Breast Cancer Screening During the COVID-19 Pandemic in the United States: Results From Real-World Health Records Data.

PURPOSE: The COVID-19 pandemic abruptly interrupted breast cancer screening, an essential preventive service in primary care. We aimed to evaluate the pandemic's impact on overall and follow-up breast cancer screening using real-world health records data. METHODS: We retrospectively analyzed a cohort of women eligible for breast cancer screening through the study period from January 1, 2017 to February 28, 2022 using TriNetX Research Network data. We examined the temporal trend of monthly screening volume throughout the study period and compared the rate of adherence to follow-up screening within 24 months after the previous screening when the follow-up screening was due in the pre-COVID period vs the COVID period. To account for multiple screenings in the longitudinal data, we applied a logistic regression model using generalized estimating equations with adjustment for individual-level covariates. RESULTS: Among 1,186,669 screening-eligible women, the monthly screening volume temporarily decreased by 80.6% from February to April 2020 and then rebounded to close to pre-COVID levels by June 2020. Yet, the follow-up screening rate decreased from 78.9% (95% CI, 78.8%-79.0%) in the pre-COVID period to 77.7% (95% CI, 77.6%-77.8%) in the COVID period. Multivariate regression analysis also showed a lower adherence to follow-up screening during the COVID period (odds ratio = 0.86; 0.86-0.87) and a greater pandemic impact among women aged 65 years and older and women of non-Hispanic "other" race (Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander). CONCLUSIONS: The COVID-19 pandemic had a transient negative effect on breast cancer screening overall and a prolonged negative effect on follow-up screening. It also exacerbated gaps in adherence to follow-up screening, especially among certain vulnerable groups, requiring innovative strategies to address potential health disparities in primary care.

Do prescription stimulants increase risk of Parkinson's disease among adults with attention-deficit hyperactivity disorder? A retrospective cohort study.

BACKGROUND: Parkinson's disease (PD) is a common neurodegenerative disorder in older adults that is associated with neuroinflammation, oxidative stress, and characterized by loss of dopaminergic cells. Illicit stimulants increase oxidative stress and are associated with increased risk of PD. Prescription stimulants are similar in mechanism to illicit stimulants, yet their influence on PD is not well described. This study aims to determine if prescription stimulants influence risk of PD among older adults with attention-deficit and hyperactivity disorder (ADHD). METHODS: We implemented a retrospective observational cohort design utilizing the TriNetX database which sources from the electronic health records of 57 healthcare organizations. Inclusion criteria were ADHD diagnosis and age ≥50. Those exposed to stimulants and the unexposed controls were matched based on demographics and known risk factors for PD. The outcome of interest was the incidence of PD over a 30-year follow-up period. We utilized TriNetX software for hazard ratio (HR) analysis. RESULTS: Among the 59,471 individuals treated with prescription stimulants 131 of them developed PD, and there were 272 individuals who developed PD that were not prescribed stimulants. This analysis yielded a HR of 0.419 (HR = 0.419 [95% CI 0.34, 0.516], P = 0.0013). CONCLUSION: Illicit stimulants are associated with increased risk of PD, but this study suggests prescribed stimulants may not impart that same risk. The reduced risk in this cohort may be due to protection from illicit substance use and oxidative stress, however additional study exploring the relationship between prescription stimulants and PD is warranted.

Assessing Risks of Early Childhood Caries in Primary Care Practice Using Electronic Health Records and Neighborhood Data.

CONTEXT: Early childhood caries (ECC) is a persistent public health challenge, affecting more than 56% of US toddlers and preschool-aged children. Despite this, ECC is largely preventable with routine oral hygiene practices, diet, and application of topical fluoride. OBJECTIVE: This study assessed the utilization of preventive oral health care in primary care practices and evaluated the variation in patient characteristic and geographic disparities. DESIGN: We conducted a retrospective study using electronic health records (EHRs) over a 2-year period. Patients' home addresses were geocoded and linked to census-based neighborhood statistics and fluoridated water accessibility. Multiple logistic regression modeling was used to assess the risk of ECC in patients with fluoride preventive care, controlled for demographics, comorbid conditions, and neighborhood risk factors. PARTICIPANTS: Patients aged 6 to 71 months who had primary care providers at family medicine and general pediatric clinics in a large academic medical center. MAIN OUTCOME MEASURE: The presence of dental caries based on diagnoses in EHRs. RESULTS: The study consisted of 10 836 patients: 17% treated with topical fluoride varnish (TFV), 12% prescribed oral fluoride supplement, 6.1% with both TFV and supplement, and 64% without fluoride treatment. Patients with fluoride treatment were 24% to 53% less likely to have ECC. Children living in rural and nonfluoridated water communities had 1.7 to 1.8 times greater risk of developing ECC. Minority, under/uninsured, and low-income patients also were at an increased risk of ECC. CONCLUSION: Despite continuing efforts to improve access to dental care for vulnerable populations, substantial disparities remain among socioeconomically disadvantaged children. To address dental care shortage, primary care clinicians should serve as the safety net to care for vulnerable and underserved children who have no or limited access to oral health services. Future research into the collaboration between primary care and dental providers at the level of both practice and professional education should be considered.

