Faculty Bibliography

BACKGROUND:One hypothesis for the respiratory syncytial virus (RSV) surge in 2022 was suppression of immune responses following SARS-CoV-2 infection. Our objective was to compare the risk of subsequent RSV and other infections among children with and without SARS-CoV-2 infection. METHODS:We conducted a retrospective cohort study using electronic health record data from 27 US health systems analyzing children aged under 5 years with SARS-CoV-2 infection (test/coded) between March and July 2022. The comparison groups were children with (a) influenza infection and (b) respiratory tract infection with no evidence of SARS-CoV-2/influenza infection. The primary and secondary outcomes were RSV infection and respiratory or any infection in the subsequent 15 to 180 days, respectively. We applied inverse probability of treatment weighting and performed weighted logistic regression modeling. RESULTS:Our primary and secondary cohorts consisted of 18 767 and 114 414 children with SARS-CoV-2 infection, and 6697 and 30 424 with influenza infection, respectively, and 46 697 with another acute respiratory tract infection. The odds of subsequent RSV were lower in the SARS-CoV-2 group compared with the influenza group (adjusted odds ratio [aOR] 0.73, 95% CI 0.61-0.86) and compared with the group with any respiratory tract infection (aOR 0.78, 95% CI 0.7-0.87). The odds of a respiratory tract infection and any infection were lower in the SARS-CoV-2 group than the influenza group (aOR 0.62, 95% CI 0.59-0.64 and aOR 0.67, 95% CI 0.65-0.7, respectively). CONCLUSIONS:We did not find an increased risk of RSV or a respiratory or any type of infection within 6 months of SARS-CoV-2 infection, compared with influenza and other respiratory illnesses.

OBJECTIVE:To examine the associations between patient out-of-pocket (OOP) costs and nonadherence to glucagon-like peptide 1 receptor agonists (GLP-1a), and the consequent impact on adverse outcomes, including hospitalizations and emergency department (ED) visits. RESEARCH DESIGN AND METHODS/METHODS:This retrospective cohort study used MarketScan Commercial data (2016-2021). The cohort included nonpregnant adults aged 18-64 years with type 2 diabetes who initiated GLP-1a therapy. Participants were continuously enrolled in the same private insurance plan for 6 months before the prescription date and 1 year thereafter. Exposures included average first 30-day OOP costs for GLP-1a, categorized into quartiles (lowest [Q1] to highest [Q4]). Primary outcomes were the annual proportion of days covered (PDC) for GLP-1a and nonadherence, defined as PDC <0.8. Secondary outcomes included diabetes-related and all-cause hospitalizations and ED visits 1 year post-GLP-1a initiation. RESULTS:Among 61,907 adults who initiated GLP-1a, higher 30-day OOP costs were associated with decreased adherence. Patients in the highest OOP cost quartile (Q4: $80-$3,375) had significantly higher odds of nonadherence (odds ratio [OR]1.25; 95% CI 1.19-1.31) compared with those in Q1 ($0-$21). Nonadherence was linked to increased incidence rates of diabetes-related hospitalizations or ED visits (incidence rate ratio [IRR] 1.86; 95% CI 1.43-2.42), cumulative length of hospitalization (IRR 1.56; 95% CI 1.41-1.72), all-cause ED visits (IRR 1.38; 95% CI 1.32-1.45), and increased ED-related costs ($69.81, 95% CI $53.54-$86.08). CONCLUSIONS:Higher OOP costs for GLP-1a were associated with reduced adherence and increased rates of adverse outcomes among type 2 diabetes patients.

