Elizabeth R. Pfoh

Background: Currently, there is no high-quality evidence guiding the treatment of asymptomatic elevated BP readings in hospitalized patients. Objective: We conducted a nationwide survey of hospitalists to identify their preferences for treating patients with asymptomatic elevated BP readings. Methods: This cross-sectional survey was conducted at five institutions in 2024. The questions, written by the research team, asked about physicians’ approach and preferences for intensifying antihypertensive medications for inpatients with asymptomatic elevated BP. We defined “elevated BP” as ≥ 140/90 mmHg and < 210/120 mmHg. We performed a descriptive analysis of the responses and compared responses across sites. Results: We received 166 responses (response rate ranged from 24 to 64% across five hospitals). There was variation in the importance of treating asymptomatically elevated BP with 27% ( n  = 45) agreeing it important and 47% disagreeing. This response was similar across all sites. The median threshold for intensification was 170–179 mmHg. Most physicians reported that they would be more likely to treat patients with a history of heart failure (73%), stroke (73%), myocardial infarction (64%), or coronary disease (57%). Physicians reported strong agreement that they “prefer not to be contacted by nurses about an asymptomatic systolic BP reading < 170 mmHg” and agreed that “treatment is driven by nurses calling physicians.” Conclusion: Almost half of the physicians believed that in the hospital setting, asymptomatic elevated BP should not be routinely treated.

Background and Objectives: Adults in low-resource neighborhoods face greater burden of preventable diseases than the general population. Methodologies to measure the impact of population-level efforts to reduce neighborhood-level disparities in health outcomes are lacking. We introduce a simulation modeling approach for incident disease and mortality risk over the life course and apply the model to assess the impact of a hypothetical population health initiative to reduce neighborhood-level disparities. Research Design and Methods: Using electronic health records, we constructed a probabilistic dynamic systems model that simulated the life course of each patient in a large primary care population, taking into account specific relationships by sex and Area Deprivation Index (ADI) quintile. The model predicted long-term incidence of 10 chronic conditions and all-cause mortality. Results: The model was reliable, with strong discrimination (C-statistic for 10-year mortality: 0.871) and calibration. Predicted median life expectancy was nearly a decade lower for patients ages 40-45 who resided in the highest (ADI quintile 5) vs the lowest (quintile 1) deprivation neighborhoods (difference [95% CI]; women, 8.6 [8.2, 9.0] years; men, 10.0 [9.6, 10.3]. A hypothetical initiative to reduce the number of smokers by 10% had minimal effect on disparities in life expectancy when implemented in the general patient population (women, −0.4 years; men, −0.2), but meaningfully narrowed disparities when focused on high-deprivation neighborhoods (women, −0.8 years; men, −0.6). Discussion and Implications: In a broad patient population, it was feasible to measure socioeconomic disparities in health outcomes and life expectancy and evaluate interventions to improve health equity.

BACKGROUND: Understanding the association between improving medication adherence, intensifying antihypertensive medications, or both on blood pressure (BP) control can guide clinical care and quality improvement. METHODS: Retrospective cohort study of primary care patients with hypertension and 2 uncontrolled BP readings in 2021. Using prescription fills, we classified patients as high (≥80%) versus low (P <0.01 versus no action). CONCLUSIONS: Physicians should simultaneously intensify treatment and encourage adherence. Health systems should encourage intensification regardless of adherence status.

Objectives: Understanding the epidemiology of treatment for patients with co-occurring depression and obesity can inform care quality. The objective of the study was to identify how patients with obesity and newly diagnosed depression are treated and whether treatment is associated with body mass index change. Methods: This cohort study included adults with obesity and newly diagnosed...

To understand Black men’s healthcare and social needs and determine if the resources that healthcare systems offer meet expectations. We surveyed men who had previously participated in at least one Minority Men’s Health Fair in Cleveland, Ohio. In this descriptive study, we spoke with men up to three times (i.e., phases) between May and October 2020 by email and/or telephone. Phase 1 was a needs assessment survey. Phase 2 involved outreach to those who identified a need to provide a resource. Phase 3 determined whether the resource met individuals’ needs. We described the demographic characteristics of the survey respondents, the percentage of men reporting a need and wanting a resource, and whether the resource resolved their need. Of the 768 men contacted, 275 completed the survey (36% response rate). The majority of respondents were 50–69 years old, identified as Black, and had at least a bachelor’s degree. Eighty-five percent reported a need, of which wellness, financial, and healthcare access were among the top-reported needs. Among the men identifying a need, 35% were interested in a resource. Resources that were provided for employment, behavioral health, oral health, vision, or wellness needs were deemed insufficient. A few individuals reported that resources for food/personal hygiene, financial support, health care access, annual health screening, and medication met their needs. Among men with healthcare and social needs, only a fraction were interested in a resource, and fewer reported that the resource met their needs. These results warrant a greater understanding of what constitutes a resolution of healthcare and social needs from patients’ perspectives.

