Publications by authors named "Michael B Rothberg"

280 Publications

Reply to Blot and Dinh.

Clin Infect Dis 2021 Jul 10. Epub 2021 Jul 10.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.1093/cid/ciab545DOI Listing
July 2021

Shared Medical Appointments and Prediabetes: The Power of the Group.

Ann Fam Med 2021 May-Jun;19(3):258-261

Center for Value-Based Care Research Cleveland Clinic, Cleveland, Ohio.

Shared medical appointments, which allow greater access to care and provide peer support, may be an effective treatment modality for prediabetes. We used a retrospective propensity-matched cohort analysis to compare patients attending a prediabetes shared medical appointment to usual care. Primary outcome was patient's weight change over 24 months. Secondary outcomes included change in hemoglobin A, low density lipoprotein, and systolic blood pressure. The shared medical appointments group lost more weight (2.88 kg vs 1.29 kg, = .003), and achieved greater reduction in hemoglobin A (-0.87% vs +0.87%, = .001) and systolic blood pressure (-4.35 mmHg vs +0.52 mmHg, = .044). The shared medical appointment model can be effective in treating prediabetes.
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http://dx.doi.org/10.1370/afm.2647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118487PMC
November 2019

Do patients who have newly identified prediabetes lose weight in the following year?

Fam Pract 2021 Jun 11. Epub 2021 Jun 11.

Cleveland Clinic Community Care, Center for Value Based Care, Cleveland Clinic, Cleveland, OH, USA.

Background: Identifying a window of opportunity when patients are motivated to lose weight might improve the effectiveness of weight loss counseling. The onset of chronic disease could create such a window.

Objective: To determine whether identifying prediabetes was associated with subsequent weight loss.

Methods: Our retrospective cohort study included adults with obesity and a primary care visit between 2015 and 2017. Data were collected and analysed in 2019/2020. We compared patients who developed prediabetes [haemoglobin A1c (HbA1c) ≥5.7 and <6.5] to patients with a normal HbA1c (<5.7). We ran linear regression models to identify the association between identifying prediabetes and percent body mass index (BMI) change at 6 and 12 months. The adjusted model controlled for demographic characteristics at baseline, Charlson comorbidity score, and metformin, antipsychotic, antidepressant and antiobesity medication prescribed in either the first 3 months (for the 6-month outcome) or first 9 months (for 12-month outcome) and clustering within physician.

Results: Of 11 290 participants, 43% developed prediabetes. At 6 months, 15% of the prediabetes group lost ≥5% of their BMI compared with 13% of the comparison group. The results were similar at 12 months with 18% of the prediabetes group losing ≥5% of their BMI compared with 17%. The prediabetes group lost a higher percentage of their BMI (β = -0.7% versus -0.3% at 6 months and β = -0.5% versus 0.01% at 12 months).

Conclusions: While the percent of BMI change was small, patients with newly identified prediabetes lost more weight than a comparison group.
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http://dx.doi.org/10.1093/fampra/cmab049DOI Listing
June 2021

Change in individual physicians' screening mammography completion rates following the updated USPSTF guideline supporting shared decision making: An observational cohort study.

Patient Educ Couns 2021 May 10. Epub 2021 May 10.

Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH 44195, USA.

Objective: To understand changes in physician screening practices in response to the 2009 U.S. Preventive Services Task Force recommendation supporting shared decision making (SDM) for mammography in women aged 40-49 years.

Methods: We assessed screening completion rates for physicians in the Cleveland Clinic Health System pre-2009 (2006-2008) and post-2009 (2010-2015), and rates for physicians new to the system post-2009. We used mixed effects logistic regression to estimate the odds of a woman receiving screening post-2009. If physicians practiced SDM, we hypothesized their screening rates would change after 2009. To test this, we included each physician's pre-2009 screening rate as a predictor in the model.

Results: Among 125 physicians, the screening rate increased from 40% to 45% from pre-2009 to post-2009. For physicians new to the health system post-2009 the rate was 32%. In the mixed effects model (N = 17,007), the strongest predictor of mammography receipt among patients post-2009 was their physician's pre-2009 screening rate (aOR:3.57 per 10% increase in pre-2009 rate; 95%CI:1.69-7.50).

Conclusions: Whether a woman received a mammogram post-2009 was highly associated with her physicians' pre-2009 screening rate, suggesting physicians are not individualizing screening decisions via SDM.

Practice Implications: Physicians may need support to effectively practice SDM.
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http://dx.doi.org/10.1016/j.pec.2021.05.011DOI Listing
May 2021

Oral Temperature of Noninfected Hospitalized Patients.

JAMA 2021 05;325(18):1899-1901

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jama.2021.1541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114137PMC
May 2021

Bacterial coinfection in influenza pneumonia: Rates, pathogens, and outcomes.

Infect Control Hosp Epidemiol 2021 Apr 23:1-6. Epub 2021 Apr 23.

Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Evidence from pandemics suggests that influenza is often associated with bacterial coinfection. Among patients hospitalized for influenza pneumonia, we report the rate of coinfection and distribution of pathogens, and we compare outcomes of patients with and without bacterial coinfection.

