Patient Factors Associated With Use of Adult Primary Care and Virtual Visits During the COVID-19 Pandemic.

BACKGROUND: The delivery of adult primary care (APC) shifted from predominately in-person to modes of virtual care during the COVID-19 pandemic. It is unclear how these shifts impacted the likelihood of APC use during the pandemic, or how patient characteristics may be associated with the use of virtual care. METHODS: A retrospective cohort study using person-month level datasets from 3 geographically disparate integrated health care systems was conducted for the observation period of January 1, 2020, through June 30, 2021. We estimated a 2-stage model, first adjusting for patient-level sociodemographic, clinical, and cost-sharing factors, using generalized estimating equations with a logit distribution, along with a second-stage multinomial generalized estimating equations model that included an inverse propensity score treatment weight to adjust for the likelihood of APC use. Factors associated with APC use and virtual care use were separately assessed for the 3 sites. RESULTS: Included in the first-stage models were datasets with total person-months of 7,055,549, 11,014,430, and 4,176,934, respectively. Older age, female sex, greater comorbidity, and Black race and Hispanic ethnicity were associated with higher likelihood of any APC use in any month; measures of greater patient cost-sharing were associated with a lower likelihood. Conditional on APC use, older age, and adults identifying as Black, Asian, or Hispanic were less likely to use virtual care. CONCLUSIONS: As the transition in health care continues to evolve, our findings suggest that to ensure vulnerable patient groups receive high quality health care, outreach interventions to reduce barriers to virtual care use may be warranted.

Virtual Care and Urinary Tract Infection Management: Comparing Ancillary Service Orders and Patient Order Fulfillments Between Virtual and In-person Encounters During the COVID-19 Pandemic in the United States.

BACKGROUND: During the COVID-19 pandemic, more health care issues were being managed remotely. Urinary tract infections (UTIs) are being managed more often using telehealth although few reports compare the rate of UTI ancillary service orders placed and fulfilled during these visits. OBJECTIVES: We aimed to evaluate and compare the rate of ancillary service orders and order fulfillments in incident UTI diagnoses between virtual and in-person encounters. RESEARCH DESIGN: The retrospective cohort study involved 3 integrated health care systems: Kaiser Permanente (KP) Colorado, KP Georgia, and KP Mid-Atlantic States. SUBJECTS: We included incident UTI encounters from adult primary care data from January 2019 to June 2021. MEASURES: Data were categorized as: prepandemic (January 2019-March 2020), COVID-19 Era 1 (April 2020-June 2020), and COVID-19 Era 2 (July 2020-June 2021). UTI-specific ancillary services included medication, laboratory, and imaging. Orders and order fulfillments were dichotomized for analyses. Weighted percentages for orders and fulfillments were calculated using inverse probability treatment weighting from logistic regression and compared between virtual and in-person encounters using χ2 tests. RESULTS: We identified 123,907 incident encounters. Virtual encounters increased from 13.4% prepandemic to 39.1% in COVID-19 Era 2. Ancillary service orders from virtual encounters were not placed as often as in-person encounters. However, the weighted percentage for ancillary service order fulfillment across all services remained above 65.3% across sites and eras, with many fulfillment percentages above 90%. CONCLUSIONS: Our study reported a high rate of order fulfillment for both virtual and in-person encounters. Health care systems should encourage providers to place ancillary service orders for uncomplicated diagnoses, such as UTI, to provide enhanced access to patient-centered care.

Health-care-Related Practices in Virtual Behavioral Health Treatment for Major Depression Before and During the COVID-19 Pandemic.

BACKGROUND: The abrupt shift to virtual care at the onset of the COVID-19 pandemic had the potential to disrupt care practices in virtual behavioral health encounters. We examined changes over time in virtual behavioral health-care-related practices for patient encounters with diagnoses of major depression. METHODS: This retrospective cohort study utilized electronic health record data from 3 integrated health care systems. Inverse probability of treatment weighting was used to adjust for covariates across 3 time periods, prepandemic (January 2019-March 2020), peak-pandemic shift to virtual care (April 2020-June 2020), and recovery of health care operations (July 2020-June 2021). First virtual follow-up behavioral health department encounters after an incident diagnostic encounter were examined for differences across the time periods in rates of antidepressant medication orders and fulfillments, and completion of patient-reported symptoms screeners in service of measurement-based care. RESULTS: Antidepressant medication orders declined modestly but significantly in 2 of the 3 systems during the peak-pandemic period but rebounded during the recovery period. There were no significant changes in patient fulfillment of ordered antidepressant medications. Completion of symptom screeners increased significantly in all 3 systems during the peak-pandemic period and continued to increase significantly in the subsequent period. CONCLUSIONS: A rapid shift to virtual behavioral health care was possible without compromising health-care-related practices. The transition and subsequent adjustment period have instead been marked by improved adherence to measurement-based care practices in virtual visits, signaling a potential new capacity for virtual health care delivery.

