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Both community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control. Patients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect. Among 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P <.001). As compared to the comparison group, the intervention was associated with a change in HbA1c of −0.2% (95% confidence interval [CI] −0.4%-0.5%) and −0.3 (95% CI −0.5–0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%−13.9%) but not the early follow-up cohort (3.6%, 95% CI −1.5% to 8.7%) The intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed. [ABSTRACT FROM AUTHOR]

Background: The Medicare Hospital Readmissions Reduction Program has led to fewer readmissions following hospitalizations with a principal diagnosis of heart failure (HF). Patients with HF are frequently hospitalized for other causes.Objectives: This study sought to compare trends in Medicare risk-adjusted, 30-day readmissions following principal HF hospitalizations and other hospitalizations with HF.Methods: This was a retrospective study of 12,973,853 Medicare hospitalizations with a principal or secondary diagnosis of HF between January 2008 and June 2015. Hospitalizations were categorized as follows: principal HF hospitalizations; principal acute myocardial infarction or pneumonia hospitalizations with secondary HF; and other hospitalizations with secondary HF. The study examined trends in risk-adjusted, 30-day, all-cause readmission rates for each cohort and trends in differences in readmission rates among cohorts by using linear spline regression models.Results: Before passage of the Affordable Care Act in March 2010, risk-adjusted, 30-day readmission rates were stable for all 3 cohorts, with mean monthly rates of 26.1%, 24.9%, and 24.4%, respectively. Risk-adjusted readmission rates started declining after passage of the Affordable Care Act by 1.09% (95% confidence interval [CI]: 0.51% to 1.68%), 1.24% (95% CI: 0.92% to 1.57%), and 1.05% (95% CI: 0.52% to 1.58%) per year, respectively, until implementation of the Hospital Readmissions Reduction Program in October 2012 and then stabilized for all 3 cohorts.Conclusions: Patients with HF are often hospitalized for other causes, and these hospitalizations have high readmission rates. Policy changes led to decreases in readmission rates for both principal and secondary HF hospitalizations. Readmission rates in both groups remain high, suggesting that initiatives targeting all hospitalized patients with HF continue to be warranted. [ABSTRACT FROM AUTHOR]

Only half of patients with hypertension have adequately controlled blood pressure. Clinical decision support (CDS) has the potential to overcome barriers to delivering guideline-recommended care and improve hypertension management. However, optimal strategies for scaling CDS have not been well established, particularly in small, independent primary care practices which often lack the resources to effectively change practice routines. Practice facilitation is an implementation strategy that has been shown to support process changes. Our objective is to evaluate whether practice facilitation provided with hypertension-focused CDS can lead to improvements in blood pressure control for patients seen in small primary care practices. We will conduct a cluster randomized control trial to compare the effect of hypertension-focused CDS plus practice facilitation on BP control, as compared to CDS alone. The practice facilitation intervention will include an initial training in the CDS and a review of current guidelines along with follow-up for coaching and integration support. We will randomize 46 small primary care practices in New York City who use the same electronic health record vendor to intervention or control. All patients with hypertension seen at these practices will be included in the evaluation. We will also assess implementation of CDS in all practices and practice facilitation in the intervention group. The results of this study will inform optimal implementation of CDS into small primary care practices, where much of care delivery occurs in the U.S. Additionally, our assessment of barriers and facilitators to implementation will support future scaling of the intervention. ClinicalTrials.gov Identifier: NCT05588466 [ABSTRACT FROM AUTHOR]

Background: Appropriate use criteria (AUC) for cardiac stress tests address concerns about utilization growth and patient safety. We systematically reviewed studies of appropriateness, including within physician specialties; evaluated trends over time and in response to AUC updates; and characterized leading indications for inappropriate/rarely appropriate testing. Methods: We searched PubMed (2005–2015) for English-language articles reporting stress echocardiography or myocardial perfusion imaging (MPI) appropriateness. Data were pooled using random-effects meta-analysis and meta-regression. Results: Thirty-four publications of 41,578 patients were included, primarily from academic centers. Stress echocardiography appropriate testing rates were 53.0% (95% CI, 45.3%–60.7%) and 50.9% (42.6%–59.2%) and inappropriate/rarely appropriate rates were 19.1% (11.4%–26.8%) and 28.4% (23.9%–32.8%) using 2008 and 2011 AUC, respectively. Stress MPI appropriate testing rates were 71.1% (64.5%–77.7%) and 72.0% (67.6%–76.3%) and inappropriate/rarely appropriate rates were 10.7% (7.2%–14.2%) and 15.7% (12.4%–19.1%) using 2005 and 2009 AUC, respectively. There was no significant temporal trend toward rising rates of appropriateness for stress echocardiography or MPI. Unclassified stress echocardiograms fell by 79% (p = 0.04) with updated AUC. There were no differences between cardiac specialists and internists. Conclusions: Rates of appropriate use tend to be lower for stress echocardiography compared to MPI, and updated AUC reduced unclassified stress echocardiograms. There is no conclusive evidence that AUC improved appropriate use over time. Further research is needed to determine if integration of appropriateness guidelines in academic and community settings is an effective approach to optimizing inappropriate/rarely appropriate use of stress testing and its associated costs and patient harms. [ABSTRACT FROM AUTHOR]

Background: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes.Objective: The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends.Design and Patients: This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders.Main Measures: The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate.Key Results: The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period.Conclusions: The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting. [ABSTRACT FROM AUTHOR]

The article presents a study that examined the risk factors in seasonal differences in relation to hospital admission or due to seasonal variations in risk strata. It explores the predicted risk among hospitalized Medicare beneficiaries in seasonal variation for readmission of patients with cardiorespiratory conditions especially in winter months. The high prevalent cardiorespiratory conditions include heart failure, pneumonia, and chronic obstructive pulmonary disease (COPD).

