Faculty Bibliography

BACKGROUND:Studies have demonstrated that Black men may undergo definitive prostate cancer (CaP) treatment less often than men of other races, but it is unclear whether they are avoiding overtreatment of low-risk disease or experiencing a reduction in appropriate care. The authors' aim was to assess the role of race as it relates to treatment benefit in access to CaP treatment in a single-payer population. METHODS:The authors used the Veterans Health Administration (VHA) Corporate Data Warehouse to perform a retrospective cohort study of veterans diagnosed with low- or intermediate-risk CaP between 2011 and 2017. RESULTS:The authors identified 35,427 men with incident low- or intermediate-risk CaP. When they controlled for covariates, Black men had 1.05 times the odds of receiving treatment in comparison with non-Black men (P < .001), and high-treatment-benefit men had 1.4 times the odds of receiving treatment in comparison with those in the low-treatment-benefit group (P < .001). The interaction of race and treatment benefit was significant, with Black men in the high-treatment-benefit category less likely to receive treatment than non-Black men in the same treatment category (odds ratio, 0.89; P < .001). CONCLUSIONS:Although race does appear to influence the receipt of definitive treatment in the VHA, this relationship varies in the context of the patient's treatment benefit, with Black men receiving less definitive treatment in high-benefit situations. The influence of patient race at high treatment benefit levels invites further investigation into the driving forces behind this persistent disparity in this consequential group.

Clinical decision support systems, which provide automated reminders in electronic health systems, are designed to provide physicians and other health professionals support in clinical decision-making. New clinical guidance from the Advisory Committee on Immunization Practices on a new category of recommendations referred to as "shared clinical decision-making" have left providers struggling to interpret how to best implement recommendations for adult vaccines. The issue at hand is how to ensure that a conversation between the patient and provider occurs. While traditional clinical decision support systems have driven immunization for years, these systems support a binary default opt-in process. The goal for shared decision-making is the discussion rather than the vaccination. The recommended provider-patient conversations need to be supported with both provider guidance as well as tools to ensure vaccines are not omitted from the conversations, particularly as future vaccine candidates progress through the vaccine development pipeline.

The use of online medical records has increased over time and may enhance patient involvement in medical decisions. We explored sociodemographic, medical condition, and digital health correlates of using online medical records to support medical decision making. Cross-sectional data from the 2019 Health Information National Trends Survey (HINTS 5, Cycle 3, N = 5438) were analyzed. Final analyses included participants who accessed their online medical records within 12 months and had complete data for all variables (n = 1807). The outcome was, "In the past 12 months have you used your online medical record to help you make a decision about how to treat an illness or condition (yes/no)?" Univariate and multivariate odds ratios and 95% confidence intervals were calculated. Multivariately, the odds of using online medical records to support medical decision making were significantly higher for individuals who (a) used online medical records to securely send messages to health care providers, (b) used a smartphone health app to access their online medical records, (c) had online medical records that contained clinical notes, (d) reported that online medical records were useful for monitoring health, and (e) self-identified as African American, Asian, or "Other." Online medical records may support medical decision making depending on the context.

BACKGROUND:The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends ambulatory BP monitoring (ABPM) to exclude white coat hypertension (WCH) among adults with office systolic BP (SBP)/diastolic BP (DBP) of 130-159/80-99 mmHg, and masked hypertension (MHT) among adults with office SBP/DBP of 120-129/75-79 mmHg after a 3-month trial of lifestyle modification. We estimated the proportion of individuals with ideal lifestyle factors among those who meet these office BP criteria for being recommended ABPM. METHODS:We analyzed data from participants not taking antihypertensive medication in the Coronary Artery Risk Development in Young Adults (CARDIA) and Jackson Heart Study (JHS) who met the office BP criteria for screening for WCH (CARDIA n=490, JHS n=873) and MHT (CARDIA n=486, JHS n=614). We estimated the prevalence of lifestyle factors including ideal body mass index (BMI), physical activity, diet and alcohol use among participants who met office BP criteria for WCH screening and for MHT screening. RESULTS:Among participants who met office BP criteria for WCH screening, 15.5% in CARDIA and 3.6% in JHS had 3 or more ideal lifestyle factors. Among participants who met office BP criteria for MHT screening, 22.6% in CARDIA and 4.7% in JHS had 3 or more ideal lifestyle factors. Ideal BMI, diet, and physical activity was present in less than half of participants in each sample who met office BP criteria for WCH or MHT screening. CONCLUSIONS:Few participants who met office BP criteria for the screening of WCH or MHT had ideal lifestyle factors.

BACKGROUND:The effectiveness of patient decision aids (PtDAs) and other shared decision-making (SDM) interventions for socially disadvantaged populations has not been well studied. PURPOSE/OBJECTIVE:To assess whether PtDAs and other SDM interventions improve outcomes or decrease health inequalities among socially disadvantaged populations and determine the critical features of successful interventions. DATA SOURCES/METHODS:MEDLINE, CINAHL, Cochrane, PsycINFO, and Web of Science from inception to October 2019. Cochrane systematic reviews on PtDAs. STUDY SELECTION/METHODS:Randomized controlled trials of PtDAs and SDM interventions that included socially disadvantaged populations. DATA EXTRACTION/METHODS:Independent double data extraction using a standardized form and the Template for Intervention Description and Replication checklist. DATA SYNTHESIS/RESULTS:= 70%]). Only 1 trial looked at clinical outcomes (hemoglobin A1C). Five of the 12 PtDA studies that compared outcomes by disadvantaged standing found that outcomes improved more for socially disadvantaged participants. No evidence indicated which intervention characteristics were most effective. Results were similar for SDM intervention trials. LIMITATIONS/CONCLUSIONS:Sixteen PtDA studies had an overall unclear risk of bias. Heterogeneity was high for most outcomes. Most studies only had short-term follow-up. CONCLUSIONS:PtDAs led to better outcomes among socially disadvantaged populations but did not reduce health inequalities. We could not determine which intervention features were most effective.[Box: see text].

OBJECTIVE:To explore factors associated with how often US adults perceived that they were "always" involved in decisions about health care to the degree that they desired. METHODS:We examined cross-sectional, nationally representative data from the 2018 Health Information National Trends Survey. There were 3504 responses in the full HINTS dataset; 2499 remained after eliminating respondents with missing data for any factor of interest. Sociodemographic factors included age, gender, race/ethnicity, and education. Medical conditions included diabetes, hypertension, heart disease, lung disease, arthritis, cancer, and depression. Participants were asked to think about communication with health professionals during the last 12 months and how often health professionals involved them in decisions about health care. RESULTS:In univariate analyses, Asian and Hispanic race were associated with lower odds of always being involved in decisions about health care; whereas higher education and a history of cancer were associated with higher odds of "always" being involved in decisions about health care, p < 0.05. In multivariate analyses, race and education both remained significant; however, history of cancer did not. CONCLUSION/CONCLUSIONS:Differences by race/ethnicity and educational attainment exist regarding perceived involvement in decisions about health care. PRACTICE IMPLICATIONS/CONCLUSIONS:Findings may inform future shared decision making interventions.

BACKGROUND:There is increasing recognition of the importance of addressing health literacy in patient decision aid (PtDA) development. PURPOSE/OBJECTIVE:An updated review as part of IPDAS 2.0 examined the extent to which PtDAs are designed to meet the needs of people with low health literacy/socially-disadvantaged populations. DATA SOURCES/METHODS:Reference lists of Cochrane reviews of randomized controlled trials (RCTs) of PtDAs (2014, 2017, and upcoming 2021 versions). STUDY SELECTION/METHODS:RCTs that assessed the impact of PtDAs on low health literacy or other socially-disadvantaged groups (i.e., ≥50% participants from socially-disadvantaged groups and/or subgroup analysis in socially-disadvantaged group/s). DATA EXTRACTION/METHODS:Two researchers independently extracted data into a standardized form including PtDA development and evaluation details. We searched online repositories and emailed authors to access PtDAs to verify grade reading level, understandability, and actionability. DATA SYNTHESIS/RESULTS:= 92.9%). LIMITATIONS/CONCLUSIONS:Greater attention to health literacy and socially-disadvantaged populations is needed in the field of PtDAs to ensure equity in decision support.

Patient-centered care, defined as "providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions," is advocated by clinicians and professional organizations and is part of a composite criterion for augmented reimbursement for various health care settings, including patient-centered medical homes. Despite general agreement that patient-centered care is a good idea and worthy of incentivization, patient-centered care is difficult to assess accurately, scalably, and feasibly. In this commentary, we suggest that assessment of patient-centered care may be improved by identifying circumstances that indicate its probable absence-in particular, by flagging probable discordance between a patient's preferences and their treatment care plan. One potential marker of this discordance is persistent lack of control of a comorbid condition that is easily controllable by existing therapies and where existing therapies are sufficiently diverse to be compatible with a wide range of patient preferences (eg, stage 1 hypertension, type 2 diabetes with glycated hemoglobin < 8.5%). We outline how this approach may be tested, validated, and harmonized with existing quality improvement activities.

High blood pressure (BP) based on measurements obtained in the office setting has been associated with the presence and level of coronary artery calcification (CAC)-a measure of subclinical atherosclerosis. We studied the association between out-of-office BP and CAC among 557 participants who underwent 24-hour ambulatory BP monitoring at visit 1 in 2000-2004 and a computed tomography scan at visit 2 in 2005-2008 as part of the JHS (Jackson Heart Study)-a community-based cohort of African American adults. Mean awake, asleep, and 24-hour BP were calculated for each participant. Among participants included in this analysis, 279 (50%) had any CAC defined by an Agatston score >0. After multivariable adjustment including office systolic BP (SBP), the prevalence ratios for any CAC comparing the highest versus the lowest quartiles of SBP on ambulatory BP monitoring were 1.08 (95% CI, 0.84-1.39) for awake SBP, 1.32 (95% CI, 1.01-1.74) for asleep SBP, and 1.19 (95% CI, 0.91-1.55) for 24-hour SBP. After multivariable adjustment including office diastolic BP, the prevalence ratios for any CAC comparing the highest versus the lowest quartiles of awake, asleep, and 24-hour diastolic BP were 1.27 (95% CI, 1.02-1.59), 1.29 (95% CI, 1.02-1.64), and 1.25 (95% CI, 0.99-1.59), respectively. The current results suggest that higher asleep SBP and higher awake and asleep diastolic BP may be risk factors for subclinical atherosclerosis and underscore the potential role of ambulatory BP monitoring in identifying individuals at high risk for coronary artery disease.