Costs of Specialist Referrals From Employer-Sponsored Integrated Health Care Clinics Are Lower Than Those From Community Providers.

BACKGROUND: There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers. OBJECTIVE: Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers. DESIGN: Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers. PATIENTS: Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community. INTERVENTION: Specialist referral management program implemented by Crossover Health employer-sponsored clinics. MAIN MEASURES: Rates and costs of specialist referrals. KEY RESULTS: The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001). CONCLUSIONS: Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed.

Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review.

BACKGROUND: Impostor syndrome is increasingly presented in the media and lay literature as a key behavioral health condition impairing professional performance and contributing to burnout. However, there is no published review of the evidence to guide the diagnosis or treatment of patients presenting with impostor syndrome. PURPOSE: To evaluate the evidence on the prevalence, predictors, comorbidities, and treatment of impostor syndrome. DATA SOURCES: Medline, Embase, and PsycINFO (January 1966 to May 2018) and bibliographies of retrieved articles. STUDY SELECTION: English-language reports of evaluations of the prevalence, predictors, comorbidities, or treatment of impostor syndrome. DATA EXTRACTION: Two independent investigators extracted data on study variables (e.g., study methodology, treatments provided); participant variables (e.g., demographics, professional setting); diagnostic tools used, outcome variables (e.g., workplace performance, reductions in comorbid conditions); and pre-defined quality variables (e.g., human subjects approval, response rates reported). DATA SYNTHESIS: In total, 62 studies of 14,161 participants met the inclusion criteria (half were published in the past 6 years). Prevalence rates of impostor syndrome varied widely from 9 to 82% largely depending on the screening tool and cutoff used to assess symptoms and were particularly high among ethnic minority groups. Impostor syndrome was common among both men and women and across a range of age groups (adolescents to late-stage professionals). Impostor syndrome is often comorbid with depression and anxiety and is associated with impaired job performance, job satisfaction, and burnout among various employee populations including clinicians. No published studies evaluated treatments for this condition. LIMITATIONS: Studies were heterogeneous; publication bias may be present. CONCLUSIONS: Clinicians and employers should be mindful of the prevalence of impostor syndrome among professional populations and take steps to assess for impostor feelings and common comorbidities. Future research should include evaluations of treatments to mitigate impostor symptoms and its common comorbidities.

Clinical Decision Support for High-Risk Stage II Colon Cancer: A Real-World Study of Treatment Concordance and Survival.