Methods: We included adults admitted with community-acquired pneumonia (CAP) and tested for influenza from 2010 to 2015 at 179 US hospitals participating in the Premier database. Pneumonia was identified using an International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) algorithm. We used multiple logistic and gamma-generalized linear mixed models to assess the relationships between coinfection and inpatient mortality, intensive care unit (ICU) admission, length of stay, and cost.

Results: Among 38,665 patients hospitalized with CAP and tested for influenza, 4,313 (11.2%) were positive. In the first 3 hospital days, patients with influenza were less likely than those without to have a positive culture (10.3% vs 16.2%; P < .001), and cultures were more likely to contain Staphylococcus aureus (34.2% vs 28.2%; P = .007) and less likely to contain Streptococcus pneumoniae (24.9% vs 31.0%; P = .008). Of S. aureus isolates, 42.8% were methicillin resistant among influenza patients versus 53.2% among those without influenza (P = .01). After hospital day 3, pathogens for both groups were similar. Bacterial coinfection was associated with increased odds of in-hospital mortality (aOR, 3.00; 95% CI, 2.17-4.16), late ICU transfer (aOR, 2.83; 95% CI, 1.98-4.04), and higher cost (risk-adjusted mean multiplier, 1.77; 95% CI, 1.59-1.96).

Conclusions: In a large US inpatient sample hospitalized with influenza and CAP, S. aureus was the most frequent cause of bacterial coinfection. Coinfection was associated with worse outcomes and higher costs.
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http://dx.doi.org/10.1017/ice.2021.96DOI Listing
April 2021

Patient outcomes and costs associated with functional medicine-based care in a shared versus individual setting for patients with chronic conditions: a retrospective cohort study.

BMJ Open 2021 04 13;11(4):e048294. Epub 2021 Apr 13.

Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA.

Objective: To compare outcomes and costs associated with functional medicine-based care delivered in a shared medical appointment (SMA) to those delivered through individual appointments.

Design: A retrospective cohort study was performed to assess outcomes and cost to deliver care to patients in SMAs and compared with Propensity Score (PS)-matched patients in individual appointments.

Setting: A single-centre study performed at Cleveland Clinic Center for Functional Medicine.

Participants: A total of 9778 patients were assessed for eligibility and 7323 excluded. The sample included 2455 patients (226 SMAs and 2229 individual appointments) aged ≥18 years who participated in in-person SMAs or individual appointments between 1 March 2017 and 31 December 2019. Patients had a baseline Patient-Reported Outcome Measurement Information System (PROMIS) Global Physical Health (GPH) score and follow-up score at 3 months. Patients were PS-matched 1:1 with 213 per group based on age, sex, race, marital status, income, weight, body mass index, blood pressure (BP), PROMIS score and functional medicine diagnostic category.

Primary And Secondary Outcome Measures: The primary outcome was change in PROMIS GPH at 3 months. Secondary outcomes included change in PROMIS Global Mental Health (GMH), biometrics, and cost.

Results: Among 213 PS-matched pairs, patients in SMAs exhibited greater improvements at 3 months in PROMIS GPH T-scores (mean difference 1.18 (95% CI 0.14 to 2.22), p=0.03) and PROMIS GMH T-scores (mean difference 1.78 (95% CI 0.66 to 2.89), p=0.002) than patients in individual appointments. SMA patients also experienced greater weight loss (kg) than patients in individual appointments (mean difference -1.4 (95% CI -2.15 to -0.64), p<0.001). Both groups experienced a 5.5 mm Hg improvement in systolic BP. SMAs were also less costly to deliver than individual appointments.

Conclusion: SMAs deliver functional medicine-based care that improves outcomes more than care delivered in individual appointments and is less costly to deliver.
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http://dx.doi.org/10.1136/bmjopen-2020-048294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051390PMC
April 2021

Comparison of National Data Sources to Assess Preventive Care in the US Population.

J Gen Intern Med 2021 Mar 31. Epub 2021 Mar 31.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s11606-021-06707-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012018PMC
March 2021

Soliciting Patients to Help Define Treatment Thresholds.

JAMA Netw Open 2021 03 1;4(3):e211181. Epub 2021 Mar 1.

Cleveland Clinic Center for Value-Based Care Research, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.1181DOI Listing
March 2021

Reinfection Rates among Patients who Previously Tested Positive for COVID-19: a Retrospective Cohort Study.

Clin Infect Dis 2021 Mar 15. Epub 2021 Mar 15.

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, United States.

Background: Protection afforded from prior disease among patients with coronavirus disease 2019 (COVID-19) infection is unknown. If infection provides substantial long-lasting immunity, it may be appropriate to reconsider vaccination distribution plans.

Methods: This retrospective cohort study of one multi-hospital health system included 150,325 patients tested for COVID-19 infection via PCR from March 12, 2020 to August 30, 2020. Testing performed up to February 24, 2021 in these patients was included for analysis. The main outcome was reinfection, defined as infection ≥ 90 days after initial testing. Secondary outcomes were symptomatic infection and protection of prior infection against reinfection.

