Social Risks and Health Care Use in Medically Complex Patients.

Importance: Integrated health care systems have initiated major investments to identify and address social risks, particularly for patients with multiple medical conditions.

Objective: To evaluate the association of social risks with health care use among patients with complex multimorbidity.

Design, Setting, And Participants: This longitudinal cohort study assessed Kaiser Permanente Northern California (KPNC) patients with (1) moderate medical complexity (defined by high comorbidity score, high risk of hospitalization, and/or prior emergency department [ED] admissions) and (2) high medical complexity (eg, meeting additional criteria, such as ≥7 medications and laboratory evidence of poor disease control).

Associations Between Different Self-reported Social Risks and Neighborhood-level Resources in Medicaid Patients.

Background: Adverse social conditions are a key contributor to health disparities. Improved understanding of how social risk factors interact with each other and with neighborhood characteristics may inform efforts to reduce health disparities.

Data: A questionnaire of 29,281 patients was collected through the enrollment of Medicaid beneficiaries in a large Northern California integrated health care delivery system between May 2016 and February 2020.

Accounting for Social Risk Does not Eliminate Race/Ethnic Disparities in COVID-19 Infection Among Insured Adults: a Cohort Study.

Background: Communities of color have been disproportionately impacted by the COVID-19 epidemic in the USA.

Objectives: To examine the relationship of self-reported social health needs with SARS-COV-2 infection by race/ethnicity among insured adults with access to high-quality health care.

Design And Participants: A prospective cohort study of 26,741 adult Kaiser Permanente Northern California members insured by Medicaid and 58,802 Kaiser Permanente Colorado members insured by Medicare Advantage who completed social risk assessments prior to the onset of the COVID-19 pandemic.

Aligning care with the personal values of patients with complex care needs.

Objective: To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs.

Data Sources/study Setting: Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two integrated health care delivery systems.

Study Design: Qualitative study using semi-structured interviews.

Engaging patients in population-based chronic disease management: A qualitative study of barriers and intervention opportunities.

Objective: Cardiovascular disease (CVD) continues to be a leading cause of morbidity in the U.S. Managing CVD risk factors, such as diabetes or hypertension, can be challenging for many individuals.

Changing Results-Engage and Activate to Enhance Wellness: A Randomized Clinical Trial to Improve Cardiovascular Risk Management.

Background Despite the success of current cardiovascular disease (CVD) management programs, many patients do not achieve optimal control of CVD-related risk factors. New strategies are needed to better activate and engage these patients. Methods and Results We conducted a parallel, 2-arm, randomized controlled trial, CREATE Wellness (Changing Results-Engage and Activate to Enhance Wellness) from February 2015 to September 2017 with 12-month follow-up to September 2018.

Patient-Defined Visit Priorities in Primary Care: Psychosocial Versus Medically-Related Concerns.

Background: Primary care providers (PCPs) are often challenged to address multiple patient concerns during time-limited visits. The need for PCPs to limit the number of issues addressed may have a negative impact on discussion of patient-defined visit priorities.

Methods: Using data from a recent clinical trial (Aligning Patients and Providers, ClinicalTrials.

Translating/Creating a Culturally Responsive Spanish-Language Mobile App for Visit Preparation: Case Study of "Trans-Creation".

Background: Health information technology (IT) tools are increasingly used to improve patient care. However, implementation of English-only health IT tools could potentially worsen health disparities for non-English speakers.

Objective: We aim to describe the "trans-creation" process of developing linguistically and culturally appropriate health IT tools through a detailed case analysis of a waiting room health mobile app designed to help Spanish-speaking Latino people prepare for primary care visits.

Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study.

Introduction: Latinos face unique challenges engaging with their health care providers for risk management of cardiovascular disease (CVD).

Objective: To better understand differences in how Latinos and non-Latino whites (NLWs) experience CVD care.

Methods: We examined self-reported activation, engagement, confidence, and communication comparing Latinos (n = 194) and NLWs (n = 208).

Visit Planning Using a Waiting Room Health IT Tool: The Aligning Patients and Providers Randomized Controlled Trial.

