A blueprint for the primary prevention of cancer: Targeting established, modifiable risk factors.

In the United States, it is estimated that more than 1.7 million people will be diagnosed with cancer, and more than 600,000 will die of the disease in 2018. The financial costs associated with cancer risk factors and cancer care are enormous. To substantially reduce both the number of individuals diagnosed with and dying from cancer and the costs associated with cancer each year in the United States, government and industry and the public health, medical, and scientific communities must work together to develop, invest in, and implement comprehensive cancer control goals and strategies at the national level and expand ongoing initiatives at the state and local levels. This report is the second in a series of articles in this journal that, together, describe trends in cancer rates and the scientific evidence on cancer prevention, early detection, treatment, and survivorship to inform the identification of priorities for a comprehensive cancer control plan. Herein, we focus on existing evidence about established, modifiable risk factors for cancer, including prevalence estimates and the cancer burden due to each risk factor in the United States, and established primary prevention recommendations and interventions to reduce exposure to each risk factor.

Association Between Use of Primary-Prevention Implantable Cardioverter-Defibrillators and Mortality in Patients With Heart Failure: A Prospective Propensity Score-Matched Analysis From the Swedish Heart Failure Registry.

BACKGROUND: Most randomized trials on implantable cardioverter-defibrillator (ICD) use for primary prevention of sudden cardiac death in heart failure with reduced ejection fraction enrolled patients >20 years ago. We investigated the association between ICD use and all-cause mortality in a contemporary heart failure with reduced ejection fraction cohort and examined relevant subgroups. METHODS: Patients from the Swedish Heart Failure Registry fulfilling the European Society of Cardiology criteria for primary-prevention ICD were included. The association between ICD use and 1-year and 5-year all-cause and cardiovascular (CV) mortality was assessed by Cox regression models in a 1:1 propensity score-matched cohort and in prespecified subgroups. RESULTS: Of 16 702 eligible patients, only 1599 (10%) had an ICD. After matching, 1305 ICD recipients were compared with 1305 nonrecipients. ICD use was associated with a reduction in all-cause mortality risk within 1 year (hazard ratio, 0.73 [95% CI, 0.60-0.90]) and 5 years (hazard ratio, 0.88 [95% CI, 0.78-0.99]). Results were consistent in all subgroups including patients with versus without ischemic heart disease, men versus women, those aged <75 versus ≥75 years, those with earlier versus later enrollment in the Swedish heart failure registry, and patients with versus without cardiac resynchronization therapy. CONCLUSIONS: In a contemporary heart failure with reduced ejection fraction population, ICD for primary prevention was underused, although it was associated with reduced short- and long-term all-cause mortality. This association was consistent across all the investigated subgroups. These results call for better implementation of ICD therapy.

A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research.

INTRODUCTION: The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated. METHOD: A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018. RESULTS: The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes. CONCLUSION: This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry. IMPLICATIONS: This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

Time trends analysis of statin prescription prevalence, therapy initiation, dose intensity, and utilization from the hospital information system of Jinshan Hospital, Shanghai (2012-2018).

BACKGROUND: Statin remains a mainstay in the prevention and treatment of cardiovascular diseases. Statin utilization has evolved over time in many countries, but data on this topic from China are quite limited. This study aimed to investigate the changing trends of statins prescription, as well as detail the statin utilization through a successive longitudinal study. METHODS: The prescription database was established based on electronic health records retrieved from the hospital information system of Jinshan Hospital, Fudan University from January 2012 to December 2018 in Shanghai, China. The prescription rates and proportions of different statin types and doses among all patients were examined. Sub-analyses were performed when stratifying the patients by age, gender, dose intensity, and preventative intervention. RESULTS: During the study period, a total of 51,083 patients, who were prescribed for statins, were included in this study (mean [SD] age, 59.78 [±13.16] years; 53.60% male, n = 27, 378). The overall statins prescription rate in which patients increased from 2012 (1.24, 95% CI: 1.21-1.27%) to 2018 (3.16, 95% CI: 3.11-3.20%), P < 0.001. Over 90% of patients were given a moderate dose of statins. Patients with a history of coronary and cerebrovascular events (over 32%) were more likely to be prescribed with statins for preventative intervention. Furthermore, our study has witnessed a significant rise in statin therapy in primary and secondary prevention. CONCLUSIONS: In conclusion, statins were frequently prescribed and steadily increased over time in our study period. There were also changes in statin drug choices and dosages. A coordinated effort among the patient, clinical pharmacist, stakeholders and health system is still needed to improve statin utilization in clinical practice in the future.