Results: Of 150,325 patients, 8,845 (5.9%) tested positive and 141,480 (94.1%) tested negative prior to August 30. 1,278 (14.4%) of the positive patients were retested after 90 days, and 62 had possible reinfection. Of those, 31 (50%) were symptomatic. Of those with initial negative testing, 5,449 (3.9%) were subsequently positive and 3,191 of those (58.5%) were symptomatic. Protection offered from prior infection was 81.8% (95% confidence interval 76.6 to 85.8), and against symptomatic infection was 84.5% (95% confidence interval 77.9 to 89.1). This protection increased over time.

Conclusions: Prior infection in patients with COVID-19 was highly protective against reinfection and symptomatic disease. This protection increased over time, suggesting that viral shedding or ongoing immune response may persist beyond 90 days and may not represent true reinfection. As vaccine supply is limited, patients with known history of COVID-19 could delay early vaccination to allow for the most vulnerable to access the vaccine and slow transmission.
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http://dx.doi.org/10.1093/cid/ciab234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989568PMC
March 2021

Risk of In-Hospital Falls among Medications Commonly Used for Insomnia in Hospitalized Patients.

Sleep 2021 Mar 12. Epub 2021 Mar 12.

Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

Study Objectives: To investigate the risk of in-hospital falls among patients receiving medications commonly used for insomnia in the hospital setting.

Methods: Retrospective cohort study of all adult hospitalizations to a large academic medical center from 1/2007 to 7/2013. We excluded patients admitted for a primary psychiatric disorder. Medication exposures of interest, defined by pharmacy charges, included benzodiazepines, non-benzodiazepine benzodiazepine receptor agonists (BZRAs), trazodone, atypical antipsychotics, and diphenhydramine. In-hospital falls were ascertained from an online patient safety reporting system.

Results: Among the 225,498 hospitalizations (median age = 57 years; 57.9% female) in our cohort, 84,911 (37.7%) had exposure to at least one of the five medication classes of interest; benzodiazepines were the most commonly used (23.5%), followed by diphenydramine (8.3%), trazodone (6.6%), BZRAs (6.4%), and atypical antipsychotics (6.3%). A fall occurred in 2,427 hospitalizations (1.1%). The rate of falls per 1,000 hospital days was greater among hospitalizations with exposure to each of the medications of interest, compared to unexposed: 3.6 versus 1.7 for benzodiazepines (adjusted hazard ratio [aHR] 1.8, 95%CI 1.6-1.9); 5.4 versus 1.8 for atypical antipsychotics (aHR 1.6, 95%CI 1.4-1.8); 3.0 versus 2.0 for BZRAs (aHR 1.5, 95%CI 1.3-1.8); 3.3 versus 2.0 for trazodone (aHR 1.2, 95%CI 1.1-1.5); and 2.5 versus 2.0 for diphenhydramine (aHR 1.2, 95%CI 1.03-1.5).

Conclusions: In this large cohort of hospitalizations at an academic medical center, we found an association between each of the sedating medications examined and in-hospital falls. Benzodiazepines, BZRAs, and atypical antipsychotics had the strongest associations.
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http://dx.doi.org/10.1093/sleep/zsab064DOI Listing
March 2021

Characterizing the Variation of Alcohol Cessation Pharmacotherapy in Primary Care.

J Gen Intern Med 2021 Jul 29;36(7):1989-1996. Epub 2021 Jan 29.

Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.

Background: Alcohol use disorder (AUD) imposes a high mortality and economic burden. Effective treatment is available, though underutilized.

Objective: Describe trends in AUD pharmacotherapy, variation in prescribing, and associated patient factors.

Design: Retrospective cohort using electronic health records from 2010 to 2019.

Participants: Primary care patients from 39 clinics in Ohio and Florida with diagnostic codes for alcohol dependence or abuse plus social history indicating alcohol use. PCPs in family or internal medicine with at least 20 AUD patients.

Main Measures: Pharmacotherapy for AUD (naltrexone, acamprosate, and disulfiram), abstinence from alcohol, patient demographics, and comorbidities. Generalized linear mixed models were used to identify patient factors associated with prescriptions and the association of pharmacotherapy with abstinence.

Key Results: We identified 13,250 patients; average age was 54 years, 66.9% were male, 75.0% were White, and median household income was $51,776 per year. Over 10 years, the prescription rate rose from 4.4 to 5.6%. Patients who were Black (aOR 0.74; 95% CI 0.58, 0.94) and insured by Medicare versus commercial insurance (aOR 0.61; 95% CI 0.48, 0.78) were less likely to be treated. Higher median household income ($10,000 increment, aOR 1.06; 95% CI 1.03, 1.10) and Medicaid versus commercial insurance (aOR 1.52; 95% CI 1.24, 1.87) were associated with treatment. Receiving pharmacotherapy was associated with subsequent documented abstinence from alcohol (aOR 1.60; 95% CI 1.33, 1.92). We identified 236 PCPs. The average prescription rate was 3.6% (range 0 to 24%). The top decile prescribed to 14.6% of their patients. The bottom 4 deciles had no prescriptions. Family physicians had higher rates of pharmacotherapy than internists (OR 1.50; 95% CI 1.21, 1.85).

Conclusions: Medications for AUD are infrequently prescribed, but there is considerable variation among PCPs. Increasing the use of pharmacotherapy by non-prescribers may increase abstinence from alcohol.
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http://dx.doi.org/10.1007/s11606-020-06454-1DOI Listing
July 2021

Factors Impacting Physician Referral To and Patient Attendance at Weight Management Programs Within a Large Integrated Health System.

