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Housing instability is a key social determinant of health and has been linked to adverse short- and long-term health. Eviction reflects a severe form of housing instability and disproportionately affects minority and women residents in the USA; however, its relationship with mortality has not previously been described.To evaluate the independent association of county-level eviction rates with all-cause mortality in the USA after adjustment for county demographic, socioeconomic, and health-related characteristics.Cross-sectional.Six hundred eighty-six US counties with available 2016 county-level eviction and mortality data.2016 US county-level eviction rate.2016 US county-level age-adjusted all-cause mortality.Among 686 counties (66.1 million residents, 50.5% [49.7-51.2] women, 2% [0.5-11.1] Black race) with available eviction and mortality data in 2016, we observed a significant and graded relationship between county-level eviction rate and all-cause mortality. Counties in the highest eviction tertile demonstrated a greater proportion of residents of Black race and women and a higher prevalence of poverty and comorbid health conditions. After adjustment for county-level sociodemographic traits and prevalent comorbid health conditions, age-adjusted all-cause mortality was highest among counties in the highest eviction tertile (Tertile 3 vs 1 (per 100,000 people) 33.57: 95% CI: 10.5-56.6 p=.004). Consistent results were observed in continuous analysis of eviction, with all-cause mortality increasing by 9.32 deaths per 100,000 people (4.77, 13.89, p.0001) for every 1% increase in eviction rates. Significant interaction in the relationship between eviction and all-cause mortality was observed by the proportion of Black and women residents.In this cross-sectional analysis, county-level eviction rates were significantly associated with all-cause mortality with the strongest effects observed among counties with the highest proportion of Black and women residents. State and federal protections from evictions may help to reduce the health consequences of housing instability and address disparities in health outcomes.

Background: Few empirical data are available to inform older adults’ decisions about whether to screen or continue screening for colorectal cancer based on their prior history of screening, particularly among individuals with a prior negative exam. Methods: Using a retrospective cohort of older adults receiving healthcare at three Kaiser Permanente integrated healthcare systems in Northern California (KPNC), Southern California (KPSC), and Washington (KPWA), we estimated the cumulative risk of colorectal cancer incidence and mortality among older adults who had a negative colonoscopy 10 years earlier, accounting for death from other causes. Results: Screen-eligible adults ages 76 to 85 years who had a negative colonoscopy 10 years earlier were found to be at a low risk of colorectal cancer diagnosis, with a cumulative incidence of 0.39% [95% CI, 0.31%–0.48%) at 2 years that increased to 1.29% (95% CI, 1.02%–1.61%) at 8 years. Cumulative mortality from colorectal cancer was 0.04% (95% CI, 0.02%–0.08%) at 2 years and 0.46% (95% CI, 0.30%–0.70%) at 8 years. Conclusions: These low estimates of cumulative colorectal cancer incidence and mortality occurred in the context of much higher risk of death from other causes. Impact: Knowledge of these results could bear on older adults’ decision to undergo or not undergo further colorectal cancer screening, including choice of modality, should they decide to continue screening. See related commentary by Lieberman, p. 6

Background Continuity of care (CoC) is an important component of health care delivery that can have cost implications and improve patient outcomes. We analysed data obtained from the Department of Veterans Affairs to examine the relationship between CoC and use of image-oriented diagnostic tests in patients with comorbid chronic conditions. Methods A longitudinal, retrospective cohort study involving participants ≥18 years old, with comorbid diabetes and chronic kidney disease. We used a multivariate linear regression model to test whether greater care continuity, measured using a care continuity index (CCI), is associated with less frequent use of diagnostic tests. Results Total of 267,442 patients and 8,142,036 tests were included. Of the diagnostic tests we chose to evaluate, the 4 most frequently ordered tests were X-ray (45.6%), electrocardiogram (EKG, 16.8%), computerized tomography (CT, 13.4%), and magnetic resonance imaging (MRI, 3.4%). Overall, greater CCI was associated with fewer use of tests (P < 0.001). A 1 standard deviation (SD, 0.27) increase in CCI was associated with 4.2% decrease (P < 0.001) in number of tests. But a mixed pattern existed. For X-ray and EKG, greater continuity was associated with less testing, 6.2% (P < 0.001) and 3.3% (P < 0.05) reductions, respectively. Whereas, for CT and MRI, greater continuity was associated with more testing, 2.3% (P < 0.001) and 1.4% increases (P < 0.01), respectively. Conclusion Overall, greater CoC was associated with fewer use of tests, representing a greater presumed efficiency of care. This has implications for designing health care delivery.

