County-Level Cardiac Rehabilitation and Broadband Availability: Opportunities for Hybrid Care in the United States.

PURPOSE: Cardiac rehabilitation (CR) improves patient outcomes and quality of life and can be provided virtually through hybrid CR. However, little is known about CR availability in conjunction with broadband access, a requirement for hybrid CR. This study examined the intersection of CR and broadband availability at the county level, nationwide. METHODS: Data were gathered and analyzed in 2022 from the 2019 American Community Survey, the Centers for Medicare & Medicaid Services, and the Federal Communications Commission. Spatially adaptive floating catchments were used to calculate county-level percent CR availability among Medicare fee-for-service beneficiaries. Counties were categorized: by CR availability, whether lowest (ie, CR deserts), medium, or highest; and by broadband availability, whether CR deserts with majority-available broadband, or dual deserts. Results were stratified by state. County-level characteristics were examined for statistical significance by CR availability category. RESULTS: Almost half of US adults (n = 116 325 976, 47.2%) lived in CR desert counties (1691 counties). Among adults in CR desert counties, 96.8% were in CR deserts with majority-available broadband (112 626 906). By state, the percentage of the adult population living in CR desert counties ranged from 3.2% (New Hampshire) to 100% (Hawaii and Washington, DC). Statistically significant differences in county CR availability existed by race/ethnicity, education, and income. CONCLUSIONS: Almost half of US adults live in CR deserts. Given that up to 97% of adults living in CR deserts may have broadband access, implementation of hybrid CR programs that include a telehealth component could expand CR availability to as many as 113 million US adults.

Changes in Self-Measured Blood Pressure Monitoring Use in 14 States From 2019 to 2021: Impact of the COVID-19 Pandemic.

BACKGROUND: Self-measured blood pressure monitoring (SMBP) is an important out-of-office resource that is effective in improving hypertension control. Changes in SMBP use during the Coronavirus Disease 2019 (COVID-19) pandemic have not been described previously. METHODS: Behavioral Risk Factor Surveillance System (BRFSS) data were used to quantify changes in SMBP use between 2019 (prior COVID-19 pandemic) and 2021 (during the COVID-19 pandemic). Fourteen states administered the SMBP module in both years. All data were self-reported from adults who participated in the BRFSS survey. We assessed the receipt of SMBP recommendations from healthcare professionals and actual use of SMBP among those with hypertension (n = 68,820). Among those who used SMBP, we assessed SMBP use at home and sharing BP readings electronically with healthcare professionals. RESULTS: Among adults with hypertension, there was no significant changes between 2019 and 2021 in those reporting SMBP use (57.0% vs. 55.7%) or receiving recommendations from healthcare professionals to use SMBP (66.4% vs. 66.8%). However, among those who used SMBP, there were significant increases in use at home (87.7% vs. 93.5%) and sharing BP readings electronically (8.6% vs. 13.1%) from 2019 to 2021. Differences were noted by demographic characteristics and residence state. CONCLUSIONS: Receiving a recommendation from the healthcare provider to use SMBP and actual use did not differ before and during the COVID-19 pandemic. However, among those who used SMBP, home use and sharing BP readings electronically with healthcare professional increased significantly, although overall sharing remained low (13.1%). Maximizing advances in virtual connections between clinical and community settings should be leveraged for improved hypertension management.

State-Level Hypertension Prevalence and Control Among Adults in the U.S.

INTRODUCTION: Improving hypertension control is a national priority. Electronic health record data have the potential to augment traditional surveillance systems. This study aimed to assess hypertension prevalence and control at the state level using a previously established electronic health record-based phenotype for hypertension. METHODS: Adult patients (N=11,031,368) were included from the IQVIA ambulatory electronic medical record-U.S. 2019 data set. IQVIA ambulatory electronic medical record comprises electronic health records from >100,000 providers and includes patients from every U.S. state and Washington DC. Authors compared hypertension prevalence and control estimates against those from the Behavioral Risk Factor Surveillance System 2019. Results were age-standardized and stratified by state and sociodemographic characteristics. Statistical analyses were conducted in 2022-2023. RESULTS: IQVIA ambulatory electronic medical record-U.S. patients had a median age of 55 years, and 56.7% were women. Overall age-standardized hypertension prevalence was higher in IQVIA ambulatory electronic medical record-U.S. (35.0%) than in the Behavioral Risk Factor Surveillance System (29.7%), however, state-level geographic patterns were similar, with the highest burden in the South and Appalachia. Similar patterns were also observed by sociodemographic characteristics in both data sets: hypertension prevalence was higher in older age groups (than younger), men (than women), and Black patients (than other races). Hypertension control varied widely across states: among states with >1% data coverage, control rates were lowest in Nevada (51.1%), Washington DC (52.0%), and Mississippi (55.2%); highest in Kansas (73.4%), New Jersey (72.3%), and Iowa (71.9%). CONCLUSIONS: This study provided the first-ever estimates of hypertension control for all states and Washington DC. Electronic health record-based surveillance could support hypertension prevention and control efforts at the state level.