External Validation of the COVID-NoLab and COVID-SimpleLab Prognostic Tools.

Our objective was to externally validate 2 simple risk scores for mortality among a mostly inpatient population with COVID-19 in Canada (588 patients for COVID-NoLab and 479 patients for COVID-SimpleLab). The mortality rates in the low-, moderate-, and high-risk groups for COVID-NoLab were 1.1%, 9.6%, and 21.2%, respectively. The mortality rates for COVID-SimpleLab were 0.0%, 9.8%, and 20.0%, respectively. These values were similar to those in the original derivation cohort. The 2 simple risk scores, now successfully externally validated, offer clinicians a reliable way to quickly identify low-risk inpatients who could potentially be managed as outpatients in the event of a bed shortage. Both are available online (https://ebell-projects.shinyapps.io/covid_nolab/ and https://ebell-projects.shinyapps.io/COVID-SimpleLab/).

Risks of Severe COVID-19 Outcomes Among Patients With Diabetic Polyneuropathy in the United States.

CONTEXT: Diabetic neuropathy (DN) affects more than 50% of diabetic patients who are also likely to have compromised immune system and respiratory function, both of which can make them susceptible to the SARS-CoV-2 virus. OBJECTIVE: To assess the risk of severe COVID-19 illness among adults with DN, compared with those with no DN and those with no diabetes. SETTING: The analysis utilized electronic health records from 55 US health care organizations in the TriNetX research database. DESIGN: A retrospective cohort study. PARTICIPANTS: The analysis included 882 650 adults diagnosed with COVID-19 in January 2020 to June 2021, including 16 641 with DN, 81 329 with diabetes with no neuropathy, and 784 680 with no diabetes. OUTCOME MEASURES: The presence of health care utilization (admissions to emergency department, hospital, intensive care unit), 30-day mortality, clinical presentation (cough, fever, hypoxemia, dyspnea, or acute respiratory distress syndrome), and diagnostic test results after being infected affected by COVID-19. RESULTS: The DN cohort was 1.19 to 2.47 times more likely than the non-DN cohorts to utilize care resources, receive critical care, and have higher 30-day mortality rates. Patients with DN also showed increased risk (1.13-2.18 times) of severe symptoms, such as hypoxemia, dyspnea, and acute respiratory distress syndrome. CONCLUSIONS: Patients with DN had a significantly greater risk of developing severe COVID-19-related complications than those with no DN. It is critical for the public health community to continue preventive measures, such as social distancing, wearing masks, and vaccination, to reduce infection rates, particularly in higher risk groups, such as those with DN.

Transitioning from insulin to dipeptidyl-peptidase 4 (DPP-4) inhibitors for type 2 diabetes.

Insulin administration is time intensive and costly in facility staffing. When we started nursing home patients with type 2 diabetes (T2D) on DPP-4 inhibitors, we tapered insulin when finger stick blood sugar levels dropped to <200 mg/dL. Of 34 patients we were able to stop mealtime insulin in 28 (82%) and stop all insulin in 20 (59%). On average, hemoglobin A1c (HbA1c) decreased 0.5% and weight by 2.8 pounds. Among the 20 who stopped all insulin, HbA1c improved in 11 on average 1% (p=0.02), and weight decreased in 11 on average 4.1 pounds (p=0.66). 12 patients were switched in one day because of a low insulin dose or low HbA1c Tapering duration in the other 8 ranged from 10-727 days with an insulin dose of 28 to 84 units daily. Larger studies are needed to confirm our findings, develop a protocol for tapering insulin, and measure hypoglycemia, comfort and cost.

Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project.

