomized controlled trial that used a patient-shared electronic medical record, home blood pressure (BP) monitoring, and web-based pharmacist care to improve BP control (

Recombinant zoster vaccine (RZV) (Shingrix; GlaxoSmithKline, Brentford, United Kingdom) is an adjuvanted glycoprotein vaccine that was licensed in 2017 to prevent herpes zoster (shingles) and its complications in older adults. In this prospective, postlicensure Vaccine Safety Datalink study using electronic health records, we sequentially monitored a real-world population of adults aged ≥50 years who received care in multiple US Vaccine Safety Datalink health systems to identify potentially increased risks of 10 prespecified health outcomes, including stroke, anaphylaxis, and Guillain-Barré syndrome (GBS). Among 647,833 RZV doses administered from January 2018 through December 2019, we did not detect a sustained increased risk of any monitored outcome for RZV recipients relative to either historical (2013–2017) recipients of zoster vaccine live, a live attenuated virus vaccine (Zostavax; Merck & Co. Inc. Kenilworth, New Jersey), or contemporary non-RZV vaccine recipients who had an annual well-person visit during the 2018–2019 study period. We confirmed prelicensure trial findings of increased risks of systemic and local reactions following RZV. Our study provides additional reassurance about the overall safety of RZV. Despite a large sample, uncertainty remains regarding potential associations with GBS due to the limited number of confirmed GBS cases that were observed. [ABSTRACT FROM AUTHOR]