BACKGROUND: Prognostic and pathologic risk factors typically guide clinicians and patients in their choice of surveillance or adjuvant chemotherapy when managing high-risk stage II colon cancer. However, variations in treatment and outcomes in patients with stage II colon cancer remain. OBJECTIVE: This study aimed to assess the survival benefits of treatments concordant with suggested therapeutic options from Watson for Oncology, a clinical decision support system. DESIGN: This is a retrospective observational study of concordance between actual treatment and Watson for Oncology therapeutic options. SETTING: This study was conducted at a top-tier cancer center in China. PATIENTS: Postoperative treatment data were retrieved from the electronic health records of 306 patients with high-risk stage II colon adenocarcinoma. MAIN OUTCOME MEASURES: The primary outcomes measured were the treatment patterns plus 3- and 5-year overall and disease-free survival for concordant and nonconcordant cases. RESULTS: Overall concordance was 90%. Most nonconcordant care resulted from adjuvant chemotherapy use (rather than surveillance) in patients with high-level microsatellite instability and ≥70 years old. No difference in overall survival (p = 0.56) or disease-free survival (p = 0.19) was observed between concordance groups. Patients receiving adjuvant chemotherapy had significantly higher 5-year overall survival than those undergoing surveillance (94% vs 84%, p = 0.01). LIMITATIONS: This study was limited by the use of retrospective cases drawn from patients presenting for surgery, the lack of complete follow-up data for 58% of patients who could not be included in the analysis, and a survival analysis that assumes no unmeasured correlation between survival and censoring. CONCLUSIONS: Watson for Oncology produced therapeutic options highly concordant with human decisions at a top-tier cancer center in China. Treatment patterns suggest that Watson for Oncology may be able to guide clinicians to minimize overtreatment of patients with high-risk stage II colon cancer with chemotherapy. Survival analyses suggest the need for further investigation to specifically assess the association between surveillance, single-agent and multiagent chemotherapy, and survival outcomes in this population. See Video Abstract at http://links.lww.com/DCR/B291. APOYO A LA DECISIÓN CLÍNICA DEL CÁNCER DE COLON EN ESTADIO II DE ALTO RIESGO: UN ESTUDIO DEL MUNDO REAL SOBRE LA CONCORDANCIA DEL TRATAMIENTO Y LA SUPERVIVENCIA: Los factores de riesgo pronósticos y patológicos generalmente guían a los médicos y pacientes en su elección de vigilancia o quimioterapia adyuvante cuando se trata el cáncer de colon en estadio II de alto riesgo. Sin embargo, las variaciones en el tratamiento y los resultados en pacientes con cáncer de colon en estadio II permanecen.Evaluar los beneficios de supervivencia de los tratamientos concordantes con las opciones terapéuticas sugeridas por "Watson for Oncology" (Watson para la oncología), un sistema de apoyo a la decisión clínica.Estudio observacional retrospectivo de concordancia entre el tratamiento real y las opciones terapéuticas de Watson para oncología.Un centro oncológico de primer nivel en China.Datos de tratamiento postoperatorio de registros de salud electrónicos de 306 pacientes con adenocarcinoma de colon en estadio II de alto riesgo.Patrones de tratamiento más supervivencia global y libre de enfermedad a 3 y 5 años para casos concordantes y no concordantes.La concordancia general fue del 90%. La mayoría de la atención no concordante resultó del uso de quimioterapia adyuvante (en lugar de vigilancia) en pacientes de alto nivel con inestabilidad de microsatélites y pacientes ≥70 años. No se observaron diferencias en la supervivencia global (p = 0,56) o la supervivencia libre de enfermedad (p = 0,19) entre los grupos de concordancia. Los pacientes que recibieron quimioterapia adyuvante tuvieron una supervivencia global a los 5 años significativamente más alta que los que fueron sometidos a vigilancia (94% frente a 84%, p = 0,01).Uso de casos retrospectivos extraídos de pacientes que se presentan para cirugía, falta de datos de seguimiento completos para el 58% de los pacientes que no pudieron ser incluidos en el análisis, y análisis de supervivencia que asume que no exite una correlación no medida entre supervivencia y censura.Watson para Oncología produjo opciones terapéuticas altamente concordantes con las decisiones humanas en un centro oncológico de primer nivel en China. Los patrones de tratamiento sugieren que Watson para Oncología puede guiar a los médicos para minimizar el sobretratamiento de pacientes con cáncer de colon en estadio II de alto riesgo con quimioterapia. Los análisis de supervivencia sugieren la necesidad de realizar mas investigaciónes para evaluar específicamente la asociación entre la vigilancia, la quimioterapia con uno solo o múltiples agentes y los resultados de supervivencia en esta población. Consulte Video Resumen en http://links.lww.com/DCR/B291. (Traducción-Dr. Gonzalo Hagerman).

Are organic foods safer or healthier than conventional alternatives?: a systematic review.

