BACKGROUND:The US is experiencing an unprecedented sexually transmitted infections (STIs) epidemic. Although recent provisional data show some stabilization or minor declines in case rates for chlamydia, gonorrhea and syphilis, overall rates remain significantly higher than a decade ago. Local health departments (LHDs) play a crucial role in preventing and treating STIs, but some LHDs are demonstrably more effective than others. This study utilized a positive deviance (PD) approach to identify and analyze US counties with unexpectedly low STI rates. METHODS:We used a cross-sectional study design, analyzing data from 981 counties across the US, using a two-step approach: (1) multivariate linear regression to identify PD counties, and (2) multivariate logistic regression to examine predictors of PD status. RESULTS:We identified 187 (19.06%) high-performing counties, considering internal and external factors, and investigated predictors that affect the identification of these high-performing counties. These counties were more likely to have the smallest population category (<25,000), which had 6.47 times odds of being identified as PD counties compared with counties of ≥1 million, counties with high social vulnerability in specific subcategories (racial and ethnic subgroup, housing, and transportation), and counties with LHDs that provided STI-related treatment services directly and through community partnerships. CONCLUSIONS:Our findings demonstrate the potential of using a PD approach for identifying and learning from high-performing LHDs. The identification of high-performing counties provides a foundation for future research to explore the nuanced interventions contributing to their success, ultimately informing targeted public health strategies and resource allocation.

INTRODUCTION:Sexually transmitted infections including chlamydia, gonorrhea, and syphilis, remain a serious public health concern in the U.S. Social determinants of health, such as local social capital, eviction rate, and prison incarceration rate, impact health outcomes and potentially influence risk of sexually transmitted infection acquisition and transmission. This study investigated longitudinal associations between social determinants of health and sexually transmitted infection case rates at the county level in the U.S. over 20 years from 2000 to 2019. METHODS:The study team compiled data on social determinants of health and annual sexually transmitted infection case rates (chlamydia, gonorrhea, and syphilis) for all U.S. counties over the 20-year period. Panel regression models were employed to examine associations between social determinants of health and sexually transmitted infection case rates, controlling for confounders. RESULTS:The study team found significant links between social capital, eviction rate, prison incarceration rate and sexually transmitted infection case rates. Higher social capital was associated with lower chlamydia (β= -6.77, p<0.05) and gonorrhea rates (β= -7.22, p<0.01), while higher eviction rates were associated with higher rates of all 3 sexually transmitted infections (β=9.71, p<0.001 for chlamydia, β=7.32, p<0.001 for gonorrhea, and β=0.15, p<0.001 for primary and secondary syphilis, respectively) and higher prison incarceration rates were associated with higher gonorrhea rates (β=0.13, p<0.05). CONCLUSIONS:This study provides valuable insights into the annual associations of social determinants on sexually transmitted infection rates over 20 years. These findings inform the development of effective interventions and policies to address rising sexually transmitted infection case rates and promote health equity across diverse communities.

Background: Primary care intensive management programs utilize interdisciplinary care teams to comprehen-sively meet the complex care needs of patients at high risk for hospitalization. The mixed evidence on the effectiveness of these programs focuses on average treatment effects that may mask heterogeneous treatment effects (HTEs) among subgroups of patients. We test for HTEs by patients' demographic, economic, and social characteristics.Methods: Retrospective analysis of a VA randomized quality improvement trial. 3995 primary care patients at high risk for hospitalization were randomized to primary care intensive management (n = 1761) or usual pri-mary care (n = 1731). We estimated HTEs on ED and hospital utilization one year after randomization using model-based recursive partitioning and a pre-versus post-with control group framework. Splitting variables included administratively collected demographic characteristics, travel distance, copay exemption, risk score for future hospitalizations, history of hospital discharge against medical advice, homelessness, and multiple resi-dence ZIP codes.Results: There were no average or heterogeneous treatment effects of intensive management one year after enrollment. The recursive partitioning algorithm identified variation in effects by risk score, homelessness, and whether the patient had multiple residences in a year. Within each distinct subgroup, the effect of intensive management was not statistically significant.Conclusions: Primary care intensive management did not affect acute care use of high-risk patients on average or differentially for patients defined by various demographic, economic, and social characteristics. Implications: Reducing acute care use for high-risk patients is complex, and more work is required to identify patients positioned to benefit from intensive management programs.