The Use of Oral Anticoagulants in Patients with Atrial Fibrillation in the Emergency Department.

BACKGROUND AND AIM: Atrial Fibrillation is the leading cause of embolic stroke, yet less than half of high-risk patients with atrial fibrillation are on adequate stroke prevention with oral anticoagulants. Guidelines for the primary prevention of stroke recognize the emergency department as a location for physicians to identify atrial fibrillation and initiate anticoagulants. We sought to compare anticoagulant prescription rates in patients with atrial fibrillation in various provider settings to identify opportunities for improvement in cardioembolic stroke prevention. METHODS: A retrospective cohort study of 436 patients with atrial fibrillation presenting to the emergency department from 2014 to 2018 was performed. Baseline characteristics, stroke risk, and rates of anticoagulant prescription were compared across 3 groups: (1) patients discharged from the emergency department, (2) patients admitted under observation status, and (3) patients admitted to inpatient hospital service. RESULTS: Among 436 patients (47% women, 51% Hispanic), we identified 105 in the emergency department cohort, 131 in the observation cohort and 200 in the inpatient cohort. The average CHA2DS2-VASc score was 2.5 in the emergency department cohort, 2.6 in the observation cohort and 3.3 in the inpatient cohort. Anticoagulants were prescribed for high-risk patients (CHA2DS2-VASc score ≥ 2) in 17.5% (7/40) of the emergency department cohort compared to 73% (38/52, P< .0001) of the observation cohort and 80% (82/103 P< .0001) of the inpatient cohort. CONCLUSION: Patients with atrial fibrillation are more likely to be prescribed anticoagulants if admitted to inpatient or under observation status compared to the emergency department.

A Qualitative Study of Community-Based HIV/AIDS Prevention Interventions, Programs, and Projects for Rural and Remote Regions in Canada: Implementation Challenges and Lessons Learned.

CONTEXT: Fifteen percent to 20% of the Canadian and American populations live outside urban areas, and despite growing regional HIV/AIDS-related health disparities, there is little published research specific to rural or remote (rural/remote) HIV/AIDS prevention programming. OBJECTIVE: To document implementation challenges, lessons learned, and evaluation approaches of promising and proven HIV/AIDS prevention programs and interventions developed and delivered by organizations with rural/remote catchment areas in Canada to provide a foundation for information sharing among agencies. DESIGN: Qualitative study design, using a community-based participatory research approach. We screened Canadian community-based organizations with an HIV/AIDS prevention mandate to determine whether they offered services for rural/remote populations and invited organizational representatives to participate in semistructured telephone interviews. Interviews were audio-recorded and transcribed. Content analysis was used to identify categories in the interview data. SETTING: Canada, provinces (all except Prince Edward Island), and territories (all except Nunavut). PARTICIPANTS: Twenty-four community-based organizations. RESULTS: Screening calls were completed with 74 organizations, of which 39 met study criteria. Twenty-four (62%) interviews were conducted. Populations most frequently served were Indigenous peoples (n = 13 organizations) and people who use drugs (n = 8 organizations) (categories not mutually exclusive). Key lessons learned included the importance of involving potential communities served in program development; prioritizing community allies/partnerships; building relationships; local relevancy and appropriateness; assessing community awareness or readiness; program flexibility/adaptability; and addressing stigma. Evaluation activities were varied and used for funder reporting and organizational learning. CONCLUSIONS: Rural/remote HIV/AIDS programs across Canada expressed similar challenges and lessons learned, suggesting that there is potential for knowledge exchange, and development of a community of practice. Top-down planning and evaluation models may fail to capture program achievements in rural/remote contexts. The long-term engagement practices that render rural/remote programs promising do not always conform to planning and implementation requirements of limited funding.

