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BACKGROUND Digital health programs that incorporate frequent blood pressure (BP) self-monitoring and comprehensive support for behavior change offer a scalable solution for hypertension (HTN) management. OBJECTIVE We examined the impact of a digital HTN self-management and lifestyle change support program on BP over 12 months. METHODS Data was analyzed from a retrospective observational cohort of commercially insured members (n=1,117) that started the Omada for HTN program between 1/1/19-9/30/21. Paired t-tests and linear regression were used to measure change in SBP over 12 months, by SBP control at baseline (≥130 vs. RESULTS Members were on average 50.9 years old, 50.8% were female, 60.5% white and 70.5% had uncontrolled SBP at baseline (≥130). At 12 months, members with uncontrolled SBP experienced significant reductions in both unadjusted (mean (95%CI): -8.1mmHg (-9.0, -7.1)) and adjusted SBP (-8.0mmHg (-9.0, -7.1)). Members with uncontrolled SBP also had significant reductions in diastolic BP (-4.7mmHg; -5.3, -4.1), weight (-6.5lbs (-7.7, -5.3); 2.7% weight loss) and body mass index (-1.1kg/m2) (-1.3, -0.9)). Those with controlled SBP maintained within BP goal range. Additionally, 48% of members with uncontrolled BP experienced enough change in BP to improve their BP category. CONCLUSIONS This study provides real-world evidence that a comprehensive digital health program involving HTN education, at-home BP monitoring, and behavior change coaching support was effective for self-managing HTN over 12 months.

In 1984, the U.S. Preventive Services Task Force (USPSTF) was founded to create evidence-based recommendations guiding the use of diverse preventive services, including screening tests, behavioral interventions, and medications. Recommendations from this independent expert group are widely followed, and in some cases have produced substantial changes in clinical practice. One example, prostate cancer screening with prostate-specific antigen, was routinely performed among middle-aged and elderly men for decades until the USPSTF 2012 recommendation against this practice.1 Like prostate cancer, many diseases that are the subject of their preventive service recommendations disproportionately affect racial/ethnic minorities. This highlights a unique opportunity for USPSTF’s recommendations to reduce health disparities. The USPSTF follows a rigorous, transparent, and dynamic process for reviewing existing evidence and developing its recommendations.2 Using commissioned systematic literature reviews, the USPSTF considers the quality of evidence supporting each preventive service, and the magnitude of net benefit from implementing it. These reviews assess the certainty of the existing evidence, in addition to the magnitude of benefits and harms associated with the service. This process is intended to “maximize population health benefits while minimizing harms.”3 Weighing the potential impacts of preventive service recommendations from a population perspective may help achieve the greatest benefit for the largest number of Americans. However, some subpopulations may derive more benefit or experience greater harm from certain preventive services. If there is insufficient evidence to recommend a preventive service in the entire population, it is unlikely that the same service will benefit high-risk groups such as racial/ethnic minorities. However, it is possible that racial/ethnic differences in benefits and harms of recommended services or differential implementation of those services by race/ethnicity could widen health disparities in some groups. The USPSTF currently addresses high-risk subgroups in several ways.4 Most recommendations target specific groups defined by a limited number of risk factors, such as individuals’ age, sex, and specific exposures like smoking. The USPSTF also targets high-risk subgroups defined by numerous risk factors that are captured in multivariate risk models, like the 2016 statin recommendation,5 which require a calculation to determine eligibility. Although some risk models include race/ethnicity, none of the current USPTSF recommendations use race/ethnicity as a deciding factor.

