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Health Care Delivery and Policy - Health Care Delivery and Policy Publications

CT Use Reduction In Ostensive Ureteral Stone (CURIOUS)

Computed tomography (CT) is performed in over 90% of patients diagnosed with ureteral stones, but only 10% of patients presenting to the emergency department (ED) with acute flank pain are hospitalized for a clinically important stone or non-stone diagnosis. Hydronephrosis can be accurately detected using point-of-care ultrasound and is a key predictor of ureteral stone and risk of subsequent complications. The absence of hydronephrosis is insufficient to exclude a stone. We created a sensitive clinical decision rule to predict clinically important ureteral stones. We hypothesized that this rule could identify patients at low risk for this outcome. We conducted a retrospective cohort study in a random sample of 4000 adults who presented to one of 21 Kaiser Permanente Northern California EDs and underwent a CT for suspected ureteral stone from 1/1/2016 to 12/31/2020. The primary outcome was clinically important stone, defined as stone resulting in hospitalization or urologic procedure within 60 days. We used recursive partition analysis to generate a clinical decision rule predicting the outcome. We estimated the C-statistic (area under the curve), plotted the receiver operating characteristic (ROC) curve for the model, and calculated sensitivity, specificity, and predictive values of the model based on a risk threshold of 2%. Among 4000 patients, 354 (8.9%) had a clinically important stone. Our partition model resulted in four terminal nodes with risks ranging from 0.4% to 21.8%. The area under the ROC curve was 0.81 (95% CI 0.80, 0.83). Using a 2% risk cut point, a clinical decision tree including hydronephrosis, hematuria, and a history of prior stones predicted complicated stones with sensitivity 95.5% (95% CI 92.8%-97.4%), specificity 59.9% (95% CI 58.3%-61.5%), positive predictive value 18.8% (95% CI 18.1%-19.5%), and negative predictive value 99.3% (95% CI 98.8%-99.6%). Application of this clinical decision rule to imaging decisions would have led to 63% fewer CT scans with a miss rate of 0.4%. A limitation was the application of our decision rule only to patients who underwent CT for suspected ureteral stone. Thus, this rule would not apply to patients who were thought to have ureteral colic but did not receive a CT because ultrasound or history were sufficient for diagnosis. These results could inform future prospective validation studies.

Authors: Durant, Edward J; Engelhart, Darcy C; Ma, Annie A; Warton, E Margaret; Arasu, Vignesh A; Bernal, Raymond; Rauchwerger, Adina S; Reed, Mary E; Vinson, David R

Am J Emerg Med. 2023 May;67:168-175. Epub 2023-02-24.

PubMed abstract

Association of Surgical Timing with Outcomes in Early Stage Lung Cancer

Optimal time to surgery for lung cancer is not well established. We aimed to assess whether time to surgery correlates with outcomes. We assessed patients 18-84 years old who were diagnosed with stage I/II lung cancer at our integrated healthcare system from 2009 to 2019. Time to surgery was defined to start with disease confirmation (imaging or biopsy) prior to the surgery scheduling date. Outcomes of unplanned return to care within 30 days of lung cancer surgery, all-cause mortality, and disease recurrence were compared based on time to surgery before and after 2, 4, and 12 weeks. Of 2861 included patients, 70% were over 65 years old and 61% were female. Time to surgery occurred in 1-2 weeks for 6%, 3-4 weeks for 31%, 5-12 weeks for 58%, and 13-26 weeks for 5% of patients. Patients with time to surgery > 4 (vs. ≤ 4) weeks had greater risk of both death (hazard ratio (HR) 1.18, 95% confidence interval (CI) 1.00-1.39) and recurrence (HR 1.33, 95% CI 1.10-1.62). Associations were not statistically significant when dichotomizing time to surgery at 2 or 12 weeks for death (2 week HR 1.23, 95% CI 0.93-1.64; 12 week HR 1.35, 95% CI 0.97-1.88) and recurrence (2 week HR 1.54, 95% CI 0.85-2.80; 12 week HR 2.28, 95% CI 0.80-6.46). Early stage lung cancer patients with time to surgery within 4 weeks experienced lower rates of recurrence. Optimal time to surgical resection may be shorter than previously reported.

Authors: Banks, Kian C; Dusendang, Jennifer R; Schmittdiel, Julie A; Hsu, Diana S; Ashiku, Simon K; Patel, Ashish R; Sakoda, Lori C; Velotta, Jeffrey B

World J Surg. 2023 May;47(5):1323-1332. Epub 2023-01-25.

PubMed abstract

Performance of a Prediction Model of Suicide Attempts Across Race and Ethnicity

This study examines whether race disparities exist in the prediction of suicide attempts and if have they have detrimental effects on individuals and health care systems.

Authors: Papini, Santiago; Hsin, Honor; Kipnis, Patricia; Liu, Vincent X; Lu, Yun; Sterling, Stacy A; Iturralde, Esti

JAMA Psychiatry. 2023 Apr 01;80(4):399-400.

PubMed abstract

Effects of COVID-19 shelter-in-place confinement on diabetes prevention health behaviors among US adults with prediabetes: A cross-sectional survey

The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant lifestyle changes due to shelter-in-place confinement orders. The study’s purpose was to assess if the COVID-19 pandemic affected self-reported diabetes prevention behaviors among American adults with prediabetes. As part of a randomized clinical trial among adults with prediabetes and overweight/obesity, questions were added to existing study surveys to assess the effect of the COVID-19 pandemic on diabetes prevention behaviors and stress. Survey responses were summarized using frequencies. 259 study participants completed seven COVID-19 survey questions from June 2020 to June 2021. Participants were 62.9% female, 42.5% White, 31.3% Black, 11.6% Asian, 8.1% Hispanic, and 6.6% Other. Over 75% of participants reported that the COVID-19 pandemic affected physical activity levels, with 82.1% of those affected reporting decreased physical activity; 70.3% reported that the pandemic affected their eating habits, with 61.7% of those affected reporting their eating habits became less healthy; 73.7% reported that the pandemic affected their level of stress, with 97.4% of those affected reporting that their level of stress had increased; 60% reported that the pandemic affected their motivation to adopt/maintain healthy habits, with 72.9% of those affected reporting their motivation decreased. A high percentage of study participants with prediabetes reported decreases in health promotion behaviors and increases in stress due to the COVID-19 pandemic. Consequently, the pandemic could lead to increased diabetes incidence. Strategies to improve diabetes prevention behaviors and address mental health concerns among those at-risk for diabetes are critical during and after the COVID-19 pandemic.

Authors: Thomas, Tainayah Whitney; Lindsey, Rebecca; Yassin, Maher; Rodriguez, Luis A; Heisler, Michele; Schmittdiel, Julie A

Prev Med Rep. 2023 Apr;32:102139. Epub 2023-02-13.

PubMed abstract

Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic.

BACKGROUND: Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients’ experiences, it is unclear whether telehealth supported this relationship. n OBJECTIVE: We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth. n RESEARCH DESIGN: This was a cohort study. n PARTICIPANTS: Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020. n METHODS: Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020. n RESULTS: MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing. n CONCLUSIONS: Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

Authors: Tierney, Aaron A;Payán, Denise D;Brown, Timothy T;Aguilera, Adrian;Shortell, Stephen M;Rodriguez, Hector P

Med Care. 2023 Apr 01;61(Suppl 1):S62-S69. doi: 10.1097/MLR.0000000000001811. Epub 2023 Mar 9.

PubMed abstract

Development and Validation of a Diabetic Retinopathy Risk Stratification Algorithm

Although diabetic retinopathy is a leading cause of blindness worldwide, diabetes-related blindness can be prevented through effective screening, detection, and treatment of disease. The study goal was to develop risk stratification algorithms for the onset of retinal complications of diabetes, including proliferative diabetic retinopathy, referable retinopathy, and macular edema. Retrospective cohort analysis of patients from the Kaiser Permanente Northern California Diabetes Registry who had no evidence of diabetic retinopathy at a baseline diabetic retinopathy screening during 2008-2020 was performed. Machine learning and logistic regression prediction models for onset of proliferative diabetic retinopathy, diabetic macular edema, and referable retinopathy detected through routine screening were trained and internally validated. Model performance was assessed using area under the curve (AUC) metrics. The study cohort (N = 276,794) was 51.9% male and 42.1% White. Mean (±SD) age at baseline was 60.0 (±13.1) years. A machine learning XGBoost algorithm was effective in identifying patients who developed proliferative diabetic retinopathy (AUC 0.86; 95% CI, 0.86-0.87), diabetic macular edema (AUC 0.76; 95% CI, 0.75-0.77), and referable retinopathy (AUC 0.78; 95% CI, 0.78-0.79). Similar results were found using a simpler nine-covariate logistic regression model: proliferative diabetic retinopathy (AUC 0.82; 95% CI, 0.80-0.83), diabetic macular edema (AUC 0.73; 95% CI, 0.72-0.74), and referable retinopathy (AUC 0.75; 95% CI, 0.75-0.76). Relatively simple logistic regression models using nine readily available clinical variables can be used to rank order patients for onset of diabetic eye disease and thereby more efficiently prioritize and target screening for at risk patients.

Authors: Tarasewicz, Dariusz; Karter, Andrew J; Pimentel, Noel; Moffet, Howard H; Thai, Khanh K; Schlessinger, David; Sofrygin, Oleg; Melles, Ronald B

Diabetes Care. 2023 Mar 17.

PubMed abstract


At least 10% of lung cancers arise in adults who have never smoked. Data remain inconclusive on whether lung cancer incidence has been increasing among never-smoking adults. How have age-adjusted incidence rates of lung cancer changed temporally, especially among never-smoking adults? Trends in lung cancer incidence were examined using linked electronic health record and cancer registry data on a dynamic cohort of adults aged ≥30 years at risk for incident lung cancer between 1/1/2007 and 12/31/2018 from an integrated healthcare system in northern California. Truncated age-adjusted lung cancer incidence rates and average annual percentage change (AAPC) in rates were estimated, overall and separately for ever- and never-smoking adults by age, sex, and race/ethnicity. Our cohort included 3,751,348 (52.5% female; 48.0% non-Hispanic White; 63.1% never-smoking) adults, among whom 18,627 (52.7% female; 68.6% non-Hispanic White; 15.4% never-smoking) were diagnosed with lung cancer. The overall lung cancer incidence rate declined from 91.1 to 63.7 per 100,000 person-years between 2007-2009 and 2016-2018 (AAPC, -3.9%; 95% CI, -4.2%, -3.6%). Among ever-smoking adults, incidence rates declined overall from 167.0 to 113.4 per 100,000 person-years (AAPC, -4.2%; 95% CI, -4.4%, -3.9%) and, to varying degrees, within all age, sex, and racial/ethnic groups. Among never-smoking adults, incidence rates were relatively constant, with three-year period estimates ranging from 19.9 to 22.6 per 100,000 person-years (AAPC, 0.9%; 95% CI, -0.3%, 2.1%). Incidence rates for never-smoking adults appeared stable over time within age, sex, and racial/ethnic groups, except for those of Asian and Pacific Islander (API) origin (AAPC, 2.0%; 95% CI, 0.1%, 3.9%), whose rates were about twice as high compared to their counterparts. These observed trends underscore the need to further elucidate the etiology of lung cancer in never-smoking adults, including why incidence is higher and rising in never-smoking API adults.

Authors: Sakoda, Lori C; Alabaster, Amy; Sumner, Eric T; Gordon, Nancy P; Quesenberry, Charles P; Velotta, Jeffrey B

Chest. 2023 Mar 17.

PubMed abstract

Identifying Predictors of Homelessness Among Adults in a Large Integrated Health System in Northern California

Introduction Homelessness contributes to worsening health and increased health care costs. There is little published research that leverages rich electronic health record (EHR) data to predict future homelessness risk and inform interventions to address it. The authors’ objective was to develop a model for predicting future homelessness using individual EHR and geographic data covariates. Methods This retrospective cohort study included 2,543,504 adult members (≥ 18 years old) from Kaiser Permanente Northern California and evaluated which covariates predicted a composite outcome of homelessness status (hospital discharge documentation of a homeless patient, medical diagnosis of homelessness, approved medical financial assistance application for homelessness, and/or “homeless/shelter” in address name). The predictors were measured in 2018-2019 and included prior diagnoses and demographic and geographic data. The outcome was measured in 2020. The cohort was split (70:30) into a derivation and validation set, and logistic regression was used to model the outcome. Results Homelessness prevalence was 0.35% in the overall sample. The final logistic regression model included 26 prior diagnoses, demographic, and geographic-level predictors. The regression model using the validation set had moderate sensitivity (80.4%) and specificity (83.2%) for predicting future cases of homelessness and achieved excellent classification properties (area under the curve of 0.891 [95% confidence interval = 0.884-0.897]). Discussion This prediction model can be used as an initial triage step to enhance screening and referral tools for identifying and addressing homelessness, which can improve health and reduce health care costs. Conclusions EHR data can be used to predict chance of homelessness at a population health level.

Authors: Rodriguez, Luis A; Thomas, Tainayah W; Finertie, Holly; Wiley, Deanne; Dyer, Wendy T; Sanchez, Perla E; Yassin, Maher; Banerjee, Somalee; Adams, Alyce; Schmittdiel, Julie A

Perm J. 2023 Mar 15;27(1):56-71. Epub 2023-03-13.

PubMed abstract

Data-driven classification of health status of older adults with diabetes: The diabetes and aging study

We set out to identify empirically-derived health status classes of older adults with diabetes based on clusters of comorbid conditions which are associated with future complications. We conducted a cohort study among 105,786 older (≥65 years of age) adults with type 2 diabetes enrolled in an integrated healthcare delivery system. We used latent class analysis of 19 baseline comorbidities to derive health status classes and then compared incident complication rates (events per 100 person-years) by health status class during 5 years of follow-up. Complications included infections, hyperglycemic events, hypoglycemic events, microvascular events, cardiovascular events, and all-cause mortality. Three health status classes were identified: Class 1 (58% of the cohort) had the lowest prevalence of most baseline comorbidities, Class 2 (22%) had the highest prevalence of obesity, arthritis, and depression, and Class 3 (20%) had the highest prevalence of cardiovascular conditions. The risk for incident complications was highest for Class 3, intermediate for Class 2 and lowest for Class 1. For example, the age, sex and race-adjusted rates for cardiovascular events (per 100 person-years) for Class 3, Class 2 and Class 1 were 6.5, 2.3, and 1.6, respectively; 2.1, 1.2, 0.7 for hypoglycemia; and 8.0, 3.8, and 2.3 for mortality. Three health status classes of older adults with diabetes were identified based on prevalent comorbidities and were associated with marked differences in risk of complications. These health status classes can inform population health management and guide the individualization of diabetes care.

Authors: Huang, Elbert S; Liu, Jennifer Y; Lipska, Kasia J; Grant, Richard W; Laiteerapong, Neda; Moffet, Howard H; Schumm, L Philip; Karter, Andrew J

J Am Geriatr Soc. 2023 Mar 08.

PubMed abstract

Using Peer Support to Prevent Diabetes: Results of a Pragmatic RCT

High-contact structured diabetes prevention programs are effective in lowering weight and HbA1cs, yet their intensity level can create barriers to participation. Peer support programs improve clinical outcomes among adults with Type 2 diabetes, but their effectiveness in diabetes prevention is unknown. This study examined whether a low-intensity peer support program improved outcomes more than enhanced usual care in a diverse population with prediabetes. The intervention was tested in a pragmatic 2-arm RCT. Participants were adults with prediabetes at 3 healthcare centers. Participants randomized to the enhanced usual care arm received educational materials. Participants in the Using Peer Support to Aid in Prevention and Treatment in Prediabetes arm were matched with a peer supporter: another patient who had made healthy lifestyle changes and was trained in autonomy-supportive action planning. Peer supporters were instructed to provide weekly telephone support to their peers on specific action steps toward behavioral goals for 6 months, then monthly support for 6 months. Changes in primary outcomes of weight and HbA1c and secondary outcomes of enrollment in formal diabetes prevention programs, self-reported diet, physical activity, health-specific social support, self-efficacy, motivation, and activation at 6 and 12 months were examined. Data collection occurred from October 2018 to March 2022, with analyses completed in September 2022. Among 355 randomized patients, in intention-to-treat analyses, there were no between-group differences in HbA1c or weight changes at 6 and 12 months. Using Peer Support to Aid in Prevention and Treatment in Prediabetes participants were more likely to enroll in structured programs at 6 (AOR=2.45, p=0.009) and 12 (AOR=2.21, p=0.016) months and to report eating whole grains at 6 (4.49, p=0.026) and 12 (4.22, p=0.034) months. They reported greater improvements in perceived social support for diabetes prevention behaviors at 6 (6.39, p<0.001) and 12 (5.48, p<0.001) months, with no differences in other measures. A stand-alone, low-intensity peer support program improved social support and participation in formal diabetes prevention programs but not weight or HbA1c. It will be important to examine whether peer support could effectively complement higher-intensity, structured diabetes prevention programs. This trial is registered at, NCT03689530. Full protocol available at

Authors: Heisler, Michele; Dyer, Wendy T; Finertie, Holly; Stoll, Shelley C; Wiley, Deanne; Turner, Cassie D; Sedgwick, Tali; Kullgren, Jeffrey; Richardson, Caroline R; Hedderson, Monique; Schmittdiel, Julie A

Am J Prev Med. 2023 Mar 08.

PubMed abstract

Telehealth During COVID-19 for Adults with Multiple Chronic Conditions: Associations with Self-Reported Food Insecurity and with Physical Limitations

Background: Adults with chronic medical conditions complicated by food insecurity or physical limitations may have higher barriers to accessing telehealth implemented during the COVID-19 pandemic. Objective: To examine the relationships of self-reported food insecurity and physical limitations with changes in health care utilization and medication adherence comparing the year before (March 2019-February 2020) and the first year of the COVID-19 pandemic (April 2020-March 2021) among patients with chronic conditions insured by Medicaid or Medicare Advantage. Methods: A prospective cohort study of 10,452 Kaiser Permanente Northern California members insured by Medicaid and 52,890 Kaiser Permanente Colorado members insured by Medicare Advantage was conducted. Difference-in-differences (DID) between the pre-COVID and COVID years in telehealth versus in-person health care utilization and adherence to chronic disease medicines by food insecurity and by physical limitation status were measured. Results: Food insecurity and physical limitations were each associated with small but significantly greater shifts from in-person to telehealth. Medicare Advantage members with physical limitations also had significantly greater decline in adherence to chronic medications from year to year compared with those without physical limitations (DID from pre-COVID year to COVID year ranged from 0.7% to 3.6% greater decline by medication class, p < 0.01). Conclusions: Food insecurity and physical limitations did not present significant barriers to the transition to telehealth during the COVID pandemic. The greater decrease in medication adherence among older patients with physical limitations suggests that care systems must further address the needs of this high-risk population.

Authors: McCloskey, Jodi K; Ellis, Jennifer L; Uratsu, Connie S; Drace, Melanie L; Ralston, James D; Bayliss, Elizabeth A; Grant, Richard W

Telemed J E Health. 2023 Mar 06.

PubMed abstract

Associations of polygenic risk scores with posttraumatic stress symptom trajectories following combat deployment

Identification of genetic risk factors may inform the prevention and treatment of posttraumatic stress disorder (PTSD). This study evaluates the associations of polygenic risk scores (PRS) with patterns of posttraumatic stress symptoms following combat deployment. US Army soldiers of European ancestry (n = 4900) provided genomic data and ratings of posttraumatic stress symptoms before and after deployment to Afghanistan in 2012. Latent growth mixture modeling was used to model posttraumatic stress symptom trajectories among participants who provided post-deployment data (n = 4353). Multinomial logistic regression models tested independent associations between trajectory membership and PRS for PTSD, major depressive disorder (MDD), schizophrenia, neuroticism, alcohol use disorder, and suicide attempt, controlling for age, sex, ancestry, and exposure to potentially traumatic events, and weighted to account for uncertainty in trajectory classification and missing data. Participants were classified into low-severity (77.2%), increasing-severity (10.5%), decreasing-severity (8.0%), and high-severity (4.3%) posttraumatic stress symptom trajectories. Standardized PTSD-PRS and MDD-PRS were associated with greater odds of membership in the high-severity v. low-severity trajectory [adjusted odds ratios and 95% confidence intervals, 1.23 (1.06-1.43) and 1.18 (1.02-1.37), respectively] and the increasing-severity v. low-severity trajectory [1.12 (1.01-1.25) and 1.16 (1.04-1.28), respectively]. Additionally, MDD-PRS was associated with greater odds of membership in the decreasing-severity v. low-severity trajectory [1.16 (1.03-1.31)]. No other associations were statistically significant. Higher polygenic risk for PTSD or MDD is associated with more severe posttraumatic stress symptom trajectories following combat deployment. PRS may help stratify at-risk individuals, enabling more precise targeting of treatment and prevention programs.