[Aspirin for primary cardiovascular prevention : the end of an era ?] / Aspirine en prévention cardiovasculaire primaire†: la fin d'une époque†?

Low-dose aspirin in primary prevention of cardiovascular disease is still debated. Recent clinical trials of aspirin vs placebo reported an unfavourable risk-benefit ratio with an increase in major bleedings without reduction on the occurrence of non-fatal cardiovascular events. These studies also highlight that current cardiovascular risk calculators overestimate cardiovascular risk, which is probably related to the improvement in the management of cardiovascular risk factors over the last decades. In accordance with European cardiovascular prevention recommendations, aspirin should not be prescribed for the primary prevention of cardiovascular disease.

L'aspirine à faible dose en prévention primaire des maladies cardiovasculaires (CV) ne fait pas l'unanimité. De nouvelles études parues en 2018 mettent en évidence un rapport risques/bénéfices défavorable avec une augmentation des hémorragies majeures sans effets sur la survenue d'événements CV non mortels. Ces études soulignent également que les calculateurs actuels du risque CV surévaluent celui-ci, et ceci est probablement lié à l'amélioration depuis quelques décennies de la prise en charge des facteurs de risque CV. En accord avec les recommandations européennes de prévention CV, la prescription d'aspirine n'est donc plus recommandée aux adultes sans maladie CV manifeste.

Decline in Cardiovascular Mortality: Possible Causes and Implications.

If the control of infectious diseases was the public health success story of the first half of the 20th century, then the decline in mortality from coronary heart disease and stroke has been the success story of the century's past 4 decades. The early phase of this decline in coronary heart disease and stroke was unexpected and controversial when first reported in the mid-1970s, having followed 60 years of gradual increase as the US population aged. However, in 1978, the participants in a conference convened by the National Heart, Lung, and Blood Institute concluded that a significant recent downtick in coronary heart disease and stroke mortality rates had definitely occurred, at least in the US Since 1978, a sharp decline in mortality rates from coronary heart disease and stroke has become unmistakable throughout the industrialized world, with age-adjusted mortality rates having declined to about one third of their 1960s baseline by 2000. Models have shown that this remarkable decline has been fueled by rapid progress in both prevention and treatment, including precipitous declines in cigarette smoking, improvements in hypertension treatment and control, widespread use of statins to lower circulating cholesterol levels, and the development and timely use of thrombolysis and stents in acute coronary syndrome to limit or prevent infarction. However, despite the huge growth in knowledge and advances in prevention and treatment, there remain many questions about this decline. In fact, there is evidence that the rate of decline may have abated and may even be showing early signs of reversal in some population groups. The National Heart, Lung, and Blood Institute, through a request for information, is soliciting input that could inform a follow-up conference on or near the 40th anniversary of the original landmark conference to further explore these trends in cardiovascular mortality in the context of what has come before and what may lie ahead.

For Whom the Bell Tolls : Refining Risk Assessment for Sudden Cardiac Death.

Sudden cardiac death is one of the most important causes of death worldwide. Advancements in medical treatment, percutaneous interventions, and device therapy (ICD and CRTD) showed consistent reduction in mortality, mainly in survivors of SCD and in patients with ischemic cardiomyopathy and depressed left ventricular function. Patients with non-ischemic cardiomyopathies, mildly reduced LV function, and channelopathies have increased risk for SCD. Identifying the subgroup of these patients before they experience life-threatening or fatal events is essential to further improve outcomes. In this review, we aimed to summarize the current knowledge for risk stratification and primary prevention, to describe the gaps in evidence, and to discuss future directions for screening and treating patients at risk for SCD. PURPOSE OF REVIEW: The purpose of this review is to provide a comprehensive description of the etiologies of sudden cardiac death, risk stratification strategies, and to describe the current medical and interventional therapies. We aimed to discuss the current gaps in our knowledge of primary prevention of SCD and to review novel approaches and interventions. RECENT FINDINGS: The incidence of SCD has decreased in the last two decades due to improved pharmacological treatment and ICD implantation in SCD survivors and in patients with reduced left ventricular function and ischemic cardiomyopathy. The efficacy of ICD in patients with non-ischemic cardiomyopathy is challenged by new findings from the DANISH trial. Catheter ablation is new emerging strategy to prevent SCD in patients with scar relater or PVC-triggered ventricular arrhythmias. Despite the new treatments, SCD is still a major burden. ICD remains the cornerstone for patients with ischemic cardiomyopathy, whereas appropriate risk stratification of the patients with non-ischemic cardiomyopathy and channelopathies is needed to further improve outcomes. The future of ablation as the treatment and prevention of SCD remains to be studied.