BACKGROUND: The health benefits of organic foods are unclear. PURPOSE: To review evidence comparing the health effects of organic and conventional foods. DATA SOURCES: MEDLINE (January 1966 to May 2011), EMBASE, CAB Direct, Agricola, TOXNET, Cochrane Library (January 1966 to May 2009), and bibliographies of retrieved articles. STUDY SELECTION: English-language reports of comparisons of organically and conventionally grown food or of populations consuming these foods. DATA EXTRACTION: 2 independent investigators extracted data on methods, health outcomes, and nutrient and contaminant levels. DATA SYNTHESIS: 17 studies in humans and 223 studies of nutrient and contaminant levels in foods met inclusion criteria. Only 3 of the human studies examined clinical outcomes, finding no significant differences between populations by food type for allergic outcomes (eczema, wheeze, atopic sensitization) or symptomatic Campylobacter infection. Two studies reported significantly lower urinary pesticide levels among children consuming organic versus conventional diets, but studies of biomarker and nutrient levels in serum, urine, breast milk, and semen in adults did not identify clinically meaningful differences. All estimates of differences in nutrient and contaminant levels in foods were highly heterogeneous except for the estimate for phosphorus; phosphorus levels were significantly higher than in conventional produce, although this difference is not clinically significant. The risk for contamination with detectable pesticide residues was lower among organic than conventional produce (risk difference, 30% [CI, -37% to -23%]), but differences in risk for exceeding maximum allowed limits were small. Escherichia coli contamination risk did not differ between organic and conventional produce. Bacterial contamination of retail chicken and pork was common but unrelated to farming method. However, the risk for isolating bacteria resistant to 3 or more antibiotics was higher in conventional than in organic chicken and pork (risk difference, 33% [CI, 21% to 45%]). LIMITATION: Studies were heterogeneous and limited in number, and publication bias may be present. CONCLUSION: The published literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods. Consumption of organic foods may reduce exposure to pesticide residues and antibiotic-resistant bacteria. PRIMARY FUNDING SOURCE: None.

Digitally Enabled Peer Support Intervention to Address Loneliness and Mental Health: Prospective Cohort Analysis.

BACKGROUND: Social isolation and loneliness affect 61% of US adults and are associated with significant increases in excessive mental and physical morbidity and mortality. Annual health care spending is US $1643 higher for socially isolated individuals than for those not socially isolated. OBJECTIVE: We prospectively evaluated the effects of participation with a digitally enabled peer support intervention on loneliness, depression, anxiety, and health-related quality of life among adults with loneliness. METHODS: Adults aged 18 years and older living in Colorado were recruited to participate in a peer support program via social media campaigns. The intervention included peer support, group coaching, the ability to become a peer helper, and referral to other behavioral health resources. Participants were asked to complete surveys at baseline, 30, 60, and 90 days, which included questions from the validated University of California, Los Angeles Loneliness Scale, Patient Health Questionnaire 2-Item Scale, General Anxiety Disorder 7-Item Scale, and a 2-item measure assessing unhealthy days due to physical condition and mental condition. A growth curve modeling procedure using multilevel regression analyses was conducted to test for linear changes in the outcome variables from baseline to the end of the intervention. RESULTS: In total, 815 ethnically and socially diverse participants completed registration (mean age 38, SD 12.7; range 18-70 years; female: n=310, 38%; White: n=438, 53.7%; Hispanic: n=133, 16.3%; Black: n=51, 6.3%; n=263, 56.1% had a high social vulnerability score). Participants most commonly joined the following peer communities: loneliness (n=220, 27%), building self-esteem (n=187, 23%), coping with depression (n=179, 22%), and anxiety (n=114, 14%). Program engagement was high, with 90% (n=733) engaged with the platform at 60 days and 86% (n=701) at 90 days. There was a statistically (P<.001 for all outcomes) and clinically significant improvement in all clinical outcomes of interest: a 14.6% (mean 6.47) decrease in loneliness at 90 days; a 50.1% (mean 1.89) decline in depression symptoms at 90 days; a 29% (mean 1.42) reduction in anxiety symptoms at 90 days; and a 13% (mean 21.35) improvement in health-related quality of life at 90 days. Based on changes in health-related quality of life, we estimated a reduction in annual medical costs of US $615 per participant. The program was successful in referring participants to behavioral health educational resources, with 27% (n=217) of participants accessing a resource about how to best support those experiencing psychological distress and 15% (n=45) of women accessing a program about the risks of excessive alcohol use. CONCLUSIONS: Our results suggest that a digitally enabled peer support program can be effective in addressing loneliness, depression, anxiety, and health-related quality of life among a diverse population of adults with loneliness. Moreover, it holds promise as a tool for identifying and referring members to relevant behavioral health resources.