Time-series analysis of recent antihyperglycemic medication prescribing trends for a diverse sample of Medicare enrollees with type 2 diabetes mellitus in an integrated health system.

PURPOSE: Despite high type 2 diabetes mellitus (T2DM) prevalence in Medicare enrollees, newer therapeutic options, and revised treatment guidelines, little is known about US antihyperglycemic prescribing trends after 2015. This research describes recent monthly antihyperglycemic prescribing trends in a large, diverse population of Medicare enrollees from the US Mid-Atlantic region. METHODS: Encounter data (July 2018-July 2020) for Medicare enrollees 65 years of age or older with T2DM were extracted from electronic health records of a large integrated health system. Descriptive time-series regression models were estimated to describe monthly prescribing rates (ie, prescription orders per 100 eligible plan members with T2DM) overall and by medication subgroups for all-eligible and continuously-eligible samples. Trends in monthly prescription orders per 100 eligible plan members with T2DM were reported. RESULTS: The monthly all-eligible member sample (n > 22,000) exhibited an overall positive baseline monthly prescribing rate of 23.88 T2DM medication orders per 100 members with T2DM and a significant positive monthly prescribing rate trend (ie, change) of 0.12 T2DM medication orders per 100 members with T2DM (P < 0.05). Subgroup T2DM medication order rates per 100 members with T2DM at baseline were 16.28 for first-generation medications, 3.87 for human insulins, 3.04 for insulin analogs, 0.58 for second-generation medications, and 0.11 for combination medications. Human insulins, insulin analogs, and second-generation medications had positive monthly trends (P < 0.05). Among second-generation medications, sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) agonists had positive monthly trends (P < 0.05). Continuously eligible members with T2DM (n = 19,185) had no significant overall monthly prescribing trend; however, human insulins, insulin analogs, and second-generation medications and the SGLT-2 inhibitor class had positive monthly prescribing trends (P < 0.05). CONCLUSION: In a diverse Medicare sample, this study observed increasing monthly trends for second-generation medications, human insulins, and insulin analogs consistent with emerging evidence. Among second-generation medications, SGLT-2 inhibitors became the most commonly prescribed over time.

Development and Validation of a Healthcare Utilization-Based Algorithm to Identify Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

Introduction: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are important events that may precipitate other adverse outcomes. Accurate AECOPD event identification in electronic administrative data is essential for improving population health surveillance and practice management. Objective: Develop codified algorithms to identify moderate and severe AECOPD in two US healthcare systems using administrative data and electronic medical records, and validate their performance by calculating positive predictive value (PPV) and negative predictive value (NPV). Methods: Data from two large regional integrated health systems were used. Eligible patients were identified using International Classification of Diseases (Ninth Edition) COPD diagnosis codes. Two algorithms were developed: one to identify potential moderate AECOPD by selecting outpatient/emergency visits associated with AECOPD-related codes and antibiotic/systemic steroid prescriptions; the other to identify potential severe AECOPD by selecting inpatient visits associated with corresponding codes. Algorithms were validated via patient chart review, adjudicated by a pulmonologist. To estimate PPV, 300 potential moderate AECOPD and 250 potential severe AECOPD events underwent review. To estimate NPV, 200 patients without any AECOPD identified by the algorithms (100 patients each without moderate or severe AECOPD) during the two years following the index date underwent review to identify AECOPD missed by the algorithm (false negatives). Results: The PPVs (95% confidence interval [CI]) for both moderate and severe AECOPD were high: 293/298 (98.3% [96.1-99.5]) and 216/225 (96.0% [92.5-98.2]), respectively. NPV was lower for moderate AECOPD (75.0% [65.3-83.1]) than for severe AECOPD (95.0% [88.7-98.4]). Results were consistent across both healthcare systems. Conclusion: This study developed healthcare utilization-based algorithms to identify moderate and severe AECOPD in two separate healthcare systems. PPV for both algorithms was high; NPV was lower for the moderate algorithm. Replication and consistency of results across two healthcare systems support the external validity of these findings.

