Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians.

DESCRIPTION: The American College of Physicians (ACP) developed this clinical guideline to update recommendations on newer pharmacologic treatments of type 2 diabetes. This clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients' values and preferences, and costs. METHODS: This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacologic treatments of type 2 diabetes, including glucagon-like peptide-1 (GLP-1) agonists, a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins, used either as monotherapy or in combination with other medications. The Clinical Guidelines Committee prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia. Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome, but data were insufficient for network meta-analysis and were not rated with GRADE. AUDIENCE AND PATIENT POPULATION: The audience for this clinical guideline is physicians and other clinicians. The population is nonpregnant adults with type 2 diabetes. RECOMMENDATION 1: ACP recommends adding a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence). • Use an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure. • Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke. RECOMMENDATION 2: ACP recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).

Interventions to Reduce Loneliness in Community-Living Older Adults: a Systematic Review and Meta-analysis.

BACKGROUND: The problem of loneliness has garnered increased attention from policymakers, payors, and providers due to higher rates during the pandemic, particularly among seniors. Prior systematic reviews have in general not been able to reach conclusions about effectiveness of interventions. METHODS: Computerized databases were searched using broad terms such as "loneliness" or "lonely" or "social isolation" or "social support" from Jan 1, 2011 to June 23, 2021. We reference mined existing systematic reviews for additional and older studies. The Social Interventions Research & Evaluation Network database and Google were searched for gray literature on Feb 4, 2022. Eligible studies were RCTs and observational studies of interventions to reduce loneliness in community-living adults that used a validated loneliness scale; studies from low- or middle-income countries were excluded, and studies were excluded if restricted to populations where all persons had the same disease (such as loneliness in persons with dementia). RESULTS: A total of 5971 titles were reviewed and 60 studies were included in the analysis, 36 RCTs and 24 observational studies. Eleven RCTs and 5 observational studies provided moderate certainty evidence that group-based treatment was associated with reduced loneliness (standardized mean difference for RCTs = - 0.27, 95% CI - 0.48, - 0.08). Five RCTs and 5 observational studies provided moderate certainty evidence that internet training was associated with reduced loneliness (standardized mean difference for RCTs = - 0.22, 95% CI - 0.30, - 0.14). Low certainty evidence suggested that group exercises may be associated with very small reductions in loneliness. Evidence was insufficient to reach conclusions about group-based activities, individual in-person interactions, internet-delivered interventions, and telephone-delivered interventions. DISCUSSION: Low-to-moderate certainty evidence exists that group-based treatments, internet training, and possibly group exercises are associated with modest reductions in loneliness in community-living older adults. These findings can inform the design of supplemental benefits and the implementation of evidence-based interventions to address loneliness. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO ( CRD42021272305 ).

Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review.

BACKGROUND: The Veterans Health Administration (VA) serves Veterans in the nation's largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic. METHODS: We searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps. RESULTS: Thirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed. DISCUSSION: VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.

Endoscopic therapies for patients with obesity: a systematic review and meta-analysis.

BACKGROUND: Obesity is a major threat to public health and traditional bariatric surgery continues to have low utilization. Endoscopic treatments for obesity have emerged that offer less risk, but questions remain regarding efficacy, durability, and safety. We compared the efficacy of endoscopic bariatric procedures as compared to other existing treatments. METHODS: A literature search of Embase, Cochrane Central, and Pubmed was conducted from January 1, 2014 to December 7, 2021, including endoscopic bariatric therapies that were FDA or CE approved at the time of search to non-endoscopic treatments. Thirty-seven studies involving 15,639 patients were included. Primary outcomes included % total body weight loss (%TBWL), % excess body weight loss (%EBWL), and adverse events. Secondary outcomes included quality of life data and differences in hemoglobin A1C levels. Strength of clinical trial and observational data were graded according to the Cochrane methods. RESULTS: Intragastric balloons achieved greater %TBWL with a range of 7.6-14.1% compared to 3.3-6.7% with lifestyle modification at 6 months, and 7.5-14.0% compared to 3.1-7.9%, respectively, at 12 months. When endoscopic sleeve gastroplasty (ESG) was compared to laparoscopic sleeve gastrectomy (LSG), ESG had less %TBWL at 4.7-14.4% compared to 18.8-26.5% after LSG at 6 months, and 4.5-18.6% as compared to 28.4-29.3%, respectively, at 12 months. For the AspireAssist, there was greater %TBWL with aspiration therapy compared to lifestyle modification at 12 months, 12.1-18.3% TBWL versus 3.5-5.9% TBWL, respectively. All endoscopic interventions had higher adverse events rates compared to lifestyle modification. CONCLUSION: This review is the first to evaluate various endoscopic bariatric therapies using only RCTs and observational studies for evaluation of weight loss compared with conservative management, lifestyle modification, and bariatric surgery. Endoscopic therapies result in greater weight loss compared to lifestyle modification, but not as much as bariatric surgery. Endoscopic therapies may be beneficial as an alternative to bariatric surgery.