J Gen Intern Med 2021 Jan 22. Epub 2021 Jan 22.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland, OH, USA.

Background: Identifying which patients receive referrals to and which ones attend weight management programs can provide insights into how physicians manage obesity.

Objective: To describe patient factors associated with referrals, which primarily reflect physician priorities, and attendance, which reflects patient priorities. We also examine the influence of the individual physician by comparing adjusted rates of referral and attendance across physicians.

Design: Retrospective cohort study.

Participants: Adults with a body mass index (BMI) ≥ 30 kg/m who had a primary care visit between 2015 and 2018 at a large integrated health system MAIN MEASURES: Referrals and visits to programs were collected from the EHR in 2019 and analyzed in 2019-2020. Multilevel logistic regression models were used to identify the association between patient characteristics and (1) receiving a referral, and (2) attending a visit after a referral. We compared physicians' adjusted probabilities of referring patients and of their patients attending a visit.

Key Results: Our study included 160,163 adults, with a median BMI of 35 kg/m. Seventeen percent of patients received ≥ 1 referral and 29% of those attended a visit. The adjusted odds of referral increased 57% for patients with a BMI 35-39 (versus 30-34) and 32% for each comorbidity (p < 0.01). Attending a visit was less strongly associated with BMI (aOR 1.18 for 35-39 versus 30-34, 95% CI 1.09-1.27) and not at all with comorbidity. For the physician-level analysis, the adjusted probability of referral had a much wider range (0 to 83%; mean = 19%) than did the adjusted probability of attendance (range 27 to 34%).

Conclusions: Few patients attended a weight management program. Physicians vary greatly in their probability of referring patients to programs but not in their patients' probability of attending.
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http://dx.doi.org/10.1007/s11606-020-06520-8DOI Listing
January 2021

Influenza, Like COVID-19, Needs Randomized Trials.

J Gen Intern Med 2021 06 22;36(6):1490-1491. Epub 2021 Jan 22.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s11606-020-06567-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822583PMC
June 2021

Treatment of Patients with Prediabetes in a Primary Care Setting 2011-2018: an Observational Study.

J Gen Intern Med 2021 04 15;36(4):923-929. Epub 2021 Jan 15.

Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.

Background: Over one third of American adults are at high risk for developing diabetes, which can be delayed or prevented using interventions such as medical nutrition therapy (MNT) or metformin. Physicians' self-reported rates of prediabetes treatment are improving, but patterns of actual referral, prescription, and MNT visits are unknown.

Objective: To characterize treatment of prediabetes in primary care.

Design: We conducted a retrospective cohort study using electronic health record data. We described patterns of treatment and used multivariable logistic regression to evaluate the association of patient factors and PCP-specific treatment rate with patient treatment.

Patients: We included overweight or obese outpatients who had a first prediabetes-range hemoglobin A1c (HbA1c) during 2011-2018 and had primary care provider (PCP) follow-up within a year.

Main Measures: We collected patient characteristics and the following treatments: metformin prescription; referral to MNT, diabetes education, endocrinology, or bariatric medicine; and MNT visit. We did not capture within-visit physician counseling.

Key Results: Of 16,713 outpatients with prediabetes, 20.4% received treatment, including metformin prescriptions (7.8%) and MNT referrals (11.3%), but only 7.4% of referred patients completed a MNT visit. The strongest predictor of treatment was the patient's PCP's treatment rate. Some PCPs never treated prediabetes, but two treated more than half of their patients; 62% had no patients complete a MNT visit. Being younger or female and having higher body mass index or HbA1c were also positively associated with treatment. Compared to white patients, black patients were more likely to receive MNT referral and less likely to receive metformin.

Conclusions: Almost 80% of patients with new prediabetes never received treatment, and those who did receive referrals had very poor visit completion. Treatment rates appear to reflect provider rather than patient preferences.
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http://dx.doi.org/10.1007/s11606-020-06354-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041989PMC
April 2021

Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.

Healthc (Amst) 2021 Mar 4;9(1):100518. Epub 2021 Jan 4.

Center for Community Health Integration, Case Western Reserve University, Cleveland, OH, USA.

Background: Home visits after hospital discharge may reduce future healthcare utilization. We assessed the association of home visits by advanced practice registered nurses (APRN) and paramedics with healthcare utilization and mortality, and provider and patient experience.

Methods: We conducted a retrospective cohort study using convergent mixed methods in one health system including adult medical patients discharged to home from November 2017-September 2019. We assessed outcomes for home visit vs. matched comparison patients at 30, 90, and 180 days, including hospital admission, emergency department (ED) use, and death: Phase 1 (APRN or paramedic visits assigned by geographic location) and Phase 2 (APRN and paramedic visit teams assigned to patients). Patients declining home visits and those accepting were also compared. Semi-structured interviews were conducted with home visit patients and providers, primary care providers, and nurse care coordinators.

