Implementing and Enhancing Social and Economic Needs Screening at a Federally Qualified Health Center.

BACKGROUND: Programs to screen for social and economic needs (SENs) are challenging to implement. AIM: To describe implementation of an SEN screening program for patients obtaining care at a federally qualified health center (FQHC). SETTING: Large Chicago-area FQHC where many patients are Hispanic/Latino and insured through Medicaid. PROGRAM DESCRIPTION: In the program's phase 1 (beginning April 2020), a prescreening question asked about patients' interest in receiving community resources; staff then called interested patients. After several refinements (e.g., increased staffing, tailored reductions in screening frequency) to address challenges such as a large screening backlog, program phase 2 began in February 2021. In phase 2, a second prescreening question asked about patients' preferred modality to learn about community resources (text/email versus phone calls). PROGRAM EVALUATION: During phase 1, 8925 of 29,861 patients (30%) expressed interest in community resources. Only 40% of interested patients were successfully contacted and screened. In phase 2, 5781 of 21,737 patients (27%) expressed interest in resources; 84% of interested patients were successfully contacted by either text/email (43%) or phone (41%). DISCUSSION: Under one-third of patients obtaining care at an FQHC expressed interest in community resources for SENs. After program refinements, rates of follow-up with interested patients substantially increased.

Association Between ICD-10 Codes for Social Needs and Subsequent Emergency and Inpatient Use.

BACKGROUND: International Classification of Diseases, 10th revision Z codes capture social needs related to health care encounters and may identify elevated risk of acute care use. OBJECTIVES: To examine associations between Z code assignment and subsequent acute care use and explore associations between social need category and acute care use. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Adults continuously enrolled in a commercial or Medicare Advantage plan for ≥15 months (12-month baseline, 3-48 month follow-up). OUTCOMES: All-cause emergency department (ED) visits and inpatient admissions during study follow-up. RESULTS: There were 352,280 patients with any assigned Z codes and 704,560 sampled controls with no Z codes. Among patients with commercial plans, Z code assignment was associated with a 26% higher rate of ED visits [adjusted incidence rate ratio (aIRR) 1.26, 95% CI: 1.25-1.27] and 42% higher rate of inpatient admissions (aIRR 1.42, 95% CI: 1.39-1.44) during follow-up. Among patients with Medicare Advantage plans, Z code assignment was associated with 42% (aIRR 1.42, 95% CI: 1.40-1.43) and 28% (aIRR 1.28, 95% CI: 1.26-1.30) higher rates of ED visits and inpatient admissions, respectively. Within the Z code group, relative to community/social codes, socioeconomic Z codes were associated with higher rates of inpatient admissions (commercial: aIRR 1.10, 95% CI: 1.06-1.14; Medicare Advantage: aIRR 1.24, 95% CI 1.20-1.27), and environmental Z codes were associated with lower rates of both primary outcomes. CONCLUSIONS: Z code assignment was independently associated with higher subsequent emergency and inpatient utilization. Findings suggest Z codes' potential utility for risk prediction and efforts targeting avoidable utilization.

Association of primary care visit length with outpatient utilization, continuity, and care processes.