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Supplementary Figure 3

DOC file, 30K, Definitions for Categories of Process Failures.

PDF file, 64K, Study Population.

Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers’ perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017–2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40–49, 50–74, and ≥75 years. For patients 50–74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40–49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e.

Supplementary Figure 1

Background: No completed trials have compared carotid artery stenting (CAS) to medical therapy (MT). We examined the effectiveness of CAS compared with MT in patients with asymptomatic carotid stenosis. Methods: We conducted a retrospective cohort study of 219 979 Veterans ≥65 years who received carotid imaging for asymptomatic carotid stenosis between 2005 and 2009 in the US Veterans Health Administration. We constructed a sample of patients who received MT (n=2509) and comparable patients who received CAS (n=551) and followed them for 5 years. Using target trial methodology, we computed weighted Kaplan-Meier curves and estimated the risk of fatal and nonfatal stroke in each group over 5 years of follow-up. We also estimated the cumulative incidence functions for fatal and nonfatal stroke accounting for nonstroke deaths as competing risks. Results: Five hundred fifty-one patients received CAS, and 2509 patients received MT. The observed rate of stroke or death (perioperative complications) within 30 days in the CAS arm was 2.2%. Using the target trial methodology, the 5-year risk of fatal and nonfatal stroke was similar among patients assigned to CAS (6.9%) compared with patients assigned to MT (7.1%; risk difference, −0.1% [95% CI, −2.6% to 2.7%]). In an analysis that incorporated the competing risk of death, the risk difference between the two arms remained nonsignificant (risk difference, −1.5% [95% CI, −3.0% to 0.3%]). Conclusions: In this sample of older male adults, we found no difference between MT and CAS in the treatment of asymptomatic carotid stenosis. Future studies in other settings are needed to confirm these findings.

PDF file - 83K, Statistical details regarding specification of cross-classified logistic models.

Background: To reduce colorectal cancer mortality, positive fecal blood tests must be followed by colonoscopy.Methods: We identified 62,384 individuals ages 50 to 89 years with a positive fecal blood test between January 1, 2011 and December 31, 2012 in four health care systems within the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We estimated the probability of follow-up colonoscopy and 95% confidence intervals (CI) using the Kaplan–Meier method. Overall differences in cumulative incidence of follow-up across health care systems were assessed with the log-rank test. HRs and 95% CIs were estimated from multivariate Cox proportional hazards models.Results: Most patients who received a colonoscopy did so within 6 months of their positive fecal blood test, although follow-up rates varied across health care systems (P Conclusion: Individual characteristics and health care system were associated with colonoscopy after positive fecal blood tests. Patterns were consistent across health care systems, but proportions of patients receiving follow-up varied. These findings suggest that there is room to improve follow-up of positive colorectal cancer screening tests.Impact: Understanding the timing of colonoscopy after positive fecal blood tests and characteristics associated with lack of follow-up may inform future efforts to improve follow-up. Cancer Epidemiol Biomarkers Prev; 25(2); 344–50. ©2016 AACR.

Supplementary Table S1. Characteristics of PROSPR participants with a positive fecal occult blood test with no covariate information missing, 2011-2012 (N=47,827). Supplementary Table S2. Associations between patient characteristics and time to colonoscopy follow-up after positive fecal occult blood test in PROSPR healthcare systems, 2011-2012, over different follow-up periods.

Background: We (i) described variability in colorectal cancer (CRC) test use across multiple levels, including physician, clinic, and neighborhood; and (ii) compared the performance of novel cross-classified models versus traditional hierarchical models.Methods: We examined multilevel variation in CRC test use among patients not up-to-date with screening in a large, urban safety net health system (2011–2012). Outcomes included: (i) fecal occult blood test (FOBT) or (ii) colonoscopy and were ascertained using claims data during a 1-year follow-up. We compared Bayesian (i) cross-classified four-level logistic models nesting patients within separate, nonoverlapping “levels” (physicians, clinics, and census tracts) versus (ii) three hierarchical two-level models using deviance information criterion. Models were adjusted for covariates (patient sociodemographic factors, driving time to clinic, and census tract poverty rate).Results: Of 3,195 patients, 157 (4.9%) completed FOBT and 292 (9.1%) completed colonoscopy during the study year. Patients attended 19 clinics, saw 177 physicians, and resided in 332 census tracts. Significant variability was observed across all levels in both hierarchical and cross-classified models that was unexplained by measured covariates. For colonoscopy, variance was similar across all levels. For FOBT, physicians, followed by clinics, demonstrated the largest variability. Model fit using cross-classified models was superior or similar to 2-level hierarchical models.Conclusions: Significant and substantial variability was observed across neighborhood, physician, and clinic levels in CRC test use, suggesting the importance of factors at each of these levels on CRC testing.Impact: Future multilevel research and intervention should consider the simultaneous influences of multiple levels, including clinic, physician, and neighborhood. Cancer Epidemiol Biomarkers Prev; 23(7); 1346–55. ©2014 AACR.