Mental Health Service Utilization Rates Among Commercially Insured Adults in the US During the First Year of the COVID-19 Pandemic.

Importance: The COVID-19 pandemic has been associated with an elevated prevalence of mental health conditions and disrupted mental health care throughout the US. Objective: To examine mental health service use among US adults from January through December 2020. Design, Setting, and Participants: This cohort study used county-level service utilization data from a national US database of commercial medical claims from adults (age >18 years) from January 5 to December 21, 2020. All analyses were conducted in April and May 2021. Main Outcomes and Measures: Per-week use of mental health services per 10 000 beneficiaries was calculated for 5 psychiatric diagnostic categories: major depressive disorder (MDD), anxiety disorders, bipolar disorder, adjustment disorders, and posttraumatic stress disorder (PTSD). Changes in service utilization rates following the declaration of a national public health emergency on March 13, 2020, were examined overall and by service modality (in-person vs telehealth), diagnostic category, patient sex, and age group. Results: The study included 5 142 577 commercially insured adults. The COVID-19 pandemic was associated with more than a 50% decline in in-person mental health care service utilization rates. At baseline, there was a mean (SD) of 11.66 (118.00) weekly beneficiaries receiving services for MDD per 10 000 enrollees; this declined by 6.44 weekly beneficiaries per 10 000 enrollees (ß, -6.44; 95% CI, -8.33 to -4.54). For other disorders, these rates were as follows: anxiety disorders (mean [SD] baseline, 12.24 [129.40] beneficiaries per 10 000 enrollees; ß, -5.28; 95% CI, -7.50 to -3.05), bipolar disorder (mean [SD] baseline, 3.32 [60.39] beneficiaries per 10 000 enrollees; ß, -1.81; 95% CI, -2.75 to -0.87), adjustment disorders (mean [SD] baseline, 12.14 [129.94] beneficiaries per 10 000 enrollees; ß, -6.78; 95% CI, -8.51 to -5.04), and PTSD (mean [SD] baseline, 4.93 [114.23] beneficiaries per 10 000 enrollees; ß, -2.00; 95% CI, -3.98 to -0.02). Over the same period, there was a 16- to 20-fold increase in telehealth service utilization; the rate of increase was lowest for bipolar disorder (mean [SD] baseline, 0.13 [16.72] beneficiaries per 10 000 enrollees; ß, 1.40; 95% CI, 1.04-1.76) and highest for anxiety disorders (mean [SD] baseline, 0.20 [9.28] beneficiaries per 10 000 enrollees; ß, 9.12; 95% CI, 7.32-10.92). When combining in-person and telehealth service utilization rates, an overall increase in care for MDD, anxiety, and adjustment disorders was observed over the period. Conclusions and Relevance: In this cohort study of US adults, we found that the COVID-19 pandemic was associated with a rapid increase in telehealth services for mental health conditions, offsetting a sharp decline in in-person care and generating overall higher service utilization rates for several mental health conditions compared with prepandemic levels.

Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications.

BACKGROUND: Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. PURPOSE: To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. DATA SOURCES: Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. STUDY SELECTION: Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. DATA EXTRACTION: Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. DATA SYNTHESIS: 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. LIMITATIONS: The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. CONCLUSION: Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.

The impact of the COVID-19 pandemic and policy response on health care utilization: Evidence from county-level medical claims and cellphone data.