Authors: Campbell-Sills, Laura; Papini, Santiago; Norman, Sonya B; Choi, Karmel W; He, Feng; Sun, Xiaoying; Kessler, Ronald C; Ursano, Robert J; Jain, Sonia; Stein, Murray B

Psychol Med. 2023 Mar 06:1-10.

PubMed abstract

Evaluation of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage

Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI). To derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage. This retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022. Assigned ESI level. Rate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage. A total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]). In this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.

Authors: Sax, Dana R; Mark, Dustin G; Vinson, David R; Ballard, Dustin W; Reed, Mary E; Kaiser Permanente CREST (Clinical Research on Emergency Services & Treatments) Network,; et al.

JAMA Netw Open. 2023 Mar 01;6(3):e233404. Epub 2023-03-01.

PubMed abstract

Validation of a Hypoglycemia Risk Stratification Tool Using Data From Continuous Glucose Monitors

This cohort study uses data from continuous glucose monitoring to validate a hypoglycemia risk stratification tool.

Authors: Karter, Andrew J; Parker, Melissa M; Moffet, Howard H; Lipska, Kasia J; Ralston, James D; Huang, Elbert S; Gilliam, Lisa K

JAMA Netw Open. 2023 Mar 01;6(3):e236315. Epub 2023-03-01.

PubMed abstract

Practice Patterns and Outcomes Associated With Anticoagulation Use Following Sepsis Hospitalizations With New-Onset Atrial Fibrillation

Practice patterns and outcomes associated with the use of oral anticoagulation for arterial thromboembolism prevention following a hospitalization with new-onset atrial fibrillation (AF) during sepsis are unclear. Retrospective, observational cohort study of patients ≥40 years of age discharged alive following hospitalization with new-onset AF during sepsis across 21 hospitals in the Kaiser Permanente Northern California health care delivery system, years 2011 to 2018. Primary outcomes were ischemic stroke/transient ischemic attack (TIA), with a safety outcome of major bleeding events, both within 1 year of discharge alive from sepsis hospitalization. Adjusted risk differences for outcomes between patients who did and did not receive oral anticoagulation within 30 days of discharge were estimated using marginal structural models fitted by inverse probability weighting using Super Learning within a target trial emulation framework. Among 82 748 patients hospitalized with sepsis, 3992 (4.8%) had new-onset AF and survived to hospital discharge; mean age was 78±11 years, 53% were men, and 70% were White. Patients with new-onset AF during sepsis averaged 45±33% of telemetry monitoring entries with AF, and 27% had AF present on the day of hospital discharge. Within 1 year of hospital discharge, 89 (2.2%) patients experienced stroke/TIA, 225 (5.6%) had major bleeding, and 1011 (25%) died. Within 30 days of discharge, 807 (20%) patients filled oral anticoagulation prescriptions, which were associated with higher 1-year adjusted risks of ischemic stroke/TIA (5.69% versus 2.32%; risk difference, 3.37% [95% CI, 0.36-6.38]) and no significant difference in 1-year adjusted risks of major bleeding (6.51% versus 7.10%; risk difference, -0.59% [95% CI, -3.09 to 1.91]). Sensitivity analysis of ischemic stroke-only outcomes showed a risk difference of 0.15% (95% CI, -1.72 to 2.03). After hospitalization with new-onset AF during sepsis, oral anticoagulation use was uncommon and associated with potentially higher stroke/TIA risk. Further research to inform mechanisms of stroke and TIA and management of new-onset AF after sepsis is needed.

Authors: Walkey, Allan J; Myers, Laura C; Thai, Khanh K; Kipnis, Patricia; Desai, Manisha; Go, Alan S; Lu, Yun; Clancy, Heather; Devis, Ycar; Neugebauer, Romain; Liu, Vincent X

Circ Cardiovasc Qual Outcomes. 2023 Mar;16(3):e009494. Epub 2023-02-28.

PubMed abstract

Racial and Ethnic Differences in Medication Initiation Among Adults Newly Diagnosed with Type 2 Diabetes

Given persistent racial/ethnic differences in type 2 diabetes outcomes and the lasting benefits conferred by early glycemic control, we examined racial/ethnic differences in diabetes medication initiation during the year following diagnosis. Among adults newly diagnosed with type 2 diabetes (2005-2016), we examined how glucose-lowering medication initiation differed by race/ethnicity during the year following diagnosis. We specified modified Poisson regression models to estimate the association between race/ethnicity and medication initiation in the entire cohort and within subpopulations defined by HbA1c, BMI, age at diagnosis, comorbidity, and neighborhood deprivation index (a census tract-level socioeconomic indicator). Among the 77,199 newly diagnosed individuals, 47% started a diabetes medication within 12 months of diagnosis. The prevalence of medication initiation ranged from 32% among Chinese individuals to 58% among individuals of Other/Unknown races/ethnicities. Compared to White individuals, medication initiation was less likely among Chinese (relative risk: 0.78 (95% confidence interval 0.72, 0.84)) and Japanese (0.82 (0.75, 0.90)) individuals, but was more likely among Hispanic/Latinx (1.27 (1.24, 1.30)), African American (1.14 (1.11, 1.17)), other Asian (1.13 (1.08, 1.18)), South Asian (1.10 (1.04, 1.17)), Other/Unknown (1.31 (1.24, 1.39)), American Indian or Alaska Native (1.11 (1.04, 1.18)), and Native Hawaiian/Pacific Islander (1.28 (1.19, 1.37)) individuals. Racial/ethnic differences dissipated among individuals with higher HbA1c values. Initiation of glucose-lowering treatment during the year following type 2 diabetes diagnosis differed markedly by race/ethnicity, particularly for those with lower HbA1c values. Future research should examine how patient preferences, provider implicit bias, and shared decision-making contribute to these early treatment differences.

Authors: Gopalan, Anjali; Winn, Aaron N; Karter, Andrew J; Laiteerapong, Neda

J Gen Intern Med. 2023 Mar;38(4):994-1000. Epub 2022-08-04.

PubMed abstract

Among-Hospital Variation in ICU Admission Practices and Associated Outcomes for Patients with Acute Respiratory Failure

Rationale: We have previously shown that hospital strain is associated with intensive care unit (ICU) admission and that ICU admission, compared with ward admission, may benefit certain patients with acute respiratory failure (ARF). Objectives: To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. Methods: We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. Results: There was significant among-hospital variation in ICU admission rates, in hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF (n = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared with the ward, but among the 27 hospitals (n = 224-3,324), this effect varied from 5.85 days shorter (95% confidence interval [CI], -8.84 to -2.86; P < 0.001) to 4.38 days longer (95% CI, 1.86-6.90; P = 0.001). Corresponding ranges for in-hospital mortality with ICU compared with ward admission revealed odds ratios from 0.08 (95% CI, 0.01-0.56; P < 0.007) to 8.89 (95% CI, 1.60-79.85; P = 0.016) among patients with ARF (pooled odds ratio, 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. Conclusions: Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.

Authors: Anesi, George L; Liu, Vincent X; et al.

Ann Am Thorac Soc. 2023 Mar;20(3):406-413.

PubMed abstract

Development and Validation of an Electronic Health Record-based Score for Triage to Perioperative Medicine

To develop an electronic health record-based risk model for perioperative medicine (POM) triage and compare this model with legacy triage practices that were based on clinician assessment. POM clinicians seek to address the increasingly complex medical needs of patients prior to scheduled surgery. Identifying which patients might derive the most benefit from evaluation is challenging. Elective surgical cases performed within a health system 2014- 2019 (N = 470,727) were used to develop a predictive score, called the Comorbidity Assessment for Surgical Triage (CAST) score, using split validation. CAST incorporates patient and surgical case characteristics to predict the risk of 30-day post-operative morbidity, defined as a composite of mortality and major NSQIP complications. Thresholds of CAST were then selected to define risk groups, which correspond with triage to POM appointments of different durations and modalities. The predictive discrimination CAST score was compared with the surgeon’s assessments of patient complexity and the American Society of Anesthesiologists class. The CAST score demonstrated a significantly higher discrimination for predicting post-operative morbidity (area under the receiver operating characteristic curve 0.75) than the surgeon’s complexity designation (0.63; P < 0.001) or the American Society of Anesthesiologists (0.65; P < 0.001) ( Fig. 1 ). Incorporating the complexity designation in the CAST model did not significantly alter the discrimination (0.75; P = 0.098). Compared with the complexity designation, classification based on CAST score groups resulted a net reclassification improvement index of 10.4% ( P < 0.001) ( Table 1 ). A parsimonious electronic health record-based predictive model demonstrates improved performance for identifying pre-surgical patients who are at risk than previously-used assessments for POM triage.

Authors: Le, Sidney T; Corbin, Dalton; Myers, Laura C; Kipnis, Patricia; Cohn, Bradley; Liu, Vincent X

Ann Surg. 2023 Mar 01;277(3):e520-e527. Epub 2021-11-09.

PubMed abstract

Sex- and ethnic-specific patterns in the incidence of hip fracture among older US Asian and non-Hispanic White adults

Asian and Pacific Islander (Asian/PI) adults have lower hip fracture incidence than non-Hispanic White (NHW) adults, but data regarding Asian/PI subgroups are limited. We compared hip fracture incidence among older US Asian/PI and NHW populations, including ethnic subgroup differences. Using observational data from a California healthcare system, we identified Asian/PI and NHW adults aged ≥50 years (2000-2019) and followed subjects to 2021 for hip fracture determined by principal/primary hospital diagnosis or by secondary hospital diagnosis with hip/femur procedure codes. Age-adjusted hip fracture incidence was calculated with 95% confidence intervals (CIs). Log-Poisson regression was used to determine fracture incidence rate ratios (IRRs, [CI]; NHW or Chinese as reference) adjusting for age and year. Among 215,359 Asian/PI and 776,839 NHW women, hip fracture incidence was 1.34 (1.28-1.40) and 2.97 (2.94-3.01) per 1000 person-years, respectively, with IRR 0.45 (0.43-0.47). Among 188,328 Asian/PI and 697,046 NHW men, hip fracture incidence was 0.62 (0.58-0.67) and 1.81 (1.78-1.84) per 1000 person-years, respectively, with IRR 0.34 (0.32-0.37). For the four largest Asian/PI subgroups, Filipina women (IRR 0.85 [0.75-0.96]) had lower, and Japanese (IRR 1.36 [1.20-1.54]) and South Asian (IRR 1.36 [1.07-1.72]) women had higher hip fracture incidence compared to Chinese women. Hip fracture incidence was only higher among South Asian (IRR 1.61 [1.21-2.14]) compared to Chinese men. Hip fracture incidence among US Asian/PI adults was 55% (women) and 66% (men) lower than NHW adults, but incidence varied by Asian/PI subgroup. The heterogeneity among Asian/PI adults highlights the importance of examining fracture risk by ethnic subgroup.

Authors: Lo, Joan C; Chandra, Malini; Lee, David R; Darbinian, Jeanne A; Gordon, Nancy P; Zeltser, David W; Grimsrud, Christopher D; Lee, Catherine

J Am Geriatr Soc. 2023 Feb 15.

PubMed abstract

Risk of venous thromboembolism in non-respiratory and respiratory presentations of COVID-19 in critically ill patients

Authors: Roubinian, Nareg H; Vinson, David R; Pai, Ashok P; Myers, Laura C; Skarbinski, Jacek; Lee, Catherine; Mark, Dustin G; Liu, Vincent X

Chest. 2023 Feb 12.

PubMed abstract

Hospital Strain and Variation in Sepsis ICU Admission Practices and Associated Outcomes

To understand how strain-process-outcome relationships in patients with sepsis may vary among hospitals. Retrospective cohort study using a validated hospital capacity strain index as a within-hospital instrumental variable governing ICU versus ward admission, stratified by hospital. Twenty-seven U.S. hospitals from 2013 to 2018. High-acuity emergency department patients with sepsis who do not require life support therapies. None. The mean predicted probability of ICU admission across strain deciles ranged from 4.9% (lowest ICU-utilizing hospital for sepsis without life support) to 61.2% (highest ICU-utilizing hospital for sepsis without life support). The difference in the predicted probabilities of ICU admission between the lowest and highest strain deciles ranged from 9.0% (least strain-sensitive hospital) to 45.2% (most strain-sensitive hospital). In pooled analyses, emergency department patients with sepsis (n = 90,150) experienced a 1.3-day longer median hospital length of stay (LOS) if admitted initially to the ICU compared with the ward, but across the 27 study hospitals (n = 517-6,564), this effect varied from 9.0 days shorter (95% CI, -10.8 to -7.2; p < 0.001) to 19.0 days longer (95% CI, 16.7-21.3; p < 0.001). Corresponding ranges for inhospital mortality with ICU compared with ward admission revealed odds ratios (ORs) from 0.16 (95% CI, 0.03-0.99; p = 0.04) to 4.62 (95% CI, 1.16-18.22; p = 0.02) among patients with sepsis (pooled OR = 1.48). There is significant among-hospital variation in ICU admission rates for patients with sepsis not requiring life support therapies, how sensitive those ICU admission decisions are to hospital capacity strain, and the association of ICU admission with hospital LOS and hospital mortality. Hospital-level heterogeneity should be considered alongside patient-level heterogeneity in critical and acute care study design and interpretation.

Authors: Anesi, George L; Dress, Erich; Chowdhury, Marzana; Wang, Wei; Small, Dylan S; Delgado, M Kit; Bayes, Brian; Barreda, Fernando X; Halpern, Scott D; Liu, Vincent X

Crit Care Explor. 2023 Feb;5(2):e0858. Epub 2023-02-02.

PubMed abstract

Posttraumatic stress disorder symptom trajectories in a 16-month COVID-19 pandemic period

COVID-19 pandemic presents an unheralded opportunity to better understand trajectories of posttraumatic stress disorder (PTSD) symptoms across a prolonged period of social disruption and stress. We tracked PTSD symptoms among trauma-exposed individuals in the United States and sought to identify population-based variability in PTSD symptom trajectories and understand what, if any, early pandemic experiences predicted membership in one trajectory versus others. As part of a longitudinal study of U.S. residents during the pandemic, participants who reported at least one potentially traumatic experience in their lifetime (N = 1,206) at Wave 1 (April 2020) were included in the current study. PTSD symptoms were assessed using the PCL-5 at four time points extending to July 2021. Latent growth mixture modeling was used to identify heterogeneous symptom trajectories. Trajectory membership was regressed on experiences from the early stage of the pandemic as measured using the Epidemic-Pandemic Impacts Inventory in a model that controlled for variables with documented associations to PTSD trajectories, including age, sex, income, and trauma history. Four trajectories were identified, categorized as resilient (73.0%), recurring (13.3%), recovering (8.3%), and chronic (5.5%). Emotional and physical health problems and positive changes associated with the early phase of the pandemic were each significant predictors of trajectory membership over and above all other variables in the model. Predictors primarily differentiated the resilient trajectory from each of the other three trajectories. Distinct PTSD symptom trajectories during the COVID-19 pandemic suggest a need for targeted efforts to help individuals at most risk for ongoing distress.

Authors: López-Castro, Teresa; Papini, Santiago; Bauer, Alexandria; Swarbrick, Margaret; Paul, Lynn K; Nizzi, Marie-Christine; Stanley, Damian; Team, Covid-Dynamic; Hien, Denise

J Trauma Stress. 2023 Feb;36(1):180-192. Epub 2022-12-26.

PubMed abstract

Cross-Sectional Association of Patient Language and Patient-Provider Language Concordance with Video Telemedicine Use Among Patients with Limited English Proficiency

Telemedicine’s dramatic increase during the COVID-19 pandemic elevates the importance of addressing patient-care gaps in telemedicine, especially for patients with limited English proficiency. To examine the associations of patient language and patient-provider language concordance with telemedicine visit type (video versus telephone visit). Cross-sectional automated data study of patient-scheduled primary care telemedicine appointments from March 16, 2020, to October 31, 2020. Northern California integrated healthcare delivery system. All 22,427 completed primary care telemedicine visits scheduled by 13,764 patients with limited English proficiency via the patient portal. Cross-sectional association of electronic health record-documented patient language (Spanish as referent) and patient-provider language concordance with patients’ choice of a video (versus telephone) visit, accounting for patient sociodemographics, technology access, and technology familiarity factors. Of all patient-scheduled visits, 34.5% (n = 7747) were video visits. The top three patient languages were Spanish (42.4%), Cantonese (16.9%), and Mandarin (10.3%). Adjusting for sociodemographic and technology access and familiarity factors and compared to patients speaking Spanish, video visit use was higher among patients speaking Cantonese (OR = 1.34, 95% CI: 1.18-1.52), Mandarin (OR = 1.33, 95% CI: 1.16-1.52), or Vietnamese (OR = 1.27, 95% CI: 1.09-1.47), but lower among patients speaking Punjabi (OR = 0.75, 95% CI: 0.75, 0.62-0.91). Language concordance was associated with lower video visit use (OR = 0.86, 95% CI: 0.80-0.93) and moderated associations of speaking Spanish, Cantonese, and Korean with video visit use. In addition, for all language groups, those with prior video visit use were more likely to re-use video visits compared to those with no prior use (p < .05 for all languages except Hindi with p = 0.06). Among linguistically diverse patients with limited English proficiency, video telemedicine use differed by specific language. Disaggregating patient subpopulation data is necessary for identifying those at greatest risk of being negatively impacted by the digital divide.

Authors: Hsueh, Loretta; Huang, Jie; Millman, Andrea K; Gopalan, Anjali; Parikh, Rahul K; Teran, Silvia; Reed, Mary E

J Gen Intern Med. 2023 Feb;38(3):633-640. Epub 2022-11-10.

PubMed abstract

Risk of cardiac events after elective versus urgent or emergent noncardiac surgery: Implications for quality measurement and improvement

Patient populations differ for elective vs urgent and emergent surgery. The effect of this difference on surgical outcome is not well understood and may be important for improving surgical safety. Our primary hypothesis was that there is an association of surgical acuity with risk of postoperative cardiac events. Secondarily, we examined elective vs urgent and emergent patients separately to understand patient characteristics that are associated with postoperative cardiac events. We performed a retrospective cohort study of patients ≥65 years undergoing noncardiac elective or urgent/emergent surgery. Logistic regression estimated the association of surgical acuity with a postoperative cardiac event, which was defined as myocardial infarction or cardiac arrest within 30 days of surgery. For the secondary analysis, we modeled the outcome after stratifying by acuity. The study included 161,177 patients with 1014 cardiac events. The unadjusted risk of a postoperative cardiac event was 3.2 per 1000 among elective patients and 28.7 per 1000 among urgent and emergent patients (adjusted odds ratio 4.10, 95% confidence interval 3.56-4.72). After adjustment, increased age, higher baseline cardiac risk, peripheral vascular disease, hypertension, worse American Society of Anesthesiologist (ASA) physical classification, and longer operative time were associated with a postoperative cardiac event. Higher baseline cardiac risk was more strongly associated with postoperative cardiac events in elective patients. In contrast, worse ASA physical classification was more strongly associated with postoperative cardiac events in urgent and emergent patients. Black patients had higher odds of a postoperative cardiac event only in urgent and emergent patients compared to White patients. Quality measurement and improvement to address postoperative cardiac risk should consider patients based on surgical acuity.

Authors: Yap, Edward N; Dusendang, Jennifer R; Ng, Kevin P; Keny, Hemant V; Webb, Christopher A; Weyker, Paul D; Thoma, Mark S; Solomon, Matthew D; Herrinton, Lisa J

J Clin Anesth. 2023 Feb;84:110994. Epub 2022-11-07.

PubMed abstract

Clinical Assessment of Residents: A Survey of Clinician Educators Regarding Resident Assessment Burden and Modifiable Factors.

BACKGROUND: A fundamental role of the clinician educator is to provide thoughtful assessments for resident development. A gap in the literature exists about whether the completion of assessments contributes to clinician educator burden. n OBJECTIVE: We sought to understand the degree to which completing resident assessments contributes to clinician educator burden, the drivers behind such perception, and whether modifiable factors exist. n METHODS: In October 2020, we conducted a cross-sectional study of adult hospital medicine clinician educators to explore burden associated with resident assessment. The authors developed a 10-item electronic survey (Likert type and sliding scale responses), asking about demographics, context, frequency and degree of burden, burdensome aspects of assessments, estimated time for assessments, and percentage of assessments turned in late or never. We conducted subgroup analyses for differences in responses based on sex and number of years practicing, and regression analyses for predictors of burden degree. n RESULTS: Fifty of 81 (62%) surveyed faculty responded. Two percent (1 of 50) reported no burden, while 42% (21 of 50) reported infrequent (“never,” “rarely,” “sometimes”) and 56% (28 of 50) reported frequent (“often,” “always”) burden. Of those experiencing burden, 67% (33 of 49) reported slight or moderate, and 33% (16 of 49) reported significant or extreme burden. Potentially modifiable causes included assessment request boluses, lag time between resident service and assessment requests, and technology involved. Female clinician educators estimated submitting a higher percentage of late assessments than males (65% vs 41%, n CONCLUSIONS: Our findings suggest that resident assessments are a source of burden among adult hospital medicine clinician educators and that several potentially modifiable factors may underlie this burden.