Background: Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure.Objective: To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making.Design: Analyses of repeated cross-sectional data.Setting: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010).Patients: Adults without coronary heart disease.Measurements: Cardiac stress test referrals and inappropriate use.Results: Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a cardiac stress test was ordered or performed increased from 28 per 10,000 visits to 45 per 10,000 visits. No trend was found toward more frequent testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac stress tests with imaging comprised a growing portion of all tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a cardiac stress test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]).Limitation: Cross-sectional design with limited clinical data.Conclusion: National growth in cardiac stress test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about cardiac stress test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease.Primary Funding Source: National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences. [ABSTRACT FROM AUTHOR]

Background: Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure. Objective: To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making. Design: Analyses of repeated cross-sectional data. Setting: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010). Patients: Adults without coronary heart disease. Measurements: Cardiac stress test referrals and inappropriate use. Results: Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a cardiac stress test was ordered or performed increased from 28 per 10 000 visits to 45 per 10 000 visits. No trend was found toward more frequent t testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac stress tests with imaging comprised a growing portion of all tests, increasing from 59% in 1993 to 1995 to 87% in 20 8 to 2010. At least 34 .6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a cardiac stress test (odds ratio, 0.91 [9 5% Cl, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [Cl, 0.55 to 1.02]). Limitation: Cross-sectional design with limited clinical data. Conclusion: National growth in cardiac stress test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about cardiac stress test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to evaluate the association of physician continuity of care with length of stay, likelihood of weekend discharge, in-hospital mortality and 30-day readmission. Design A cohort study of hospitalized medical patients. The primary exposure was the weekend usual provider continuity (UPC) over the initial weekend of care. This metric was adapted from an outpatient continuity of care index. Regression models were developed to determine the association between UPC and outcomes. Setting An academic medical center. Main outcome measure Length of stay which was calculated as the number of days from the first Saturday of the hospitalization to the day of discharge. Results Of the 3391 patients included in this study, the prevalence of low, moderate and high UPC for the initial weekend of hospitalization was 58.7, 22.3 and 19.1%, respectively. When compared with low continuity of care, both moderate and high continuity of care were associated with reduced length of stay, with adjusted rate ratios of 0.92 (95% CI 0.86–1.00) and 0.64 (95% CI 0.53–0.76), respectively. High continuity of care was associated with likelihood of weekend discharge (adjusted odds ratio 2.84, 95% CI 2.11–3.83) but was not significantly associated with mortality (adjusted odds ratio 0.72, 95% CI 0.29–1.80) or readmission (adjusted odds ratio 0.88, 95% CI 0.68–1.14) when compared with low continuity of care. Conclusions Increased weekend continuity of care is associated with reduced length of stay. Improvement in weekend cross-coverage and patient handoffs may be useful to improve clinical outcomes. [ABSTRACT FROM PUBLISHER]

Abstract: Objective: Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on use of the electronic health record was associated with patient-level outcomes. Methods: We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed “electronic health record interactions.” Hospitalizations were categorized on the basis of the mean difference in electronic health record interactions between the first Friday and the first Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates. Results: Electronic health record interactions decreased from Friday to Saturday in 77% of the 9051 hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturday electronic health record interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in electronic health record interactions were 1.05 (95% confidence interval [CI], 1.00-1.10), 1.11 (95% CI, 1.05-1.17), and 1.25 (95% CI, 1.15-1.35), respectively. Although a large decrease in electronic health record interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25). Conclusions: Intensity of inpatient care, measured by electronic health record interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity. [Copyright &y& Elsevier]

Objectives: The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes. Background: Performance measures for heart failure target patients with a principal diagnosis of heart failure. However, patients with heart failure are commonly hospitalized for other causes and may benefit from treatments such as angiotensin-converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction. Methods: We assessed rates of compliance with care measures for patients hospitalized with acute or chronic heart failure in the ARIC (Atherosclerosis Risk In Communities) study surveillance catchment area from 2005 to 2009. Rates of compliance were compared between patients with a principal discharge diagnosis of heart failure and those with another principal discharge diagnosis. Results: Of 4,345 hospitalizations of heart failure patients, 39.6% carried a principal diagnosis of heart failure. Patients with a principal heart failure diagnosis had higher rates of LV function assessment (89.1% vs. 82.5%; adjusted prevalence ratio [aPR]: 1.07; 95% confidence interval [CI]: 1.04 to 1.10) and discharge ACE inhibitor/angiotensin receptor blocker (ARB) in LV dysfunction (64.1% vs. 56.3%; aPR: 1.11; 95% CI: 1.03 to 1.20) as compared to patients hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with reductions in 1-year post-discharge mortality (adjusted odds ratio: 0.66, 95% CI: 0.51 to 0.85; adjusted odds ratio: 0.72, 95% CI: 0.54 to 0.96, respectively) that did not differ for patients with versus without a principal heart failure diagnosis. Conclusions: Compared with individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes were less likely to receive guideline recommended care. Quality initiatives may improve care by targeting hospitalizations with either principal or secondary heart failure diagnoses. [Copyright &y& Elsevier]