The Centers for Medicare and Medicaid Innovation (CMMI) gave rise to the State Innovation Models (SIMs). Medicaid Integrated Purchasing for Physical and Behavioral Health, referred to as Payment Model 1 (PM1), was a core payment redesign area of the Washington State SIM project under which our research team was contracted to provide an evaluation. In doing so, we leveraged an open systems conceptual model to assess qualitatively Early Adopter stakeholders' perceived effects of implementation. Between 2017 and 2019, we conducted three rounds of interviews, examining themes of care coordination, common facilitators and barriers to integration, and potential concerns for sustaining the initiative into the future. Further, we noted the initiative's complexity may require the establishment of enduring partnerships, secure funding sources, and committed regional leadership to ensure longer-term success.

BACKGROUND:The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA's Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams.METHODS:The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation's overall goal is to assess CRH's return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners.DISCUSSION:Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

OBJECTIVE:To compare the estimated associations between annual sexually transmitted diseases (STD) expenditures per capita and STD incidence rates among Florida and Washington local health departments (LHDs) from 2001 to 2017, using two approaches-a longitudinal regression model with lagged STD spending and a regression model with the Arellano-Bond panel estimator. DATA SOURCES:Secondary data for LHDs were obtained from Florida and Washington state government offices and combined with county sociodemographic and health system data from the federal government. STUDY DESIGN:We examined LHDs in Florida and Washington using a longitudinal panel study design to estimate ecological relationships between annual STD expenditures per capita and annual STD incidence rates from 2001 to 2017, with LHDs as the unit of analysis. We compared two regression models: generalized estimating equations (GEE) and the Arellano-Bond panel estimator (an instrumental variable approach). DATA COLLECTION:The secondary data were combined to build a longitudinal panel database for LHDs in Florida and Washington from 2001 to 2017. PRINCIPAL FINDINGS:In the GEE model with both states, greater STD spending in a prior year was associated unexpectedly with greater STD incidence rates in succeeding years. The Arellano-Bond models for both states had the expected inverse associations but were not significant. In the Arellano-Bond models for Florida, a $1 increase in STD spending in previous years was followed by decreases in STD incidence rates ranging between 29 and 58 points in succeeding years (0.09 ≥ p ≥ 0.04). CONCLUSIONS:In longitudinal panel data for LHDs in two states, the Arellano-Bond estimator, or other instrumental variable approach, is preferred over conventional regression models to obtain unbiased estimates of the relationship between annual STD spending rates and annual STD rates. Future studies will require accurate, standardized, and detailed longitudinal data and rigorous analytic approaches, such as those illustrated in our study.

In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person's loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context - economic, social/cultural, political/judicial, and geographic - drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.

Impact on Heath Services Utilization, Payment, and Quality in Federally Qualified Health Centers of Washington State's Value-Based Payment Model Douglas A. Conrad, PhD (bio), Bailey Ingraham, MS, PhC (bio), Paul Fishman, PhD (bio), Lingmei Zhou, MS (bio), David Grembowski, PhD (bio), Norma B. Coe, PhD (bio), Aniyar Izguttinov, MPH (bio), Suzanne J. Wood, PhD (bio), Jordan Banks, PhD Candidate (bio), and Lydia Andris, MPA (bio) Federally qualified health centers (FQHCs) were created in 1965 to provide comprehensive primary, behavioral health, and dental care as well as enabling services that include transportation, translation, and case management services to all Americans regardless of their insurance status or ability to pay.1 As of 2021, more than 1,400 health centers with over 12,000 care sites provided health services to nearly 30 million individuals (8% of the United States population).2 Federally qualified health centers must either be in medically underserved areas (MUA) or serve medically underserved populations (MUPs), as a result, FQHCs are a critical source of care for the most vulnerable Americans. For example, approximately half of all FQHC patients are insured through Medicaid, one third of whom live in poverty, 1.4 million are homeless, and 885,000 are children served at school-based clinics.2 Federally qualified health centers are funded through two federal programs: the Health Center Program and the Community Health Center Fund2 which was established through the Affordable Care Act (ACA). Together these programs provided [End Page 1905] $5.78 billion in funding to FQHCs in fiscal year 2021—more than twice the amount allocated 10 years earlier. In 29 states, FQHCs receive state-specific support to supplement federal resources. Increased federal and state support for FQHCs was motivated in large part by the increased demand for their services from individuals newly insured through the ACA.2 The growth in demand for FQHC services and increased ACA-driven funding has focused attention on these centers as models for providing value-driven care designed to achieve the triple aims of patient-centered, high-quality, and cost-efficient care. To support this effort, the Centers for Medicare and Medicaid Services (CMS) are transitioning primary care payment from the prevailing prospective payment per encounter (PPS) model2 to alternative payment models (APMs) in the form of value-based care delivery and payment.2 The Centers for Medicare and Medicaid Services also gave states the option to create APMs, provided the affected FQHCs did not receive lower payments than would have occurred under PPS. For example, Washington State Medicaid adopted prospective per member per month (PMPM) for primary care, with financial incentives to meet population quality and performance indicators set at the beginning of the contractual period. Several states have explored APMs for FQHCs,2 but there is little current peer-reviewed evidence of their impact on health, use, cost, and quality of care. The best evidence to date is from Oregon's experience with an FQHC APM introduced in 2013.3,4,5 Oregon FQHCs are paid a capitated PMPM with quality-based financial incentives tied to colorectal cancer and depression screening, blood sugar control for individuals with diabetes, and measures related to childhood nutrition and weight and hypertension control. Cottrell et al.'s3 qualitative examination of the Oregon initiative found innovations in scheduling (longer patient visits; dedicated time for care coordination); changes in visit types (group visits; telephone visits); transformations in use of human resources (use of an online patient portal); and changing team composition (adding a clinical pharmacist; altering role descriptions [e.g., for medical assistants]). Initial results among the first 10 centers that participated in the APM showed small reductions in ER visits and hospital use, with some increases in quality, patient experience, and access.3 Ukhanova et al.5 examined the APM's impact on preventive service use and found that it "did not negatively impact delivery of preventive care,"5[p.1] based on screening rates among affected clinics not falling as much as those in comparator clinics. Lindner et. al estimated that the Oregon APM led to a 42.4% relative reduction in price-weighted primary care services compared with comparator clinics, almost fully due to the decline...