Authors: Tierney, Aaron A;Rosner, Benjamin I

J Grad Med Educ. 2023 Feb;15(1):92-97. doi: 10.4300/JGME-D-22-00188.1..

PubMed abstract

COVID-19 bacteremic co-infection is a major risk factor for mortality, ICU admission, and mechanical ventilation

Recent single-center reports have suggested that community-acquired bacteremic co-infection in the context of Coronavirus disease 2019 (COVID-19) may be an important driver of mortality; however, these reports have not been validated with a multicenter, demographically diverse, cohort study with data spanning the pandemic. In this multicenter, retrospective cohort study, inpatient encounters were assessed for COVID-19 with community-acquired bacteremic co-infection using 48-h post-admission blood cultures and grouped by: (1) confirmed co-infection [recovery of bacterial pathogen], (2) suspected co-infection [negative culture with ≥ 2 antimicrobials administered], and (3) no evidence of co-infection [no culture]. The primary outcomes were in-hospital mortality, ICU admission, and mechanical ventilation. COVID-19 bacterial co-infection risk factors and impact on primary outcomes were determined using multivariate logistic regressions and expressed as adjusted odds ratios with 95% confidence intervals (Cohort, OR 95% CI, Wald test p value). The studied cohorts included 13,781 COVID-19 inpatient encounters from 2020 to 2022 in the University of Alabama at Birmingham (UAB, n = 4075) and Ochsner Louisiana State University Health-Shreveport (OLHS, n = 9706) cohorts with confirmed (2.5%), suspected (46%), or no community-acquired bacterial co-infection (51.5%) and a comparison cohort consisting of 99,170 inpatient encounters from 2010 to 2019 (UAB pre-COVID-19 pandemic cohort). Significantly increased likelihood of COVID-19 bacterial co-infection was observed in patients with elevated ≥ 15 neutrophil-to-lymphocyte ratio (UAB: 1.95 [1.21-3.07]; OLHS: 3.65 [2.66-5.05], p < 0.001 for both) within 48-h of hospital admission. Bacterial co-infection was found to confer the greatest increased risk for in-hospital mortality (UAB: 3.07 [2.42-5.46]; OLHS: 4.05 [2.29-6.97], p < 0.001 for both), ICU admission (UAB: 4.47 [2.87-7.09], OLHS: 2.65 [2.00-3.48], p < 0.001 for both), and mechanical ventilation (UAB: 3.84 [2.21-6.12]; OLHS: 2.75 [1.87-3.92], p < 0.001 for both) across both cohorts, as compared to other risk factors for severe disease. Observed mortality in COVID-19 bacterial co-infection (24%) dramatically exceeds the mortality rate associated with community-acquired bacteremia in pre-COVID-19 pandemic inpatients (5.9%) and was consistent across alpha, delta, and omicron SARS-CoV-2 variants. Elevated neutrophil-to-lymphocyte ratio is a prognostic indicator of COVID-19 bacterial co-infection within 48-h of admission. Community-acquired bacterial co-infection, as defined by blood culture-positive results, confers greater increased risk of in-hospital mortality, ICU admission, and mechanical ventilation than previously described risk factors (advanced age, select comorbidities, male sex) for COVID-19 mortality, and is independent of SARS-CoV-2 variant.

Authors: Patton, Michael John; Liu, Vincent X; Gaggar, Amit; et al.

Crit Care. 2023 Jan 23;27(1):34. Epub 2023-01-23.

PubMed abstract

Associations between alcohol brief intervention in primary care and drinking and health outcomes in adults with hypertension and type 2 diabetes: a population-based observational study

To evaluate associations between alcohol brief intervention (BI) in primary care and 12-month drinking outcomes and 18-month health outcomes among adults with hypertension and type 2 diabetes (T2D). A population-based observational study using electronic health records data. An integrated healthcare system that implemented system-wide alcohol screening, BI and referral to treatment in adult primary care. Adult primary care patients with hypertension (N=72 979) or T2D (N=19 642) who screened positive for unhealthy alcohol use between 2014 and 2017. We examined four drinking outcomes: changes in heavy drinking days/past 3 months, drinking days/week, drinks/drinking day and drinks/week from baseline to 12-month follow-up, based on results of alcohol screens conducted in routine care. Health outcome measures were changes in measured systolic and diastolic blood pressure (BP) and BP reduction ≥3 mm Hg at 18-month follow-up. For patients with T2D, we also examined change in glycohaemoglobin (HbA1c) level and ‘controlled HbA1c’ (HbA1c<8%) at 18-month follow-up. For patients with hypertension, those who received BI had a modest but significant additional -0.06 reduction in drinks/drinking day (95% CI -0.11 to -0.01) and additional -0.30 reduction in drinks/week (95% CI -0.59 to -0.01) at 12 months, compared with those who did not. Patients with hypertension who received BI also had higher odds for having clinically meaningful reduction of diastolic BP at 18 months (OR 1.05, 95% CI 1.00 to 1.09). Among patients with T2D, no significant associations were found between BI and drinking or health outcomes examined. Alcohol BI holds promise for reducing drinking and helping to improve health outcomes among patients with hypertension who screened positive for unhealthy drinking. However, similar associations were not observed among patients with T2D. More research is needed to understand the heterogeneity across diverse subpopulations and to study BI's long-term public health impact.

Authors: Chi, Felicia W; Weisner, Constance M; Satre, Derek D; Grant, Richard W; Metz, Verena E; Sterling, Stacy A; et al.

BMJ Open. 2023 Jan 19;13(1):e064088. Epub 2023-01-19.

PubMed abstract

The Safety of Inpatient Health Care

Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted. We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events. In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%). Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).

Authors: Bates, David W; Myers, Laura C; Mort, Elizabeth; et al.

N Engl J Med. 2023 Jan 12;388(2):142-153.

PubMed abstract

Risk of posthospital venous thromboembolism in patients with COVID-19 varies by SARS-CoV-2 period and vaccination status

Authors: Roubinian, Nareg H; Vinson, David R; Knudson-Fitzpatrick, Tess Wheeler; Mark, Dustin G; Skarbinski, Jacek; Lee, Catherine; Liu, Vincent X; Pai, Ashok P

Blood Adv. 2023 Jan 10;7(1):141-144.

PubMed abstract

Cigarette Smoking and Risk of SARS-CoV-2 infection and Disease Severity Among Adults in an Integrated Health Care System in California

The relationship between tobacco smoking status and SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) severity is highly debated. We conducted a retrospective cohort study of?>2.4 million adults in a large healthcare system to evaluate whether smoking is associated with SARS-CoV-2 infection and disease severity. This retrospective cohort study of 2,427,293 adults in KPNC from March 5, 2020 (baseline) to December 31, 2020 (pre-vaccine) included smoking status (current, former, never), socio-demographics, and comorbidities from the electronic health record. SARS-CoV-2 infection (identified by a positive PCR test) and COVID-19 severity (hospitalization, ICU admission or death???30 days of COVID-19 diagnosis) were estimated in time-to-event analyses using Cox proportional hazard regression models adjusting for covariates. Secondary analyses examined COVID-19 severity among patients with COVID-19 using logistic regression. During the study, 44,270 patients had SARS-CoV-2 infection. Current smoking was associated with lower adjusted rates of SARS-CoV-2 infection (aHR?=?0.64 95% CI: 0.61-0.67), COVID-19-related hospitalization (aHR?=?0.48 95% CI: 0.40-0.58), ICU admission (aHR?=?0.62 95% CI: 0.42-0.87), and death (aHR?=?0.52 95% CI: 0.27-0.89) than never-smoking. Former smoking was associated with a lower adjusted rate of SARS-CoV-2 infection (aHR?=?0.96 95% CI: 0.94-0.99) and higher adjusted rates of hospitalization (aHR?=?1.10 95% CI: 1.03-1.08) and death (aHR?=?1.32 95% CI: 1.11-1.56) than never-smoking. Logistic regression analyses among patients with COVID-19 found lower odds of hospitalization for current versus never-smoking and higher odds of hospitalization and death for former versus never-smoking. In the largest US study to date on smoking and COVID-19, current and former smoking showed lower risk of SARS-CoV-2 infection than never-smoking, while a history of smoking was associated with higher risk of severe COVID-19. In this cohort study of 2.4 million adults, adjusting for socio-demographics and medical comorbidities, current tobacco smoking was associated with a lower risk of both SARS-CoV-2 infection and severe COVID-19 illness compared to never-smoking. A history of smoking was associated with a slightly lower risk of SARS-CoV-2 infection and a modestly higher risk of severe COVID-19 illness compared to never-smoking. The lower observed COVID-19 risk for current versus never-smoking deserves further investigation. Results support prioritizing individuals with smoking-related comorbidities for vaccine outreach and treatments as they become available.

Authors: Young-Wolff, Kelly C; Slama, Natalie; Alexeeff, Stacey E; Sakoda, Lori C; Fogelberg, Renee; Myers, Laura C; Campbell, Cynthia I; Adams, Alyce S; Prochaska, Judith J

Nicotine Tob Res. 2023 Jan 05;25(2):211-220.

PubMed abstract

Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated “Hub-and-Spoke” Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation?

Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization. This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a “hub-and-spoke” model of neuroscience care in which two centers service as neuroscience “hubs” and the remaining 19 centers service as referral “spokes.” Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less]. A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44). Within an integrated “hub-and-spoke” neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a “hub-and-spoke” care model for patients with nontraumatic ICH, although additional investigations are warranted.

Authors: Mark, Dustin G; Huang, Jie; Sonne, D Chris; Rauchwerger, Adina S; Reed, Mary E; Kaiser Permanente CREST Network Investigators,

Neurocrit Care. 2023 Jan 04.

PubMed abstract

Trends in Outpatient Visits and Hospital and Intensive Care Unit Admissions of Adults With COVID-19 in an Integrated US Health Care System, March 2020 to January 2022

This cohort study of patients at a single integrated health system examines trends in COVID-19–related treatment location and mortality.

Authors: Myers, Laura C; Ng, Kevin; Plimier, Colleen; Daly, Kathleen A; Kipnis, Patricia; Liu, Vincent X

JAMA Netw Open. 2023 Jan 03;6(1):e2253269. Epub 2023-01-03.

PubMed abstract

Primary care video and telephone telemedicine during the COVID-19 pandemic: treatment and follow-up health care utilization

Telemedicine use expanded greatly during the COVID-19 pandemic, and broad use of telemedicine is expected to persist beyond the pandemic. More evidence on the efficiency and safety of different telemedicine modalities is needed to inform clinical and policy decisions around telemedicine use. To evaluate the efficiency and safety of telemedicine, we compared treatment and follow-up care between video and telephone visits during the COVID-19 pandemic. Observational study of patient-scheduled telemedicine visits for primary care. We used multivariate logistic regression to compare treatment (medication prescribing, laboratory/imaging orders) and 7-day follow-up care (in-person office visits, emergency department visits, and hospitalizations) between video and telephone visits, adjusted for patient characteristics. Among 734,442 telemedicine visits, 58.4% were telephone visits. Adjusted rates of medication prescribing and laboratory/imaging orders were higher in video visits than telephone visits, with differences of 3.5% (95% CI, 3.3%-3.8%) and 3.9% (95% CI, 3.6%-4.1%), respectively. Adjusted rates of 7-day follow-up in-person office visits, emergency department visits, and hospitalizations were lower after video than telephone visits, with differences of 0.7% (95% CI, 0.5%-0.9%), 0.3% (95% CI, 0.2%-0.3%), and 0.04% (95% CI, 0.02%-0.06%), respectively. Among telemedicine visits with primary care clinicians, return visits were not common and downstream emergency events were rare. Adjusted rates of treatment measures were higher and adjusted rates of follow-up care were lower for video visits than telephone visits. Although video visits were marginally more efficient than telephone visits, telephone visits may offer an accessible option to address patient primary care needs without raising safety concerns.

Authors: Huang, Jie; Gopalan, Anjali; Muelly, Emilie; Hsueh, Loretta; Millman, Andrea; Graetz, Ilana; Reed, Mary

Am J Manag Care. 2023 Jan 01;29(1):e13-e17. Epub 2023-01-01.

PubMed abstract

Risk of hospitalization in a sample of COVID-19 patients with and without chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) may have worse coronavirus disease-2019 (COVID-19)-related outcomes. We compared COVID-19 hospitalization risk in patients with and without COPD. This retrospective cohort study included patients ≥40 years, SARS-CoV-2 positive, and with Kaiser Permanente Northern California membership ≥1 year before COVID-19 diagnosis (electronic health records and claims data). COVID-19-related hospitalization risk was assessed by sequentially adjusted logistic regression models and stratified by disease severity. Secondary outcome was death/hospice referral after COVID-19. Of 19,558 COVID-19 patients, 697 (3.6%) had COPD. Compared with patients without COPD, COPD patients were older (median age: 69 vs 53 years); had higher Elixhauser Comorbidity Index (5 vs 0) and more median baseline outpatient (8 vs 4), emergency department (2 vs 1), and inpatient (2 vs 1) encounters. Unadjusted analyses showed increased odds of hospitalization with COPD (odds ratio [OR]: 3.93; 95% confidence interval [CI]: 3.40-4.60). After full risk adjustment, there were no differences in odds of hospitalization (OR: 1.14, 95% CI: 0.93-1.40) or death/hospice referral (OR: 0.96, 95% CI: 0.72-1.27) between patients with and without COPD. Primary/secondary outcomes did not differ by COPD severity, except for higher odds of hospitalization in COPD patients requiring supplemental oxygen versus those without COPD (OR: 1.84, 95% CI: 1.02-3.33). Except for hospitalization among patients using supplemental oxygen, no differences in odds of hospitalization or death/hospice referral were observed in the COVID-19 patient sample depending on whether they had COPD.

Authors: Myers, Laura C; Murray, Richard; Donato, Bonnie; Liu, Vincent X; Kipnis, Patricia; Shaikh, Asif; Franchino-Elder, Jessica

Respir Med. 2023 Jan;206:107064. Epub 2022-11-26.

PubMed abstract

The intensity of anticoagulant dosing in hospitalized patients with COVID-19: An observational, comparative effectiveness study

The question of anticoagulant dosing in hospitalized patients with coronavirus disease-2019 (COVID-19) is unresolved, with randomized trials showing mixed results and heterogeneity of treatment effects for in-hospital death. To examine the association between the intensity of anticoagulation and clinical outcomes in hospitalized patients with COVID-19. Retrospective cohort study of patients with COVID-19 and respiratory impairment who were hospitalized between 3/1/2020-12/31/2020 in two Kaiser Permanente regions. We fit propensity score models using categorical regression to estimate the probability of receiving standard prophylactic, intermediate, or full-dose anticoagulation beginning on the day of admission or on the day of first respiratory deterioration. Exposure was defined by the highest dose on the day of admission or within 24?hours after deterioration. The primary outcome was in-hospital death. We included 17,130 patients in the day of admission analysis and 4,924 patients who experienced respiratory deterioration. There were no differences in propensity score-adjusted odds of in-hospital death for patients who received either intermediate (odds ratio [OR]: 1.00, 95% confidence intervals [CI] 0.89-1.12) or full anticoagulation (OR: 1.00, 95% CI: 0.85-1.17) compared with standard prophylaxis beginning on the day of admission. Similarly, there were no differences in in-hospital death for either intermediate (OR: 1.22, 95% CI: 0.82-1.82) or full anticoagulation (OR: 1.50, 95% CI: 0.90-2.51) compared with standard prophylaxis on the day of deterioration. Results of this real-world, comparative effectiveness study showed no differences in in-hospital death among newly admitted or deteriorating patients with COVID-19 who received intermediate-dose or full anticoagulation compared with standard prophylaxis.

Authors: Myers, Laura C; Xu, Stanley; Chen, Aiyu; Greene, John D; Creekmur, Beth; Bruxvoort, Katia; Escobar, Gabriel J; Adams, John L; Langer-Gould, Annette; Liu, Vincent X; Gould, Michael K

J Hosp Med. 2023 Jan;18(1):43-54. Epub 2022-11-22.

PubMed abstract

Anakinra or high-dose corticosteroids in COVID-19 pneumonia patients who deteriorate on low-dose dexamethasone: An observational study of comparative effectiveness

To assess whether escalating to high-dose corticosteroids or anakinra compared with continuing low-dose corticosteroids reduced mortality in patients with severe COVID-19 whose respiratory function deteriorated while receiving dexamethasone 6 mg daily. We conducted a retrospective cohort study between March 1 to December 31, 2020, of hospitalized patients with confirmed COVID-19 pneumonia. In-hospital death was analyzed using logistic regression with inverse probability of treatment weighting of receiving anakinra, high-dose corticosteroid (dexamethasone >10 mg daily), or remaining on low-dose corticosteroids on the day of first respiratory deterioration. We analyzed 6671 patients whose respiratory status deteriorated while receiving dexamethasone 6 mg daily for COVID-19 pneumonia, of whom 6265 stayed on low-dose corticosteroids, 232 were escalated to high-dose corticosteroids, and 174 to anakinra in addition to corticosteroids. The propensity score-adjusted odds of death were higher in the anakinra (odds ratio [OR] 1.76; 95% CI 1.13-2.72) and high-dose corticosteroid groups (OR 1.53; 95% CI 1.14-2.07) compared with those who continued low-dose corticosteroids on the day of respiratory deterioration. The odds of hospital-acquired infections were also higher in the anakinra (OR 2.00; 95% CI 1.28-3.11) and high-dose corticosteroid groups (OR 1.43; 95% CI 1.00-2.04) compared with low-dose corticosteroid group. Our findings do not support escalating patients with COVID-19 pneumonia who deteriorate on low-dose corticosteroids to high-dose corticosteroids or anakinra.

Authors: Langer-Gould, Annette; Xu, Stanley; Myers, Laura C; Chen, Aiyu; Greene, John D; Creekmur, Beth; Bruxvoort, Katia; Adams, John L; Liu, Vincent; Gould, Michael K

Int J Infect Dis. 2023 Jan;126:87-93. Epub 2022-11-18.

PubMed abstract

Association between anaemia and hospital readmissions in patients undergoing major surgery requiring postoperative intensive care

Anaemia is a common sequela of surgery, although its relationship with patient recovery is unclear. The goal of this investigation was to assess the associations between haemoglobin concentrations at the time of hospital discharge following major surgery and early post-hospitalisation outcomes, with a primary outcome of 30 day unanticipated hospital readmissions. This investigation includes data from two independent population-based observational cohorts of adult surgical patients (aged ≥ 18 years) requiring postoperative intensive care unit admission between 1 January 2010 and 31 December 2019 in hospitals in Olmsted County, Minnesota, and between 1 July 2010 and 30 June 2017 in the Kaiser Permanente Northern California integrated healthcare system, California. Cox proportional hazards models assessed the associations between discharge haemoglobin concentrations (per 10 g.l-1 ) and outcomes, with prespecified multivariable adjustment. A total of 3260 patients were included from Olmsted County hospitals and 29,452 from Kaiser Permanente Northern California. In adjusted analyses, each 10 g.l-1 decrease in haemoglobin at hospital discharge was associated with a 9% (hazard ratio 1.09, 95%CI 1.02-1.18; p = 0.014) and 8% increase (hazard ratio 1.08, 95%CI 1.06-1.11; p < 0.001) in the hazard for readmission within 30 days in Olmsted County and Kaiser Permanente Northern California, respectively. In a sensitivity analysis exploring relationships across varying levels of pre-operative anaemia severity, these associations remained consistent, with lower discharge haemoglobin concentrations associated with higher readmissions irrespective of pre-operative anaemia severity. Anaemia at hospital discharge in surgical patients requiring postoperative intensive care is associated with increased rates of hospital readmission in two large independent cohorts. Future studies are necessary to evaluate strategies to prevent and/or treat anaemia in these patients for the improvement of post-hospitalisation outcomes.

Authors: Warner, M A; Hanson, A C; Plimier, C; Lee, C; Liu, V X; Richards, T; Kor, D J; Roubinian, N H

Anaesthesia. 2023 Jan;78(1):45-54. Epub 2022-09-08.

PubMed abstract

Predicting Post-Sepsis Cardiovascular Events with Death as a Competing Risk

Authors: Myers, Laura C; Lee, Catherine; Go, Alan S; Liu, Vincent X; Walkey, Allan J; et al.

Ann Am Thorac Soc. 2023 Jan;20(1):145-148.