Burnout, employee engagement, and changing organizational contexts in VA primary care during the early COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic involved a rapid change to the working conditions of all healthcare workers (HCW), including those in primary care. Organizational responses to the pandemic, including a shift to virtual care, changes in staffing, and reassignments to testing-related work, may have shifted more burden to these HCWs, increasing their burnout and turnover intent, despite their engagement to their organization. Our objectives were (1) to examine changes in burnout and intent to leave rates in VA primary care from 2017-2020 (before and during the pandemic), and (2) to analyze how individual protective factors and organizational context affected burnout and turnover intent among VA primary care HCWs during the early months of the pandemic. METHODS: We analyzed individual- and healthcare system-level data from 19,894 primary care HCWs in 139 healthcare systems in 2020. We modeled potential relationships between individual-level burnout and turnover intent as outcomes, and individual-level employee engagement, perceptions of workload, leadership, and workgroups. At healthcare system-level, we assessed prior-year levels of burnout and turnover intent, COVID-19 burden (number of tests and deaths), and the extent of virtual care use as potential determinants. We conducted multivariable analyses using logistic regression with standard errors clustered by healthcare system controlled for individual-level demographics and healthcare system complexity. RESULTS: In 2020, 37% of primary care HCWs reported burnout, and 31% reported turnover intent. Highly engaged employees were less burned out (OR = 0.57; 95% CI 0.52-0.63) and had lower turnover intent (OR = 0.62; 95% CI 0.57-0.68). Pre-pandemic healthcare system-level burnout was a major predictor of individual-level pandemic burnout (p = 0.014). Perceptions of reasonable workload, trustworthy leadership, and strong workgroups were also related to lower burnout and turnover intent (p < 0.05 for all). COVID-19 burden, virtual care use, and prior year turnover were not associated with either outcome. CONCLUSIONS: Employee engagement was associated with a lower likelihood of primary care HCW burnout and turnover intent during the pandemic, suggesting it may have a protective effect during stressful times. COVID-19 burden and virtual care use were not related to either outcome. Future research should focus on understanding the relationship between engagement and burnout and improving well-being in primary care.

Gender Differences in the Relationship Between Workplace Civility and Burnout Among VA Primary Care Providers.

BACKGROUND: Civility, or politeness, is an important part of the healthcare workplace, and its absence can lead to healthcare provider and staff burnout. Lack of civility is well-documented among mostly female nurses, but is not well-described among the gender-mixed primary care provider (PCP) workforce. Understanding civility and its relationship to burnout among male and female PCPs could help lead to tailored interventions to improve civility and reduce burnout in primary care. OBJECTIVE: To analyze gender differences in civility, burnout, and the relationship between civility and burnout among male and female PCPs. DESIGN: Multi-level logistic regression analysis of a cross-sectional national survey. PARTICIPANTS: A total of 3216 PCP respondents (1946 women and 1270 men) in 135 medical centers from a 2019 national Veterans Health Administration (VA) survey. MAIN MEASURES: Outcomes: burnout; predictors: workplace civility and gender; controls: race, ethnicity, VA tenure, and supervisory status. KEY RESULTS: Workplace civility was rated higher (p<0.001) among male (mean = 4.07, standard deviation [SD] = 0.36, range 1-5) compared to female (mean = 3.88, SD = 0.33) PCPs. Almost half of the sample reported burnout (47.6%), but this difference was not significant (p = 0.73) between the genders. Higher workplace civility was significantly related to lower burnout among female PCPs (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31 to 0.69), but not among male PCPs (OR = 0.71, 95% CI = 0.42 to 1.22). Interactions between civility and other demographic variables (race, ethnicity, VA tenure, or supervisory status) were not significantly related to burnout. CONCLUSION: Female PCPs report lower workplace civility than male PCPs. An inverse relationship between civility and burnout is present for women but not men. More research is needed on this phenomenon. Interventions tailored to gender- and primary care-specific needs should be employed to increase civility and reduce burnout among PCPs.

