A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions.

BACKGROUND: Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress. METHODS AND FINDINGS: To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, 'other'). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary. CONCLUSIONS: Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

Differences in primary cardiovascular disease prevention between the 2013 and 2016 cholesterol guidelines and impact of the 2017 hypertension guideline in the United States.

The US Preventive Services Task Force cholesterol guideline recommended statins for fewer adults than the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline by setting a higher 10-year atherosclerotic cardiovascular disease threshold (≥10.0% vs ≥7.5%) and requiring concomitant diabetes mellitus, hypertension, dyslipidemia, or cigarette smoking. The 2017 ACC/AHA hypertension guideline lowered the hypertension threshold, increasing 2016 guideline statin-eligible adults. Cross-sectional data on US adults aged 40 to 75 years enabled estimated numbers for the 2013 guideline and 2016 guideline with hypertension thresholds of ≥140/≥90 mm Hg and ≥130/80 mm Hg, respectively, on: (1) untreated, statin-eligible adults for primary atherosclerotic cardiovascular disease prevention (25.40, 14.72, 15.35 million); (2) atherosclerotic cardiovascular disease events prevented annually (124 000, 70 852, 73 199); (3) number needed to treat (21, 21, 21); and (4) number needed to harm (38, 143, 143) per 1000 patient-years for incident diabetes mellitus (42 800, 6700, 7100 cases per year). Despite the lower hypertension threshold, the 2013 cholesterol guideline qualifies approximately 10 million more adults for statins and prevents approximately 50 600 more primary atherosclerotic cardiovascular disease events but induces approximately 35 700 more diabetes mellitus cases annually than the 2016 guideline.

Cholesterol Control Among Uninsured Adults Did Not Improve From 2001-2004 to 2009-2012 as Disparities With Both Publicly and Privately Insured Adults Doubled.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) control is higher among insured than uninsured adults, but data on time trends and contributing factors are incomplete and important for improving health equity. METHODS AND RESULTS: Awareness, treatment, and control of elevated LDL-C were compared among insured versus uninsured and publicly versus privately insured adults, aged 21 to 64 years, in National Health and Nutrition Examination Surveys from 2001 to 2004, 2005 to 2008, and 2009 to 2012 using Adult Treatment Panel-3 criteria. Compared with insured adults, uninsured adults were younger; were more often minority; reported lower incomes, less education, and fewer healthcare encounters; and had lower awareness and treatment of elevated LDL-C (P<0.0001). LDL-C control was higher among insured than uninsured adults in 2001 to 2004 (mean±SEM, 21.4±1.6% versus 10.5±2.6%; P<0.01), and the gap widened by 2009 to 2012 (35.1±1.9% versus 11.3±2.2%; P<0.0001). Despite more minorities (P<0.01), greater poverty, and less education (P<0.001), publicly insured adults had more healthcare visits/year than privately insured adults (P<0.001) and similar awareness, treatment, and control of LDL-C from 2001 to 2012. In multivariable logistic regression, significant positive predictors of cholesterol awareness, treatment, and control included more frequent health care (strongest), increasing age, private healthcare insurance versus uninsured, and hypertension. Public insurance (versus uninsured) was a significant positive predictor of LDL-C control, whereas income <200% versus ≥200% of federal poverty was a significant negative predictor. CONCLUSIONS: LDL-C control improved similarly over time in publicly and privately insured adults but was stagnant among the uninsured. Healthcare insurance largely addresses socioeconomic barriers to effective LDL-C management, yet poverty retains an independent adverse effect.

Opportunities for improving cardiovascular health outcomes in adults younger than 65 years with guideline-recommended statin therapy.

The impact of age, race/ethnicity, healthcare insurance, and selected clinical variables on statin-preventable ASCVD were quantified in adults aged 21 to 79 years from National Health and Nutrition Examination Surveys 2007-2012 using the 2013 American College of Cardiology/American Heart Association guideline on the treatment of cholesterol. Among ≈42.4 million statin-eligible, untreated adults, 52.6% were hypertensive and 71% were younger than 65 years. Of ≈232 000 statin-preventable ASCVD events annually, most occur in individuals younger than 65 years, with higher proportions in blacks and Hispanics than whites (73.0% and 69.2% vs 56.9%, respectively; P<.01). Among adults younger than 65 years, the ratio of statin-eligible but untreated to statin-treated adults was higher in blacks and Hispanics than whites (3.0 and 2.9 vs 1.3, respectively; P<.01), and blacks, men, hypertensives, and cigarette smokers were more likely to be statin eligible than their statin-ineligible counterparts by multivariable logistic regression. Two thirds of untreated statin-eligible adults had two or more healthcare visits per year. Identifying and treating more statin-eligible adults in the healthcare system could improve cardiovascular health equity.