PubMed abstract

Fostering a High-Functioning Team in Cancer Care Using the 4R Oncology Model: Assessment in a Large Health System and a Blueprint for Other Institutions

Delivering cancer care by high-functioning multidisciplinary teams promises to address care fragmentation, which threatens care quality, affects patient outcomes, and strains the oncology workforce. We assessed whether the 4R Oncology model for team-based interdependent care delivery and patient self-management affected team functioning in a large community-based health system. 4R was deployed at four locations in breast and lung cancers and assessed along four characteristics of high-functioning teams: recognition as a team internally and externally; commitment to an explicit shared goal; enablement of interdependent work to achieve the goal; and engagement in regular reflection to adapt objectives and processes. We formed an internally and externally recognized team of 24 specialties committed to a shared goal of delivering multidisciplinary care at the optimal time and sequence from a patient-centric viewpoint. The team conducted 40 optimizations of interdependent care (22 for breast, seven for lung, and 11 for both cancers) at four points in the care continuum and established an ongoing teamwork adaptation process. Half of the optimizations entailed low effort, while 30% required high level of effort; 78% resulted in improved process efficiency. 4R facilitated development of a large high-functioning team and enabled 40 optimizations of interdependent care along the cancer care continuum in a feasible way. 4R may be an effective approach for fostering high-functioning teams, which could contribute to improving viability of the oncology workforce. Our intervention and taxonomy of results serve as a blueprint for other institutions motivated to strengthen teamwork to improve patient-centered care.

Authors: Liu, Raymond; Gordon, Nancy; Sakoda, Lori C; Trosman, Julia R; et al.

JCO Oncol Pract. 2023 Jan;19(1):e125-e137. Epub 2022-09-30.

PubMed abstract

Cardiovascular Disease Risk Factors Among Middle-Aged and Older Adult Vietnamese American Members of a Northern California Health Plan

There is increasing recognition that cardiovascular disease (CVD) risk factors vary by Asian subgroups. We examined CVD risk factor prevalence among Vietnamese adults in a northern California health plan. We used electronic health record data to examine smoking, overweight/obesity (body mass index ≥23.0 kg/m2), obesity (body mass index ≥27.5 kg/m2), prediabetes, diabetes, and hypertension among middle-aged (n = 12 757; aged 45-64 years) and older (n = 3418; aged 65-84 years) Vietnamese adults, including 37.8% whose preferred language was Vietnamese. Findings were compared with East Asian adults. Current smoking prevalence was 20.3% for middle-aged men, 7.0% for older men, and <1% for women in both age groups. Obesity prevalence was 12.0% for older men, 17.9% for middle-aged men, and 10% for women in both age groups. Among middle-aged men and women, 20.9% and 17.0% had hypertension and 13.5% and 8.5% had diabetes, respectively. Among older men and women, 64.0% and 60.0% had hypertension and 32.8% and 29.3% had diabetes, respectively. In both age groups, Vietnamese language preference was associated with higher risk of smoking (men only) and of diabetes and hypertension (women only). Compared with East Asian adults, Vietnamese adults had lower obesity prevalence but similar prevalence of diabetes, prediabetes, and hypertension. Vietnamese men were more likely and Vietnamese women less likely than East Asian adults to be current smokers. Study results suggest that more research on health conditions, lifestyle, and social factors among Vietnamese American adults is needed to develop culturally competent interventions to reduce CVD risk in this growing ethnic group.

Authors: Haysbert, Donna B; Lo, Joan C; Ramalingam, Nirmala D; Gordon, Nancy P

Public Health Rep. 2023 Jan-Feb;138(1):123-130. Epub 2022-02-20.

PubMed abstract

Incidence and Medical Hospitalization Rates of Patients With Pediatric Eating Disorders

Objective Eating disorders typically onset in preadolescence and adolescence and cause negative mental and physical health sequelae over the life span. This study examined the incidence and medical hospitalization rates of pediatric eating disorders in an integrated health system in the United States. Methods This retrospective cohort study examined 4883 Kaiser Permanente Northern California members 8-18 years of age with an eating disorder diagnosis from January 2015 to June 2019. Medical hospitalizations include admissions at any of the 13 Kaiser Permanente Northern California hospitals with a primary or secondary eating disorder diagnosis. Results Incidence rates ranged between 177 and 205 per 100,000 adolescents per year. More than half the adolescents were non-White: 10.8% Asian, 4.3% Black, 26.7% Hispanic/Latinx, 8.4% multiracial, 0.3% Native American/Alaskan Native, and 0.5% Native Hawaiian/Pacific Islander. Thirteen percent had a body mass index (BMI) below the 5th percentile, 61.8% had a BMI between the 5th and the 84th percentiles, 19.7% had a BMI above the 85th percentile, and 5.6% had an unknown BMI. During the 12-month follow-up period, 5.4% of adolescents had medical hospitalizations. Conclusions This study adds to the evidence that eating disorders affect children/adolescents across all weight/BMI ranges and racial/ethnic backgrounds. Future studies call for exploration on treatment strategies that tailor to the diverse populations.

Authors: Lau, Josephine S; Uong, Stephen P; Hartman, Lauren; Eaton, Abigail; Schmittdiel, Julie

Perm J. 2022 Dec 19;26(4):56-61. Epub 2022-11-18.

PubMed abstract

Team is brain: leveraging EHR audit log data for new insights into acute care processes

To determine whether novel measures of contextual factors from multi-site electronic health record (EHR) audit log data can explain variation in clinical process outcomes. We selected one widely-used process outcome: emergency department (ED)-based team time to deliver tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS). We evaluated Epic audit log data (that tracks EHR user-interactions) for 3052 AIS patients aged 18+ who received tPA after presenting to an ED at three Northern California health systems (Stanford Health Care, UCSF Health, and Kaiser Permanente Northern California). Our primary outcome was door-to-needle time (DNT) and we assessed bivariate and multivariate relationships with six audit log-derived measures of treatment team busyness and prior team experience. Prior team experience was consistently associated with shorter DNT; teams with greater prior experience specifically on AIS cases had shorter DNT (minutes) across all sites: (Site 1: -94.73, 95% CI: -129.53 to 59.92; Site 2: -80.93, 95% CI: -130.43 to 31.43; Site 3: -42.95, 95% CI: -62.73 to 23.17). Teams with greater prior experience across all types of cases also had shorter DNT at two sites: (Site 1: -6.96, 95% CI: -14.56 to 0.65; Site 2: -19.16, 95% CI: -36.15 to 2.16; Site 3: -11.07, 95% CI: -17.39 to 4.74). Team busyness was not consistently associated with DNT across study sites. EHR audit log data offers a novel, scalable approach to measure key contextual factors relevant to clinical process outcomes across multiple sites. Audit log-based measures of team experience were associated with better process outcomes for AIS care, suggesting opportunities to study underlying mechanisms and improve care through deliberate training, team-building, and scheduling to maximize team experience.

Authors: Rose, Christian; Thombley, Robert; Noshad, Morteza; Lu, Yun; Clancy, Heather A; Schlessinger, David; Li, Ron C; Liu, Vincent X; Chen, Jonathan H; Adler-Milstein, Julia

J Am Med Inform Assoc. 2022 Dec 13;30(1):8-15.

PubMed abstract

Persistent Steroid Exposure Before Coronavirus Disease 2019 Diagnosis and Risk of Hospitalization in Patients With Chronic Obstructive Pulmonary Disease

It is unclear whether persistent inhaled steroid exposure in chronic obstructive pulmonary disease (COPD) patients before coronavirus disease 2019 (COVID-19) is associated with hospitalization risk. To examine the association between persistent steroid exposure and COVID-19-related hospitalization risk in COPD. This retrospective cohort study used electronic health records from the Kaiser Permanente Northern California healthcare system (February 2, 2020, to September 30, 2020) for patients aged ≥40 years with COPD and a positive polymerase chain reaction test result for COVID-19. Primary exposure was persistent oral and/or inhaled steroid exposure defined as ≥6 months of prescriptions filled in the year before COVID-19 diagnosis. Multivariable logistic regression was performed for the primary outcome of COVID-19-related hospitalization or death/hospice referral. Steroid exposure in the month before COVID-19 diagnosis was a covariate. Of >4.3 million adults, 697 had COVID-19 and COPD, of whom 270 (38.7%) had COVID-19-related hospitalizations. Overall, 538 (77.2%) were neither exposed to steroids in the month before COVID-19 diagnosis nor persistently exposed; 53 (7.6%) exposed in the month before but not persistently; 23 (3.3%) exposed persistently but not in the month before; and 83 (11.9%) exposed both persistently and in the month before. Adjusting for all confounders including steroid use in the month before, the odds ratio for hospitalization was 0.77 (95% CI 0.41-1.46) for patients persistently exposed to steroids before COVID-19 diagnosis. No association was observed between persistent steroid exposure and the risk of COVID-19-related hospitalization in COPD patients.

Authors: Myers, Laura C; Murray, Richard K; Donato, Bonnie M K; Liu, Vincent X; Kipnis, Patricia; Kipnis, Patricia; Shaikh, Asif; Franchino-Elder, Jessica

Chronic Obstr Pulm Dis. 2022 Dec 05.

PubMed abstract

High-dose corticosteroids in patients hospitalized for COVID-19 pneumonia: an observational study of comparative effectiveness

To assess whether high- compared with low-dose corticosteroids started upon hospitalization reduce mortality in patients with severe COVID-19 pneumonia or in subgroups stratified by severity of respiratory impairment on admission. We conducted a retrospective cohort study of patients with confirmed SARS-CoV-2 infection who required oxygen supplementation upon hospitalization between March 1 and December 31, 2020. In-hospital death was analyzed using logistic regression with inverse probability of treatment weighting of receiving low- or high-dose corticosteroid (dexamethasone 6-10 mg daily or >10-20 mg daily or other corticosteroid equivalents). We analyzed 13,366 patients who received low-dose and 948 who received high-dose corticosteroids, of whom 31.3% and 40.4% had severe respiratory impairment (>15 l/min of oxygen or mechanical ventilation) upon admission, respectively. There were no differences in the propensity score-adjusted odds of death (odds ratio 1.17, 95% CI 0.72-1.90) or infections (odds ratio 0.70, 95% CI 0.44-1.11) for patients who received high-dose compared with low-dose corticosteroids, beginning on the day of admission. No significant differences in subgroups stratified by severity of respiratory impairment were found. Initiating high-dose compared with low-dose corticosteroids among newly hospitalized patients with COVID-19 pneumonia did not improve survival. However, benefit of high-dose corticosteroids in specific subgroups cannot be excluded.

Authors: Langer-Gould, Annette; Xu, Stanley; Myers, Laura C; Chen, Aiyu; Greene, John D; Creekmur, Beth; Bruxvoort, Katia; Adams, John L; Liu, Vincent; Gould, Michael K

Int J Infect Dis. 2022 Dec;125:184-191. Epub 2022-10-29.

PubMed abstract

Characterizing Equity of Intensive Care Unit Admissions for Sepsis and Acute Respiratory Failure

Rationale: Patients who identify as from racial or ethnic minority groups who have sepsis or acute respiratory failure (ARF) experience worse outcomes relative to nonminority patients, but processes of care accounting for disparities are not well-characterized. Objectives: Determine whether reductions in intensive care unit (ICU) admission during hospital-wide capacity strain occur preferentially among patients who identify with racial or ethnic minority groups. Methods: This retrospective cohort among 27 hospitals across the Philadelphia metropolitan area and Northern California between 2013 and 2018 included adult patients with sepsis and/or ARF who did not require life support at the time of hospital admission. An updated model of hospital-wide capacity strain was developed that permitted determination of relationships between patient race, ethnicity, ICU admission, and strain. Results: After adjustment for demographics, disease severity, and study hospital, patients who identified as Asian or Pacific Islander had the highest adjusted ICU admission odds relative to patients who identified as White in both the sepsis and ARF populations (odds ratio, 1.09; P = 0.006 and 1.26; P < 0.001). ICU admission was also elevated for patients with ARF who identified as Hispanic (odds ratio, 1.11; P = 0.020). Capacity strain did not modify differences in ICU admission for patients who identified with a minority group in either disease population (all interactions, P > 0.05). Conclusions: Systematic differences in ICU admission patterns were observed for patients that identified as Asian, Pacific Islander, and Hispanic. However, ICU admission was not restricted from these groups, and capacity strain did not preferentially reduce ICU admission from patients identifying with minority groups. Further characterization of provider decision-making can help contextualize these findings as the result of disparate decision-making or a mechanism of equitable care.

Authors: Chesley, Christopher F; Anesi, George L; Chowdhury, Marzana; Schaubel, Doug; Liu, Vincent X; Lane-Fall, Meghan B; Halpern, Scott D

Ann Am Thorac Soc. 2022 Dec;19(12):2044-2052.

PubMed abstract

Association Between Vaccination Against COVID-19 and Postmenopausal Bleeding

Authors: Suh-Burgmann, Elizabeth J; Tierney, Cassidy; Hung, Yun-Yi; Schmittdiel, Julie A

Am J Obstet Gynecol. 2022 Dec;227(6):907-908. Epub 2022-07-12.

PubMed abstract

Bariatric Surgery and Risk of Death in Persons with Chronic Kidney Disease

A retrospective cohort study investigated the association between having surgery and risk of mortality for up to 5 years and if this association was modified by incident ESRD during the follow-up period. Summary of Background Data: Mortality risk in individuals with pre-dialysis CKD is high and few effective treatment options are available. Whether bariatric surgery can improve survival in people with CKD is unclear. Patients with class II and III obesity and pre-dialysis CKD stages 3-5 who underwent bariatric surgery between January 1, 2006 and September 30, 2015 (n = 802) were matched to patients who did not have surgery (n = 4933). Mortality was obtained from state death records and ESRD was identified through state-based or healthcare system-based registries. Cox regression models were used to investigate the association between bariatric surgery and risk of mortality and if this was moderated by incident ESRD during the follow-up period. Patients were primarily women (79%), non-Hispanic White (72%), under 65 years old (64%), who had a body mass index > 40kg/m 2 (59%), diabetes (67%), and hypertension (89%). After adjusting for incident ESRD, bariatric surgery was associated with a 79% lower 5-year risk of mortality compared to matched controls (hazard ratio = 0.21; 95% confidence interval: 0.14-0.32; P < 0.001). Incident ESRD did not moderate the observed association between surgery and mortality (hazard ratio = 1.59; 95% confidence interval: 0.31-8.23; P =0.58). Bariatric surgery is associated with a reduction in mortality in pre-dialysis patients regardless of developing ESRD. These findings are significant because patients with CKD are at relatively high risk for death with few efficacious interventions available to improve survival.

Authors: Coleman, Karen J; Fisher, David; Friedman, Allon N; et al.

Ann Surg. 2022 Dec 01;276(6):e784-e791. Epub 2021-03-01.

PubMed abstract

Telemedicine implementation and use in community health centers during COVID-19: Clinic personnel and patient perspectives.

In March 2020, federal and state telehealth policy changes catalyzed telemedicine adoption and use in community health centers. There is a dearth of evidence on telemedicine implementation and use in these safety net settings and a lack of information reflecting the perspectives of patients with limited English proficiency. We conducted in-depth interviews with clinic personnel and patients during the pandemic in two federally qualified health centers that primarily serve Chinese and Latino immigrants. Twenty-four interviews (clinic personnel ​= ​15; patients who primarily speak a language other than English ​= ​9) were completed remotely between December 2020 and April 2021. Interview scripts included questions about their telemedicine experiences, technology, resources and needs, barriers, facilitators, language access, and continued use, with a brief socio-demographic survey. Data analyses involved a primarily deductive approach and thematic analysis of transcript content. Both FQHCs adopted telemedicine in a few weeks and transitioned primarily to video and audio-only visits within two months. Findings reveal third-party language interpretation services were challenging to integrate into telemedicine video visits. Bilingual personnel who provided language concordant care were seen as essential for efficient and high-quality patient telemedicine experiences. Audio-only visits were of particular benefit to reach patients of older age, with limited English proficiency, and with limited digital literacy. Continued use of telemedicine is contingent on reimbursement policy decisions and interventions to increase patient digital literacy and technological resources. Results highlight the importance of reimbursing audio-only visits post-pandemic and investing in efforts to improve the quality of language services in telemedicine encounters.

Authors: Payán, Denise D;Frehn, Jennifer L;Garcia, Lorena;Tierney, Aaron A;Rodriguez, Hector P

SSM Qual Res Health. 2022 Dec;2:100054. doi: 10.1016/j.ssmqr.2022.100054. Epub 2022 Feb 10.

PubMed abstract

The association between video or telephone telemedicine visit type and orders in primary care

Telemedicine is increasingly relied upon for care delivery in primary care, but the impact of visit type on clinical ordering behavior is uncertain. Within Kaiser Permanente Northern California, we identified patients who self-scheduled and completed telemedicine encounters with their personal primary care provider or another available primary care provider in the same medical group, between April 1st, 2020, and October 31st, 2020, while physical distancing restrictions for COVID-19 were in place. We collected patient sociodemographic and clinical characteristics, measures of technology access, and categorized the most common primary encounter diagnoses. We measured proportions of patient-scheduled video versus telephone visits for each of eight diagnosis groups (Skin & Soft Tissue, Musculoskeletal Pain, Back Pain, General Gastrointestinal, Hypertension & Diabetes, Mental Health, Upper Respiratory, and Abdominal Pain), and compared physician orders for medications, antibiotics, lab and imaging studies by visit type within each diagnosis group. There were 273,301 included encounters, with 86,676 (41.5%) video visits and 122,051 (58.5%) telephone visits. Of the diagnosis groups, Skin & Soft Tissue conditions had the highest proportion of video visits (59.7%), while Mental Health conditions had the highest proportion of telephone visits (71.1%). After adjusting for covariates, the overall rates of medication orders (46.6% vs. 44.5%), imaging orders (17.3% vs. 14.9%), lab orders (19.5% vs. 17.2%), and antibiotic orders (7.5% vs. 5.2%) were higher during video visits as compared to telephone visits (p < 0.05). The largest difference within diagnosis groups was for Skin & Soft Tissue conditions, where the rate of medication orders was 9.1% higher than during video visits than telephone visits (45.5% vs. 36.5%, p < 0.05). We observed statistically significant differences in clinician orders by visit type during telemedicine encounters for common primary care conditions. Our findings suggest that, for certain conditions, visual information conveyed during video visits may promote clinical work-up and treatment.

Authors: Juergens, Nathan; Huang, Jie; Gopalan, Anjali; Muelly, Emilie; Reed, Mary

BMC Med Inform Decis Mak. 2022 Nov 19;22(1):302. Epub 2022-11-19.

PubMed abstract

Prevalence of sleep-related problems and risks in a community-dwelling older adult population: a cross-sectional survey-based study

Despite evidence of adverse health consequences of inadequate restorative sleep for older adults, assessment of sleep quantity, quality, and use of sleep aids is not routinely done. We aimed to characterize sleep problems, sleep risks, and advice received about sleep in a community-dwelling older adult population, overall and in subgroups with health conditions and functional difficulties. This cross-sectional study used weighted self-report data for 5074 Kaiser Permanente Northern California members aged 65-79y who responded to a 2017 or 2020 Member Health Survey. We estimated usual amount of sleep (< 6, 6 to < 7, ≥7 hours) and prevalence of sleep problems (frequent insomnia, frequent daytime fatigue, poor quality sleep, and potential sleep apnea (OSA) symptoms (frequent very loud snoring, apnea episodes)) for older adults overall, by self-rated health, and in subgroups reporting hypertension, diabetes, heart disease, frequent problems with balance/walking, and frequent memory problems. We also estimated percentages who regularly used sleep aids and had discussed sleep adequacy with a healthcare professional in the past year. Approximately 30% of older adults usually got less than the recommended ≥7 hours sleep per day, and 9% experienced frequent daytime fatigue, 13% frequent insomnia, 18% frequent insomnia/poor quality sleep, and 8% potential OSA symptoms. Prevalence of frequent insomnia was higher among women than men (16% vs. 11%). Higher percentages of those in fair/poor health and those with frequent balance/walking and memory problems reported sleeping < 6 hours per day and having all four types of sleep problems. Nearly 20% of all older adults (22% of women vs. 17% of men) and 45% of those with frequent insomnia (no sex difference) reported regular sleep aid use. Only 10% of older adults reported discussing sleep with a healthcare professional whereas > 20% reported discussing diet and exercise. Large percentages of older adults experience sleep problems or get less sleep than recommended for optimal sleep health. Older patients should routinely be assessed on multiple components of sleep health (sleep hygiene, quantity, quality, problems, and sleep aid use) and educated about sleep hygiene and the importance of getting adequate restorative sleep for their overall health and wellbeing.

Authors: Gordon, Nancy P; Yao, Jimmy H; Brickner, Leslea A; Lo, Joan C

BMC Public Health. 2022 Nov 08;22(1):2045. Epub 2022-11-08.