OBJECTIVETo estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families.DATA SOURCES/STUDY SETTINGAdministrative data (January 2013-December 2016) on Washington State employees.STUDY DESIGNWe compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64).DATA COLLECTION/EXTRACTION METHODSWe used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.PRINCIPAL FINDINGSWe estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.CONCLUSIONSWashington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.

Using the Veterans Health Administration's 2018 national provider and staff survey, this study describes the practice patterns of 1453 primary care providers for specialty care consults, program referrals, secure messaging, and telephone visits; and examines whether the practice patterns are associated with provider burnout in primary care teamlets. About 51% of providers experienced moderate to severe burnout and 22% had severe burnout. Providers who embraced all 4 practice approaches had lower odds of severe burnout than providers endorsing none of the approaches (odds ratio range, 0.35-0.39). Associations were weaker for providers with moderate to severe burnout.

The Washington State Innovation Model (SIM) $65 million Test Award from the Center for Medicare and Medicaid Innovation is a statewide intervention expected to improve population health, quality of care, and cost growth through 4 initiatives in 2016-2018: (1) regional accountable communities of health linking health and social services to address local needs; (2) a practice transformation support hub; (3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and (4) data and analytic infrastructure development to support system transformation with common measures. A mixed-methods study design and data from the 2013-2018 Behavioral Risk Factor Surveillance System Surveys are used to estimate whether SIM resulted in changes in access to care, health behaviors, and health status in Washington's adult population. Semi-structured qualitative interviews also were conducted to assess stakeholder perceptions of SIM performance. SIM may have reduced binge drinking, but no effects were detected for heavy drinking, physical activity, smoking, having a regular doctor checkup, unmet health care needs, and fair or poor health status. Complex interventions, such as SIM, may have unintended consequences. SIM was associated unexpectedly with increased unhealthy days, but whether the association was related to the Initiative or other factors is unclear. Over 3 years, stakeholders generally agreed that SIM was implemented successfully and increased Washington's readiness for system transformation but had not yet produced expected outcomes, partly because SIM had not spread statewide. Stakeholders perceived that scaling up SIM statewide takes time to achieve and remains challenging.

Abstract:The Washington State Innovation Models (SIM) $65 million Test Award from the Center for Medicare & Medicaid Services' Innovation Center is a statewide intervention expected to improve population health, quality of care, and cost growth through four initiatives: 1) regional accountable communities of health linking health and social services to address local needs; 2) a practice transformation support hub; 3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and 4) data and analytic infrastructure development to support system transformation with common measures. We develop a conceptual model based on diffusion theory and apply the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) to structure our evaluation. We find that in three years (2016–2018), SIM built the infrastructure for system transformation and increased Washington's readiness for health system change in the next decade. However, the initiatives have not spread statewide, which may take over 10 years.