Objectives: This study sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis.Background: Heart failure patients are frequently admitted for both heart failure and other causes.Methods: Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based on the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and sex-standardized hospitalization rates were determined by dividing the number of hospitalizations by the U.S. population in a given year and using direct standardization.Results: The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, whereas secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and sex-adjusted rates of primary heart failure hospitalizations decreased steadily from 2001 to 2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased from 1,370 to 1,476 per 100,000 people from 2001 to 2006, then decreased to 1,359 per 100,000 people in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections.Conclusions: Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and noncardiac conditions. [ABSTRACT FROM AUTHOR]

Objectives This study sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis. Background Heart failure patients are frequently admitted for both heart failure and other causes. Methods Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based on the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and sex-standardized hospitalization rates were determined by dividing the number of hospitalizations by the U.S. population in a given year and using direct standardization. Results The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, whereas secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and sex-adjusted rates of primary heart failure hospitalizations decreased steadily from 2001 to 2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased from 1,370 to 1,476 per 100,000 people from 2001 to 2006, then decreased to 1,359 per 100,000 people in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections. Conclusions Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and noncardiac conditions. [ABSTRACT FROM AUTHOR]

OBJECTIVE--This study sought to investigate an association of HbA1c (A1C) with incident heart failure among individuals without diabetes and compare it to fasting glucose. RESEARCH DESIGN AND METHODS--We studied 11,057 participants of the Atherosclerosis Risk in Communities (ARIC) Study without heart failure or diabetes at baseline and estimated hazard ratios of incident heart failure by categories of A1C (<5.0, 5.0-5.4 [reference], 5.5-5.9, and 6.0-6.4%) and fasting glucose (<90, 90-99 [reference], 100-109, and 110-125 mg/dl) using Cox proportional hazards models. RESULTS--A total of 841 cases of incident heart failure hospitalization or deaths (International Classification of Disease, 9th/10th Revision, 428/I50) occurred during a median follow-up of 14.1 years (incidence rate 5.7 per 1,000 person-years). After the adjustment for covariates including fasting glucose, the hazard ratio of incident heart failure was higher in individuals with A1C 6.0-6.4% (1.40 [95% CI, 1.09-1.79]) and 5.5-6.0% (1.16 [0.98-1.37]) as compared with the reference group. Similar results were observed when adjusting for insulin level or limiting to heart failure cases without preceding coronary events or developed diabetes during follow-up. In contrast, elevated fasting glucose was not associated with heart failure after adjustment for covariates and A1C. Similar findings were observed when the top quartile (A1C, 5.7-6.4%, and fasting glucose, 108-125 mg/dl) was compared with the lowest quartile (<5.2% and <95 mg/dl, respectively). CONCLUSIONS--Elevated A1C (≥5.5-6.0%) was associated with incident heart failure in a middle-aged population without diabetes, suggesting that chronic hyperglycemia prior to the development of diabetes contributes to development of heart failure. Diabetes 59:2020-2026, 2010 [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine the association between severe mental illness (SMI) and quality of care in heart failure. Methods: We conducted a cohort study between 2001 and 2004 of disabled Maryland Medicaid participants with heart failure. Quality measures and clinical outcomes were compared for individuals with and without SMI. Results: Of 1801 individuals identified with heart failure, 341 had comorbid SMI. SMI was not associated with differences in quality measures, including left ventricular assessment [adjusted relative risk (aRR) 0.99; 95% CI 0.91–1.07], utilization of angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (aRR 1.04; 95% CI 0.92–1.17), or beta-blocker use (aRR 1.13; 95% CI 0.99–1.29). During the study period, 52.2% of individuals in the cohort filled a prescription for an ACE inhibitor or ARB and 45.5% filled a beta-blocker prescription. Individuals with and without SMI had similar rates of clinical outcomes, including hospitalizations, readmissions, and mortality. Both medication interventions were associated with improved mortality. Conclusions: In this sample of disabled Medicaid recipients with heart failure, persons with SMI received similar quality of care as those without SMI. Both groups had low rates of beneficial medical treatments. Quality improvement programs should consider how best to target these vulnerable populations. [Copyright &y& Elsevier]

The article discusses a study conducted to compare location of death for physicians with that of other clinicians, non-health care professionals with similar education levels, and the general population. It is stated that the study found that physicians were less likely to die in a hospital than the general population, but equally as likely to die in a hospital as others in health care or with similar educational attainment.