The COVID-19 pandemic has forced federal, state, and local policymakers to respond by legislating, enacting, and enforcing social distancing policies. However, the impact of these policies on healthcare utilization in the United States has been largely unexplored. We examine the impact of county-level shelter in place ordinances on healthcare utilization using two unique datasets-employer-sponsored insurance for over 6 million people in the US and cell phone location data. We find that introduction of these policies was associated with reductions in the use of preventive care, elective care, and the number of weekly visits to physician offices, hospitals and other health care-related industries. However, controlling for county-level exposure to the COVID-19 pandemic as a way to account for the endogenous nature of policy implementation reduces the impact of these policies. Our results imply that while social distancing policies do lead to reductions in healthcare utilization, much of these reductions would have occurred even in the absence of these policies.

Spatial modeling of vaccine deserts as barriers to controlling SARS-CoV-2.

BACKGROUND: COVID-19 vaccine distribution is at risk of further propagating the inequities of COVID-19, which in the United States (US) has disproportionately impacted the elderly, people of color, and the medically vulnerable. We sought to measure if the disparities seen in the geographic distribution of other COVID-19 healthcare resources were also present during the initial rollout of the COVID-19 vaccine. METHODS: Using a comprehensive COVID-19 vaccine database (VaccineFinder), we built an empirically parameterized spatial model of access to essential resources that incorporated vaccine supply, time-willing-to-travel for vaccination, and previous vaccination across the US. We then identified vaccine deserts-US Census tracts with localized, geographic barriers to vaccine-associated herd immunity. We link our model results with Census data and two high-resolution surveys to understand the distribution and determinates of spatially accessibility to the COVID-19 vaccine. RESULTS: We find that in early 2021, vaccine deserts were home to over 30 million people, >10% of the US population. Vaccine deserts were concentrated in rural locations and communities with a higher percentage of medically vulnerable populations. We also find that in locations of similar urbanicity, early vaccination distribution disadvantaged neighborhoods with more people of color and older aged residents. CONCLUSION: Given sufficient vaccine supply, data-driven vaccine distribution to vaccine deserts may improve immunization rates and help control COVID-19.

COVID-19 has affected the elderly, people of color, and individuals with chronic illnesses more than the general population. Large barriers to accessing the COVID-19 vaccine could make this problem worse. We used a website called VaccineFinder, which has information on the location of most COVID-19 vaccine doses in the US, to measure vaccine accessibility in early 2021. We then identified vaccine deserts, defined as small US regions with poor access to the COVID-19 vaccine. We found that over 10% of the US lived in a vaccine desert. Overall, we found that vaccines were less available to people in rural areas, people of color, and individuals with chronic illnesses. It will be important to reverse this pattern and ensure enough vaccines are sent to these communities to help reduce the spread of COVID-19.

Weight Loss-Associated Decreases in Medical Care Expenditures for Commercially Insured Patients With Chronic Conditions.

OBJECTIVE: Savings associated with weight loss for populations with chronic conditions are poorly understood. The purpose of this study was to estimate medical expenditure savings associated with weight loss among commercially insured adults with chronic medical conditions. METHODS THE: 2001-2015 Medical Expenditure Panel Survey data were used to estimate the effect of changes in body mass index (BMI) on health expenditures from instrumental variable regression models. RESULTS: Decreases in annual medical expenditures associated with a reduction in BMI of 1 kg/m2 varied by condition (eg, $289 for back pain and $752 for diabetes). The greater the weight loss, the greater the savings. The higher the baseline BMI, the greater the savings for similar levels of weight loss. CONCLUSIONS: The detailed estimates of savings for populations with chronic conditions can be used by employers to evaluate the cost-effectiveness of weight management interventions.

