Improving Adherence to Cardiovascular Therapies: An Economic Evaluation of a Randomized Pragmatic Trial.

OBJECTIVE: Preplanned economic analysis of a pragmatic trial using electronic-medical-record-linked interactive voice recognition (IVR) reminders for enhancing adherence to cardiovascular medications (i.e., statins, angiotensin-converting enzyme inhibitors [ACEIs], and angiotensin receptor blockers [ARBs]). METHODS: Three groups, usual care (UC), IVR, and IVR plus educational materials (IVR+), with 21,752 suboptimally adherent patients underwent follow-up for 9.6 months on average. Costs to implement and deliver the intervention (from a payer perspective) were tracked during the trial. Medical care costs and outcomes were ascertained using electronic medical records. RESULTS: Per-patient intervention costs ranged from $9 to $17 for IVR and from $36 to $47 for IVR+. For ACEI/ARB, the incremental cost-effectiveness ratio for each percent adherence increase was about 3 times higher with IVR+ than with IVR ($6 and $16 for IVR and IVR+, respectively). For statins, the incremental cost-effectiveness ratio for each percent adherence increase was about 7 times higher with IVR+ than with IVR ($6 and $43 for IVR and IVR+, respectively). Considering potential cost offsets from reduced cardiovascular events, the probability of breakeven was the highest for UC, but the IVR-based interventions had a higher probability of breakeven for subgroups with a baseline low-density lipoprotein (LDL) level of more than 100 mg/dl and those with two or more calls. CONCLUSIONS: We found that the use of an automated voice messaging system to promote adherence to ACEIs/ARBs and statins may be cost-effective, depending on a decision maker's willingness to pay for unit increase in adherence. When considering changes in LDL level and downstream medical care offsets, UC is the optimal strategy for the general population. However, IVR-based interventions may be the optimal choice for those with elevated LDL values at baseline.

Participation Rates in 11 National Dental Practice-Based Research Network Surveys 2014-2022.

Surveys of health professionals typically have low response rates, which have decreased in recent years. We report on the methods used, participation rates, and study time for 11 national questionnaire studies of dentists conducted from 2014-2022. Participation rates decreased (87%-25%). Concurrent with this decrease was a decrease in the intensity with which the practitioners were recruited. Participation rates were higher when postal mail invitation and paper options were used (84% vs. 58%, p < .001). Completion rates were nearly twice as high in studies that recruited in waves than those that did not (61% vs. 35%, p = .003). Study time varied from 2.6 to 28.4 weeks. Study time was longest when postal mail and completion on paper were used (26.0 vs. 11.3 weeks, p = .01). Among studies using only online methods, study time was longer when invitations were staggered than when all invitations went out in one bolus (means 12.0 and 5.2, p = .04). Study time was positively correlated with participation rates (Spearman r = .80, p = .005). General dentists participated at an average of 12% higher rates than specialists. Recruitment methodology, such as recruiting in waves or stages, should be considered when designing surveys.

Four "lessons learned" while implementing a multi-site caries prevention trial.

As the number of dental-related randomized clinical trials (RCTs) increases, there is a need for literature to help investigators inexperienced in conducting RCTs design and implement studies. This commentary describes four "lessons learned" or considerations important in the planning and initial implementation of RCTs in dentistry that, to our knowledge, have not been discussed in the general dental literature describing trial techniques. These considerations are a) preparing or securing a thorough systematic review; b) developing a comprehensive set of study documents; c) designing and testing multiple recruitment strategies; and d) employing a run-in period prior to enrollment. Attention to these considerations in the planning phases of a dental RCT can help ensure that the trial is clinically relevant while also maximizing the likelihood that its implementation will be successful.

Design of the Prevention of Adult Caries Study (PACS): a randomized clinical trial assessing the effect of a chlorhexidine dental coating for the prevention of adult caries.

