Disagreement between pharmacy claims and direct interview to identify patients with non-adherence to chronic cardiometabolic medications.

BACKGROUND: Accurate methods of identifying patients with suboptimal adherence to cardiometabolic medications are needed, and each approach has benefits and tradeoffs. METHODS: We used data from a large trial of patients with poorly controlled cardiometabolic disease and evidence of medication non-adherence measured using pharmacy claims data whose adherence was subsequently assessed during a telephone consultation with a clinical pharmacist. We then evaluated if the pharmacist assessment agreed with the non-adherence measured using claims. When pharmacist and claims assessments disagreed, we identified reasons why claims were insufficient and used multivariable modified Poisson regression to identify patient characteristics associated with disagreement. RESULTS: Of 1,069 patients identified as non-adherent using claims (proportion of days covered [PDC] <80%), 646 (60.4%) were confirmed as non-adherent on pharmacist interview. For the 423 patients (39.6%) where the interview disagreed with the claims, the most common reasons were paying cash or using an alternate insurance (36.6%), medication discontinuation or regimen change (32.8%), and recently becoming adherent (26.7%). Compared to patients whose claims and interview both showed non-adherence, patients whose interview disagreed with claims were less likely to miss outpatient office visits (RR:0.91, 95%CI:0.85-0.97) and more likely to have a baseline PDC above the median (RR:1.35, 95%CI:1.10-1.64). CONCLUSIONS: Among patients identified as non-adherent by claims, 39.6% were observed to be adherent when assessed during pharmacist consultation. This discrepancy was largely driven by paying out-of-pocket, using alternative insurance, or medication discontinuation or change. These findings have important implications for using pharmacy claims to identify and intervene upon medication non-adherence.

The Indian Health Service and American Indian/Alaska Native Health Outcomes.

The Indian Health Service (IHS) has made huge strides in narrowing health disparities between American Indian and Alaska Native (AI/AN) populations and other racial and ethnic groups. Yet, health disparities experienced by AI/AN people persist, with deep historical roots combined with present-day challenges. Here we review the history of the IHS from colonization to the present-day system, highlight persistent disparities in AI/AN health and health care, and discuss six key present-day challenges: inadequate funding, limited human resources, challenges associated with transitioning services from federal to Tribal control through contracting and compacting, evolving federal and state programs, the need for culturally sensitive services, and the promise and challenges of health technology.

Association Between Cost-Saving Prescription Policy Changes and Adherence to Chronic Disease Medications: an Observational Study.

BACKGROUND: Pharmacy benefit design is one tool for improving access and adherence to medications for the management of chronic disease. OBJECTIVE: We assessed the effects of pharmacy benefit design programs, including a change in pharmacy benefit manager (PBM), institution of a prescription out-of-pocket maximum, and a mandated switch to 90 days' medication supply, on adherence to chronic disease medications over time. DESIGN: We used a difference-in-differences design to assess changes in adherence to chronic disease medications after the transition to new prescription policies. SUBJECTS: We utilized claims data from adults aged 18-64, on ≥ 1 medication for chronic disease, whose insurer instituted the prescription policies (intervention group) and a propensity score-matched comparison group from the same region. MAIN MEASURES: The outcome of interest was adherence to chronic disease medications measured by proportion of days covered (PDC) using pharmacy claims. KEY RESULTS: There were 13,798 individuals in each group after propensity score matching. Compared to the matched control group, adherence in the intervention group decreased in the first quarter of 2015 and then increased back to pre-intervention trends. Specifically, the change in adherence compared to the last quarter of 2014 in the intervention group versus controls was - 3.6 percentage points (pp) in 2015 Q1 (p < 0.001), 0.65 pp in Q2 (p = 0.024), 1.1 pp in Q3 (p < 0.001), and 1.4 pp in Q4 (p < 0.001). CONCLUSIONS: In this cohort of commercially insured adults on medications for chronic disease, a change in PBM accompanied by a prescription out-of-pocket maximum and change to 90 days' supply was associated with short-term disruptions in adherence followed by return to pre-intervention trends. A small improvement in adherence over the year of follow-up may not be clinically significant. These findings have important implications for employers, insurers, or health systems wishing to utilize pharmacy benefit design to improve management of chronic disease.