Phenomenon: Chronic disease is a leading cause of death and disability in the United States. With an increase in the demand for healthcare and rising costs related to chronic care, physicians need to be better trained to address chronic disease at various stages of illness in a collaborative and cost-effective manner. Specific and measurable learning objectives are key to the design and evaluation of effective training, but there has been no consensus on chronic disease learning objectives appropriate to medical student education. Approach: Wagner's Chronic Care Model (CCM) was selected as a theoretical framework to guide development of an enhanced chronic disease prevention and management (CDPM) curriculum. Findings of a literature review of CDPM competencies, objectives, and topical statements were mapped to each of the six domains of the CCM to understand the breadth of existing learning topics within each domain. At an in-person meeting, medical educators prepared a survey for the modified Delphi approach. Attendees identified 51 possible learning objectives from the literature review mapping, rephrased the CCM domains as competencies, constructed possible CDPM learning objectives for each competency with the goal of reaching multi-institutional consensus on a limited number of CDPM learning objectives that would be feasible for institutions to use to guide enhancement of medical student curricula related to CDPM. After the meeting, the group developed a survey which included 39 learning objectives. In the study phase of the modified Delphi approach, 32 physician CDPM experts and educators completed an online survey to prioritize the top 20 objectives. The next step occurred at a CDPM interest group in-person meeting with the goal of identifying the top 10 objectives. Findings: The CCM domains were reframed as the following competencies for medical student education: patient self-care management, decision support, clinical information systems, community resources, delivery systems and teams, and health system practice and improvement. Eleven CDPM learning objectives were identified within the six competencies that were most important in developing curriculum for medical students. Insights: These learning objectives cut across education on the prevention and management of individual chronic diseases and frame chronic disease care as requiring the health system science competencies identified in the CCM. They are intended to be used in combination with traditional disease-specific pathophysiology and treatment objectives. Additional efforts are needed to identify specific curricular strategies and assessment tools for each learning objective.

Accurate blood pressure measurement is crucial for proper screening, diagnosis, and monitoring of high blood pressure. However, providers are not aware of proper blood pressure measurement skills, do not master all the appropriate skills, or miss key steps in the process, leading to inconsistent or inaccurate readings. Training in blood pressure measurement for most providers is usually limited to a one-time brief demonstration during professional education coursework. The American Medical Association and the American Heart Association developed a 30-minute e-Learning module designed to refresh and improve existing blood pressure measurement knowledge and clinical skills among practicing providers. One hundred seventy-seven practicing providers, which included medical assistants, nurses, advanced practice providers, and physicians, participated in a multi-site randomized educational study designed to assess the effect of this e-Learning module on blood pressure measurement knowledge and skills. Participants were randomized 1:1 to either the intervention or control group. The intervention group followed a pre-post assessment approach, and the control group followed a test-retest approach. The initial assessment showed that participants in both the intervention and control groups correctly performed less than half of the 14 skills considered necessary to obtain an accurate blood pressure measurement (mean scores 5.5 and 5.9, respectively). Following the e-Learning module, the intervention group performed on average of 3.4 more skills correctly vs 1.4 in the control group (P .01). Our findings reinforce existing evidence that errors in provider blood pressure measurements are highly prevalent and provide novel evidence that refresher training improves measurement accuracy.

The objective of this study was to determine if certified electronic health record technology (CEHRT) can be used to identify and refer patients with prediabetes to lifestyle change programs (LCPs) recognized by the National Diabetes Prevention Program (DPP). This pilot utilized a prediabetes registry, patient portal, and clinical decision support to increase referrals. Data from 36 primary care providers showed 4930 patients were eligible for DPP LCP, 293 referrals were generated, compared to 20 referrals in the baseline period, and 116 patients enrolled. Referral to enrollment conversion rates were 41% in the study period and 69% in the post-study 1-year period. CEHRT functionalities can support systematic identification and management of prediabetes. The referral rate increased 7-fold compared to the baseline period, with high referral to enrollment conversion rates. CEHRT coupled with active provider engagement can serve as a tool to identify prediabetes patients and facilitate LCP referrals and enrollment.

Approximately 1 in 3 American adults has prediabetes, a condition characterized by blood glucose levels that are above normal, not in the type 2 diabetes ranges, and that increases the risk of developing type 2 diabetes. Evidence-based treatments can be used to prevent or delay type 2 diabetes in adults with prediabetes. The American Medical Association (AMA) has collaborated with health care organizations across the country to build sustainable diabetes prevention strategies. In 2017, the AMA formed the Diabetes Prevention Best Practices Workgroup (DPBP) with representatives from 6 health care organizations actively implementing diabetes prevention. Each organization had a unique strategy, but all included the National Diabetes Prevention Program lifestyle change program as a core evidence-based intervention. DPBP established the goal of disseminating best practices to guide other health care organizations in implementing diabetes prevention and identifying and managing patients with prediabetes. Workgroup members recognized similarities in some of their basic steps and considerations and synthesized their practices to develop best practice recommendations for 3 strategy maturity phases. Recommendations for each maturity phase are classified into 6 categories: (1) organizational support; (2) workforce and funding; (3) promotion and dissemination; (4) clinical integration and support; (5) evaluation and outcomes; (6) and program. As the burden of chronic disease grows, prevention must be prioritized and integrated into health care. These maturity phases and best practice recommendations can be used by any health care organization committed to diabetes prevention. Further research is suggested to assess the impact and adoption of diabetes prevention best practices.