Low Blood Pressure Is Associated With Greater Risk for Cardiovascular Events in Treated Adults With and Without Apparent Treatment-Resistant Hypertension.

Apparent treatment-resistant hypertension (aTRH) may confound the reported relationship between low blood pressure (BP) and increased cardiovascular disease (CVD) in treated hypertensive patients. Incident CVD was assessed in treated hypertensive patients with and without aTRH (BP ≥140 and/or ≥90 mm Hg on ≥3 medications or <140/<90 mm Hg on ≥4 BP medications) at three BP levels: 1: <120 and/or <70 mm Hg and <140/<90 mm Hg; 2: 120-139/70-89 mm Hg; and 3: ≥140 and/or ≥90 mm Hg. Electronic health data were matched to emergency and hospital claims for incident CVD in 118 356 treated hypertensive patients. In adults with and without aTRH, respectively, CVD was greater in level 1 versus level 2 (multivariable hazard ratio, 1.88 [95% confidence interval [CI], 1.70-2.07]; 1.71 [95% CI, 1.59-1.84]), intermediate in level 1 versus level 3 (hazard ratio, 1.32 [95% CI, 1.21-1.44]; 0.99, [95% CI, 0.92-1.07]), and lowest in level 2 versus level 3 (hazard ratio, 0.70 [95% CI, 0.65-0.76]; 0.58, [95% CI, 0.54-0.62]). Low treated BP was associated with more CVD than less stringent BP control irrespective of aTRH.

2013 ACC/AHA Cholesterol Guideline and Implications for Healthy People 2020 Cardiovascular Disease Prevention Goals.

BACKGROUND: Healthy People 2020 aim to reduce fatal atherosclerotic cardiovascular disease (ASCVD) by 20%, which translates into 310 000 fewer events annually assuming proportional reduction in fatal and nonfatal ASCVD. We estimated preventable ASCVD events by implementing the American College of Cardiology/American Heart Association (ACC/AHA) 2013 Cholesterol Guideline in all statin-eligible adults. Absolute risk reduction (ARR) and number needed-to-treat (NNT) were calculated. METHODS AND RESULTS: National Health and Nutrition Examination Survey data for 2007-2012 were analyzed for adults aged 21 to 79 years and extrapolated to the US population. Literature-guided assumptions were used including (1) low-density lipoprotein cholesterol falls 33% with moderate-intensity statins and 51% with high-intensity statins; (2) for each 39 mg/dL decline in low-density lipoprotein cholesterol, 10-year ASCVD10 risk would fall 21% when ASCVD10 risk was ≥20% and 33% when ASCVD10 risk was <20%; and (3) either all statin-eligible untreated adults or all with ASCVD10 risk ≥7.5% would receive statins. Of 175.9 million adults aged 21 to 79 years not taking statins, 44.8 million (25.5%) were statin eligible. Treating all statin-eligible adults would prevent an estimated 243 589 ASCVD events annually (ARR 5.4%, 10-year NNT 18). Treating all statin-eligible adults with ASCVD10 risk ≥7.5% reduces the number treated to 32.2 million (28.2% fewer), whereas ASCVD events prevented annually fall only 10.5% to 217 974 (6.8% ARR, NNT 15). CONCLUSIONS: Implementing the ACC/AHA 2013 Cholesterol Guideline in all untreated, statin-eligible adults could achieve ≈78% of the Healthy People 2020 ASCVD prevention goal. Most of the benefit is attained by individuals with 10-year ASCVD risk ≥7.5%.

Blood Pressure Control Provides Less Cardiovascular Protection in Adults With Than Without Apparent Treatment-Resistant Hypertension.