Development of a Hypertension Electronic Phenotype for Chronic Disease Surveillance in Electronic Health Records: Key Analytic Decisions and Their Effects.

INTRODUCTION: Modernizing chronic disease surveillance with electronic health record (EHR) data may provide better data to improve hypertension prevention and control, but no consensus exists for an EHR-based surveillance definition for hypertension. The Multi-State EHR-Based Network for Disease Surveillance (MENDS) pilot surveillance system was used to develop and test an electronic phenotype for hypertension. METHODS: We used MENDS data from 1,671,279 patients in Louisiana to examine the effect of different analytic decisions on estimates of hypertension prevalence. Decisions included 1) whether to restrict surveillance to patients with recent blood pressure measurements, 2) varying the number and recency of encounters to define the population at risk of hypertension, 3) how to define hypertension (diagnosis codes, antihypertensive medication, blood pressure measurements, or combinations of these), and 4) how to handle multiple blood pressure measurements on the same day. Results were compared with independent estimates of hypertension prevalence in Louisiana from the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: Applying varying criteria resulted in hypertension prevalence estimates ranging from 19.7% to 59.3%. A hypertension surveillance strategy that includes a population with at least 1 clinical encounter with measured blood pressure in the previous 2 years and identifies hypertension using all available data (≥1 diagnosis code, ≥1 antihypertensive medication, and ≥2 elevated blood pressure values ≥140/90 mm Hg on separate days) generated estimates in line with population-based survey data. This definition estimated the crude 2019 hypertension prevalence in the state of Louisiana as 43.4% (age-adjusted, 41.0%), comparable with the crude BRFSS estimate of 39.7% (age adjusted, 37.1%). CONCLUSION: Applying different criteria to define hypertension using EHR data has a large effect on hypertension prevalence estimates. The proposed electronic phenotype generates hypertension prevalence estimates that align with independent estimates from BRFSS.

Leveraging Electronic Health Records to Construct a Phenotype for Hypertension Surveillance in the United States.

BACKGROUND: Hypertension is an important risk factor for cardiovascular diseases. Electronic health records (EHRs) may augment chronic disease surveillance. We aimed to develop an electronic phenotype (e-phenotype) for hypertension surveillance. METHODS: We included 11,031,368 eligible adults from the 2019 IQVIA Ambulatory Electronic Medical Records-US (AEMR-US) dataset. We identified hypertension using three criteria, alone or in combination: diagnosis codes, blood pressure (BP) measurements, and antihypertensive medications. We compared AEMR-US estimates of hypertension prevalence and control against those from the National Health and Nutrition Examination Survey (NHANES) 2017-18, which defined hypertension as BP ≥130/80 mm Hg or ≥1 antihypertensive medication. RESULTS: The study population had a mean (SD) age of 52.3 (6.7) years, and 56.7% were women. The selected three-criteria e-phenotype (≥1 diagnosis code, ≥2 BP measurements of ≥130/80 mm Hg, or ≥1 antihypertensive medication) yielded similar trends in hypertension prevalence as NHANES: 42.2% (AEMR-US) vs. 44.9% (NHANES) overall, 39.0% vs. 38.7% among women, and 46.5% vs. 50.9% among men. The pattern of age-related increase in hypertension prevalence was similar between AEMR-US and NHANES. The prevalence of hypertension control in AEMR-US was 31.5% using the three-criteria e-phenotype, which was higher than NHANES (14.5%). CONCLUSIONS: Using an EHR dataset of 11 million adults, we constructed a hypertension e-phenotype using three criteria, which can be used for surveillance of hypertension prevalence and control.

Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association.

Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.

Cuff Size Variation Across Manufacturers of Home Blood Pressure Devices: A Current Patient Dilemma.

BACKGROUND: The American Heart Association (AHA) recommends cuff sizes of blood pressure (BP) monitoring devices based on patient arm circumference, which is critical for accurate BP measurement. This study aimed to assess cuff size variation across validated BP devices and to examine the degree of alignment with the AHA recommendations. METHODS: Data on home BP devices were obtained from the US BP Validated Device Listing website and listed cuff sizes were compared against AHA recommendations: small adult (22-26 cm), adult (27-34 cm), large (35-44 cm), and extra-large (XL) (45-52 cm). RESULTS: There were 42 home validated BP devices from 13 manufacturers, and none offered cuffs that were aligned with the AHA recommendations. Over half of the devices (22, 52.4%) were compatible with only a broad-range cuff, generally excluding arm sizes larger than 44 cm. Only 5 devices from 4 manufacturers offered a cuff labeled "XL," and of these, only 3 devices had sizes that covered the AHA XL range. Terminology lacked consistency with manufacturers using: different labels to describe the same-sized cuffs (e.g., 22-42 cm was labeled "integrated," "standard," "adult," "large," and "wide range"); the same labels to describe differently sized cuffs (e.g., cuffs labeled "large" were sized 22-42 cm, 32-38 cm, 32-42 cm, 36-45 cm). CONCLUSIONS: Manufacturers of US home BP devices employ inconsistent terminologies and thresholds for cuff sizes, and sizes were not aligned with AHA recommendations. This lack of standardization could pose challenges for clinicians and patients attempting to select a properly sized cuff to support hypertension diagnosis and management.

Self-Measured Blood Pressure Telemonitoring Programs: A Pragmatic How-to Guide.

Self-measured blood pressure (SMBP) telemonitoring is the process of securely storing and tele-transmitting reliably measured, patient self-performed blood pressure (BP) measurements to healthcare teams, while ensuring that these data are viewable and clinically actionable for the purposes of improving hypertension diagnosis and management. SMBP telemonitoring is a vital component of an overall hypertension control strategy. Herein, we present a pragmatic guide for implementing SMBP in clinical practice and provide a comprehensive list of resources to assist with implementation. Initial steps include defining program goals and scope, selecting the target population, staffing, choosing appropriate (clinically validated) BP devices with proper cuff sizes, and selecting a telemonitoring platform. Adherence to recommended data transmission, security, and data privacy requirements is essential. Clinical workflow implementation involves patient enrollment and training, review of telemonitored data, and initiating or titrating medications in a protocolized fashion based upon this information. Utilizing a team-based care structure is preferred and calculation of average BP for hypertension diagnosis and management is important to align with clinical best practice recommendations. Many stakeholders in the United States are engaged in overcoming challenges to SMBP program adoption. Major barriers include affordability, clinician and program reimbursement, availability of technological elements, challenges with interoperability, and time/workload constraints. Nevertheless, it is anticipated that uptake of SMBP telemonitoring, still at a nascent stage in many parts of the world, will continue to grow, propagated by increased clinician familiarity, broader platform availability, improvements in interoperability, and reductions in costs that occur with scale, competition, and technological innovation.

Recommended and observed statin use among U.S. adults - National Health and Nutrition Examination Survey, 2011-2018.

BACKGROUND: The American College of Cardiology/American Heart Association Blood Cholesterol Guideline was published in 2013 (2013 Cholesterol Guideline) and the Multi-society Guideline on the Management of Blood Cholesterol in 2018 (2018 Cholesterol Guideline). OBJECTIVE: To compare differences in population level estimates for statin recommendations and use between guidelines. METHODS: Using four 2-year cycles from the National Health and Nutrition Examination Survey (2011-2018), we analyzed data from 8,642 non-pregnant adults aged ≥20 years with complete information for blood cholesterol measurements and other cardiovascular risk factors used to define treatment recommendations in the 2013 or 2018 Cholesterol Guidelines. We compared the prevalence of statin recommendations and use between the guidelines, overall and among patient management groups. RESULTS: Under the 2013 Cholesterol Guideline, an estimated 77.8 million (33.6%) adults would be recommended statins, compared to 46.1 million (19.9%) recommended and 50.1 million (21.6%) considered for statins by the 2018 Cholesterol Guideline. Statin use among those recommended treatment was similar utilizing the 2018 Cholesterol Guideline (47.4%) compared to the 2013 Cholesterol Guideline (47.0%). Differences were observed across demographic and patient management groups. CONCLUSION: Compared to the 2013 Cholesterol Guideline, the prevalence of statin recommendations decreased utilizing the 2018 Cholesterol Guideline algorithm, though additional persons would be considered for treatment after risk factor assessment and patient-clinician discussion under the 2018 Cholesterol Guideline. Statin use was suboptimal (<50%) for those recommended treatment under either guideline. Optimizing patient-clinician risk discussions and shared decision making may be needed to improve treatment rates.

Leveraging Electronic Health Record Data for Timely Chronic Disease Surveillance: The Multi-State EHR-Based Network for Disease Surveillance.

CONTEXT: Electronic health record (EHR) data can potentially make chronic disease surveillance more timely, actionable, and sustainable. Although use of EHR data can address numerous limitations of traditional surveillance methods, timely surveillance data with broad population coverage require scalable systems. This report describes implementation, challenges, and lessons learned from the Multi-State EHR-Based Network for Disease Surveillance (MENDS) to help inform how others work with EHR data to develop distributed networks for surveillance. PROGRAM: Funded by the Centers for Disease Control and Prevention (CDC), MENDS is a data modernization demonstration project that aims to develop a timely national chronic disease sentinel surveillance system using EHR data. It facilitates partnerships between data contributors (health information exchanges, other data aggregators) and data users (state and local health departments). MENDS uses query and visualization software to track local emerging trends. The program also uses statistical and geospatial methods to generate prevalence estimates of chronic disease risk measures at the national and local levels. Resulting data products are designed to inform public health practice and improve the health of the population. IMPLEMENTATION: MENDS includes 5 partner sites that leverage EHR data from 91 health system and clinic partners and represents approximately 10 million patients across the United States. Key areas of implementation include governance, partnerships, technical infrastructure and support, chronic disease algorithms and validation, weighting and modeling, and workforce education for public health data users. DISCUSSION: MENDS presents a scalable distributed network model for implementing national chronic disease surveillance that leverages EHR data. Priorities as MENDS matures include producing prevalence estimates at various geographic and subpopulation levels, developing enhanced data sharing and interoperability capacity using international data standards, scaling the network to improve coverage nationally and among underrepresented geographic areas and subpopulations, and expanding surveillance of additional chronic disease measures and social determinants of health.

Blood Pressure Cuff Sizes for Adults in the United States: National Health and Nutrition Examination Survey, 2015-2020.

BACKGROUND: Hypertension, defined as blood pressure (BP) ≥130/80 mm Hg or antihypertensive medication use, affects approximately half of US adults, and appropriately sized BP cuffs are important for accurate BP measurement and hypertension management. METHODS: This cross-sectional study analyzed 13,038 US adults (≥18 years) in the National Health and Nutrition Examination Survey 2015-March 2020 cycles. Recommended BP cuff sizes were categorized based on mid-arm circumference: small adult (≤26 cm), adult (>26 to ≤34 cm), large adult (>34 to ≤44 cm), and extra-large adult (>44 cm). Analyses were weighted and proportions were extrapolated to the US population. RESULTS: Among US adults (246 million), recommended cuff sizes were: 6% (16 million) small adult, 51% adult (125 million), 40% large adult (98 million), and 3% extra-large adult (8 million). Among adults with hypertension (116 million), large or extra-large cuffs were needed by over half (51%) overall, including 65% of those aged 18-34 years and 84% of those with obesity (BMI ≥30 kg/m2). By race/ethnicity, the proportion needing a large or extra-large cuff was 57% of non-Hispanic Black adults, 54% of Hispanic adults, 51% of non-Hispanic White adults, and 23% of non-Hispanic Asian adults. Approximately 40% of adults with hypertension in Medicare needed a large or extra-large cuff, compared to 54% for private insurance and 53% for Medicaid. CONCLUSIONS: Over half of US adults with hypertension need a large or extra-large BP cuff.

An Opportunity to Better Address Hypertension in Women: Self-Measured Blood Pressure Monitoring.

More than 56 million women in the United States have hypertension, including almost one in five women of reproductive age. The prevalence of hypertensive disorders of pregnancy is on the rise, putting more women at risk for adverse pregnancy-related outcomes and atherosclerotic cardiovascular disease later in life. Hypertension can be better detected and controlled in women throughout their life course by supporting self-measured blood pressure monitoring. In this study, we present some potential strategies for strengthening our nation's ability to address hypertension in women focusing on pregnancy-related considerations for self-measured blood pressure monitoring.

Antihypertensive and Statin Medication Adherence Among Medicare Beneficiaries.