Purpose The purpose of this study was to examine the development and preliminary effectiveness of a novel Prediabetes Decision Aid on adoption of intensive lifestyle interventions (ILIs) and metformin. Little research has focused on increasing uptake of these evidence-based treatments, especially among non-English speakers and those with low educational attainment. Methods Investigators developed an English and Spanish decision aid displaying information about type 2 diabetes (T2DM) risk and treatments to prevent T2DM and prompting patients to identify next steps for management. This pilot study was a single-arm, pretest-posttest trial of 40 adult patients with prediabetes, obesity, and ≥1 office visit within the prior 12 months. Participants reviewed this tool briefly with a study team member, and data were collected on 3 coprimary outcomes: knowledge about T2DM risk, decisional conflict, and intention to adopt treatment. Exploratory outcomes included subsequent documentation of prediabetes in chart notes and adoption of ILIs or metformin. Results Almost all participants were women, with nearly half expressing Spanish language preference and low educational attainment. A nonsignificant increase in knowledge was observed across all subgroups. Decisional conflict was significantly reduced from pretest to posttest and was similar between subgroups defined by language preference and educational attainment. While intention to adopt ILIs increased across all subgroups, this change was only significant among Spanish speakers and participants with low educational attainment. At 6 months, 17 participants had subsequent provider documentation of prediabetes, and 12 adopted ILIs or metformin. Conclusions The decision aid improved patient-reported outcomes and promoted treatment adoption in a diverse patient sample.

Clinical–community linkages enhance health care delivery and enable physician–patient partnerships to achieve better health. The Michigan State University (MSU) Model of Health Extension includes a strategy for forming these linkages by focusing on increasing primary care patient referrals and enrollment in health programs. This article shares the results of a survey of Michigan internal medicine and family medicine physicians ( n = 323) to better understand attitudes toward and familiarity with community-based education (CBE) programs and to assess the logistical requirements to make CBE referrals efficient and sustainable. Survey results showed that at most, 55% of respondents were aware of at least one CBE program implemented by Cooperative Extension. Of those who were aware, over 85% agreed that the programs have positive benefits for patients. Thirty-five percent reported at least one referral barrier, and familiarity with the CBE programs was a significant predictor for reporting all referral barriers. The results suggest that increasing physicians’ familiarity of CBE health programs is a key first step in identifying ideal strategies to overcome referral barriers. Data from this study may help determine scalable state level models for increasing awareness of chronic disease prevention and other CBE programs in efforts to improve the health of the nation.

PURPOSE This study gathers validity evidence of an expanded History and Physical examination (H&P 360) to address chronic diseases through incorporation of biopsychosocial elements that are lacking in traditional H&P assessments via a multisite randomized controlled trial among medical students. METHOD Third- and fourth-year medical students (n = 159) at 4 schools participated in an Objective Structured Clinical Examination designed with 2 cases for chronic disease. Students were randomized into the treatment group, which involved brief written instructions on how to use the H&P 360 followed by a standardized patient (SP) interaction, or the control group, which used the traditional H&P in an SP interaction without additional instructions. Validity evidence was gathered for content (alignment with an empirically derived expanded history list), response process (feedback from raters and learners on the process), internal structure (reliability and item-level psychometrics), relations to other variables (comparison between treatment and control groups), and consequences (survey results from learners on experience). RESULTS H&P 360 items were blueprinted by faculty experts. SP observation checklist grading was consistent, and postassessment debrief confirmed favorable educational experience among learners. The reliability of the H&P 360 was .76. Overall mean scores on the H&P 360 content (mean = 15.96, standard deviation [SD] = 3.66) were significantly higher compared with the traditional H&P (mean = 10.99, SD = 2.69, Cohen's d = 1.17, P < .001). CONCLUSIONS Medical students using the H&P 360 collected significantly more biopsychosocial information compared with students using the traditional H&P, providing empirical support for teaching and assessing biopsychosocial information. The assessment demonstrated strong validity evidence supporting the use of the H&P 360 assessment in medical schools.