BACKGROUND: Little is known about how variation in the scheduled length of primary care visits can impact patients' patterns of health care utilization. OBJECTIVE: To evaluate how the scheduled length of in-person visits with primary care physicians (PCPs) was associated with PCP and patient characteristics, outpatient utilization, and preventive care receipt. METHODS: This retrospective cohort study examined data from a large American academic health system. PCP visit length template was defined as either 15- and 30-min scheduled appointments (i.e. 15/30), or 20- and 40-min scheduled appointments (i.e. 20/40). RESULTS: Of 222 included PCPs, 85 (38.3%) used the 15/30 template and 137 (61.7%) used the 20/40 template. The 15/30 group had higher proportions of male (49.4%, vs. 35.8% in the 20/40 group) and family medicine (37.6% vs. 21.2%) physicians. In adjusted patient-level analysis (N = 238,806), having a 15/30 PCP was associated with 9% more primary care visits (incidence rate ratio [IRR], 1.09; 95% confidence interval [CI], 1.03-1.14), and 8% fewer specialty care visits (IRR, 0.92; 95% CI, 0.86-0.98). PCP visit length template was not associated with significant differences in obstetrics/gynaecology visits, continuity of care, or preventive care receipt. In interaction analyses, having a 15/30 PCP was associated with additional primary care visits among non-Hispanic White patients (IRR, 1.10; 95% CI, 1.04-1.16) but not among non-Hispanic Black patients. CONCLUSION: PCPs' choices about the scheduled length of in-person visits may impact their patients' specialty care use, and have varying impacts across different racial/ethnic groups.

Checkup Visits in Adult Federally Qualified Health Center Patients: a Retrospective Cohort Study.

BACKGROUND: Checkup visits (i.e., general health checks) can increase preventive service completion and lead to improved treatment of new chronic illnesses. After the onset of the COVID-19 pandemic, preventive service completion decreased in many groups that receive care in safety net settings. OBJECTIVE: To examine potential benefits associated with checkups in federally qualified health center (FQHC) patients. DESIGN: Retrospective cohort study, from March 2018 to February 2022. PATIENTS: Adults at seven FQHCs in Illinois. INTERVENTIONS: Checkups during a two-year Baseline (i.e., pre-COVID-19) period and two-year COVID-19 period. MAIN MEASURES: The primary outcome was COVID-19 period checkup completion. Secondary outcomes were: mammography completion; new diagnoses of four common chronic illnesses (hypertension, diabetes, depression, or high cholesterol), and; initiation of chronic illness medications. KEY RESULTS: Among 106,114 included patients, race/ethnicity was most commonly Latino/Hispanic (42.1%) or non-Hispanic Black (30.2%). Most patients had Medicaid coverage (40.4%) or were uninsured (33.9%). While 21.0% of patients completed a checkup during Baseline, only 15.3% did so during the COVID-19 period. In multivariable regression analysis, private insurance (versus Medicaid) was positively associated with COVID-19 period checkup completion (adjusted relative risk [aRR], 1.15; 95% confidence interval, [CI], 1.10-1.19), while non-Hispanic Black race/ethnicity (versus Latino/Hispanic) was inversely associated with checkup completion (aRR, 0.89; 95% CI, 0.85-0.93). In secondary outcome analysis, COVID-19 period checkup completion was associated with 61% greater probability of mammography (aRR, 1.61; 95% CI, 1.52-1.71), and significantly higher probability of diagnosis, and treatment initiation, for all four chronic illnesses. In exploratory interaction analysis, checkup completion was more modestly associated with diagnosis and treatment of hypertension and high cholesterol in some younger age groups (versus age ≥ 65). CONCLUSIONS: In this large FQHC cohort, checkup completion markedly decreased during the pandemic. Checkup completion was associated with preventive service completion, chronic illness detection, and initiation of chronic illness treatment.

Primary care delivery of behavioral weight loss services for adults with cardiovascular risk factors: development of pragmatic practice components and results of a randomized feasibility trial.

