Chamberlain, Alanna M.

Background Among patients with heart failure (HF), social risk factors (SRFs) are associated with poor outcomes. However, less is known about how co‐occurrence of SRFs affect all‐cause health care utilization for patients with HF. The objective was to address this gap using a novel approach to classify co‐occurrence of SRFs. Methods and Results This was a cohort study of residents living in an 11‐county region of southeast Minnesota, aged ≥18 years with a first‐ever diagnosis for HF between January 2013 and June 2017. SRFs, including education, health literacy, social isolation, and race and ethnicity, were obtained via surveys. Area‐deprivation index and rural‐urban commuting area codes were determined from patient addresses. Associations between SRFs and outcomes (emergency department visits and hospitalizations) were assessed using Andersen‐Gill models. Latent class analysis was used to identify subgroups of SRFs; associations with outcomes were examined. A total of 3142 patients with HF (mean age, 73.4 years; 45% women) had SRF data available. The SRFs with the strongest association with hospitalizations were education, social isolation, and area‐deprivation index. We identified 4 groups using latent class analysis, with group 3, characterized by more SRFs, at increased risk of emergency department visits (hazard ratio [HR], 1.33 [95% CI, 1.23–1.45]) and hospitalizations (HR, 1.42 [95% CI, 1.28–1.58]). Conclusions Low educational attainment, high social isolation, and high area‐deprivation index had the strongest associations. We identified meaningful subgroups with respect to SRFs, and these subgroups were associated with outcomes. These findings suggest that it is possible to apply latent class analysis to better understand the co‐occurrence of SRFs among patients with HF.

Background: The communities in which people live affect their health. We aimed to determine whether neighborhood characteristics are associated with outcomes in patients with atrial fibrillation (AF) in a Midwest community. Methods: Patients with incident AF from 2013-2017 from a 27-county region who survived >90 days after their diagnosis were identified (N=14,725). Patient addresses were linked to publicly-available data on population density (rural-urban commuting area; RUCA) and neighborhood socioeconomic status (area deprivation index; ADI). Patients were followed for ischemic stroke or transient ischemic attack (TIA), heart failure (HF), dementia/delirium, and all-cause death through 2021. Cox regression determined risk of outcomes by RUCA category (urban, micropolitan, small rural, isolated) and ADI quartile after adjustment for age, sex, race/ethnicity, and CHA2DS2-VASc score. Results: After excluding persons missing race/ethnicity (n=46), RUCA (n=1,465), and ADI (n=1,640), 13,233 patients with AF (mean age 73.8 years, 57% men) remained. After a median follow-up of 4.7 years, 5,989 patients died; 582 experienced a stroke/TIA, 4,122 (of 9,156 patients at risk) developed HF, and 1,758 (of 12,154 patients at risk) developed dementia/delirium. Persons living in isolated areas (HR 1.14, 95% CI 1.05-1.24) and the highest ADI quartile (HR 1.59, 95% CI 1.37-1.85) experienced the greatest risk of death (Figure). A trend toward an increased risk of HF was observed for the 2 highest ADI quartiles (p-trend <0.01), although the estimates did not reach statistical significance. The risk of other outcomes did not differ by RUCA or ADI category. Conclusion: Patients with AF residing in isolated areas and neighborhoods with greater area deprivation experience increased risks of death. Additional research is needed to better understand how neighborhood characteristics influence treatment, co-morbid conditions, and other outcomes in patients with AF.