Background Screening with fecal immunochemical testing (FIT) reduces colorectal cancer mortality; however, screening remains low in underserved populations. Mailed outreach, including an invitation letter, FIT, and test instructions, is an evidence-based strategy to improve screening. Aims To examine screening completion and yield in a mailed outreach program in a safety-net healthcare system. Methods We identified and mailed outreach invitations to patients due for screening in a large safety-net system between September 1, 2018, and August 31, 2019. We examined: (1) screening completion, the proportion of patients completing FIT or screening colonoscopy within 6 months of the mailed invitation; and (2) timely diagnostic colonoscopy, the proportion of patients completing colonoscopy within 6 months of positive FIT. Results We mailed 14,879 invitations to 13,190 patients. Nearly half (n = 6098, 46.2%) of patients completed screening: 4,896 (80.3%) completed FIT through mailed outreach; 1,114 (18.3%) FIT through usual care; and 88 (1.4%) screening colonoscopy through usual care. Of patients with a positive FIT (n = 289), 50.5% completed diagnostic colonoscopy within 6 months, 10.7% within 6–12 months, and 4.8% after 12 months. A total of 8 cancers and 83 advanced adenomas were detected in the 191 patients completing diagnostic colonoscopy. Conclusion After implementing and scaling up mailed outreach in a safety-net system, about half of patients completed screening, and the majority did so through mailed outreach. However, many patients failed to complete diagnostic colonoscopy after positive FIT. Results highlight the importance of adapting mailed outreach programs to local contexts and constraints of healthcare systems, in order to support efforts to improve CRC screening in underserved populations.

Patients with previous cancer are often excluded from clinical trials despite limited evidence about their prognosis. We examined the effect of previous cancer on overall and colorectal cancer (CRC)‐specific survival of patients newly diagnosed with CRC. This population‐based cohort study from the U.S.A. included patients aged ≥66 years and diagnosed with CRC between 2005 and 2015 in linked Surveillance, Epidemiology, and End Results‐Medicare data. We estimated the stage‐specific effects of a previous cancer on overall survival using Cox regression and on CRC‐specific survival using competing risk regression. We also examined the effect of previous cancer type, timing, and stage on overall survival. Of 112,769 patients, 14.1% were previously diagnosed with another cancer––commonly prostate (32.9%) or breast (19.4%) cancer, with many (47.1%) diagnosed, Patients with previous cancer are often excluded from clinical trials despite limited evidence about their prognosis. We examined the effect of previous cancer on overall and colorectal cancer (CRC)‐specific survival of patients newly diagnosed with CRC. Among other findings, we identified that for all CRC stages except IV, in which there was no difference, patients with previous cancer had worse overall survival compared to those without previous cancer.

Background: Cancer screening is a complex process involving multiple steps and levels of influence (e.g., patient, provider, facility, health care system, community, or neighborhood). We describe the design, methods, and research agenda of the Population-based Research to Optimize the Screening Process (PROSPR II) consortium. PROSPR II Research Centers (PRC), and the Coordinating Center aim to identify opportunities to improve screening processes and reduce disparities through investigation of factors affecting cervical, colorectal, and lung cancer screening in U.S. community health care settings. Methods: We collected multilevel, longitudinal cervical, colorectal, and lung cancer screening process data from clinical and administrative sources on >9 million racially and ethnically diverse individuals across 10 heterogeneous health care systems with cohorts beginning January 1, 2010. To facilitate comparisons across organ types and highlight data breadth, we calculated frequencies of multilevel characteristics and volumes of screening and diagnostic tests/procedures and abnormalities. Results: Variations in patient, provider, and facility characteristics reflected the PROSPR II health care systems and differing target populations. PRCs identified incident diagnoses of invasive cancers, in situ cancers, and precancers (invasive: 372 cervical, 24,131 colorectal, 11,205 lung; in situ: 911 colorectal, 32 lung; precancers: 13,838 cervical, 554,499 colorectal). Conclusions: PROSPR II's research agenda aims to advance: (i) conceptualization and measurement of the cancer screening process, its multilevel factors, and quality; (ii) knowledge of cancer disparities; and (iii) evaluation of the COVID-19 pandemic's initial impacts on cancer screening. We invite researchers to collaborate with PROSPR II investigators. Impact: PROSPR II is a valuable data resource for cancer screening researchers.