Background: Intensive lifestyle interventions (ILI) improve weight loss and cardiovascular risk factors, but health systems face challenges implementing them. We engaged stakeholders to cocreate and evaluate feasibility of primary care implementation strategies and of a pragmatic randomization procedure to be used for a future effectiveness trial. Methods: The study setting was a single, urban primary care office. Patients with BMI ≥ 27 and ≥ 1 cardiovascular risk factor were sent a single electronic health record (EHR) message between December 2019 and January 2020 offering services to support an initial weight loss goal of about 10 pounds in 10 weeks. All patients who affirmed weight loss interest were pragmatically enrolled in the trial and offered "Basic Lifestyle Services" (BLS), including a scale that transmits weight data to the EHR using cellular networks, a coupon to enroll in lifestyle coaching resources through a partnering fitness organization, and periodic EHR messages encouraging use of these resources. About half (n = 42) of participants were randomized by an automated EHR algorithm to also receive "Customized Lifestyle Services" (CLS), including weekly email messages adapted to individual weight loss progress and telephonic coaching by a nurse for those facing challenges. Interventions and assessments spanned January to July 2020, with interference by the coronavirus pandemic. Weight measures were collected from administrative sources. Qualitative analysis of stakeholder recommendations and patient interviews assessed acceptability, appropriateness, and sustainability of intervention components. Results: Over 6 weeks, 426 patients were sent the EHR invitation message and 80 (18.8%) affirmed interest in the weight loss goal and were included for analysis. EHR data were available to ascertain a 6-month weight value for 77 (96%) patients. Overall, 62% of participants lost weight; 15.0% exhibited weight loss ≥ 5%, with no statistically significant difference between CLS or BLS arms (p = 0.85). CLS assignment increased participation in daily self-weighing (43% versus 21% of patients through 12 weeks) and enrollment in referral-based lifestyle support resources (52% versus 37%). Conclusions: This preliminary study demonstrates feasibility of implementation strategies for primary care offices to offer and coordinate ILI core components, as well as a pragmatic randomization procedure for use in a future randomized comparative trial.

Treatment modification after initiating second-line medication for type 2 diabetes.

OBJECTIVES: To describe changes in antidiabetic medication (ADM) use and characteristics associated with changes in ADM use after initiation of noninsulin second-line therapy. STUDY DESIGN: Retrospective cohort study. METHODS: This study analyzed private health plan claims for adults with type 2 diabetes who initiated 1 of 5 index ADM classes: sulfonylureas, dipeptidyl peptidase 4 inhibitors (DPP4is), sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or thiazolidinediones. Analyses evaluated 3 treatment modification outcomes-discontinuation, switching, and intensification-over 12-month follow-up. RESULTS: Of 82,624 included adults, nearly two-thirds (63.6%) experienced any treatment modification. Discontinuation was the most common modification (38.6%), especially among patients prescribed GLP-1 RAs (50.3%). Switching occurred in 5.2% of patients and intensification in 19.8%. In adjusted analysis, compared with patients prescribed sulfonylureas, discontinuation risk was 7% higher (HR, 1.07; 95% CI, 1.04-1.10) among patients prescribed DPP4is and 28% higher (HR, 1.28; 95% CI, 1.23-1.33) among patients prescribed GLP-1 RAs. Compared with sulfonylureas, all other index ADM classes had higher risks of switching and lower risks of intensification. Younger age group and female sex were both associated with higher risks of all modifications. Compared with index ADM prescription by a family medicine or internal medicine physician, index prescription by an endocrinologist was associated with both lower discontinuation risk and higher intensification risk. CONCLUSIONS: Most patients experienced a treatment modification within 1 year. Results highlight the need for new prescribing approaches and patient supports that can maximize medication adherence and reduce health system waste.

Social Needs Identified by Diagnostic Codes in Privately Insured U.S. Adults.