Uncontrolled hypertension is common and frequently related to inadequate adherence to prescribed medications, resulting in suboptimal blood pressure control and increased healthcare utilization. Although healthcare providers have the opportunity to improve medication adherence, they may lack the tools to address adherence at the point of care. This study aims to assess the usability of a digital tool designed to improve medication adherence and blood pressure control among patients with hypertension who are not adherent to therapy. By evaluating usability, the study seeks to refine the tool's design, underscore the role of technology in managing hypertension, and provide insights to inform clinical decisions.We performed qualitative usability testing of an electronic health record (EHR)-integrated intervention with medical assistants (MAs) and primary care providers (PCPs) from a large integrated health system. Usability was assessed with these end-users using the "think aloud" and "near live" approaches. This evaluation was guided by two frameworks: the End-User Computing Satisfaction Index (EUCSI) and the Technology Acceptance Model (TAM). Interviews were analyzed using a thematic analysis approach.Thematic saturation was reached after usability testing was performed with 10 participants, comprising 5 PCPs and 5 MAs. The study identified several strengths within the content, format, ease of use, timeliness, accuracy, and usefulness of the tool, including the user-friendly content presentation, the usefulness of adherence information, and timely alerts that fit into the workflow. Challenges centered around alert visibility and specificity of information.Leveraging the two conceptual frameworks (TAM and EUCSI) to test the usability of the medication adherence tool was helpful. The tool's several strengths and opportunities for improvement were found. The resulting suggestions will be used to support the enhancement of the design for optimal implementation in a clinical trial.

The COVID-19 pandemic has been associated with increased neuropsychiatric conditions in children and youths, with evidence suggesting that SARS-CoV-2 infection may contribute additional risks beyond pandemic stressors. This study aims to assess the full spectrum of neuropsychiatric conditions in COVID-19 positive children (ages 5-12) and youths (ages 12-20) compared to a matched COVID-19 negative cohort, accounting for factors influencing infection risk. Using EHR data from 25 institutions in the RECOVER program, we conduct a retrospective analysis of 326,074 COVID-19 positive and 887,314 negative participants matched for risk factors and stratified by age. Neuropsychiatric outcomes are examined 28 to 179 days post-infection or negative test between March 2020 and December 2022. SARS-CoV-2 positivity is confirmed via PCR, serology, or antigen tests, while negativity requires negative test results and no related diagnoses. Risk differences reveal higher frequencies of neuropsychiatric conditions in the COVID-19 positive cohort. Children face increased risks for anxiety, OCD, ADHD, autism, and other conditions, while youths exhibit elevated risks for anxiety, suicidality, depression, and related symptoms. These findings highlight SARS-CoV-2 infection as a potential contributor to neuropsychiatric risks, emphasizing the importance of research into tailored treatments and preventive strategies for affected individuals.

BACKGROUND:Despite the widespread use of electronic health records, a standardized approach to identify heart failure patients is lacking. We sought to create and validate definitions for identifying patients with heart failure using electronic health record data. METHODS:To define heart failure, we developed 8 distinct definitions created from combinations of heart failure diagnosis based on ICD-10 codes listed in the clinical encounter, problem list or past medical history, and/or ejection fraction ≤40%. To validate our definitions, we used stratified sampling and physician chart review guided by the Universal Definition of Heart Failure as our gold standard and compared their performance using sensitivity and positive predictive value. RESULTS:We identified 41,392 patients who met at least one of our eight definitions for heart failure, plus an additional 2,692 patients with an ICD-10 diagnosis of heart failure outside of a standard clinical setting and 696,896 patients with a cardiovascular diagnosis other than heart failure. Using these groups, we randomly sampled a total of 528 charts for physician chart review. Sensitivities of the eight definitions of heart failure ranged from 10.3% to 42.0%, and positive predictive values ranged from 80.7% to 98.6%. CONCLUSIONS:We found that patients meeting EHR-based definitions of heart failure likely represented true clinical cases of disease. Nevertheless, the definitions captured less than half of the patients with heart failure, thus severely underestimating the prevalence of disease and underlining a need for more comprehensive methods to effectively use this data to understand the epidemiological burden of heart failure.

