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Background Accurate blood pressure (BP) measurement is essential to identify and manage hypertension. Prior studies have reported a difference between BP measured in routine patient care and in research studies. We aimed to investigate the agreement between BP measured in routine care and research-grade BP in Kaiser Permanente Southern California, a large, integrated healthcare system with initiatives to standardize BP measurements during routine patient care visits. Methods We included adults ≥65 years old with hypertension, taking antihypertensive medication, and participating in the Ambulatory Blood Pressure in Older Adults (AMBROSIA) study in 2019–2021. Clinic BP from routine care visits was extracted from the electronic health record. Research-grade BP was obtained by trained AMBROSIA study staff via an automatic oscillometric device. The mean difference between routine care and research-grade BP, limits of agreement, and correlation were assessed. Results We included 309 participants (mean age 75 years; 54% female; 49% non-Hispanic white). Compared with measurements from routine care, mean research-grade systolic BP (SBP) was 0.1 mm Hg higher (95% CI: −1.5 to 1.8) and diastolic BP (DBP) was 0.4 mm Hg lower (95% CI: −1.6 to 0.7). Limits of agreement were −29 to 30 mm Hg for SBP and −21 to 20 mm Hg for DBP. The intraclass correlation coefficient was 0.42 (95% CI: 0.33 to 0.51) for SBP and 0.43 (95% CI: 0.34 to 0.52) for DBP. Conclusions High within-person variation and moderate correlation were present between BP measured in routine care and following a research protocol suggesting the importance of standardized measurements.

Accurate diagnosis of arrhythmias is improved with longer monitoring duration but can risk delayed diagnosis. We compared diagnostic yield, outcomes, and resource utilization by arrhythmia monitoring strategy in 330 matched adults (mean age 64 years, 40% women, and 30% non-White) without previously documented atrial fibrillation or atrial flutter (AF/AFL) who received ambulatory electrocardiographic monitoring by 14-day Zio XT (patch-based continuous monitor), 24-hour Holter, or 30-day event monitor (external loop recorder) between October 2011 and May 2014. Patients were matched by age, gender, site, likelihood of receiving Zio XT patch, and indication for monitoring, and subsequently followed for monitoring results, management changes, clinical outcomes, and resource utilization. AF/AFL ≥30 seconds was noted in 6% receiving Zio XT versus 0% by Holter (p = 0.04) and 3% by event monitor (p = 0.07). Nonsustained ventricular tachycardia was noted in 24% for Zio XT patch versus 8% (p0.001) for Holter and 4% (p0.001) for event monitor. No significant differences between monitoring strategies in outcomes or resource utilization were observed. Prolonged monitoring with 14-day Zio XT patch or 30-day event monitor was superior to 24-hour Holter in detecting new AF/AFL but not different from each other. Documented nonsustained ventricular tachycardia was more frequent with Zio XT than 24-hour Holter and 30-day event monitor without apparent increased risk of adverse outcomes or excess utilization. In conclusion, additional efforts are needed to further personalize electrocardiographic monitoring strategies that optimize clinical management and outcomes.

Aims This study aimed to develop and apply natural language processing (NLP) algorithms to identify recurrent atrial fibrillation (AF) episodes following rhythm control therapy initiation using electronic health records (EHRs). Methods and results We included adults with new-onset AF who initiated rhythm control therapies (ablation, cardioversion, or antiarrhythmic medication) within two US integrated healthcare delivery systems. A code-based algorithm identified potential AF recurrence using diagnosis and procedure codes. An automated NLP algorithm was developed and validated to capture AF recurrence from electrocardiograms, cardiac monitor reports, and clinical notes. Compared with the reference standard cases confirmed by physicians’ adjudication, the F-scores, sensitivity, and specificity were all above 0.90 for the NLP algorithms at both sites. We applied the NLP and code-based algorithms to patients with incident AF (n = 22 970) during the 12 months after initiating rhythm control therapy. Applying the NLP algorithms, the percentages of patients with AF recurrence for sites 1 and 2 were 60.7% and 69.9% (ablation), 64.5% and 73.7% (cardioversion), and 49.6% and 55.5% (antiarrhythmic medication), respectively. In comparison, the percentages of patients with code-identified AF recurrence for sites 1 and 2 were 20.2% and 23.7% for ablation, 25.6% and 28.4% for cardioversion, and 20.0% and 27.5% for antiarrhythmic medication, respectively. Conclusion When compared with a code-based approach alone, this study's high-performing automated NLP method identified significantly more patients with recurrent AF. The NLP algorithms could enable efficient evaluation of treatment effectiveness of AF therapies in large populations and help develop tailored interventions.

Background: Despite their effectiveness in reducing low-density lipoprotein-cholesterol (LDL-C) and cardiovascular disease (CVD) risk, high-intensity statins are underutilized among patients with LDL-C ≥ 190 mg/dL. We aimed to determine if a patient outreach program (KP Sure Net) automating high-intensity statin orders and lipid panels improved statin initiation and lab completions. Methods: Kaiser Permanente Southern California adults 20-60 years of age with LDL-C ≥ 190 mg/dL and no recent statin use were compared pre- (January 2016-September 2018, n=3,534) and post- (April 2019-July 2021, n=3,555) program implementation to examine statin prescriptions and fills, lab completions, and improved LDL-C ( Results: Among adults identified during pre- and post-implementation, 759 (21.5%) and 976 (27.5%), respectively, received a statin prescription. Adults with a prescription post- versus pre-implementation were more likely to be younger, identify as Black or Asian ethnicity, be English-speaking and have higher income, but were similar by sex, education, insurance, and comorbidity burden. (Table) After multivariable adjustment, adults post- versus pre-implementation had a higher likelihood of receiving a statin prescription (RR 1.36, 95% CI 1.25, 1.48), filling their statin (RR 1.32, 95% CI 1.26, 1.38), completing their lipid panel (RR 1.60, 95% CI 1.44, 1.78), and improving LDL-C (RR 1.36, 95% CI 1.20, 1.53). Conclusion: Automating statin orders and lipid panels for high-risk adults improved prescription rates, fills and LDL-C. Understanding facilitators and barriers to adherence is an important next step in improving patients’ health.

Limited data exist in large, representative populations about whether the risk of thromboembolic events varies after receiving four-factor human prothrombin complex concentrate (4F-PCC) versus treatment with human plasma for urgent reversal of oral vitamin K antagonist therapy. We conducted a multicenter observational study to compare the 45-day risk of thromboembolic events in adults with warfarin-associated major bleeding after treatment with 4F-PCC (Kcentra®) or plasma. Hospitalized patients in two large integrated healthcare delivery systems who received 4F-PCC or plasma for reversal of warfarin due to major bleeding from January 1, 2008 to March 31, 2020 were identified and were matched 1:1 on potential confounders and a high-dimensional propensity score. Arterial and venous thromboembolic events were identified up to 45 days after receiving 4F-PCC or plasma from electronic health records and adjudicated by physician review. Among 1119 patients receiving 4F-PCC and a matched historical cohort of 1119 patients receiving plasma without a recent history of thromboembolism, mean (SD) age was 76.7 (10.5) years, 45.6% were women, and 9.4% Black, 14.6% Asian/Pacific Islander, and 15.7% Hispanic. The 45-day risk of thromboembolic events was 3.4% in those receiving 4F-PCC and 4.1% in those receiving plasma (P = 0.26; adjusted hazard ratio 0.76; 95% confidence interval 0.49-1.16). The adjusted risk of all-cause death at 45 days post-treatment was lower in those receiving 4F-PCC compared with plasma. Among a large, ethnically diverse cohort of adults treated for reversal of warfarin-associated bleeding, receipt of 4F-PCC was not associated with an excess risk of thromboembolic events at 45 days compared with plasma therapy.

