Effectiveness of Enhanced Performance Feedback on Appropriate Use of Blood Transfusions: A Comparison of 2 Cluster Randomized Trials.

Importance: Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. Objective: To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. Design, Setting, and Participants: Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. Interventions: Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. Main Outcomes and Measures: The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. Results: One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]). Conclusions and Relevance: This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs. Trial Registration: isrctn.org Identifier: ISRCTN15490813.

Geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia: a spatial and geographically weighted regression analysis.

BACKGROUND: Maintaining and effectively utilizing maternal continuum of care could save an estimated 860,000 additional mothers and newborn lives each year. In Ethiopia, the number of maternal and neonatal deaths occurred during pregnancy, childbirth, and the postpartum period was very high. It is indisputable that area-based heterogeneity of zero utilization for a standard maternal continuum of care is critical to improve maternal and child health interventions. However, none of the previous studies explored the spatial distribution of zero utilization for maternal continuum of care. Hence, this study was aimed to explore geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia. METHODS: A total of 4178 women who gave birth five years preceding the 2016 Ethiopian demographic and health survey were included. ArcGIS version 10.7, SaT Scan version 9.6, and GWR version 4.0 Software was used to handle mapping, hotspot, ordinary least square, Bernoulli model analysis, and to model spatial relationships. Finally, a statistical decision was made at a p-value< 0.05 and at 95% confidence interval. MAIN FINDINGS: The proportion of mothers who had zero utilization of a standard maternal continuum of care was 48.8% (95% CI: 47.3-50.4). Hot spot (high risk) regions for zero utilization of maternal continuum of care was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Respondents who had poor wealth index, uneducated mothers, and mothers who declared distance as a big problem could increase zero utilization of maternal continuum of care by 0.24, 0.27, and 0.1 times. CONCLUSION: Five women out of ten could not utilize any components of a standard maternal continuum of care. Hot spot (high risk) areas was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Poor wealth index, uneducated mothers, and mothers who declare distance as a big problem were factors significantly associated with zero utilization of maternal continuum of care. Thus, geographical based intervention could be held to curve the high prevalence of zero utilization of maternal continuum of care.

Missed and Delayed Preventive Health Care Visits Among US Children Due to the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic led to a substantial drop in US children's preventive care, which had not fully rebounded by the end of 2020. We sought to estimate the overall prevalence of missed, skipped, or delayed preventive checkups among households with children in the last 12 months because of the pandemic. METHODS: We used data from the US Census Bureau's Household Pulse Survey, Phase 3.1 (collected April-May 2021). The analytic sample included 48 824 households with ≥1 child or adolescent aged <18 years. We estimated both national and state-level prevalences, examined associations with sociodemographic and household characteristics, and described reasons for missed or delayed preventive visits. RESULTS: Overall, 26.4% (95% CI, 25.5%-27.2%) of households reported that ≥1 child or adolescent had missed or delayed a preventive visit because of COVID-19; percentages varied by state, from 17.9% in Wyoming to 37.0% in Vermont. The prevalence of missed or delayed preventive visits was significantly higher among respondents who reported material hardships (ie, not caught up on rent/mortgage, difficulty paying usual household expenses, children not eating enough because of lack of affordability) than among respondents who did not report material hardships. The most common reasons for missing or delaying preventive visits were concern about visiting a health care provider, limited appointment availability, and the provider's location being closed. CONCLUSIONS: Programs and policies could reduce gaps in children's preventive care caused by the pandemic, with a particular focus on addressing social determinants of health.

Socioeconomic Determinants of the Use of Molecular Testing in Stage IV Colorectal Cancer.