PURPOSE: Many women diagnosed with breast cancer have survived previous cancer yet little is known about the impact of previous cancer on overall and cancer-specific survival. METHODS: This population-based cohort study using SEER-Medicare data included women (age ≥66 years) diagnosed with breast cancer between 2005–2015. Separately by breast cancer stage, we estimated effect of previous cancer on overall survival using Cox regression and on cause-specific survival using competing risk regression; all survival analyses adjusted for covariates. RESULTS: Of 138,576 women diagnosed with breast cancer, 8% had a previous cancer of another organ site, most commonly colorectal or uterine cancer or melanoma. Many of these women (46.3%) were diagnosed within 5 years of breast cancer. For all breast cancer stages except IV wherein there was no difference, women with vs. without previous cancer had worse overall survival. This survival disadvantage was driven by deaths due to the previous cancer and other causes. In contrast, women with previous cancer generally had favorable breast-cancer specific survival, although this varied by stage. Overall survival varied by previous cancer type, timing, and stage; previous lung cancer, cancer diagnosed within 1 year of incident breast cancer, and previous cancer at a distant stage were associated with the worst survival. In contrast, women with a previous melanoma had equivalent overall survival to women without previous cancer. CONCLUSION: We observed variable impact of previous cancer on overall and breast-cancer specific survival depending on breast cancer stage at diagnosis and the type, timing, and stage of previous cancer.

Background A growing number of women newly diagnosed with breast cancer have survived a previous cancer. Although little is known about their prognosis, this population is frequently excluded from clinical trials. Additional evidence about the survival of this population is needed, so that trial sponsors and investigators can create evidence-based trial eligibility criteria. Among women newly diagnosed with breast cancer, we examined the impact of previous cancer on overall and cancer-specific survival. Methods This population-based cohort study included patients age ≥66 years and diagnosed with breast cancer between 2005-2015 in linked SEER-Medicare data. Separately by breast cancer stage, we estimated overall survival using Cox regression and cause-specific survival using competing risk regression for women with and without previous cancer, adjusting for numerous covariates and competing risk of death from previous cancer, other causes, or the incident breast cancer. Results Of 138,576 women diagnosed with incident breast cancer, 10,822 (8%) had a previous cancer of another organ site. Many of these (n=5,014, 46.3%) were diagnosed ≤5 years of breast cancer. For all breast cancer stages except IV in which there was no significant survival difference, women with vs. without previous cancer had worse overall survival. This survival disadvantage was driven by deaths due to the previous cancer and other causes. In contrast, women with previous cancer generally had favorable breast-cancer specific survival; however this varied somewhat by stage and over time. Conclusions Many women newly diagnosed with breast cancer are already cancer survivors. These women had generally worse overall survival, worse survival from other causes, but their disease-specific survival varied depending on their breast cancer stage and over time. Citation Format: Sandi L Pruitt, Hong Zhu, Daniel Heitjan, David E Gerber, Bhumika Maddineni, Danyi Xiong, Ethan Halm, Caitlin Murphy. Survival among female breast cancer patients who have survived a previous cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS11-31.

Background Accrual to cancer clinical trials is suboptimal. Few data exist regarding whether financial reimbursement might increase accruals. Objective The objective of this study was to assess perceptions about reimbursement to overcome barriers to trial accrual. Research design This was a cross-sectional survey. Subjects Oncologists identified from the American Medical Association Physician Masterfile. Measures We report descriptive statistics, associations of physician characteristics with perceptions of reimbursement, domains, and subthemes of free-text comments. Results Respondents (n=1030) were mostly medical oncologists (59.4%), ages 35-54 (67%), and male (75%). Overall, 30% reported discussing trials with >25% of patients. Barriers perceived were administrative/regulatory, physician/staff time, and eligibility criteria. National Cancer Institute cooperative group participants and practice owners were more likely to endorse higher reimbursement. Respondents indicated targeted reimbursement would help improve infrastructure, but also noted potential ethical problems with reimbursement for discussion (40.7%) and accrual (85.9%). Free-text comments addressed reimbursement sources, recipients, and concerns about the real and apparent conflict of interest. Conclusions Though concerns about a potential conflict of interest remain paramount and must be addressed in any new system of reimbursement, oncologists believe reimbursement to enhance infrastructure could help overcome barriers to trial accrual.