Background: Prior studies demonstrated a higher risk of acute cardiovascular disease (CVD) around population-wide psychosocial or environmental stressors. Less is known about the impact of sociopolitical events. The objective of the current study was to examine acute CVD hospitalizations following the 2020 presidential election. Methods: We examined hospitalizations for acute CVD around the 2020 presidential election, among adults enrolled in Kaiser Permanente Southern and Northern California, two integrated health care delivery systems that provide care for >9 million persons. CVD was defined as hospitalizations for acute myocardial infarction (AMI), heart failure (HF) or stroke. Rate ratios (RR) and 95% confidence intervals (CIs) were calculated comparing rates in the five days following the 2020 election to the same five days two weeks prior. Results: Among 6,396,830 members ≥18 years, rates of hospitalization for CVD following the election (666 hospitalizations; rate = 760.5 per 100,00 person-years [PY]) were 1.17 times higher (95% CI 1.05, 1.31) compared to the same five days two weeks prior (569 hospitalizations; rate = 648.0 per 100,000 PY). (Table) RR for AMI, stroke, and HF were 1.42 (95% CI 1.13, 1.79), 1.02 (95% CI 0.86, 1.21) and 1.18 (95% CI 0.98, 1.42), respectively. Conclusions: Higher rates of acute CVD were observed following the 2020 presidential election. Awareness of the heightened risk of CVD and strategies to mitigate risk during significant sociopolitical events are needed.

Background Coronavirus disease 2019 (COVID-19) social distancing policies resulted in reductions in community movement, however, fall rates during this time have not been described. Methods This prospective study included adults ≥65 years old participating in the Ambulatory Blood Pressure in Older Adults (AMBROSIA) cohort and who completed ≥1 monthly falls calendar (August 2019–March 2021; n = 250). Months were grouped to correspond to the fall 2020 phased reopening (August–October) and the shelter-in-place policy during the winter 2020 surge (November–January) in Los Angeles, California and compared to the same months, 1 year earlier (ie, before the pandemic). Results Participants had a mean (standard deviation [SD]) age of 75.2 (6.1) years, 49.6% were White, and 53.2% were women. We obtained 2 795 falls calendars during follow-up. Overall, 110 (44.0%) participants reported a total of 421 falls (rate 15.1 per 100 calendar months). The highest monthly fall rate during the pandemic was 22.9 (95% confidence interval [CI] 16.4–31.1) per 100 calendar-months in August 2020. The lowest fall rate during the pandemic was 8.6 (95% CI 3.5–17.8) per 100 calendar-months in February 2021. During the pandemic, fall rates in August, September, and October 2020 were higher than the previous year (rate ratio 1.8 [95% CI 1.1–2.9]), and fall rates in November and December 2020 and January 2021 were lower than the previous year (rate ratio 0.5 [95% CI 0.4–0.8]). Conclusion As the pandemic continues and older adults resume community mobility after a shelter-in-place period, providers should pay attention to the risk of falls.

BACKGROUND: During the early phases of the COVID-19 pandemic pandemic, stay-at-home orders and fear of acquiring COVID-19 may have led to an avoidance of care for medical emergencies, including acute myocardial infarction (AMI). We evaluated whether a decline in rates of AMI occurred during the COVID-19 stay-at-home order. METHODS: Rates of AMI per 100,000 member-weeks were calculated for Kaiser Permanente Southern California patients from January 1 to March 3, 2020 (prepandemic period) and from March 20 to July 31, 2020 (pandemic period), and during the same periods in 2019. Rate ratios (RRs) were calculated comparing the time periods using Poisson regression. Case fatality rates (CFRs) were also compared. RESULTS: Rates of AMI were lower during the pandemic period of 2020 compared to the same period of 2019 [3.20 vs 3.76/100,000 member-weeks; RR, 0.85; 95% confidence interval (CI) 0.80–0.90]. There was no evidence that rates of AMI differed during the 2020 prepandemic period compared to the same period in 2019 (4.45 vs 4.24/100,000 member-weeks; RR, 0.95; 95% CI, 0.88–1.03). AMI rates were lower during the early pandemic period (March 20–May 7: RR, 0.70; 95% CI, 0.66–0.77), but not during the later pandemic period (May 8–July 31: RR, 0.95; 95% CI, 0.88–1.02) compared to 2019. In-hospital and 30-day case fatality rates were higher during the pandemic period of 2020 compared to 2019 (8.8% vs 6.1% and 6.5% vs 5.0%, respectively). CONCLUSION: AMI rates were lower during the COVID-19 pandemic compared to the same period in 2019. During stay-at-home orders, public health campaigns that encourage people to seek care for medical emergencies are warranted.

ImportanceA higher percentage of non-Hispanic Black (hereinafter, Black) adults vs non-Hispanic White (hereinafter, White) adults with hypertension have uncontrolled blood pressure (BP) contributing to racial and ethnic disparities in cardiovascular disease. In 2010, Kaiser Permanente Southern California began implementing quality improvement (QI) strategies aimed at reducing this disparity.ObjectiveTo examine the change in BP control between Black and White patients before and after the implementation of a QI program.Design, Setting, and ParticipantsA QI quasi-experimental, difference-in-difference analysis was conducted of Kaiser Permanente Southern California patients 18 years or older included in the population care management hypertension registry. The study was conducted from December 31, 2008, to December 31, 2019. Data analysis was performed from November 20, 2020, to November 7, 2022.InterventionsQuality improvement program implementation began in 2010.Main Outcomes and MeasuresBlood pressure control (systolic BP ResultsThe number of patients with hypertension increased from 624 094 in 2008 (mean [SD] age, 61.8 [13.5] years; 330 551 [53.0%] female patients; 89 407 [14.3%] Black and 284 116 [45.5%] White patients) to 855 257 in 2019 (mean [SD] age, 64.5 [13.6] years; 444 422 [52.0%] female patients; 107 054 [12.5%] Black and 331 932 [38.8%] White patients). Blood pressure control increased an absolute 4.6% (95% CI, 4.3%-4.8%) among Black patients and 2.1% (95% CI, 2.0%-2.2%) among White patients from before to after the QI program implementation (difference-in-difference: 2.5%; 95% CI, 2.2%-2.8%). The largest reduction in BP control disparity between Black and White female patients was for those aged 50 to 64 years (difference-in-difference: 3.8%; 95% CI, 3.2%-4.4%) and for those aged 18 to 49 years between Black and White male patients (difference-in-difference: 4.2%; 95% CI, 3.0%-5.5%). The proportion of BP control among Black male patients aged 18 to 49 years was the lowest throughout 2008-2019 compared with male and female patients in other age and racial and ethnic groups. In 2019, uncontrolled BP was more common among Black vs White patients (prevalence ratio: 1.13; 95% CI, 1.12-1.14).Conclusions and RelevanceThis QI program noted that disparities in BP control between Black and White patients were decreased but not eliminated following implementation of QI strategies aimed at reducing disparities in BP control. These findings suggest that more focused interventions may be needed to increase BP control among Black individuals.