Trends in buprenorphine treatment disparities during the COVID pandemic in Massachusetts.

Background: Racial, sex, and age disparities in buprenorphine treatment have previously been demonstrated. We evaluated trends in buprenorphine treatment disparities before and after the onset of the COVID pandemic in Massachusetts. Methods: This cross-sectional study used data from an integrated health system comparing 12-months before and after the March 2020 Massachusetts COVID state of emergency declaration, excluding March as a washout period. Among patients with a clinical encounter during the study periods with a diagnosis of opioid use disorder or opioid poisoning, we extracted outpatient buprenorphine prescription rates by age, sex, race and ethnicity, and language. Generating univariable and multivariable Poisson regression models, we calculated the probability of receiving buprenorphine. Results: Among 4,530 patients seen in the period before the COVID emergency declaration, 57.9% received buprenorphine. Among 3,653 patients seen in the second time period, 55.1% received buprenorphine. Younger patients (<24) had a lower likelihood of receiving buprenorphine in both time periods (adjusted prevalence ratio (aPR), 0.56; 95% CI, 0.42-0.75 before vs. aPR, 0.76; 95% CI, 0.60-0.96 after). Male patients had a greater likelihood of receiving buprenorphine compared to female patients in both time periods (aPR: 1.05; 95% CI, 1.00-1.11 vs. aPR: 1.09; 95% CI, 1.02-1.16). Racial disparities emerged in the time period following the COVID pandemic, with non-Hispanic Black patients having a lower likelihood of receiving buprenorphine compared to non-Hispanic white patients in the second time period (aPR, 0.85; 95% CI, 0.72-0.99). Conclusions: Following the onset of the COVID pandemic in Massachusetts, ongoing racial, age, and gender disparities were evident in buprenorphine treatment with younger, Black, and female patients less likely to be treated with buprenorphine across an integrated health system.

Comparison of a new 3-item self-reported measure of adherence to medication with pharmacy claims data in patients with cardiometabolic disease.

BACKGROUND: Less than half of patients with cardiometabolic disease consistently take prescribed medications. While health insurers and some delivery organizations use claims to measure adherence, most clinicians do not have access during routine interactions. Self-reported scales exist, but their practical utility is often limited by length or cost. By contrast, the accuracy of a new 3-item self-reported measure has been demonstrated in individuals with HIV. We evaluated its concordance with claims-based adherence measures in cardiometabolic disease. METHODS: We used data from a recently-completed pragmatic trial of patients with cardiometabolic conditions. After 12 months of follow-up, intervention subjects were mailed a survey with the 3-item measure that queries about medication use in the prior 30 days. Responses were linearly transformed and averaged. Adherence was also measured in claims in month 12 and months 1-12 of the trial using proportion of days covered (PDC) metrics. We compared validation metrics for non-adherence for self-report (average <0.80) compared with claims (PDC <0.80). RESULTS: Of 459 patients returning the survey (response rate: 43.5%), 50.1% were non-adherent in claims in month 12 while 20.9% were non-adherent based on the survey. Specificity of the 3-item metric for non-adherence was high (month 12: 0.83). Sensitivity was relatively poor (month 12: 0.25). Month 12 positive and negative predictive values were 0.59 and 0.52, respectively. CONCLUSIONS: A 3-item self-reported measure has high specificity but poor sensitivity for non-adherence versus claims in cardiometabolic disease. Despite this, the tool could help target those needing adherence support, particularly in the absence of claims data.

Development of an electronic health record-based chronic kidney disease registry to promote population health management.