BACKGROUND: Dental caries is one of the primary causes of tooth loss among adults. It is estimated to affect a majority of Americans aged 55 and older, with a disproportionately higher burden in disadvantaged populations. Although a number of treatments are currently in use for caries prevention in adults, evidence for their efficacy and effectiveness is limited. METHODS/DESIGN: The Prevention of Adult Caries Study (PACS) is a multicenter, placebo-controlled, double-blind, randomized clinical trial of the efficacy of a chlorhexidine (10% w/v) dental coating in preventing adult caries. Participants (n = 983) were recruited from four different dental delivery systems serving four diverse communities, including one American Indian population, and were randomized to receive either chlorhexidine or a placebo treatment. The primary outcome is the net caries increment (including non-cavitated lesions) from baseline to 13 months of follow-up. A cost-effectiveness analysis also will be considered. DISCUSSION: This new dental treatment, if efficacious and approved for use by the Food and Drug Administration (FDA), would become a new in-office, anti-microbial agent for the prevention of adult caries in the United States. TRIAL REGISTRATION NUMBER: NCT00357877.

Data Quality Assessment and Multi-Organizational Reporting: Tools to Enhance Network Knowledge.

OBJECTIVE: Multi-organizational research requires a multi-organizational data quality assessment (DQA) process that combines and compares data across participating organizations. We demonstrate how such a DQA approach complements traditional checks of internal reliability and validity by allowing for assessments of data consistency and the evaluation of data patterns in the absence of an external "gold standard." METHODS: We describe the DQA process employed by the Data Coordinating Center (DCC) for Kaiser Permanente's (KP) Center for Effectiveness and Safety Research (CESR). We emphasize the CESR DQA reporting system that compares data summaries from the eight KP organizations in a consistent, standardized manner. RESULTS: We provide examples of multi-organization comparisons from DQA to confirm expectations about different aspects of data quality. These include: 1) comparison of direct data extraction from the electronic health records (EHR) and 2) comparison of non-EHR data from disparate sources. DISCUSSION: The CESR DCC has developed codes and procedures for efficiently implementing and reporting DQA. The CESR DCC approach is to 1) distribute DQA tools to empower data managers at each organization to assess their data quality at any time, 2) summarize and disseminate findings to address data shortfalls or document idiosyncrasies, and 3) engage data managers and end-users in an exchange of knowledge about the quality and its fitness for use. CONCLUSION: The KP CESR DQA model is applicable to networks hoping to improve data quality. The multi-organizational reporting system promotes transparency of DQA, adds to network knowledge about data quality, and informs research.

Direct care workers in the National Drug Abuse Treatment Clinical Trials Network: characteristics, opinions, and beliefs.

OBJECTIVE: Individuals with direct care responsibilities in 348 drug abuse treatment units were surveyed to obtain a description of the workforce and to assess support for evidence-based therapies. METHODS: Surveys were distributed to 112 programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN). Descriptive analyses characterized the workforce. Analyses of covariance tested the effects of job category on opinions about evidence-based practices and controlled for the effects of education, modality (outpatient or residential), race, and gender. RESULTS: Women made up two-thirds of the CTN workforce. One-third of the workforce had a master's or doctoral degree. Responses from 1,757 counselors, 908 support staff, 522 managers-supervisors, and 511 medical staff (71% of eligible participants) suggested that the variables that most were most consistently associated with responses were job category (19 of 22 items) and education (20 of 22 items). Managers-supervisors were the most supportive of evidence-based therapies, and support staff were the least supportive. Generally, individuals with graduate degrees had more positive opinions about evidence-based therapies. Support for using medications and contingency management was modest across job categories. CONCLUSIONS: The relatively traditional beliefs of support staff could inhibit the introduction of evidence-based practices. Programs initiating changes in therapeutic approaches may benefit from including all employees in change efforts.

Implications of American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Guidelines on Statin Underutilization for Prevention of Cardiovascular Disease in Diabetes Mellitus Among Several US Networks of Community Health Centers.