PubMed abstract

Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease

For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown. To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis. Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018. One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure. The primary outcome was 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model. Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6% [95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4% [95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5% [95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P<.001 for interaction). Among Medicare beneficiaries with end-stage kidney disease, longer intervals between hemodialysis and surgery were significantly associated with higher risk of postoperative mortality, mainly among those who did not receive hemodialysis on the day of surgery. However, the magnitude of the absolute risk differences was small, and the findings are susceptible to residual confounding.

Authors: Fielding-Singh, Vikram; Vanneman, Matthew W; Grogan, Tristan; Neelankavil, Jacques P; Winkelmayer, Wolfgang C; Chang, Tara I; Liu, Vincent X; Lin, Eugene

JAMA. 2022 Nov 08;328(18):1837-1848.

PubMed abstract

Trends and Risk Factors for Venous Thromboembolism Among Hospitalized Medical Patients

While hospital-associated venous thromboembolism (HA-VTE) is a known complication of hospitalization, contemporary incidence and outcomes data are scarce and methodologically contested. To define and validate an automated electronic health record (EHR)-based algorithm for retrospective detection of HA-VTE and examine contemporary HA-VTE incidence, previously reported risk factors, and outcomes. This cohort study was conducted using hospital admissions between January 1, 2013, and June 30, 2021, with follow-up until December 31, 2021. All medical (non-intensive care unit) admissions at an integrated health care delivery system with 21 hospitals in Northern California during the study period were included. Data were analyzed from January to June 2022. Previously reported risk factors associated with HA-VTE and administration of pharmacological prophylaxis were evaluated as factors associated with HA-VTE. Yearly incidence rates and timing of HA-VTE events overall and by subtype (deep vein thrombosis, pulmonary embolism, both, or unknown), as well as readmissions and mortality rates. Among 1 112 014 hospitalizations involving 529 492 patients (268 797 [50.8%] women; 75 238 Asian [14.2%], 52 697 Black [10.0%], 79 398 Hispanic [15.0%], and 307 439 non-Hispanic White [58.1%]; median [IQR] age, 67.0 [54.0-79.0] years), there were 13 843 HA-VTE events (1.2% of admissions) occurring in 10 410 patients (2.0%). HA-VTE events increased from 307 of 29 095 hospitalizations (1.1%) in the first quarter of 2013 to 551 of 33 729 hospitalizations (1.6%) in the first quarter of 2021. Among all HA-VTE events, 10 746 events (77.6%) were first noted after discharge. In multivariable analyses, several factors were associated with increased odds of HA-VTE, including active cancer (adjusted odds ratio [aOR], 1.96; 95% CI, 1.85-2.08), prior VTE (aOR, 1.71; 95% CI, 1.63-1.79), and reduced mobility (aOR, 1.63; 95% CI, 1.50-1.77). Factors associated with decreased likelihood of HA-VTE included Asian race (vs non-Hispanic White: aOR, 0.65; 95% CI, 0.61-0.69), current admission for suspected stroke (aOR, 0.73; 95% CI, 0.65-0.81), and Hispanic ethnicity (vs non-Hispanic White: aOR, 0.81; 95% CI, 0.77-0.86). HA-VTE events were associated with increased risk of readmission (hazard ratio [HR], 3.33; 95% CI, 3.25-3.41) and mortality (HR, 1.63; 95% CI, 1.57-1.70). This study found that HA-VTE events occurred in 1.2% of medical admissions, increased over time, and were associated with increased adverse outcomes. These findings suggest that approaches designed to mitigate occurrence and outcomes associated with HA-VTE may remain needed.

Authors: Neeman, Elad; Liu, Vincent; Mishra, Pranita; Thai, Khanh K; Xu, James; Clancy, Heather A; Schlessinger, David; Liu, Raymond

JAMA Netw Open. 2022 Nov 01;5(11):e2240373. Epub 2022-11-01.

PubMed abstract

Use of Cannabidiol (CBD) oil in the treatment of PTSD: Study design and rationale for a placebo-controlled randomized clinical trial

The burden of illness for PTSD is staggering and confers significant interference in work, social functioning, as well as increased risk for other physical and mental health problems. Recently, there’s been considerable attention paid to the potential therapeutic use of cannabidiol (CBD) products in the treatment of a variety of physical and mental health problems. The endocannabinoid system (ECS) is a logical therapeutic target for combating PTSD and other fear-based disorders given that cannabinoid receptors and other molecular mediators crucial for ECS signaling are richly expressed in a variety of brain regions that govern the regulation of learned fear and defensive behavior. This is an 8-week single-site Phase II randomized double-blind placebo-controlled fixed dose clinical trial. Participants recruited throughout the United States (N = 150) meeting DSM-5 criteria for posttraumatic stress disorder are randomly assigned to one of three treatment arms: (a) 300 mg CBD Isolate; (b) 300 mg CBD Broad Spectrum; and (c) Placebo oil. The primary outcome is PTSD symptom severity as indexed by the PTSD Checklist for DSM-5 (PCL-5) assessed at post treatment (Week 9) and follow-up (Week 13). Secondary outcomes including patient-rated depression, overall disability, anxiety, quality of life, and alcohol use are assessed weekly throughout the trial. Safety and CBD adherence are assessed daily throughout the trial. This is the first placebo-controlled clinical trial investigating (a) CBD for the treatment of PTSD; and (b) the first study to test the relative efficacy of CBD Isolate vs CBD Broad Spectrum. Trial registration registered (12/12/2019), trial identifier NCT04197102. issued 08/04/2022, protocol amendment number #2019-05-0123.

Authors: Telch, Michael J; Fischer, Caitlin M; Zaizar, Eric D; Rubin, Mikael; Papini, Santiago

Contemp Clin Trials. 2022 Nov;122:106933. Epub 2022-09-22.

PubMed abstract

Quantifying Frailty Requires a Conceptual Model Before a Statistical Model-Reply

Authors: Le, Sidney T; Liu, Vincent X; Cespedes Feliciano, Elizabeth M

JAMA Surg. 2022 Nov 01;157(11):1065-1066.

PubMed abstract

Covid-19 Vaccination and the Timing of Surgery Following Covid-19 Infection

To evaluate whether COVID-19 vaccination status or mode of anesthesia modified the temporal harms associated with surgery following coronavirus disease-2019 (COVID-19) infection. Surgery shortly after COVID-19 infection is associated with higher rates of complications, leading to recommendations to delay surgery following COVID-19 infection when possible. However, prior studies were based on populations with low or no prevalence of vaccination. A retrospective cohort study of patients who underwent scheduled surgery in a health system from January 1, 2018 to February 28, 2022 (N=228,913) was performed. Patients were grouped by time of surgery relative to COVID-19 test positivity: 0 to 4 weeks after COVID-19 (“early post-COVID-19”), 4 to 8 weeks after COVID-19 (“mid post-COVID-19”), >8 weeks after COVID-19 (“late post-COVID-19”), surgery at least 30 days before subsequent COVID-19 (“pre-COVID-19”), and surgery with no prior or subsequent test positivity for COVID-19. Among patients who were not fully vaccinated at the time of COVID-19 infection, the adjusted rate of perioperative complications for the early post-COVID-19 group was significantly higher than for the pre-COVID-19 group (relative risk: 1.55; P =0.05). No significantly higher risk was identified between these groups for patients who were fully vaccinated (0.66; P =1.00), or for patients who were not fully vaccinated and underwent surgery without general anesthesia (0.52; P =0.83). Surgery shortly following COVID-19 infection was not associated with higher risks among fully vaccinated patients or among patients who underwent surgery without general anesthesia. Further research will be valuable to understand additional factors that modify perioperative risks associated with prior COVID-19 infection.

Authors: Le, Sidney T; Kipnis, Patricia; Cohn, Bradley; Liu, Vincent X

Ann Surg. 2022 11 01;276(5):e265-e272. Epub 2022-07-15.

PubMed abstract

Telemedicine implementation trends in surgical specialties before and after COVID-19 shelter in place: Adjusting to a changing landscape

The COVID-19 pandemic caused a shift from in-person care to telemedicine, providing a unique opportunity to evaluate trends and efficiency of telemedicine usage within surgical subspecialties in a large, integrated health care system before and after shelter in place mandates. This retrospective cohort study included all of the Kaiser Permanente Northern California members referred to surgical services from January 1, 2019 to June 13, 2020 and receiving a surgical procedure. We compared the patient referrals (categorized as benign, urgent, or cancer) before and after shelter in place mandates, and we examined rates of telemedicine (video or telephone) usage for preoperative consultations, postoperative visits, time from referral to first surgical encounter, and to surgery or procedure. In multivariate analyses, we assessed the patient and provider characteristics associated with telemedicine usage. There was a total of 34,875 surgical referrals resulting in a procedure, with a significant decline in referral after shelter in place mandates. Preoperative encounter types shifted from 89.8% in-person before shelter in place mandates to 70.2% telemedicine after shelter in place mandates (P < .0001). The median time from referral to first encounter decreased after shelter in place mandates, as did median time to procedure. After shelter in place mandates, postoperative encounters were mainly telemedicine (65.8%) compared with before shelter in place mandates (41.7%) (P < .0001). Overall, there was a comparable uptake of telemedicine usage in almost all evaluated categories of patient characteristics after shelter in place mandates. Within a health care system with prior telemedicine capability, surgical specialties were able to shift to telemedicine rapidly, equitably, and efficiently in the preoperative and postoperative encounters of benign, urgent, and cancer diagnosis during mandated COVID-19 restrictions.

Authors: Kuehner, Gillian; Wu, Weilu; Choe, Giye; Douaiher, Jeffrey; Reed, Mary

Surgery. 2022 Nov;172(5):1471-1477. Epub 2022-06-13.

PubMed abstract

Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study

The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized. To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed. Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients). Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.

Authors: Vinson, David R; Reed, Mary E; Mark, Dustin G; PEPC Investigators of the KP CREST Network,; et al.

J Gen Intern Med. 2022 11;37(14):3620-3629. Epub 2022-01-12.

PubMed abstract

Prevalence of prediabetes and diabetes vary by ethnicity among U.S. Asian adults at healthy weight, overweight, and obesity ranges: an electronic health record study

Asian adults develop Type 2 diabetes at a lower body mass index (BMI) compared to other racial/ethnic groups. We examined the variation in prevalence of prediabetes and diabetes among Asian ethnic groups within weight strata by comparing middle-aged Chinese, Filipino, South Asian, and White adults receiving care in the same integrated healthcare delivery system. Our retrospective cross-sectional U.S. study examined data from 283,110 (non-Hispanic) White, 33,263 Chinese, 38,766 Filipino, and 17,959 South Asian adults aged 45-64 years who were members of a Northern California health plan in 2016 and had measured height and weight. Prediabetes and diabetes were classified based on laboratory data, clinical diagnoses, or diabetes pharmacotherapy. Age-standardized prevalence of prediabetes and diabetes were compared by race/ethnicity within healthy weight, overweight, and obesity categories, using standard BMI thresholds for White adults (18.5 to < 25, 25 to < 30, ≥ 30 kg/m2) and lower BMI thresholds for Asian adults (18.5 to < 23, 23 to < 27.5, ≥ 27.5 kg/m2). Prevalence ratios (PRs) were used to compare the prevalence of diabetes and prediabetes for Asian groups to White adults in each weight category, adjusted for age and BMI. Across all weight categories, diabetes prevalence was higher for Asian than White adults, and among Asian groups it was highest for Filipino and South Asian adults. Compared to White, PRs for South Asian men/women at healthy BMI were 1.8/2.8 for prediabetes and 5.9/8.0 for diabetes, respectively. The PRs for Filipino men/women at healthy BMI were 1.8/2.6 for prediabetes and 5.0/7.5 for diabetes, respectively. For Chinese men/women at healthy BMI, the PRs for prediabetes (2.1/2.9) were similar to Filipino and South Asian, but the PRs for diabetes were lower (2.1/3.4). Chinese, Filipino, and South Asian adults have higher prevalence of prediabetes and diabetes than White adults in all weight categories, despite using lower BMI thresholds for weight classification in Asian groups. Within Asian ethnic groups, Filipino and South Asian adults had considerably higher diabetes prevalence than Chinese adults. Our data emphasize the disproportionate metabolic risk among middle-aged Asian adults and underscore the need for diabetes screening among high-risk Asian groups at healthy BMI levels.

Authors: Vicks, William S; Lo, Joan C; Guo, Lynn; Rana, Jamal S; Zhang, Sherry; Ramalingam, Nirmala D; Gordon, Nancy P

BMC Public Health. 2022 Oct 22;22(1):1954. Epub 2022-10-22.

PubMed abstract

Quantifying the breadth of antibiotic exposure in sepsis and suspected infection using spectrum scores

A retrospective cohort study. Studies to quantify the breadth of antibiotic exposure across populations remain limited. Therefore, we applied a validated method to describe the breadth of antimicrobial coverage in a multicenter cohort of patients with suspected infection and sepsis. We conducted a retrospective cohort study across 21 hospitals within an integrated healthcare delivery system of patients admitted to the hospital through the ED with suspected infection or sepsis and receiving antibiotics during hospitalization from January 1, 2012, to December 31, 2017. We quantified the breadth of antimicrobial coverage using the Spectrum Score, a numerical score from 0 to 64, in patients with suspected infection and sepsis using electronic health record data. Of 364,506 hospital admissions through the emergency department, we identified 159,004 (43.6%) with suspected infection and 205,502 (56.4%) with sepsis. Inpatient mortality was higher among those with sepsis compared to those with suspected infection (8.4% vs 1.2%; P < .001). Patients with sepsis had higher median global Spectrum Scores (43.8 [interquartile range IQR 32.0-49.5] vs 43.5 [IQR 26.8-47.2]; P < .001) and additive Spectrum Scores (114.0 [IQR 57.0-204.5] vs 87.5 [IQR 45.0-144.8]; P < .001) compared to those with suspected infection. Increased Spectrum Scores were associated with inpatient mortality, even after covariate adjustments (adjusted odds ratio per 10-point increase in Spectrum Score 1.31; 95%CI 1.29-1.33). Spectrum Scores quantify the variability in antibiotic breadth among individual patients, between suspected infection and sepsis populations, over the course of hospitalization, and across infection sources. They may play a key role in quantifying the variation in antibiotic prescribing in patients with suspected infection and sepsis.

Authors: Smith, Joshua T; Manickam, Raj N; Barreda, Fernando; Greene, John D; Bhimarao, Meghana; Pogue, Jason; Jones, Makoto; Myers, Laura; Prescott, Hallie C; Liu, Vincent X

Medicine (Baltimore). 2022 Oct 14;101(41):e30245.

PubMed abstract

Barriers and Opportunities Regarding Implementation of a Machine Learning-Based Acute Heart Failure Risk Stratification Tool in the Emergency Department

Hospital admissions for patients with acute heart failure (AHF) remain high. There is an opportunity to improve alignment between patient risk and admission decision. We recently developed a machine learning (ML)-based model that stratifies emergency department (ED) patients with AHF based on predicted risk of a 30-day severe adverse event. Prior to deploying the algorithm and paired clinical decision support, we sought to understand barriers and opportunities regarding successful implementation. We conducted semi-structured interviews with eight front-line ED providers and surveyed 67 ED providers. Audio-recorded interviews were transcribed and analyzed using thematic analysis, and we had a 65% response rate to the survey. Providers wanted decision support to be streamlined into workflows with minimal disruptions. Most providers wanted assistance primarily with ED disposition decisions, and secondarily with medical management and post-discharge follow-up care. Receiving feedback on patient outcomes after risk tool use was seen as an opportunity to increase acceptance, and few providers (<10%) had significant hesitations with using an ML-based tool after education on its use. Engagement with key front-line users on optimal design of the algorithm and decision support may contribute to broader uptake, acceptance, and adoption of recommendations for clinical decisions.

Authors: Sax, Dana R; Sturmer, Lillian R; Mark, Dustin G; Rana, Jamal S; Reed, Mary E

Diagnostics (Basel). 2022 Oct 11;12(10). Epub 2022-10-11.

PubMed abstract

Comparing the effectiveness of a brief intervention to reduce unhealthy alcohol use among adult primary care patients with and without depression: A machine learning approach with augmented inverse probability weighting

The combination of unhealthy alcohol use and depression is associated with adverse outcomes including higher rates of alcohol use disorder and poorer depression course. Therefore, addressing alcohol use among individuals with depression may have a substantial public health impact. We compared the effectiveness of a brief intervention (BI) for unhealthy alcohol use among patients with and without depression. This observational study included 312,056 adult primary care patients at Kaiser Permanente Northern California who screened positive for unhealthy drinking between 2014 and 2017. Approximately half (48%) received a BI for alcohol use and 9% had depression. We examined 12-month changes in heavy drinking days in the previous three months, drinking days per week, drinks per drinking day, and drinks per week. Machine learning was used to estimate BI propensity, follow-up participation, and alcohol outcomes for an augmented inverse probability weighting (AIPW) estimator of the average treatment (BI) effect. This approach does not depend on the strong parametric assumptions of traditional logistic regression, making it more robust to model misspecification. BI had a significant effect on each alcohol use outcome in the non-depressed subgroup (-0.41 to -0.05, all ps < .003), but not in the depressed subgroup (-0.33 to -0.01, all ps > .28). However, differences between subgroups were nonsignificant (0.00 to 0.11, all ps > .44). On average, BI is an effective approach to reducing unhealthy drinking, but more research is necessary to understand its impact on patients with depression. AIPW with machine learning provides a robust method for comparing intervention effectiveness across subgroups.

Authors: Papini, Santiago; Chi, Felicia W; Schuler, Alejandro; Satre, Derek D; Liu, Vincent X; Sterling, Stacy A

Drug Alcohol Depend. 2022 Oct 01;239:109607. Epub 2022-08-27.

PubMed abstract

Identifying modifiable obesogenic behaviors among Latino adolescents in primary pediatric care.

Latino adolescents engage in more obesogenic behaviors, including sedentary behaviors and sugary drink consumption, than White adolescents. However, it is unclear whether engagement in obesogenic behaviors differs within the Latino population. Cross-sectional data were examined from Latino adolescents ages 13-17 with a well-child visit (2016-2019) in an integrated healthcare system. Adolescents self-reported on four daily obesogenic behaviors: 1) consuming < 5 servings of fruits/vegetables; 2) drinking > 1 juice/soda; 3) exercising/playing sports < 60 min; and 4) > 2 h screen time. A composite variable of >/= 3 self-reported behaviors was constructed. Multivariable logistic regression was used to examine associations between obesogenic behaviors with age category (13-15 or 16-17 years), sex, household language preference (English/Spanish), neighborhood deprivation index (NDI quartiles), and body mass index (BMI). Among 77,514 Latino adolescents (mean age 14.7 +/- 1.4; 50 % female), 23 % lived in Spanish-speaking households, 43 % resided in census tracts with the highest (most deprived) NDI quartile, and 45 % had an overweight or obese BMI. Older (vs younger) adolescents had higher odds of insufficient fruit/vegetable intake (OR 1.20; CI 1.17-1.24), greater sedentary behavior (OR 1.51; 1.46-1.56), and reporting > 2 h screen time (OR 1.07; 1.03-1.11). Adolescents in the 4th (vs 1st) NDI quartile (OR 1.34; 1.26-1.42) and those with obesity (vs healthy weight) (OR 1.55; 1.42-1.70 for class 3 obesity) had higher odds of >/= 3 obesogenic behaviors. In conclusion, among Latino adolescents, older age, obesity, and living in more deprived neighborhoods were associated with greater obesogenic behaviors. Identifying adolescents more likely to engage in obesogenic behaviors can inform targeted lifestyle interventions.

Authors: Rodriguez LA; Gopalan A; Darbinian JA; Chandra M; Greenspan LC; Howell A; Lo JC

Prev Med Rep. 2022 Jul 30;29:101939. doi: 10.1016/j.pmedr.2022.101939. eCollection 2022 Oct.

PubMed abstract

Unsupervised probabilistic models for sequential Electronic Health Records

We develop an unsupervised probabilistic model for heterogeneous Electronic Health Record (EHR) data. Utilizing a mixture model formulation, our approach directly models sequences of arbitrary length, such as medications and laboratory results. This allows for subgrouping and incorporation of the dynamics underlying heterogeneous data types. The model consists of a layered set of latent variables that encode underlying structure in the data. These variables represent subject subgroups at the top layer, and unobserved states for sequences in the second layer. We train this model on episodic data from subjects receiving medical care in the Kaiser Permanente Northern California integrated healthcare delivery system. The resulting properties of the trained model generate novel insight from these complex and multifaceted data. In addition, we show how the model can be used to analyze sequences that contribute to assessment of mortality likelihood.

Authors: Kaplan, Alan D; Greene, John D; Liu, Vincent X; Ray, Priyadip

J Biomed Inform. 2022 Oct;134:104163. Epub 2022-08-28.

