Faculty Bibliography

Research Objective: Studies have found that race/ethnicity concordance between patients and providers improves medication adherence among patients with hypertension and single CVD outcomes (eg, blood pressure control). Our objective was to examine the association of patient-physician race/ethnicity concordance on adherence to the Million Hearts "ABCS" CVD guidelines: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation. To the best of our knowledge, this is the first study to examine the impact of race/ ethnicity concordance on guideline adherence to multiple CVD outcome measures.
Study Design: This study was part of HealthyHearts NYC, a stepped-wedge cluster randomized controlled trial funded through AHRQ's EvidenceNOW initiative to test the effectiveness of practice facilitation on helping primary care practices adhere to CVD guidelines. The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (a) proportion of patients who use tobacco who received a cessation intervention (smokers counseled) and (b) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). Practice-level outcome data were extracted for thirteen quarters from practices' electronic health record (EHR) systems, encompassing the control, intervention, and follow-up periods of the intervention. Patient-physician race/ethnicity concordance was calculated using patient race/ethnicity data extracted from the practices' EHR and physician race/ethnicity data collected via a Provider Survey. The concordance measure was calculated as the proportion of patients with the same race/ethnicity as the physician, for example, if practice is led by an Asian physician, and patients are 33% non-Hispanic white, 5% non-Hispanic black, 5% Hispanic, and 57% Asian, the concordance is 0.57. Population Studied: 211 small primary care practices in NYC. Principal Findings: 57.7% of Hispanic, 53.6% of black, 73.6% of Asian, 74.2% of non-Hispanic white, and 24.1% of Hawaiian/Pacific Islander patients had the same race/ethnicity as their physicians. 44.7% of physicians had the same race/ethnicity as at least 70% of their patients. Patient-physician race/ethnicity concordance was associated with adherence to four of our six outcome measures: aspirin (IRR = 1.08, 95% CI: 1.03-1.14, P < .001); blood pressure (IRR = 1.09, 95% CI: 1.07-1.12, P < .001); smoking screening and cessation (IRR = 1.06, 95% CI: 1.04-1.08, P < .001); and ABC composite (IRR = 1.42, 95% CI: 1.33-1.52, P < 0.001). We did not find an association for race/ethnicity concordance with Cholesterol and Smokers Counseled.
Conclusion(s): Increasing opportunities for patient-physician race/ ethnicity concordance may improve adherence to CVD guidelines. The largest improvement was observed in the ABC Composite measure, suggesting that patient-physician race/ethnicity concordance is particularly important for managing medically complex patients who have multiple chronic diseases. Implications for Policy or Practice: Health policy should fund programs that support the recruitment and retention of a wide diversity of students and faculty to increase the level of concordance in patient-clinician encounters. Policy makers may also want to consider legislation to help support or protect small practices that predominantly serve communities of color, where a large proportion of the physicians may be racially/ ethnically concordant with the patient population. Medical education programs should incorporate patient-physician communication training to minimize gaps potentially created by race/ethnicity discordance

BACKGROUND:There is concern about the potential of an increased risk related to medications that act on the renin-angiotensin-aldosterone system in patients exposed to coronavirus disease 2019 (Covid-19), because the viral receptor is angiotensin-converting enzyme 2 (ACE2). METHODS:We assessed the relation between previous treatment with ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, or thiazide diuretics and the likelihood of a positive or negative result on Covid-19 testing as well as the likelihood of severe illness (defined as intensive care, mechanical ventilation, or death) among patients who tested positive. Using Bayesian methods, we compared outcomes in patients who had been treated with these medications and in untreated patients, overall and in those with hypertension, after propensity-score matching for receipt of each medication class. A difference of at least 10 percentage points was prespecified as a substantial difference. RESULTS:Among 12,594 patients who were tested for Covid-19, a total of 5894 (46.8%) were positive; 1002 of these patients (17.0%) had severe illness. A history of hypertension was present in 4357 patients (34.6%), among whom 2573 (59.1%) had a positive test; 634 of these patients (24.6%) had severe illness. There was no association between any single medication class and an increased likelihood of a positive test. None of the medications examined was associated with a substantial increase in the risk of severe illness among patients who tested positive. CONCLUSIONS:We found no substantial increase in the likelihood of a positive test for Covid-19 or in the risk of severe Covid-19 among patients who tested positive in association with five common classes of antihypertensive medications.

Importance/UNASSIGNED:An estimated 12% of adults 18 years or older and 8% of adolescents aged 12 to 17 years report unhealthy use of prescription or illegal drugs in the US. Objective/UNASSIGNED:To update its 2008 recommendation, the USPSTF commissioned reviews of the evidence on screening by asking questions about drug use and interventions for unhealthy drug use in adults and adolescents. Population/UNASSIGNED:This recommendation statement applies to adults 18 years or older, including pregnant and postpartum persons, and adolescents aged 12 to 17 years in primary care settings. This statement does not apply to adolescents or adults who have a currently diagnosed drug use disorder or are currently undergoing or have been referred for drug use treatment. This statement applies to settings and populations for which services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Evidence Assessment/UNASSIGNED:In adults, the USPSTF concludes with moderate certainty that screening by asking questions about unhealthy drug use has moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred. In adolescents, because of the lack of evidence, the USPSTF concludes that the benefits and harms of screening for unhealthy drug use are uncertain and that the balance of benefits and harms cannot be determined. Recommendation/UNASSIGNED:The USPSTF recommends screening by asking questions about unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents. (I statement).