Who Is (and Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has forced telehealth to be the primary means through which patients interact with their providers. There is a concern that the pandemic will exacerbate the existing disparities in overall healthcare utilization and telehealth utilization. Few national studies have examined the changes in telehealth use during the COVID-19 pandemic. METHODS: Data on 6.8 and 6.4 million employer-based health plan beneficiaries in 2020 and 2019, respectively, were collected in 2020. Unadjusted rates were compared both before and after the week of the declaration of the COVID-19 pandemic as a national emergency. Trends in weekly utilization were also examined using a difference-in-differences regression framework to quantify the changes in telemedicine and office-based care utilization while controlling for the patient's demographic and county-level sociodemographic measures. All analyses were conducted in 2020. RESULTS: More than a 20-fold increase in the incidence of telemedicine utilization after March 13, 2020 was observed. Conversely, the incidence of office-based encounters declined by almost 50% and was not fully offset by the increase in telemedicine. The increase in telemedicine was greatest among patients in counties with low poverty levels (ß=31.70, 95% CI=15.17, 48.23), among patients in metropolitan areas (ß=40.60, 95% CI=30.86, 50.34), and among adults than among children aged 0-12 years (ß=57.91, 95% CI=50.32, 65.49). CONCLUSIONS: The COVID-19 pandemic has affected telehealth utilization disproportionately on the basis of patient age and both the county-level poverty rate and urbanicity.

Inadequate Measles, Mumps, Rubella, and Varicella Immunity Among Employees.

OBJECTIVES: The purpose of this cohort study was to evaluate measles, mumps, rubella (MMR), and varicella immunity among a population of adult employees receiving primary care in an employer-sponsored health center. METHODS: Participants were eligible for MMR and varicella immunity screening if they were an employee receiving primary care in an employer-sponsored health center between January 1, 2019 and November 1, 2020 who could not provide proof of immunization and 1) had it recommended by their provider, 2) specifically requested immunity testing (often because they had heard of measles outbreaks in their country of origin), or 3) were seen for an immigration physical for their Green Card application. RESULTS: Overall, 3494 patients were screened for their MMR immunity. Of these, 3057 were also screened for varicella immunity. Among these patients, 13.9% lacked measles immunity, 0.83% lacked immunity to all 3 components of MMR, and 13.2% lacked varicella immunity. Among the 262 patients who presented specifically for immunity screening, the rates of lacking immunity were higher for all conditions: 22.7% lacked measles immunity and 9.2% lacked varicella immunity. CONCLUSION: Given declines in immunizations during the COVID-19 pandemic, there is reason to be concerned that measles and varicella-associated morbidity and mortality may rise. Employers, especially those with large foreign-born populations or who require international travel may want to educate their populations about common contagious illnesses and offer immunity validation or vaccinations at no or low cost.

Social Determinants of Health Challenges Are Prevalent Among Commercially Insured Populations.

OBJECTIVES: To evaluate the prevalence of social determinants of health (SDoH) factors in a large commercially-insured population and to characterize the prevalence of common conditions (eg, diabetes, behavioral health issues) and addressable health services utilization concerns (eg, lack of preventive care) for which employers offer no- and low-cost benefit programs. METHODS: We identified groups with SDoH challenges within a commercially-insured population of 5.1 M through administrative data and self-report. Using medical claims and health assessment data, we identified populations with SDoH needs who had common conditions for which employers often provide no- or low-cost benefit programs (ie, diabetes, behavioral health conditions, high-risk pregnancy, overweight/obesity). Additionally, we sought populations with common addressable health services utilization concerns such as avoidable emergency room visits, lack of preventive care services, or non-adherence to medications. We used univariate analyses to describe the prevalence of SDoH risks in the population of interest. RESULTS: Twenty-seven percent of this commercially-insured population live in a zip code where the median income is at or below 200% of the Federal Poverty Line. Respondents identified cost (55%) and family, school, or work responsibilities (26%) as key barriers to care. ER overutilization rates are higher in lower income zip codes than wealthier zip codes (34% vs 9%) as is the prevalence of diabetes, overweight/obesity, and behavioral issues, and decreased use of preventive services. Fifteen percent of the study population live in a low-access food area. There is considerable variability in access to employer-sponsored resources to address these needs (70% of employers provide behavioral health programs; 63% provide telehealth programs, but only 1% offer healthy food programs and less than 0.5% offer either child care or transportation support programs). CONCLUSIONS: Commercially insured populations could benefit from employer-sponsored programs or benefits that address key SDoH barriers such as financial support, healthy food programs, child-care, and transportation.