Background Health systems are screening patients for health-related social needs (HRSN) but the optimal approach is unknown. Objective To describe the variation in responding to an HRSN questionnaire delivered via patient portal, and whether referral to and resources provided by social workers differed by response status. Design Retrospective observational study. Participants Primary care patients with a visit between June 2020 and January 2022. Intervention HRSN questionnaire Main Measures We identified each patient’s index visit (e.g., date of their first questionnaire response for responders or their first visit within the study period for non-responders). Through the EHR, we identified patients’ demographic characteristics. We linked the area deprivation index (ADI) to each patient and grouped patients into quintiles. We used multilevel logistic regressions to identify characteristics associated with responding to the questionnaire and, for responders, reporting a need. We also determined if responder status was associated with receiving a social worker referral or receiving a resource. We included patient demographics and ADI quintile as fixed variables and practice site as a random variable. Key Results Our study included 386,997 patients, of which 51% completed at least one HRSN questionnaire question. Patients with Medicaid insurance (AOR: 0.62, 95%CI: 0.61, 0.64) and those who lived in higher ADI neighborhoods had lower adjusted odds of responding (AOR: 0.76, 95% CI: 0.75, 0.78 comparing quintile 5 to quintile 1). Of responders, having Medicaid insurance (versus private) increased the adjusted odds of reporting each of the HRSN needs by two- to eightfold (p < 0.01). Patients who completed a questionnaire (versus non-responders) had similar adjusted odds of receiving a referral (AOR: 0.91, 95% CI: 0.80, 1.02) and receiving a resource from a SW (AOR: AOR: 1.18, 95%CI: 0.79, 1.77). Conclusion HRSN questionnaire responses may not accurately represent the needs of patients, especially when delivered solely via patient portal.

Background: Understanding whether practices retain outcomes attained during a quality improvement (QI) initiative can inform resource allocation. Objective: We report blood pressure (BP) control and medication intensification in the 3 years after a 2016 QI initiative ended. Research Design: Retrospective cohort Subjects: Adults with a diagnosis of hypertension who had a primary care visit in a large-integrated health system between 2015 and 2019 Measures: We report BP control (<140/90 mm Hg) at the last reading of each year. We used a multilevel regression to identify the adjusted propensity to receive medication intensification among patients with an elevated BP in the first half of the year. To examine variation, we identified the average predicted probability of control for each practice. Finally, we grouped practices by the proportion of their patients whose BP was controlled in 2016: lowest performing (<75%), middle (≥75%–<85%), and highest performing (≥85%). Results: The dataset contained 184,981 patients. From 2015 to 2019, the percentage of patients in control increased from 74% to 82%. In 2015, 38% of patients with elevated BP received medication intensification. This increased to 44% in 2016 and 50% in 2019. Practices varied in average BP control (from 62% to 91% in 2016 and 68% to 90% in 2019). All but one practice had a substantial increase from 2015 to 2016. Most maintained the gains through 2019. Higher-performing practices were more likely to intensify medications than lower-performing practices. Conclusions: Most practices maintained gains 3 years after the QI program ended. Low-performing practices should be the focus of QI programs.

Objective: Demand for systematic linkage of patients to behavioral health care has increased because of the widespread implementation of depression screening. This study assessed the impact of deploying behavioral health social workers (BHSWs) in primary care on behavioral health visits for depression or anxiety. Methods: This quasi-experimental, stepped-wedge study included adults with a primary care visit between 2016 and 2019 at Cleveland Clinic, a large integrated health system. BHSWs were deployed in 40 practices between 2017 and 2019. Patients were allocated to a control group (diagnosed before BHSW deployment) and an intervention group (diagnosed after deployment). Data were collected on behavioral health visits (i.e., to therapists and psychiatrists) within 30 days of the diagnosis. Multilevel logistic regression models identified associations between BHSW deployment period and behavioral health visit, adjusted for demographic variables and clustering within each group. Results: Of 68,659 persons with a diagnosis, 21% had a depression diagnosis, 49% an anxiety diagnosis, and 31% both diagnoses. In the period after BHSW deployment, the proportion of patients with depression who had a behavioral health visit increased by 10 percentage points, of patients with anxiety by 9 percentage points, and of patients with both disorders by 11 percentage points. The adjusted odds of having a behavioral health visit was higher in the postdeployment period for patients with depression (adjusted odds ratio [AOR]=4.35, 95% confidence interval [CI]=3.50–5.41), anxiety (AOR=4.27, 95% CI=3.57–5.11), and both (AOR= 3.26, 95% CI=2.77–3.84). Conclusions: Integration of BHSWs in primary care was associated with increased behavioral health visits.

Purpose The United States Preventive Services Task Force recommends primary care physicians refer patients at high risk for BRCA1/2 mutations to genetic testing when appropriate. The objective of our study was to describe referrals for BRCA1/2 testing in a large integrated health system and to assess factors associated with referral. Methods This retrospective cohort study includes female patients between 18 and 50 years who had a primary care visit in the Cleveland Clinic Health System between 2010 and 2019. We used multivariable logistic regression to estimate differences in the odds of a woman being referred for BRCA1/2 testing by patient factors and referring physician specialty. We also assessed variation in referrals by physicians. Results Among 279,568 women, 5% were high risk. Of those, 22% were referred for testing. Black patients were significantly less likely to be referred than white patients (aOR 0.87; 95% CI 0.77, 0.98) and Jewish patients were more likely to be referred than non-Jewish patients (aOR 2.13; 95% CI 1.68, 2.70). Patients primarily managed by OB/GYN were significantly more likely to be referred than those cared for via Internal/Family Medicine (aOR 1.45; 95% CI 1.30, 1.61). Less than a quarter of primary care physicians ever referred a patient for testing. Conclusion The majority of primary care patients at high risk for a BRCA1/2 mutation were not referred for testing, and over a decade, most physicians never referred a single patient. Internal/Family Medicine physicians, in particular, need support in identifying and referring women who could benefit from testing.