INTRODUCTION: The relationships between healthcare use and social needs are not fully understood. In 2015, International Classification of Diseases, Tenth Revision coding introduced voluntary Z codes for social needs‒related healthcare encounters. This study evaluated early national patterns of Z codes in privately insured adults. METHODS: In 2021, the authors conducted a case-control analysis of national commercial health payer claims from 2016 to 2019. Among adults with ≥6 months of continuous enrollment and ≥1 medical claims, patients with any assigned Z codes were defined as cases. Controls were selected through stratified random sampling. Z codes were organized under 3 categories: socioeconomic, community/social, and environmental. RESULTS: Of 29.5 million adults, 521,334 patients (1.8%) had any assigned Z codes. Among all the Z codes, 53.5% identified community/social issues, 30.3% identified environmental issues, and 16.2% identified socioeconomic issues. Among socioeconomic Z codes, housing needs were frequently identified, but needs for food, utility bills, and transportation were very rarely identified. In multivariable regression analysis, females had higher odds of Z code assignment than males. Depression and chronic pulmonary disease were the 2 common comorbidities (≥5% prevalence in cases and controls) that were highly associated with Z code assignment. Less common comorbidities strongly associated with Z code assignment were drug abuse, alcohol abuse, psychoses, and AIDS/HIV. CONCLUSIONS: In this national study of privately insured patients, many Z codes identified healthcare encounters caused by social stressors, whereas few identified food- or transportation-related causes. Depression and chronic pulmonary disease were highly associated with Z code assignment.

Predicting Postpartum Transition to Primary Care in Community Health Centers.

INTRODUCTION: Although the transition to primary care after routine postpartum care has been recommended to mitigate adverse maternal outcomes, little is known about real-world transition patterns. The objective of this study was to describe the patterns and predictors of transition in a postpartum cohort receiving care at federally qualified health centers and a subcohort of clinically high-risk patients. METHODS: Electronic health record data collected between 2017 and 2019 were analyzed in 2021 for unadjusted analyses and multivariable regression models for both the full and high-risk cohorts. The primary outcome was completion of a primary care visit within 6 months of delivery. Primary predictors in both cohorts were insurance loss, postpartum visit, first-trimester visit, and medical visit within the year prepregnancy; for the full cohort, high-risk status was also studied. RESULTS: The full cohort (N=7,926) analysis showed that 17.3% completed a primary care visit. In unadjusted and adjusted analysis, all 5 predictors were significantly associated with primary care visit completion; 25.0% of high-risk patients completed a primary care visit, and patients who lost insurance had 66% lower odds of primary care visit completion (95% CI=0.24, 0.48). In unadjusted and adjusted analysis for the high-risk cohort (n=1,956, 24.7% of full cohort), all predictors except postpartum visit were significantly associated with primary care visit completion. CONCLUSIONS: Postpartum patients at federally qualified health centers transitioned to primary care at low rates; insurance loss was one significant barrier to care. Strategies to increase continuity, including improving insurance access, should be studied. Future research is needed to study structural inequity, the impact of primary care on maternal outcomes, and patient experience.

Addressing Medical and Social Needs to Reduce Unnecessary Health Care Utilization and Costs: A Qualitative Study.

This study explored the goals, and care delivery approaches, of 14 interventions to address patients' medical and social needs. In qualitative interviews with clinicians and researchers, several themes emerged. Participants frequently described their overall goal as meeting patients' diverse needs to prevent avoidable acute care utilization. Medical needs were addressed by ensuring patients received primary care and actively coordinating care across clinical settings. Participants perceived social needs as tightly linked with medical needs, as well as a need for interpersonal skills among intervention staff. Descriptions of overall approaches to meeting patients' needs frequently aligned with principles of trauma-informed care and patient-centered care.

"It closes the gap when the ball is dropped": patient perspectives of a novel smartphone app for regional care coordination after hospital encounters.