BACKGROUND: Little is known about statin underutilization among diabetes mellitus patients cared for in community health centers, which tend to serve socioeconomically disadvantaged populations. Implications of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on preexisting gaps in statin treatment in this population are unclear. METHODS AND RESULTS: We included 32 440 adults (45% male, 63% nonwhite, 29% uninsured/Medicaid) aged 40 to 75 years with diabetes mellitus who received care within 16 community health center groups in 11 states in the Community Health Applied Research Network during 2013. Statin prescribing was analyzed as a function of concordance with the National Cholesterol Education Program Adult Treatment Panel 2001 and ACC/AHA 2013 guidelines. More patients' treatments were concordant with the ACC/AHA (52.8%) versus the National Cholesterol Education Program Adult Treatment Panel (36.2%) guideline. Female sex was associated with lower concordance for both (odds ratio [OR] 0.90, CI 0.85-0.94; and OR 0.84, CI 0.80-0.88, respectively). Being insured, an Asian/Pacific Islander, or primarily Spanish speaking were associated with greater concordance for both guidelines: 35.5% (11 526/32 440) were concordant with neither guideline, the majority (79.7%) having no statin prescribed; 28.2% (9168/32 440) were concordant with ACC/AHA but not the National Cholesterol Education Program Adult Treatment Panel. 8.7% of these patients had a low-density lipoprotein cholesterol >160 mg/dL despite having a moderate- or high-intensity statin prescribed. And 11.6% (3772/32 440) were concordant with the National Cholesterol Education Program Adult Treatment Panel but not with ACC/AHA. Most of these patients had a low-density lipoprotein cholesterol between 70 and 99 mg/dL with no or a low-intensity statin prescribed. CONCLUSIONS: Opportunities exist to improve cholesterol management in diabetes mellitus patients in community health centers. Addressing care gaps could improve cardiovascular disease prevention in this high-risk population.

Pragmatic (trial) informatics: a perspective from the NIH Health Care Systems Research Collaboratory.

Pragmatic clinical trials (PCTs) are research investigations embedded in health care settings designed to increase the efficiency of research and its relevance to clinical practice. The Health Care Systems Research Collaboratory, initiated by the National Institutes of Health Common Fund in 2010, is a pioneering cooperative aimed at identifying and overcoming operational challenges to pragmatic research. Drawing from our experience, we present 4 broad categories of informatics-related challenges: (1) using clinical data for research, (2) integrating data from heterogeneous systems, (3) using electronic health records to support intervention delivery or health system change, and (4) assessing and improving data capture to define study populations and outcomes. These challenges impact the validity, reliability, and integrity of PCTs. Achieving the full potential of PCTs and a learning health system will require meaningful partnerships between health system leadership and operations, and federally driven standards and policies to ensure that future electronic health record systems have the flexibility to support research.

Difference in Effectiveness of Medication Adherence Intervention by Health Literacy Level.

CONTEXT: There is little research investigating whether health information technologies, such as interactive voice recognition, are effective ways to deliver information to individuals with lower health literacy. OBJECTIVE: Determine the extent to which the impact of an interactive voice recognition-based intervention to improve medication adherence appeared to vary by participants' health literacy level. DESIGN: Promoting Adherence to Improve Effectiveness of Cardiovascular Disease Therapies (PATIENT) was a randomized clinical trial designed to test the impact, compared with usual care, of 2 technology-based interventions that leveraged interactive voice recognition to promote medication adherence. A 14% subset of participants was sent a survey that included questions on health literacy. This exploratory analysis was limited to the 833 individuals who responded to the survey and provided data on health literacy. MAIN OUTCOME MEASURES: Adherence to statins and/or angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers. RESULTS: Although intervention effects did not differ significantly by level of health literacy, the data were suggestive of differential intervention effects by health literacy level. CONCLUSIONS: The differences in intervention effects for high vs low health literacy in this exploratory analysis are consistent with the hypothesis that individuals with lower health literacy may derive greater benefit from this type of intervention compared with individuals with higher health literacy. Additional studies are needed to further explore this finding.