Quantifying the Value of Prevention: A Survey of Public Health Departments' Quantitative and Economic Modeling Capacity.

OBJECTIVE: To improve the understanding of local health departments' (LHDs') capacity for and perceived barriers to using quantitative/economic modeling information to inform policy and program decisions. DESIGN: We developed, tested, and deployed a novel survey to examine this topic. SETTING: The study's sample frame included the 200 largest LHDs in terms of size of population served plus all other accredited LHDs (n = 67). The survey was e-mailed to 267 LHDs; respondents completed the survey online using SurveyMonkey. PARTICIPANTS: Survey instructions requested that the survey be completed from the perspective of the entire health department by LHD's top executive or designate. A total of 63 unique LHDs responded (response rate: 39%). MAIN OUTCOME MEASURE(S): Capacity for quantitative and economic modeling was measured in 5 categories (routinely use information from models we create ourselves; routinely use information from models created by others; sometimes use information from models we create ourselves; sometimes use information from models created by others; never use information from modeling). Experience with modeling was measured in 4 categories (very, somewhat, not so, not at all). RESULTS: Few (9.5%) respondents reported routinely using information from models, and most who did used information from models created by others. By contrast, respondents reported high levels of interest in using models and in gaining training in their use and the communication of model results. The most commonly reported barriers to modeling were funding and technical skills. Nearly all types of training topics listed were of interest. CONCLUSIONS: Across a sample of large and/or accredited LHDs, we found modest levels of use of modeling coupled with strong interest in capacity for modeling and therefore highlight an opportunity for LHD growth and support. Both funding constraints and a lack of knowledge of how to develop and/or use modeling are barriers to desired progress around modeling. Educational or funding opportunities to promote capacity for and use of quantitative and economic modeling may catalyze use of modeling by public health practitioners.

Structure, Process, and Quality Indicators for Pressure Injury Prevention and Care in Austrian Hospitals: A Quality Improvement Project.

The purpose of this quality improvement point-prevalence project conducted in 2017 was to describe the structure, process, and outcome indicators for pressure injury (PI) prevention and care in 37 Austrian hospitals with 208 wards and 2955 patients, with an average age of 66 years. Structural indicators such as PI guideline availability were measured on hospital and ward levels. On the process level, patients were assessed to determine whether PI interventions such as mobilization or use of moisturizer/barrier cream were implemented. On the outcome level, data on the presence of hospital-acquired PIs based on skin inspection were collected. These data were collected using the Austrian version of the National Prevalence Measurement of Care Problems, a standardized survey. Structural level results showed PI protocols or guidelines were available in 75.7% of the participating institutions. Staff education such as refresher courses was seldom available on the ward level (46.6%). Process-level results indicated the most commonly applied intervention in both patients at risk of or had a PI was the use of skin-protectant moisture barrier creams (63.1% and 85.2%, respectively). Patients with PIs also frequently received interventions focusing on the heels (72.9%) and mobilization (69.2%). With regard to the outcome level, the overall and hospital-acquired PI prevalence rates were 3.6% and 1.3%, respectively. We recommend focusing on staff, patient and family education including the prevention and treatment of hydration and nutritional deficits, an uncommonly used intervention in Austria based on these data, to improve the quality of PI prevention and care in the hospital setting.

Low-Density Lipoprotein Cholesterol Lowering for the Primary Prevention of Cardiovascular Disease Among Men With Primary Elevations of Low-Density Lipoprotein Cholesterol Levels of 190 mg/dL or Above: Analyses From the WOSCOPS (West of Scotland Coronary Prevention Study) 5-Year Randomized Trial and 20-Year Observational Follow-Up.