The State of Washington received a State Innovation Models (SIM) $65 million award from the federal Centers for Medicare & Medicaid Services to improve population health and quality of care and reduce the growth of health care costs in the entire state, which has over 7 million residents. SIM is a “complex intervention” that implements several interacting components in a complex, decentralized health system to achieve goals, which poses challenges for evaluation. Our purpose is to present the state-level evaluation methods for Washington's SIM, a 3-year intervention (2016-2018). We apply the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) evaluation framework to structure our evaluation. We create a conceptual model and a plan to use multiple and mixed methods to study SIM performance in the RE-AIM components from a statewide, population-based perspective.

Purpose: Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown. Methods: We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout. Results: Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1–4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1–4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49–0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33–2.5). Conclusions: Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses.

Introduction Strategic and budgetary considerations have shifted local health departments (LHDs) away from safety net clinical services and toward population-focused services. Federally Qualified Health Centers (FQHCs) play an increasing role in the safety net, and may complement or substitute for LHD clinical services. The authors examined the association between FQHC service levels in communities and the presence of specific LHD clinical services in 2010 and 2013. Methods Data from LHD surveys and FQHC service data were merged for 2010 and 2013. Multivariate regression and instrumental variable methods were used to examine FQHC service levels that might predict related LHD service presence or discontinuation from 2010 to 2013. Results There were modest reductions in LHD service presence and increases in FQHC service volume over the time period. LHD primary care and dental service presence were inversely associated with higher related FQHC service volume. LHD prenatal care service presence, as well as a measure of change in general service approach, were not significantly associated with FQHC service volume. Conclusions LHDs were less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, certain clinical services, such as prenatal care, may complement the public health mission—and LHDs may be strategically placed to continue to deliver these services.

Following an arduous, 6-year policy-making process, Vermont is the first state implementing a unified, statewide all-payer integrated delivery system with value-based payment, along with aligned medical and social service reforms, for almost all residents and providers in a state. Commercial, Medicare, and Medicaid value-based payment for most Vermonters will be administered through a new statewide accountable care organization in 2018-2022. The purpose of this article is to describe the 10 conditions that increased Vermont's readiness to implement statewide system transformation. The authors reviewed documents, conducted internet searches of public information, interviewed key informants annually in 2014-2016, cross-validated factual and narrative interpretation, and performed content analyses to derive conditions that increased readiness and their implications for policy and practice. Four social conditions (leadership champions; a common vision; collaborative culture; social capital and collective efficacy) and 6 support conditions (money; statewide data; legal infrastructure; federal policy promoting payment reform; delivery system transformation aligned with payment reform; personnel skilled in system reform) increased Vermont's readiness for system transformation. Vermont's experience indicates that increasing statewide readiness for reform is slow, incremental, and exhausting to overcome the sheer inertia of large fee-based systems. The new payments may work because statewide, uniform population-based payment will affect the health care of almost all Vermonters, creating statewide, uniform provider incentives to reduce volume and making the current fee-based system less viable. The conditions for readiness and statewide system transformation may be more likely in states with regulated markets, like Vermont, than in states with highly competitive markets.

BACKGROUND:The magnitude of risk of serious infections due to available medical therapies of inflammatory bowel disease (IBD) remains controversial. We conducted a systematic review and network meta-analysis of the existing IBD literature to estimate the risk of serious infection in adult IBD patients associated with available medical therapies. METHODS:Studies were identified by a literature search of PubMed, Cochrane Library, Medline, Web of Science, Scopus, EMBASE, and ProQuest Dissertations and Theses. Randomized controlled trials comparing IBD medical therapies with no restrictions on language, country of origin, or publication date were included. A network meta-analysis was used to pool direct between treatment comparisons with indirect trial evidence while preserving randomization. RESULTS:Thirty-nine articles fulfilled the inclusion criteria; one study was excluded from the analysis due to disconnectedness. We found no evidence of increased odds of serious infection in comparisons of the different treatment strategies against each other, including combination therapy with a biologic and immunomodulator compared to biologic monotherapy. Similar results were seen in the comparisons between the newer biologics (e.g. vedolizumab) and the anti-tumor necrosis factor agents. CONCLUSIONS:No treatment strategy was found to confer a higher risk of serious infection than another, although wide confidence intervals indicate that a clinically significant difference cannot be excluded. These findings provide a better understanding of the risk of serious infection from IBD pharmacotherapy in the adult population. PROSPERO REGISTRATION:The protocol for this systematic review was registered on PROSPERO ( CRD42014013497 ).