Aims Human immunodeficiency virus (HIV) increases the risk of heart failure (HF), but whether it influences subsequent morbidity and mortality remains unclear. Methods and results We investigated the risks of hospitalization for HF, HF-related emergency department (ED) visits, and all-cause death in an observational cohort of incident HF patients with and without HIV using data from three large US integrated healthcare delivery systems. We estimated incidence rates and adjusted hazard ratios (aHRs) by HIV status at the time of HF diagnosis for subsequent outcomes. We identified 448 persons living with HIV (PLWH) and 3429 without HIV who developed HF from a frequency-matched source cohort of 38 868 PLWH and 386 586 without HIV. Mean age was 59.5 ± 11.3 years with 9.8% women and 31.8% Black, 13.1% Hispanic, and 2.2% Asian/Pacific Islander. Compared with persons without HIV, PLWH had similar adjusted rates of HF hospitalization [aHR 1.01, 95% confidence interval (CI): 0.81–1.26] and of HF-related ED visits [aHR 1.22 (95% CI: 0.99–1.50)], but higher adjusted rates of all-cause death [aHR 1.31 (95% CI: 1.08–1.58)]. Adjusted rates of HF-related morbidity and all-cause death were directionally consistent across a wide range of CD4 counts but most pronounced in the subset with a baseline CD4 count Conclusion In a large, diverse cohort of adults with incident HF receiving care within integrated healthcare delivery systems, PLWH were at an independently higher risk of all-cause death but not HF hospitalizations or HF-related ED visits. Future studies investigating modifiable HIV-specific risk factors may facilitate more personalized care to optimize outcomes for PLWH and HF.

Background: Prior studies have found a large difference between blood pressure (BP) when measured routinely in the clinic compared with research studies. We aimed to compare routine clinic BP to research-grade BP in a large, integrated health care system that has initiatives to standardize clinic BP measurements. Methods: We identified Kaiser Permanente Southern California members ≥ 65 years old diagnosed with hypertension and taking antihypertensive medication from the Ambulatory Blood Pressure in Older Adults (AMBROSIA) study. Research-grade BPs were obtained under standardized conditions by certified research staff using a semi-automatic oscillometric device, pre-programmed to take 3 measurements at 1-minute intervals. The average of the 3 BPs was used. The most recent (prior to study enrollment) routine clinic BP from an outpatient, non-urgent clinical care encounter, measured using a semi-automatic oscillometric device, was obtained via electronic health records. If there were multiple BP readings on the same day, the first reading was used. The mean difference between clinic BP and research-grade BP was tested using paired t-tests, while the Pearson correlation and a Bland-Altman analysis were used to assess level of agreement. Results: We included 309 participants (mean age 75 ± 6 years; 54% female; 49% non-Hispanic white, 17% non-Hispanic Black, 17% Hispanic, 15% Asian/Pacific Islander). When measured in routine clinic practice and in the research study, the mean (SD) systolic BP (SBP) was 135 (16) mm Hg and 132 (15) mm Hg, respectively, (mean difference = - 2.7 mm Hg; 95% CI -4.6 to -0.9; limits of agreement = -36 to 30 mm Hg) and the mean diastolic BP (DBP) was 70 (10) mm Hg and 69 (10) mm Hg, respectively (mean difference = - 0.9 mm Hg; 95% CI -2.1 to 0.3; limits of agreement = -22 to 20 mm Hg). Pearson correlation analysis showed modest correlations between the two types of BP measurements (SBP r=0.40, p Conclusion: The difference between clinic and research-grade BP was, on average, small, but differences at the individual level were often substantial.

Clinical guidelines recommend initiating combination antihypertensive therapy for many patients with hypertension. However, data on the risk of side effects are limited. We evaluated side effects associated with initiating combination therapy versus monotherapy among patients with hypertension from Kaiser Permanente Southern California between 2008-2014. Patient characteristics, antihypertensive medication use, and possible side effects were collected using electronic health records. We examined the association of initial combination therapy and incidence of side effects including acute kidney injury, hypotension, injurious fall, hyperkalemia, hypokalemia, hyponatremia, or hyperuricemia using multivariable Cox Proportional hazards models. Of 164,805 patients, 44% initiated combination therapy (34% angiotensin converting enzyme inhibitor (ACEI)-thiazide diuretics (TD); 10% other combinations) and 56% initiated monotherapy (22% ACEIs; 16% TD; 11% beta blockers (BB); 7% calcium channel blockers). Incidence rates of side effects were between 3.8 for hyperkalemia to 55.5 for hypokalemia per 1000 person-yrs during median follow-up of 0.27-0.45 yrs. Initiation of ACEI-TD combination therapy was associated with a lower risk of hyperkalemia than ACEI monotherapy and a lower risk of hypokalemia than TD monotherapy ( Table ). Initiation of ACEI-TD combination therapy was associated with a higher risk of hyponatremia, hyperuricemia, and hypotension, but not associated with injurious falls when compared with other monotherapy groups. Monitoring for side effects following initiation of antihypertensive medication with combination therapy may be useful.

The Bladder Cancer Quality of Life Study collected detailed and sensitive patient-reported outcomes from bladder cancer survivors in the period after bladder removal surgery, when participation in survey research may present a burden. This paper describes the study recruitment methods and examines the response rates and patterns of missing data. Detailed surveys focusing on quality of life, healthcare decision-making, and healthcare expenses were mailed to patients 5–7 months after cystectomy. We conducted up to 10 follow-up recruitment calls. We analyzed survey completion rates following each contact in relation to demographic and clinical characteristics, and patterns of missing data across survey content areas. The overall response rate was 71% (n = 269/379). This was consistent across patient clinical characteristics; response rates were significantly higher among patients over age 70 and significantly lower among racial and ethnic minority patients compared to non-Hispanic white patients. Each follow-up contact resulted in marginal survey completion rates of at least 10%. Rates of missing data were low across most content areas, even for potentially sensitive questions. Rates of missing data differed significantly by sex, age, and race/ethnicity. Despite the effort required to participate in research, this population of cancer survivors showed willingness to share detailed information about quality of life, health care decision-making, and expenses, soon after major cancer surgery. Additional contacts were effective at increasing participation. Response patterns differed by race/ethnicity and other demographic factors. Our data collection methods show that it is feasible to gather detailed patient-reported outcomes during this challenging period.

Background Timely follow-up of abnormal laboratory results is important for high-quality care. We sought to identify risk factors, facilitators, and barriers to timely follow-up of an abnormal estimated glomerular filtration rate (eGFR) for the diagnosis of chronic kidney disease. Study Design Mixed-methods study: retrospective electronic health record (EHR) analyses, physician interviews. Setting & Participants Large integrated health care delivery system. Quantitative analyses included 244,540 patients 21 years or older with incident abnormal eGFRs from January 1, 2010, to December 31, 2015, ordered by 7,164 providers. Qualitative analyses included 15 physician interviews. Exposures Patient-, physician-, and system-level factors. Outcome Timely follow-up of incident abnormal eGFRs, defined as repeat eGFR obtained within 60 to 150 days, follow-up testing before 60 days that indicated normal kidney function, or diagnosis before 60 days of chronic kidney disease or kidney cancer. Analytical Approach Multivariable robust Poisson regression models accounting for clustering within provider were used to estimate risk ratios (RRs) and 95% CIs for lack of timely follow-up. Team coding was used to identify themes from physician interviews. Results 58% of patients lacked timely follow-up of their incident abnormal eGFRs (ie, had a care gap). An abnormal creatinine result flag in the EHR was associated with better follow-up (RR for care gap, 0.65; 95% CI, 0.64-0.66). Patient online portal use and physician panel size were weakly associated with follow-up. Patients seen by providers behind on managing their EHR message box were at higher risk for care gaps. Physician interviews identified system-level (eg, panel size and assistance in managing laboratory results) and provider-level (eg, proficiency using EHR tools) factors that influence laboratory result management. Limitations Unable to capture intentional delays in follow-up testing. Conclusions Timely follow-up of abnormal results remains challenging in an EHR-based integrated health care delivery system. Strategies improving provider EHR message box management and leveraging health information technology (eg, flagging abnormal eGFR results), making organizational/staffing changes (eg, increasing the role of nurses in managing laboratory results), and boosting patient engagement through better patient portals may improve test follow-up.