Background: Despite the broad adoption of electronic health records (EHRs) for inpatient and outpatient care, and wide availability of EHR-linked portals, these tools are not always effective in informing primary care teams about patients' emergency department (ED) visits or inpatient admissions, leading to persistent gaps in care coordination. The objective of this study was to understand how patients with limited patient portal use in a safety net setting engaged with a smartphone app that used location tracking to detect and notify care teams about patients' hospital use in order to stimulate care coordination and follow-up care. Methods: We recruited English- and Spanish-speaking adults at high risk of hospital use from a Federally Qualified Health Center (FQHC). The app detected when patients visited the hospital and asked them to confirm a hospital visit. When confirmed, the app notified the primary care team about the visit, and the care team followed up with patients according to the FQHC protocols for care coordination. We collected qualitative data on app experience from participants who used the app for four months and used a general inductive approach to identify recurring themes. Results: Participants generally reported a positive app experience, as it helped solve the problem of poor follow-up care. "I liked the goal of the app…Ultimate goal of it was comforting", recounted one participant when describing her app experience. Participants thought the app push notifications could be refined and the app itself could be modernized. Participants also suggested improvements to the push notifications they received from the app and the visit information they entered into the app for care teams to receive. Some participants also suggested improvements to the FQHC's care coordination workflows facilitated by the app, like an immediate connection to the patient's primary care team. Conclusions: The app was well received by low-income patients at high risk of ED/inpatient visits. Future research is needed to determine feasibility of implementation in other settings.

Randomized Trial Evaluating Health System Expenditures with Transitional Care Services for Adults with No Usual Source of Care at Discharge.

BACKGROUND: Multidisciplinary transitional care services reduce readmissions for high-risk patients, but it is unclear if health system costs to offer these intensive services are offset by avoidance of higher downstream expenditures. OBJECTIVE: To evaluate net costs for a health system offering transitional care services DESIGN: One-year pragmatic, randomized trial PARTICIPANTS: Adults aged ≥ 18 without a usual source of follow-up care at the time of hospital discharge were enrolled through a high-volume, urban academic medical center in Chicago, IL, USA, from September 2015 through February 2016. INTERVENTIONS: Eligible patients were silently randomized before discharge by an automated electronic health record algorithm allocating them in a 1:3 ratio to receive routine coordination of post-discharge care (RC) versus being offered intensive, multidisciplinary transitional care (TC) services. MAIN MEASUREMENTS: Health system costs were collected from facility administrative systems and transformed to standardized costs using Medicare reference files. Multivariable generalized linear models estimated proportional differences in net costs over one year. KEY RESULTS: Study patients (489 TC; 164 RC) had a mean age of 44 years; 34% were uninsured, 55% had public insurance, and 49% self-identified as Black or Latinx. Over 90 days, cost differences between groups were not statistically significant. Over 180 days, the TC group had 41% lower ED/observation costs (adjusted cost ratio [aCR], 0.59; 95% CI, 0.36-0.97), 50% lower inpatient costs (aCR, 0.50; 95% CI, 0.27-0.95), and 41% lower total healthcare costs (aCR, 0.59; 95% CI, 0.36-0.99) than the RC group. Over 365 days, total cost differences remained of similar magnitude but no longer were statistically significant. CONCLUSIONS: Offering TC services for vulnerable adults at discharge reduced net health system expenditures over 180 days. The promising economic case for multidisciplinary transitional care interventions warrants further research. TRIAL REGISTRATION: National Clinical Trials Registry (NCT03066492).

Initiating second-line antidiabetic medication among older adults with type 2 diabetes on Metformin.

BACKGROUND: Antidiabetic medications (ADM), especially sulfonylureas (SFU) and basal insulin (BI), are associated with increased risk of hypoglycemia, which is especially concerning among older adults in poor health. The objective of this study was to investigate prescribing patterns of ADM in older adults according to their health status. METHODS: This case control study analyzed administrative claims between 2013 and 2017 from a large national payer. The study population was derived from a nationwide database of 84,720 U.S. adults aged ≥65, who were enrolled in Medicare Advantage health insurance plans. Participants had type 2 diabetes on metformin monotherapy, and started a second-line ADM during the study period. The exposure was a binary variable for health status, with poor health defined by end-stage medical conditions, dementia, or residence in a long-term nursing facility. The outcome was a variable identifying which second-line ADM class was started, categorized as SFU, BI, or other (i.e. all other ADM classes combined). RESULTS: Over half of participants (54%) received SFU as initial second-line ADM, 14% received BI, and 32% received another ADM. In multivariable models, the odds of filling SFU or BI was higher for participants in poor health than those in good or intermediate health [OR 1.13 (95% CI 1.05-1.21) and OR 2.34 (95% CI 2.14-2.55), respectively]. SFU and BI were also more commonly filled by older adults with poor glycemic control. CONCLUSIONS: Despite clinical consensus to use caution prescribing SFU and BI among older adults in poor health, these medications remain frequently used in this particularly vulnerable population.

Association of Primary Care Physician Compensation Incentives and Quality of Care in the United States, 2012-2016.

BACKGROUND: Physician compensation incentives may have positive or negative effects on clinical quality. OBJECTIVE: To assess the association between various physician compensation incentives on technical indicators of primary care quality. DESIGN: Cross-sectional, nationally representative retrospective analysis. PARTICIPANTS: Visits by adults to primary care physicians in the National Ambulatory Medical Care Survey from 2012-2016. We analyzed 49,580 sampled visits, representing 1.45 billion primary care visits. MAIN MEASURES: We assessed the association between 5 compensation incentives - quality measure performance, patient experience scores, individual productivity, practice financial performance, or practice efficiency - and 10 high-value and 7 low-value care measures as well as high-value and low-value care composites. KEY RESULTS: Quality measure performance was an incentive in 22% of visits; patient experience scores, 17%; individual productivity, 57%; practice financial performance, 63%; and practice efficiency, 12%. In adjusted models, none of the compensation incentives were consistently associated with individual high- and low-value measures. None of the compensation incentives were associated with high- or low-value care composites. For example, quality measure performance compensation was not significantly associated with high-value care (visits with quality incentive, 47% of eligible measures met; without quality incentive, 43%; adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI], 0.91 to 1.15) or low-value care (aOR, 0.99; 95% CI, 0.82-1.19). Physician compensation incentives that might be expected to increase low-value care did not: patient experience (aOR for low-value care composite, 0.83; 95% CI, 0.65-1.05), individual productivity (aOR, 1.03; 95% CI, 0.88-1.22), and practice financial performance (aOR, 1.05; 95% CI, 0.81-1.36). CONCLUSION: In this retrospective, cross-sectional, nationally representative analysis of care in the United States, physician compensation incentives were not generally associated with more or less high- or low-value care.

Glycemic Outcomes of Second-Line Diabetes Drug Choice in a Real-World Population.

Hypoglycemia and acute metabolic complications (AMCs; ketoacidosis, hyperosmolarity, and coma) are glycemic outcomes that have high cost and high morbidity; these outcomes must be taken into consideration when choosing initial second-line therapy after metformin. We conducted a retrospective cohort study analyzing national administrative data from adults with type 2 diabetes mellitus who started a second-line diabetes medication (sulfonylureas [SFUs], thiazolidinediones [TZDs], glucagon-like peptide 1 [GLP-1] agonists, dipeptidyl peptidase 4 [DPP-4] inhibitors, basal insulin, or sodium-glucose contransporter 2 [SGLT-2] inhibitors) between April 1, 2011 and September 30, 2015 (N=43,288) and compared rates of hypoglycemia and AMCs. Most patients (24,506 [56.6%]) were prescribed sulfonylurea as second-line treatment, followed by DPP-4 inhibitors (7953 [18.4%]), GLP-1 agonists (3854 [8.9%]), basal insulin (2542 [5.9%]), SGLT-2 inhibitors (2537 [5.9%), and TZDs (1896 [4.4%]). Baseline rates of hypoglycemia varied more than 5-fold across initial second-line antidiabetic medication classes, and rates of AMCs varied 7-fold. Compared with patients taking an SFU, lower adjusted rates of hypoglycemia were associated with taking a DPP-4 inhibitor (63% lower rate; incidence rate ratio [IRR], 0.37; 95% CI, 0.25 to 0.57), SGLT-2 inhibitor (54% lower; IRR, 0.46; 95% CI, 0.22 to 0.94), or TZD (79% lower; IRR, 0.21; 95% CI, 0.08 to 0.56) but not a glucagon-like peptide 1 agonist or basal insulin. For AMCs, only initiation of a DPP-4 inhibitor (43% lower rate; IRR, 0.57; 95% CI, 0.41 to 0.81) was associated with a lower adjusted rate compared with SFU. Use of SGLT-2 inhibitors was not associated with a substantially increased rate of acute metabolic complications compared with SFU. Special attention still needs to be paid to glycemic outcomes when choosing a second-line diabetes therapy following metformin.

General Health Checks in Adult Primary Care: A Review.

Importance: General health checks, also known as general medical examinations, periodic health evaluations, checkups, routine visits, or wellness visits, are commonly performed in adult primary care to identify and prevent disease. Although general health checks are often expected and advocated by patients, clinicians, insurers, and health systems, others question their value. Observations: Randomized trials and observational studies with control groups reported in prior systematic reviews and an updated literature review through March 2021 were included. Among 19 randomized trials (906 to 59 616 participants; follow-up, 1 to 30 years), 5 evaluated a single general health check, 7 evaluated annual health checks, 1 evaluated biannual checks, and 6 evaluated health checks delivered at other frequencies. Twelve of 13 observational studies (240 to 471 415 participants; follow-up, cross-sectional to 5 years) evaluated a single general health check. General health checks were generally not associated with decreased mortality, cardiovascular events, or cardiovascular disease incidence. For example, in the South-East London Screening Study (n = 7229), adults aged 40 to 64 years who were invited to 2 health checks over 2 years, compared with adults not invited to screening, experienced no 8-year mortality benefit (6% vs 5%). General health checks were associated with increased detection of chronic diseases, such as depression and hypertension; moderate improvements in controlling risk factors, such as blood pressure and cholesterol; increased clinical preventive service uptake, such as colorectal and cervical cancer screening; and improvements in patient-reported outcomes, such as quality of life and self-rated health. In the Danish Check-In Study (n = 1104), more patients randomized to receive to a single health check, compared with those randomized to receive usual care, received a new antidepressant prescription over 1 year (5% vs 2%; P = .007). In a propensity score-matched analysis (n = 8917), a higher percentage of patients who attended a Medicare Annual Wellness Visit, compared with those who did not, underwent colorectal cancer screening (69% vs 60%; P < .01). General health checks were sometimes associated with modest improvements in health behaviors such as physical activity and diet. In the OXCHECK trial (n = 4121), fewer patients randomized to receive annual health checks, compared with those not randomized to receive health checks, exercised less than once per month (68% vs 71%; difference, 3.3% [95% CI, 0.5%-6.1%]). Potential adverse effects in individual studies included an increased risk of stroke and increased mortality attributed to increased completion of advance directives. Conclusions and Relevance: General health checks were not associated with reduced mortality or cardiovascular events, but were associated with increased chronic disease recognition and treatment, risk factor control, preventive service uptake, and improved patient-reported outcomes. Primary care teams may reasonably offer general health checks, especially for groups at high risk of overdue preventive services, uncontrolled risk factors, low self-rated health, or poor connection or inadequate access to primary care.

Association Between Internal Medicine Residency Applicant Characteristics and Performance on ACGME Milestones During Intern Year.