Background:Implementation of Patient Aligned Care Teams (PACT), a patient-centered medical home model, has been inconsistent among the >900 primary care facilities in the Veterans Health Administration. Objective:Estimate if the degree of PACT implementation at a facility varied with the percentage of minority veteran patients at the facility. Research Design:Cross-sectional, facility-level analysis of PACT implementation measures in 2012. Subjects:Veterans Health Administration hospital-based and community-based primary care facilities. Measures:We used a previously validated PACT Implementation Progress Index (Pi2) and its 8 domains: access, continuity of care, care coordination, comprehensiveness, self-management support, and patient-centered care and communication, shared decision-making domains, and team functioning. Facilities were categorized as low (<5.2%, n=208), medium (5.2%–25.8%, n=413), and high (>25.8%, n=206) percent minority based on the percent of their own veteran population. Results:Most minority veterans received care in high minority (69%) and medium minority facilities (29%). In adjusted analyses, medium and high minority facilities scored 0.773 (P=0.009) and 0.930 (P=0.008) points lower on the Pi2 score relative to low minority facilities. Relative to low minority facilities, both medium and high minority facilities were less likely of having high Pi2 scores (≥2) and more likely of having low Pi2 scores (⩽−2). Both medium and high minority facilities had the same 3 domain scores lower than low minority facilities (care coordination, comprehensiveness, and self-management). Conclusion:Overall PACT implementation varied with respect to the racial/ethnic composition of a facility, with medium and high minority facilities having a lower implementation scores.

BACKGROUND:In 2003, Group Health implemented a pharmacy-based, systemwide outreach effort to increase the preventive use of statins and angiotensin-converting enzyme inhibitors in enrollees at risk for cardiovascular disease, including all enrollees with diabetes.OBJECTIVE:To estimate the associations between the use of statins and major vascular events and the total costs in 2006-2010 for enrollees with diabetes, using a pharmacy-based, systemwide outreach.METHODS:In a 14-year (1997-2010) longitudinal cohort study design, the study population consisted of 6,975 Group Health enrollees with type 1 or type 2 diabetes, who were enrolled continuously and had no statin use before the Group Health outreach in 1997-2002. Health outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Statin exposure was measured by cumulative statin use since 2003, weighted by the effect of the statin type and dose on the lowering of low-density lipoprotein levels. Regression models estimated associations between cumulative statin use, health outcomes, and total costs in 2006-2010.RESULTS:Among enrollees with no statin use before outreach began in 2003, about half had no or low exposure to statins by the end of 2005. In 2006-2010, cumulative statin use was greater among enrollees with risk factors for cardiovascular disease. Greater statin use was related to lower cardiovascular deaths and incidence of stroke and myocardial infarction, greater but nonsignificant all-cause mortality, and unrelated to total costs.CONCLUSIONS:Population-based pharmacy outreach increased statin use for eligible enrollees with diabetes, which was related to better cardiovascular outcomes. Generally, statin use was unrelated to all-cause mortality and total costs.DISCLOSURES:This study was funded by Grant No. R21 HS019501 from the Agency for Healthcare Research and Quality (AHRQ) and was conducted as part of the AHRQ announcement Optimizing Prevention and Healthcare Management for the Complex Patient (R21; RFA-HS-10-009). Ralston and Anderson are employees of Group Health and the Group Health Research Institute, which provided the data for this study. Study concept and design were contributed by Grembowski, Ralston, and Anderson. Anderson assisted with data collection and analysis, and data interpretation was performed by Anderson, along with Grembowski and Ralston. The manuscript was prepared by Grembowski, along with Ralston and Anderson.

Background/Aims. Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC). In addition, there may be an association between leukemia and lymphoma and IBD. We conducted a systematic review and meta-analysis of the IBD literature to estimate the incidence of CRC, leukemia, and lymphoma in adult IBD patients. Methods. Studies were identified by a literature search of PubMed, Cochrane Library, Medline, Web of Science, Scopus, EMBASE, and ProQuest Dissertations and Theses. Pooled incidence rates (per 100,000 person-years [py]) were calculated through use of a random effects model, unless substantial heterogeneity prevented pooling of estimates. Several stratified analyses and metaregression were performed to explore potential study heterogeneity and bias. Results. Thirty-six articles fulfilled the inclusion criteria. For CRC, the pooled incidence rate in CD was 53.3/100,000 py (95% CI 46.3-60.3/100,000). The incidence of leukemia was 1.5/100,000 py (95% CI -0.06-3.0/100,000) in IBD, 0.3/100,000 py (95% CI -1.0-1.6/100,000) in CD, and 13.0/100,000 py (95% CI 5.8-20.3/100,000) in UC. For lymphoma, the pooled incidence rate in CD was 0.8/100,000 py (95% CI -0.4-2.1/100,000). Substantial heterogeneity prevented the pooling of other incidence estimates. Conclusion. The incidence of CRC, leukemia, and lymphoma in IBD is low.