PURPOSE: Patient centered care aims to align treatment with patient goals, especially when treatment options have equivalent clinical outcomes. For surgeries with lasting impacts that alignment is critical. To our knowledge no psychometrically tested preference elicitation measures exist to support patients with bladder cancer treated with cystectomy, who can often choose between ileal conduit and neobladder diversions. In this study we created a scale to measure how patient goals align with each type of urinary diversion and the associated surgical outcomes. MATERIALS AND METHODS: We performed formative research through focus groups and clinician outreach to adapt a goal dissonance measure. We mailed a survey to adult Kaiser Permanente(®) members who underwent cystectomy for bladder cancer between January 2013 and June 2015. Eligible patients were identified through electronic health records and chart review. Surveys were mailed 5 to 7 months postoperatively. We administered our 10-item decision dissonance scale along with other decision making measures. We explored goal alignment as well as dissonance. Psychometric analysis included factor analysis, evaluation of scale scores between surgery groups and evaluation with other decision making scores. RESULTS: We identified 10 goals associated with ileal conduit or neobladder diversion. Using survey data on 215 patients our scale differentiated patient goals associated with each diversion choice. On average patients with a neobladder strongly valued neobladder aligned goals such as maintaining body integrity and volitional voiding through the urethra. Patients with an ileal conduit had neutral values on average across all goals. CONCLUSIONS: Our measure lays the foundation for a simple value elicitation approach which could facilitate shared decision making about urinary diversion choice.

High-risk medication dispenses to patients with a prior fall or hip fracture represent a potentially dangerous disease-drug interaction among older adults. The research team quantified the prevalence, identified risk factors, and generated patient and provider insights into high-risk medication dispenses in a large, community-based integrated health system using a commonly used quality measure.This was a mixed methods study with a convergent design combining a retrospective cohort study using electronic health record (EHR) data, individual interviews of primary care physicians, and a focus group of patient advisors.Of 113,809 patients ≥ 65 years with a fall/fracture in 2009-2015, 35.4% had a potentially harmful medication dispensed after their fall/fracture. Most medications were prescribed by primary care providers. Older age, male gender, and race/ethnicity other than non-Hispanic White were associated with a reduced risk of high-risk medication dispenses. Patients with a pre-fall/fracture medication dispense were substantially more likely to have a post-fall/fracture medication dispense (hazard ratio [HR] = 13.26, 95% confidence interval [CI] = 12.91-13.61). Both patients and providers noted that providers may be unaware of patient falls due to inconsistent assessments and patient reluctance to disclose falls. Providers also noted the lack of a standard location to document falls and limited decision support alerts within the EHR.High-risk medication dispenses are common among older patients with a history of falls/fractures. Future interventions should explore improved assessment and documentation of falls, decision support, clinician training strategies, patient educational resources, building trusting patient-clinician relationships to facilitate long-term medication discontinuation among persistent medication users, and a focus on fall prevention.

Background: Stay at home orders and fear of acquiring COVID-19 may have led to an avoidance of care for medical emergencies including acute myocardial infarction (AMI). We sought to examine rates of confirmed AMI cases between January 1-June 30, 2019 and 2020. Methods: We identified Kaiser Permanente Southern California members ≥ 18 years old with a hospitalization or emergency department visit for AMI, defined by ICD-10 primary diagnosis codes. Rates of AMI per 100,000 member-weeks were calculated for pre-pandemic and pandemic periods of January 1-March 3, 2020 and March 20-June 30, 2020, respectively, and in the same periods of 2019 overall and for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), separately. March 4-19, 2020 was considered a washout period given the gradual rollout of stay-at-home orders. Rate ratios (RR) and 95% confidence intervals (CI) were calculated comparing pre-pandemic and pandemic periods of 2020 to 2019 using Poisson regression. Results: The mean age of patients presenting with AMI during the 2020 (n=3,029) and 2019 (n=3,518) periods was 69 years, and a majority of events occurred among men (62%) and whites (47%). Rates of AMI in the pre-pandemic period of 2020 and same period in 2019 were 4.23 and 4.45 per 100,000 member weeks, respectively. During the pandemic period of 2020 and the same period in 2019, rates were 3.04 and 3.85 per 100,000 member-weeks, respectively. (Figure) There was no evidence rates of AMI were different during the pre-pandemic period of 2020 compared to the same period in 2019 (RR 0.95, 95% CI 0.88, 1.03). In contrast, rates of AMI were lower during the pandemic period of 2020 compared to the same period of 2019 (RR 0.79, 95% CI 0.74, 0.85), and among NSTEMI (RR 0.80, 95% CI 0.74, 0.86) and STEMI (0.74, 95% CI 0.66, 0.84) cases. Conclusion: AMI rates were lower during the COVID-19 pandemic compared to the year prior. Public health messaging is important to ensure people seek care for medical emergencies.

Background Previous reports suggest that the use of angiotensin‐converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may upregulate angiotensin‐converting enzyme 2 receptors and increase severe acute respiratory syndrome coronavirus 2 infectivity. We evaluated the association between ACEI or ARB use and coronavirus disease 2019 (COVID‐19) infection among patients with hypertension. Methods and Results We identified patients with hypertension as of March 1, 2020 (index date) from Kaiser Permanente Southern California. Patients who received ACEIs, ARBs, calcium channel blockers, beta blockers, thiazide diuretics (TD), or no therapy were identified using outpatient pharmacy data covering the index date. Outcome of interest was a positive reverse transcription polymerase chain reaction test for COVID‐19 between March 1 and May 6, 2020. Patient sociodemographic and clinical characteristics were identified within 1 year preindex date. Among 824 650 patients with hypertension, 16 898 (2.0%) were tested for COVID‐19. Of those tested, 1794 (10.6%) had a positive result. Overall, exposure to ACEIs or ARBs was not statistically significantly associated with COVID‐19 infection after propensity score adjustment (odds ratio [OR], 1.06; 95% CI, 0.90–1.25) for ACEIs versus calcium channel blockers/beta blockers/TD; OR, 1.10; 95% CI, 0.91–1.31 for ARBs versus calcium channel blockers/beta blockers/TD). The associations between ACEI use and COVID‐19 infection varied in different age groups ( P ‐interaction=0.03). ACEI use was associated with lower odds of COVID‐19 among those aged ≥85 years (OR, 0.30; 95% CI, 0.12–0.77). Use of no antihypertensive medication was significantly associated with increased odds of COVID‐19 infection compared with calcium channel blockers/beta blockers/TD (OR, 1.32; 95% CI, 1.11–1.56). Conclusions Neither ACEI nor ARB use was associated with increased likelihood of COVID‐19 infection. Decreased odds of COVID‐19 infection among adults ≥85 years using ACEIs warrants further investigation.