Use of buprenorphine for those with employer-sponsored insurance during the initial phase of the COVID-19 pandemic.

OBJECTIVE: To quantify weekly rates of use of buprenorphine for those with employer-based insurance and whether the rate differs based on county-level measures of race, historical fatal drug overdose rate, and COVID-19 case rate. METHODS: We used 2020 pharmaceutical claims for 4.8 million adults from a privately insured population to examine changes in the use of buprenorphine to treat opioid use disorder in 2020 during the onset of the COVID-19 pandemic. We quantified variation by examining changes in use rates across counties based on their fatal drug overdose rate in 2018, number of COVID-19 cases per capita, and percent nonwhite. RESULTS: Weekly use of buprenorphine was relatively stable between the first week of January (0.6 per 10,000 enrollees, 95%CI = 0.2 to 1.1) and the last week of August (0.8 per 10,000 enrollees, 95%CI = 0.4 to 1.3). We did not find evidence of any consistent change in use of buprenorphine by county-level terciles for COVID-19 rate as of August 31, 2020, age-adjusted fatal drug overdose rate, and percent nonwhite. Use was consistently higher for counties in the highest tercile of county age-adjusted fatal drug overdose rate when compared to counties in the lowest tercile of county age-adjusted fatal drug overdose rate. DISCUSSION: Our results provide early evidence that new federal- and state-level policies may have steadied the rate of using buprenorphine for those with employer-based insurance during the pandemic.

Employer-Sponsored Health Centers Provide Access to Integrated Care via a Hybrid of Virtual and In-Person Visits.

Background: Since the explosion of telemedicine resulting from the SARS-CoV2 pandemic, employers have been particularly interested in virtual primary care as a novel means of expanding primary care services. The purpose of this study is to describe a model of integrated care delivered both in-person and virtually at employer-sponsored health centers nationwide. The key outcomes of this analysis were the proportion of all care delivered in-person and virtually by clinical discipline, the types of care and member satisfaction for care delivered in-person and virtually, and a description of the use of multiple clinical disciplines by the employee population. Methods: Retrospective observational study comparing health services utilization of primary care, behavioral health, and physical medicine services both in-person and virtually in employer-sponsored clinics between January 1, 2020 and June 30, 2021. Results: Of the 331,967 visits with employer-sponsored health center staff, 63% were in-person and 37% were delivered virtually. Most visits were for primary care services (59.5%), with physical medicine visits and behavioral health visits accounting for 25.1% and 15.4%, respectively. Whereas the preponderance of behavioral health visits were virtual visits (72.5%), less than a quarter (18.2%) of physical medicine visits were delivered virtually. 19.6% of patients were seen by more than two clinical disciplines and 2.6% were seen by three different disciplines. Overall, patients were highly likely to recommend the health center across both modalities (Net Promoter Score 89.1 for in-person care and 88.4 for virtual care). Discussion: The future of employer-sponsored integrated team-based care may require a hybrid approach that can lean heavily on virtual visits but requires the infrastructure necessary for in-person care.

Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials.

BACKGROUND: Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics. METHODS: We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat. FINDINGS: Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5.9 years (IQR 5.0-10.0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0.91, 95% CI 0.82-1.02; p=0.12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0.70, 0.56-0.87); however, mortality was similar between groups in patients without diabetes (HR 0.98, 0.86-1.12; p=0.014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1.25 (0.94-1.66) in patients younger than 55 years, 0.90 (0.75-1.09) in patients aged 55-64 years, and 0.82 (0.70-0.97) in patients 65 years and older (p=0.002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics. INTERPRETATION: Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.

