Advance care planning (ACP), especially among vulnerable older adults, remains underused in primary care. Additionally, many ACP initiatives fail to integrate directly into the electronic health record (EHR), resulting in infrequent and disorganized documentation.OBJECTIVE To determine whether a nurse navigator-led ACP pathway combined with a health care professional-facing EHR interface improves the occurrence of ACP discussions and their documentation within the EHR. DESIGN, SETTING, AND PARTICIPANTSThis was a randomized effectiveness trial using the Zelen design, in which patients are randomized prior to informed consent, with only those randomized to the intervention subsequently approached to provide informed consent. Randomization began November 1, 2018, and follow-up concluded November 1, 2019. The study population included patients 65 years or older with multimorbidity combined with either cognitive or physical impairments, and/or frailty, assessed from 8 primary care practices in North Carolina. INTERVENTIONS Participants were randomized to either a nurse navigator-led ACP pathway (n = 379) or usual care (n = 380). MAIN OUTCOMES AND MEASURESThe primary outcome was documentation of a new ACP discussion within the EHR. Secondary outcomes included the usage of ACP billing codes, designation of a surrogate decision maker, and ACP legal form documentation. Exploratory outcomes included incident health care use. RESULTS Among 759 randomized patients (mean age 77.7 years, 455 women [59.9%]), the nurse navigator-led ACP pathway resulted in a higher rate of ACP documentation (42.2% vs 3.7%, P < .001) as compared with usual care. The ACP billing codes were used more frequently for patients randomized to the nurse navigator-led ACP pathway (25.3% vs 1.3%, P < .001). Patients randomized to the nurse navigator-led ACP pathway more frequently designated a surrogate decision maker (64% vs 35%, P < .001) and completed ACP legal forms (24.3% vs 10.0%, P < .001). During follow-up, the incidence of emergency department visits and inpatient hospitalizations was similar between the randomized groups (hazard ratio, 1.17; 95% CI, 0.92-1.50). CONCLUSIONS AND RELEVANCEA nurse navigator-led ACP pathway integrated with a health care professional-facing EHR interface increased the frequency of ACP discussions and their documentation. Additional research will be required to evaluate whether increased EHR documentation leads to improvements in goal-concordant care.TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03609658

Objective Health systems could adopt population-level approaches to screening by identifying potential screening candidates from the electronic health record and reaching out to them via the patient portal. However, whether patients would read or act on sent information is unknown. We examined the feasibility of this digital health outreach strategy. Methods We conducted a single-arm pragmatic trial in a large academic health system. An electronic health record algorithm identified primary care patients who were potentially eligible for lung cancer screening (LCS). Identified patients were sent a patient portal invitation to visit a LCS interactive Web site which assessed screening eligibility and included a decision aid. The primary outcome was screening completion. Secondary outcomes included the proportion of patients who read the invitation, visited the interactive Web site, and completed the interactive Web site. Results We sent portal invitations to 1,000 patients. Almost all patients (86%, 862/1,000) read the invitation, 404 (40%) patients visited the interactive Web site, and 349 patients (35%) completed it. Of the 99 patients who were confirmed screening eligible by the Web site, 81 made a screening decision (30% wanted screening, 44% unsure, 26% declined screening), and 22 patients had a chest computed tomography completed. Conclusion The digital outreach strategy reached the majority of patient portal users. While the study focused on LCS, this digital outreach approach could be generalized to other health needs. Given the broad reach and potential low cost of this digital strategy, future research should investigate best practices for implementing the system.

Background Reference limits for echocardiographic quantification of cardiac chambers in Hispanics are not well studied. Methods and Results We examined the reference values of left atrium (LA) and ventricle (LV) structure in a large ethnically diverse Hispanic cohort. Two-dimensional transthoracic echocardiography was performed in 1,818 participants of the Echocardiographic Study of Latinos (ECHO-SOL). Individuals with body mass index ≥30kg/m2, hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation were excluded leaving 525 participants defined as healthy reference-cohort. We estimated 95th weighted percentiles of LV end systolic volume, LV end diastolic volume, relative wall and septal thickness, LV mass and left atrial volume. We then used upper reference limits of the 2005 and 2015 American Society of Echocardiography (ASE) and 95th percentile of reference cohort to classify the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) target population into abnormal and normal. Reference limits were also calculated for each of 6 Hispanic origins. Using ASE 2015 defined reference values we categorized 7%, 21%, 57% and 17% of males and 18%, 29%, 60% and 26% of females as having abnormal LV mass index, relative, septal and posterior wall thickness, respectively. Conversely, 10%, and 11% of males and 4% and 2% of females were classified as having abnormal end-diastolic volume and internal diameter by ASE 2015 cut-offs, respectively. Similar differences were found when we used 2005 ASE cut offs. Several differences were noted in distribution of cardiac structure and volumes among various Hispanic/Latino origins. Cubans had highest values of echocardiographic measures and Central Americans had the lowest. Conclusions This is the first large study that provides normal reference values for cardiac structure. It further demonstrates that a considerable segment of Hispanic/Latinos residing in US may be classified as having abnormal measures of cardiac chambers when 2015 and 2005 ASE reference cut-offs are used.

Background: Hybrid closed-loop (HCL) insulin pump therapy (Medtronic 670G) is an emerging technology that is growing in use worldwide. Initial clinical trials demonstrated the effectiveness of HCL in reducing hypoglycemia and improving glucose control; however, these subjects were intensely monitored and supervised. There has been concern regarding the ability of patients to remain in auto mode. We aimed to assess HCL when used in a typical outpatient endocrine clinic. Methods: We initially analyzed data from 80 individuals with type 1 diabetes managed in an endocrine clinic by a single certified diabetes educator (CDE). We then included our other providers and had 230 subjects by the end of the study. Patients were either transitioned from traditional insulin pump or multiple daily insulin injection therapy (MDI) to HCL. Patients initiated to HCL pump therapy from July 2017 through February 2020 were studied. Endpoints of change in time in hypoglycemic/hyperglycemic range and time in target range were analyzed. The primary outcome was a change in percent time in the target range during manual mode compared with auto mode. Results: There was an 18.2% increase in average time in target range when comparing manual mode to auto mode (59.3% vs 70.1%, P < .0001). Average time in hyperglycemic range was significantly reduced by 26.7% (39.0% vs 28.6%, P < .0001) but without increasing average time in hypoglycemic range (1.7% vs 1.3%, P = 0.95). Conclusions: HCL was effective in reducing hyperglycemia and increasing time in the target range but did not increase hypoglycemia. These data suggest HCL will improve the metrics of glucose control.