Previous research suggests that stressors may trigger the onset of acute cardiovascular disease (CVD) events within hours to days, but there has been limited research around sociopolitical events such as presidential elections. Among adults ≥18 y of age in Kaiser Permanente Southern California, hospitalization rates for acute CVD were compared in the time period immediately prior to and following the 2016 presidential election date. Hospitalization for CVD was defined as an inpatient or emergency department discharge diagnosis of acute myocardial infarction (AMI) or stroke using International Classification of Diseases, 10th revision codes. Rate ratios (RR) and 95% confidence intervals (CIs) were calculated comparing CVD rates in the 2 d following the 2016 election to rates in the same 2 d of the prior week. In a secondary analysis, AMI and stroke were analyzed separately. The rate of CVD events in the 2 d after the 2016 presidential election (573.14 per 100,000 person-years [PY]) compared to the rate in the window prior to the 2016 election (353.75 per 100,000 PY) was 1.62 times higher (95% CI 1.17, 2.25). Results were similar across sex, age, and race/ethnicity groups. The RRs were similar for AMI (RR 1.67, 95% CI 1.00, 2.76) and stroke (RR 1.59, 95% CI 1.03, 2.44) separately. Transiently heightened cardiovascular risk around the 2016 election may be attributable to sociopolitical stress. Further research is needed to understand the intersection between major sociopolitical events, perceived stress, and acute CVD events.

IntroductionType 2 diabetes (T2D) is a common condition that, if left untreated or poorly managed, can lead to adverse microvascular and macrovascular complications. We estimated the prevalence and incidence of microvascular and macrovascular complications among patients newly diagnosed with T2D within a US integrated healthcare system.Research design and methodsWe conducted a retrospective cohort study among patients newly diagnosed with T2D between 2003 and 2014. We evaluated 13 complications, including chronic kidney disease (CKD), cardiovascular disease (CVD), and all-cause mortality through 2018. Multivariable Cox proportional hazards models were used to study factors associated with complications.ResultsWe identified 135 199 patients with incident T2D. The mean age was 58 years, and 48% were women. The prevalence of CKD was the highest of the complications at the time of T2D diagnosis (prevalence=12.3%, 95% CI 12.2% to 12.5%), while the prevalence of CVD was among the lowest at 3.3% (95% CI 3.2% to 3.3%). The median time to incidence of a T2D complication ranged from 3.0 to 5.2 years. High incidence rates (95% CI) of T2D complications included peripheral neuropathy (26.9, 95% CI 26.5 to 27.3 per 1000 person-years (PY)), CKD (21.2, 95% CI 20.9 to 21.6 per 1000 PY), and CVD (11.9, 95% CI 11.7 to 12.2 per 1000 PY). The trend of 5-year incidence rates of T2D complications by diagnosis year decreased over time (p valueConclusionThough incidence rates of T2D complications were lower in more recent years (2010–2014), a significant proportion of patients had complications at T2D diagnosis. Earlier preventive therapies as well as managing modifiable factors may help delay the development and progression of T2D complications.

Patients with type 2 diabetes (T2D) are at increased risk of chronic kidney disease (CKD) or end-stage renal disease (ESRD). We estimated the prevalence and incidence of CKD/ESRD among adults with incident T2D within a U.S. integrated healthcare system. Incident T2D between 2003-2014 was identified based on a validated algorithm. CKD was defined as eGFR We identified 135,199 incident T2D [mean age 58 years, 48% women, 36% White, 35% Hispanic, 12% Black, 13% Asian]. Median follow up was 6 years. Prevalence of CKD and ESRD was 12.3% and 0.2%, respectively. Median (IQR) eGFR closest to index was 86 (70-101) ml/min/1.73m2. The CKD/ESRD incidence rates decreased for recent diagnoses (2-year CKD incidence: 35.4 vs. 16.6 per 1000 person-years for those diagnosed in 2003-2004 vs. 2013-2014) (Table). Older age, white race, lower eGFR, higher A1c, and hypertension were associated with increased CKD incidence. Though incidence rates are improving, a significant proportion of patients had reduced eGFR including CKD/ESRD at diagnosis. Disclosure J. An: Research Support; Self; Merck & Co., Inc., Novartis AG. G.A. Nichols: Research Support; Self; Boehringer Ingelheim International GmbH, Bristol-Myers Squibb, Merck & Co., Inc. L. Qian: None. Z. Li: None. M.A. Munis: None. R. Wei: None. T. Harrison: None. T. Weiss: Employee; Self; Merck & Co., Inc. S. Rajpathak: Employee; Self; Menarini Group. K. Reynolds: Research Support; Self; CSL Behring, Merck & Co., Inc., National Institutes of Health, Novartis Pharmaceuticals Corporation.

Patients with type 2 diabetes mellitus (T2D) are at risk of various comorbidities. We investigated the timing of incident T2D complications over the course of 15 years and clinical characteristics associated with those complications in a large U.S. integrated healthcare system. We identified incident T2D between 2003-2014 with a validated algorithm using electronic health records. T2D complications included micro- and macro-vascular diseases, depression, and all-cause mortality. We calculated incidence rates per 1000 person-years and median time to developing each complication through 2018. Multivariable Poisson regression models were used to investigate factors associated with early T2D complications defined as shorter than the median time to incidence. We identified 135,199 patients with newly diagnosed T2D and followed them for a median six years [mean age 58 years, 48% female, 36% White, 35% Hispanic, 12% Black, 13% Asian]. Median times to incidence of depression, peripheral vascular disease, stable angina, and chronic kidney disease (CKD) were shorter than median times to incidence of lower extremity amputation, stroke, and heart failure (Table). Having hypertension and lower eGFR were associated with shorter time to CKD whereas male was associated with shorter time to composite cardiovascular events. Older age and a higher comorbidity score were associated with shorter time to both. Disclosure J. An: Research Support; Self; Merck & Co., Inc., Novartis AG. G.A. Nichols: Research Support; Self; Boehringer Ingelheim International GmbH, Bristol-Myers Squibb, Merck & Co., Inc. L. Qian: None. Z. Li: None. M.A. Munis: None. R. Wei: None. T. Harrison: None. T. Weiss: Employee; Self; Merck & Co., Inc. S. Rajpathak: Employee; Self; Menarini Group. K. Reynolds: Research Support; Self; CSL Behring, Merck & Co., Inc., National Institutes of Health, Novartis Pharmaceuticals Corporation.

Background Trends in acute myocardial infarction (AMI) incidence rates for diverse races/ethnicities are largely unknown, presenting barriers to understanding the role of race/ethnicity in AMI occurrence. Methods and Results We identified AMI hospitalizations for Kaiser Permanente Southern California members, aged ≥35 years, during 2000 to 2014 using discharge diagnostic codes. We excluded hospitalizations with missing race/ethnicity information. We calculated annual incidence rates (age and sex standardized to the 2010 US census population) for AMI, ST‐segment–elevation myocardial infarction, and non–ST‐segment–elevation myocardial infarction by race/ethnicity (Hispanic and non‐Hispanic racial groups: Asian or Pacific Islander, black, and white). Using Poisson regression, we estimated annual percentage change in AMI, non–ST‐segment–elevation myocardial infarction, and ST‐segment–elevation myocardial infarction incidence by race/ethnicity and AMI incidence rate ratios between race/ethnicity pairs, adjusting for age and sex. We included 18 630 776 person‐years of observation and identified 44 142 AMI hospitalizations. During 2000 to 2014, declines in AMI, non–ST‐segment–elevation myocardial infarction, and ST‐segment–elevation myocardial infarction were 48.7%, 34.2%, and 69.8%, respectively. Age‐ and sex‐standardized AMI hospitalization rates/100 000 person‐years declined for Hispanics (from 307 to 162), Asians or Pacific Islanders (from 271 to 158), blacks (from 347 to 199), and whites (from 376 to 189). Annual percentage changes ranged from −2.99% to −4.75%, except for blacks, whose annual percentage change was −5.32% during 2000 to 2009 and −1.03% during 2010 to 2014. Conclusions During 2000 to 2014, AMI, non–ST‐segment–elevation myocardial infarction, and ST‐segment–elevation myocardial infarction hospitalization incidence rates declined substantially for each race/ethnic group. Despite narrowing rates among races/ethnicities, differences persist. Understanding these differences can help identify unmet needs in AMI prevention and management to guide targeted interventions.