Systematic review: safety and efficacy of extended-duration antiviral chemoprophylaxis against pandemic and seasonal influenza.

BACKGROUND: Neuraminidase inhibitors (NAIs) are stockpiled internationally for extended use in an influenza pandemic. PURPOSE: To evaluate the safety and efficacy of extended-duration (>4 weeks) NAI chemoprophylaxis against influenza. DATA SOURCES: Studies published in any language through 11 June 2009 identified by searching 10 electronic databases and 3 trial registries. STUDY SELECTION: Randomized, placebo-controlled, double-blind human trials of extended-duration NAI chemoprophylaxis that reported outcomes of laboratory-confirmed influenza or adverse events. DATA EXTRACTION: 2 reviewers independently assessed study quality and abstracted information from eligible studies. DATA SYNTHESIS: Of 1876 potentially relevant citations, 7 trials involving 7021 unique participants met inclusion criteria. Data were pooled by using random-effects models. Chemoprophylaxis with NAIs decreased the frequency of symptomatic influenza (relative risk [RR], 0.26 [95% CI, 0.18 to 0.37]; risk difference [RD], -3.9 percentage points [CI, -5.8 to -1.9 percentage points]) but not asymptomatic influenza (RR, 1.03 [CI, 0.81 to 1.30]; RD, -0.4 percentage point [CI, -1.6 to 0.9 percentage point]). Adverse effects were not increased overall among NAI recipients (RR, 1.01 [CI, 0.94 to 1.08]; RD, 0.1 percentage point [CI, -0.2 to 0.4 percentage point]), but nausea and vomiting were more common among those who took oseltamivir (RR, 1.48 [CI, 1.86 to 2.33]; RD, 1.7 percentage points [CI, 0.6 to 2.9 percentage points]). Prevention of influenza did not statistically significantly differ between zanamivir and oseltamivir. LIMITATIONS: All trials were industry-sponsored. No study was powered to detect rare adverse events, and none included diverse racial groups, children, immunocompromised patients, or individuals who received live attenuated influenza virus vaccine. CONCLUSION: Extended-duration zanamivir and oseltamivir chemoprophylaxis seems to be highly efficacious for preventing symptomatic influenza among immunocompetent white and Japanese adults. Extended-duration oseltamivir is associated with increased nausea and vomiting. Safety and efficacy in several subpopulations that might receive extended-duration influenza chemoprophylaxis are unknown.

Systematic review: elective induction of labor versus expectant management of pregnancy.

BACKGROUND: The rates of induction of labor and elective induction of labor are increasing. Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature. PURPOSE: To compare the benefits and harms of elective induction of labor and expectant management of pregnancy. DATA SOURCES: MEDLINE (through February 2009), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials (through March 2009), bibliographies of included studies, and previous systematic reviews. STUDY SELECTION: Experimental and observational studies of elective induction of labor reported in English. DATA EXTRACTION: Two authors abstracted study design; patient characteristics; quality criteria; and outcomes, including cesarean delivery and maternal and neonatal morbidity. DATA SYNTHESIS: Of 6117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials (RCTs) and 25 observational studies. Overall, expectant management of pregnancy was associated with a higher odds ratio (OR) of cesarean delivery than was elective induction of labor (OR, 1.22 [95% CI, 1.07 to 1.39]; absolute risk difference, 1.9 percentage points [CI, 0.2 to 3.7 percentage points]) in 9 RCTs. Women at or beyond 41 completed weeks of gestation who were managed expectantly had a higher risk for cesarean delivery (OR, 1.21 [CI, 1.01 to 1.46]), but this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73 [CI, 0.67 to 4.5]). Women who were expectantly managed were more likely to have meconium-stained amniotic fluid than those who were electively induced (OR, 2.04 [CI, 1.34 to 3.09]). LIMITATIONS: There were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality and were not generalizable to current practice. CONCLUSION: RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided.