Nicholas Chiu

Background: Cardiovascular mortality has worsened among rural adults compared with urban counterparts over recent decades. Medicare Advantage (MA) enrollment is increasing in rural areas, yet its impact on access and affordability for high‐risk cardiovascular populations remains unclear. This study evaluated differences in health care access, preventive care, and affordability barriers between rural adults with cardiometabolic conditions enrolled in MA versus traditional Medicare. Methods: A cross‐sectional analysis was performed using 2021 to 2022 Medicare Current Beneficiary Survey data. Multivariable logistic regression was used to estimate adjusted risk differences (aRD) in access, preventive care, and affordability barriers between rural MA and traditional Medicare enrollees, adjusting for sociodemographic characteristics. Results: The study included 4274 rural beneficiaries with cardiometabolic conditions (weighted population 16 352 800, 53% women). Compared with traditional Medicare, MA enrollees were significantly less likely to miss an annual wellness visit (40.1% versus 50.1%; aRD, −13.4% [95% CI, −17.0% to −9.8%]) or face barriers to preventive care, such as not having annual cholesterol checks (aRD, −3.2% [95% CI, −5.2% to −1.2%]) and influenza vaccinations (aRD, −4.3% [95% CI, −7.8% to −0.7%]). However, MA beneficiaries were more likely to have problems paying medical bills (12.2% versus 6.9%; aRD, 2.5% [95% CI, 0.4%–4.6%]). Conclusions: Rural MA beneficiaries with cardiometabolic conditions experienced fewer barriers to preventive care but reported greater difficulty paying medical bills than those in traditional Medicare. As MA expands in rural America, policies are needed to address affordability challenges while preserving access to preventive services.

Background: Hypertension control has worsened nationally, and treatment intensification is important for control. National trends for appropriate blood pressure intensification for older adults are unknown. We determine the proportion of ambulatory visits where older adults with hypertension were appropriately intensified on antihypertensives from 2008 to 2018. Methods: Data from National Ambulatory Medical Care Survey were used. National Ambulatory Medical Care Survey is a nationally representative sample of ambulatory visits. Adults 60 years or older were included. Appropriate antihypertensive intensification was defined as addition of an antihypertensive for a blood pressure reading above target. We examined appropriate intensification by blood pressure targets set by the American College of Cardiology–American Heart Association, the European Society of Cardiology, and the American College of Physicians–American Academy of Family Physicians guidelines for older adults. Further, we defined an additional all-inclusive criterion meeting all 3 guidelines. Results: From 2008 to 2018, appropriate intensification by American College of Cardiology/American Heart Association occurred at 11.1% (95% CI, 9.8%–12.5%) of visits, decreasing from 13.6% (95% CI, 15.6%–28.7%) of visits in 2008 to 2009 to 10.4% (95% CI, 10.9%–26.4%) in 2015 to 2018. Appropriate intensification by European Society of Cardiology occurred at 14.2% (12.1%–16.6%) of visits over 2008 to 2018, decreasing from 16.9% (95% CI, 13.5%–21.0%) in 2008 to 2009 to 12.5% (95% CI, 7.4%–20.3%) from 2015 to 2018. Appropriate intensification by American Academy of Family Physicians/American College of Physicians occurred at 18.9% (16.2%–22.0%) of visits over 2008 to 2018, decreasing from 24.7% (95% CI, 20.2%–29.0%) in 2008 to 2009 to 14.9% (95% CI, 9.0%–23.7%) from 2015 to 2018. By all-inclusive criteria, intensification trended toward worsening with time: odds ratio: 0.93 ([95% CI, 0.87–1.00]; P =0.07). Conclusions: Appropriate treatment intensification for older adults with hypertension in the United States was suboptimal over the past decade.

Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular disease, stroke, and death. Among adults with hypertension, orthostatic hypotension has also been shown to predict patterns of blood pressure dysregulation that may not be appreciated in the office setting, including nocturnal nondipping. Individuals with uncontrolled hypertension are at particular risk of orthostatic hypotension and may meet diagnostic criteria for the condition with a smaller relative reduction in blood pressure compared with normotensive individuals. Antihypertensive medications are commonly de-prescribed to address orthostatic hypotension; however, this approach may worsen supine or seated hypertension, which may be an important driver of adverse events in this population. There is significant variability between guidelines for the diagnosis of orthostatic hypotension with regards to timing and position of blood pressure measurements. Clinically relevant orthostatic hypotension may be missed when standing measurements are delayed or when taken after a seated rather than supine position. The treatment of orthostatic hypotension in patients with hypertension poses a significant management challenge for clinicians; however, recent evidence suggests that intensive blood pressure control may reduce the risk of orthostatic hypotension. A detailed characterization of blood pressure variability is essential to tailoring a treatment plan and can be accomplished using both in-office and out-of-office monitoring.

Nicholas Chiu, Rahul Aggarwal, Inmaculada Hernandez, Rishi Wadhera, Colette Dejong, Chien-Wen Tseng, Robert W. Yeh, Dhruv S. Kazi; Spending on Insulin by U.S. P

The U.S. Preventive Services Task Force (USPSTF) recommends screening adults aged 35 to 70 years with a body mass index (BMI) of 25 kg/m2 or greater for diabetes. Differences in diabetes prevalence... Visual U.S. Diabetes Screening by Race and Ethnicity: BMI and Age Thresholds. The U.S. Preventive Services Task Force (USPSTF) recommends screening adults aged 35 to 70 years with a body m... Background: Racial/ethnic minority populations in the United States have increased rates of diabetes compared with White populations. The 2021 guidelines from the U.S. Preventive Services Task Forc...