Abstract Whether initiation of statins could increase survival free of dementia and disability in adults aged ≥75 years is unknown. PREVENTABLE, a double‐blind, placebo‐controlled randomized pragmatic clinical trial, will compare high‐intensity statin therapy (atorvastatin 40 mg) with placebo in 20,000 community‐dwelling adults aged ≥75 years without cardiovascular disease, disability, or dementia at baseline. Exclusion criteria include statin use in the prior year or for >5 years and inability to take a statin. Potential participants are identified using computable phenotypes derived from the electronic health record and local referrals from the community. Participants will undergo baseline cognitive testing, with physical testing and a blinded lipid panel if feasible. Cognitive testing and disability screening will be conducted annually. Multiple data sources will be queried for cardiovascular events, dementia, and disability; survival is site‐reported and supplemented by a National Death Index search. The primary outcome is survival free of new dementia or persisting disability. Co‐secondary outcomes are a composite of cardiovascular death, hospitalization for unstable angina or myocardial infarction, heart failure, stroke, or coronary revascularization; and a composite of mild cognitive impairment or dementia. Ancillary studies will offer mechanistic insights into the effects of statins on key outcomes. Biorepository samples are obtained and stored for future study. These results will inform the benefit of statins for increasing survival free of dementia and disability among older adults. This is a pioneering pragmatic study testing important questions with low participant burden to align with the needs of the growing population of older adults.

Background: Multimorbidity (MM) and functional limitation (FL) are associated with poor outcomes in heart failure (HF). However, the individual and combined effect of these on mental health and quality of life in patients with HF is not well understood. Methods: Patients aged ≥ 30 years with 2 or more HF diagnostic codes and 1 or more HF-related prescription drugs from four US institutions were mailed a survey to measure functional status (activities of daily living [ADLs]), quality of life and mental health (PROMIS-29 Health Profile) and social support (PROMIS Informational Support, Instrumental Support, and Social Isolation Short Forms). The sampling frame was restricted to patients with a first ever-diagnosis of HF on or after 1/1/2013 at 1 of the participating sites and on or after 1/1/2015 for the other 3 participating sites. A total of 3330 patients returned the survey (response rate 35%); among these, 3020 completed the questions of interest for this analysis and were retained. MM was defined as the presence of ≥ 2 non-cardiovascular comorbidities, and FL was defined as reporting any limitation in at least 1 of 8 ADLs. Patients were categorized into 4 groups by MM (Yes/No) and FL (Yes/No). We dichotomized the subscale scores of the PROMIS-29 at the median and calculated odd ratios for the 4 MM/FL groups. Results: Among 3020 patients with HF (45% female; mean age 73±12 years), 29% had neither MM or FL, 24% had MM only, 22% had FL only, and 25% had both. After adjustment, having both MM and FL or only FL was associated with increased odds of higher anxiety, depression, fatigue, sleep, and pain scores compared to having neither (Figure); having MM only was associated with a higher pain score. Conclusions: Patients with both FL and MM and only FL have similar odds of poor mental health and quality of life scores, underscoring the importance of the role that FL plays in outcomes in patients with HF.

Background: Most patients with heart failure (HF) have multimorbidity which may cause difficulties with self-management. Understanding the determinants of successful self-management and the resources patients draw upon to effectively manage their health is fundamental to designing new practice models to improve outcomes in HF. Methods: We developed a survey guided by the Chronic Care Model to understand the distribution of patient-centric factors, including health literacy, social support, self-management, and functional and mental status in patients with HF. The survey was administered to HF patients from 4 health care systems participating in PCORnet® (the National Patient-Centered Clinical Research Network). Patients were identified utilizing data available in the PCORnet common data model on or after 1/1/2013 at 1 health system and on or after 1/1/2015 at 3 health systems: age ≥30 years, ≥2 HF diagnostic codes, and ≥1 HF-related prescription (positive predictive value of algorithm: 81%). Results: A total of 10,662 patients with HF were identified, 9684 were mailed a survey, and 3330 completed a survey (response rate: 35%). Responders were older than non-responders (74 vs. 71 years), less racially diverse (3% vs. 12% non-White), less likely to have reduced ejection fraction (EF; 22% vs. 27% with EF <40%), and had higher prevalence of most chronic conditions. Responders reported their health was generally good or fair, they frequently had cardiovascular comorbidities, more than half had difficulty climbing stairs, and more than 10% reported difficulties with bathing, preparing meals, and using transportation (Table). Nearly 80% of patients had family or friends sit with them during a doctor visit, and most (54%) manage their health by themselves. Conclusion: More than half of patients with HF manage their health by themselves even though most bring someone along to their health care appointments. Increased understanding of self-management resources may guide the development of interventions to improve HF outcomes.