BACKGROUND: Patients with primary elevations of low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL are at a higher risk of atherosclerotic cardiovascular disease as a result of long-term exposure to markedly elevated LDL-C levels. Therefore, initiation of statin therapy is recommended for these individuals. However, there is a lack of randomized trial evidence supporting these recommendations in primary prevention. In the present analysis, we provide hitherto unpublished data on the cardiovascular effects of LDL-C lowering among a primary prevention population with LDL-C ≥190 mg/dL. METHODS: We aimed to assess the benefits of LDL-C lowering on cardiovascular outcomes among individuals with primary elevations of LDL-C ≥190 mg/dL without preexisting vascular disease at baseline. We performed post hoc analyses from the WOSCOPS (West of Scotland Coronary Prevention Study) randomized, placebo-controlled trial, and observational posttrial long-term follow-up, after excluding individuals with evidence of vascular disease at baseline. WOSCOPS enrolled 6595 men aged 45 to 64 years, who were randomly assigned to pravastatin 40 mg/d or placebo. In the present analyses, 5529 participants without evidence of vascular disease were included, stratified by LDL-C levels into those with LDL-C <190 mg/dL (n=2969; mean LDL-C 178±6 mg/dL) and those with LDL-C ≥190 mg/dL (n=2560; mean LDL-C 206±12 mg/dL). The effect of pravastatin versus placebo on coronary heart disease and major adverse cardiovascular events were assessed over the 4.9-year randomized controlled trial phase and on mortality outcomes over a total of 20 years of follow-up. RESULTS: Among 5529 individuals without vascular disease, pravastatin reduced the risk of coronary heart disease by 27% (P=0.002) and major adverse cardiovascular events by 25% (P=0.004) consistently among those with and without LDL-C ≥190 mg/dL (P-interaction >0.9). Among individuals with LDL-C ≥190 mg/dL, pravastatin reduced the risk of coronary heart disease by 27% (P=0.033) and major adverse cardiovascular events by 25% (P=0.037) during the initial trial phase and the risk of coronary heart disease death, cardiovascular death, and all-cause mortality by 28% (P=0.020), 25% (P=0.009), and 18% (P=0.004), respectively, over a total of 20 years of follow-up. CONCLUSIONS: The present analyses provide robust novel evidence for the short- and long-term benefits of lowering LDL-C for the primary prevention of cardiovascular disease among individuals with primary elevations of LDL-C ≥190 mg/dL.

Progress in preventive therapy for cancer: a reminiscence and personal viewpoint.

Prophylactic drug treatment with aspirin, statins and anti-hypertensive agents has had a major impact on the incidence of cardiovascular disease and is now well established. Progress in therapeutic cancer prevention has been much slower; only recently have effective agents been clearly established. Breast cancer has led the way and endocrine agents used to treat it-notably tamoxifen and the aromatase inhibitors-have now been shown to have a substantial preventive effect as well. However, these agents carry some toxicity and thus identifying high-risk women who are likely to benefit most is a key priority. In contrast, the ability of low-dose aspirin to prevent about one-third of colorectal, gastric, and oesophageal cancers, combined with its much lower toxicity profile, make it attractive for a much larger proportion of the general population. Vaccination against the human papilloma virus is also a preventive intervention with large benefits for the whole population. Here I recall my involvement in these initiatives and offer a personal viewpoint on what has been achieved and what remains to be done.

Global status of diabetes prevention and prospects for action: A consensus statement.

Primary prevention of type 2 diabetes (T2D) should be achievable through the implementation of early and sustainable measures. Several randomized control studies that found success in preventing the progression to T2D in high-risk populations have identified early and intensive intervention based on an individualized prevention model as the key factor for participant benefit. The global prevalence of both overweight and obesity has now been widely recognized as the major epidemic of the 21st century. Obesity is a major risk factor for the progression from normal glucose tolerance to prediabetes and then to T2D. However, not all obese individuals will develop prediabetes or progress to diabetes. Intensive, multicomponent behavioural interventions for overweight and obese adults can lead to weight loss. Diabetes medications, including metformin, GLP-1 agonists, glitazones, and acarbose, can be considered for selected high-risk patients with prediabetes when lifestyle-based programmes are proven unsuccessful. Nutrition education is the cornerstone of a healthy lifestyle. Also, physical activity is an integral part of the prediabetes management plan and one of the main pillars in the prevention of diabetes. Mobile phones, used extensively worldwide, can facilitate communication between health professionals and the general population, and have been shown to be helpful in the prevention of T2D. Universal screening is needed. Noninvasive risk scores should be used in all countries, but they should be locally validated in all ethnic populations focusing on cultural differences around the world. Lifestyle interventions reduce the progression to prediabetes and diabetes. Nevertheless, many questions still need to be answered.