Trends in Robot-Assisted Procedures for General Surgery in the Veterans Health Administration.

INTRODUCTION: Implementation of robot-assisted procedures is growing. Utilization within the country's largest healthcare network, the Veterans Health Administration, is unclear. METHODS: A retrospective cohort study using data from the Department of Veterans Affairs Corporate Data Warehouse from January 2015 through December 2019. Trends in robot utilization for cholecystectomy, ventral hernia repair, and inguinal hernia repair were characterized nationally and regionally by Veterans Integrated Services Network. Patients, who underwent laparoscopic repairs for these procedures and open hernia repairs, were included to determine proportion performed robotically. RESULTS: We identified 119,191 patients, of which 5689 (4.77%) received a robotic operation. The proportion of operations performed robotically increased from 1.49% to 10.55% (7.08-fold change; slope, 2.14% per year; 95% confidence interval [0.79%, 3.49%]). Ventral hernia repair had the largest growth in robotic procedures (1.51% to 13.94%; 9.23-fold change; slope, 2.86% per year; 95% confidence interval [1.04%, 4.68%]). Regions with the largest increase in robotic utilization were primarily along the Northeast, Midwest, and West Coast. CONCLUSIONS: Robot utilization in general surgery is increasing at different rates across the United States in the Veterans Health Administration. Future studies should investigate the regional disparities and drivers of this approach.

Robot-Assisted General Surgery Procedures at the Veterans Health Administration: A Comparison of Surgical Techniques.

INTRODUCTION: The use of the robot in general surgery has exploded in the last decade. The Veterans Health Administration presents a unique opportunity to study differences between surgical approaches due to the ability to control for health system and insurance variability. This study compares clinical outcomes between robot-assisted and laparoscopic or open techniques for three general surgery procedures. METHODS: A retrospective observational study using the Veterans Affair Surgical Quality Improvement Program database. Operative time, length of stay, and complications were compared for cholecystectomy (robot-assisted versus laparoscopic), ventral, and inguinal hernia repair (robot-assisted versus laparoscopic or open) from 2015 to 2019. RESULTS: More than 80,000 cases were analyzed (21,652 cholecystectomy, 9214 ventral hernia repairs, and 51,324 inguinal hernia repairs). Median operative time was longer for all robot-assisted approaches as compared to laparoscopic or open techniques with the largest difference seen between open and robot-assisted primary ventral hernia repair (unadjusted difference of 93 min, P < 0.001). Median length of stay was between 1 and 4 d and significantly for robot-assisted ventral hernia repairs (versus open, P < 0.01; versus lap for recurrent hernia, P < 0.05). Specific postoperative outcomes of interest were overall low with few differences between techniques. CONCLUSIONS: While the robotic platform was associated with longer operative time, these findings must be interpreted in the context of a learning curve and indications for use (i.e., use of the robot for technically challenging cases). Our findings suggest that at the Veterans Health Administration, the robot is as safe a platform for common general surgery procedures as traditional approaches. Future studies should focus on patient-centered outcomes including pain and cosmesis.

Effect of interventions for non-emergent medical transportation: a systematic review and meta-analysis.