Objective: We aimed to characterize seasonal variation in US population-based blood pressure (BP) control and BP-related metrics and evaluate the association between outdoor temperature and BP control variation. Methods: We queried electronic health records (EHRs) from 26 health systems, representing 21 states, to summarize BP metrics by quarters of 12-month periods from January 2017 to March 2020. Patients with at least one ambulatory visit during the measurement period and a hypertension diagnosis during the first 6 months or prior to the measurement period were included. Changes in BP control, BP improvement, medication intensification, average SBP reduction after medication intensification across quarters and association with outdoor temperature were analyzed using weighted generalized linear models with repeated measures. Results: Among 1 818 041 people with hypertension, the majority were more than 65 years of age (52.2%), female (52.1%), white non-Hispanic (69.8%) and had stage 1/2 hypertension (64.8%). Overall, BP control and process metrics were highest in quarters 2 and 3, and lowest in quarters 1 and 4. Quarter 2 had the highest percentage of improved BP (31.95 ± 0.90%) and average SBP reduction after medication intensification (16 ± 0.23 mmHg). Quarter 3 had the highest percentage of BP controlled (62.25 ± 2.55%) and lowest with medication intensification (9.73 ± 0.60%). Results were largely consistent in adjusted models. Average temperature was associated with BP control metrics in unadjusted models, but associations were attenuated following adjustment. Conclusion: In this large, national, EHR-based study, BP control and BP-related process metrics improved during spring/summer months, but outdoor temperature was not associated with performance following adjustment for potential confounders.

Background Larger within‐patient variability of lipid levels has been associated with increased risk of cardiovascular disease (CVD); however, measures of lipid variability require ≥3 measurements and are not currently used clinically. We investigated the feasibility of calculating lipid variability within a large electronic health record–based population cohort and assessed associations with incident CVD. Methods and Results We identified all individuals ≥40 years of age who resided in Olmsted County, MN, on January 1, 2006 (index date), without prior CVD, defined as myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, or CVD death. Patients with ≥3 measurements of total cholesterol, low‐density lipoprotein cholesterol, high‐density lipoprotein cholesterol, or triglycerides during the 5 years before the index date were retained. Lipid variability was calculated using variability independent of the mean. Patients were followed through December 31, 2020 for incident CVD. We identified 19 652 individuals (mean age 61 years; 55% female), who were CVD‐free and had variability independent of the mean calculated for at least 1 lipid type. After adjustment, those with highest total cholesterol variability had a 20% increased risk of CVD (Q5 versus Q1 hazard ratio, 1.20 [95% CI, 1.06–1.37]). Results were similar for low‐density lipoprotein cholesterol and high‐density lipoprotein cholesterol. Conclusions In a large electronic health record–based population cohort, high variability in total cholesterol, high‐density lipoprotein cholesterol, and low‐density lipoprotein cholesterol was associated with an increased risk of CVD, independent of traditional risk factors, suggesting it may be a possible risk marker and target for intervention. Lipid variability can be calculated in the electronic health record environment, but more research is needed to determine its clinical utility.