Introduction Intensive behavioral counseling is effective in preventing type 2 diabetes, and insurance coverage for such interventions is increasing. Although primary care provider referrals are not required for entry to the Centers for Disease Control and Prevention (CDC)–recognized National Diabetes Prevention Program lifestyle change program, referral rates remain suboptimal. This study aims to assess the association between primary care provider behaviors regarding prediabetes screening, testing, and referral and awareness of the CDC-recognized lifestyle change program and the Prevent Diabetes STAT: Screen, Test, and Act Today™ toolkit. Awareness of the lifestyle change program and the STAT toolkit, use of electronic health records, and the ratio of lifestyle change program classes to primary care physicians were hypothesized to be positively associated with primary care provider prediabetes screening, testing, and referral behaviors. Methods Responses from primary care providers (n=1,256) who completed the 2016 DocStyles cross-sectional web-based survey were analyzed in 2017 to measure self-reported prediabetes screening, testing, and referral behaviors. Multivariate logistic regression was used to estimate the effects of primary care provider awareness and practice characteristics on these behaviors, controlling for provider characteristics. Results Overall, 38% of primary care providers were aware of the CDC-recognized lifestyle change program, and 19% were aware of the STAT toolkit; 27% screened patients for prediabetes using a risk test; 97% ordered recommended blood tests; and 23% made referrals. Awareness of the lifestyle change program and the STAT toolkit was positively associated with screening and referring patients. Primary care providers who used electronic health records were more likely to screen, test, and refer. Referring was more likely in areas with more lifestyle change program classes. Conclusions This study highlights the importance of increasing primary care provider awareness of and referrals to the CDC-recognized lifestyle change program.

IN BRIEF Type 2 diabetes can be prevented or delayed in people with prediabetes through participation in an intensive lifestyle change program (LCP), particularly one based on the Diabetes Prevention Program research study. Digital health offers opportunities to extend the reach of such LCPs and possibly improve on these programs, which traditionally have been delivered in person. In this review, we describe the current state of evidence regarding digital health–supported LCPs and discuss gaps in research and opportunities for future efforts.

Despite evidence of the effectiveness of behavioral change interventions for type 2 diabetes prevention, health care provider referrals to organizations offering the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP) remain suboptimal. This study examined facilitators of LCP referrals among primary care providers and pharmacists (providers). We analyzed data on 1956 providers from 2016 to 2017 DocStyles web-based surveys. Pearson chi-square or Fisher's exact tests were used for bivariate associations between facilitators, provider characteristics, and their self-reported referral and bi-directional referral (where they received patient status updates back from the LCPs) to an LCP. Multiple logistic regressions were used to estimate the effects of facilitators to referral practices, controlling for providers' characteristics. Geocoding was done at the street level for in-person, public LCP class locations and at the zip code level for survey respondents to create a density measure for LCP availability within 10 miles. Overall, 21% of providers referred their patients with prediabetes to LCPs, and 6.4% engaged in bi-directional referral. Provider practices that established clinical-community linkages (CCLs) with LCPs (AOR = 4.88), used electronic health records (EHRs) to manage patients (AOR = 2.94), or practiced within 10 miles of an in-person, public LCP class location (AOR = 1.49) were more likely to refer. Establishing CCLs with LCPs (AOR = 8.59) and using EHRs (AOR = 1.86) were also facilitators of bi-directional referral. This study highlights the importance of establishing CCLs between provider settings and organizations offering the National DPP LCP, increasing use of EHRs to manage patients, and increasing availability of in-person LCP class locations near provider practices.