Building a Governance Strategy for CER: The Patient Outcomes Research to Advance Learning (PORTAL) Network Experience.

INTRODUCTION: The Patient Outcomes Research to Advance Learning (PORTAL) Network was established with funding from the Patient-Centered Outcomes Research Institute (PCORI) in 2014. The PORTAL team adapted governance structures and processes from past research network collaborations. We will review and outline the structures and processes of the PORTAL governance approach and describe how proactively focusing on priority areas helped us to facilitate an ambitious research agenda. BACKGROUND: For years a variety of funders have supported large-scale infrastructure grants to promote the use of clinical datasets to answer important comparative effectiveness research (CER) questions. These awards have provided the impetus for health care systems to join forces in creating clinical data research networks. Often, these scientific networks do not develop governance processes proactively or systematically, and address issues only as problems arise. Even if network leaders and collaborators foresee the need to develop governance approaches, they may underestimate the time and effort required to develop sound processes. The resulting delays can impede research progress. INNOVATION: Because the PORTAL sites had built trust and a foundation of collaboration by participating with one another in past research networks, essential elements of effective governance such as guiding principles, decision making processes, project governance, data governance, and stakeholders in governance were familiar to PORTAL investigators. This trust and familiarity enabled the network to rapidly prioritize areas that required sound governance approaches: responding to new research opportunities, creating a culture of trust and collaboration, conducting individual studies, within the broader network, assigning responsibility and credit to scientific investigators, sharing data while protecting privacy/security, and allocating resources. The PORTAL Governance Document, complete with a Toolkit of Appendices is included for reference and for adaptation by other networks. CREDIBILITY: As a result of identifying project-based governance priorities (IRB approval, subcontracting, selection of new research including lead PI and participating sites, and authorship) and data governance priorities (reciprocal data use agreement, analytic plan procedures, and other tools for data governance), PORTAL established most of its governance structure by Month 6 of the 18 month project. This allowed science to progress and collaborators to experience first-hand how the structures and procedures functioned in the remaining 12 months of the project, leaving ample time to refine them and to develop new structures or processes as necessary. DISCUSSION: The use of procedures and processes with which participating investigators and their home institutions were already familiar allowed project and regulatory requirements to be established quickly to protect patients, their data, and the health care systems that act as stewards for both. As the project progressed, PORTAL was able to test and adjust the structures it put place, and to make substantive revisions by Month 17. As a result, priority processes have been predictable, transparent and effective. CONCLUSION/NEXT STEPS: Strong governance practices are a stewardship responsibility of research networks to justify the trust of patients, health plan members, health care delivery organizations, and other stakeholders. Well-planned governance can reduce the time necessary to initiate the scientific activities of a network, a particular concern when the time frame to complete research is short. Effective network and data governance structures protect patient and institutional data as well as the interests of investigators and their institutions, and assures that the network has built an environment to meet the goals of the research.

Results of the Community Health Applied Research Network (CHARN) National Research Capacity Survey of Community Health Centers.

BACKGROUND: The mission of the Community Health Applied Research Network (CHARN) is to build capacity to carry out Patient-Centered Outcomes Research at community health centers (CHCs), with the ultimate goal to improve health care for vulnerable populations. OBJECTIVES: The CHARN Needs Assessment Staff Survey investigates CHCs' involvement in research, as well as their need for research training and resources. Results will be used to guide future training. METHODS: The survey was developed and implemented in partnership with CHARN CHCs. Data were collected across CHARN CHCs. Data analysis and reports were conducted by the CHARN data coordinating center (DCC). RESULTS: Survey results highlighted gaps in staff research training, and these gaps varied by staff role. CONCLUSIONS: There is considerable variation in research involvement, partnerships, and focus both within and across CHCs. Development of training programs to increase research capacity should be tailored to address the specific needs and roles of staff involved in research.