BACKGROUND: Electronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners Healthcare System (PHS), encompassing multiple academic and community hospitals and outpatient care facilities in Massachusetts, developed an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care. METHODS: Patients are included in the registry based on the following criteria: 1) two estimated glomerular filtration rate (eGFR) results < 60 ml/min/1.73m2 separated by 90 days, including the most recent eGFR being < 60 ml/min/1.73m2; or 2) the most recent two urine protein values > 300 mg protein/g creatinine on either urine total protein/creatinine ratio or urine albumin/creatinine ratio; or 3) an EHR problem list diagnosis of end stage renal disease (ESRD). The registry categorizes patients by CKD stage and includes rates of annual testing for eGFR and proteinuria, blood pressure control, use of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), nephrotoxic medication use, hepatitis B virus (HBV) immunization, vascular access placement, transplant status, CKD progression risk; number of outpatient nephrology visits, and hospitalizations. RESULTS: The CKD registry includes 60,503 patients and has revealed several opportunities for care improvement including 1) annual proteinuria testing performed for 17% (stage 3) and 31% (stage 4) of patients; 2) ACE-I/ARB used in 41% (stage 3) and 46% (stage 4) of patients; 3) nephrotoxic medications used among 23% of stage 4 patients; and 4) 89% of stage 4 patients lack HBV immunity. For advanced CKD patients there are opportunities to improve vascular access placement, transplant referrals and outpatient nephrology contact. CONCLUSIONS: A CKD registry can identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation. No linkage to Social Security Death Master File or US Renal Data System (USRDS) databases limits our ability to track mortality and progression to ESRD.

Choosing wisely--the politics and economics of labeling low-value services.

More than 40 medical specialties have identified "Choosing Wisely" lists of five overused or low-value services. But these services vary widely in potential impact on care and spending, and specialty societies often name other specialties' services as low value.

Physician and Patient Views on Public Physician Rating Websites: A Cross-Sectional Study.

BACKGROUND: Numerical ratings and narrative comments about physicians are increasingly available online. These physician rating websites include independent websites reporting crowd-sourced data from online users and health systems reporting data from their internal patient experience surveys. OBJECTIVE: To assess patient and physician views on physician rating websites. DESIGN: Cross-sectional physician (electronic) and patient (paper) surveys conducted in August 2015. PARTICIPANTS: Eight hundred twenty-eight physicians (response rate 43%) affiliated with one of four hospitals in a large accountable care organization in eastern Massachusetts; 494 adult patients (response rate 34%) who received care in this system in May 2015. MAIN MEASURES: Use and perceptions of physician rating websites. KEY RESULTS: Fifty-three percent of physicians and 39% of patients reported visiting a physician rating website at least once. Physicians reported higher levels of agreement with the accuracy of numerical data (53%) and narrative comments (62%) from health system patient experience surveys compared to numerical data (36%) and narrative comments (36%) on independent websites. Patients reported higher levels of agreement with trusting the accuracy of data obtained from independent websites (57%) compared to health system patient experience surveys (45%). Twenty-one percent of physicians and 51% of patients supported posting narrative comments online for all consumers. The majority (78%) of physicians believed that posting narrative comments online would increase physician job stress; smaller proportions perceived a negative effect on the physician-patient relationship (46%), health care overuse (34%), and patient-reported experiences of care (33%). Over one-fourth of patients (29%) believed that posting narrative comments would cause them to be less open. CONCLUSIONS: Physicians and patients have different views on whether independent or health system physician rating websites are the more reliable source of information. Their views on whether such data should be shared on public websites are also discordant.

How Primary Care Physicians Integrate Price Information into Clinical Decision-Making.