Pollen Exposure and Associated Healthcare Utilization: A Population-based Study Using Health Maintenance Organization Data in the Washington, DC, Area.

Rationale: Most studies of the healthcare utilization impact of pollen exposure have focused on emergency department visits or hospital admissions. However, other frequent but lower cost services-phone calls and e-mails to providers and office visits-may also be affected. Objectives: The objective of our study was to estimate the impact of tree and grass pollen exposures on respiratory-related healthcare utilization across a range of medical services, including calls and e-mails to providers, nonurgent face-to-face visits, urgent and emergent care visits, and hospitalizations. Methods: We conducted a retrospective observational study of daily tree and grass pollen counts linked to electronic health records of Kaiser Permanente beneficiaries in the metropolitan Washington, DC, area for 2013-2014. Results: The proportion of Kaiser Permanente beneficiaries with respiratory-related healthcare utilization was significantly greater (for P ⩽ 0.05) given a 1 standard deviation increase in same-day pollen exposure. For tree pollen, a 1 standard deviation increase in same-day pollen exposure was associated with relative increases in utilization ranging from 1.77% (95% confidence interval [CI], 0.07-4.17%) for urgent and emergent care visits to 12.84% (95% CI, 11.02-14.65%) for provider calls/e-mails. For grass pollen exposure, a 1 standard deviation increase in same-day pollen exposure was associated with relative increases in utilization ranging from 1.42% (95% CI, 0.39-2.46) for provider face-to-face visits to 11.09% (95% CI, 9.26-12.92) for provider calls/e-mails. Conclusions: Increased pollen exposure was associated with increases in healthcare utilization across a range of services, with relatively higher increases in provider calls/e-mails and lower increases in emergent or acute care. If climate change increases intensity and geographic scope of pollen exposure as predicted and if this study's estimates of association of peak pollen exposure on healthcare utilization are generalizable, then the impact of climate change on healthcare utilization may be significant.

The Contribution of Patient, Primary Care Physician, and Primary Care Clinic Factors to Good Bone Health Care.

BACKGROUND/OBJECTIVE: Patient, provider, and system factors can contribute to chronic care management and outcomes. Few studies have examined these multilevel associations with osteoporosis care and outcomes. We examined how key process and structural factors at the patient, primary care physician (PCP), and primary care clinic (PCC) levels were associated with guideline concordant osteoporosis pharmacotherapy, daily calcium intake, vitamin D supplementation, and weekly exercise sessions at 52 weeks following enrollment in a cluster randomized controlled trial. METHODS: We conducted a secondary analysis of observational data from 1 site of the trial. The study sample included 1996 men and women ≥ 50 years of age at the time of recruitment following completion of a dual-energy x-ray absorptiometry (DXA) scan and who had complete data at baseline and 52 weeks. Our primary independent variable was "relationship continuity": the DXA-ordering provider was the patient's PCP. Hierarchical linear and logistic regression accounted for patient, provider, and primary care clinic characteristics. RESULTS: In multivariable regression analyses, relationship continuity (ie, the PCP ordered the study DXA) was associated with higher average daily calcium intake and likelihood of vitamin D supplementation at 52 weeks. No PCP or primary care clinic factors were associated with osteoporosis care. CONCLUSIONS: The relationship continuity, in which the provider ordering a DXA is the patient's PCP and therefore also presents the results of a DXA, may help to promote patient behaviors associated with good bone health.

Diet and exercise changes following bone densitometry in the Patient Activation After DXA Result Notification (PAADRN) study.