Hypertension control may offer less protection from incident cardiovascular disease (CVDi ) in adults with than without apparent treatment-resistant hypertension (aTRH), ie, blood pressure uncontrolled while taking three or more antihypertensive medications or controlled to <140/<90 mm Hg while taking four or more antihypertensive medications. Electronic health data were matched to health claims for 2006-2012. Patients with CVDi in 2006-2007 or with untreated hypertension were excluded, leaving 118,356 treated hypertensives, including 40,690 with aTRH, and 460,599 observation years. Blood pressure and medication number were determined by all clinic visit means from 2008 to CVDi or end of study. Primary outcome was first CVDi (stroke, coronary heart disease, heart failure) from hospital and emergency department claims. Controlling for age, race, sex, diabetes, chronic kidney disease, and statin use, hypertension control afforded less CVDi protection in patients with aTRH (hazard ratio, 0.87; 95% confidence interval, 0.82-0.93) than without aTRH (hazard ratio, 0.69; 95% confidence interval, 0.65-0.74; P<.001). Strategies beyond hypertension control may prevent more CVDi in patients with aTRH.

Comparative impact of implementing the 2013 or 2014 cholesterol guideline on vascular events in a quality improvement network.

OBJECTIVES: The Quality and Care Model Committee for a clinically integrated network requested a comparative analysis on the projected cardiovascular benefits of implementing either the 2013 and 2014 cholesterol guideline in a South Carolina patient population. A secondary request was to assess the relative risk of the two guidelines based on the literature. METHODS: Electronic health data were obtained on 1,580,860 adults aged 21-80 years who had had one or more visits from January 2013 to June 2015; 566,688 had data to calculate 10-year atherosclerotic cardiovascular disease (ASCVD10) risk. Adults with end-stage renal disease (n = 7852), congestive heart failure (n = 19,818), alcohol or drug abuse (n = 68,547), or currently on statins (n = 154,964) were excluded leaving 315,508 for analysis. Estimated reduction in ASCVD10 assumed that: (a) moderate-intensity statins lowered low-density lipoprotein cholesterol (LDL-C) by 35% and high-intensity statins by 50%; (b) ASCVD events declined 22% for each 1 mmol/l fall in LDL-C. RESULTS: Among the 315,508 adults in the analysis, 131,289 (41.6%) were eligible for statins according to the 2013 guideline and 137,375 (43.5%) to the 2014 guideline. The 2013 and 2014 guidelines were estimated to prevent 6780 and 5915 ASCVD events over 10 years with: (a) relative risk reductions of 29.0% and 21.8%; (b) absolute risk reductions of 5.2% and 4.3%; (c) number needed-to-treat (NNT) of 19 and 23, respectively. The greater projected cardiovascular protection with the 2013 guideline was largely related to greater use of high-dose statins, which carry a greater risk for adverse events. The literature indicates that the NNT for benefit with high-intensity versus moderate-intensity statins is 31 in high-risk patients with a number needed-to-harm of 47. CONCLUSIONS: The 2013 guideline is projected to prevent more clinical ASCVD events and with lower NNTs than the 2014 guideline, yet both have substantial benefit. The 2013 guideline is also expected to generate more adverse events, but the risk-benefit profile appears favor .

Impact of Implementing the 2013 ACC/AHA Cholesterol Guidelines on Vascular Events in a Statewide Community-Based Practice Registry.

Electronic health record data were analyzed to estimate the number of statin-eligible adults with the 2013 American College of Cardiology/American Heart Association cholesterol guidelines not taking statin therapy and the impact of recommended statin therapy on 10-year atherosclerotic cardiovascular disease (ASCVD10 ) events. Adults aged 21 to 80 years in an outpatient network with ≥1 clinic visit(s) from January 2011 to June 2014 with data to calculate ASCVD10 were eligible. Moderate-intensity statin therapy was assumed to lower low-density lipoprotein cholesterol by 30% and high-intensity therapy was assumed to reduce low-density lipoprotein cholesterol by 50%. ASCVD events were assumed to decline 22% for each 39 mg/dL decline in low-density lipoprotein cholesterol. Among 411,768 adults, 260,434 (63.2%) were not taking statins and 103,478 (39.7%) were eligible for a statin, including 79,069 (76.4%) patients with hypertension. Estimated ASCVD10 events were 18,781 without and 13,328 with statin therapy, a 29.0% relative and 5.3% absolute risk reduction with a number needed to treat of 19. The 2013 cholesterol guidelines are a relatively efficient approach to reducing ASCVD in untreated, statin-eligible adults who often have concomitant hypertension.

The growing gap in hypertension control between insured and uninsured adults: National Health and Nutrition Examination Survey 1988 to 2010.