Background: A growing body of evidence suggests that stressors are associated with heightened cardiovascular risk within hours after the triggering event, and stress from election campaigns is associated with a heightened risk of pre-term birth. Hypothesis: Potential stress from the 2016 presidential election was associated with an increased hospitalization rate for acute myocardial infarction (AMI) in the following week. Methods: Among active members 18 years of age and older in Kaiser Permanente Southern California, AMI was defined as an inpatient hospitalization with a primary discharge diagnosis of ICD-10-CM codes I21.x or I22.x. In an ecological analysis, we calculated relative risks (RR) and 95% confidence intervals (CI) comparing rates of AMI per 100,000 person-years (PY) within one week following the date of the 2016 presidential election (risk window) to rates in the prior two weeks (control window) overall and within subgroups by age, sex, and race/ethnicity. We repeated the above analysis comparing rates of AMI within one week of the 2016 election date to rates in the prior week. Results: Compared to the rates of MI in the two weeks before the 2016 election (171.6 per 100,000 PY), the rate of AMI hospitalization in the week following election day (242.2 per 100,000 PY) was 1.41 times higher (95% CI 1.14, 1.75). (Table) Heightened AMI risk after the 2016 election was also observed among adults 55-74 years of age (RR 1.47, 95% CI 1.10, 1.98), men (RR 1.54, 95% CI 1.17, 2.02), and white individuals (RR 1.52, 95% CI 1.12, 2.06). However, there was no evidence of heterogeneity across age, sex, or race/ethnicity groups (p-values 0.98, 0.30, and 0.65, respectively). Using a one-week control window, similar results were observed. Conclusion: Increased AMI rates among subsets of the population coincident with the 2016 election is consistent with published data suggesting that acute sociopolitical stress may have adverse health effects.

Prior studies found a higher risk of acute cardiovascular disease (CVD) around population-wide psychosocial or environmental stressors. Less is known about acute CVD risk in relation to political events.To examine acute CVD hospitalizations following the 2020 presidential election.This retrospective cohort study examined acute CVD hospitalizations following the 2020 presidential election. Participants were adult members aged 18 years or older at Kaiser Permanente Southern California and Kaiser Permanente Northern California, 2 large, integrated health care delivery systems. Statistical analysis was performed from March to July 2021.2020 US presidential election.Hospitalizations for acute CVD around the 2020 presidential election were examined. CVD was defined as hospitalizations for acute myocardial infarction (AMI), heart failure (HF), or stroke. Rate ratios (RR) and 95% CIs were calculated comparing rates of CVD hospitalization in the 5 days following the 2020 election with the same 5-day period 2 weeks prior.Among 6 396 830 adults (3 970 077 [62.1%] aged 18 to 54 years; 3 422 479 [53.5%] female; 1 083 128 [16.9%] Asian/Pacific Islander, 2 101 367 [32.9%] Hispanic, and 2 641 897 [41.3%] White), rates of hospitalization for CVD following the election (666 hospitalizations; rate = 760.5 per 100 000 person-years [PY]) were 1.17 times higher (95% CI, 1.05-1.31) compared with the same 5-day period 2 weeks prior (569 hospitalizations; rate = 648.0 per 100 000 PY). Rates of AMI were significantly higher following the election (RR, 1.42; 95% CI, 1.13-1.79). No significant difference was found for stroke (RR, 1.02; 95% CI, 0.86-1.21) or HF (RR, 1.18; 95% CI, 0.98-1.42).Higher rates of acute CVD hospitalization were observed following the 2020 presidential election. Awareness of the heightened risk of CVD and strategies to mitigate risk during notable political events are needed.

Objective To compare renal function decline, incident end-stage renal disease (ESRD), and mortality among patients with 5 common glomerular diseases in a large diverse population. Patients and Methods A retrospective cohort study (between January 1, 2000, and December 31, 2011) of patients with glomerulonephropathy using the electronic health record of an integrated health system was performed. Estimated glomerular filtration rate (eGFR) change, incident ESRD, and mortality were compared among patients with biopsy-proven focal segmental glomerulosclerosis (FSGS), membranous glomerulonephritis (MN), minimal change disease (MCD), immunoglobulin A nephropathy (IgAN), and lupus nephritis (LN). Competing risk models were used to estimate hazard ratios for different glomerulonephropathies for incident ESRD, with mortality as a competing outcome after adjusting for potential confounders. Results Of the 2350 patients with glomerulonephropathy (208 patients [9%] younger than 18 years) with a mean follow-up of 4.5±3.6 years, 497 (21%) progressed to ESRD and 195 (8%) died before ESRD. The median eGFR decline was 1.0 mL/min per 1.73 m 2 per year but varied across different glomerulonephropathies ( P P =.24). Conclusion Our findings from a real-world clinical environment revealed significant differences in eGFR decline and ESRD risk among patients with 5 glomerulonephropathies. These variations in presentation and outcomes warrant different management strategies and expectations.

Objective: The role of uncontrolled blood pressure (BP) in COVID-19 severity among patients with hypertension is unclear. We evaluated the association between uncontrolled BP and the risk of hospitalization and/or mortality in patients with hypertension from a large US integrated healthcare system. Methods: We identified patients with hypertension and a positive RT-PCR test result or a diagnosis of COVID-19 between March 1 – September 1, 2020 from Kaiser Permanente Southern California. BP categories was defined using the most recent outpatient BP measurement during 12 months prior to COVID-19 infection. The primary outcome of interest was all-cause hospitalization or mortality within 30 days from COVID-19 infection. Results: Among 12,548 patients with hypertension and COVID-19 (mean age = 60 years, 47% male), 63% had uncontrolled BP (≥130/80 mm Hg) prior to COVID-19. Twenty-one percent were hospitalized or died within 30 days of COVID-19 infection. Uncontrolled BP was not associated with higher hospitalization or mortality (adjusted rate ratios for BP ≥ 160/100 mm Hg vs

Objective To assess the health-related quality of life (HRQoL) of patients with prostate cancer up to 24 months after treatment in a contemporary large diverse population. Patients and Methods Patients with newly diagnosed prostate cancer from March 2011 to January 2014 in our healthcare system were included. The Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire was administered before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment up to November 2014 for all methods of treatment. The Kruskall–Wallis test was used to compare the distribution of each EPIC-26 domain score at each time point, and mixed models were used to assess the overall scores over the period after treatment. Results In all, 5 727 patients were included. There were data for 3 422, 2 329, 2 017, 1 922, 1 772, 1 260, and 837 patients before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment, respectively. At 1 month, bowel scores were the lowest for patients that had had radiation therapy, and urinary irritative symptoms were the lowest for those who had had brachytherapy. There were sexual function declines for all the treatment methods, with surgery having the steepest decline; open radical prostatectomy (ORP) had a greater decline than robot-assisted laparoscopic prostatectomy (RALP). Patients who underwent RALP had a better return of sexual function, approaching that of brachytherapy and radiation therapy at 24 months. Urinary incontinence (UI) also declined the most in surgical patients, with RALP patients improving slightly more than ORP patients at 12–24 months. Conclusions Patients' HRQoL after prostate cancer treatment varies by treatment method. Notably, sexual function recovers most for RALP patients. UI remains worse at 24 months after surgery, compared to other methods of prostate cancer treatment.