Rationale: Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication. Aims and Objectives: In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart. Methods: We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review. Results: There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%−57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry. Conclusion: The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication. [ABSTRACT FROM AUTHOR]

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce heart failure (HF) hospitalizations, recurrent cardiovascular events, and chronic kidney disease (CKD) progression, and thus constitute a Class 1a recommendation in people with diabetes and atherosclerotic cardiovascular disease, HF, or CKD and in people with severe albuminuria or HF, regardless of diabetes status. The purpose of this study was to comprehensibly characterize the rate of SGLT2 inhibitor prescriptions among people with a Class 1a recommendation for SGLT2 inhibitor use. Among 3,189,827 adults from 28 U.S. health systems within Optum Labs Data Warehouse between April 1, 2022, and March 31, 2023, we assessed SGLT2 inhibitor prescription rates, stratified by presence of diabetes and Class 1a recommendation. Among 716,387 adults with diabetes, 63.4% had a Class 1a recommendation for SGLT2 inhibitor therapy. There was little difference by Class 1a recommendation status (present: 11.9%; 95% CI: 11.9%-12.0% vs absent: 11.4%; 95% CI: 11.3%-11.6%; standardized mean difference: 1.3%). Among 2,473,440 adults without diabetes, 6.2% had a Class 1a recommendation for SGLT2 inhibitor therapy, and 3.1% (3.0%-3.2%) of those received a prescription. Internists/family practitioners initiated SGLT2 inhibitor prescriptions most commonly among people with diabetes, whereas specialists initiated SGLT2 inhibitor prescriptions most commonly among people without diabetes. No health system had >25% SGLT2 inhibitor prescription rate among people with a Class 1a recommendation. Health systems with higher proportions of patients with commercial insurance and lower proportions with Medicare had higher SGLT2 inhibitor prescription rates. In this analysis of U.S. data from 2022 to 2023, SGLT2 inhibitor prescription among people with a Class 1a recommendation is low. Interventions are needed to increase uptake of guideline-recommended SGLT2 inhibitor use. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions This study aimed to examine the prevalence of inappropriate tight glycemic control in older adults with type 2 diabetes and other chronic conditions in New York City, and to identify factors associated with this practice.We conducted a retrospective cohort study using the INSIGHT Clinical Research Network. The study population included 11,728 and 15,196 older adults in New York City (age ≥ 75 years) with a diagnosis of type 2 diabetes, and at least one other chronic medical condition, in 2017 and 2022, respectively. The main outcome of interest was inappropriate tight glycemic control, defined as HbA1c <7.0% (<53 mmol/mol) with prescription of at least one high‐risk agent (insulin or insulin secretagogue).The proportion of older adults with inappropriate tight glycemic control decreased by nearly 19% over a five‐year period (19.4% in 2017 to 15.8% in 2022). There was a significant decrease in insulin (27.8% in 2017; 24.3% in 2022) and sulfonylurea (29.4% in 2017; 21.7% in 2022) medication prescription, and increase in use of GLP‐1 agonists (1.8% in 2017; 11.4% in 2022) and SGLT‐2 inhibitors (5.8% in 2017; 25.1% in 2022), among the total population. Factors associated with inappropriate tight glycemic control in 2022 included history of heart failure (adjusted odds ratio [aOR] 1.38), chronic kidney disease ([aOR] 1.93), colorectal cancer ([aOR] 1.38), acute myocardial infarction ([aOR] 1.28), “other” ([aOR] 0.72) or “unknown” ([aOR] 0.72) race, and a point increase in BMI ([aOR] 0.98).We found an encouraging trend toward less use of high‐risk medication strategies for older adults with type 2 diabetes and multiple chronic conditions. However, one in six patients in 2022 still had inappropriate tight glycemic control, indicating a need for continued efforts to optimize diabetes management in this population. [ABSTRACT FROM AUTHOR]

Background: Evidence-based therapy for heart failure remains underutilized at hospital discharge, particularly for patients with heart failure who are hospitalized for another cause. We developed clinical decision support (CDS) to recommend an angiotensin converting enzyme (ACE) inhibitor during hospitalization to promote its continuation at discharge. The CDS was designed to be implemented in both interruptive and non-interruptive versions.Objectives: To compare the effectiveness and implementation of interruptive and non-interruptive versions of a CDS to improve care for heart failure.Methods: Hospitalizations of patients with reduced ejection fraction were pseudo-randomized to deliver interruptive or non-interruptive CDS alerts to providers based on even or odd medical record number. We compared discharge utilization of an ACE inhibitor or angiotensin receptor blocker (ARB) for these two implementation approaches. We also assessed adoption and implementation fidelity of the CDS.Results: Of 958 hospitalizations, interruptive alert hospitalizations had higher rates of discharge utilization of ACE inhibitors or ARBs than non-interruptive alert hospitalizations (79.6% vs. 74.2%, p = 0.05). Utilization was higher for interruptive alert versus non-interruptive alert hospitalizations which were principally for causes other than heart failure (79.8% vs. 73.4%; p = 0.05) but no difference was observed among hospitalizations with a principal heart failure diagnosis (85.9% vs.81.7%; p = 0.49). As compared to non-interruptive hospitalizations, interruptive alert hospitalizations were more likely to have had: an alert with any response (40.6% vs. 13.1%, p < 0.001), contraindications reported (33.1% vs 11.3%, p < 0.001), and an ACE inhibitor ordered within twelve hours of the alert (17.6% vs 10.3%, p < 0.01). The response rate for the interruptive alert was 1.7%, and a median (25th, 75th percentile) of 14 (5,32) alerts were triggered per hospitalization.Conclusions: A CDS implemented as an interruptive alert was associated with improved quality of care for heart failure. Whether the potential benefits of CDS in improving cardiovascular care were worth the high burden of interruptive alerts deserves further consideration. CLINICALTRIALS.Gov Identifier: NCT02858674. [ABSTRACT FROM AUTHOR]