IMPORTANCE/UNASSIGNED:Medication nonadherence is present in nearly half of patients with hypertension but is underrecognized in clinical care. Data linkages between electronic health records and pharmacies have created opportunities for scalable assessment of medication adherence at the point of care. OBJECTIVE/UNASSIGNED:To test the effectiveness of a multicomponent intervention that identified patients with uncontrolled hypertension and medication nonadherence using linked electronic health record-pharmacy data combined with team-based care to address adherence barriers. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:TEAMLET (Leveraging Electronic Health Record Technology and Team Care to Address Medication Adherence) was a pragmatic, 2-arm, cluster randomized clinical trial conducted between October 2022 and November 2024 in 10 primary care sites in New York. The study included adults with uncontrolled hypertension and low medication adherence, defined as proportion of days covered (PDC) less than 80%. Data analysis was performed from November 2024 to January 2025. INTERVENTION/UNASSIGNED:The intervention consisted of the following: (1) automated identification of patients with medication nonadherence at the time of the visit; (2) prompting of medical assistants to screen for barriers to adherence; (3) clinical decision support alerting the primary care physicians and nurse practitioners to barriers to adherence; and (4) adherence discussion between the primary care physician or nurse practitioner and the patient. The comparator was usual care. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was change in PDC from baseline to 12 months. RESULTS/UNASSIGNED:Among 1726 patients (mean [SD] age, 67.2 [13.9] years; 887 [51.4%] female), the mean (SD) baseline PDC was 33.2% (30.5%) overall (32.4% [30.4%] in the intervention group and 34.0% [30.6%] in the control group). The mean (SD) PDC at 12 months was 51.1% (39.5%) for the intervention group and 53.1% (39.6%) for the control group. No difference was found in the change in PDC from baseline to 12 months between the intervention and control groups (mean [SD] absolute change in PDC, 18.5 [41.1] vs 18.2 [40.9] percentage points, respectively; adjusted difference, -0.15 percentage point; 95% CI, -4.06 to 3.76 percentage points). Change in systolic blood pressure and patients who became adherent (PDC ≥80%) at 12 months were also similar between groups. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this pragmatic trial, an intervention that combined team-based primary care with automated identification of patients with antihypertensive medication nonadherence did not lead to improvements in adherence or blood pressure. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT05349422.

OBJECTIVE:The objective of this study is to examine real-world dose titration patterns of semaglutide for weight management (Wegovy, Novo Nordisk A/S) in US adults and identify characteristics associated with early discontinuation. METHODS:We identified 15,811 commercially insured adults who started semaglutide for weight management (administrated through single-dose prefilled pens) between June 2021 and December 2023. We depicted dose-titration patterns over 5 months and identified factors associated with discontinuation using multivariable Cox regression. Sensitivity analyses examined patterns after supply shortage resolution (after October 2023). RESULTS:Most semaglutide users deviated from the recommended monthly dose-escalation schedule within the first 5 months. By the fifth month, nearly one-half (46%) had discontinued the treatment, with similar rates (48%) among those initiating after supply stabilization. Discontinuation was strongly associated with copayment amount, with rates increased from 41% in the lowest quintile ($1-$54 per month) to 51% in the highest quintile ($161-$1460 per month). Higher discontinuation rates were also associated with lower household income and education level. CONCLUSIONS:The deviations from the recommended dose-escalation schedule and high discontinuation rate among real-world semaglutide users indicate important challenges in the delivery of evidence-based care. Policy interventions that reduce financial barriers to the persistence of semaglutide are needed.

IMPORTANCE/OBJECTIVE:Patients with poor glycaemic control have a high risk for major cardiovascular events. Improving glycaemic monitoring in patients with diabetes can improve morbidity and mortality. OBJECTIVE:To assess the effectiveness of a patient portal message in prompting patients with poorly controlled diabetes without a recent glycated haemoglobin (HbA1c) result to have their HbA1c repeated. DESIGN/METHODS:A pragmatic, randomised clinical trial. SETTING/METHODS:A large academic health system consisting of over 350 ambulatory practices. PARTICIPANTS/METHODS:Patients who had an HbA1c greater than 10% who had not had a repeat HbA1c in the prior 6 months. EXPOSURES/METHODS:A single electronic health record (EHR)-based patient portal message to prompt patients to have a repeat HbA1c test versus usual care. MAIN OUTCOMES/RESULTS:The primary outcome was a follow-up HbA1c test result within 90 days of randomisation. RESULTS:The study included 2573 patients with a mean (SD) HbA1c of 11.2%. Among 1317 patients in the intervention group, 24.2% had follow-up HbA1c tests completed within 90 days, versus 21.1% of 1256 patients in the control group (p=0.07). Patients in the intervention group were more likely to log into the patient portal within 60 days as compared with the control group (61.2% vs 52.3%, p<0.001). CONCLUSIONS:Among patients with poorly controlled diabetes and no recent HbA1c result, a brief patient portal message did not significantly increase follow-up testing but did increase patient engagement with the patient portal. Automated patient messages could be considered as a part of multipronged efforts to involve patients in their diabetes care.