The Future of Migraine Prevention.

Barring unforeseen circumstances, we anticipate the arrival of the first mechanism-specific class of molecules for migraine prevention in 2018. Despite many ground-breaking advances in the field over the last several years, these agents, broadly identified as calcitonin gene-related peptide-based pharmaceuticals, have captured the imagination and attention of the lay press and much of the headache community. This paper will address the factors, both class-specific and systems-based, that are likely to affect the launch, access, compliance, and adherence related to this new class, as well as attempt to place these novel medications in context of the current state and anticipated changes in headache medicine.

Recent advances in the prevention of mental disorders.

PURPOSE: Prevention of mental disorders is a rapidly growing area of research with substantial potential benefits for population health. This paper reviews the evidence base for prevention of depression, anxiety, and schizophrenia. METHODS: We synthesized evidence from recent systematic reviews and meta-analyses published between 2013 and 2018 on prevention of depression, anxiety, and first-episode psychosis. We included reviews of randomized controlled trials testing psychological, psychosocial, and pharmacological preventive interventions. RESULTS: There is good evidence that depression and anxiety can be prevented, although effect sizes are generally small. Indicated prevention of first-episode psychosis appears promising. Economic evaluations provide support for prevention of depression, anxiety, and first-episode psychosis, but more studies evaluating costs and benefits are needed to strengthen the knowledge base, particularly regarding long-term outcomes, which include chronicity of the prevented disorder, as well as later occurence of important comorbid mental and physical health problems. Promising areas for further development include internet- or computer-based prevention strategies, mindfulness-based interventions, and integration of prevention programs within occupational settings. CONCLUSIONS: A number of interventions to prevent mental disorders are efficacious. While intervention effect sizes are generally small for prevention of depression and anxiety, they may nonetheless be of significant population benefit. Using the growing evidence base to inform policy and dissemination of evidence-based prevention programs is critical for moving prevention science into real-world settings.

Genetic Risk Prediction for Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease: an Update.

PURPOSE OF REVIEW: This review aims to summarize the research on genetic risk scores and their ability to improve risk prediction in both a primary and a secondary prevention population. RECENT FINDINGS: Several groups have examined the role of genetic scores in different patient populations. Recent studies have capitalized on the growing number of identified genetic variants to construct polygenic risk scores that include hundreds and sometimes thousands of SNPs. Also, recent studies have demonstrated that individuals with high genetic risk scores can attenuate their risk with lifestyle modifications and with statins, for which the benefit of treatment may be greater in those at highest genetic risk. Genetic risk scores when added to existing clinical models appear to improve risk prediction, particularly in the setting of incident cardiovascular disease and may provide actionable information to optimize prevention early in life. Future research will need to establish how to best use this genetic risk information either as a means to further individualize treatment decisions or to better identify high-risk populations.

Association of the US Department of Justice Investigation of Implantable Cardioverter-Defibrillators and Devices Not Meeting the Medicare National Coverage Determination, 2007-2015.