Background: Poorly controlled diabetes can be difficult to manage, particularly in high-risk patients and in settings without an endocrinologist. Project ECHO is a case-based learning and tele-mentoring model that connects primary care providers (PCPs) with specialists. We evaluated the impact of the ECHO model on healthcare utilization and care for Medicaid patients with diabetes in New Mexico (NM). Methods: Between January 2015 and April 2017, patients with complex diabetes from 10 federally qualified health centers in NM were recruited to receive diabetes care from a PCP and community health worker upskilled via weekly Endo ECHO sessions. We included patients with 6 months of continuous enrollment in the NM Medicaid claims database and performed 5:1 propensity matching of participants to comparison Medicaid beneficiaries. We used a difference-in-difference (DID) approach to compare utilization and processes of care between study participants and controls. Results: Of 539 Medicaid patients enrolled in Endo ECHO, 235 met inclusion criteria and were successfully matched to comparison patients. Outpatient visits increased for study participants in the pre- versus post-enrollment period (801 vs. 1056 per 1,000 patients/month) but not for comparators (785 vs. 680 per 1000 patients/month, DID p<0.01). We observed no difference in inpatient (131 vs. 134 per 1,000 patients/month) or ED utilization (24 vs. 26 per 1,000) in the pre- versus post-enrollment period for study participants. The intervention was associated with increased metformin utilization (DID 15.2%, p=0.01), but had no effect on expenditures, statin utilization, or ACE inhibitor/ARB utilization for hypertension. Discussion: Patient enrollment in Endo ECHO was associated with increased outpatient utilization and increased compliance with some, but not all, process measures. No impact was observed on hospitalizations or ED visits. Ongoing evaluation will determine the impact of the ECHO model on clinical outcomes. Disclosure: S. Blecker: Advisory Panel; Self; Medtronic. E. Lemieux: None. M. Paul: None. C. Berry: None. M.F. Bouchonville: None. B. Hager: None. S. Arora: None. J. Billings: None. Funding: The Leona M. and Harry B. Helmsley Charitable Trust [ABSTRACT FROM AUTHOR]

Discusses research being done on the effectiveness of losartan-based therapy in reducing stroke and new-onset diabetes in hypertensive patients. Reference to study by R.B. Devereux and colleagues, published in the March 2002 issue of the journal 'Lancet'; Information on the study population; Intervention administered to the patients.

Background: Engagement with self-monitoring of blood pressure (BP) declines, on average, over time but may vary substantially by individual. Objectives: We aimed to describe different 1-year patterns (groups) of self-monitoring of BP behaviors, identify predictors of those groups, and examine the association of self-monitoring of BP groups with BP levels over time. Methods: We analyzed device-recorded BP measurements collected by the Health eHeart Study—an ongoing prospective eCohort study—from participants with a wireless consumer-purchased device that transmitted date- and time-stamped BP data to the study through a full 12 months of observation starting from the first day they used the device. Participants received no instruction on device use. We applied clustering analysis to identify 1-year self-monitoring, of BP patterns. Results: Participants had a mean age of 52 years and were male and White. Using clustering algorithms, we found that a model with three groups fit the data well: persistent daily use (9.1% of participants), persistent weekly use (21.2%), and sporadic use only (69.7%). Persistent daily use was more common among older participants who had higher Week 1 self-monitoring of BP frequency and was associated with lower BP levels than the persistent weekly use or sporadic use groups throughout the year. Conclusion: We identified three distinct self-monitoring of BP groups, with nearly 10% sustaining a daily use pattern associated with lower BP levels. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Everolimus-Eluting Stents or Bypass Surgery for Multivessel Coronary Disease" published in the March 26, 2015 issue is presented.

The article presents the authors' views on a research paper, published in this issue on a randomized control trial conducted by researcher D. Edelman and colleagues to evaluate the effectiveness of a telephone-based nurse behavioral management intervention among diabetics and hypertension patients. They opine that a lesser role in the observed lack of effectiveness of a patient-level intervention is played by differences in settings.

Mineralocorticoid receptor antagonists (MRAs) are underprescribed for patients with heart failure with reduced ejection fraction (HFrEF). This study sought to compare effectiveness of 2 automated, electronic health record–embedded tools vs usual care on MRA prescribing in eligible patients with HFrEF. BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure) was a 3-arm, pragmatic, cluster-randomized trial comparing the effectiveness of an alert during individual patient encounters vs a message about multiple patients between encounters vs usual care on MRA prescribing. This study included adult patients with HFrEF, no active MRA prescription, no contraindication to MRAs, and an outpatient cardiologist in a large health system. Patients were cluster-randomized by cardiologist (60 per arm). The study included 2,211 patients (alert: 755, message: 812, usual care [control]: 644), with average age 72.2 years, average ejection fraction 33%, who were predominantly male (71.4%) and White (68.9%). New MRA prescribing occurred in 29.6% of patients in the alert arm, 15.6% in the message arm, and 11.7% in the control arm. The alert more than doubled MRA prescribing compared to usual care (relative risk: 2.53; 95% CI: 1.77-3.62; P < 0.0001) and improved MRA prescribing compared to the message (relative risk: 1.67; 95% CI: 1.21-2.29 ; P = 0.002). The number of patients with alert needed to result in an additional MRA prescription was 5.6. An automated, patient-specific, electronic health record–embedded alert increased MRA prescribing compared to both a message and usual care. These findings highlight the potential for electronic health record–embedded tools to substantially increase prescription of life-saving therapies for HFrEF. (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations—Heart Failure [BETTER CARE-HF]; NCT05275920) [Display omitted] [ABSTRACT FROM AUTHOR]