Background: The 2017 ACC/AHA Hypertension Guideline recommends use of telehealth and other digital strategies to accurately diagnose and treat high blood pressure (HBP). While these recommendations are based on robust evidence demonstrating the effectiveness of digital health interventions for HBP management, physician practices and healthcare systems are uncertain as to how best to put these into practice. Furthermore, “telehealth” by itself is an enabling technology, not a stand-alone quality improvement strategy. Hence, it is important to implement those guideline-based interventions delivered via telehealth technologies with the highest quality of evidence to make a significant impact on the effective diagnosis and management of patients with HBP. Session objectives: From this presentation, attendees can 1) Recognize benefits and challenges of deploying digital technologies used to measure and control HBP, 2) Explain how the best evidence for proper use of digital technologies enables key patient interventions to diagnose and treat HBP 3) Describe how implementation of the AHA/AMA “ Target: BP ” initiative promotes guideline-based care enabled by digital technologies 4) Demonstrate how the use of the AMA Digital Health Implementation Playbook supports successful implementation of a HBP control strategy that addresses the needs of both physicians and patients. Approach: The presenters will 1) Summarize the 2017 ACC/AHA recommendations for telehealth in HBP management, which are based upon systematic evidence reviews 2) Discuss the AHA/AMA Target: BP initiative , a quality improvement program to improve HBP control tested in 16 physician practices ( with16,000 patients; this will include description of key components of the performance improvement program and summary of evidence for its effectiveness; 3) Provide an overview of the AMA Digital Health Implementation Playbook, developed with input from over 80 stakeholders with experience implementing digital health solutions; 4) Describe key steps to implementing a practice-based digital strategy for HBP management outlined by the Playbook; and 5) Summarize current related Medicare and Commercial payment policies for digital health services. Conclusions: To more effectively engage patients in managing HBP, healthcare teams must incorporate guideline-based clinical interventions enabled by digital solutions such as telehealth to optimize BP control in their patient populations. Utilizing practical guidance from the AMA/AHA Target: BP improvement program and the AMA Digital Health Implementation Playbook, healthcare providers are best positioned to deliver telehealth-enabled optimal BP care consistent with the ACC/AHA 2017 Hypertension Guidelines.

BACKGROUND Management of hypertension employing digital health technologies (DHT) has been proven to improve long-term patient outcomes. However, the uptake of DHT has been surprisingly low in clinical practice. Despite showing great promise to improve patient outcomes and disease management, there is limited information on the factors that contribute to the limited adoption of DHT particularly for hypertension management. OBJECTIVE This review provides a comprehensive summary of barriers to and facilitators of DHT adoption for hypertension management reported in the published literature with a focus on provider and patient-related perspectives. METHODS This review was conducted using the methodological framework developed by Arskey and O’Malley. Systematic literature searches were conducted on PubMed/ Medline, CINAHL, and EMBASE. Articles that reported on barriers to and/or facilitators of digital health adoption for hypertension management, published in English between 2008 and 2017 were eligible. Studies not reporting on barriers or facilitators to DHT adoption for management of hypertension were excluded. A total of 2299 articles were identified based on criteria above after removing duplicates and were assessed for eligibility. Of these, 2165 references did not meet the inclusion criteria. After assessing 134 studies in full-text, 98 studies were excluded (full texts were unavailable or studies did not fulfill the inclusion criteria) resulting in a final set of 32 articles. Four hand-picked articles were also included in the review. RESULTS A total of 36 studies were selected for data extraction after abstract and full-text screening by two independent reviewers. All conflicts were resolved by a third reviewer. Thematic analysis was conducted to identify major themes pertaining to barriers and facilitators of DHT from both provider and patient perspectives. Key facilitators of DHT adoption by physicians identified include integration with clinical workflow, ease of use, improvement in patient outcomes and organizational support. Improved patient-provider relationship, positive impact on well-being and self-management were most frequently reported facilitators for patients. Barriers to use of DHTs reported by physicians include mistrust in technology, data security, lack of usability, and organizational support and commitment to DHT adoption. Finally, a lack of perceived benefit from technology, lack of ease of use and concern over data security were some of the barriers commonly reported by patients. CONCLUSIONS Although technology has evolved at a rapid pace, many facilitators and barriers reported by patients and providers are consistent over time. Our findings suggest the settings and context in which DHT are implemented, and individuals involved in implementation such as providers, patients and leadership influence adoption in healthcare settings. Real-world testing and incorporating feedback from key stakeholders including patients, providers and hospital management while designing DHT will improve their usability and thereby the adoption. Finally, to fully realize the potential of digitally enabled hypertension management, there is a greater need to validate these technologies to provide patients and providers with reliable and accurate information on both clinical outcomes and cost effectiveness.