Results: In Phase 1, the 101 home visit matched to 303 comparison patients showed no differences in readmissions, ED visits, or death at 30, 90, and 180 days. In Phase 2, 157 home visit matched to 471 comparison patients had fewer 30-day readmissions (19.1% vs. 28.7%, p 0.024) and no differences in other outcomes. Compared with patients declining home visits, patients accepting had lower odds of 30-day readmission. In 44 interviews, themes of Medication Understanding, Knowledge Gap after Discharge, Patient Medical Complexity, Social Context, and Patient Engagement/Need for Reassurance emerged.

Conclusion: Post-discharge home visits by APRNs and paramedics working together were associated with reduced 30-day readmissions. Identified themes could inform strategies to improve patient support.
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http://dx.doi.org/10.1016/j.hjdsi.2020.100518DOI Listing
March 2021

Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions.

JAMA Intern Med 2021 Mar;181(3):345-352

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.

Importance: Despite high prevalence of elevated blood pressure (BP) among medical inpatients, BP management guidelines are lacking for this population. The outcomes associated with intensifying BP treatment in the hospital are poorly studied.

Objectives: To characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification.

Design, Setting, And Participants: This cohort study took place from January 1 to December 31, 2017, with 1 year of follow-up at 10 hospitals within the Cleveland Clinic Hospitals health care system. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching.

Exposures: Acute hypertension treatment, defined as administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment.

Main Outcomes And Measures: The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year.

Results: Among 22 834 adults hospitalized for noncardiovascular diagnoses (mean [SD] age, 65.6 [17.9] years; 12 993 women [56.9%]; 15 963 White patients [69.9%]), 17 821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5904 (33.1%) were treated. A total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P < .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year.

Conclusions And Relevance: In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.
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http://dx.doi.org/10.1001/jamainternmed.2020.7501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770615PMC
March 2021

Risk Factors, Management, and Outcomes of Legionella Pneumonia in a Large, Nationally Representative Sample.

Chest 2021 May 19;159(5):1782-1792. Epub 2020 Dec 19.

Medicine Institute Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH.

Background: American Thoracic Society/Infectious Diseases Society of America guidelines recommend against routine Legionella pneumophila testing, but recommend that hospitalized patients with community-acquired pneumonia receive empiric treatment covering Legionella. Testing, empiric treatment, and outcomes for patients with Legionella have not been well described.

Research Question: Is testing for Legionella pneumophila appropriate, and could it impact treatment?

Study Design And Methods: We conducted a large retrospective cohort analysis using Premier Healthcare Database data from 2010 to 2015. We included adults with a principal diagnosis code for pneumonia (or a principal diagnosis of respiratory failure or sepsis with secondary diagnosis of pneumonia) if they also received treatment for pneumonia on hospital days 1-3. We categorized Legionella-tested patients by test result, identified patient characteristics associated with testing and test result, and examined seasonal and regional patterns of Legionella pneumonia (LP) diagnoses. Empiric therapy for LP was defined as a macrolide, quinolone, or doxycycline, administered on each of the first two hospital days.

Results: Of 166,689 eligible patients, 43,070 (26%) were tested for Legionella, and 642 (1.5%) tested positive. Although only 36% of tests were ordered from June to October, 70% of positive test results occurred during this time. Only 30% of patients with hyponatremia, 32% with diarrhea, and 27% in the ICU were tested. Of patients with positive test results, 495 of 642 (77%) had received empiric Legionella therapy. Patients with LP did not have more severe presentation. They had more frequent late decompensation, but similar mortality to patients without LP.

Interpretation: Legionella is an uncommon cause of community-acquired pneumonia, occurring primarily from late spring through early autumn. Testing is uncommon, even among patients with risk factors, and many patients with positive test results failed to receive empiric coverage for LP.
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http://dx.doi.org/10.1016/j.chest.2020.12.013DOI Listing
May 2021

Respiratory viral testing and antibacterial treatment in patients hospitalized with community-acquired pneumonia.

Infect Control Hosp Epidemiol 2021 Jul 1;42(7):817-825. Epub 2020 Dec 1.

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.

Objective: Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization.

Design: Retrospective cohort study.

Setting: The study included 179 US hospitals.

Patients: Adults admitted with pneumonia between July 2010 and June 2015.

Methods: We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients.

Results: Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P < .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P < .001) but varied by bacterial testing: 8.1 versus 8.0 days (P = .60) if bacterial tests were positive; 5.3 versus 6.1 days (P < .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P < .001) if bacterial tests were not obtained (interaction P < .001).

Conclusions: A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.
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http://dx.doi.org/10.1017/ice.2020.1312DOI Listing
July 2021

Functional Recovery Rate: A Feasible Method for Evaluating and Comparing Rehabilitation Outcomes Between Skilled Nursing Facilities.

J Am Med Dir Assoc 2021 Aug 16;22(8):1633-1639.e3. Epub 2020 Nov 16.

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA; Department of Internal Medicine and Geriatrics, Community Care, Cleveland Clinic, Cleveland, OH, USA.

Objectives: The recovery of patients' physical function and the rate at which this occurs are important parameters for evaluating value in post-acute care (PAC). However, no metrics are presently used to compare skilled nursing facilities (SNFs) based on the functional recovery rates (FRRs) for patients in their care. The objectives of this study were to examine whether the average FRR differed significantly among SNFs and to compare the FRR to other measures currently used to assess care quality in SNFs.

Design: Retrospective observational study.