INTRODUCTION: Transportation is an important social determinant of health. We conducted a systematic review of the associations on health and health care utilization of interventions aimed at reducing barriers to non-emergency transportation and non-medical transportation. METHODS: We searched three databases and the gray literature through mid-January 2022. Included studies needed to assess an intervention targeted at non-emergency or non-medical transportation barriers, report missed (or kept) visits, health care utilization, costs, or health outcomes. Data extraction was performed in duplicate and included information about study design, results, and risk of bias. Primary outcomes were frequency of missed appointments, health care utilization, costs, and health outcomes. Synthesis was both narrative and meta-analytic using a random effects model. RESULTS: Twelve studies met inclusion criteria, three randomized trials, one controlled trial, and eight observational studies. All included studies had some element of risk of bias. Populations studied usually had chronic or serious health conditions or were poor. Interventions included van rides, bus or taxi vouchers, ride-sharing services, and others. Meta-analysis of seven studies (three trials, four observational studies) yielded a pooled estimate of missed appointments = 0.63 (95% confidence interval [CI] 0.48, 0.83) favoring interventions. Evidence on cost, utilization, and health outcomes were too sparse to support conclusions. Evidence on the effect of non-medical transportation is limited to a single study. CONCLUSIONS AND RELEVANCE: Interventions aimed at non-emergency transportation barriers to access health care are associated with fewer missed appointments; the association with costs, utilization or health outcomes is insufficiently studied to reach conclusions. This review was registered in PROSPERO as ID CRD42020201875.

Scaling Beyond Early Adopters: a Content Analysis of Literature and Key Informant Perspectives.

BACKGROUND: Innovations and improvements in care delivery are often not spread across all settings that would benefit from their uptake. Scale-up and spread efforts are deliberate efforts to increase the impact of innovations successfully tested in pilot projects so as to benefit more people. The final stages of scale-up and spread initiatives must contend with reaching hard-to-engage sites. OBJECTIVE: To describe the process of scale-up and spread initiatives, with a focus on hard-to-engage sites and strategies to approach them. DESIGN: Qualitative content analysis of systematically identified literature and key informant interviews. PARTICIPANTS: Leads from large magnitude scale-up and spread projects. APPROACH: We conducted a systematic literature search on large magnitude scale-up and spread and interviews with eight project leads, who shared their perspectives on strategies to scale-up and spread clinical and administrative practices across healthcare systems, focusing on hard-to-engage sites. We synthesized these data using content analysis. KEY RESULTS: Searches identified 1919 titles, of which 52 articles were included. Thirty-four discussed general scale-up and spread strategies, 11 described hard-to-engage sites, and 7 discussed strategies for hard-to-engage sites. These included publications were combined with interview findings to describe a fourth phase of the national scale-up and spread process, common challenges for spreading to hard-to-engage sites, and potential benefits of working with hard-to-engage sites, as well as useful strategies for working with hard-to-engage sites. CONCLUSIONS: We identified scant published evidence that describes strategies for reaching hard-to-engage sites. The sparse data we identified aligned with key informant accounts. Future work could focus on better documentation of the later stages of spread efforts, including specific tailoring of approaches and strategies used with hard-to-engage sites. Spread efforts should include a "flexible, tailored approach" for this highly variable group, especially as implementation science is looking to expand its impact in routine care settings.

Association between care coordination tasks with non-VA community care and VA PCP burnout: an analysis of a national, cross-sectional survey.

BACKGROUND: The scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout. METHODS: Our cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate). RESULTS: 51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records. CONCLUSIONS: VA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience.

Distinguishing High-Performing Health Systems Using a Composite of Publicly Reported Measures of Ambulatory Care.