OBJECTIVES: Treatment with epidermal growth factor receptor monoclonal antibodies extends life for patients with advanced colorectal cancers (CRCs) whose tumors exhibit wild-type KRAS, but KRAS testing may be underused. We studied the role of socioeconomic factors in the application of KRAS testing. MATERIALS AND METHODS: We identified subjects with stage IV colorectal adenocarcinoma diagnosed 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. We used multivariable logistic regression models to evaluate associations between clinical/demographic factors and the rate of KRAS testing. We used multivariable-adjusted Cox proportional hazards models to assess survival. RESULTS: We identified 37,676 patients with stage IV CRC, 31.1% of whom were tested for KRAS mutations, of those who had documented KRAS testing, 44% were KRAS mutant. Patients were more likely to be tested if they were younger (odds ratio [OR]=5.10 for age 20 to 29 vs. 80+, 95% confidence interval [CI]: 3.99-6.54, P<0.01), diagnosed more recently (OR=1.92 for 2015 vs. 2010, 95% CI: 1.77-2.08, P<0.01), or lived in an area of high median household income (OR=1.24 for median household income of >$69,311 vs. <$49,265, 95% CI: 1.14-1.35, P<0.01). Patients were less likely to be tested if they had Medicaid (OR=0.83, 95% CI: 0.77-0.88, P<0.01) or were unmarried (OR=0.78, 95% CI: 0.75-0.82, P<0.0001). The risk of death was decreased in patients who received KRAS testing (hazard ratio=0.77, 95% CI: 0.75-0.80, P<0.01). CONCLUSIONS: We found a low rate of KRAS testing in CRC patients with those living in low-income areas less likely to be tested, even after controlling for Medicaid insurance. Our study suggests that socioeconomic disparities persist despite Medicaid insurance.

Women's Knowledge, Attitude and Practice on Cervical Cancer and Its Screening in Dhaka, Bangladesh.

Background: Cervical cancer is the fourth most common cancer among women in the world. Visual Inspection with Acetic Acid (VIA) is a common screening test for cervical cancer in Bangladesh. This study will assess the knowledge, attitude and practice towards cervical cancer and screening among women residing in Dhaka district. Methods: A cross-sectional survey was conducted among 956 women aged 30 years and above in Dhaka. The women's score on knowledge, attitude and practice were categorized as sufficient or insufficient. We calculated frequencies and used binary logistic regression to describe and assess the association between scores and socio-demographic characteristics of respondents. Results: Most (87%) respondent knew about cervical cancer and 13% knew that HPV is a risk factor for cervical cancer. Women who had sufficient knowledge were more likely to test VIA than those who had insufficient knowledge (39%, OR: 2.5; CI: 1.6, 2.8). Most (92%) would advise other women to have a VIA test. However, only 26% had a VIA test and 2% were vaccinated in private health care facilities for Human Papilloma Virus (HPV). Women who had sufficient attitude were equally likely to test VIA than those who had insufficient attitude. The VIA was underutilized because of low privacy during examination, unaware that VIA screened for cervical cancer, belief that they must pay for the test, and nurses performed examination. Conclusion: Women were knowledgeable about cervical cancer and likely to have a VIA test. However, the VIA test in underutilized and HPV vaccine coverage was low.

Regional socio-environmental characteristics associated with inadequate prenatal care during pregnancy: an ecological study of 47 prefectures in Japan.

BACKGROUND: Prenatal care (PNC) is a crucial health service that reduces the potential risks of adverse pregnancy and childbirth outcomes. It is monitored as one of the indicators of Universal Health Coverage (UHC) under the United Nations' Sustainable Development Goals. However, there are still mothers who do not use PNC, even when UHC has been achieved. As there have been few reports on the impact of local socio-environmental characteristics within the country, this study aimed to examine the association between local socio-environmental factors and inadequate use of PNC in Japan. METHODS: We conducted an ecological analysis of 47 prefectures in Japan using public open data. The dependent variables were the inadequate use of PNC, which are the rates of pregnant women who missed visiting PNC until 28 weeks' gestational age (GA) or those who never attended PNC before childbirth, and the independent variables were prefectural data of socio-economic, educational, and healthcare workforce-related factors. Multiple logistic regression analysis was used to examine the associations. RESULTS: The rate of pregnant women with late PNC initiation and never attending PNC before childbirth was 3.00-11.24 and 0.23-8.06 per 1000 pregnant women, respectively. Population numbers and densities, divorce rates, percentages of non-Japanese nationalities, and low percentages of high school enrolment were positively associated with inadequate PNC use. There was no statistically significant association with healthcare workforce, such as the number of obstetricians and gynaecologists. CONCLUSIONS: This ecological study revealed that inadequate PNC use is more common in urban areas with more non-Japanese nationality and lower education enrolment. There may be a need to provide education for those who do not have access to reproductive health education, such as that offered in high schools. Further studies are required to examine factors that affect access to PNC in Japan.