Diabetes is a major source of morbidity and mortality in the USA with over 1.5 million new cases diagnosed every year.[1] Diabetes is monitored using hemoglobin A1c (HbA1c) as it correlates with burden of disease.[2]-[4] Clinical practice guidelines recommend HbA1c be repeated every 3 months if a patient's value is above 7%, because a higher HbA1c correlates with worse outcomes.[5]-[9] Complications are particularly high in patients with an HbA1c above 10% and even a 1% reduction in HbA1c can reduce complications by 21%.[5] Thus, while regular monitoring of above-goal HbA1c levels is recommended, ensuring patients with an HbA1c over 10% have timely follow-up testing is especially important. Using this trigger, we found that delayed follow-up HbA1c testing is extremely common among those with poorly controlled diabetes, with 45% of patients with an HbA1c over 10% not receiving follow-up testing within 6 months. The initial numerator, representing patients without an appropriate follow-up HbA1c result, was defined as patients without a follow-up clinic visit within 3 months of the index HbA1c test. [Extracted from the article]

Background: Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence. Objective: This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults. Design: A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019. Participants: Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes. Interventions: A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification. Main Measures: Patient-level CW compliance. Key Results: CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)—16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%). Conclusions: The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics. NIH Trial Registry Number: NCT03409523 [ABSTRACT FROM AUTHOR]

Background: Guidelines recommend coronary artery bypass graft surgery (CABG) over percutaneous coronary intervention (PCI) for multivessel disease and severe left ventricular systolic dysfunction. However, CABG has not been compared with PCI in such patients in randomized trials.Methods and Results: Patients with multivessel disease and severe left ventricular systolic dysfunction (ejection fraction ≤35%) who underwent either PCI with everolimus-eluting stent or CABG were selected from the New York State registries. The primary outcome was long-term all-cause death. Secondary outcomes were individual outcomes of myocardial infarction, stroke, and repeat revascularization. Among the 4616 patients who fulfilled our inclusion criteria (1351 everolimus-eluting stent and 3265 CABG), propensity score matching identified 2126 patients with similar propensity scores. In the short term, PCI was associated with a lower risk of stroke (hazard ratio [HR], 0.05; 95% confidence interval [CI], 0.01-0.39; P=0.004) in comparison with CABG. At long-term follow-up (median, 2.9 years), PCI was associated with a similar risk of death (HR, 1.01; 95% CI, 0.81-1.28; P=0.91), a higher risk of myocardial infarction (HR, 2.16; 95% CI, 1.42-3.28; P=0.0003), a lower risk of stroke (HR, 0.57; 95% CI, 0.33-0.97; P=0.04), and a higher risk of repeat revascularization (HR, 2.54; 95% CI, 1.88-3.44; P<0.0001). The test for interaction was significant (P=0.002) for completeness of revascularization, such that, in patients in whom complete revascularization was achieved with PCI, there was no difference in myocardial infarction between PCI and CABG.Conclusions: Among patients with multivessel disease and severe left ventricular systolic dysfunction, PCI with everolimus-eluting stent had comparable long-term survival in comparison with CABG. PCI was associated with higher risk of myocardial infarction (in those with incomplete revascularization) and repeat revascularization, and CABG was associated with higher risk of stroke. [ABSTRACT FROM AUTHOR]

Background: Randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD).Objectives: This study evaluated outcomes of PCI versus CABG in patients with CKD.Methods: Patients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization.Results: Of 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG.Conclusions: In patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI. [ABSTRACT FROM AUTHOR]

he article discusses research which compared the outcomes of percutaneous coronary intervention (PCI) with everolimus-eluting stents and coronary-artery bypass grafting (CABG) in patients with multivessel coronary artery disease. Topics covered include the primary and secondary outcomes of the study such as the rates of stroke, the association of PCI with a risk of death and the significance of the higher risk of myocardial infarction with PCI among patients with incomplete revascularization.

Background: Reduced low forced expiratory volume in 1 second (FEV1) is reportedly associated with an increased risk of atrial fibrillation (AF). Extant reports do not provide separate estimates for never smokers or for blacks, who incongruously have lower AF incidence than whites.Methods and Results: We examined 15 004 middle-aged blacks and whites enrolled in the Atherosclerosis Risk in Communities (ARIC) cohort study. Standardized spirometry data were collected at the baseline examination. Incident AF was identified from the first among the following: International Classification of Diseases codes for AF on hospital discharge records or death certificates or 12-lead ECGs performed during 3 triennial follow-up visits. Over an average follow-up of 17.5 years, a total of 1691 participants (11%) developed new-onset AF. The rate of incident AF was inversely associated with FEV1 in each of the 4 race and sex groups. After multivariable adjustment for traditional cardiovascular disease risk factors and height, hazard ratios of AF comparing the lowest with the highest quartile of FEV1 were 1.37 (95% confidence interval, 1.02-1.83) for white women, 1.49 (95% confidence interval, 1.16-1.91) for white men, 1.63 (95% confidence interval, 1.00-2.66) for black women, and 2.36 (95% confidence interval, 1.30-4.29) for black men. The above associations were observed across all smoking status categories. Moderate/severe airflow obstruction (FEV1/forced vital capacity <0.70 and FEV1 < 80% of predicted value) was also associated with higher AF incidence.Conclusions: In this large population-based study with a long-term follow-up, reduced FEV1 and obstructive respiratory disease were associated with a higher AF incidence after adjustment for measured confounders. [ABSTRACT FROM AUTHOR]