PubMed abstract

Current Emergency Department Disposition of Patients With Acute Heart Failure: An Opportunity for Improvement

Emergency department (ED) providers play a critical role in the stabilization and diagnostic evaluation of patients presenting with acute heart failure (AHF), and EDs are key areas for establishing current best practices and future considerations for the disposition of and decision making for patients with AHF. These elements include accurate risk assessment; response to initial treatment and shared decision making concerning optimal venue of care; reframing of physicians’ risk perceptions for patients presenting with AHF; exploration of alternative venues of care beyond hospitalization; population-level changes in demographics, management and outcomes of HF patients; development and testing of data-driven pathways to assist with disposition decisions in the ED; and suggested outcomes for measuring success.

Authors: Sax, Dana R; Mark, Dustin G; Rana, Jamal S; Reed, Mary E; Lindenfeld, Joann; Stevenson, Lynne W; Storrow, Alan B; Butler, Javed; Pang, Peter S; Collins, Sean P

J Card Fail. 2022 10;28(10):1545-1559. Epub 2022-05-29.

PubMed abstract

Pulmonary Embolism

Authors: Vinson, David R; Rouleau, Samuel G; Casey, Scott D

N Engl J Med. 2022 Sep 29;387(13):1242.

PubMed abstract

Strategies Facilitating Video Visit Implementation by a Medical Group Serving a Diverse Population

IntroductionVideo visits have created new opportunities to enhance access to care, but limited information exists on strategies medical groups can employ to facilitate video visit use by higher-risk patients. Our objective was to identify generalizable strategies to facilitate successful delivery of video visits by systems serving highly diverse patient populations. MethodsThe authors conducted a qualitative study of physicians and staff members in a large group practice with 4.5 million patients with diverse race and ethnicity and socioeconomic status. Semi-structured interviews were conducted between January 2021 and April 2021, with key informants identified via purposive and snowball sampling. Video-recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. ResultsThe 42 key informants included regional and medical center leaders, primary care physicians, service managers, and medical assistants. Participants described clinical leadership in technology and multidisciplinary collaboration as crucial to sustained video care adoption. Strategies to facilitate real-time learning included local innovation, rapid communication channels, and psychological safety. The organization offered broad access to frequently updated data reports to help managers and practitioners understand processes, measure performance, and share best practices. Medical assistants and physicians developed new approaches to empathize, tailor interactions with patients, and overcome psychological and technical barriers to connecting via video. ConclusionsKey strategies for sustained video care adoption included clinical leadership articulating its purpose, multidisciplinary collaboration, local innovation, effective data use, empathy, and personalized care. These findings provide a model for how health care systems can foster robust adoption of technologies to serve diverse populations.

Authors: Lieu, Tracy A; Altschuler, Andrea; Hsueh, Loretta; Warton, E Margaret; Levan, Christine; Dixon, Matthew; San, Karen; Awsare, Sameer; Chen, Yi-Fen Irene; Lee, Edward R; Reed, Mary E

Perm J. 2022 Sep 14;26(3):20-29. Epub 2022-07-20.

PubMed abstract

Improving outcomes in malignant pleural mesothelioma in an integrated health care system

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor that should be managed by an experienced surgical and multidisciplinary group. Our objective was to determine the impact of proficient surgeons and MPM bi-disciplinary review on outcomes of patients with MPM. Through this cohort study, electronic medical records of 368 adult patients with MPM from 1/1/2009 to 12/31/2020 were reviewed and compared before and after MPM surgeries were regionalized to specialized surgeons and bi-disciplinary review of MPM patient treatment options. We used the Kaplan-Meier method and log-rank tests to compare survival rates by period, by treatment type, and by stage. Patients were followed from cancer diagnosis date until they died or end of study follow-up, whichever occurred first. We also conducted Cox proportional hazards regression model to examine the overall survival (OS) with adjustments for age, histology, stage, and Charlson comorbidity index (CCI). Despite similar staging, more patients received any MPM directed treatment from 2015-2020 compared with those patients from 2009-2014. Specifically, there was an increase in patients who received pleurectomy/decortication (PD) from 2015-2020 compared to those who received PD in 2009-2014. Patients with similar age, CCI, stage, and histology had an increase in OS of 12 months with multimodality therapy (surgery, systemic therapy, +/- radiation) compared to those patients who received no treatment. Consolidating mesothelioma surgery to a specialized surgical team and regular bi-disciplinary review of MPM cases to determine appropriate multimodality therapy, increases the incorporation of surgical treatments in the management of patients with MPM.

Authors: Ossowski, Stephanie; Hung, Yun-Yi; Banks, Kian; Hsu, Diana; Herrinton, Lisa; Ashiku, Simon; Patel, Ashish; Suga, J Marie; Velotta, Jeffrey B

J Thorac Dis. 2022 Sep;14(9):3352-3363.

PubMed abstract

Primary Care Visits Are Timelier When Patients Choose Telemedicine: A Cross-Sectional Observational Study

Introduction: Telemedicine could increase timely access to primary care-a key dimension of care quality. Methods: Among patient-scheduled appointments with their own primary care providers using the online portal in a large integrated health care delivery system, we measured the association between visit type (telemedicine or in-person) and appointment timeliness. We calculated the calendar days between the scheduling date and the actual appointment time. Results: Overall, 2,178,440 primary care visits were scheduled and 14% were done through telemedicine. The mean calendar days between the scheduling and the appointment time were 1.80 for telephone visits, 2.29 for video visits, and 3.52 for in-person visits. After multivariate adjustment, 66.61% (confidence interval [95% CI]: 66.44-66.79) of telephone visits, 56.58% (95% CI: 55.90-57.27) of video visits, and 46.49% (95% CI: 46.42-46.57) of in-person visits were scheduled to occur within 1 day of making the appointment. Conclusions: In a setting with comparable in-person and telemedicine scheduling availability, choosing telemedicine was associated with more timely access to primary care.

Authors: Graetz, Ilana; Huang, Jie; Muelly, Emilie; Gopalan, Anjali; Reed, Mary E

Telemed J E Health. 2022 Sep;28(9):1374-1378. Epub 2022-02-03.

PubMed abstract

Ovarian Cystadenomas: Growth Rate and Reliability of Imaging Measurements

To evaluate the growth rate of benign ovarian cystadenomas and the degree of variability in ultrasound measurements. Two independent retrospective cohorts of women found to have benign cystadenomas at surgery were identified. To assess growth rate, ultrasounds on women in a community-based health system were reviewed and the growth rate was determined based on the maximum reported size dimension using a mixed effect model. To assess measurement variability, two radiologists independently measured presurgical adnexal imaging findings for women in a tertiary care referral setting. Interobserver, intra-observer, and intermodality (cine clip versus still images) variability in measurements was determined using correlation coefficients (CC) and Bland-Altman analysis, with the proportion of measurements varying by more than 1 cm calculated. For growth rate assessment, 405 women with 1412 ultrasound examinations were identified. The median growth rate was 0.65 cm/year with mucinous cystadenomas growing faster at 0.83 cm/year compared to 0.51 cm/year for serous cystadenomas (median test P < .0001). To evaluate measurement variability, 75 women were identified with 176 ultrasound studies. The within-subject standard deviations for ultrasound measurements were 0.74 cm for cine clip images and 0.41 cm for static images, with 11% of measurements overall differing by more than 1 cm. Cystadenomas grow on average 0.65 cm/year, which is similar in magnitude to the inherent error observed in measurement on ultrasound, suggesting that repeat ultrasound at intervals of longer than a year will often be needed to accurately assess growth if a cyst represents a benign cystadenoma.

Authors: Suh-Burgmann, Elizabeth; Nakhaei, Masoud; Gupta, Sonia; Brook, Alexander; Hecht, Jonathan; Hung, Yun-Yi; Levine, Deborah

J Ultrasound Med. 2022 Sep;41(9):2157-2167. Epub 2021-11-30.

PubMed abstract

Risk of severe COVID-19 infection among adults with prior exposure to children

Susceptibility and severity of COVID-19 infection vary widely. Prior exposure to endemic coronaviruses, common in young children, may protect against SARS-CoV-2. We evaluated risk of severe COVID-19 among adults with and without exposure to young children in a large, integrated healthcare system. Adults with children 0-5 years were matched 1:1 to adults with children 6-11 years, 12-18 years, and those without children based upon a COVID-19 propensity score and risk factors for severe COVID-19. COVID-19 infections, hospitalizations, and need for intensive care unit (ICU) were assessed in 3,126,427 adults, of whom 24% (N = 743,814) had children 18 years or younger, and 8.8% (N = 274,316) had a youngest child 0-5 years. After 1:1 matching, propensity for COVID-19 infection and risk factors for severe COVID-19 were well balanced between groups. Rates of COVID-19 infection were slightly higher for adults with exposure to older children (incident risk ratio, 1.09, 95% confidence interval, [1.05-1.12] and IRR 1.09 [1.05-1.13] for adults with children 6-11 and 12-18, respectively), compared to those with children 0-5 years, although no difference in rates of COVID-19 illness requiring hospitalization or ICU admission was observed. However, adults without exposure to children had lower rates of COVID-19 infection (IRR 0.85, [0.83-0.87]) but significantly higher rates of COVID-19 hospitalization (IRR 1.49, [1.29-1.73]) and hospitalization requiring ICU admission (IRR 1.76, [1.19-2.58]) compared to those with children aged 0-5. In a large, real-world population, exposure to young children was associated with less severe COVID-19 illness. Endemic coronavirus cross-immunity may play a role in protection against severe COVID-19.

Authors: Solomon, Matthew D; Escobar, Gabriel J; Lu, Yun; Schlessinger, David; Steinman, Jonathan B; Steinman, Lawrence; Lee, Catherine; Liu, Vincent X

Proc Natl Acad Sci U S A. 2022 Aug 16;119(33):e2204141119. Epub 2022-07-27.

PubMed abstract

The Kaiser Permanente Northern California Advance Alert Monitor Program: An Automated Early Warning System for Adults at Risk for In-Hospital Clinical Deterioration

In-hospital deterioration among ward patients is associated with substantially increased adverse outcome rates. In 2013 Kaiser Permanente Northern California (KPNC) developed and implemented a predictive analytics-driven program, Advance Alert Monitor (AAM), to improve early detection and intervention for in-hospital deterioration. The AAM predictive model is designed to give clinicians 12 hours of lead time before clinical deterioration, permitting early detection and a patient goals-concordant response to prevent worsening. Across the 21 hospitals of the KPNC integrated health care delivery system, AAM analyzes electronic health record (EHR) data for patients in medical/surgical and telemetry units 24 hours a day, 7 days a week. Patients identified as high risk by the AAM algorithm trigger an alert for a regional team of experienced critical care virtual quality nurse consultants (VQNCs), who then cascade validated, actionable information to rapid response team (RRT) nurses at local hospitals. RRT nurses conduct bedside assessments of at-risk patients and formulate interdisciplinary clinical responses with hospital-based physicians, bedside nurses, and supportive care teams to ensure a well-defined escalation plan that includes clarification of the patients’ goals of care. Since 2019 the AAM program has been implemented at all 21 KPNC hospitals. The use of predictive modeling embedded within the EHR to identify high-risk patients has produced the standardization of monitoring workflows, clinical rescue protocols, and coordination to ensure that care is consistent with patients’ individual goals of care. An evaluation of the program, using a staggered deployment sequence over 19 hospitals, demonstrates that the AAM program is associated with statistically significant decreases in mortality (9.8% vs. 14.4%), hospital length of stay, and ICU length of stay. Statistical analyses estimated that more than 500 deaths were prevented each year with the AAM program. Unlocking the potential of predictive modeling in the EHR is the first step toward realizing the promise of artificial intelligence/machine learning (AI/ML) to improve health outcomes. The AAM program leveraged predictive analytics to produce highly reliable care by identifying at-risk patients, preventing deterioration, and reducing adverse outcomes and can be used as a model for how clinical decision support and inpatient population management can effectively improve care.

Authors: Martinez, Vanessa A; Liu, Vincent X; et al.

Jt Comm J Qual Patient Saf. 2022 Aug;48(8):370-375.

PubMed abstract

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

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. 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. Living in the least resourced quartile of neighborhoods as measured by a census-tract level Neighborhood Deprivation Index score. Five self-reported social risk factors: financial need, food insecurity, housing barriers, transportation barriers, and functional limitations. Nearly half (42.0%) of patients reported at least 1 social risk factor; 22.4% reported 2 or more. Mean correlation coefficient between social risk factors was ρ=0.30. Multivariable logistic models controlling for age, race/ethnicity, sex, count of chronic conditions, and insurance source estimated that living in the least resourced neighborhoods was associated with greater odds of food insecurity (adjusted odds ratio=1.07, 95% confidence interval: 1.00-1.13) and transportation barriers (adjusted odds ratio=1.20, 95% confidence interval: 1.11-1.30), but not financial stress, housing barriers, or functional limitations. We found that among 5 commonly associated social risk factors, Medicaid patients in a large Northern California health system typically reported only a single factor and that these factors did not correlate strongly with each other. We found only modestly greater social risk reported by patients in the least resourced neighborhoods. These results suggest that individual-level interventions should be targeted to specific needs whereas community-level interventions may be similarly important across diverse neighborhoods.

Authors: Miller-Rosales, Chris; McCloskey, Jodi; Uratsu, Connie S; Ralston, James D; Bayliss, Elizabeth A; Grant, Richard W

Med Care. 2022 08 01;60(8):563-569. Epub 2022-05-30.

PubMed abstract

Impact of cannabidiol-rich hemp extract oil on reconsolidation disruption of naturalistic interoceptive aversive memory in humans: Protocol for a randomized clinical trial

Preclinical experiments with rodents demonstrate that cannabidiol (CBD), the non-psychotomimetic constituent of the Cannabis sativa plant, disrupts reconsolidation of aversive memories conditioned in the laboratory when administered within the memory reconsolidation window (< 6 h. post-retrieval) by indirectly activating cannabinoid type-1 (CB1) receptors in the dorsal anterior cingulate cortex (dACC). Based on these findings, we aim to test whether administration of 300 mg CBD-rich hemp extract oil following fear reactivation of an aversive interoceptive threat memory can disrupt reconsolidation of naturalistic aversive memories in humans. More specifically, naturalistic interoceptive aversive memories, a form of transdiagnostic fear memory that contributes to the pathogenesis of fear-related disorders such as panic disorder, posttraumatic stress disorder (PTSD), and illness anxiety disorder. For this proof-of-concept, placebo-controlled double-blind trial, volunteers (n = 99) reporting elevated fears of somatic sensations will be stratified on biological sex and randomized to one of three intervention arms: (a). CBD-rich oil administered within the reconsolidation window, (b) Placebo oil administered within the reconsolidation window; or (c) CBD-rich oil administered outside of the reconsolidation window. Change in emotional reactivity to a 35% CO2 challenge from baseline to two-week follow-up will serve as our primary outcome. Study findings may contribute towards the development of a novel brief transdiagnostic intervention guided by reconsolidation theory for individuals prone to fear-related psychiatric disorders. Identifier: NCT04726475.

Authors: Zaizar, Eric D; Papini, Santiago; O'Connor, Patrick; Telch, Michael J

Contemp Clin Trials. 2022 Aug;119:106847. Epub 2022-07-08.

PubMed abstract

Temporal Trends in Antimicrobial Prescribing During Hospitalization for Potential Infection and Sepsis

Some experts have cautioned that national and health system emphasis on rapid administration of antimicrobials for sepsis may increase overall antimicrobial use even among patients without sepsis. To assess whether temporal changes in antimicrobial timing for sepsis are associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among all hospitalized patients at risk for sepsis. This is an observational cohort study of hospitalized patients at 152 hospitals in 2 health care systems during 2013 to 2018, admitted via the emergency department with 2 or more systemic inflammatory response syndrome (SIRS) criteria. Data analysis was performed from June 10, 2021, to March 22, 2022. Hospital-level temporal trends in time to first antimicrobial administration. Antimicrobial outcomes included antimicrobial use, days of therapy, and broadness of antibacterial coverage. Clinical outcomes included in-hospital mortality, 30-day mortality, length of hospitalization, and new multidrug-resistant (MDR) organism culture positivity. Among 1 559 523 patients admitted to the hospital via the emergency department with 2 or more SIRS criteria (1 269 998 male patients [81.4%]; median [IQR] age, 67 [59-77] years), 273 255 (17.5%) met objective criteria for sepsis. In multivariable models adjusted for patient characteristics, the adjusted median (IQR) time to first antimicrobial administration to patients with sepsis decreased by 37 minutes, from 4.7 (4.1-5.3) hours in 2013 to 3.9 (3.6-4.4) hours in 2018, although the slope of decrease varied across hospitals. During the same period, antimicrobial use within 48 hours, days of antimicrobial therapy, and receipt of broad-spectrum coverage decreased among the broader cohort of patients with SIRS. In-hospital mortality, 30-day mortality, length of hospitalization, new MDR culture positivity, and new MDR blood culture positivity decreased over the study period among both patients with sepsis and those with SIRS. When examining hospital-specific trends, decreases in antimicrobial use, days of therapy, and broadness of antibacterial coverage for patients with SIRS did not differ by hospital antimicrobial timing trend for sepsis. Overall, there was no evidence that accelerating antimicrobial timing for sepsis was associated with increasing antimicrobial use or impaired antimicrobial stewardship. In this multihospital cohort study, the time to first antimicrobial for sepsis decreased over time, but this trend was not associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among the broader population at-risk for sepsis, which suggests that shortening the time to antibiotics for sepsis is feasible without leading to indiscriminate antimicrobial use.

Authors: Prescott, Hallie C; Liu, Vincent X; et al.

JAMA Intern Med. 2022 08 01;182(8):805-813.

PubMed abstract

Adults hospitalized with breakthrough COVID-19 have lower mortality than matched unvaccinated adults

Coronavirus disease 2019 (COVID-19) breakthrough infections are common. Evaluate in-hospital mortality of patients with COVID-19 by vaccination status using retrospective cohort study. We generated propensity scores for receipt of full vaccination in adults requiring supplemental oxygen hospitalized at Kaiser Permanente Northern California (1 April 2021 to 30 November 2021) with positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction tests. Optimal matching of fully vaccinated/unvaccinated patients was performed comparing in-hospital mortality. Of 7305 patients, 1463 (20.0%) were full, 138 (1.9%) were partial, and 5704 (78.1%) were unvaccinated. Fully vaccinated were older than partial or unvaccinated (71.0, 63.0, and 54.0 years, respectively, p < 0.001) with more comorbidities (Comorbidity Point Scores 33.0, 22.0, and 10.0, p < 0.001) and immunosuppressant (11.5%, 8.7%, and 3.0%, p < 0.001) or chemotherapy exposure (2.8%, 0.7%, and 0.4%, p < 0.001). Fewer fully vaccinated patients died compared to matched unvaccinated (9.0% vs. 16.3%, p < 0.0001). Fully vaccinated patients are less likely to die compared to matched unvaccinated patients.

Authors: Myers, Laura C; Kipnis, Patricia; Greene, John; Lawson, Brian; Escobar, Gabriel J; Fireman, Bruce H; Klein, Nicola P; Liu, Vincent X

J Intern Med. 2022 08;292(2):377-384. Epub 2022-05-17.

PubMed abstract

Reach, acceptability, and perceived success of a telehealth diabetes prevention program among racially and ethnically diverse patients with gestational diabetes: the GEM cluster-randomized trial

Patients with gestational diabetes mellitus and from racial/ethnic minority groups face disproportionate risk for type 2 diabetes. Lifestyle interventions, if accessible and acceptable to diverse patients, could advance diabetes prevention and mitigate racial/ethnic disparities. Here we describe overall and race/ethnicity-specific reach, acceptability, and perceived success from an effective telehealth diabetes prevention lifestyle program for patients with gestational diabetes mellitus, implemented in the Gestational Diabetes Effects on Moms (GEM) cluster-randomized controlled trial. GEM tested a program of 13 telephone sessions and behavior change techniques (BCTs, e.g., goal setting) in a healthcare system. We evaluated participation (completing ≥1 session), acceptability of BCTs, and perceived success reaching program goals. Among 1,087 patients (75.2% from minority groups), 50.3% participated. Participation rates were 61.7% among Black, 56.4% among Hispanic, 55.6% among multiracial/other, 53.0% among White, and 43.7% among Asian/Pacific Islander patients. Evaluation survey respondents (n = 433/547; 79.2%) largely rated BCTs as very helpful (range 40.9%-58.4%) or moderately helpful (27.3%-34.9%). Respondents from minority groups largely rated goal setting for weight management as very or moderately helpful, with fewer minority respondents rating it as only a little/not at all helpful than White respondents (p = .02). Black and White respondents reported more limited success reaching a healthy weight than Asian/Pacific Islander, Hispanic, and multiracial/other women (p = .005). A telehealth diabetes prevention lifestyle program demonstrated reach and acceptability across racial/ethnic groups. While perceived success can be improved among Black and White participants, such programs could promote access to preventive care and help mitigate disparities in diabetes risk.