Calcium and vitamin D intake and exercise are suboptimal among older adults. Following bone densitometry, a letter communicating individualized fracture risk accompanied by an educational brochure improved participants' lifestyle-but no more than existing communication strategies-over 52 weeks. Simple communication strategies are insufficient for achieving optimal levels of bone health behaviors. PURPOSE: The Patient Activation After DXA Result Notification (PAADRN) study was designed to evaluate whether a letter with individualized fracture risk and an educational brochure mailed to patients soon after their DXA might improve bone health behaviors (daily calcium intake, vitamin D supplementation, and weekly exercise sessions) compared to slower, less individualized communication characterizing usual care. METHODS: Participants ≥ 50 years were recruited, at three sites, following their DXA and randomized with 1:1 allocation to intervention and control (usual care only) groups. Data were collected at enrollment interview and by phone survey at 12 and 52 weeks thereafter. Intention-to-treat analyses were conducted on 7749 of the 20,397 eligible participants who enrolled. Changes in bone health behaviors were compared within and between study groups. Average treatment effects and heterogeneity of treatment effects were estimated with multivariable linear and logistic regression models. RESULTS: In unadjusted analyses, calcium intake, vitamin D supplementation, and weekly exercise sessions increased significantly over 52 weeks within both the intervention and control groups (all p < 0.001). In unadjusted analyses and multivariable models, increases in each behavior did not significantly differ between the intervention and control groups. Intervention group participants with a > 20% 10-year fracture risk at enrollment did, however, have a significantly greater increase in calcium intake compared to other study participants (p = 0.031). CONCLUSIONS: Bone health behaviors improved, on average, over 52 weeks among all participants following a DXA. Receipt of the PAADRN letter and educational brochure did not directly improve bone health behaviors compared to usual care. TRIAL REGISTRATION: The Patient Activation after DXA Result Notification (PAADRN) Study is registered at ClinicalTrials.Gov: NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.

Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients.

BACKGROUND: Full disclosure of harmful errors to patients, including a statement of regret, an explanation, acceptance of responsibility and commitment to prevent recurrences is the current standard for physicians in the USA. OBJECTIVE: To examine the extent to which primary care physicians' perceptions of event-level, physician-level and organisation-level factors influence intent to disclose a medical error in challenging situations. DESIGN: Cross-sectional survey containing two hypothetical vignettes: (1) delayed diagnosis of breast cancer, and (2) care coordination breakdown causing a delayed response to patient symptoms. In both cases, multiple physicians shared responsibility for the error, and both involved oncology diagnoses. SETTING: The study was conducted in the context of the HMO Cancer Research Network Cancer Communication Research Center. PARTICIPANTS: Primary care physicians from three integrated healthcare delivery systems located in Washington, Massachusetts and Georgia; responses from 297 participants were included in these analyses. MAIN MEASURES: The dependent variable intent to disclose included intent to provide an apology, an explanation, information about the cause and plans for preventing recurrences. Independent variables included event-level factors (responsibility for the event, perceived seriousness of the event, predictions about a lawsuit); physician-level factors (value of patient-centred communication, communication self-efficacy and feelings about practice); organisation-level factors included perceived support for communication and time constraints. KEY RESULTS: A majority of respondents would not fully disclose in either situation. The strongest predictors of disclosure were perceived personal responsibility, perceived seriousness of the event and perceived value of patient-centred communication. These variables were consistently associated with intent to disclose. CONCLUSION: To make meaningful progress towards improving disclosure; physicians, risk managers, organisational leaders, professional organisations and accreditation bodies need to understand the factors which influence disclosure. Such an understanding is required to inform institutional policies and provider training.

The association between health literacy and cancer-related attitudes, behaviors, and knowledge.

Using a multidimensional assessment of health literacy (the Cancer Message Literacy Test-Listening, the Cancer Message Literacy Test-Reading, and the Lipkus Numeracy Scale), the authors assessed a stratified random sample of 1013 insured adults (40-70 years of age). The authors explored whether low health literacy across all 3 domains (n =111) was associated with sets of variables likely to affect engagement in cancer prevention and screening activities: (a) attitudes and behaviors relating to health care encounters and providers, (b) attitudes toward cancer and health, (c) knowledge of cancer screening tests, and (d) attitudes toward health related media and actual media use. Adults with low health literacy were more likely to report avoiding doctor's visits, to have more fatalistic attitudes toward cancer, to be less accurate in identifying the purpose of cancer screening tests, and more likely to avoid information about diseases they did not have. Compared with other participants, those with lower health literacy were more likely to say that they would seek information about cancer prevention or screening from a health care professional and less likely to turn to the Internet first for such information. Those with lower health literacy reported reading on fewer days and using the computer on fewer days than did other participants. The authors assessed the association of low health literacy with colorectal cancer screening in an age-appropriate subgroup for which colorectal cancer screening is recommended. In these insured subjects receiving care in integrated health care delivery systems, those with low health literacy were less likely to be up to date on screening for colorectal cancer, but the difference was not statistically significant.