Background--Reduced low forced expiratory volume in 1 second (FEV1) is reportedly associated with an increased risk of atrial fibrillation (AF). Extant reports do not provide separate estimates for never smokers or for blacks, who incongruously have lower AF incidence than whites. Methods and Results--We examined 15004 middle-aged blacks and whites enrolled in the Atherosclerosis Risk in Communities (ARIC) cohort study. Standardized spirometry data were collected at the baseline examination. Incident AF was identified from the first among the following: International Classification of Diseases codes for AF on hospital discharge records or death certificates or 12-lead ECGs performed during 3 triennial follow-up visits. Over an average follow-up of 17.5 years, a total of 1691 participants (11%) developed new-onset AF. The rate of incident AF was inversely associated with FEV1 in each of the 4 race and sex groups. After multivariable adjustment for traditional cardiovascular disease risk factors and height, hazard ratios of AF comparing the lowest with the highest quartile of FEV1 were 1.37 (95% confidence interval, 1.02-1.83) for white women, 1.49 (95% confidence interval, 1.16-1.91) for white men, 1.63 (95% confidence interval, 1.00-2.66) for black women, and 2.36 (95% confidence interval, 1.30-4.29) for black men. The above associations were observed across all smoking status categories. Moderate/severe airflow obstruction (FEV1 forced vital capacity <0.70 and FEW t < 80% of predicted value) was also associated with higher AF incidence. Conclusions--In this large population-based study with a long-term follow-up, reduced FEV1 and obstructive respiratory disease were associated with a higher AF incidence after adjustment for measured confounders. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between diabetes, glycemic control, and risk of fracture-related hospitalization in the Atherosclerosis Risk in Communities (ARIC) Study.Research Design and Methods: Fracture-related hospitalization was defined using International Classification of Diseases, 9th revision, codes (733.1-733.19, 733.93-733.98, or 800-829). We calculated the incidence rate of fracture-related hospitalization by age and used Cox proportional hazards models to investigate the association of diabetes with risk of fracture after adjustment for demographic, lifestyle, and behavioral risk factors.Results: There were 1,078 incident fracture-related hospitalizations among 15,140 participants during a median of 20 years of follow-up. The overall incidence rate was 4.0 per 1,000 person-years (95% confidence interval [CI], 3.8-4.3). Diagnosed diabetes was significantly and independently associated with an increased risk of fracture (adjusted hazard ratio [HR], 1.74; 95% CI, 1.42-2.14). There also was a significantly increased risk of fracture among persons with diagnosed diabetes who were treated with insulin (HR, 1.87; 95% CI, 1.15-3.05) and among persons with diagnosed diabetes with hemoglobin A1c (HbA1c) ≥8% (1.63; 1.09-2.44) compared with those with HbA1c <8%. Undiagnosed diabetes was not significantly associated with risk of fracture (HR, 1.12; 95% CI, 0.82-1.53).Conclusions: This study supports recommendations from the American Diabetes Association for assessment of fracture risk and implementation of prevention strategies in persons with type 2 diabetes, particularly those persons with poor glucose control. [ABSTRACT FROM AUTHOR]

OBJECTIVE--To examine the association between diabetes, glycemic control, and risk of fracture-related hospitalization in the Atherosclerosis Risk in Communities (ARIC) Study. RESEARCH DESIGN AND METHODS--Fracture-related hospitalization was defined using International Classification of Diseases, 9th revision, codes (733.1-733.19, 733.93- 733.98, or 800-829). We calculated the incidence rate of fracture-related hospitalization by age and used Cox proportional hazards models to investigate the association of diabetes with risk of fracture after adjustment for demographic, lifestyle, and behavioral risk factors. RESULTS--There were 1,078 incident fracture-related hospitalizations among 15,140 participants during a median of 20 years of follow-up. The overall incidence rate was 4.0 per 1,000 person-years (95% confidence interval [CI], 3.8-4.3). Diagnosed diabetes was significantly and independently associated with an increased risk of fracture (adjusted hazard ratio [HR], 1.74; 95% CI, 1.42-2.14). There also was a significantly increased risk of fracture among persons with diagnosed diabetes who were treated with insulin (HR, 1.87; 95% CI, 1.15-3.05) and among persons with diagnosed diabetes with hemoglobin A1c (HbA1c) ≥8% (1.63; 1.09-2.44) compared with those with HbA1c < 8%. Undiagnosed diabetes was not significantly associated with risk of fracture (HR, 1.12; 95% CI, 0.82-1.53). CONCLUSIONS--This study supports recommendations from the American Diabetes Association for assessment of fracture risk and implementation of prevention strategies in persons with type 2 diabetes, particularly those persons with poor glucose control. [ABSTRACT FROM AUTHOR]