BACKGROUND: Payers and policymakers are rewarding high-performing health care providers on the basis of summaries of overall quality performance, and the methods they use for measuring performance are increasingly important. OBJECTIVE: To develop and evaluate a measure that ranks health care systems by ambulatory care quality. DESIGN: Systems were ranked using a composite model that summarizes individual measures of quality, accounts for their correlation, and does not require health care systems to report every measure. The composite measure's suitability was evaluated by examining whether it captured the quality indicated by component measures (validity), whether differences in rank between health care systems were larger than statistical noise (reliability), and whether year-to-year changes in rank were small (stability). SETTING: California and Minnesota, 2014 to 2016. PARTICIPANTS: 55 health care systems. MEASUREMENTS: Publicly reported measures of ambulatory care quality. RESULTS: The composite measure was valid in that it was broadly representative of the component measures and was not dominated by any single measure. The measure was reliable because the ranks for 93% of California systems and 80% of Minnesota systems were unlikely to be more than 2 places lower or higher. The measure was stable because fewer than half of systems changed ranks by more than 2 ranks from year to year. LIMITATION: The analysis is limited to available measures of ambulatory care quality and includes only 2 states. CONCLUSION: This composite measure uses publicly reported data to produce valid, reliable, and stable ranks of ambulatory care quality for health care systems in Minnesota and California, and this approach could be used in other applications. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Getting Value From Electronic Health Records: Research Needed to Improve Practice.

Electronic health records (EHRs) are now widely adopted in the United States, but health systems have barely begun using them to deliver high-value care. More directed and rigorous research is needed to fulfill the promise of EHRs to not only store information but also support the delivery of better care. This article describes 4 potential benefits of EHR-based research: improving clinical decisions, supporting triage decisions, enabling collaboration among the care team (including patients), and increasing productivity via automation of tasks. Six recommendations are made for conducting and reporting research to catalyze value creation: develop interventions systematically by using user-centered design and a building-block approach; assess value in terms of cost, quality, outcomes, and work required of providers and patients; consider the time horizon for the intervention; test best practices for implementation in a range of real-world contexts; assess subtleties of behavior change tools used to improve high-value behaviors; and report the intervention in enough detail that it can be replicated, including context. Just as research played a critical role in developing early EHR prototypes and demonstrating their value to justify dissemination, research will continue to be essential in the next phase: expanding EHR-based interventions and maximizing their role in creating value.

Sitters as a Patient Safety Strategy to Reduce Hospital Falls: A Systematic Review.

Background: Bedside "sitters" are often used for patients at high risk for falls, but they are expensive and their effectiveness is unclear. Purpose: To review evidence about the effect of sitters and alternatives to sitters on patient falls in acute care hospitals. Data Sources: PubMed searches to 8 October 2019, other databases from inception to December 2018, citation searches on key articles, and a Google search (22 October 2019). Study Selection: English-language studies of any design that assessed the effect of adding sitters to usual care or compared alternatives to sitters (for example, video monitors or "close observation units") for adult patients on general wards of acute care hospitals and reported falls as a primary outcome. Data Extraction: Dual-reviewer extraction of study data and risk of bias; single reviewer with group discussion for GRADE (Grading of Recommendations Assessment, Development and Evaluation) certainty of evidence. Data Synthesis: Of 20 studies meeting inclusion criteria, 2 added sitters to usual care and 18 compared alternatives to sitters. There were no randomized trials, 11 time-series studies, 1 retrospective quasi-experimental study, and 8 pre-post studies. All studies had at least 1 methodological limitation. Two studies provided very-low-certainty evidence that adding sitters reduced falls. Eight studies provided moderate-certainty evidence that interventions that included video monitoring reduced sitter use and either did not affect or reduced the number of falls. Very-low-certainty evidence suggested that interventions that included nurse assessment tools (3 studies) or a close observation unit (2 studies) were effective alternatives to sitters. Limitation: No studies had low risk of bias, publication bias is likely, and studies may have been missed. Conclusion: Despite a compelling rationale, evidence is scant that adding sitters to usual care reduces falls. Primary Funding Source: Veterans Affairs Quality Enhancement Research Initiative. (PROSPERO: CRD42019127424).

What Is the Optimal Primary Care Panel Size?: A Systematic Review.