Background: In recent decades, the rates of incident acute myocardial infarction (AMI) have declined in the United States, yet disparities by sex remain. In an integrated healthcare delivery system, we examined temporal trends in incident AMI among women and men. Methods: We identified hospitalized AMI among members ≥35 years of age in Kaiser Permanente Southern California. The first hospitalization for AMI overall, and for ST-segment–elevation MI and non–ST-segment–elevation MI was identified by International Classification of Diseases, Ninth Revision, Clinical Modification primary discharge diagnosis codes in each calendar year from 2000 through 2014. Age- and sex-standardized incidence rates per 100 000 person-years were calculated by using direct adjustment to the 2010 US Census population. Average annual percent changes (AAPCs) and period percent changes were calculated, and trend tests were conducted using Poisson regression. Results: We identified 45 331 AMI hospitalizations between 2000 and 2014. Age- and sex-standardized incidence rates of AMI declined from 322.4 (95% CI, 311.0–333.9) in 2000 to 174.6 (95% CI, 168.2–181.0) in 2014, representing an AAPC of –4.4% (95% CI, –4.2 to –4.6) and a period percent change of –46.6%. The AAPC for AMI in women was –4.6% (95% CI, –4.1 to –5.2) between 2000 and 2009 and declined to –2.3% (95% CI, –1.2 to –3.4) between 2010 and 2014. The AAPC for AMI in men was stable over the study period (–4.7% [95% CI, –4.4 to –4.9]). The AAPC for ST-segment–elevation MI hospitalization overall was –8.3% (95% CI, –8.0% to –8.6%).The AAPC in ST-segment–elevation MI changed among women in 2009 (2000–2009: –10.2% [95% CI, –9.3 to –11.1] and in 2010–2014: –5.2% [95% CI, –3.1 to –7.3]) while remaining stable among men (–8.0% [95% CI, –7.6 to –8.4]). The AAPC for non–ST-segment–elevation MI hospitalization was smaller than for ST-segment–elevation MI among both women and men (–1.9% [95% CI, –1.5 to –2.3] and –2.8% [95% CI, –2.5 to –3.2], respectively). Conclusions: These results suggest that the incidence of hospitalized AMI declined between 2000 and 2014; however, declines in AMI have slowed among women in comparison with men in recent years. Determining unmet care needs among women may reduce these sex-based AMI disparities.

Objective To estimate time in suboptimal glycemic control among patients with incident type 2 diabetes (T2D) over 10 years. Methods We calculated percent of time in suboptimal glycemic control using three A1C thresholds (8%, 7.5%, 7%) following T2D diagnosis. Stratified analyses were conducted based on age and A1C levels at T2D diagnosis. Results We identified 28,315 patients with incident T2D. Percent of time in suboptimal glycemic control increased with T2D duration. Mean percent time in suboptimal A1C control in the first 2 years following diagnosis was 30%, 34% and 40% for the 8%, 7.5%, and 7% thresholds, respectively. In the 6–10 years following T2D diagnosis, the percent time in suboptimal A1C control increased to 39%, 48% and 61%, for the 8%, 7.5%, and 7% thresholds, respectively. Time in suboptimal glycemic control was longer among younger patients aged 20–44 versus ≥65 years and those with higher A1C (>8%) versus lower A1C ( Conclusions Over 10 years following diagnosis, T2D patients spent one-third to over one-half of their time in suboptimal glycemic control. Reducing time spent above desired A1C targets could lower risk of microvascular and macrovascular complications.

The Bladder Cancer Quality of Life Study collected detailed and sensitive patient-reported outcomes from bladder cancer survivors in the period after bladder removal surgery, when participation in survey research may present a burden. This paper describes the study recruitment methods and examines the response rates and patterns of missing data.Detailed surveys focusing on quality of life, healthcare decision-making, and healthcare expenses were mailed to patients 5-7 months after cystectomy. We conducted up to 10 follow-up recruitment calls. We analyzed survey completion rates following each contact in relation to demographic and clinical characteristics, and patterns of missing data across survey content areas.The overall response rate was 71% (n = 269/379). This was consistent across patient clinical characteristics; response rates were significantly higher among patients over age 70 and significantly lower among racial and ethnic minority patients compared to non-Hispanic white patients. Each follow-up contact resulted in marginal survey completion rates of at least 10%. Rates of missing data were low across most content areas, even for potentially sensitive questions. Rates of missing data differed significantly by sex, age, and race/ethnicity.Despite the effort required to participate in research, this population of cancer survivors showed willingness to share detailed information about quality of life, health care decision-making, and expenses, soon after major cancer surgery. Additional contacts were effective at increasing participation. Response patterns differed by race/ethnicity and other demographic factors. Our data collection methods show that it is feasible to gather detailed patient-reported outcomes during this challenging period.

Evidence suggests that statin therapy in patients with peripheral artery disease (PAD) is beneficial yet use remains suboptimal. We examined trends in statin use, intensity, and discontinuation among adults aged ⩾ 40 years with incident severe PAD and a subset with critical limb ischemia (CLI) between 2002 and 2015 within an integrated healthcare delivery system. Discontinuation of statin therapy was defined as the first 90-day gap in treatment within 1 year following PAD diagnosis. We identified 11,059 patients with incident severe PAD: 31.1% ( n = 3442) with CLI and 68.9% ( n = 7617) without CLI. Mean (SD) age was 68.6 (11.3) years, 60.5% were male, 54.2% white, 23.2% Hispanic, and 16.2% black. Statin use in the year before diagnosis increased from 50.4% in 2002 to 66.0% in 2015 (CLI: 43.7% to 68.0%; without CLI: 53.1% to 64.2%, respectively). The proportion of patients on high-intensity statins increased from 7.3% in 2002 to 41.9% in 2015 (CLI: 7.2% to 39.4%; without CLI: 7.4% to 44.2%, respectively). Of the 40.5% ( n = 4481) who were not on a statin in the year before diagnosis, 13.5% ( n = 607) newly initiated therapy within 1 month (CLI: 10.1% ( n = 150); without CLI: 15.3% ( n = 457)). Following diagnosis, 12.5% ( n = 660) discontinued statin therapy within 1 year (CLI: 15.5% ( n = 202); without CLI: 11.5% ( n = 458)). Although use of statins increased from 2002 to 2015, a substantial proportion of the overall PAD and CLI subpopulation remained untreated with statins, representing a significant treatment gap in a population at high risk for cardiovascular events and adverse limb outcomes.

