Publications

Objective

US health care institutions are implementing secure websites (patient portals) to achieve federal Meaningful Use (MU) certification. We sought to understand efforts to implement portals in "safety net" health care systems that provide services for low-income populations.

Materials and Methods

Our rapid ethnography involved visits at 4 California safety net health systems and in-depth interviews at a fifth. Visits included interviews with clinicians and executives ( n  = 12), informal focus groups with front-line staff ( n  = 35), observations of patient portal sign-up procedures and clinic work, review of marketing materials and portal use data, and a brief survey ( n  = 45).

Results

Our findings demonstrate that the health systems devoted considerable effort to enlisting staff support for portal adoption and integrating portal-related work into clinic routines. Although all health systems had achieved, or were close to achieving, MU benchmarks, patients faced numerous barriers to portal use and our participants were uncertain how to achieve and sustain "meaningful use" as defined by and for their patients.

Discussion

Health systems' efforts to achieve MU certification united clinic staff under a shared ethos of improved quality of care. However, MU's assumptions about patients' demand for electronic access to health information and ability to make use of it directed clinics' attention to enrollment and message routing rather than to the relevance and usability of a tool that is minimally adaptable to the safety net context.

Conclusion

We found a mismatch between MU-based metrics of patient engagement and the priorities and needs of safety net patient populations.

Adolescence and young adulthood, a period essential for determining exposures over the life-course, is an ideal time to intervene to lower cancer risk. This demographic group can be viewed as both the target audience and generator of messages for cancer prevention, such as skin cancer, obesity-, tobacco-, and human papillomavirus-related cancers. The purpose of this paper is to encourage innovative health communications that target youth; youth behavior; and the structural, environmental, and social determinants of youth behavior as critical areas of focus for cancer prevention and disparities reduction. The authors describe the rationale, processes, products, and early impacts of an award-winning youth diabetes prevention communication campaign model (The Bigger Picture) that harnesses spoken-word messages in school-based and social media presentations. The campaign supports minority adolescent and young adult artists to create content that aligns with values held closely by youth-values likely to resonate and affect change, such as defiance against authority, inclusion, and social justice. This campaign can be leveraged to prevent obesity, which is a cancer risk factor. Then, the authors propose concrete ways that The Bigger Picture's pedagogical model could be adapted for broader cancer prevention messaging for youth of color and youth stakeholders regarding tobacco-related cancers, skin cancers, and human papillomavirus-related cancers. The goal is to demonstrate how a youth-generated and youth-targeted prevention campaign can: (1) reframe conversations about cancer prevention, (2) increase awareness that cancer prevention is about social justice and health equity, and (3) catalyze action to change social norms and confront the social and environmental drivers of cancer disparities.

INTRODUCTION

Tobacco contributes to multiple cancers, and it is largely preventable. As overall smoking prevalence in California declines, smoking has become concentrated among high-risk groups. Targeting social/cultural groups (i.e., "peer crowds") that share common values, aspirations, and activities in social venues like bars and nightclubs may reach high-risk young adult smokers. Lack of population data on young adult peer crowds limits the ability to assess the potential reach of such interventions.

METHODS

This multimodal population-based household survey included young adults residing in San Francisco and Alameda counties. Data were collected in 2014 and analyzed in 2016. Multivariable logistic regressions assessed smoking by sociodemographic factors, attitudes, self-rated health, peer crowd affiliation, and bar/nightclub attendance.

RESULTS

Smoking prevalence was 15.1% overall; 35.3% of respondents sometimes or frequently attended bars. In controlled analyses, bar attendance (AOR=2.13, 95% CI=1.00, 4.53) and binge drinking (AOR=3.17, 95% CI=1.59, 6.32) were associated with greater odds of smoking, as was affiliation with "Hip Hop" (AOR=4.32, 95% CI=1.48, 12.67) and "Country" (AOR=3.13, 95% CI=1.21, 8.09) peer crowds. Multivariable models controlling for demographics estimated a high probability of smoking among bar patrons affiliating with Hip Hop (47%) and Country (52%) peer crowds.

CONCLUSIONS

Bar attendance and affiliation with certain peer crowds confers significantly higher smoking risk. Interventions targeting Hip Hop and Country peer crowds could efficiently reach smokers, and peer crowd-tailored interventions have been associated with decreased smoking and binge drinking. Targeted interventions in bars and nightclubs may be an efficient way to address these cancer risks.

BACKGROUND

The use of non-vitamin K oral anticoagulants (NOACs) has increased steadily following marketing approval; however, their relative safety in nonvalvular atrial fibrillation (NVAF) patients in real-world clinical practice remains unclear.