In the United States, 23.4 million adults have physician‐diagnosed diabetes mellitus (DM),1 81.6 million have prediabetes, and ≈18 000 people under age 20 years are diagnosed with type 1 DM each year.2 Approximately 90% to 95% of all adult DM cases are type 2.2 As such, data mentioned throughout will primarily comprise patients with type 2 DM. Patients with DM are 2 to 4 times more likely to die of cardiovascular disease (CVD) than patients without DM. The prevalence of patients living with DM and prediabetes continues to increase, putting these individuals at greater risk of having a heart attack or stroke. Often patients with DM have multiple other health problems and must also manage other cardiometabolic health risk factors such as obesity, hypertension, and high cholesterol. Because of the direct impact DM and related cardiometabolic disorders have on CVD, the American Heart Association (AHA) is building a multifaceted initiative to (1) unite the primary care, cardiology, endocrinology, and other specialty care provider communities in a comprehensive approach to caring for and treating patients with cardiometabolic conditions such as DM; (2) educate and empower people living with cardiometabolic disorders and DM to better self‐manage their condition(s) and improve their cardiovascular health. By expanding AHA's efforts to include initiatives and programs to reduce the prevalence and impact of cardiometabolic risk factors (such as prediabetes) and conditions (such as DM), the AHA will progress toward its mission of building healthier lives, free of cardiovascular diseases and stroke. To launch this new initiative, AHA held its first Cardiometabolic Health and Diabetes Summit on December 5, 2017, in Dallas, Texas. The objective was to identify and prioritize opportunities to improve cardiometabolic health and DM care in the United States (Figure 1). Open in a separate window Figure 1 American Heart Association Summit key opportunities.

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were approved in 2015 for use by adults with familial hypercholesterolemia (FH) or clinical atherosclerotic cardiovascular disease (ASCVD) requiring additional low-density lipoprotein cholesterol lowering beyond use of diet modification and maximally tolerated statin therapy. This study describes the patient, provider and payer related characteristics of prescriptions filled for this new class of injectable medication during 2016. Methods: 2016 quarterly state-level prescription data were obtained from Symphony Health Solution’s PHAST 2.0. PHAST 2.0 includes data on over 90% of prescriptions filled from US retail and mail order pharmacies and, along with market purchasing data, are used to calculate state and national estimates. PCSK9 inhibitor fills among adults aged ≥18 years were characterized by quarter, patient age, provider type, and payer type. Per-capita fill rates across US states and total and patient spending per 30-day supply were calculated. Results: In 2016, 216,082 PCSK9 inhibitor prescriptions were filled. The number of fills per quarter increased from 20,348, in Q1, to 83,812, in Q4, and fill totals were greatest among those aged 65-74 years (39.3% of fills) (Figure). Cardiologists prescribed the majority of fills (60.5%). Commercial payers (43.3%) and Medicare (43.1%) were the most frequent payers. State per-capita fill rates (per 100,000) ranged from 12.1, in WY, to 191.9, in LA (median: 69.1). Total spending per 30-day supply was $951; patient spending was $58 per 30-day supply. Conclusion: Quarterly fills for PCSK9 inhibitors quadrupled during 2016, with substantial variation in per-capita fill rates across states. Cardiologists prescribed the majority of fills, which aligns with their indicated use among adults with FH or ASCVD. Total spending per 30-day supply was considerable. Tracking of prescribing trends for these medications is warranted as additional information about their efficacy becomes available.

Clearly, the development of cardiovascular disease in adulthood is influenced by growth very early in life, even prior to birth. Substantial evidence indicates that impaired fetal growth and subsequent low birth weight are associated with adult cardiovascular disease and related mortality, and there is emerging evidence that elevated birth weight has similar associations. Patterns of rapid and slow infant growth are each associated with multiple cardiovascular disease processes, and rapid growth during childhood is also predictive of adult cardiovascular disease. Additionally, early adiposity rebound is linked to obesity and diabetes mellitus later in life.