Background: Primary care for a panel of patients is a central component of population health, but the optimal panel size is unclear. Purpose: To review evidence about the association of primary care panel size with health care outcomes and provider burnout. Data Sources: English-language searches of multiple databases from inception to October 2019 and Google searches performed in September 2019. Study Selection: English-language studies of any design, including simulation models, that assessed the association between primary care panel size and safety, efficacy, patient-centeredness, timeliness, efficiency, equity, or provider burnout. Data Extraction: Independent, dual-reviewer extraction; group consensus rating of certainty of evidence. Data Synthesis: Sixteen hypothesis-testing studies and 12 simulation modeling studies met inclusion criteria. All but 1 hypothesis-testing study were cross-sectional assessments of association. Three studies each provided low-certainty evidence that increasing panel size was associated with no or modestly adverse effects on patient-centered and effective care. Eight studies provided low-certainty evidence that increasing panel size was associated with variable effects on timely care. No studies assessed the effect of panel size on safety, efficiency, or equity. One study provided very-low-certainty evidence of an association between increased panel size and provider burnout. The 12 simulation studies evaluated 5 models; all used access as the only outcome of care. Five and 2 studies, respectively, provided moderate-certainty evidence that adjusting panel size for case mix and adding clinical conditions to the case mix resulted in better access. Limitation: No studies had concurrent comparison groups, and published and unpublished studies may have been missed. Conclusion: Evidence is insufficient to make evidence-based recommendations about the optimal primary care panel size for achieving beneficial health outcomes. Primary Funding Source: Veterans Affairs Quality Enhancement Research Initiative.

Drug therapies for chronic conditions and risk of Alzheimer's disease and related dementias: A scoping review.

INTRODUCTION: Most older Americans use drug therapies for chronic conditions. Several are associated with risk of Alzheimer's disease and related dementias (ADRD). METHODS: A scoping review was used to identify drug classes associated with increasing or decreasing ADRD risk. We analyzed size, type, and findings of the evidence. RESULTS: We identified 29 drug classes across 11 therapeutic areas, and 404 human studies. Most common were studies on drugs for hypertension (93) or hyperlipidemia (81). Fewer than five studies were identified for several anti-diabetic and anti-inflammatory drugs. Evidence was observational only for beta blockers, proton pump inhibitors, benzodiazepines, and disease-modifying anti-rheumatic drugs. For 13 drug classes, 50% or more of the studies reported consistent direction of effect on risk of ADRD. DISCUSSION: Future research targeting drug classes with limited/non-robust evidence, examining sex, racial heterogeneity, and separating classes by molecule, will facilitate understanding of associated risk, and inform clinical and policy efforts to alleviate the growing impact of ADRD.

Veteran Response to Dosage in Chiropractic Therapy (VERDICT): Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain.

BACKGROUND: Low back pain is a leading cause of disability in veterans. Chiropractic care is a well-integrated, nonpharmacological therapy in Veterans Affairs health care facilities, where doctors of chiropractic provide therapeutic interventions focused on the management of low back pain and other musculoskeletal conditions. However, important knowledge gaps remain regarding the effectiveness of chiropractic care in terms of the number and frequency of treatment visits needed for optimal outcomes in veterans with low back pain. DESIGN: This pragmatic, parallel-group randomized trial at four Veterans Affairs sites will include 766 veterans with chronic low back pain who are randomly allocated to a course of low-dose (one to five visits) or higher-dose (eight to 12 visits) chiropractic care for 10 weeks (Phase 1). After Phase 1, participants within each treatment arm will again be randomly allocated to receive either monthly chiropractic chronic pain management for 10 months or no scheduled chiropractic visits (Phase 2). Assessments will be collected electronically. The Roland Morris Disability Questionnaire will be the primary outcome for Phase 1 at week 10 and Phase 2 at week 52. SUMMARY: This trial will provide evidence to guide the chiropractic dose in an initial course of care and an extended-care approach for veterans with chronic low back pain. Accurate information on the effectiveness of different dosing regimens of chiropractic care can greatly assist health care facilities, including Veterans Affairs, in modeling the number of doctors of chiropractic that will best meet the needs of patients with chronic low back pain.

Clinical Effectiveness and Resource Utilization of Surgery versus Endovascular Therapy for Chronic Limb-Threatening Ischemia.