Objectives Improve concordance between patient end-of-life preferences and code status orders by incorporating data from a state registry with Clinical Decision Support (CDS) within the electronic health record (EHR) to preserve patient autonomy and ensure that patients receive care that aligns with their wishes. Methods Leveraging a Health Information exchange (HIE) interface between the New York State Medical Orders for Life-Sustaining Treatment (eMOLST) registry and the EHR of our academic health system, we developed a bundled CDS intervention that displays eMOLST information at the time of code status ordering and provides an in-line alert when providers enter a resuscitation order discordant with wishes documented in the eMOLST registry. To evaluate this intervention, we performed a segmented regression analysis of an interrupted times series to compare percentage of discordant orders before and after implementation among all hospitalizations for which an eMOLST was available. Results We identified a total of 3648 visits that had an eMOLST filed prior to inpatient admission and a code status order placed during admission. There was a statistically significant decrease of discordant resuscitation orders of -5.95% after the intervention went live, with a relative risk reduction of 25%, [95% CI: -9.95%, -1.94%, p=0.009] in the pre- and post-intervention period. Logistic regression model after adjusting for co-variates showed an average marginal effect of -5.12% after the intervention [CI =-9.75%, -0.50%, p=0.03]. Conclusions Our intervention resulted in a decrease in discordant resuscitation orders. This study demonstrates that accessibility to eMOLST data within the provider workflow supported by CDS can reduce discrepancies between patient end-of-life wishes and hospital code status orders.

IMPORTANCE/UNASSIGNED:It remains unclear whether children and adolescents with SARS-CoV-2 infection are at heightened risk for long-term kidney complications. OBJECTIVE/UNASSIGNED:To investigate whether SARS-CoV-2 infection is associated with an increased risk of postacute kidney outcomes among pediatric patients, including those with preexisting kidney disease or acute kidney injury (AKI). DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective cohort study used data from 19 health institutions in the National Institutes of Health Researching COVID to Enhance Recovery (RECOVER) initiative from March 1, 2020, to May 1, 2023 (follow-up ≤2 years completed December 1, 2024; index date cutoff, December 1, 2022). Participants included children and adolescents (aged <21 years) with at least 1 baseline visit (24 months to 7 days before the index date) and at least 1 follow-up visit (28 to 179 days after the index date). EXPOSURES/UNASSIGNED:SARS-CoV-2 infection, determined by positive laboratory test results (polymerase chain reaction, antigen, or serologic) or relevant clinical diagnoses. A comparison group included children with documented negative test results and no history of SARS-CoV-2 infection. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Outcomes included new-onset chronic kidney disease (CKD) stage 2 or higher or CKD stage 3 or higher among those without preexisting CKD; composite kidney events (≥50% decline in estimated glomerular filtration rate [eGFR], eGFR ≤15 mL/min/1.73 m2, dialysis, transplant, or end-stage kidney disease diagnosis), and at least 30%, 40%, or 50% eGFR decline among those with preexisting CKD or acute-phase AKI. Hazard ratios (HRs) were estimated using Cox proportional hazards regression models with propensity score stratification. RESULTS/UNASSIGNED:Among 1 900 146 pediatric patients (487 378 with and 1 412 768 without COVID-19), 969 937 (51.0%) were male, the mean (SD) age was 8.2 (6.2) years, and a range of comorbidities was represented. SARS-CoV-2 infection was associated with higher risk of new-onset CKD stage 2 or higher (HR, 1.17; 95% CI, 1.12-1.22) and CKD stage 3 or higher (HR, 1.35; 95% CI, 1.13-1.62). In those with preexisting CKD, COVID-19 was associated with an increased risk of composite kidney events (HR, 1.15; 95% CI, 1.04-1.27) at 28 to 179 days. Children with acute-phase AKI had elevated HRs (1.29; 95% CI, 1.21-1.38) at 90 to 179 days for composite outcomes. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this large US cohort study of children and adolescents, SARS-CoV-2 infection was associated with a higher risk of adverse postacute kidney outcomes, particularly among those with preexisting CKD or AKI, suggesting the need for vigilant long-term monitoring.