A Population-Based Analysis of Outpatient Thyroidectomy: Safe and Under-Utilized.

OBJECTIVES/HYPOTHESIS: Performance of thyroidectomy on an outpatient basis has gained popularity although many jurisdictions have not shifted their practice despite a strong safety profile. We sought to assess the uptake and safety of outpatient thyroidectomy in Ontario. STUDY DESIGN: Retrospective cohort study. METHODS: This was a population-based retrospecive cohort of adult patients undergoing hemithyroidectomy or total thyroidectomy between 1993 and 2017 in Ontario, Canada. Outpatient surgery was defined as discharge home on the same day of surgery. Outcomes of interest include 30-day all cause death, hematoma, emergency department use, and readmission. To adjust for confounding, propensity scores were calculated. Logistic regression models with inverse probability of treatment weighting (IPTW) were then used to estimate the exposure-outcome relationship. RESULTS: The final cohort consisted of 81,199 patients: 8,442 underwent same day surgery and 72,757 were admitted. The proportion of patients undergoing outpatient thyroidectomy increased overtime (2.3% in 1993-1994 to 17.8% in 2016-2017). Factors associated with higher odds of outpatient thyroidectomy included: younger age, less material deprivation, less comorbidities, and higher surgeon volume. The absolute number of deaths (≤5) and hematomas (64, 0.8%) in the outpatient cohort was low. After IPTW adjustment, patients with outpatient management had lower odds of neck hematoma (OR 0.73[95CI% 0.58-0.93)], but higher odds of emergency department use (OR 1.67[95%CI 1.56-1.79]). CONCLUSIONS: Outpatient thyroidectomy is not associated with an increased mortality risk. Less than one in five patients undergo outpatient thyroidectomy in Ontario, despite a well-established safety profile. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2625-2633, 2021.

Trends in Use of Cardioprotective Medication in Peripheral Artery Disease: A Nationwide Study.

Background Guideline-based cardioprotective medical therapy is intended to reduce the burden of adverse cardiovascular and limb outcomes in patients with peripheral artery disease (PAD). However, contemporary data describing trends in use of medication remains limited. The present study, therefore, aims to investigate changes in use of cardioprotective medication in PAD. Methods and Results By using Danish national healthcare registries, we identified all patients with first-time diagnosis of PAD (1997-2016) and classified them into two groups: (1) PAD+ that includes all patients with PAD with a history of cardiovascular disease, ie, myocardial infarction, atrial fibrillation, and stroke (n=162 627); and (2) PAD (n=87 935) that comprise patients without a history of cardiovascular disease. We determined the use of medication in the first 12 months after the incident diagnosis of PAD and estimated age standardized 1-year mortality rates. Our results showed increase in use of cardioprotective medication throughout the study period in both groups. However, PAD+ had a higher use of medication (acetylsalicylic acid, 3.5%-48.4%; Clopidogrel, 0%-17.6%; vitamin K antagonists, 0.9%-7.8%; new oral anticoagulants, 0.0%-10.1%; Statins, 1.9%-58.1%; angiotensin-converting enzyme inhibitors, 1.2%-20.6%), compared with PAD (acetylsalicylic acid, 2.9%-54.4%; Clopidogrel, 0%-11.9%; vitamin K antagonists, 0.9%-2.4%; new oral anticoagulants, 0.0%-3.4%; Statins, 1.5%-56.9%; angiotensin-converting enzyme, 0.9%-17.2%), respectively. Furthermore, 1-year mortality rates in PAD declined with increased use of medications during study. Conclusions In this nationwide study, use of cardioprotective medication increased considerably with time, but compared to patients with other atherosclerotic diseases, there remains an underuse of guideline-based medical therapy in patients with PAD.

Factors Associated With Access to and Timing of Coronavirus Testing Among US Adults After Onset of Febrile Illness.