BACKGROUND: The clinical effectiveness of surgical versus endovascular therapy for chronic limb-threatening ischemia (CLTI) continues to be debated, and the resources required for each therapy are unclear. METHODS: Systematic review of randomized controlled trials (RCTs) and observational studies comparing surgery with endovascular therapy for CLTI, which reported clinical effectiveness and resource utilization. Short-term and long-term clinical outcomes were examined. RESULTS: The search yielded 4,231 titles, of which 17 publications met our inclusion criteria. Five publications were all from 1 RCT, and 12 publications were observational studies. In the RCT, the surgical approach had greater resource use in the first year (total hospital days across all admissions for surgery versus angioplasty: 46.14 ± 53.87 vs. 36.35 ± 51.39; P < 0.001; also true for days in high-dependency and intensive therapy units), but differences were not statistically significant in subsequent years. All-cause mortality presented a nonsignificant difference favoring angioplasty in the first 2 years (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [95% CI], 0.75-2.15), but after 2 years, it favored surgical treatment (aHR, 0.34; 95% CI, 0.17-0.71). The observational studies reported short-term effectiveness and resource utilization favoring endovascular therapy, but most differences were not statistically significant. Long-term outcomes were more mixed; in particular, mortality outcomes generally favored surgery, although concluding that cause and effect is not possible as endovascularly treated patients tended to be older and may have had a shorter life expectancy regardless of therapy. CONCLUSIONS: The clinical effectiveness and resource utilization of surgery compared with endovascular therapy for CLTI is not known with certainty and will not be known until ongoing trials report results. It is likely that findings will vary by the time horizon, where initial outcomes and utilization tend to favor endovascular interventions, but long-term outcomes favor surgical revascularization.

Trends in the use of computerized physician order entry by health-system affiliated ambulatory clinics in the United States, 2014-2016.

BACKGROUND: Computerized provider order entry (CPOE) can help providers deliver better quality care. We aimed to understand recent trends in use of CPOE by health system-affiliated ambulatory clinics. METHODS: We analyzed longitudinal data (2014-2016) for 19,109 ambulatory clinics that participated in all 3 years of the Healthcare Information and Management Systems Society Analytics survey to assess use of CPOE and identify characteristics of clinics associated with CPOE use. We calculated descriptive statistics to examine overall trends in use, location of order entry (bedside vs. clinical station), and system-level use CPOE across all clinics. We used linear probability models to explore the association between clinic characteristics (practice size, practice type, and health system type) and two outcomes of interest: CPOE use at any point between 2014 and 2016, and CPOE use beginning in 2015 or 2016. RESULTS: Between 2014 and 2016, use of CPOE increased more than 9 percentage points from 58 to 67%. Larger clinics and those affiliated with multi-hospital health systems were more likely to have reported use of CPOE. We found no difference in CPOE use by primary care versus specialty care clinics. When used, most clinics reported using CPOE for most or all of their orders. Health systems that used CPOE usually did so for all system-affiliated clinics. CONCLUSIONS: Small practice size or not being part of a multi-hospital system are associated with lower use of CPOE between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

Developing and Testing the Agency for Healthcare Research and Quality's National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) Instrument.

In 2011, the Institute of Medicine (IOM) (now the National Academy of Medicine) published standards for trustworthy guidelines and recommended that the National Guideline Clearinghouse (NGC) of the Agency for Healthcare Research and Quality clearly indicate the extent to which guidelines adhere to these standards. To accomplish this, the authors developed and tested the NGC Extent of Adherence to Trustworthy Standards (NEATS) instrument. The standards were operationalized as an instrument containing 15 items that cover disclosure of the funding source; disclosure and management of conflicts of interest; multidisciplinary input; incorporation of patient perspectives; rigorous systematic review; recommendations accompanied by rationale, assessment of benefits and harms, clear linkage to the evidence, and assessment of strength of evidence and strength of recommendation; clear articulation of recommendations; external review by diverse stakeholders; and plans for updating. After multiple rounds of feedback from experts on clinical practice guideline development, the external validity and interrater reliability of the instrument were evaluated. For each item, 80% to 100% of survey respondents judged it to be a good measure of the IOM standards. All external stakeholders stated that NEATS was suitable for its intended goal. Interrater reliability for the final NEATS instrument had a weighted κ of 0.73. The NEATS instrument is a focused tool that provides a concise evaluation of a guideline's adherence to the IOM standards for trustworthy guidelines. It has good external validity among guideline developers and good interrater reliability across trained reviewers.