BACKGROUND: Electronic health record (EHR)-based readmission risk prediction models can be automated in real-time but have modest discrimination and may be missing important readmission risk factors. Clinician predictions of readmissions may incorporate information unavailable in the EHR, but the comparative usefulness is unknown. We sought to compare clinicians versus a validated EHR-based prediction model in predicting 30-day hospital readmissions. METHODS: We conducted a prospective survey of internal medicine clinicians in an urban safety-net hospital. Clinicians prospectively predicted patients’ 30-day readmission risk on 5-point Likert scales, subsequently dichotomized into low- vs. high-risk. We compared human with machine predictions using discrimination, net reclassification, and diagnostic test characteristics. Observed readmissions were ascertained from a regional hospitalization database. We also developed and assessed a “human-plus-machine” logistic regression model incorporating both human and machine predictions. RESULTS: We included 1183 hospitalizations from 106 clinicians, with a readmission rate of 20.8%. Both clinicians and the EHR model had similar discrimination (C-statistic 0.66 vs. 0.66, p = 0.91). Clinicians had higher specificity (79.0% vs. 48.9%, p

Background: Given the ubiquity of statin use and prevalence of thyroid diseases, such as thyroid cancer, hyperthyroidism, and thyroiditis, understanding their association deserves further attention. Objective: To examine the association between statin use and thyroid cancer, thyrotoxicosis, goiter, and thyroiditis. Methods: Using Tricare data, 2 propensity score (PS)-matched cohorts of statin users and nonusers were formed: (1) a PS-matched general cohort (all patients aged 30-85 years) and (2) a PS-matched healthy cohort (excluded patients with cardiovascular diseases or severe comorbidities). Outcomes were thyroid cancer, thyrotoxicosis, goiter, and thyroiditis. Odds ratios (ORs) and 95% CIs of outcomes were estimated using conditional regression analysis. Results: Of 43 438 patients, the PS-matched general cohort matched 6342 statin users to 6342 nonusers. The OR of thyroid cancer was 0.62 (95% CI = 0.39-0.996). There was no significant difference between statin users and nonusers in risk of thyrotoxicosis (OR = 0.88; 95% CI = 0.71-1.09), goiter (OR = 0.9; 95% CI = 0.77-1.03), or thyroiditis (OR = 0.78; 95% CI = 0.53-1.15). In the PS-matched healthy cohort (3351 statin users to 3351 nonusers), there was no difference between statin users and nonusers in any outcome. Limitations of the study include its retrospective observational design and use of administrative codes in outcomes ascertainment. Conclusion and Relevance: This study did not demonstrate any association of statins with harmful effects on thyroid diseases, which offers assurance to clinicians and patients. Furthermore, statin use appears to be associated with a decreased risk of thyroid cancer, but more studies are needed.

Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers’ perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017–2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40–49, 50–74, and ≥75 years. For patients 50–74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40–49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e.

Background: Colorectal cancer screening with fecal immunochemical testing (FIT) can reduce colorectal cancer–related mortality. Effectiveness of FIT may be compromised when patients do not adhere to a regular schedule. However, having no standard measure of repeat FIT presents challenges for assessing effectiveness across populations and settings. We compared three measures of repeat FIT in a large, integrated health care system in Dallas, Texas. Methods: We identified 18,257 patients age-eligible (50–60 years) for FIT in January 1–December 31, 2010 and followed over four rounds of screening. Measures included: (i) repeat FIT in prior screeners, or completion of FIT within 9–15 months of the previous; (ii) yes–no patterns, whereby patients were assigned yes or no in 9–15 month windows; and 3) proportion of time covered (PTC), or the amount of time patients were up-to-date with screening relative to time eligible. Results: Repeat FIT varied by measure. Using a prior screeners measure, 15.8% of patients with a normal FIT in round 1 completed repeat FIT in round 2. Repeat FIT was notably higher (52.3%) using PTC. The most common yes–no pattern was YNNN or “one-and-done,” and only 9.4% of patients completed two consecutive FITs across all rounds (YYNN). Conclusions: Different measures of repeat FIT yielded a range of estimates, making comparison across studies difficult. Researchers should weigh the advantages and disadvantages of each measure and select the most appropriate to their research question. Impact: Our study highlights the need for future research of repeat FIT measures that best approximate screening effectiveness.