Importance: The US Department of Justice (DOJ) conducted an investigation into implantable cardioverter-defibrillators (ICDs) not meeting the Centers for Medicare & Medicaid Services National Coverage Determination (NCD) criteria. Objective: To examine changes in the proportion of initial primary prevention ICDs that did not meet NCD criteria following the announcement of the DOJ investigation at hospitals that reached settlements (settlement hospitals) and those that did not (nonsettlement hospitals). Design, Setting, and Participants: Multicenter, longitudinal, serial cross-sectional analysis of 300 151 initial primary prevention ICDs among Medicare beneficiaries from January 1, 2007, through December 31, 2015, at 1809 US hospitals in the National Cardiovascular Data Registry (NCDR) ICD Registry, of which 452 hospitals (with 99 591 primary prevention ICDs) reached settlements with the DOJ. Exposures: The DOJ investigation announcement in 2010. Main Outcomes and Measures: Proportion of initial primary prevention ICDs not meeting NCD criteria. Results: In January 2007, the proportion of initial ICDs not meeting NCD criteria was 25.8% (95% CI, 24.7% to 26.8%) at settlement hospitals and 22.8% (95% CI, 22.1% to 23.5%) at nonsettlement hospitals (P < .001). Over the study period, there was a 62.7% (95% CI, 59.2% to 66.1%) relative decrease and 16.1% (95% CI, 14.8% to 17.5%) absolute decrease in the proportion of ICDs not meeting NCD criteria at settlement hospitals compared with a 53.2% (95% CI, 50.4% to 56.0%) relative decrease and 12.1% (95% CI, 11.2% to 13.0%) absolute decrease in proportion at nonsettlement hospitals (P < .001 for both; P for interaction < .001). Trends significantly differed between hospital groups only in the period following the announcement of the DOJ investigation (January 2010-June 2011) [corrected], with larger and more rapid decreases at settlement hospitals (P for interaction = .01). Over the study period, there was a 32.8% (95% CI, 29.9% to 35.7%) relative decrease and a 1703 ICDs (95% CI, 1520 to 1886) absolute decrease in the volume of primary prevention ICDs implanted at settlement hospitals compared with a 17.4% (95% CI, 14.8% to 20.0%) relative decrease and a 1495 ICDs (95% CI, 1249 to 1741) absolute decrease in volume at nonsettlement hospitals (P < .001 for both; P for interaction < .001), with more modest decreases or slight increases in secondary prevention ICD volume. These patterns were similar when examining ICD utilization among non-Medicare beneficiaries. Conclusions and Relevance: From 2007 through 2015, the volume of primary prevention implantable cardioverter-defibrillators and the proportion of devices not meeting the Centers for Medicare & Medicaid Services National Coverage Determination criteria decreased at all hospitals with substantially larger decreases at hospitals that reached settlements in the US Department of Justice investigation. These patterns extended to implantable cardioverter-defibrillators placed in non-Medicare beneficiaries, which were not the focus of the US Department of Justice investigation.

The Changing Landscape of HIV Prevention in the United States: Health Department Experiences and Local Adaptations in Response to the National HIV/AIDS Strategy and High-Impact Prevention Approach.

OBJECTIVE: HIV prevention has changed substantially in recent years due to changes in national priorities, biomedical advances, and health care reform. Starting in 2010, motivated by the National HIV/AIDS Strategy (NHAS) and the Centers for Disease Control and Prevention's (CDC's) High-Impact Prevention (HIP), health departments realigned resources so that cost-effective, evidence-based interventions were targeted to groups at risk in areas most affected by HIV. This analysis describes how health departments in diverse settings were affected by NHAS and HIP. METHODS: We conducted interviews and a consultation with health departments from 16 jurisdictions and interviewed CDC project officers who monitored programs in 5 of the jurisdictions. Participants were asked to describe changes since NHAS and HIP and how they adapted. We used inductive qualitative analysis to identify themes of change. RESULTS: Health departments improved their HIV prevention practices in different ways. They aligned jurisdictional plans with NHAS and HIP goals, increased local data use to monitor program performance, streamlined services, and strengthened partnerships to increase service delivery to persons at highest risk for infection/transmission. They shifted efforts to focus more on the needs of people with diagnosed HIV infection, increased HIV testing and routine HIV screening in clinical settings, raised provider and community awareness about preexposure prophylaxis, and used nontraditional strategies to successfully engage out-of-care people with diagnosed HIV infection. However, staff-, provider-, and data-related barriers that could slow scale-up of priority programs were consistently reported by participants, potentially impeding the ability to meet national goals. CONCLUSION: Findings suggest progress toward NHAS and HIP goals has been made in some jurisdictions but highlight the need to monitor prevention programs in different contexts to identify areas for improvement and increase the likelihood of national success. Health departments and federal funders alike can benefit from the routine sharing of successes and challenges associated with local policy implementation, considering effects on the overall portfolio of programs.