BACKGROUND: Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of "opioid guidelines" is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of "routine" system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. METHODS: Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen's d. RESULTS: Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics' trends. The Cohen's d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05). CONCLUSIONS: Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented. TRIAL REGISTRATION: Not applicable.

Managing Close Contacts of COVID-19 Confirmed Cases in Metropolitan Areas in China.

The novel coronavirus (COVID-19) outbreak has rapidly spread across the world. As medical systems continue to develop vaccines and treatments, it is crucial for the public health community to establish nonpharmaceutical interventions (NPIs) that can effectively mitigate the rate of SARS-Coronavirus-2 (SARS-CoV-2) spread across highly populated residential areas, especially among individuals who have close contact with confirmed cases. A community-driven preparedness strategy has been implemented in metropolitan areas in China. The Chinese Center for Disease Control and Prevention (CCDC) has required that all COVID-19 confirmed cases be recorded and documented in a national notifiable disease surveillance system (NDSS). After receiving reports of newly confirmed cases, an epidemiological services team at the CCDC or trained medical professionals at local clinical facilities start a case-contact investigation. A task force performs home visits to infected individuals. Persons under investigation (PUIs) can stay in designated quarantine facilities for 14 days or in special circumstances can be quarantined at home. This community-based approach involved all stakeholders including local public health departments, public safety authorities, neighborhood councils, and community health centers.

Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project.

BACKGROUND: Systematic implementation of guidelines for opioid therapy management in chronic non-cancer pain can reduce opioid-related harms. However, implementation of guideline-recommended practices in routine care is subpar. The goal of this quality improvement (QI) project is to assess whether a clinic-tailored QI intervention improves the implementation of a health system-wide, guideline-driven policy on opioid prescribing in primary care. This manuscript describes the protocol for this QI project. METHODS: A health system with 28 primary care clinics caring for approximately 294,000 primary care patients developed and implemented a guideline-driven policy on long-term opioid therapy in adults with opioid-treated chronic non-cancer pain (estimated N = 3980). The policy provided multiple recommendations, including the universal use of treatment agreements, urine drug testing, depression and opioid misuse risk screening, and standardized documentation of the chronic pain diagnosis and treatment plan. The project team drew upon existing guidelines, feedback from end-users, experts and health system leadership to develop a robust QI intervention, targeting clinic-level implementation of policy-directed practices. The resulting multi-pronged QI intervention included clinic-wide and individual clinician-level educational interventions. The QI intervention will augment the health system's "routine rollout" method, consisting of a single educational presentation to clinicians in group settings and a separate presentation for staff. A stepped-wedge design will enable 9 primary care clinics to receive the intervention and assessment of within-clinic and between-clinic changes in adherence to the policy items measured by clinic-level electronic health record-based measures and process measures of the experience with the intervention. DISCUSSION: Developing methods for a health system-tailored QI intervention required a multi-step process to incorporate end-user feedback and account for the needs of targeted clinic team members. Delivery of such tailored QI interventions has the potential to enhance uptake of opioid therapy management policies in primary care. Results from this study are anticipated to elucidate the relative value of such QI activities.

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations.

PURPOSE: Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. METHODS: We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours. RESULTS: Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%). CONCLUSIONS: Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation.

Wisconsin Firearm Mortality, 2000-2014.

BACKGROUND: Despite low firearm mortality rates in Wisconsin, overall firearm fatalities continue to rise in recent years. In 2013, the statewide age-adjusted death rate due to firearms was 9.6 per 100,000 persons, the highest mark since the new millennium. This raises not only public safety concerns, but also raises questions regarding ongoing gun violence. OBJECTIVES: To describe the population and geographic characteristics of firearm mortality rates on population and geographic characteristics in Wisconsin. METHODS: Mortality data for firearm deaths caused by suicides, homicides and other death intent were obtained from the Wisconsin Interactive Statistics on Health (WISH) query system from 2000 through 2014. The probability of firearm fatality was analyzed through log-linear Poisson regression models to assess the variations of firearm mortality risks in relation to a person's sex, age, race/ethnicity, and region. RESULTS: Firearm violence is responsible for 14% of injury-related deaths in Wisconsin. Seventy-two percent of firearm-related deaths were attributed to suicides; the majority of decedents were white men aged 45 years or older. The proportion of homicides by gun to all homicides increased from 63% in 2000 to 72% in 2014. Disproportionally high firearm homicides were found among black men aged 18 to 34 years in southeastern Wisconsin, accounting for 38% of the entire gun-related murder deaths. CONCLUSION: Our study shows that the association of the demographic and geographic characteristics with mortality rates differs among suicides, homicides and the other intent. Understanding characteristics associated with firearm related-deaths is the first step toward addressing them.