Background— Little is known regarding the adoption of direct thrombin inhibitors in clinical practice. We examine trends in oral anticoagulation for the prevention of thromboembolism in the United States. Methods and Results— We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based providers, to quantify patterns of oral anticoagulant use among all subjects and stratified by clinical indication. We quantified oral anticoagulant expenditures using the IMS Health National Prescription Audit. Between 2007 and 2011, warfarin treatment visits declined from ≈2.1 million (M) quarterly visits to ≈1.6M visits. Dabigatran use increased from 0.062M quarterly visits (2010Q4) to 0.363M visits (2011Q4), reflecting its increasing share of oral anticoagulant visits from 3.1% to 18.9%. In contrast to warfarin, the majority of dabigatran visits have been for atrial fibrillation, though this proportion decreased from 92% (2010Q4) to 63% (2011Q4), with concomitant increases in dabigatran’s off-label use. Among atrial fibrillation visits, warfarin use decreased from 55.8% visits (2010Q4) to 44.4% (2011Q4), whereas dabigatran use increased from 4.0% to 16.9%. Of atrial fibrillation visits, the fraction not treated with any oral anticoagulants has remained unchanged at ≈40%. Expenditures related to dabigatran increased rapidly from $16M in 2010Q4 to $166M in 2011Q4, exceeding expenditures on warfarin ($144M) in 2011Q4. Conclusions— Dabigatran has been rapidly adopted into ambulatory practice in the United States, primarily for treatment of atrial fibrillation, but increasingly for off-label indications. We did not find evidence that it has increased overall atrial fibrillation treatment rates.

Background: Management of hypertension employing digital health technologies (DHT) has been proven to improve long-term patient outcomes. However, the uptake of DHT has been surprisingly low in clinical practice. Despite showing great promise to improve patient outcomes and disease management, there is limited information on the factors that contribute to the limited adoption of DHT particularly for hypertension management. Objective: This review provides a comprehensive summary of barriers to and facilitators of DHT adoption for hypertension management reported in the published literature with a focus on provider and patient-related perspectives. Methods: This review was conducted using the methodological framework developed by Arskey and O’Malley. Systematic literature searches were conducted on PubMed/ Medline, CINAHL, and EMBASE. Articles that reported on barriers to and/or facilitators of digital health adoption for hypertension management, published in English between 2008 and 2017 were eligible. Studies not reporting on barriers or facilitators to DHT adoption for management of hypertension were excluded. A total of 2299 articles were identified based on criteria above after removing duplicates and were assessed for eligibility. Of these, 2165 references did not meet the inclusion criteria. After assessing 134 studies in full-text, 98 studies were excluded (full texts were unavailable or studies did not fulfill the inclusion criteria) resulting in a final set of 32 articles. Four hand-picked articles were also included in the review. Results: A total of 36 studies were selected for data extraction after abstract and full-text screening by two independent reviewers. All conflicts were resolved by a third reviewer. Thematic analysis was conducted to identify major themes pertaining to barriers and facilitators of DHT from both provider and patient perspectives. Key facilitators of DHT adoption by physicians identified include integration with clinical workflow, ease of use, improvement in patient outcomes and organizational support. Improved patient-provider relationship, positive impact on well-being and self-management were most frequently reported facilitators for patients. Barriers to use of DHTs reported by physicians include mistrust in technology, data security, lack of usability, and organizational support and commitment to DHT adoption. Finally, a lack of perceived benefit from technology, lack of ease of use and concern over data security were some of the barriers commonly reported by patients. Conclusions: Although technology has evolved at a rapid pace, many facilitators and barriers reported by patients and providers are consistent over time. Our findings suggest the settings and context in which DHT are implemented, and individuals involved in implementation such as providers, patients and leadership influence adoption in healthcare settings. Real-world testing and incorporating feedback from key stakeholders including patients, providers and hospital management while designing DHT will improve their usability and thereby the adoption. Finally, to fully realize the potential of digitally enabled hypertension management, there is a greater need to validate these technologies to provide patients and providers with reliable and accurate information on both clinical outcomes and cost effectiveness.

When you prescribe antibiotics, tell patients that taking probiotics for the entire course of treatment will help prevent diarrhea.