BACKGROUND: Little is known about how primary care physicians (PCPs) in routine outpatient practice use paid price information (i.e., the amount that insurers finally pay providers) in daily clinical practice. OBJECTIVE: To describe the experiences of PCPs who have had paid price information on tests and procedures for at least 1 year. DESIGN: Cross-sectional study using semi-structured interviews and the constant comparative method of qualitative analysis. PARTICIPANTS: Forty-six PCPs within an accountable care organization. INTERVENTION: Via the ordering screen of their electronic health record, PCPs were presented with the median paid price for commonly ordered tests and procedures (e.g., blood tests, x-rays, CTs, MRIs). APPROACH: We asked PCPs for (a) their "gut reaction" to having paid price information, (b) the situations in which they used price information in clinical decision-making separate from or jointly with patients, (c) their thoughts on who bore the chief responsibility for discussing price information with patients, and (d) suggestions for improving physician-targeted price information interventions. KEY RESULTS: Among "gut reactions" that ranged from positive to negative, all PCPs were more interested in having patient-specific price information than paid prices from the practice perspective. PCPs described that when patients' out-of-pocket spending concerns were revealed, price information helped them engage patients in conversations about how to alter treatment plans to make them more affordable. PCPs stated that having price information only slightly altered their test-ordering patterns and that they avoided mentioning prices when advising patients against unnecessary testing. Most PCPs asserted that physicians bear the chief responsibility for discussing prices with patients because of their clinical knowledge and relationships with patients. They wished for help from patients, practices, health plans, and society in order to support price transparency in healthcare. CONCLUSIONS: Physician-targeted price transparency efforts may provide PCPs with the information they need to respond to patients' concerns regarding out-of-pocket affordability rather than that needed to change test-ordering habits.

A Randomized Trial of Displaying Paid Price Information on Imaging Study and Procedure Ordering Rates.

BACKGROUND: Prior studies have demonstrated how price transparency lowers the test-ordering rates of trainees in hospitals, and physician-targeted price transparency efforts have been viewed as a promising cost-controlling strategy. OBJECTIVE: To examine the effect of displaying paid-price information on test-ordering rates for common imaging studies and procedures within an accountable care organization (ACO). DESIGN: Block randomized controlled trial for 1 year. SUBJECTS: A total of 1205 fully licensed clinicians (728 primary care, 477 specialists). INTERVENTION: Starting January 2014, clinicians in the Control arm received no price display; those in the intervention arms received Single or Paired Internal/External Median Prices in the test-ordering screen of their electronic health record. Internal prices were the amounts paid by insurers for the ACO's services; external paid prices were the amounts paid by insurers for the same services when delivered by unaffiliated providers. MAIN MEASURES: Ordering rates (orders per 100 face-to-face encounters with adult patients): overall, designated to be completed internally within the ACO, considered "inappropriate" (e.g., MRI for simple headache), and thought to be "appropriate" (e.g., screening colonoscopy). KEY RESULTS: We found no significant difference in overall ordering rates across the Control, Single Median Price, or Paired Internal/External Median Prices study arms. For every 100 encounters, clinicians in the Control arm ordered 15.0 (SD 31.1) tests, those in the Single Median Price arm ordered 15.0 (SD 16.2) tests, and those in the Paired Prices arms ordered 15.7 (SD 20.5) tests (one-way ANOVA p-value 0.88). There was no difference in ordering rates for tests designated to be completed internally or considered to be inappropriate or appropriate. CONCLUSIONS: Displaying paid-price information did not alter how frequently primary care and specialist clinicians ordered imaging studies and procedures within an ACO. Those with a particular interest in removing waste from the health care system may want to consider a variety of contextual factors that can affect physician-targeted price transparency.

Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures.

BACKGROUND: Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding. METHODS: In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance. RESULTS: Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented. CONCLUSION: Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.

Rationale and design of the Study of a Tele-pharmacy Intervention for Chronic diseases to Improve Treatment adherence (STIC2IT): A cluster-randomized pragmatic trial.