Together Achieving More: Primary Care Team Communication and Alcohol-Related Healthcare Utilization and Costs.

BACKGROUND: Identifying and engaging excessive alcohol users in primary care may be an effective way to improve patient health outcomes, reduce alcohol-related acute care events, and lower costs. Little is known about what structures of primary care team communication are associated with alcohol-related patient outcomes. METHODS: Using a sociometric survey of primary care clinic communication, this study evaluated the relation between team communication networks and alcohol-related utilization of care and costs. Between May 2013 and December 2013, a total of 155 healthcare employees at 6 primary care clinics participated in a survey on team communication. Three-level hierarchical modeling evaluated the link between connectedness within the care team and the number of alcohol-related emergency department visits, hospital days, and associated medical care costs in the past 12 months for each team's primary care patient panel. RESULTS: Teams (n = 31) whose registered nurses displayed more strong (at least daily) face-to-face ties and strong (at least daily) electronic communication ties had 10% fewer alcohol-related hospital days (rate ratio [RR] = 0.90; 95% confidence interval [CI]: 0.84, 0.97). Furthermore, in an average team size of 19, each additional team member with strong interaction ties across the whole team was associated with $1,030 (95% CI: -$1,819, -$241) lower alcohol-related patient healthcare costs per 1,000 team patients in the past 12 months. Conversely, teams whose primary care practitioner (PCP) had more strong face-to-face communication ties and more weak (weekly or several times a week) electronic communication ties had 12% more alcohol-related hospital days (RR = 1.12; 95% CI: 1.03, 1.23) and $1,428 (95% CI: $378, $2,478) higher alcohol-related healthcare costs per 1,000 patients in the past 12 months. The analyses controlled for patient age, gender, insurance, and comorbidity diagnoses. CONCLUSIONS: Excessive alcohol-using patients may fair better if cared for by teams whose face-to-face and electronic communication networks include more team members and whose communication to the PCP has been streamlined to fewer team members.

Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.

PURPOSE: Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease. METHODS: Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months. RESULTS: Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50-0.77) and lower medical care costs (-$556; 95% CI, -$781 to -$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09-1.94) and greater costs ($506; 95% CI, $202-$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes. CONCLUSIONS: Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost.

Personal, health system, and geosocial disparities in appointment nonadherence at family medicine clinics in southcentral Pennsylvania, United States.

Background: To assess the relationship between patients' demographic, health system-related, and geosocial characteristics and the risk of missed appointments among patients in family medicine practice. Methods: The study was based on a retrospective cross-sectional design using electronic health records and neighborhood-level social determents of health metrics linked by geocoded patients' home address. The study population consisted of patients who had a primary care provider and at least one appointment at 14 family medicine clinics in rural and suburban areas in January-December 2022. Negative binomial regression was utilized to examine the impact of personal, health system, and geosocial effects on the risk of no-shows and same-day cancellations. Results: A total of 258,614 appointments were made from 75,182 patients during the study period, including 7.8% no-show appointments from 20,256 patients. The analysis revealed that individuals in the ethnic minority groups were 1.24-1.65 times more likely to miss their appointments than their White counterpart. Females and English speakers had 14% lower risk for no-show. A significant increase (32%-64%) in the odds of no-shows was found among individuals on Medicaid and uninsured. Persons with prior history of no-shows or same day cancellations were 6%-27% more likely to miss their appointments. The no-show risk was also higher among people living in areas experiencing socioeconomic disadvantage. Conclusion: The risk of missed appointments is affected by personal, health system, and geosocial contexts. Future efforts aiming to reduce no-shows could develop personalized interventions targeting the at-risk populations identified in the analysis.

Assessing men with opioid use disorder for testosterone deficiency after the development of symptoms.