OBJECTIVE Variation in diabetes screening in clinical practice is poorly described. We examined the interplay of patient, provider, and clinic factors explaining variation in diabetes screening within an integrated health care system in the U.S. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of primary care patients aged 18–64 years with two or more outpatient visits between 2010 and 2015 and no diagnosis of diabetes according to electronic health record (EHR) data. Hierarchical three-level models were used to evaluate multilevel variation in screening at the patient, provider, and clinic levels across 12 clinics. Diabetes screening was defined by a resulted gold standard screening test. RESULTS Of 56,818 patients, 70% completed diabetes screening with a nearly twofold variation across clinics (51–92%; P < 0.001). Of those meeting American Diabetes Association (ADA) (69%) and U.S. Preventive Services Task Force (USPSTF) (36%) screening criteria, three-quarters were screened with a nearly twofold variation across clinics (ADA 53–92%; USPSTF 49–93%). The yield of ADA and USPSTF screening was similar for diabetes (11% vs. 9%) and prediabetes (38% vs. 36%). Nearly 70% of patients not eligible for guideline-based screening were also tested. The USPSTF guideline missed more cases of diabetes (6% vs. 3%) and prediabetes (26% vs. 19%) than the ADA guideline. After adjustment for patient, provider, and clinic factors and accounting for clustering, twofold variation in screening by provider and clinic remained (median odds ratio 1.97; intraclass correlation 0.13). CONCLUSIONS Screening practices vary widely and are only partially explained by patient, provider, and clinic factors available in the EHR. Clinical decision support and system-level interventions are needed to optimize screening practices.

Persons newly diagnosed with pancreas cancer and who have survived a previous cancer are often excluded from clinical trials, despite limited evidence about their prognosis. We examined the association between previous cancer and overall survival.This US population-based cohort study included older adults (aged ≥66 years) diagnosed with pancreas cancer between 2005 and 2015 in the linked Surveillance, Epidemiology, and End Results-Medicare data. We used Cox proportional hazards models to estimate stage-specific effects of previous cancer on overall survival, adjusting for sociodemographic, treatment, and tumor characteristics.Of 32,783 patients, 18.7% were previously diagnosed with another cancer. The most common previous cancers included prostate (29.0%), breast (18.9%), or colorectal (9.7%) cancer. More than half of previous cancers (53.9%) were diagnosed 5 or more years prior to pancreas cancer diagnosis or at an in situ or localized stage (47.8%). The proportions of patients surviving 1, 3, and 5 years after pancreas cancer were nearly identical for those with and without previous cancer. Median survival in months was as follows for those with and without previous cancer respectively: 7 versus 8 (Stage 0/I), 10 versus 10 (Stage II), 7 versus 7 (Stage III), and 3 versus 2 (Stage IV). Cox models indicated that patients with previous cancer had very similar or statistically equivalent survival to those with no previous cancer.Given nearly equivalent survival compared to those without previous cancer, cancer survivors newly diagnosed with pancreas cancer should be considered for inclusion in pancreas cancer clinical trials.

The COVID-19 pandemic has affected clinical services globally, including colorectal cancer (CRC) screening and diagnostic testing. We investigated the pandemic's impact on fecal immunochemical test (FIT) screening, colonoscopy utilization, and colorectal neoplasia detection across 21 medical centers in a large integrated health care organization.We performed a retrospective cohort study in Kaiser Permanente Northern California patients ages 18 to 89 years in 2019 and 2020 and measured changes in the numbers of mailed, completed, and positive FITs; colonoscopies; and cases of colorectal neoplasia detected by colonoscopy in 2020 vs 2019.FIT kit mailings ceased in mid-March through April 2020 but then rebounded and there was an 8.7% increase in kits mailed compared with 2019. With the later mailing of FIT kits, there were 9.0% fewer FITs completed and 10.1% fewer positive tests in 2020 vs 2019. Colonoscopy volumes declined 79.4% in April 2020 compared with April 2019 but recovered to near pre-pandemic volumes in September through December, resulting in a 26.9% decline in total colonoscopies performed in 2020. The number of patients diagnosed by colonoscopy with CRC and advanced adenoma declined by 8.7% and 26.9%, respectively, in 2020 vs 2019.The pandemic led to fewer FIT screenings and colonoscopies in 2020 vs 2019; however, after the lifting of shelter-in-place orders, FIT screenings exceeded, and colonoscopy volumes nearly reached numbers from those same months in 2019. Overall, there was an 8.7% reduction in CRC cases diagnosed by colonoscopy in 2020. These data may help inform the development of strategies for CRC screening and diagnostic testing during future national emergencies.