Setting And Participants: 3913 patients discharged from hospitals in one health system to one of 10 partner SNFs between January 2017 and September 2019.

Methods: The FRR-the difference in Activity Measure for Post-Acute Care 6-Clicks basic mobility score from SNF admission to discharge relative to the SNF length of stay (in days)-was the primary outcome. Secondary outcomes included metrics from the SNF Quality Reporting Program (functional recovery alone, discharge to the community, and 30-day hospital readmission). Differences in patients' outcomes between SNFs were tested using multiple regression in order to adjust for patient characteristics.

Results: Across the 10 SNFs, the highest adjusted mean FRR was 0.70 [95% confidence interval (CI): 0.55, 0.90] and the lowest was 0.39 (95% CI: 0.33, 0.46) points per day. Two SNFs had an adjusted mean FRR statistically higher, and 2 had an FRR statistically lower, than the sample mean (0.50, 95% CI: 0.48-0.52). SNF rankings varied by metric.

Conclusions And Implications: Individual SNFs vary in their mean FRR for patients making it a potentially useful measure of value for comparing SNFs. Standardized measurement and reporting of FRR could be beneficial to patients and their families as they consider specific SNFs for necessary post-acute rehabilitation and to hospital systems seeking to identify high-value PAC providers with whom to partner in collaborative care models.
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http://dx.doi.org/10.1016/j.jamda.2020.09.037DOI Listing
August 2021

Pathologic Complete Response to Neoadjuvant Nivolumab/Ipilimumab in a Patient with Metastatic Renal Cell Carcinoma.

Case Rep Urol 2020 1;2020:8846135. Epub 2020 Nov 1.

Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.

Nivolumab plus ipilimumab represents an effective combination of checkpoint inhibitors that can lead to a durable response with minimal toxicity in patients with metastatic renal cell carcinoma (mRCC). We present a case of a pathologic complete response to neoadjuvant nivolumab plus ipilimumab in a patient with a 13.9 cm left renal mass and significant retroperitoneal and iliac lymphadenopathy, classified as intermediate-risk mRCC. We discuss and review the literature on complete responses after systemic therapy and the ability to predict who has undergone a complete response in the face of residual radiographic evidence of disease.
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http://dx.doi.org/10.1155/2020/8846135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652618PMC
November 2020

Opportunities, Pitfalls, and Alternatives in Adapting Electronic Health Records for Health Services Research.

Med Decis Making 2021 02 24;41(2):133-142. Epub 2020 Sep 24.

Center for Health Care Research and Policy, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA.

Electronic health records (EHRs) offer the potential to study large numbers of patients but are designed for clinical practice, not research. Despite the increasing availability of EHR data, their use in research comes with its own set of challenges. In this article, we describe some important considerations and potential solutions for commonly encountered problems when working with large-scale, EHR-derived data for health services and community-relevant health research. Specifically, using EHR data requires the researcher to define the relevant patient subpopulation, reliably identify the primary care provider, recognize the EHR as containing episodic (i.e., unstructured longitudinal) data, account for changes in health system composition and treatment options over time, understand that the EHR is not always well-organized and accurate, design methods to identify the same patient across multiple health systems, account for the enormous size of the EHR, and consider barriers to data access. Associations found in the EHR may be nonrepresentative of associations in the general population, but a clear understanding of the EHR-based associations can be enormously valuable to the process of improving outcomes for patients in learning health care systems. In the context of building 2 large-scale EHR-derived data sets for health services research, we describe the potential pitfalls of EHR data and propose some solutions for those planning to use EHR data in their research. As ever greater amounts of clinical data are amassed in the EHR, use of these data for research will become increasingly common and important. Attention to the intricacies of EHR data will allow for more informed analysis and interpretation of results from EHR-based data sets.
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http://dx.doi.org/10.1177/0272989X20954403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878193PMC
February 2021

Association Between Pain, Blood Pressure, and Medication Intensification in Primary Care: an Observational Study.

J Gen Intern Med 2020 12 21;35(12):3549-3555. Epub 2020 Sep 21.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA.

Background: Treating hypertension is important but physicians often do not intensify blood pressure (BP) treatment in the setting of pain.

Objective: To identify whether reporting pain is associated with (1) elevated BP at the same visit, (2) medication intensification, and (3) elevated BP at the subsequent visit.

Design: Retrospective cohort SETTING: Integrated health system PARTICIPANTS: Adults seen in primary care EXPOSURE: Pain status based on numerical scale: mild (1-3), moderate (4-6), or severe (≥ 7).

Main Measures: We defined elevated BP as ≥ 140/80 mmHg and medication intensification as increasing the dose or adding a new antihypertensive medication. Multilevel regression models were used to find the association between pain and (1) elevated BP at the index visit; (2) medication intensification at the index visit; and (3) elevated BP at the subsequent visit. Models adjusted for demographics, chronic conditions, and clustering within physician. In the third model, we adjusted for initial systolic BP as well.