Neighborhood socioeconomic status and use of colonoscopy in an insured population--a retrospective cohort study.

BACKGROUND: Low-socioeconomic status (SES) is associated with a higher colorectal cancer (CRC) incidence and mortality. Screening with colonoscopy, the most commonly used test in the US, has been shown to reduce the risk of death from CRC. This study examined if, among insured persons receiving care in integrated healthcare delivery systems, differences exist in colonoscopy use according to neighborhood SES. METHODS: We assembled a retrospective cohort of 100,566 men and women, 50-74 years old, who had been enrolled in one of three US health plans for ≥1 year on January 1, 2000. Subjects were followed until the date of first colonoscopy, date of disenrollment from the health plan, or December 31, 2007, whichever occurred first. We obtained data on colonoscopy use from administrative records. We defined screening colonoscopy as an examination that was not preceded by gastrointestinal conditions in the prior 6-month period. Neighborhood SES was measured using the percentage of households in each subject's census-tract with an income below 1999 federal poverty levels based on 2000 US census data. Analyses, adjusted for demographics and comorbidity index, were performed using Weibull regression models. RESULTS: The average age of the cohort was 60 years and 52.7% were female. During 449,738 person-years of follow-up, fewer subjects in the lowest SES quartile (Q1) compared to the highest quartile (Q4) had any colonoscopy (26.7% vs. 37.1%) or a screening colonoscopy (7.6% vs. 13.3%). In regression analyses, compared to Q4, subjects in Q1 were 16% (adjusted HR = 0.84, 95% CI: 0.80-0.88) less likely to undergo any colonoscopy and 30%(adjusted HR = 0.70, CI: 0.65-0.75) less likely to undergo a screening colonoscopy. CONCLUSION: People in lower-SES neighborhoods are less likely to undergo a colonoscopy, even among insured subjects receiving care in integrated healthcare systems. Removing health insurance barriers alone is unlikely to eliminate disparities in colonoscopy use.

Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response.

PURPOSE: Cancer treatments are complex, involving multiple clinicians, toxic therapies, and uncertain outcomes. Consequently, patients are vulnerable when breakdowns in care occur. This study explored cancer patients' perceptions of preventable, harmful events; the impact of these events; and interactions with clinicians after such events. PATIENTS AND METHODS: In-depth telephone interviews were conducted with cancer patients from three clinical sites. Patients were eligible if they believed: something "went wrong" during their cancer care; the event could have been prevented; and the event caused, or could have caused, significant harm. Interviews focused on patients' perceptions of the event, its impact, and clinicians' responses to the event. RESULTS: Ninety-three of 416 patients queried believed something had gone wrong in their care that was preventable and caused or could have caused harm. Seventy-eight patients completed interviews. Of those interviewed, 28% described a problem with medical care, such as a delay in diagnosis or treatment; 47% described a communication problem, including problems with information exchange or manner; and 24% described problems with both medical care and communication. Perceived harms included physical and emotional harm, disruption of life, effect on family members, damaged physician-patient relationship, and financial expense. Few clinicians initiated discussion of the problematic events. Most patients did not formally report their concerns. CONCLUSION: Cancer patients who believe they experienced a preventable, harmful event during their cancer diagnosis or care often do not formally report their concerns. Systems are needed to encourage patients to report such events and to help physicians and health care systems respond effectively.

Diabetes and drug-associated hyperkalemia: effect of potassium monitoring.