Authors: Brown, Susan D; Hedderson, Monique M; Gordon, Nancy; Albright, Cheryl L; Tsai, Ai-Lin; Quesenberry, Charles P; Ferrara, Assiamira

Transl Behav Med. 2022 Jul 18;12(7):793-799.

PubMed abstract

New complementary perspectives for inpatient physical function assessment: matched clinician-report and patient-report short form measures from the PROMIS adult physical function item bank

To develop two item content-matched, precise, score-level targeted inpatient physical function (PF) short form (SF) measures: one clinician-reported, one patient-reported. Items were derived from PROMIS PF bank content; scores are reported on the PROMIS PF T-score metric. The PROMIS PF item bank was reviewed for content measuring lower-level PF status (T-scores 10-50) with high item set score-level reliability (≥ 0.90). Selected patient-reported (PR) items were also edited to function as clinician-reported (CR) items. Items were reviewed by clinicians and field tested; responses were assessed for meeting PROMIS measure development standards. New CR and PR items were calibrated using patient responses to the original PROMIS PF items as anchoring data. SFs were constructed, based on content and precision. Nine PROMIS PF items were candidates for CR and PR inpatient PF assessment; three new items were written to extend content coverage. An inpatient sample (N = 515; 55.1% female; mean age = 66.2 years) completed 12 PR items and was assessed by physical therapists (using 12 CR items). Analyses indicated item sets met expected measure development standards. Twelve new CR and three new PR items were linked to the PROMIS PF metric (raw score r = 0.73 and 0.90, respectively). A 5-item CR SF measure was constructed; score-level reliabilities were ≥ 0.90 for T-scores 13-45. A 5-item PR SF measure was assembled, mirroring CR SF content. Two item content-matched SFs have been developed for clinician and patient reporting and are an effective, efficient means of assessing inpatient PF and offer complementary perspectives.

Authors: Kallen, Michael A; Brown, Heather E; Hatton, Joeffrey R; Doyle, William A; Murphy, Ryan; Elliott, Ryan; Gutierrez, Mark A; Catherwood, Emma L; Pitman, Heather P; Liu, Vincent X; Gershon, Richard C

Qual Life Res. 2022 Jul;31(7):2201-2212. Epub 2022-03-08.

PubMed abstract

Red Blood Cell Transfusion at a Hemoglobin Threshold of Seven g/dL in Critically Ill Patients: A Regression Discontinuity Study

Rationale: In critically ill patients, a hemoglobin transfusion threshold of <7.0 g/dl compared with <10.0 g/dl improves organ dysfunction. However, it is unclear if transfusion at a hemoglobin of <7.0 g/dl is superior to no transfusion. Objectives: To compare degrees of organ dysfunction between transfusion and no transfusion at a hemoglobin threshold of <7.0 g/dl among critically ill patients using quasiexperimental regression discontinuity methods. Methods: We performed regression discontinuity analysis using hemoglobin measurements from patients admitted to intensive care units in three cohorts (Medical Information Mart for Intensive Care IV, eICU, and Premier Inc.), estimating the change in organ dysfunction (modified sequential organ failure assessment score) in the 24- to 72-hour window following each hemoglobin measurement. We compared hemoglobin concentrations just above and below 7.0 g/dl using a "fuzzy" discontinuity approach, based on the concept that measurement noise pseudorandomizes similar hemoglobin concentrations on either side of the transfusion threshold. Results: A total of 11,181, 13,664, and 167,142 patients were included in the Medical Information Mart for Intensive Care IV (MIMIC-IV), eICU, and Premier Inc. cohorts, respectively. Patient characteristics below the threshold did not differ from those above the threshold, except that crossing below the threshold resulted in a >20% absolute increase in transfusion rates in all three cohorts. Transfusion was associated with increases in hemoglobin concentration in the subsequent 24-72 hours (MIMIC-IV, 2.4 [95% confidence interval (CI), 1.1 to 3.6] g/dl; eICU, 0.7 [95% CI, 0.3 to 1.2] g/dl; Premier Inc., 1.9 [95% CI, 1.5 to 2.2] g/dl) but not with improvement in organ dysfunction (MIMIC-IV, 4.6 [95% CI, -1.2 to 10] points; eICU, 4.4 [95% CI, 0.9 to 7.8] points; Premier Inc., 1.1 [95% CI, -0.2 to 2.3] points) compared with no transfusion. Conclusions: Transfusion was not associated with improved organ dysfunction compared with no transfusion at a hemoglobin threshold of 7.0 g/dl, suggesting that evaluation of transfusion targets other than a hemoglobin threshold of 7.0 g/dl may be warranted.

Authors: Bosch, Nicholas A; Law, Anica C; Bor, Jacob; Myers, Laura C; Roubinian, Nareg H; Liu, Vincent X; Walkey, Allan J

Ann Am Thorac Soc. 2022 07;19(7):1177-1184.

PubMed abstract

Validation of Respiratory Rate-Oxygenation Index in Patients With COVID-19-Related Respiratory Failure

The respiratory rate-oxygenation (ROX) index is a fraction of oxygen saturation, Fio2, and respiratory rate that has been validated to predict receipt of invasive mechanical ventilation in patients receiving high-flow nasal cannula (HFNC). This study aimed to validate ROX in a cohort of inpatients with COVID-19-related respiratory failure. Retrospective validation of the ROX index. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and 95% CIs of ROX for invasive mechanical ventilation any time during hospitalization. Twenty-one hospitals of Kaiser Permanente Northern California, an integrated healthcare delivery system. We identified adults with positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test within 3 weeks of, or during, hospitalization between February 1, 2020, and December 31, 2020. We calculated ROX at 12 hours after HFNC initiation. We grouped patients as low (≥ 4.88), intermediate (< 4.88 and ≥ 3.85), or high (< 3.85) risk using previously published thresholds. None. We identified 1,847 patients who had no limitation of life support. Of these, 525 (31.7%) received invasive mechanical ventilation any time during hospitalization and 511 died (27.7%). The sensitivity, specificity, positive predictive value, and negative predictive value of 12-hour ROX threshold (< 3.85) predicting invasive mechanical ventilation were 32.3% (95% CI, 28.5-36.3%), 89.8% (95% CI, 88.0-91.4%), 59.4% (95% CI, 53.8-64.9%), and 74.1% (95% CI, 71.8-76.3%), respectively. The 12-hour ROX index has a positive predictive value (59.4%) using threshold of less than 3.85 for COVID-19 patients needing invasive mechanical ventilation. Our health system has embedded ROX into the electronic health record to prioritize rounding during periods of inpatient surge.

Authors: Myers, Laura C; Mark, Dustin; Ley, Brett; Guarnieri, Michael; Hofmeister, Melinda; Paulson, Shirley; Marelich, Gregory; Liu, Vincent X

Crit Care Med. 2022 07 01;50(7):e638-e642. Epub 2022-02-07.

PubMed abstract

Address Changes Are Associated With Unmet Glycemic Targets: Opportunities to Improve Processes and Outcomes of Care Among People With Type 2 Diabetes

Introduction The objective of this study was to identify and operationalize measures of potential housing insecurity within existing electronic health record data and to quantify the association between address changes and diabetes management goals among patients with type 2 diabetes. Methods We conducted a retrospective cohort study to measure potential housing insecurity in electronic health record data by quantifying the number of address changes in 2018. We considered at least one address change as a potential marker for housing insecurity. We used multivariable modified Poisson regressions to analyze the association between address change and clinical, utilization and preventive care outcomes while adjusting for patient and health system factors. Results We identified 274,123 adults with type 2 diabetes who were members of Kaiser Permanente Northern California in 2018 and 6% (N = 17,317) had at least one address change during 2018. In multivariate analyses, we found that one or more address changes was associated with greater chance of hemoglobin A1C < 9 (ARR: 1.12, 95% CI: 1.09, 1.15), lower chance of hemoglobin A1C < 8 (ARR: 0.95, 95% CI; 0.94, 0.96), lower chance of controlled blood pressure (ARR: 0.99, 95% CI: 0.98-0.99), greater chance of emergency department visits (ARR: 1.25, 95% CI: 1.23, 1.27), and lower chance of having a flu shot (ARR: 0.94, 95% CI: 0.93, 0.95) when compared to no address change. Discussion Changes in address are associated with worse diabetes management outcomes. Conclusion Identifying patients with potential housing insecurity and providing resources aimed at continuity of care and stable health care access could improve diabetes management for vulnerable populations.

Authors: Thomas, Tainayah; Dyer, Wendy; Adams, Alyce; Grant, Richard; Schmittdiel, Julie

Perm J. 2022 06 29;26(2):1-10. Epub 2022-06-15.

PubMed abstract

Opioid safety initiative associated with decreased emergency department opioid prescribing

The opioid abuse epidemic has focused attention on efforts to decrease opioid prescribing. Although education and feedback interventions are potential levers to affect opioid prescribing, their incremental contribution against a background of declining opioid prescriptions is unclear. We retrospectively evaluated opioid prescribing frequencies after an emergency physician-specific education and feedback initiative in an integrated health care system. We evaluated opioid prescriptions for adult patients discharged from 21 emergency departments (EDs) between January 1, 2014, and December 31, 2018. Applying interrupted time series methodology to account for time trends, we analyzed pre- to postintervention changes in prescribing of any opioid and in opioid prescriptions for greater than 20 tablets. We studied all ED visits, visits for back pain and acute extremity fracture, and visits stratified by physicians with high vs low frequency of opioid prescribing. We identified patient, physician, and visit characteristics associated with postintervention ED opioid prescriptions (2018). Of 1.01 million preintervention and 1.59 million postintervention ED visits, after adjusting for the background trend over time, the intervention was associated with a 3.4% decrease in frequency of opioid prescriptions post intervention (95% CI, -4% to -2.8%), with similar decreases in high-quantity prescriptions (> 20 tablets) and back pain- and acute extremity fracture-related ED visits. Postintervention adjusted analyses indicated no significant association between opioid prescription and race/ethnicity or prior history of opioid abuse. The ED Opioid Safety Initiative was associated with a near-term decrease in multiple categories of opioid prescribing, including for selected subgroups of common painful conditions.

Authors: Kene, Mamata; Bhopale, Sunil; Eaton, Abigail; Awsare, Sameer V; Reed, Mary E

Am J Manag Care. 2022 Jun 01;28(6):e203-e211. Epub 2022-06-01.

PubMed abstract

Psychosocial and diabetes risk factors among racially/ethnically diverse adults with prediabetes

Psychosocial factors such as self-efficacy may be important in helping high-risk adults prevent diabetes. We aimed to describe psychosocial and diabetes risk factors in adults with prediabetes and evaluate if these varied by demographic characteristics. Cross-sectional data came from baseline surveys and electronic health records (2018-2021) of adults with prediabetes enrolled in a randomized study of peer support for diabetes prevention at Kaiser Permanente Northern California and Michigan Medicine. Linear regression was used to compare differences between racial/ethnic groups, adjusting for age, sex, and clinic. Of 336 participants in the study, 62% were female; median age was 57; 41% were White, 35% African American, 9% Hispanic. Mean autonomous motivation was 6.6 and self-efficacy to prevent diabetes was 6.0 (1-7 scale); mean perceived social support was 47 (12-72 scale). Hispanic adults reported higher autonomous motivation and African American adults reported higher self-efficacy compared to White adults. Hispanic and African American adults had more diabetes risk factors than White adults, including greater family history of diabetes, hypertension, sugar-sweetened beverage consumption, physical inactivity and food insecurity. In conclusion, participants reported high levels of autonomous motivation and self-efficacy at baseline, with Hispanic and African American adults reporting higher levels of some psychosocial factors related to behavior change, suggesting a significant opportunity to engage a diverse population of adults with prediabetes in diabetes prevention strategies. However, Hispanic and African American participants showed greater diabetes risk factors levels. Diabetes prevention efforts should address both to reduce diabetes incidence.

Authors: Rodriguez, Luis A; Thomas, Tainayah W; Finertie, Holly; Turner, Cassie D; Heisler, Michele; Schmittdiel, Julie A

Prev Med Rep. 2022 Jun;27:101821. Epub 2022-05-05.

PubMed abstract

Risk adjusted 30-day mortality and serious adverse event rates among a large, multi-center cohort of emergency department patients with acute heart failure

Admission rates for emergency department (ED) patients with acute heart failure (AHF) remain elevated. Use of a risk stratification tool could improve disposition decision making by identifying low-risk patients who may be safe for outpatient management. We performed a secondary analysis of a retrospective, multi-center cohort of 26,189 ED patients treated for AHF from January 1, 2017 to December 31, 2018. We applied a 30-day risk model we previously developed and grouped patients into 4 categories (low, low/moderate, moderate, and high) of predicted 30-day risk of a serious adverse event (SAE). SAE consisted of death or cardiopulmonary resuscitation (CPR), intra-aorta balloon pump, endotracheal intubation, renal failure requiring dialysis, or acute coronary syndrome. We measured the 30-day mortality and composite SAE rates among patients by risk category according to ED disposition: direct discharge, discharge after observation, and hospital admission. The observed 30-day mortality and total SAE rates were less than 1% and 2%, respectively, among 25% of patients in the low and low/moderate risk groups. These rates did not vary significantly by ED disposition. An additional 23% of patients were moderate risk and experienced an approximate 2% 30-day mortality rate. Use of a risk stratification tool could help identify lower risk AHF patients who may be appropriate for ED discharge. These findings will help inform prospective testing to determine how this risk tool can augment ED decision making.

Authors: Sax, Dana R; Mark, Dustin G; Rana, Jamal S; Collins, Sean P; Huang, Jie; Reed, Mary E; CREST Network,

J Am Coll Emerg Physicians Open. 2022 Jun;3(3):e12742. Epub 2022-06-09.

PubMed abstract

Association of Medical Assistant-Supported Virtual Rooming With Successful Video Visit Connections

Authors: Lieu, Tracy A; Warton, E Margaret; Levan, Christine; San, Karen; Hsueh, Loretta; Awsare, Sameer; Reed, Mary E

JAMA Intern Med. 2022 06 01;182(6):680-682.

PubMed abstract

Higher intensity of 72-hour non-invasive cardiac test referral does not improve short-term outcomes among emergency department patients with chest pain

It is unclear whether referral for cardiac noninvasive testing (NIT) following emergency department (ED) chest pain encounters improves short-term outcomes. This was a retrospective cohort study of patients presenting with chest pain, without ST-elevation myocardial infarction or myocardial injury by serum troponin testing, between 2013 and 2019 to 21 EDs within an integrated health care system. We examined the association between NIT referral (within 72 h of the ED encounter) and a primary outcome of 60-day major adverse cardiac events (MACE). Secondary outcomes were 60-day MACE without coronary revascularization (MACE-CR) and 60-day all-cause mortality. To account for confounding by indication for NIT, we grouped patient encounters into ranked tertiles of NIT referral intensity based on the likelihood of 72-h NIT referral associated with the initially assigned emergency physician, relative to local peers and within discrete time periods. Associations between NIT referral-intensity tertile and outcomes were assessed using risk-adjusted multivariable logistic regression. Among 210,948 eligible patient encounters, 72-h NIT referral frequency was 11.9%, 18.3%, and 25.9% in low, intermediate, and high NIT referral-intensity encounters, respectively. Compared with the low referral-intensity tertile, there was a higher risk of 60-day MACE within the high referral-intensity tertile (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.04 to 1.17) due to more coronary revascularizations without corresponding differences in MACE-CR or all-cause mortality. In analyses stratified by patients’ estimated risk (HEART score; 50.5% lower risk, 38.7% moderate risk, 10.8% higher risk), the difference in 60-day MACE was primarily attributable to moderate-risk encounters (OR = 1.15, 95% CI = 1.08 to 1.24), with no differences among either lower- (OR = 1.10, 95% CI = 0.92 to 1.31) or higher- (OR = 1.01, 95% CI = 0.90 to 1.14) risk encounters. Higher referral intensity for 72-h NIT was associated with higher risk of coronary revascularization but no difference in adverse events within 60 days. These findings further call into question the urgency of NIT among ED patients without objective evidence of myocardial injury.

Authors: Mark, Dustin G; Shan, Judy; Huang, Jie; Ballard, Dustin W; Vinson, David R; Kene, Mamata V; Sax, Dana R; Rauchwerger, Adina S; Reed, Mary E; Kaiser Permanente CREST Network Investigators,

Acad Emerg Med. 2022 06;29(6):736-747. Epub 2022-02-23.

PubMed abstract

Exploratory analysis of novel electronic health record variables for quantification of healthcare delivery strain, prediction of mortality, and prediction of imminent discharge

To explore the relationship between novel, time-varying predictors for healthcare delivery strain (eg, counts of patient orders per hour) and imminent discharge and in-hospital mortality. We conducted a retrospective cohort study using data from adults hospitalized at 21 Kaiser Permanente Northern California hospitals between November 1, 2015 and October 31, 2020 and the nurses caring for them. Patient data extracted included demographics, diagnoses, severity measures, occupancy metrics, and process of care metrics (eg, counts of intravenous drip orders per hour). We linked these data to individual registered nurse records and created multiple dynamic, time-varying predictors (eg, mean acute severity of illness for all patients cared for by a nurse during a given hour). All analyses were stratified by patients’ initial hospital unit (ward, stepdown unit, or intensive care unit). We used discrete-time hazard regression to assess the association between each novel time-varying predictor and the outcomes of discharge and mortality, separately. Our dataset consisted of 84 162 161 hourly records from 954 477 hospitalizations. Many novel time-varying predictors had strong associations with the 2 study outcomes. However, most of the predictors did not merely track patients’ severity of illness; instead, many of them only had weak correlations with severity, often with complex relationships over time. Increasing availability of process of care data from automated electronic health records will permit better quantification of healthcare delivery strain. This could result in enhanced prediction of adverse outcomes and service delays. New conceptual models will be needed to use these new data elements.

Authors: Lee, Catherine; Lawson, Brian L; Mann, Ariana J; Liu, Vincent X; Myers, Laura C; Schuler, Alejandro; Escobar, Gabriel J

J Am Med Inform Assoc. 2022 05 11;29(6):1078-1090.

PubMed abstract

Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism

Physicians commonly hospitalize patients presenting to the emergency department (ED) with acute pulmonary embolism (PE), despite eligibility for safe outpatient management. Risk stratification using electronic health record-embedded clinical decision support systems can aid physician site-of-care decision-making and increase safe outpatient management. The long-term sustainability of early improvements after the cessation of trial-based, champion-led promotion is uncertain. To evaluate the sustainability of recommended site-of-care decision-making support 4 years after initial physician champion-led interventions to increase outpatient management for patients with acute PE. This retrospective cohort study was conducted in 21 US community hospitals in an integrated health system. Participants included adult patients presenting to the ED with acute PE. Study sites had participated in an original decision-support intervention trial 4 years prior to the current study period: 10 sites were intervention sites, 11 sites were controls. In that trial, decision support with champion promotion resulted in significantly higher outpatient management at intervention sites compared with controls. After trial completion, all study sites were given continued access to a modified decision-support tool without further champion-led outreach. Data were analyzed from January 2019 to February 2020. ED treatment with a modified clinical decision support tool. The main outcome was frequency of outpatient management, defined as discharge home directly from the ED, stratified by the PE Severity Index. The safety measure of outpatient care was 7-day PE-related hospitalization. This study included 1039 patients, including 533 (51.3%) women, with a median (IQR) age of 65 (52-74) years. Nearly half (474 patients [45.6%]) were rated lower risk on the PE Severity Index. Overall, 278 patients (26.8%) were treated as outpatients, with only four 7-day PE-related hospitalizations (1.4%; 95% CI, 0.4%-3.6%). The practice gap in outpatient management created by the earlier trial persisted in the outpatient management for patients with lower risk: 109 of 236 patients (46.2%) at former intervention sites vs 81 of 238 patients (34.0%) at former control sites (difference, 12.2; [95% CI, 3.4-20.9] percentage points; P = .007), with wide interfacility variation (range, 7.1%-47.1%). In this cohort study, a champion-led, decision-support intervention to increase outpatient management for patients presenting to the ED with acute pulmonary embolism was associated with sustained higher rates of outpatient management 4 years later. The application of our findings to improving sustainability of practice change for other clinical conditions warrants further study.

Authors: Vinson, David R; Casey, Scott D; Vuong, Peter L; Huang, Jie; Ballard, Dustin W; Reed, Mary E

JAMA Netw Open. 2022 May 02;5(5):e2212340. Epub 2022-05-02.

PubMed abstract

Comment on Dunne et al. The Women’s Leadership Gap in Diabetes: A Call for Equity and Excellence. Diabetes Care 2021;44:1734-1743

Authors: Schmittdiel, Julie A; Brega, Angela G; et al.

Diabetes Care. 2022 May 01;45(5):e97-e98.