OBJECTIVE

To compare the risk of major bleeding during anticoagulation therapy between warfarin and NOACs.

METHODS

This retrospective cohort study analyzed administrative claims data on new NVAF users of warfarin, dabigatran, apixaban, or rivaroxaban in routine clinical care from November 2010 to February 2015 in a commercially insured population in the United States. The primary outcome was time to first major bleeding event requiring hospitalization. Patients were followed until discontinuation or switch of anticoagulants, health plan disenrollment, death, or end of study. All patient characteristics were balanced after propensity score inverse probability of treatment (IPT) weighting. Event rates by type of anticoagulant exposure were compared using IPT-weighted Cox proportional hazards models.

RESULTS

The study cohort comprised 44,057 patients who used warfarin (n = 23,431), dabigatran (n = 8,539), apixaban (n = 3,689), and rivaroxaban (n = 8,398). Overall mean (SD) age was 70 (12) years, and 41% of the patients were women. A total of 2,337 major bleeding events occurred during 36,636.2 person-years of follow-up. The unadjusted rate of major bleeding with warfarin was 6.0 per 100 person-years versus 2.8 with dabigatran, 3.3 with apixban, and 5.0 with rivaroxaban. Relative to warfarin, major bleeding risk was lower with dabigatran (HR = 0.67, 95% CI = 0.60-0.76) and apixaban (HR = 0.52, 95% CI = 0.41-0.67). Compared with rivaroxaban, major bleeding risk was also lower with dabigatran (HR = 0.67, 95% CI = 0.58-0.78) and apixaban (HR = 0.52, 95% CI = 0.40-0.68). Major bleeding risk was similar for rivaroxaban and warfarin. Relative to apixaban, dabigatran was associated with a significantly higher risk of major gastrointestinal bleeding (HR = 1.43, 95% CI = 1.09-1.88).

CONCLUSIONS

Study results were consistent with safety findings from pivotal clinical trials comparing NOACs with warfarin and added the perspective of a large real-world observational study that compared bleeding risks associated with NOACs during anticoagulation therapy. Apixaban and dabigatran were associated with lower major bleeding risk compared with warfarin or rivaroxaban; however, apixaban had a lower risk of major gastrointestinal bleeding than dabigatran. These findings can help inform the choice of an optimal agent, which must balance effectiveness and bleeding risk in complex patients.

DISCLOSURES

This study was funded by Anthem. Adeboyeje, Sylwestrzak, and Barron are employees of HealthCore, a wholly owned and independently operated subsidiary of Anthem. White, Rosenberg, Abarca, and Crawford are employees of Anthem. Study concept and design were primarily contributed by Adeboyeje and Sylwestrzak, along with the other authors. Adeboyeje took the lead in data collection, along with Sylwestrzak and Barron. Data interpretation was performed primarily by Rosenberg, Crawford, and Redberg, with assistance from the other authors. The manuscript was written by all the authors and revised primarily by White, Abarca, and Redberg, along with the other authors.

OBJECTIVES

Statins are recommended to reduce serum cholesterol in patients at risk for atherosclerotic cardiovascular disease. Despite the prevalence of statin use, little is known about the indications for new prescriptions. We assessed the concordance of new statin prescriptions in the Veterans Health Administration (VHA) compared with the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) guidelines (the guidelines in force in 2012) and the American College of Cardiology (ACC)-American Heart Association (AHA) 2013 guidelines.

STUDY DESIGN

Cross-sectional study.

METHODS

We identified every patient who received a new prescription (no statin use in the prior year) in the VHA in 2012. Patients were excluded if they had incomplete data, triglycerides greater than 400 mg/dL, or fewer than 2 primary care visits to ensure adequate baseline data to calculate Framingham and ACC-AHA 2013 risk scores.

RESULTS

We identified 250,243 new statin prescriptions in 2012 in the VHA, with 121,081 meeting inclusion criteria. Among new prescriptions, 68% were prescribed for primary prevention and 32% were prescribed for secondary prevention. Among patients receiving new statins for primary prevention, 48% did not have an indication supported by the ATP III guideline and 20% did not have an indication supported by the ACC/AHA guideline. Overall, approximately 19% of patients may have received a statin for an indication not supported by either guideline.

CONCLUSIONS

Veterans are commonly prescribed statins for indications not supported by professional society guidelines. The finding of common use of statins outside established guidelines represents an opportunity to improve the quality and value of the healthcare delivery.