BACKGROUND: Renin-angiotensin-aldosterone system (RAAS) inhibitors are associated with hyperkalemia, but there is little evidence demonstrating patients who receive potassium monitoring have a lower rate of hyperkalemia. OBJECTIVE: To evaluate the association between potassium monitoring and serious hyperkalemia-associated adverse outcomes among patients with diabetes newly initiating RAAS inhibitor therapy. DESIGN: Retrospective observational study. PARTICIPANTS: Patients with diabetes without end-stage renal disease initiating RAAS inhibitor therapy between 2001 and 2006 at three integrated health care systems. MEASUREMENTS: Potassium monitoring and first hyperkalemia-associated adverse event during the initial year of therapy. Hyperkalemia-associated adverse events included hospitalizations, emergency department visits or deaths within 24 h of hyperkalemia diagnosis and/or diagnostic potassium >or=6 mmol/l. Incidence rates were calculated in person-years (p-y). We used inverse probability propensity score weighting to adjust for differences between patients with and without monitoring; Poisson regression was used to obtain adjusted relative risks. RESULTS: A total of 19,391 of 27,355 patients (71%) received potassium monitoring. Serious hyperkalemia-associated events occurred at an incidence rate of 10.2 per 1,000 p-y. Compared to patients without monitoring, adjusted relative risk of hyperkalemia-associated adverse events among all patients with monitoring was 0.50 (0.37, 0.66); in the subset of patients who also had chronic kidney disease (n = 2,176), adjusted relative risk was 0.29 (0.18, 0.46). CONCLUSIONS: Patients prescribed RAAS inhibitors who have both diabetes and chronic kidney disease and receive potassium monitoring are less likely to experience a serious hyperkalemia-associated adverse event compared to similar patients who did not receive potassium monitoring. This evidence supports existing consensus-based guidelines.

Increasingly restrictive definitions of hyperkalemia outcomes in a database study: effect on incidence estimates.

PURPOSE: To determine the incidence of hyperkalemia-associated adverse outcomes among ambulatory patients with diabetes newly initiating renin-angiotensin-aldosterone system (RAAS) inhibitor therapy and to examine to what extent increasingly restrictive definitions of hyperkalemia-associated outcomes influenced incidence estimates. METHODS: Retrospective cohort study of 27 355 individuals with diabetes who were new users of RAAS inhibitors at three integrated healthcare systems. RESULTS: Using the least restrictive definition of hyperkalemia-associated outcome, an ambulatory visit (AV), inpatient hospitalization (IP), or emergency department (ED) visit co-occurring within 7 days of coded hyperkalemia diagnosis and/or potassium concentration of > or =5.5 mmol/L, the incidence rate of hyperkalemia was 30.1 per 1000 person-years (p-y). Restricting to only IP or ED visits co-occurring within 24 hours of coded diagnosis and/or potassium > or =6 mmol/L, the incidence rate was 10.2 per 1000 p-y. When this latter definition was further restricted by removing available potassium laboratory values, the incidence rate declined to 9.5 per 1000 p-y. CONCLUSIONS: Modifying the definition of hyperkalemia-associated outcome resulted in up to threefold differences in incidence rate estimates. Our results demonstrate the value of including potassium laboratory results and AVs in identifying hyperkalemia from electronic data. Comparing incidence estimates across published studies requires consideration of differences in outcome definitions.

The Cardiovascular Research Network: a new paradigm for cardiovascular quality and outcomes research.

BACKGROUND: A clear need exists for a more systematic understanding of the epidemiology, diagnosis, and management of cardiovascular diseases. More robust data are also needed on how well clinical trials are translated into contemporary community practice and the associated resource use, costs, and outcomes. METHODS AND RESULTS: The National Heart, Lung, and Blood Institute recently established the Cardiovascular Research Network, which represents a new paradigm to evaluate the epidemiology, quality of care, and outcomes of cardiovascular disease and to conduct future clinical trials using a community-based model. The network includes 15 geographically distributed health plans with dedicated research centers, National Heart, Lung, and Blood Institute representatives, and an external collaboration and advisory committee. Cardiovascular research network sites bring complementary content and methodological expertise and a diverse population of approximately 11 million individuals treated through various health care delivery models. Each site's rich electronic databases (eg, sociodemographic characteristics, inpatient and outpatient diagnoses and procedures, pharmacy, laboratory, and cost data) are being mapped to create a standardized virtual data warehouse to facilitate rapid and efficient large-scale research studies. Initial projects focus on (1) hypertension recognition and management, (2) quality and outcomes of warfarin therapy, and (3) use, outcomes, and costs of implantable cardioverter defibrillators. CONCLUSIONS: The Cardiovascular Research Network represents a new paradigm in the approach to cardiovascular quality of care and outcomes research among community-based populations. Its unique ability to characterize longitudinally large, diverse populations will yield novel insights into contemporary disease and risk factor surveillance, management, outcomes, and costs. The Cardiovascular Research Network aims to become the national research partner of choice for efforts to improve the prevention, diagnosis, treatment, and outcomes of cardiovascular diseases.