Hospital readmissions are common, costly, and potentially preventable, including among people with HIV (PWH). We present the results of an evaluation of a multicomponent intervention aimed at reducing 30-day readmissions among PWH.Demographic, socioeconomic, and clinical variables were collected from the electronic health records of PWH or those with cellulitis (control group) hospitalized at an urban safety-net hospital before and after (from September 2012 to December 2016) the implementation of a multidisciplinary HIV transitional care team. After October 2014, hospitalized PWH could receive a medical HIV consultation ± a transitional care nurse intervention. The primary outcome was readmission to any hospital within 30 days of discharge. Multivariate logistic regression and propensity score analyses were conducted to compare readmissions before and after intervention implementation in PWH and people with cellulitis.Overall, among PWH, 329 of the 2049 (16.1%) readmissions occurred before and 329 of the 2023 (16.3%) occurred after the transitional care team intervention. After including clinical and social predictors, the adjusted odds ratio of 30-day readmissions for postintervention for PWH was 0.81 (95% confidence interval: 0.66 to 0.99, P= 0.04), whereas little reduction was identified for those with cellulitis (adjusted odds ratio 0.91 (95% confidence interval: 0.81 to 1.02, P= 0.10). A dose-response effect was not observed for receipt of different HIV intervention components.A multicomponent intervention reduced the adjusted risk of 30-day readmissions in PWH, although no dose-response effect was detected. Additional efforts are needed to reduce overall hospitalizations and readmissions among PWH including increasing HIV prevention, early diagnosis and engagement in care, and expanding the availability and spectrum of transitional care services.

Background Statins increase insulin resistance, which may increase risk of diabetic microvascular complications. Little is known about the impact of statins on renal, ophthalmologic, and neurologic complications of diabetes in practice. The objective of this study was to examine the association of statins with renal disease progression, ophthalmic manifestations, and neurological manifestations in diabetes. Methods This is a retrospective cohort study, new-user active comparator design, that included a national Veterans Health Administration (VA) patients with diabetes from 2003 to 2015. Patients were age 30 years or older and were regular users of the VA with data encompassing clinical encounters, demographics, vital signs, laboratory tests, and medications. Patients were divided into statin users or nonusers (active comparators). Statin users initiated statins and nonusers initiated H2-blockers or proton pump-inhibitors (H2-PPI) as an active comparator. Study outcomes were: 1) Composite renal disease progression outcome; 2) Incident diabetes with ophthalmic manifestations; and 3) Incident diabetes with neurological manifestations. Results Out of 705,774 eligible patients, we propensity score matched 81,146 pairs of statin users and active comparators. Over a mean (standard deviation) of follow up duration of 4.8 (3) years, renal disease progression occurred in 9.5% of statin users vs 8.3% of nonusers (odds ratio [OR]: 1.16; 95% confidence interval [95%CI]: 1.12–1.20), incident ophthalmic manifestations in 2.7% of statin users vs 2.0% of nonusers (OR: 1.35, 95%CI:1.27–1.44), and incident neurological manifestations in 6.7% of statin users vs 5.7% of nonusers (OR: 1.19, 95%CI:1.15–1.25). Secondary, sensitivity, and post-hoc analyses were consistent and demonstrated highest risks among the healthier subgroup and those with intensive lowering of LDL-cholesterol. Conclusions Statin use in patients with diabetes was associated with modestly higher risk of renal disease progression, incident ophthalmic, and neurological manifestations. More research is needed to assess the overall harm/benefit balance for statins in the lower risk populations with diabetes and those who receive intensive statin therapy.

Objective To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain. Methods We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting. Results Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format. Conclusions Decision aids may improve patients’ knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options.