Dietary quality assurance processes of the DASH-Sodium controlled diet study.

A thorough quality assurance (QA) program upholds the integrity of nutrition research studies by yielding reliable data and results. Continually evaluating the implementation of a procedure against a goal and making adjustments when needed enhance the quality of a study's conduct and outcomes. Controlled diet studies require QA processes at various steps beginning with the screening of study participants, through diet preparation and delivery to data collection. Staff training and observations with monitoring activities, are important so tasks are completed according to protocol. When several clinical sites participate as partners in a controlled diet study, uniform procedures must be followed and a formal standardized QA program will assist. The Dietary Approaches to Stop Hypertension (DASH)-Sodium study employed such a program, described in this article, that included training staff, observing procedures, monitoring data for completeness and accuracy, evaluating processes, giving feedback, and documenting that tasks were done according to protocol. Furthermore, QA processes were used in the areas of participant screening, orientation, diet adherence, food procurement and preparation, and exit interviews. Other researchers may implement similar activities to ensure quality in their nutrition research programs.

The Community Health Applied Research Network (CHARN) Data Warehouse: a Resource for Patient-Centered Outcomes Research and Quality Improvement in Underserved, Safety Net Populations.

BACKGROUND: The Community Health Applied Research Network, funded by the Health Resources and Services Administration, is a research network comprising 18 Community Health Centers organized into four Research Nodes (each including an academic partner) and a data coordinating center. The network represents more than 500,000 diverse safety net patients across 11 states. OBJECTIVE: The primary objective of this paper is to describe the development and implementation process of the CHARN data warehouse. METHODS: The methods involved regulatory and governance development and approval, development of content and structure of the warehouse and processes for extracting the data locally, performing validation, and finally submitting data to the data coordinating center. PROGRESS TO DATE: Version 1 of the warehouse has been developed. Tables have been added, the population and the years of electronic health records (EHR) have been expanded for Version 2. CONCLUSIONS: It is feasible to create a national, centralized data warehouse with multiple Community Health Center partners using different EHR systems. It is essential to allow sufficient time: (1) to develop collaborative, trusting relationships among new partners with varied technology, backgrounds, expertise, and interests; (2) to complete institutional, business, and regulatory review processes; (3) to identify and address technical challenges associated with diverse data environments, practices, and resources; and (4) to provide continuing data quality assessments to ensure data accuracy.

Developing a data infrastructure for a learning health system: the PORTAL network.

The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings.

Improving adherence to cardiovascular disease medications with information technology.

OBJECTIVES: Evaluate the utility of 2 electronic medical record (EMR)-linked, automated phone reminder interventions for improving adherence to cardiovascular disease medications. STUDY DESIGN: A 1-year, parallel arm, pragmatic clinical trial in which 21,752 adults were randomized to receive either usual care (UC) or 1 of 2 interventions in the form of interactive voice recognition calls-regular (IVR) or enhanced (IVR+). The interventions used automated phone reminders to increase adherence to cardiovascular disease medications. The primary outcome was medication adherence; blood pressure and lipid levels were secondary outcomes. METHODS: The study took place in 3 large health maintenance organizations. We enrolled participants who were 40 years or older, had diabetes mellitus or atherosclerotic cardiovascular disease, and were suboptimally adherent. IVR participants received automated phone calls when they were due or overdue for a refill. IVR+ participants received these phone calls, plus personalized reminder letters, live outreach calls, EMR-based feedback to their primary care providers, and additional mailed materials. RESULTS: Both interventions significantly increased adherence to statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) compared with UC (1.6 to 3.7 percentage points). Adherence to ACEIs/ARBs was also significantly higher for IVR+ relative to IVR participants. These differences persisted across subgroups. Among statin users, IVR+ participants had significantly lower low-density lipoprotein (LDL) levels at follow-up compared with UC (Δ = -1.5; 95% CI, -2.7 to -0.2 mg/dL); this effect was seen mainly in those with baseline LDL levels ≥ 100 mg/dL (Δ = -3.6; 95% CI, -5.9 to -1.3 mg/dL). CONCLUSIONS: Technology-based tools, in conjunction with an EMR, can improve adherence to chronic disease medications and measured cardiovascular disease risk factors.