Importance: Active SARS-CoV-2 (coronavirus) transmission continues in the US. It is unclear whether better access to coronavirus testing and more consistent use of testing could substantially reduce transmission. Objective: To describe coronavirus testing in persons with new onset of febrile illness and analyze whether there are changes over time and differences by race and ethnicity. Design, Setting, and Participants: This cohort study used data from the COVID-19 Citizen Science Study, launched in March 2020, which recruited participants via press release, word-of-mouth, and partner organizations. Participants completed daily surveys about COVID-19 symptoms and weekly surveys about coronavirus testing. All adults (aged at least 18 years) with a smartphone were eligible to join. For this analysis, US participants with new onset of febrile illness from April 2020 to October 2020 were included. Data analysis was performed from November 2020 to March 2021. Main Outcomes and Measures: Receipt of a coronavirus test result within 7 days of febrile illness onset. Results: Of the 2679 participants included in this analysis, the mean (SD) age was 46.3 (13.4) years, 1983 were female (74%), 2017 were college educated (75%), and a total of 3865 distinct new febrile illness episodes were reported (300 episodes [7.8%] from Hispanic participants, 71 episodes [1.8%] from Black participants, and 3494 episodes [90.4%] from not Black, not Hispanic participants) between April 2 and October 23, 2020. In weekly surveys delivered during the 14 days after fever onset, 12% overall (753 participants) indicated receipt of a test result. Using serial survey responses and parametric time-to-event modeling, it was estimated that by 7 days after onset of febrile illness, a total of 20.5% (95% CI, 19.1%-22.0%) had received a test result. This proportion increased from 9.8% (95% CI, 7.5%-12.0%) early in the epidemic to 24.1% (95% CI, 21.5%-26.7%) at the end of July, but testing rates did not substantially improve since then, increasing to 25.9% (95% CI; 21.6%-30.3%) in late October at the start of the winter surge. Black participants reported receiving a test result about half as often as others (7% [7 of 103] of survey responses vs 12% [53 of 461] for Hispanic vs 13% [693 of 5516] for not Black, not Hispanic; P = .03). This association was not statistically significant in adjusted time-to-event models (hazard ratio = 0.59 vs not Black, not Hispanic participants; 95% CI, 0.26-1.34). Conclusions and Relevance: Systematic underuse of coronavirus testing was observed in this cohort study through late October 2020, at the beginning of the winter COVID-19 surge, which may have contributed to preventable coronavirus transmission.

Impact of lockdown on emergency general surgery during first 2020 COVID-19 outbreak.

PURPOSE: To evaluate and analyze the impact of lockdown strategy due to coronavirus disease 2019 (COVID-19) on emergency general surgery (EGS) in the Milan area at the beginning of pandemic outbreak. METHODS: A survey was distributed to 14 different hospitals of the Milan area to analyze the variation of EGS procedures. Each hospital reported the number of EGS procedures in the same time frame comparing 2019 and 2020. The survey revealed that the number of patients during the COVID-19 pandemic outbreak in 2020 was reduced by 19% when compared with 2019. The decrease was statistically significant only for abdominal wall surgery. Interestingly, in 2020, there was an increase of three procedures: surgical intervention for acute mesenteric ischemia (p = 0.002), drainage of perianal abscesses (p = 0.000285), and cholecystostomy for acute cholecystitis (p = 0.08). CONCLUSIONS: During the first COVID-19 pandemic wave in the metropolitan area of Milan, the number of patients operated for emergency diseases decreased by around 19%. We believe that this decrease is related either to the fear of the population to ask for emergency department (ED) consultation and to a shift towards a more non-operative management in the surgeons 'decision making' process. The increase of acute mesenteric ischaemia and perianal abscess might be related to the modification of dietary habits and reduction of physical activity related to the lockdown.

Patterns of cost-related medication underuse among Canadian adults with cancer: a cross-sectional study using survey data.

BACKGROUND: Cost-related medication underuse (CRMU) has been reported within the general population in Canada. In this study, we assessed patterns of CRMU among Canadian adults with cancer. METHODS: This is a cross-sectional study using survey data. We accessed data sets from the 2015/16 Canadian Community Health Survey (CCHS) and reviewed the records of adults (≥ 18 yr) with a history of cancer who were prescribed medication in the previous 12 months. We collected information about sociodemographic features, health behaviours and CRMU, and conducted a multivariable logistic regression analysis for factors associated with CRMU. RESULTS: A total of 8581 participants were eligible for the current study. In the weighted multivariable logistic regression analysis, the following factors were associated with CRMU: younger age (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.79-3.63), female sex (male sex v. female sex OR 0.62, 95% CI 0.44-0.88), Indigenous racial background (Indigenous v. White OR 2.37, 95% CI 1.49- 3.77), unmarried status (OR 1.59, 95% CI 1.09-2.30), poor self-perceived health (excellent v. poor self-perceived health OR 0.36, 95% CI 0.17-0.77), lower annual income (< $20 000 v. income ≥ $80 000 OR 3.08, 95% CI 1.75-5.41) and lack of insurance for prescription medications (OR 2.49, 95% CI 1.77-3.50). INTERPRETATION: The toll of CRMU among adults seems to be unequally carried by women, racial minorities, and younger (< 65 yr) and uninsured patients with cancer. Discussion about a national pharmacare program for people without private insurance is needed.

Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018.

BACKGROUND: Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub-Saharan Africa (SSA) with radiotherapy access. METHODS: A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non-adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease. RESULTS: In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43-61). Receptor status was missing for 71% (248). 199 (57%) had non-metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post-mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study-defined non-adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non-adherence (aOR: 0.18, 95% CI: 0.09, 0.36). CONCLUSIONS: Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient-level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.

The wider implications of the COVID-19 pandemic: Assessing the impact of accident and emergency use for frequent attenders.

INTRODUCTION: Emergency departments have seen altered patterns of attendance since the beginning of the COVID-19 pandemic, with reductions in the number of attendances for non-COVID-19 - patients. We assessed the use of the emergency department by frequent attenders during the height of the COVID-19 pandemic and explored any changes in emergency department attendance by this group. METHODS: As part of ongoing improvement work, we utilised a cohort design to evaluate the difference in patterns of attendance for the frequent attender group in a single centre. We created a 2019 'top attender' cohort and a similar cohort for 2020. We compared admission patterns between the two time periods in order to understand the impact of the COVID-19 pandemic on this group. RESULTS: Both groups were predominately male. Mental health and substance misuse use problems were common across both cohorts. The majority of patients lived in a socio-economically deprived areas. The median number emergency department visits in 2019, for the top attender cohort was 6 (IQR: 4-9) vs 4 (IQR: 2-7) for the top attender cohort of 2020 (p < .0013). CONCLUSION: This single centre evaluation has shown a significant reduction in emergency department attendances for a frequent attender cohort in a single centre. Future work should investigate the longer-term impact which the COVID-19 pandemic has had on this patient group.

Primary care continuity and potentially avoidable hospitalization in persons with dementia.

BACKGROUND/OBJECTIVE: To measure the association between high primary care continuity and potentially avoidable hospitalization in community-dwelling persons with dementia. Our hypothesis was that high primary care continuity is associated with fewer potentially avoidable hospitalizations. DESIGN: Population-based retrospective cohort (2012-2016), with inverse probability of treatment weighting using the propensity score. SETTING: Quebec (Canada) health administrative database, recording most primary, secondary and tertiary care services provided via the public universal health insurance system. PARTICIPANTS: Population-based sample of 22,060 community-dwelling 65 + persons with dementia on March 31st, 2015, with at least two primary care visits in the preceding year (mean age 81 years, 60% female). Participants were followed for 1 year, or until death or long-term care admission. EXPOSURE: High primary care continuity on March 31st, 2015, i.e., having had every primary care visit with the same primary care physician, during the preceding year. MAIN OUTCOME MEASURES: Primary: Potentially avoidable hospitalization in the follow-up period as defined by ambulatory care sensitive conditions (ACSC) hospitalization (general and older population definitions), 30-day hospital readmission; Secondary: Hospitalization and emergency department visit. RESULTS: Among the 22,060 persons, compared with the persons with low primary care continuity, the 14,515 (65.8%) persons with high primary care continuity had a lower risk of ACSC hospitalization (general population definition) (relative risk reduction 0.82, 95% CI 0.72-0.94), ACSC hospitalization (older population definition) (0.87, 0.79-0.95), 30-day hospital readmission (0.81, 0.72-0.92), hospitalization (0.90, 0.86-0.94), and emergency department visit (0.92, 0.90-0.95). The number needed to treat to prevent one event were, respectively, 118 (69-356), 87 (52-252), 97 (60-247), 23 (17-34), and 29 (21-47). CONCLUSION: Increasing continuity with a primary care physician might be an avenue to reduce potentially avoidable hospitalizations in community-dwelling persons with dementia on a population-wide level.