Key Results: Our population included 56,322 patients; 3155 (6%) reported mild pain, 5050 (9%) reported moderate pain, and 4647 (8%) reported severe pain at the index visit. Compared with no pain, the adjusted odds ratios of elevated BP were 1.38 (95% CI: 1.28-1.48) for severe pain, 1.06 (95% CI: 0.99-1.14) for moderate pain, and 1.02 (95% CI: 0.93-1.12) for mild pain. Adjusted odds ratios of medication intensification at the index visit were 0.65 (95% CI: 0.54-0.80) for mild pain, 0.61 (95% CI: 0.52-0.72) for moderate pain, and 0.55 (95% CI: 0.47-0.64) for severe pain. Among patients with elevated BP at the index visit, reporting pain at the index visit was not associated with elevated BP at the subsequent visit.

Conclusions: When patients reported pain, physicians were less likely to intensify antihypertensive treatment; nevertheless, patients reporting pain were not more likely to have elevated BP at the subsequent visit.
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http://dx.doi.org/10.1007/s11606-020-06208-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728880PMC
December 2020

Pneumonia and alcohol use disorder: Implications for treatment.

Cleve Clin J Med 2020 Jul 31;87(8):493-500. Epub 2020 Jul 31.

Center for Value-Based Care Research, and Vice Chair, Research, Department of Internal Medicine and Geriatrics, Cleveland Clinic Community Care, Cleveland Clinic

Patients with alcohol use disorder (AUD) are at higher risk of pneumonia and of poor outcomes. This article reviews the etiology of pneumonia in patients with AUD, its impact on mortality and resource utilization, and its implications for treatment.
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http://dx.doi.org/10.3949/ccjm.87a.19105DOI Listing
July 2020

Assessment of Physician Priorities in Delivery of Preventive Care.

JAMA Netw Open 2020 07 1;3(7):e2011677. Epub 2020 Jul 1.

Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.

Importance: Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services.

Objective: To understand primary care physicians' prioritization of preventive services.

Design, Setting, And Participants: This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019.

Exposures: A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services.

Main Outcomes And Measures: Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model.

Results: Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model.

Conclusions And Relevance: In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.11677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103855PMC
July 2020

Assessment of the Accuracy of Using ICD-9 Diagnosis Codes to Identify Pneumonia Etiology in Patients Hospitalized With Pneumonia.

JAMA Netw Open 2020 07 1;3(7):e207750. Epub 2020 Jul 1.

Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio.

Importance: Administrative databases may offer efficient clinical data collection for studying epidemiology, outcomes, and temporal trends in health care delivery. However, such data have seldom been validated against microbiological laboratory results.

Objective: To assess the validity of International Classification of Diseases, Ninth Revision (ICD-9) organism-specific administrative codes for pneumonia using microbiological data (test results for blood or respiratory culture, urinary antigen, or polymerase chain reaction) as the criterion standard.

Design, Setting, And Participants: Cross-sectional diagnostic accuracy study conducted between February 2017 and June 2019 using data from 178 US hospitals in the Premier Healthcare Database. Patients were aged 18 years or older admitted with pneumonia and discharged between July 1, 2010, and June 30, 2015. Data were analyzed from February 14, 2017, to June 27, 2019.

Exposures: Organism-specific pneumonia identified from ICD-9 codes.

Main Outcomes And Measures: Sensitivity, specificity, positive predictive value, and negative predictive value of ICD-9 codes using microbiological data as the criterion standard.

Results: Of 161 529 patients meeting inclusion criteria (mean [SD] age, 69.5 [16.2] years; 51.2% women), 35 759 (22.1%) had an identified pathogen. ICD-9-coded organisms and laboratory findings differed notably: for example, ICD-9 codes identified only 14.2% and 17.3% of patients with laboratory-detected methicillin-sensitive Staphylococcus aureus and Escherichia coli, respectively. Although specificities and negative predictive values exceeded 95% for all codes, sensitivities ranged downward from 95.9% (95% CI, 95.3%-96.5%) for influenza virus to 14.0% (95% CI, 8.8%-20.8%) for parainfluenza virus, and positive predictive values ranged downward from 91.1% (95% CI, 89.5%-92.6%) for Staphylococcus aureus to 57.1% (95% CI, 39.4%-73.7%) for parainfluenza virus.

Conclusions And Relevance: In this study, ICD-9 codes did not reliably capture pneumonia etiology identified by laboratory testing; because of the high specificities of ICD-9 codes, however, administrative data may be useful in identifying risk factors for resistant organisms. The low sensitivities of the diagnosis codes may limit the validity of organism-specific pneumonia prevalence estimates derived from administrative data.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.7750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376393PMC
July 2020

Comparative Effectiveness of Commercial Bowel Preparations in Ambulatory Patients Presenting for Screening or Surveillance Colonoscopy.

Dig Dis Sci 2021 Jun 20;66(6):2059-2068. Epub 2020 Jul 20.

Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: Inadequate bowel preparation (IBP) is associated with reduced adenoma detection. However, limited research has examined the impact of different commercial bowel preparations (CBPs) on IBP and adenoma detection. We aim to determine whether type of CBP used is associated with IBP or adenoma detection.

Methods: We retrospectively evaluated outpatient, screening or surveillance colonoscopies performed in the Cleveland Clinic health system between January 2011 and June 2017. IBP was defined by the Aronchick scale. Multilevel mixed-effects logistic regression was performed to assess the association between CBP type and IBP and adenoma detection. Fixed effects were defined as demographics, comorbidities, medication use, and colonoscopy factors. Random effect of individual endoscopist was considered.