Predictors of coronal caries progression in adults: results from the Prevention of Adult Caries Study.

OBJECTIVES: This secondary analysis of data from the Prevention of Adult Caries Study (PACS) assesses risk factors for progression of coronal caries. METHODS: Participants (n = 983) were adults at increased caries risk with at least one cavitated and one noncavitated lesions who were enrolled in a randomized clinical trial to test the effect of a 10% w/v chlorhexidine varnish coating on caries progression. Calibrated examiners scored tooth surfaces using a modified International Caries Detection and Assessment System (ICDAS) classification at baseline and at 7 and 13 months postrandomization. Potential baseline predictors of caries risk were used in adjusted negative binomial regression models to predict net D2FS increment and in linear regression models to predict the rank-normalized net D12FS increment. RESULTS: Mean (SD) D2FS and D12FS increments were and 2.4 (3.1) and 2.1 (6.9), respectively. In multivariate analyses, two or more baseline D2 lesions, consumption of acidic drinks, and increasing age were all significantly associated with increased D2FS and D12FS risk. Daily flossing also was associated with increased D2FS risk. More frequent dental care at baseline was associated with significantly decreased caries risk for both increments. CONCLUSIONS: The general concordance of risk factors in the D12FS and D2FS models lends support to the hypothesis that the D1 increment is an intermediate stage in the progression to fully cavitated lesions.

Electronic health records based phenotyping in next-generation clinical trials: a perspective from the NIH Health Care Systems Collaboratory.

Widespread sharing of data from electronic health records and patient-reported outcomes can strengthen the national capacity for conducting cost-effective clinical trials and allow research to be embedded within routine care delivery. While pragmatic clinical trials (PCTs) have been performed for decades, they now can draw on rich sources of clinical and operational data that are continuously fed back to inform research and practice. The Health Care Systems Collaboratory program, initiated by the NIH Common Fund in 2012, engages healthcare systems as partners in discussing and promoting activities, tools, and strategies for supporting active participation in PCTs. The NIH Collaboratory consists of seven demonstration projects, and seven problem-specific working group 'Cores', aimed at leveraging the data captured in heterogeneous 'real-world' environments for research, thereby improving the efficiency, relevance, and generalizability of trials. Here, we introduce the Collaboratory, focusing on its Phenotype, Data Standards, and Data Quality Core, and present early observations from researchers implementing PCTs within large healthcare systems. We also identify gaps in knowledge and present an informatics research agenda that includes identifying methods for the definition and appropriate application of phenotypes in diverse healthcare settings, and methods for validating both the definition and execution of electronic health records based phenotypes.

Results from the Xylitol for Adult Caries Trial (X-ACT).

BACKGROUND: Although caries is prevalent in adults, investigators have tested few preventive therapies in adult populations. In a randomized controlled trial, the authors evaluated the effectiveness of xylitol lozenges in preventing caries in adults at elevated risk of developing caries. METHODS: The Xylitol for Adult Caries Trial (X-ACT) was a three-site placebo-controlled randomized trial. Participants (n = 691) aged 21 through 80 years consumed five 1.0-gram xylitol or placebo lozenges daily for 33 months. They underwent clinical examinations at baseline and at 12, 24 and 33 months. RESULTS: Xylitol lozenges reduced the caries increment 10 percent. This reduction, which represented less than one-third of a surface per year, was not statistically significant. There was no indication of a dose-response effect. CONCLUSIONS: Daily use of xylitol lozenges did not result in a statistically or clinically significant reduction in 33-month caries increment among adults at an elevated risk of developing caries. CLINICAL IMPLICATIONS: These results suggest that xylitol used as a supplement in adults does not reduce their caries experience significantly.