Hypertension awareness, treatment, and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 data in adults aged 18 to 64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988 to 1994 to 17.4% in 2005 to 2010. In 1988 to 1994, hypertension awareness, treatment, and control to <140/<90 mm Hg (30.1% versus 26.5%; P=0.27) were similar in insured and uninsured adults. By 2005 to 2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%; P<0.001) was explained approximately equally by lower awareness (65.2% versus 80.7%), fewer aware adults treated (75.2% versus 88.5%), and fewer treated adults controlled (63.1% versus 73.5%; all P<0.001). Publicly insured and uninsured adults had similar income. Yet, hypertension control was similar across time periods in publicly and privately insured adults, despite lower income and education in the former. In multivariable analysis, hypertension control in 2005 to 2010 was associated with visit frequency (odds ratio, 3.4 [95% confidence interval, 2.4-4.8]), statin therapy (1.8 [1.4-2.3]), and healthcare insurance (1.6 [1.2-2.2]) but not poverty index (1.04 [0.96-1.12]). Public or private insurance linked to more frequent healthcare, greater awareness and effective treatment of hypertension, and appropriate statin use could reverse a long-term trend of growing inequity in hypertension control between insured and uninsured adults.

Diabetes and age-related demographic differences in risk factor control.

Disparate vascular outcomes in diabetes by race and/or ethnicity may reflect differential risk factor control, especially pre-Medicare. Assess concurrent target attainment for glycohemoglobin <7%, non-high density lipoprotein-cholesterol <130 mg/dL, and blood pressure <140/<90 mm Hg in white, black, and Hispanic diabetics <65 years and ≥65 years of age. The National Health and Nutrition Examination Surveys 1999-2010 data were analyzed on diagnosed and undiagnosed diabetics ≥18 years old. Concurrent target attainment was higher in whites (18.7%) than blacks (13.4% [P = .02] and Hispanics [10.3%, P < .001] <65 years but not ≥65 years of age; 20.0% vs. 15.9% [P = .13], 19.5% [P = .88]). Disparities in health care insurance among younger whites, blacks, and Hispanics, respectively, (87.4% vs. 81.1%, P < .01; 68.0%, P < .001) and infrequent health care (0-1 visits/y; 14.3% vs. 15.0%, P = not significant; 32.0%, P < .001) declined with age. Cholesterol treatment predicted concurrent control in both age groups (multivariable odds ratio >2, P < .001). Risk factor awareness and treatment were lower in Hispanics than whites. When treated, diabetes and hypertension control were greater in whites than blacks or Hispanics. Concurrent risk factor control is low in all diabetics and could improve with greater statin use. Insuring younger adults, especially Hispanic, could raise risk factor awareness and treatment. Improving treatment effectiveness in younger black and Hispanic diabetics could promote equitable risk factor control.

Closing the gap in hypertension control between younger and older adults: National Health and Nutrition Examination Survey (NHANES) 1988 to 2010.

BACKGROUND: Joint National Committee goal blood pressure for all adults was <140/<90 mm Hg or lower from 1984 to 2013. Adults aged ≥60 years (older) have mainly isolated systolic hypertension, with major trials attaining systolic blood pressure <150 but not <140 mm Hg. The main objective was to assess changes in hypertension control to <140/<90 mm Hg in younger (aged <60 years) and older adults and <150/<90 mm Hg in the latter. METHODS AND RESULTS: National Health and Nutrition Examination Surveys (NHANES) 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed in adults aged ≥18 years. From 1988 to 1994 to 2005 to 2010, hypertension control to <140/<90 mm Hg improved in older (31.6% to 53.1%; P<0.001) and younger (45.7% to 55.9%; P<0.001) patients. The age gap in control declined from 14.1% (P<0.01) in 1988 to 1994 to 2.8% (P=0.13) in 2005 to 2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger (56.8% to 73.4%) patients controlled (all P<0.001). Control to <150/<90 mm Hg rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but increased more in older patients (P<0.01). Blood pressure control was higher in both age groups with ≥2 healthcare visits per year and on statin therapy. CONCLUSIONS: The age gap in hypertension control to <140/<90 mm Hg was virtually eliminated in 2005 to 2010 as clinicians intensified therapy, especially in older patients in whom isolated systolic hypertension predominates, controlling 70% to <150/<90 mm Hg. More frequent healthcare visits and the use of statin therapy may improve hypertension control in all adults.