Previous research has documented higher mortality rates and risk of diabetes complications in ethnic minorities in the U.S. While genetic predisposition and lifestyle are potential important factors associated with this disparity, the role of access to care has not been well studied. We examined all-cause mortality and incidence of cardiovascular disease (CVD) by race/ethnicity in a type 2 diabetes (T2DM) population within in a large U.S. integrated healthcare system. We identified adult patients with incident T2DM between 1/1/2003-12/31/2014 using electronic health record (EHR) data and followed them through 6/30/2018. Patient demographics, CVD risk factors, medical history, and medication use were ascertained from the EHR. Age- and sex-adjusted all-cause mortality and incidence rates of myocardial infarction (MI) and heart failure (HF) were estimated by race/ethnicity. Hazard ratios were estimated using multivariable Cox proportional hazards models. We identified 135,199 patients with incident T2DM (mean±SD age: 58±13 years, 48% female, and median follow-up 6 years). 36% were white, 35% Hispanic, 12% Asian, and 12% black. All-cause mortality and incidence of MI and HF were highest among whites followed by blacks (Table). These findings suggest that improving access to quality care may help reduce racial/ethnic health disparities among patients with T2DM. Disclosure J. An: Research Support; Self; Merck & Co., Inc. G.A. Nichols: Research Support; Self; Amarin Corporation, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Scientific Affairs, LLC., Merck Sharp & Dohme Corp. L. Qian: None. R. Wei: None. T. Harrison: None. M.A. Munis: None. Z. Li: None. T. Weiss: Employee; Self; Merck & Co., Inc. K. Iglay: Employee; Self; Merck & Co., Inc. Stock/Shareholder; Self; Merck & Co., Inc. S. Rajpathak: None. K. Reynolds: Research Support; Self; Amarin Corporation, Amgen Inc., Merck Sharp & Dohme Corp., Novartis AG.

The elevated risk of cardiovascular diseases (CVD) in patients with type 2 diabetes mellitus (T2DM) is well established, however, development of these comorbidities from T2DM diagnosis over an extended time period has not been adequately studied. We estimated the cumulative incidence of CVD in T2DM over the course of 15 years in a large U.S. integrated healthcare delivery system. The study population included adult T2DM patients diagnosed between 1/1/2003 and 12/31/2014 based on validated algorithms using the electronic health record (EHR). Patients were followed from 6 months after their T2DM diagnosis date through 6/30/2018. Patient demographics, CVD risk factors, medical history, and medication use were ascertained from the EHR. The cumulative incidence of myocardial infarction (MI), heart failure (HF) and all-cause mortality was estimated separately at 2, 5, 10, 13 and 15 years among the patients who did not have a prior history of each condition (at-risk population) using the Kaplan-Meier method. We identified 135,199 patients newly diagnosed with T2DM. Mean (SD) age was 58 (13) years, 48% were female, 36% were white, 35% Hispanic, 12% black, and 12% Asian. Median follow-up was 6 years. At baseline, 1.3% had MI and 3.5% had HF. By 15 years following T2DM diagnosis, 30.0% of the cohort died, 7.6% had MI and 11.5% HF. The 2-, 5-, 10-, 13-, and 15-year cumulative incidence among the population-at-risk are shown in the Table. Disclosure J. An: Research Support; Self; Merck & Co., Inc. G.A. Nichols: Research Support; Self; Amarin Corporation, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Scientific Affairs, LLC., Merck Sharp & Dohme Corp. L. Qian: None. R. Wei: None. T. Harrison: None. M.A. Munis: None. Z. Li: None. T. Weiss: Employee; Self; Merck & Co., Inc. K. Iglay: Employee; Self; Merck & Co., Inc. Stock/Shareholder; Self; Merck & Co., Inc. S. Rajpathak: None. K. Reynolds: Research Support; Self; Amarin Corporation, Amgen Inc., Merck Sharp & Dohme Corp., Novartis AG.

Background Older adults with chronic kidney disease (CKD)-discordant conditions (comorbid conditions with treatment recommendations that potentially complicate CKD management) have higher risk of hospitalization and death. Our goal is to develop a CKD-Discordance Index using electronic health records to improve recognition of discordance. Methods This retrospective cohort study included Kaiser Permanente Southern California patients aged ≥65 years and older with incident CKD (N = 30,932). To guide inclusion of conditions in the Index and weight each condition, we first developed a prediction model for 1-year hospitalization risk using Cox regression. Points were assigned proportional to regression coefficients derived from the model. Next, the CKD-Discordance Index was calculated as an individual’s total points divided by the maximum possible discordance points. The association between CKD-Discordance Index and hospitalizations, emergency department visits, and mortality was accessed using multivariable-adjusted Cox regression model. Results Overall, mean (SD) age was 77.9 (7.6) years, 55% of participants were female, 59.3% were white, and 32% (n = 9,869) had ≥1 hospitalization during 1 year of follow-up. The CKD-Discordance Index included the following variables: heart failure, gastroesophageal reflux disease/peptic ulcer disease, osteoarthritis, dementia, depression, cancer, chronic obstructive pulmonary disease/asthma, and having four or more prescribers. Compared to those with a CKD-Discordance Index of 0, adjusted hazard ratios (95% confidence interval) for hospitalization were 1.39 (1.27–1.51) and 1.81 (1.64–2.01) for those with a CKD-Discordance Index of 0.001–0.24 and ≥0.25, respectively (ptrend < .001). A graded pattern of risk was seen for emergency department visits and all-cause mortality. Conclusion A data-driven approach identified CKD-discordant indicators for a CKD-Discordance Index. Higher CKD-Discordance Index was associated with health care utilization and mortality.

Objective Although recent evidence suggests no increased risk of severe COVID-19 outcomes associated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) use, the relationship is less clear among patients with hypertension and diverse racial/ethnic groups. This study evaluates the risk of hospitalization and mortality among patients with hypertension and COVID-19 in a large US integrated healthcare system. Methods Patients with hypertension and COVID-19 (between March 1- September 1, 2020) on ACEIs or ARBs were compared with patients on other frequently used antihypertensive medications. Results Among 14,129 patients with hypertension and COVID-19 infection (mean age 60 years, 48% men, 58% Hispanic), 21% were admitted to the hospital within 30 days of COVID-19 infection. Of the hospitalized patients, 24% were admitted to intensive care units, 17% required mechanical ventilation, and 10% died within 30 days of COVID-19 infection. Exposure to ACEIs or ARBs prior to COVID-19 infection was not associated with an increased risk of hospitalization or all-cause mortality (rate ratios for ACEIs vs other antihypertensive medications ​= ​0.98, 95% CI: 0.88, 1.08; ARBs vs others ​= ​1.00, 95% CI: 0.90, 1.11) after applying inverse probability of treatment weights. These associations were consistent across racial/ethnic groups. Use of ACEIs or ARBs during hospitalization was associated with a lower risk of all-cause mortality (odds ratios for ACEIs or ARBs vs others ​= ​0.50, 95% CI: 0.34, 0.72). Conclusion Our study findings support continuation of ACEI or ARB use for patients with hypertension during the COVID-19 pandemic and after COVID-19 infection., Graphical abstract Image 1

Aims To investigate the discontinuation of oral antihyperglycemic agents (OHA), and examine factors associated with OHA discontinuation, and the effect of OHA discontinuation on glycemic control and healthcare utilization among diabetes patients prescribed dual OHA therapy. Methods We identified 23,612 adult patients aged > 18 years with a diagnosis of type 2 diabetes who initiated dual OHA therapy between 1/1/2005 and 6/30/2010. The date of initiation of the second OHA was defined as the index date. Discontinuation was defined as a gap > 1.5 times the last days' supply without subsequent reinitiation. Results Over 24 months, 16.9% discontinued 1 OHA and 9.2% discontinued both. Patients who discontinued were more likely to be female, younger, Black or of Hispanic ethnicity, have more comorbidities, higher medication co-pays, start both OHAs together, have higher healthcare utilization before the index date and less likely to use prescription mail order compared with patients who did not discontinue. In multivariable regression models, patients who discontinued were more likely to be hospitalized or have emergency department visits during follow-up. Conclusions Discontinuation of OHAs is common among patients with diabetes and is associated with several patient factors and increased healthcare utilization. Future research should further examine reasons for OHA discontinuation.