Importance:In 2017, an estimated 7.9% of persons aged 12 to 17 years reported illicit drug use in the past month, and an estimated 50% of adolescents in the US had used an illicit drug by the time they graduated from high school. Young adults aged 18 to 25 years have a higher rate of current illicit drug use, with an estimated 23.2% currently using illicit drugs. Illicit drug use is associated with many negative health, social, and economic consequences and is a significant contributor to 3 of the leading causes of death among young persons (aged 10-24 years): unintentional injuries including motor vehicle crashes, suicide, and homicide. Objective:To update its 2014 recommendation, the USPSTF commissioned a review of the evidence on the potential benefits and harms of interventions to prevent illicit drug use in children, adolescents, and young adults. Population:This recommendation applies to children (11 years and younger), adolescents (aged 12-17 years), and young adults (aged 18-25 years), including pregnant persons. Evidence Assessment:Because of limited and inadequate evidence, the USPSTF concludes that the benefits and harms of primary care-based interventions to prevent illicit drug use in children, adolescents, and young adults are uncertain and that the evidence is insufficient to assess the balance of benefits and harms. More research is needed. Recommendation:The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care-based behavioral counseling interventions to prevent illicit drug use, including nonmedical use of prescription drugs, in children, adolescents, and young adults. (I statement).

INTRODUCTION/BACKGROUND:Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention. DESIGN/METHODS:The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019. SETTING/PARTICIPANTS/METHODS:A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves. INTERVENTION/METHODS:The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines. MAIN OUTCOME MEASURES/METHODS:The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). RESULTS:The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002). CONCLUSIONS:Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context. TRIAL REGISTRATION/BACKGROUND:This study is registered at www.clinicaltrials.gov NCT02646488.

Importance:Tobacco use is the leading cause of preventable death in the US. An estimated annual 480 000 deaths are attributable to tobacco use in adults, including from secondhand smoke. It is estimated that every day about 1600 youth aged 12 to 17 years smoke their first cigarette and that about 5.6 million adolescents alive today will die prematurely from a smoking-related illness. Although conventional cigarette use has gradually declined among children in the US since the late 1990s, tobacco use via electronic cigarettes (e-cigarettes) is quickly rising and is now more common among youth than cigarette smoking. e-Cigarette products usually contain nicotine, which is addictive, raising concerns about e-cigarette use and nicotine addiction in children. Exposure to nicotine during adolescence can harm the developing brain, which may affect brain function and cognition, attention, and mood; thus, minimizing nicotine exposure from any tobacco product in youth is important. Objective:To update its 2013 recommendation, the USPSTF commissioned a review of the evidence on the benefits and harms of primary care interventions for tobacco use prevention and cessation in children and adolescents. The current systematic review newly included e-cigarettes as a tobacco product. Population:This recommendation applies to school-aged children and adolescents younger than 18 years. Evidence Assessment:The USPSTF concludes with moderate certainty that primary care-feasible behavioral interventions, including education or brief counseling, to prevent tobacco use in school-aged children and adolescents have a moderate net benefit. The USPSTF concludes that there is insufficient evidence to determine the balance of benefits and harms of primary care interventions for tobacco cessation among school-aged children and adolescents who already smoke, because of a lack of adequately powered studies on behavioral counseling interventions and a lack of studies on medications. Recommendation:The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care-feasible interventions for the cessation of tobacco use among school-aged children and adolescents. (I statement).

Importance:Bacterial vaginosis is common and is caused by a disruption of the microbiological environment in the lower genital tract. In the US, reported prevalence of bacterial vaginosis among pregnant women ranges from 5.8% to 19.3% and is higher in some races/ethnicities. Bacterial vaginosis during pregnancy has been associated with adverse obstetrical outcomes including preterm delivery, early miscarriage, postpartum endometritis, and low birth weight. Objective:To update its 2008 recommendation, the USPSTF commissioned a review of the evidence on the accuracy of screening and the benefits and harms of screening for and treatment of bacterial vaginosis in asymptomatic pregnant persons to prevent preterm delivery. Population:This recommendation applies to pregnant persons without symptoms of bacterial vaginosis. Evidence Assessment:The USPSTF concludes with moderate certainty that screening for asymptomatic bacterial vaginosis in pregnant persons not at increased risk for preterm delivery has no net benefit in preventing preterm delivery. The USPSTF concludes that for pregnant persons at increased risk for preterm delivery, the evidence is conflicting and insufficient, and the balance of benefits and harms cannot be determined. Conclusions and Recommendation:The USPSTF recommends against screening for bacterial vaginosis in pregnant persons not at increased risk for preterm delivery. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in pregnant persons at increased risk for preterm delivery. (I statement).

BACKGROUND:Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity. METHODS:A systematic review was conducted of articles published in Medline, Embase and the Cochrane Library up to January 2018. Randomised controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorised by whether they examined a low/high intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12-months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis. RESULTS:A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (-3.12 mmHg, [95%CI -4.78, -1.46 mmHg]; p value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (p<0.001 for all outcomes), and possibly stroke (p<0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes or chronic kidney disease. CONCLUSIONS:Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high intensity co-interventions.