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In 2016 fee-for-service Medicare began reimbursing physicians for advance care planning conversations with enrollees during outpatient visits and waived the copayment for advance care planning when it was part of the Medicare annual wellness visit. Advance care planning is intended to help providers treat patients in ways consistent with their wishes and may also reduce unnecessary health care use and spending. Examining fee-for-service Medicare claims, we found a substantial increase in outpatient advance care planning claims between 2016 and 2019, although prevalence remained below 7.5 percent for all patient subgroups analyzed. Roughly half of beneficiaries with advance care planning claims received the service at an annual wellness visit; the remainder received it at a different outpatient visit. Among those with claims, Black, Hispanic, and Medicaid dual-eligible patients and patients with comorbidities were less likely to have a claim at an annual wellness visit, largely because they have fewer such visits overall. Medicare's annual wellness visits offer the potential to expand enrollees' access to advance care planning at no expense to them, in advance of serious illness, and to populations less likely to undertake advance care planning generally.

Objective: The aim of this study was to estimate frequency and prevalence of obesity, metabolic syndrome, and diabetes mellitus in US adults., Methods: Data were extracted from the National Health and Nutrition Examination Survey (NHANES; 2003-2004 to 2013-2014) (n = 32,188). The frequency and prevalence of diabetes mellitus, metabolic syndrome, obesity (BMI ≥ 30 kg/m 2 ), and abdominal obesity were calculated and extrapolated to the US adult population. Average levels of high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were also assessed., Results: Mean HDL-C remained constant over the study in men (~48 mg/dL) and women (~58 mg/dL). A downward trend was observed for median TG levels in men (122 mg/dL, 2003-2004; 98 mg/dL, 2013-2014) and women (110 mg/dL, 2003-2004; 90 mg/dL, 2013-2014). The estimated frequency of obesity increased by 20.4 million, and the estimated frequency of diabetes increased by 9 million, affecting 21.2 million (10%) and 30.2 million (13%) US adults, respectively. The estimated frequency (and prevalence) of metabolic syndrome was unchanged at ~50 million (23%)., Conclusions: The frequency and prevalence of key cardiovascular risk factors, particularly diabetes and obesity, continue to increase in US adults and represent a substantial clinical burden. More effective preventive interventions are required to reduce the rising prevalence of obesity and its metabolic sequelae., (© 2019 The Obesity Society.)

Background: Small autopsy studies and clinical practice indicated that carotid atherosclerosis develops in an asymmetrical helical pattern coinciding with regions of low shear stress. We investigated the distribution of carotid atherosclerosis as determined by maximum carotid intima-media thickness (CIMT), to assess if we could confirm this atherosclerotic configuration across various populations with different cardiovascular risk., Methods and Results: We used the individual baseline CIMT data from 3364 subjects from four recent international multicentre randomized controlled trials in which the carotid artery was systematically examined using the same ultrasound protocol and method to quantify CIMT. For each subject, circumferential information on the maximum CIMT of the left and right carotid arteries was obtained for the common carotid, bifurcation, and internal carotid artery segments. In each segment (common, bifurcation, internal), mixed modelling was used to study the differences in CIMT between angles, sides, gender, age, race, and studies. Each segment showed a different circumferential CIMT pattern. In all segments there were statistically significant differences between maximum CIMT across circumferential angles (p < 0.001); on average CIMT was highest in the posteromedial wall of the bifurcation and internal carotid segments and in the anterolateral wall of the common carotid segment. This asymmetric circumferential pattern was found to be identical in men and women, in young and old age, in different race groups, and across the studies., Conclusions: We confirmed the asymmetrical helix-like distribution of atherosclerosis in the carotid arteries and expand the evidence by showing that the atherosclerotic configuration is similar across populations with different vascular risks and across gender, age, and race. This has implications for future design of carotid ultrasound studies, as the angle of insonation is an important predictor of maximum CIMT.

Objective: Carotid intima-media thickness (CIMT) is an index for changes in atherosclerosis burden and changes in CIMT may relate to clinical events. We present baseline data from the METEOR study, a randomized, placebo-controlled trial evaluating the efficacy of rosuvastatin 40 mg on changes in CIMT. We set out to compare differences in CIMT between several subgroups of individuals., Design and Methods: A total of 984 individuals aged 45-70 years (men) or 55-70 (women) were randomized. Participants were required to have: maximum CIMT > or = 1.2-< 3.5 mm; 2+ risk factors and 10-year coronary heart disease (CHD) risk < 10%, or < 2 CHD risk factors. Demographic characteristics were compared in two groups: USA versus Europe, and individuals with maximum CIMT < 2 mm versus those with CIMT > or = 2 mm., Baseline Data: Overall, mean age was 57 years and mean low-density lipoprotein cholesterol was 152 mg/dL (3.9 mmol/L). Body mass index (BMI), triglyceride and high-sensitivity C-reactive protein levels were all higher in US individuals, whereas smoking, hypertension and high-density lipoprotein cholesterol levels were higher in Europeans. Mean CIMT levels were the same in both populations, and the percentage of individuals with > or = 2 CHD risk factors was similar. Increased baseline CIMT (> 2 mm) was related to increasing age, male gender, smoking, hypertension and lipid levels., Conclusions: In this global trial, differences in baseline characteristics between participants from the USA and Europe are apparent. However, a strong association between CIMT and several cardiovascular risk factors was observed across the two continents.