BACKGROUND: Approximately half of patients with chronic cardiometabolic conditions are nonadherent with their prescribed medications. Interventions to improve adherence have been only modestly effective because they often address single barriers to adherence, intervene at single points in time, or are imprecisely targeted to patients who may not need adherence assistance. OBJECTIVE: To evaluate the effect of a multicomponent, behaviorally tailored pharmacist-based intervention to improve adherence to medications for diabetes, hypertension, and hyperlipidemia. TRIAL DESIGN: The STIC2IT trial is a cluster-randomized pragmatic trial testing the impact of a pharmacist-led multicomponent intervention that uses behavioral interviewing, text messaging, mailed progress reports, and video visits. Targeted patients are those who are nonadherent to glucose-lowering, antihypertensive, or statin medications and who also have evidence of poor disease control. The intervention is tailored to patients' individual health barriers and their level of health activation. We cluster-randomized 14 practice sites of a large multispecialty group practice to receive either the pharmacist-based intervention or usual care. STIC2IT has enrolled 4,076 patients who will be followed up for 12months after randomization. The trial's primary outcome is medication adherence, assessed using pharmacy claims data. Secondary outcomes are disease control and health care resource utilization. CONCLUSION: This trial will determine whether a technologically enabled, behaviorally targeted pharmacist-based intervention results in improved adherence and disease control. If effective, this strategy could be a scalable method of offering tailored adherence support to those with the greatest clinical need.

The role of neighborhood characteristics and the built environment in understanding racial/ethnic disparities in childhood obesity.

BACKGROUND: Childhood obesity prevalence remains high and racial/ethnic disparities may be widening. Studies have examined the role of health behavioral differences. Less is known regarding neighborhood and built environment mediators of disparities. The objective of this study was to examine the extent to which racial/ethnic disparities in elevated child body mass index (BMI) are explained by neighborhood socioeconomic status (SES) and built environment. METHODS: We collected and analyzed race/ethnicity, BMI, and geocoded address from electronic health records of 44,810 children 4 to 18years-old seen at 14 Massachusetts pediatric practices in 2011-2012. Main outcomes were BMI z-score and BMI z-score change over time. We used multivariable linear regression to examine associations between race/ethnicity and BMI z-score outcomes, sequentially adjusting for neighborhood SES and the food and physical activity environment. RESULTS: Among 44,810 children, 13.3% were black, 5.7% Hispanic, and 65.2% white. Compared to white children, BMI z-scores were higher among black (0.43units [95% CI: 0.40-0.45]) and Hispanic (0.38 [0.34-0.42]) children; black (0.06 [0.04-0.08]), but not Hispanic, children also had greater increases in BMI z-score over time. Adjusting for neighborhood SES substantially attenuated BMI z-score differences among black (0.30 [0.27-0.34]) and Hispanic children (0.28 [0.23-0.32]), while adjustment for food and physical activity environments attenuated the differences but to a lesser extent than neighborhood SES. CONCLUSIONS: Neighborhood SES and the built environment may be important drivers of childhood obesity disparities. To accelerate progress in reducing obesity disparities, interventions must be tailored to the neighborhood contexts in which families live.

Overuse of colonoscopy for colorectal cancer screening and surveillance.

BACKGROUND: Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources. OBJECTIVE: Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse. DESIGN, SETTING, AND PARTICIPANTS: Our approach was a retrospective cohort study using electronic health record data for patients 50-65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice. MAIN OUTCOME MEASURES: We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies. KEY RESULTS: We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88%) and many surveillance colonoscopies (49%) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1-10.0; hyperplastic polyp: 5.7 years, IQR: 4.9-9.7; low-risk adenoma: 5.1 years, IQR: 3.3-6.3; high-risk adenoma: 2.9 years, IQR: 2.0-3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95% CI: 3.15-12.50) and surveillance colonoscopy (OR 13.47, 95% CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam. CONCLUSIONS: Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.

Choosing wisely: prevalence and correlates of low-value health care services in the United States.