Objectives Obesity is a potentially modifiable risk factor that has been consistently associated with the development and progression of multi-morbidity (MM). However, obesity may be more problematic for some persons compared to others because of interactions with other risk factors. Therefore, we studied the effect of interactions between patient characteristics and overweight and obesity on the rate of accumulation of MM. Methods We studied 4 cohorts of persons ages 20-, 40-, 60-, and 80-years residing in Olmsted County, Minnesota between 2005 and 2014 using the Rochester Epidemiology Project (REP) medical records-linkage system. Body mass index, sex, race, ethnicity, education, and smoking status were extracted from REP indices. The rate of accumulation of MM was calculated as the number of new chronic conditions accumulated per 10 person years through 2017. Poisson rate regression models were used to identify associations between characteristics and rate of MM accumulation. Additive interactions were summarized using relative excess risk due to interaction, attributable proportion of disease, and the synergy index. Results Greater than additive synergistic associations were observed between female sex and obesity in the 20- and 40-year cohorts, between low education and obesity in the 20-year cohort (both sexes), and between smoking and obesity in the 40-year cohort (both sexes). Conclusions Interventions targeted at women, persons with lower education, and smokers who also have obesity may result in the greatest reduction in the rate of MM accumulation. However, interventions may need to focus on persons prior to mid-life to have the greatest effect.

Background Uncontrolled blood pressure (BP) remains a leading cause of death in the United States. The American Medical Association developed a quality improvement program to improve BP control, but it is unclear how to efficiently implement this program at scale across multiple health systems. Methods and Results We conducted BP MAP (Blood Pressure Measure Accurately, Act Rapidly, and Partner With Patients), a comparative effectiveness trial with clinic‐level randomization to compare 2 scalable versions of the quality improvement program: Full Support (with support from quality improvement expert) and Self‐Guided (using only online materials). Outcomes were clinic‐level BP control (<140/90 mm Hg) and other BP‐related process metrics calculated using electronic health record data. Difference‐in‐differences were used to compare changes in outcomes from baseline to 6 months, between intervention arms, and to a nonrandomized Usual Care arm composed of 18 health systems. A total of 24 safety‐net clinics in 9 different health systems underwent randomization and then simultaneous implementation. BP control increased from 56.7% to 59.1% in the Full Support arm, and 62.0% to 63.1% in the Self‐Guided arm, whereas BP control dropped slightly from 61.3% to 60.9% in the Usual Care arm. The between‐group differences‐in‐differences were not statistically significant (Full Support versus Self‐Guided=+1.2% [95% CI, −3.2% to 5.6%], P =0.59; Full Support versus Usual Care=+3.2% [−0.5% to 6.9%], P =0.09; Self‐Guided versus Usual Care=+2.0% [−0.4% to 4.5%], P =0.10). Conclusions In this randomized trial, 2 methods of implementing a quality improvement intervention in 24 safety net clinics led to modest improvements in BP control that were not statistically significant. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03818659.

Objectives To compare the agreement between percentile ranks from 4 multi-morbidity scores. Design Population-based descriptive study. Setting Olmsted County, Minnesota (USA). Participants We used the medical records-linkage system of the Rochester Epidemiology Project (REP; http://www.rochesterproject.org ) to identify all residents of Olmsted County, Minnesota who reached one or more birthdays between 1 January 2005 and 31 December 2014 (10 years). Methods For each person, we calculated 4 multi-morbidity scores using readily available diagnostic code lists from the US Department of Health and Human Services, the Clinical Classifications Software, and the Elixhauser Comorbidity Index. We calculated scores using diagnostic codes received in the 5 years before the index birthday and fit quantile regression models across age and separately by sex to transform unweighted, simple counts of conditions into percentile ranks as compared to peers of same age and of same sex. We compared the percentile ranks of the 4 multi-morbidity scores using intra-class correlation coefficients (ICCs). Results We assessed agreement in 181,553 persons who reached a total of 1,075,433 birthdays at ages 18 years through 85 years during the study period. In general, the percentile ranks of the 4 multi-morbidity scores exhibited high levels of agreement in 6 score-to-score pairwise comparisons. The agreement increased with older age for all pairwise comparisons, and ICCs were consistently greater than 0.65 at ages 50 years and older. Conclusions The assignment of percentile ranks may be a simple and intuitive way to assess the underlying trait of multi-morbidity across studies that use different measures.