OBJECTIVE: Individuals with opioid use disorder (OUD) have reduced life expectancy and inferior outcomes when treated for depression, diabetes, and fractures. Their elevated risk of testosterone deficiency may contribute to all of these relationships, however few individuals prescribed opioids are evaluated with testosterone assays. The purpose of this study is to determine whether patients with opioid use disorder are evaluated for testosterone deficiency after development of a symptom that may merit investigation, such as erectile dysfunction (ED). METHOD: We conducted a retrospective longitudinal cohort study that utilized data from a national database called TriNetX. Patients were eligible for inclusion if they were 20 to 90 years of age, male, and diagnosed with erectile dysfunction. We utilized descriptive statistics and logistic regression to address study aims. RESULTS: Testosterone testing was uncommon for all patients with ED. Among 20,658 patients, it was assessed in 11.2% with OUD and 15.1% without OUD. Among those screened, 40% individuals with OUD and ED had testosterone deficiency. Odds of screening those with OUD were lower than matched controls (RR 0.74). CONCLUSIONS: Individuals with OUD are at increased risk of testosterone deficiency than the general population, but nearly 90% are not evaluated for this condition even after development symptoms. That 40% of individuals assessed were classified as testosterone deficient suggests endocrine disorders may be contributing to increased fracture risk, chronic pain, and severe depression commonly encountered in patients with OUD. Addressing this care gap may reduce morbidity and mortality associated with opioid use disorder.

Integrated pain care models and the importance of aligning stakeholder values.

Sustained widespread deployment of clinically and cost-effective models of integrated pain care could be bolstered by optimally aligning shared stakeholder values.

Assessing the risk of COVID-19 reinfection and severe outcomes among individuals with substance use disorders: a retrospective study using real-world electronic health records.

OBJECTIVE: Despite advancement in vaccines and treatments for COVID-19 over the past 2 years, many concerns remain about reinfection and waning immunity against COVID-19 and its variants, especially among people with substance use disorder (SUD). The study assessed the risk of COVID-19 reinfection and severe illness among adults with SUD and their vaccination status to inform management in this vulnerable population as the pandemic continues. DESIGN: Retrospective cohort study. SETTING: Nationwide electronic health records (TriNetX database) in the USA among adults with COVID-19 infection from January 2020 to June 2022. PARTICIPANTS: Adults (age ≥18 years) who were infected by COVID-19, excluding those who had cancer or lived in nursing homes or palliative care facilities. OUTCOME MEASURES: COVID-19 reinfection was defined as a new diagnosis after 45 days of the initial infection. Logistic regression was applied to assess the OR of COVID-19 reinfection and severe outcomes within 30 day of reinfection for adults with alcohol (AUD), opioid (OUD), cocaine (CUD), stimulant (STUD), cannabis (CAUD) and other use disorders, controlled for demographic and comorbid conditions. RESULTS: The SUD cohort was 13%-29% more likely to be reinfected by COVID-19 and had significantly higher 30-day mortality. Adults with AUD, STUD and OUD were at greater risks (adjusted ORs, AORs=1.69-1.86) of emergency department, hospital and intensive care admissions after 30 days of reinfection. Individuals with SUD and multiple vaccines doses were associated with decreased risks of worse COVID-19 outcomes. Lower COVID-19 reinfection rates (AORs=0.67-0.84) were only found among individuals with AUD, CUD or CAUD who had COVID-19 vaccination. CONCLUSIONS: Individuals with SUD had greater risks of COVID-19 reinfection and poor outcomes, especially those with OUD, STUD and AUD. Multiple vaccinations are recommended to reduce severe illness after COVID-19 reinfection in the SUD population.

Opioid dose risk, clinician and patient characteristics, and adherence to opioid prescribing recommendations in chronic non-cancer pain.

OBJECTIVE: This study aims to assess associations between morphine-equivalent daily dose (MEDD) of opioids, clinician and patient characteristics, and prescriber adherence to guidelines for long-term opioid therapy (LTOT) in chronic noncancer pain (CNCP) and to elucidate potential relationships associated with increased-risk opioid prescribing. DESIGN: Retrospective cross-sectional study. SETTING: Academic health system's 33 primary care clinics. PATIENTS: Adults (≥18 years old) prescribed LTOT (10 + outpatient prescriptions in the past year) for CNCP. MAIN OUTCOME MEASURE(S): Electronic health record data on prescribed opioids (for MEDD), clinician/patient characteristics, and adherence rates to LTOT guideline-concordant recommendations. RESULTS: A total of 2,738 patients were eligible, 61.6 percent Lower, 15.7 percent Moderate, and 22.7 percent Higher Risk MEDD (<50, 50-89, and ≥90 mg/day, respectively). Higher MEDD correlated (p < 0.001) with Medicare insurance, current cigarette smoking, higher pain intensity and interference scores, and the presence of opioid use disorder diagnoses. Male clinicians more frequently prescribed (p < 0.001) and male patients were more likely to be prescribed (p < 0.001) higher MEDD compared to their female counterparts. Higher Risk MEDD was associated with higher coprescribed benzodiazepines (p = 0.015), lower depression screening (p = 0.048), urine drug testing (p = 0.003), comparable active treatment agreement (p = 0.189), opioid misuse risk screening (p = 0.619), and prescription drug monitoring checks (p = 0.203). CONCLUSIONS: This study documented that higher MEDD was associated with risks of worse health outcomes without improved adherence to opioid prescribing guideline recommendations. Enhanced clinician awareness of factors associated with MEDD has the potential to mitigate LTOT risks and improve overall patient care.