Results: Of 153,639 colonoscopies, 75,874 records met inclusion criteria. Median age was 54; 50% were female; 17.7% had IBP, and adenoma detection rate was 32.6%. In adjusted analyses, compared to GoLYTELY, only NuLYTELY [OR 0.66 (95% CI 0.60, 0.72)] and SuPREP [OR 0.53 (95% CI 0.40, 0.69)] were associated with reduced IBP. Adenoma detection did not vary based on the type of bowel preparation used.

Conclusions: Among patients referred for screening or surveillance colonoscopy, choice of CBP was not associated with adenoma detection. Decisions about CBP should be based on other factors, such as tolerability, cost, or safety.
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http://dx.doi.org/10.1007/s10620-020-06492-zDOI Listing
June 2021

The Association Between Physician Race/Ethnicity and Patient Satisfaction: an Exploration in Direct to Consumer Telemedicine.

J Gen Intern Med 2020 09 6;35(9):2600-2606. Epub 2020 Jul 6.

Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA.

Background: Patient satisfaction measures have important implications for physicians. Patient bias against non-White physicians may impact physician satisfaction ratings, but this has not been widely studied.

Objective: To assess differences in patient satisfaction by physician race/ethnicity.

Design: A cross-sectional observational study.

Participants: Patients seeking care on a large nationwide direct to consumer telemedicine platform between July 2016 and July 2018 and their physicians.

Main Measures: Patient satisfaction was ascertained immediately following the encounter on scales of 1 to 5 stars and scored two ways: (1) top-box satisfaction (5 stars versus fewer) and (2) dissatisfaction (2 or fewer stars versus 3 or more). To approximate the information patients would use to make assumptions about physician race/ethnicity, four reviewers classified physicians into categories based on physician name and photo. These included White American, Black American, South Asian, Middle Eastern, Hispanic, and East Asian. Mixed effects logistic regression was used to assess differences in patient top-box satisfaction and patient dissatisfaction by physician race/ethnicity, controlling for patient characteristics, prescription receipt, physician specialty, and whether the physician trained in the USA versus internationally.

Key Results: The sample included 119,016 encounters with 390 physicians. Sixty percent were White American, 14% South Asian, 7% Black American, 7% Hispanic, 6% Middle Eastern, and 6% East Asian. Encounters with South Asian physicians (aOR 0.70; 95% CI 0.54-0.91) and East Asian physicians (aOR 0.72; 95% CI 0.53-0.99) were significantly less likely than those with White American physicians to result in top-box satisfaction. Compared to encounters with White American physicians, those with Black American physicians (aOR 1.72; 95% CI 1.12-2.64), South Asian physicians (aOR 1.77; 95% CI 1.23-2.56), and East Asian physicians (aOR 2.10; 95% CI 1.38-3.20) were more likely to result in patient dissatisfaction.

Conclusions: In our study, patients reported lower satisfaction with some groups of non-White American physicians, which may have implications for their compensation, professional reputation, and job satisfaction.
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http://dx.doi.org/10.1007/s11606-020-06005-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459065PMC
September 2020

Variation in Patient Smoking Cessation Rates Among Health-Care Providers: An Observational Study.

Chest 2020 11 16;158(5):2038-2046. Epub 2020 Jun 16.

Medicine Institute, Cleveland Clinic, Cleveland, OH; Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH. Electronic address:

Background: Physicians play a crucial role in providing smoking cessation counseling and medications. However, it is unknown whether individual physicians' approaches affect whether patients quit.

Research Question: This study assessed patient quit rates within a national quality-improvement learning collaborative to document variation in quit rates at the physician, practice, and health system levels.

Study Design And Methods: A retrospective cohort study was conducted of primary care patients identified from the Optum analytics database containing longitudinal ambulatory data for patients from 22 health-care organizations between January 2012 and December 2018. The study included smokers aged ≥ 18 years who attended at least three ambulatory visits, with two visits at least 1 year apart. The primary study outcome was abstinence for ≥ 1 year. A mixed effects logistic regression model was used to predict the probability of quitting as a function of patient variables. Quit rates were then adjusted by patient factors and calculated at the level of clinician, clinic/practice, and health system.

Results: Across all systems, 56% of patients had a documented smoking status in 2017. Among nearly 1 million smokers, 24% quit smoking. In the regression model, patient characteristics associated with quitting included older age, Hispanic ethnicity, being married, urban residence, commercial insurance, pregnancy, and a diagnosis of pneumonia, myocardial infarction, ischemic heart disease, cataract, or asthma. Medicaid insurance, low income, high BMI, peripheral vascular disease, alcohol-related diagnosis, and COPD were negatively associated with smoking cessation. Adjusted quit rates ranged from 14.3% to 34.5% across 20 health systems, 5% to 66% among 1,399 practice sites, and 4% to 87% among 3,803 health-care providers. Of smokers, 10.2% were prescribed smoking deterrents, and 3.9% were referred for counseling.

Interpretation: Smoking cessation rates varied substantially at the practitioner, practice site, and health system levels. It is likely that individual physician approaches to smoking cessation influence patients' likelihood of quitting.
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http://dx.doi.org/10.1016/j.chest.2020.05.599DOI Listing
November 2020
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