INTRODUCTION: Medication adherence is important for optimal management of chronic conditions, including hypertension and hypercholesterolemia. This study describes adherence to antihypertensive and statin medications, individually and collectively, and examines variation in adherence by demographic and geographic characteristics. METHODS: The 2017 prescription drug event data for beneficiaries with Medicare Part D coverage were assessed. Beneficiaries with a proportion of days covered ≥80% were considered adherent. Adjusted prevalence ratios were estimated to quantify the associations between demographic and geographic characteristics and adherence. Adherence estimates were mapped by county of residence using a spatial empirical Bayesian smoothing technique to enhance stability. Analyses were conducted in 2019‒2021. RESULTS: Among the 22.5 million beneficiaries prescribed antihypertensive medications, 77.1% were adherent; among the 16.1 million prescribed statin medications, 81.9% were adherent; and among the 13.5 million prescribed antihypertensive and statin medications, 70.3% were adherent to both. Adherence varied by race/ethnicity: American Indian/Alaska Native (adjusted prevalence ratio=0.83, 95% confidence limit=0.82, 0.842), Hispanic (adjusted prevalence ratio=0.90, 95% confidence limit=0.90, 0.91), and non-Hispanic Black (adjusted prevalence ratio=0.87, 95% confidence limit=0.86, 0.87) beneficiaries were less likely to be adherent than non-Hispanic White beneficiaries. County-level adherence ranged across the U.S. from 25.7% to 88.5% for antihypertensive medications, from 36.0% to 93.8% for statin medications, and from 20.8% to 92.9% for both medications combined and tended to be the lowest in the southern U.S. CONCLUSIONS: This study highlights opportunities for efforts to remove barriers and support medication adherence, especially among racial/ethnic minority groups and within the regions at greatest risk for adverse cardiovascular outcomes.

Blood Pressure Control Among Non-Hispanic Black Adults Is Lower Than Non-Hispanic White Adults Despite Similar Treatment With Antihypertensive Medication: NHANES 2013-2018.

BACKGROUND: Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on antihypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults. METHODS: Data from 2013 to 2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by antihypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) among 4,739 adults. RESULTS: Among those treated with antihypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%-Black adults vs. 23.5%-White adults) and calcium channel blockers (24.2%-Black adults vs. 14.7%-White adults) compared with White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%-Black adults vs. 47.3%-White adults), calcium channel blockers (30.2%-Black adults vs. 40.1%-White adults), and number of medication classes used. CONCLUSIONS: Suboptimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice.

Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension.

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

How Do We Jump-Start Self-measured Blood Pressure Monitoring in the United States? Addressing Barriers Beyond the Published Literature.

Hypertension is highly prevalent in the United States, and many persons with hypertension do not have controlled blood pressure. Self-measured blood pressure monitoring (SMBP), when combined with clinical support, is an evidence-based strategy for lowering blood pressure and improving control in persons with hypertension. For years, there has been support for widespread implementation of SMBP by national organizations and the federal government, and SMBP was highlighted as a primary intervention in the 2020 Surgeon General's Call to Action to Control Hypertension, yet optimal SMBP use remains low. There are well-known patient and clinician barriers to optimal SMBP documented in the literature. We explore additional high-level barriers that have been encountered, as broad policy and systems-level changes have been attempted, and offer potential solutions. Collective efforts could modernize data transfer and processing, improve broadband access, expand device coverage and increase affordability, integrate SMBP into routine care and reimbursement practices, and strengthen patient engagement, trust, and access.

Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE.

PURPOSE: This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence. METHODS: We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type. RESULTS: In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate >50% and 23 states falling below the overall rate for the United States. CONCLUSIONS: The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.

Cruise Ship Travel in the Era of Coronavirus Disease 2019 (COVID-19): A Summary of Outbreaks and a Model of Public Health Interventions.

BACKGROUND: Cruise travel contributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission when there were relatively few cases in the United States. By 14 March 2020, the Centers for Disease Control and Prevention (CDC) issued a No Sail Order suspending US cruise operations; the last US passenger ship docked on 16 April. METHODS: We analyzed SARS-CoV-2 outbreaks on cruises in US waters or carrying US citizens and used regression models to compare voyage characteristics. We used compartmental models to simulate the potential impact of 4 interventions (screening for coronavirus disease 2019 (COVID-19) symptoms; viral testing on 2 days and isolation of positive persons; reduction of passengers by 40%, crew by 20%, and reducing port visits to 1) for 7-day and 14-day voyages. RESULTS: During 19 January to 16 April 2020, 89 voyages on 70 ships had known SARS-CoV-2 outbreaks; 16 ships had recurrent outbreaks. There were 1669 reverse transcription polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infections and 29 confirmed deaths. Longer voyages were associated with more cases (adjusted incidence rate ratio, 1.10, 95% confidence interval [CI]: 1.03-1.17, P < .003). Mathematical models showed that 7-day voyages had about 70% fewer cases than 14-day voyages. On 7-day voyages, the most effective interventions were reducing the number of individuals onboard (43.3% reduction in total infections) and testing passengers and crew (42% reduction in total infections). All four interventions reduced transmission by 80.1%, but no single intervention or combination eliminated transmission. Results were similar for 14-day voyages. CONCLUSIONS: SARS-CoV-2 outbreaks on cruises were common during January-April 2020. Despite all interventions modeled, cruise travel still poses a significant SARS-CoV-2 transmission risk.