Gaps in Evidence-Based Therapy Use in Insured Patients in the United States With Type 2 Diabetes Mellitus and Atherosclerotic Cardiovascular Disease.

Background Evidence-based therapies are generally underused for cardiovascular risk reduction; however, less is known about contemporary patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. Methods and Results Pharmacy and medical claims data from within Anthem were queried for patients with established atherosclerotic cardiovascular disease and type 2 diabetes mellitus. Using an index date of April 18, 2018, we evaluated the proportion of patients with a prescription claim for any of the 3 evidence-based therapies on, or covering, the index date ±30 days: high-intensity statin, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and sodium glucose cotransporter-2 inhibitor or glucagon-like peptide-1 receptor agonist. The potential benefit of achieving 100% adoption of all 3 evidence-based therapies was simulated using pooled treatment estimates from clinical trials. Of the 155 958 patients in the sample, 24.7% were using a high-intensity statin, 53.1% were using an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and 9.9% were using either an sodium glucose cotransporter-2 inhibitor or glucagon-like peptide-1 receptor agonists. Overall, only 2.7% of the population were covered by prescriptions for all 3 evidence-based therapies, and 37.4% were on none of them. Over a 12-month period, 70.6% of patients saw a cardiologist, while only 18% saw an endocrinologist. Increasing the use of evidence-based therapies to 100% over 3 years of treatment could be expected to reduce 4546 major atherosclerotic cardiovascular events (myocardial infarction, stroke, or cardiovascular death) in eligible but untreated patients. Conclusions Alarming gaps exist in the contemporary use of evidence-based therapies in this large population of insured patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. These data provide a call to action for patients, providers, industry, regulators, professional societies, and payers to close these gaps in care.

Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease.

BACKGROUND/OBJECTIVES: Older adults (>75 years of age) represent two-thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi-society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD. DESIGN: Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018. SETTING: A large multi-specialty health system in Northern California. PARTICIPANTS: A total of 24,651 adults older than 75 years with ASCVD. MEASUREMENTS: Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors. RESULTS: The study cohort included 24,651 patients older than 75 years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins. CONCLUSIONS: Despite increasing prescription rates between 2007 and 2018, guideline-recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD.

Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines.

BACKGROUND: Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings. METHODS: We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy. RESULTS: Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]). CONCLUSION: The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.

Treatment of post-prostatectomy urinary incontinence and erectile dysfunction: there is insufficient utilisation of care in German cancer survivors.

PURPOSE: Treatment of post-prostatectomy urinary incontinence (UI) and erectile dysfunction (ED) increases quality of life (QoL). Aim of our study was to evaluate the utilisation of care among patients with post-prostatectomy UI and ED in Germany. METHODS: The HAROW study documented treatment of patients with localised prostate cancer (≤ T2c) in Germany. 1260 patients underwent radical prostatectomy (RP). Patients answered validated questionnaires after a median follow-up of 6.3 years. Response rate was 76.8%. RESULTS: Median age at RP was 65 (IQR 60-69) years. 14% (134/936) used more than one pad per day for UI. 25% (26/104, 30 missing) of UI patients underwent surgery to improve continence. Of patients without surgery, 41% (31/75) reported a moderate-to-severe issue concerning their incontinence with worse mental health and QoL. 81% (755/936) patients were unable to have an erection firm enough for sexual intercourse. Of all ED patients, 40% (319/793) used ED treatment regularly or tried it at least once. 49% (243/499) of patients with interest in sex never tried ED treatment. In multivariate analysis, patients not using ED treatments were older (≥ 70 years OR 4.1), and more often had preoperative ED (OR 2.3) and less interest in sex (OR 2.2). Nevertheless, 30% (73/240) of these patients had moderate-to-severe issues with their ED reporting worse mental health and QoL. CONCLUSION: Almost half of the patients without post-prostatectomy UI and ED treatment reported moderate-to-severe issues with a significant decrease in QoL. This indicates an insufficient utilisation of care in Germany.