Gardening Is Associated With Better Cardiovascular Health Status Among Older Adults in the United States: Analysis of the 2019 Behavioral Risk Factor Surveillance System Survey.

BACKGROUND: Gardening benefits health in older adults, but previous studies have limited generalizability or do not adequately adjust for sociodemographic factors or physical activity (PA). OBJECTIVE: We examined health outcomes, fruits and vegetables (F&V) intake, and 10-year mortality risk among gardeners and exercisers compared with nonexercisers. DESIGN: Cross-sectional data of noninstitutionalized US adults in the 2019 Behavioral Risk Factor Surveillance System was collected via landline and cellular phone survey. PARTICIPANTS/SETTING: Adults 65 years and older reporting any PA (n = 146,047) were grouped as gardeners, exercisers, or nonexercisers. MAIN OUTCOME MEASURES: Outcomes included cardiovascular disease (CVD) risk factors, mental and physical health, F&V intake, and 10-year mortality risk. STATISTICAL ANALYSES: Summary statistics were calculated and adjusted logistic regression models were conducted to calculate adjusted odds ratios (aORs) and 95% CIs, accounting for the complex survey design. RESULTS: The sample included gardeners (10.2%), exercisers (60.0%), and nonexercisers (30.8%). Gardeners, compared with nonexercisers, had significantly lower odds of reporting all studied health outcomes and higher odds of consuming 5 or more F&V per day (CVD: aOR 0.60, 95% CI 0.53 to 0.68; stroke: aOR 0.55, 95% CI 0.47 to 0.64; heart attack: aOR 0.63, 95% CI 0.55 to 0.73, high cholesterol: aOR 0.86, 95% CI 0.79 to 0.93; high blood pressure: aOR 0.74, 95% CI 0.68 to 0.81; diabetes: aOR 0.51, 95% CI 0.46 to 0.56; body mass index ≥25: aOR 0.74, 95% CI 0.68 to 0.80; poor mental health status: aOR 0.50, 95% CI 0.43 to 0.59; poor physical health status: aOR 0.35, 95% CI 0.31 to 0.39; 5 or more F&V per day: aOR 1.56, 95% CI 1.40 to 1.57; high 10-year mortality risk: aOR 0.39, 95% CI 0.36 to 0.42). Male and female gardeners had significantly lower odds of reporting diabetes even when compared with exercisers. CONCLUSIONS: Among adults 65 years and older, gardening is associated with better CVD health status, including lower odds of diabetes. Future longitudinal or interventional studies are warranted to determine whether promoting gardening activities can be a CVD risk reduction strategy.

Disparities in Use of Patient Portals Among Adults in Family Medicine.

OBJECTIVE: This study examined patient portal utilization by analyzing the pattern of time and feature use of patients, and thus to identify functionalities of portal use and patient characteristics that may inform future strategies to enhance communication and care coordination through online portals. METHODS: We conducted a retrospective study of patients at 18 family medicine clinics over a 5-year period using access log records in the electronic health record database. Dimensionality reduction analysis was applied to group portal functionalities into 4 underlying feature domains: messaging, health information management, billing/insurance, and resource/education. Negative binomial regression analysis was used to evaluate how patient and practice characteristics affected the use of each feature domain. RESULTS: Patients with more chronic conditions, lab tests, or prescriptions generally showed greater patient portal usage. However, patients who were male, elderly, in minority groups, or living in rural areas persistently had lower portal usage. Individuals on public insurance were also less likely than those on commercial insurance to use patient portals, although Medicare patients showed greater portal usage on health information management features, and uninsured patients had greater usage on viewing resource/education features. Having Internet access only affected the use of messaging features. CONCLUSION: Efforts to enroll patients in online portals do not guarantee patients will use the portals to manage their health. When considering the use of patient portals for improving telehealth, clinicians need to be aware of technological, socioeconomic, and cultural challenges faced by their patients.