Background: Urgent, unplanned hospital readmissions are increasingly being used to gauge the quality of care. We reviewed urgent readmissions to determine which were potentially avoidable and compared rates of all-cause and avoidable readmissions. Methods: In a multicentre, prospective cohort study, we reviewed all urgent readmissions that occurred within six months among patients discharged to the community from 11 teaching and community hospitals between October 2002 and July 2006. Summaries of the readmissions were reviewed by at least four practising physicians using standardized methods to judge whether the readmission was an adverse event (poor clinical outcome due to medical care) and whether the adverse event could have been avoided. We used a latent class model to determine whether the probability that each readmission was truly avoidable exceeded 50%. Results: Of the 4812 patients included in the study, 649 (13.5%, 95% confidence interval [CI] 12.5%-14.5%) had an urgent readmission within six months after discharge. We considered 104 of them (16.0% of those readmitted, 95% CI 13.3%-19.1%; 2.2% of those discharged, 95% CI 1.8%-2.6%) to have had a potentially avoidable readmission. The proportion of patients who had an urgent readmission varied significantly by hospital (range 7.5%- 22.5%; X2 = 92.9, p < 0.001); the proportion of readmissions deemed avoidable did not show significant variation by hospital (range 1.2%- 3.7%; X2 = 12.5, p < 0.25). We found no association between the proportion of patients who had an urgent readmission and the proportion of patients who had an avoidable readmission (Pearson correlation 0.294; p = 0.38). In addition, we found no association between hospital rankings by proportion of patients readmitted and rankings by proportion of patients with an avoidable readmission (Spearman correlation coefficient 0.28, p = 0.41). Interpretation: Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions with a potentially avoidable readmission. [ABSTRACT FROM AUTHOR]

Background: Patients receiving diabetes specialty care experience higher quality care, fewer complications and improved survival; however, access to specialists is limited in medically underserved areas. The Endo ECHO program connects specialists at academic medical centers with PCPs through virtual clinics. We report the comparability of quality measures between Endo ECHO patients and those receiving diabetes specialty care. Methods: Patients with complex diabetes from 10 Endo ECHO clinics in NM completed surveys assessing healthcare quality one year after program enrollment. Patients at the University of New Mexico Diabetes Comprehensive Care Center (DCCC) served as a comparison group and completed the same survey. Results: Five hundred thirty-three ECHO patients and 139 DCCC patients completed surveys. ECHO patients were much less likely to identify English as their primary language (69% ECHO vs. 91% DCCC, p<0.0001) and reported lower levels of educational attainment (40% ECHO with at least some college vs. 60% DCCC, p<0.0001). DCCC patients were more likely to report a positive overall health status (42% ECHO vs. 68% DCCC, p<0.0001), yet there was no difference in overall concern about health across groups. ECHO patients reported more frequent visits to their usual source of diabetes care (72% ECHO with 4 or more annual visits vs. 58% DCCC, p<0.0001). There were no differences in the frequency of A1C testing or feet checks by a provider; however, more DCCC patients reported regular eye exams (69% ECHO vs. 87% DCCC, p<0.0001) and that their provider had assessed smoking status (70% ECHO vs. 82% DCCC, p<0.0001). Conclusions: Endo ECHO patients faced greater medical literacy barriers yet reported similar outcomes for several, but not all, diabetes care quality measures as compared to those reported by patients at the DCCC. Endo ECHO may be a suitable alternative to specialty care for patients in medically underserved areas; ongoing evaluation will determine its impact on clinical outcomes. Disclosure: M.M. Paul: None. A. Davila Saad: None. J. Billings: None. S. Blecker: Advisory Panel; Self; Medtronic. M.F. Bouchonville: None. B. Hager: None. S. Arora: None. C. Berry: None. Funding: The Leona M. and Harry B. Helmsley Charitable Trust [ABSTRACT FROM AUTHOR]

Background: Individuals living with complex diabetes in medically underserved areas face additional barriers to accessing needed services and support. This study used photo elicitation interviews (PEI) to develop a rich understanding of everyday life among individuals with complex diabetes living in such areas of New Mexico (NM). Methods: Five individuals with T1DM and 3 with complex T2DM receiving care through Endo ECHO in NM received digital cameras and the task of taking photographs about their experience of living with diabetes, and then participated in interviews with our team, during which they selected 10 photos from their collections to discuss. Interviews were recorded and transcribed, and then coded using Grounded Theory in an iterative process. Results: Six family-codes emerged: Self-management, health care, support, complications, food, and coping strategies. Three overarching axial codes were identified: Rural living, body self-knowledge, and diabetes burden. A picture of the relentless and never-ending nature of managing diabetes emerged in the analysis. Over half of the photos were of food, both healthy and forbidden; food is an overriding concern, and participants' understanding of healthy food varied greatly. Participants noted important sources of support and optimism, and the joy of activities beyond diabetes care such as online gaming, raising chickens, or hiking. Conclusions: Participants shared their unique perspectives; however, regardless of participants' age, diabetes diagnosis, and gender, they uniformly expressed acute awareness of the permanent burden of their condition, the challenges of self-management, and the need to overcome the barriers of living in medically underserved areas. PEI proved to be a valuable method for ascertaining a deep understanding of individuals' daily experience of living with complex diabetes. Disclosure: M.M. Paul: None. A. Davila Saad: None. M. Tagliaferro: None. J. Billings: None. S. Blecker: Advisory Panel; Self; Medtronic. C. Berry: None. Funding: The Leona M. and Harry B. Helmsley Charitable Trust [ABSTRACT FROM AUTHOR]

Background: Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden. Methods: We will apply a systematic, user-centered design approach to incorporate BE "nudges" into a CDS module and will perform user testing in two "vanguard" sites. To accomplish this, we will conduct (1) semi-structured interviews with key informants (n = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics. Discussion: We hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases. [ABSTRACT FROM AUTHOR]