BACKGROUND: Specialty societies in the United States identified low-value tests and procedures that contribute to waste and poor health care quality via implementation of the American Board of Internal Medicine Foundation's Choosing Wisely initiative. OBJECTIVE: To develop claims-based algorithms, to use them to estimate the prevalence of select Choosing Wisely services and to examine the demographic, health and health care system correlates of low-value care at a regional level. DESIGN: Using Medicare data from 2006 to 2011, we created claims-based algorithms to measure the prevalence of 11 Choosing Wisely-identified low-value services and examined geographic variation across hospital referral regions (HRRs). We created a composite low-value care score for each HRR and used linear regression to identify regional characteristics associated with more intense use of low-value services. PATIENTS: Fee-for-service Medicare beneficiaries over age 65. MAIN MEASURES: Prevalence of selected Choosing Wisely low-value services. KEY RESULTS: The national average annual prevalence of the selected Choosing Wisely low-value services ranged from 1.2% (upper urinary tract imaging in men with benign prostatic hyperplasia) to 46.5% (preoperative cardiac testing for low-risk, non-cardiac procedures). Prevalence across HRRs varied significantly. Regional characteristics associated with higher use of low-value services included greater overall per capita spending, a higher specialist to primary care ratio and higher proportion of minority beneficiaries. CONCLUSIONS: Identifying and measuring low-value health services is a prerequisite for improving quality and eliminating waste. Our findings suggest that the delivery of wasteful and potentially harmful services may be a fruitful area for further research and policy intervention for HRRs with higher per-capita spending. These findings should inform action by physicians, health systems, policymakers, payers and consumer educators to improve the value of health care by targeting services and areas with greater use of potentially inappropriate care.

Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial.

IMPORTANCE: Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established. OBJECTIVE: To determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk. DESIGN, SETTING, AND PARTICIPANTS: Four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25,627 potentially eligible patients of those PCPs, 1503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not. INTERVENTIONS: Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation. MAIN OUTCOMES AND MEASURES: Change in LDL-C level at 12 months. RESULTS: Patients in the shared physician-patient incentives group achieved a mean reduction in LDL-C of 33.6 mg/dL (95% CI, 30.1-37.1; baseline, 160.1 mg/dL; 12 months, 126.4 mg/dL); those in physician incentives achieved a mean reduction of 27.9 mg/dL (95% CI, 24.9-31.0; baseline, 159.9 mg/dL; 12 months, 132.0 mg/dL); those in patient incentives achieved a mean reduction of 25.1 mg/dL (95% CI, 21.6-28.5; baseline, 160.6 mg/dL; 12 months, 135.5 mg/dL); and those in the control group achieved a mean reduction of 25.1 mg/dL (95% CI, 21.7-28.5; baseline, 161.5 mg/dL; 12 months, 136.4 mg/dL; P < .001 for comparison of all 4 groups). Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5 mg/dL; 95% CI, 3.8-13.3; P = .002). CONCLUSIONS AND RELEVANCE: In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01346189.

Disparities in evaluation of patients with rectal bleeding 40 years and older.

BACKGROUND & AIMS: Rectal bleeding is associated with colorectal cancer. We characterized the evaluation of patients aged 40 years and older with rectal bleeding and identified characteristics associated with inadequate evaluation. METHODS: We conducted a retrospective review of records of outpatient visits that contained reports of rectal bleeding for patients aged 40 years and older (N = 480). We studied whether patient characteristics affected whether or not they received a colonoscopy examination within 90 days of presentation with rectal bleeding. Patient characteristics included demographics; family history of colon cancer and polyps; and histories of screening colonoscopies, physical examinations, referrals to specialists at the index visit, and communication of laboratory results. Data were collected from medical records, and patient income levels were estimated based on Zip codes. RESULTS: Nearly half of the patients presenting with rectal bleeding received colonoscopies (48.1%); 81.7% received the procedure within 90 days. A history of a colonoscopy examination was more likely to be reported in white patients compared with Hispanic or Asian patients (P = .012 and P = .006, respectively), and in high-income compared with low-income patients (P = .022). A family history was more likely to be documented among patients with private insurance than those with Medicaid or Medicare (P = .004). A rectal examination was performed more often for patients who were white or Asian, male, and with high or middle incomes, compared with those who were black, Hispanic, female, or with low incomes (P = .027). White patients were more likely to have their laboratory results communicated to them than black patients (P = .001). CONCLUSIONS: Sex, race, ethnicity, patient income, and insurance status were associated with disparities in evaluation of rectal bleeding. There is a need to standardize the evaluation of patients with rectal bleeding.