BACKGROUND: Residency programs apply varying criteria to the resident selection process. However, it is unclear which applicant characteristics reflect preparedness for residency. OBJECTIVE: We determined the applicant characteristics associated with first-year performance in internal medicine residency as assessed by performance on Accreditation Council for Graduate Medical Education (ACGME) Milestones. METHODS: We examined the association between applicant characteristics and performance on ACGME Milestones during intern year for individuals entering Northwestern University's internal medicine residency between 2013 and 2018. We used bivariate analysis and a multivariable linear regression model to determine the association between individual factors and Milestone performance. RESULTS: Of 203 eligible residents, 198 (98%) were included in the final sample. One hundred fourteen residents (58%) were female, and 116 residents (59%) were White. Mean Step 1 and Step 2 CK scores were 245.5 (SD 12.0) and 258 (SD 10.8) respectively. Step 1 scores, Alpha Omega Alpha membership, medicine clerkship grades, and interview scores were not associated with Milestone performance in the bivariate analysis and were not included in the multivariable model. In the multivariable model, overall clerkship grades, ranking of the medical school, and year entering residency were significantly associated with Milestone performance (P ≤ .04). CONCLUSIONS: Most traditional metrics used in residency selection were not associated with early performance on ACGME Milestones during internal medicine residency.

Costs for commercially insured adults prescribed second-line diabetes medications.

OBJECTIVES: To examine differences in health care costs associated with choice of second-line antidiabetes medication (ADM) for commercially insured adults with type 2 diabetes. STUDY DESIGN: Retrospective cohort study with multiple pretests and posttests. METHODS: Included patients initiated second-line ADM therapy between 2011 and 2015, with variable follow-up through 2017. The 6 index medication classes were sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), basal insulin, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and thiazolidinediones (TZDs). Multivariable regression models compared between-class changes in adjusted quarterly costs after second-line ADM initiation. RESULTS: The study cohort included 34,963 adults. Most were prescribed a sulfonylurea (46.0%) or DPP-4 inhibitor (30.4%). Adjusted quarterly index medication costs were significantly higher for all patients receiving nonsulfonylurea medications, ranging from $108 (95% CI, $99-$118) for TZDs to $742 (95% CI, $720-$765) for GLP-1 RAs. Changes in quarterly total health care costs were significantly higher for all nonsulfonylurea classes. Conversely, changes in quarterly nonpharmacy medical costs were significantly lower for patients receiving DPP-4 inhibitors (-$67; 95% CI, -$92 to -$43), GLP-1 RAs (-$43; 95% CI, -$85 to -$1), and SGLT-2 inhibitors (-$46; 95% CI, -$87 to -$6); changes in all other quarterly costs besides the index medication were significantly lower for patients receiving DPP-4 inhibitors (-$60; 95% CI, -$94 to -$26) and SGLT-2 inhibitors (-$113; 95% CI, -$169 to -$57). CONCLUSIONS: The higher cost of nonsulfonylurea medications was the main driver of relative increases in total costs. Relative decreases in nonpharmacy medical costs among patients receiving newer ADM classes reflect these medications' potential value.

Development of a Smartphone App for Regional Care Coordination Among High-Risk, Low-Income Patients.

Background: Despite widespread adoption of health information technology, U.S. providers face persistent barriers to coordination of care. We sought to develop and implement a patient-centered smartphone app that facilitates care coordination when patients receive care at any hospital in a region. Materials and Methods: Partnering with patients and primary care teams at a federally qualified health center (FQHC), we developed an app that (1) used real-time location data to identify encounters at 41 regional hospitals; (2) sent notifications to users' phones, asking them to confirm hospital arrival/discharge, and; (3) sent automated messages to primary care teams about confirmed hospital encounters. App design included multiple, successive rounds of active patient participation. In a small beta test of the initial version of the app, high-risk, low-income FQHC patients ran the app on their phone for 3 months. A formative mixed methods evaluation examined the app's technical performance and user experience. Results: Twelve patients enrolled in the beta test and provided follow-up data; 11 (92%) were racial/ethnic minorities. Participants obtained emergency or inpatient care at four regional hospitals. The app had 75% sensitivity to detect events when notifications should have fired, and 90% positive predictive value (PPV) of events when notifications fired. Barriers to implementation related to the app's user interface and the performance of its location tracking algorithm. Conclusions: We partnered with patients from a traditionally underserved population to develop a new smartphone-based approach to regional care coordination. The app had moderate sensitivity and high PPV for identifying regional hospital visits.