Purpose: Time during primary care visits is limited. We tested the hypothesis that a waiting room health information technology (IT) tool to help patients identify and voice their top visit priorities would lead to better visit interactions and improved quality of care.

Methods: We designed a waiting room tool, the Visit Planner, to guide adult patients through the process of identifying their top priorities for their visit and effectively expressing these priorities to their clinician.

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial.

Background: Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.

Objective: To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.

Design: We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.

Which Complex Patients Should Be Referred for Intensive Care Management? A Mixed-Methods Analysis.

Background: A large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management.

Objective: To characterize factors that best identify which complex patients are most suited for intensive care management.

CREATE Wellness: A multi-component behavioral intervention for patients not responding to traditional Cardiovascular disease management.

Background/aims: Cardiovascular disease (CVD) is the leading cause of death in the US. Many patients do not benefit from traditional disease management approaches to CVD risk reduction. Here we describe the rationale, development, and implementation of a multi-component behavioral intervention targeting patients who have persistently not met goals of CVD risk factor control.

'The Hand on the Doorknob': Visit Agenda Setting by Complex Patients and Their Primary Care Physicians.

Background: Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions.

Design, Setting, And Participants: We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n = 17) from 3 different health systems to investigate how patients and physicians prepare for visits, how visit agendas are determined, and how discussion priorities are established during time-limited visits.

Key Results: Visit flow and alignment were enhanced when both patients and physicians were effectively prepared before the visit, when the patient brought up highest-priority items first, the physician and patient worked together at the beginning of the visit to establish the visit agenda, and other team members contributed to agenda setting.

Primary care visit preparation and communication for patients with poorly controlled diabetes: A qualitative study of patients and physicians.

Objective: The purpose of this study was to examine how patients with diabetes and their primary care physicians identify and discuss visit priorities prior to and during visits.

Methods: We conducted a qualitative study involving patients with diabetes (4 focus groups, n=29) and primary care physicians (6 provider practice meeting discussions, n=67).

Results: Four key themes related to prioritization were identified: 1) the value of identifying visit priorities before the visit; 2) challenges to negotiating priorities during the time-limited visit; 3) the importance of "non-medical" priorities; and 4) the need for strategies to help patients prepare for visits.

Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system.

Background/aims: Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care.

Methods: We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record.

Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels.

Background: Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk.

Improving treatment intensification to reduce cardiovascular disease risk: a cluster randomized trial.

Background: Blood pressure, lipid, and glycemic control are essential for reducing cardiovascular disease (CVD) risk. Many health care systems have successfully shifted aspects of chronic disease management, including population-based outreach programs designed to address CVD risk factor control, to non-physicians. The purpose of this study is to evaluate provision of new information to non-physician outreach teams on need for treatment intensification in patients with increased CVD risk.

Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?

Background: Patient-physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient-physician communication.

Objective: To examine the association of patient race/ethnicity and language and patient-physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system.

Design: We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005.

The predictors of patient-physician race and ethnic concordance: a medical facility fixed-effects approach.

Objective: To examine the predictors of patient-physician race/ethnicity concordance among diabetes patients in an integrated delivery system.

Data Source: Kaiser Permanente's Northern California Diabetes Registry of 2005.

Study Design: Logistic regression predicted concordance for each racial/ethnic group.

Mail-order pharmacy use and adherence to diabetes-related medications.

Objective: To investigate whether patients who use mail-order pharmacies were more likely to have good medication adherence than patients who use local pharmacies.

Study Design: Cross-sectional investigation.

Methods: We conducted cross-sectional analyses of patients from the Kaiser Permanente Northern California (KPNC) diabetes registry who received a new antiglycemic, antihypertensive, or lipid-lowering index medication between January 1, 2006, and May 31, 2006.

The association of patient-physician gender concordance with cardiovascular disease risk factor control and treatment in diabetes.

Background: Gender concordance between patients and their physicians is related to prevention screening and other quality indicators. Research suggests female physicians may place greater emphasis on preventive care than male physicians; however, little is known about whether physician gender and patient-physician gender concordance are associated with cardiovascular disease (CVD) risk factor levels and treatment. Our objective was to examine associations between patient gender, physician gender, and their interaction with CVD risk factor control, medication adherence, and treatment intensification in diabetes.