PubMed abstract

Association Between High-Deductible Health Plans and Engagement in Routine Medical Care for Type 2 Diabetes in a Privately Insured Population: A Propensity Score-Matched Study

High-deductible health plans (HDHPs) are increasingly more common but can be challenging for patients to navigate and may negatively affect care engagement for chronic conditions such as type 2 diabetes. We sought to understand how higher out-of-pocket costs affect participation in provider visits, medication adherence, and routine monitoring by patients with type 2 diabetes with an HDHP. In a retrospective cohort of 19,379 Kaiser Permanente Northern California patients with type 2 diabetes (age 18-64 years), 6,801 patients with an HDHP were compared with those with a no-deductible plan using propensity score matching. We evaluated the number of telephone and office visits with primary care, oral diabetic medication adherence, and rates of HbA1c testing, blood pressure monitoring, and retinopathy screening. Patients with an HDHP had fewer primary care office visits compared with patients with no deductible (4.25 vs. 4.85 visits per person; P < 0.001), less retinopathy screening (49.9% vs. 53.3%; P < 0.001), and fewer A1c and blood pressure measurements (46.7% vs. 51.4%; P < 0.001 and 93.2% vs. 94.4%; P = 0.004, respectively) compared with the control group. Medication adherence was not significantly different between patients with an HDHP and those with no deductible (57.4% vs. 58.6%; P = 0.234). HDHPs seem to be a barrier for patients with type 2 diabetes and reduce care participation in both visits with out-of-pocket costs and preventive care without out-of-pocket costs, possibly because of the increased complexity of cost sharing under an HDHP, potentially leading to decreased monitoring of important clinical measurements.

Authors: Wu, You M; Huang, Jie; Reed, Mary E

Diabetes Care. 2022 05 01;45(5):1193-1200.

PubMed abstract

Comparison of Electronic Frailty Metrics for Prediction of Adverse Outcomes of Abdominal Surgery

Electronic frailty metrics have been developed for automated frailty assessment and include the Hospital Frailty Risk Score (HFRS), the Electronic Frailty Index (eFI), the 5-Factor Modified Frailty Index (mFI-5), and the Risk Analysis Index (RAI). Despite substantial differences in their construction, these 4 electronic frailty metrics have not been rigorously compared within a surgical population. To characterize the associations between 4 electronic frailty metrics and to measure their predictive value for adverse surgical outcomes. This retrospective cohort study used electronic health record data from patients who underwent abdominal surgery from January 1, 2010, to December 31, 2020, at 20 medical centers within Kaiser Permanente Northern California (KPNC). Participants included adults older than 50 years who underwent abdominal surgical procedures at KPNC from 2010 to 2020 that were sampled for reporting to the National Surgical Quality Improvement Program. Pearson correlation coefficients between electronic frailty metrics and area under the receiver operating characteristic curve (AUROC) of univariate models and multivariate preoperative risk models for 30-day mortality, readmission, and morbidity, which was defined as a composite of mortality and major postoperative complications. Within the cohort of 37 186 patients, mean (SD) age, 67.9 (female, 19 127 [51.4%]), correlations between pairs of metrics ranged from 0.19 (95% CI, 0.18- 0.20) for mFI-5 and RAI 0.69 (95% CI, 0.68-0.70). Only 1085 of 37 186 (2.9%) were classified as frail based on all 4 metrics. In univariate models for morbidity, HFRS demonstrated higher predictive discrimination (AUROC, 0.71; 95% CI, 0.70-0.72) than eFI (AUROC, 0.64; 95% CI, 0.63-0.65), mFI-5 (AUROC, 0.58; 95% CI, 0.57-0.59), and RAI (AUROC, 0.57; 95% CI, 0.57-0.58). The predictive discrimination of multivariate models with age, sex, comorbidity burden, and procedure characteristics for all 3 adverse surgical outcomes improved by including HFRS into the models. In this cohort study, the 4 electronic frailty metrics demonstrated heterogeneous correlation and classified distinct groups of surgical patients as frail. However, HFRS demonstrated the highest predictive value for adverse surgical outcomes.

Authors: Le, Sidney T; Liu, Vincent X; Kipnis, Patricia; Zhang, Jie; Peng, Peter D; Cespedes Feliciano, Elizabeth M

JAMA Surg. 2022 05 01;157(5):e220172. Epub 2022-05-11.

PubMed abstract

Perinatal Complications in Individuals in California With or Without SARS-CoV-2 Infection During Pregnancy

Additional research from population-based studies is needed to inform the treatment of SARS-CoV-2 infection during pregnancy and to provide health risk information to pregnant individuals. To assess the risk of perinatal complications associated with SARS-CoV-2 infection and to describe factors associated with hospitalizations. This population-based cohort study included 43 886 pregnant individuals with longitudinal electronic health record data from preconception to delivery who delivered at Kaiser Permanente Northern California between March 1, 2020, and March 16, 2021. Individuals with diagnostic codes for COVID-19 that did not have a confirmatory polymerase chain reaction test for SARS-CoV-2 were excluded. SARS-CoV-2 infection detected by polymerase chain reaction test (from 30 days before conception to 7 days after delivery) as a time varying exposure. Severe maternal morbidity including 21 conditions (eg, acute myocardial infarction, acute renal failure, acute respiratory distress syndrome, and sepsis) that occurred at any time during pregnancy or delivery; preterm birth; pregnancy hypertensive disorders; gestational diabetes; venous thromboembolism (VTE); stillbirth; cesarean delivery; and newborn birth weight and respiratory conditions. Standardized mean differences between individuals with and without SARS-CoV-2 were calculated. Cox proportional hazards regression was used to estimate the hazard ratios (HRs) and 95% CIs for the association between SARS-CoV-2 infection and perinatal complications and hospitalization and to consider the timing of SARS-CoV-2 infection relative to outcomes. In this study of 43 886 pregnant individuals (mean [SD] age, 30.7 [5.2] years), individuals with a SARS-CoV-2 infection (1332 [3.0%]) were more likely to be younger, Hispanic, multiparous individuals with a higher neighborhood deprivation index and obesity or chronic hypertension. After adjusting for demographic characteristics, comorbidities, and smoking status, individuals with SARS-CoV-2 infection had higher risk for severe maternal morbidity (HR, 2.45; 95% CI, 1.91-3.13), preterm birth (<37 weeks; HR, 2.08; 95% CI, 1.75-2.47), and VTE (HR, 3.08; 95% CI, 1.09-8.74) than individuals without SARS-CoV-2. SARS-CoV-2 infection was also associated with increased risk of medically indicated preterm birth (HR, 2.56; 95% CI, 2.06-3.19); spontaneous preterm birth (HR, 1.61; 95% CI, 1.22-2.13); and early (HR, 2.52; 95% CI, 1.49-4.24), moderate (HR, 2.18; 95% CI, 1.25-3.80), and late (HR, 1.95; 95% CI, 1.61-2.37) preterm birth. Among individuals with SARS-CoV-2 infection, 76 (5.7%) had a hospitalization; pregestational diabetes (HR, 7.03; 95% CI, 2.22-22.2) and Asian or Pacific Islander (HR, 2.33; 95% CI, 1.06-5.11) and Black (HR, 3.14; 95% CI, 1.24-7.93) race and ethnicity were associated with an increased risk of hospitalization. In this cohort study, SARS-CoV-2 infection was associated with increased risk of severe maternal morbidity, preterm birth, and VTE. The study findings inform clinicians and patients about the risk of perinatal complications associated with SARS-CoV-2 infection in pregnancy and support vaccination of pregnant individuals and those planning conception.

Authors: Ferrara, Assiamira; Hedderson, Monique M; Zhu, Yeyi; Avalos, Lyndsay A; Kuzniewicz, Michael W; Myers, Laura C; Ngo, Amanda L; Gunderson, Erica P; Ritchie, Jenna L; Quesenberry, Charles P; Greenberg, Mara

JAMA Intern Med. 2022 05 01;182(5):503-512.

PubMed abstract

Continuous Glucose Monitor Use Prevents Glycemic Deterioration in Insulin-Treated Patients with Type 2 Diabetes

Continuous glucose monitoring (CGM) is indicated in poorly controlled insulin-treated patients with type 2 diabetes (T2D) to improve glycemic control and reduce the risk of hypoglycemia, but the benefits of CGM for lower risk patients have not been well studied. Among 17,422 insulin-treated patients with T2D with hemoglobin A1c (HbA1c) <8% and no recent severe hypoglycemia (based on emergency room visits or hospitalizations), CGM initiation occurred in 149 patients (17,273 noninitiators served as reference). Changes in HbA1c and severe hypoglycemia rates for the 12 months before and after CGM initiation were calculated. CGM initiation was associated with decreased HbA1c (-0.06%), whereas noninitiation was associated with increased HbA1c (+0.32%); a weighted adjusted difference-in-difference model of change in HbA1c yielded a net benefit of -0.30%; 95% CI -0.50%, -0.10%; P = 0.004). No significant differences were observed for severe hypoglycemia. CGM may be useful in preventing glycemic deterioration in well-controlled patients with insulin-treated T2D.

Authors: Karter, Andrew J; Parker, Melissa M; Moffet, Howard H; Gilliam, Lisa K; Dlott, Richard

Diabetes Technol Ther. 2022 05;24(5):332-337. Epub 2022-02-18.

PubMed abstract

Video Telehealth Access and Changes in HbA1c Among People With Diabetes

Video telehealth can offer people convenient, real-time access to clinicians without arranging transportation or time off work. Among people with diabetes, this study examines the association between video telehealth access and changes in HbA1c. This longitudinal cohort study (2016-2019) used linear regression with person-level fixed effects, stratified by baseline HbA1c (last value in 2015), to examine the association between video visit access and changes in HbA1c. HbA1c values were categorized into 3 periods of video visit exposure: (1) before any video visit, (2) during video visit transition year (calendar year of the first video visit), and (3) after video visits. The model compared changes in HbA1c values collected before the patient had any video visits with those collected after the transition year. Analyses were conducted in September 2020. Among 204,301 people with diabetes, video visit access was associated with a statistically significant reduction of 0.15 (95% CI= -0.19, -0.11) percentage points in HbA1c, with greater reductions among patients with an elevated baseline HbA1c value (-0.22 percentage points, 95% CI= -0.32, -0.11) and with no baseline HbA1c measurement (-0.39 percentage points, 95% CI= -0.71, -0.07). Gaining access to video telehealth was associated with reductions in HbA1c among people with diabetes. Video telehealth offers people with chronic conditions a new, convenient way to access health care, is not associated with worsening HbA1c, and may support better disease management, particularly among patients with higher baseline HbA1c.

Authors: Graetz, Ilana; Huang, Jie; Muelly, Emilie R; Hsueh, Loretta; Gopalan, Anjali; Reed, Mary E

Am J Prev Med. 2022 05;62(5):782-785. Epub 2021-12-08.

PubMed abstract

Association of Low-Density Lipoprotein Testing after an Atherosclerotic Cardiovascular Event with Subsequent Statin Adherence and Intensification

This study aimed to evaluate associations between outpatient low-density lipoprotein cholesterol (LDL-C) testing and subsequent statin adherence and intensification in patients after an atherosclerotic cardiovascular (ASCVD) event. This was a longitudinal study of adult members of Kaiser Permanente Northern California hospitalized with an ASCVD event (myocardial infarction or stroke) during January 01, 2016, to December 31, 2017, with follow-up through December 31, 2019. Outcomes were statin adherence (estimated using continuous medication gap [CMG]) and intensification (defined by an increased dose or switch to a higher-intensity statin) based on pharmacy dispensing. The exposure of interest was first outpatient LDL-C test after an ASCVD event. Baseline for follow-up was LDL-C test date or a date assigned using incidence density sampling. Multivariate logistic regression models were specified to estimate the odds ratios for statin adherence or intensification among those with vs without an LDL-C test, with adjustment for age, sex, race/ethnicity, smoking, hypertension, diabetes, body mass index, and estimated glomerular filtration rate. There were 19,604 adults hospitalized with ASCVD, including 7054 adults not on high-intensity statins. The mean age was 69.5 years and 33.0% were female. Prevalence of good adherence (continuous medication gap ≤20%) was significantly higher (80.2% vs 75.9%; odds ratio 1.38; 95% confidence interval, 1.28-1.49; P <.001) among participants who had an LDL-C test compared with participants who did not. LDL-C testing was associated with significantly higher rates of treatment intensification (16.1% vs 10.7%; odds ratio 1.51; 95% confidence interval,1.29-1.76; P <0.001). Low-density lipoprotein cholesterol testing is recommended for patients with a history of ASCVD and may be a high-value and low-cost intervention to improve adherence and statin management.

Authors: Rana, Jamal S; Virani, Salim S; Moffet, Howard H; Liu, Jennifer Y; Coghlan, Landis A; Vasadia, Jitesh; Ballantyne, Christie M; Karter, Andrew J

Am J Med. 2022 05;135(5):603-606. Epub 2021-11-30.

PubMed abstract

Evaluation of Incident 7-Day Infection and Sepsis Hospitalizations in an Integrated Health System

Rationale: Prehospital opportunities to predict infection and sepsis hospitalization may exist, but little is known about their incidence following common healthcare encounters. Objectives: To evaluate the incidence and timing of infection and sepsis hospitalization within 7 days of living hospital discharge, emergency department discharge, and ambulatory visit settings. Methods: In each setting, we identified patients in clinical strata based on the presence of infection and severity of illness. We estimated number needed to evaluate values with hypothetical predictive model operating characteristics. Results: We identified 97,614,228 encounters, including 1,117,702 (1.1%) hospital discharges, 4,635,517 (4.7%) emergency department discharges, and 91,861,009 (94.1%) ambulatory visits between 2012 and 2017. The incidence of 7-day infection hospitalization varied from 37,140 (3.3%) following inpatient discharge to 50,315 (1.1%) following emergency department discharge and 277,034 (0.3%) following ambulatory visits. The incidence of 7-day infection hospitalization was increased for inpatient discharges with high readmission risk (10.0%), emergency department discharges with increased acute or chronic severity of illness (3.5% and 4.7%, respectively), and ambulatory visits with acute infection (0.7%). The timing of 7-day infection and sepsis hospitalizations differed across settings with an early rise following ambulatory visits, a later peak following emergency department discharges, and a delayed peak following inpatient discharge. Theoretical number needed to evaluate values varied by strata, but following hospital and emergency department discharge, were as low as 15-25. Conclusions: Incident 7-day infection and sepsis hospitalizations following encounters in routine healthcare settings were surprisingly common and may be amenable to clinical predictive models.

Authors: Liu, Vincent X; Manickam, Raj N; Greene, John D; Schuler, Alejandro; Kipnis, Patricia; Bhimarao, Meghana; Barreda, Fernando; Escobar, Gabriel J

Ann Am Thorac Soc. 2022 05;19(5):781-789.

PubMed abstract

Prospective evaluation of social risks, physical function, and cognitive function in prediction of non-elective rehospitalization and post-discharge mortality

Increasing evidence suggests that social factors and problems with physical and cognitive function may contribute to patients’ rehospitalization risk. Understanding a patient’s readmission risk may help healthcare providers develop tailored treatment and post-discharge care plans to reduce readmission and mortality. This study aimed to evaluate whether including patient-reported data on social factors; cognitive status; and physical function improves on a predictive model based on electronic health record (EHR) data alone. We conducted a prospective study of 1,547 hospitalized adult patients in 3 Kaiser Permanente Northern California hospitals. The main outcomes were non-elective rehospitalization or death within 30 days post-discharge. Exposures included patient-reported social factors and cognitive and physical function (obtained in a pre-discharge interview) and EHR-derived data for comorbidity burden, acute physiology, care directives, prior utilization, and hospital length of stay. We performed bivariate comparisons using Chi-square, t-tests, and Wilcoxon rank-sum tests and assessed correlations between continuous variables using Spearman’s rho statistic. For all models, the results reported were obtained after fivefold cross validation. The 1,547 adult patients interviewed were younger (age, p = 0.03) and sicker (COPS2, p < 0.0001) than the rest of the hospitalized population. Of the 6 patient-reported social factors measured, 3 (not living with a spouse/partner, transportation difficulties, health or disability-related limitations in daily activities) were significantly associated (p < 0.05) with the main outcomes, while 3 (living situation concerns, problems with food availability, financial problems) were not. Patient-reported cognitive (p = 0.027) and physical function (p = 0.01) were significantly lower in patients with the main outcomes. None of the patient-reported variables, singly or in combination, improved predictive performance of a model that included acute physiology and longitudinal comorbidity burden (area under the receiver operator characteristic curve was 0.716 for both the EHR model and maximal performance of a random forest model including all predictors). In this insured population, incorporating patient-reported social factors and measures of cognitive and physical function did not improve performance of an EHR-based model predicting 30-day non-elective rehospitalization or mortality. While incorporating patient-reported social and functional status data did not improve ability to predict these outcomes, such data may still be important for improving patient outcomes.

Authors: Clancy, Heather A; Zhu, Zheng; Gordon, Nancy P; Kipnis, Patricia; Liu, Vincent X; Escobar, Gabriel J

BMC Health Serv Res. 2022 Apr 29;22(1):574. Epub 2022-04-29.

PubMed abstract

Association of standardized radiology reporting and management of abdominal CT and MRI with diagnosis of pancreatic cancer

Follow-up of abdominal computed tomography (CT) and magnetic resonance imaging (MRI) findings suspicious for pancreatic cancer may be delayed if documentation is unclear. We evaluated whether standardized reporting and follow-up of imaging results reduced time to diagnosis of pancreatic cancer. We used a quasi-experimental stepped-wedge cluster design to evaluate the effectiveness of newly implemented radiology reporting system. The system standardizes the reporting of CT and MRI reports using hashtags that classify pancreatic findings. The system also automates referral of patients with findings suspicious for pancreatic cancer to a multidisciplinary care team for rapid review and follow-up. The study examined 318,331 patients who underwent CT or MRI that included the abdomen during 2016 through 2019 who had not had an eligible CT or MRI in the preceding 24 months. We evaluated the association of the intervention with incidence of pancreatic cancer within 60 days and 120 days after imaging. 38% of patients received the intervention and 1,523 (0.48%) patients were diagnosed with pancreatic cancer. In multivariable analysis accounting for age, race/ethnicity, sex, Charlson comorbidity, history of cancer, diabetes, and 4-month calendar period, the intervention was associated with nearly 50% greater odds of diagnosing pancreatic cancer within 60 days (adjusted OR, 1.47, 95% CI, 1.05-2.06) and 120 days (adjusted OR, 1.46, 95% CI, 1.04-2.06). In this large quasi-experimental community-based observational study, implementation standardized reporting of abdominal CT and MRI reports with clinical navigation was effective for increasing the detection and diagnosis of pancreatic cancer.

Authors: Ormsby EL; Kojouri K; Chang PC; Lin TY; Vuong B; Ramirez RM; Schueler KM; Sweet CF; Herrinton LJ

Clin Gastroenterol Hepatol. 2022 Apr 15.

PubMed abstract

Developing a shared sepsis data infrastructure: a systematic review and concept map to FHIR

The development of a shared data infrastructure across health systems could improve research, clinical care, and health policy across a spectrum of diseases, including sepsis. Awareness of the potential value of such infrastructure has been heightened by COVID-19, as the lack of a real-time, interoperable data network impaired disease identification, mitigation, and eradication. The Sepsis on FHIR collaboration establishes a dynamic, federated, and interoperable system of sepsis data from 55 hospitals using 2 distinct inpatient electronic health record systems. Here we report on phase 1, a systematic review to identify clinical variables required to define sepsis and its subtypes to produce a concept mapping of elements onto Fast Healthcare Interoperability Resources (FHIR). Relevant papers described consensus sepsis definitions, provided criteria for sepsis, severe sepsis, septic shock, or detailed sepsis subtypes. Studies not written in English, published prior to 1970, or “grey” literature were prospectively excluded. We analyzed 55 manuscripts yielding 151 unique clinical variables. We then mapped variables to their corresponding US Core FHIR resources and specific code values. This work establishes the framework to develop a flexible infrastructure for sharing sepsis data, highlighting how FHIR could enable the extension of this approach to other important conditions relevant to public health.

Authors: Brant EB; Kennedy JN; King AJ; Gerstley LD; Mishra P; Schlessinger D; Shalaby J; Escobar GJ; Angus DC; Seymour CW; Liu VX

NPJ Digit Med. 2022 Apr 04;5(1):44. Epub 2022-04-04.

PubMed abstract

Prognostic Accuracy of Presepsis and Intrasepsis Characteristics for Prediction of Cardiovascular Events After a Sepsis Hospitalization

Sepsis survivors face increased risk for cardiovascular complications; however, the contribution of intrasepsis events to cardiovascular risk profiles is unclear. Kaiser Permanente Northern California (KPNC) and Intermountain Healthcare (IH) integrated healthcare delivery systems. Sepsis survivors (2011-2017 [KPNC] and 2018-2020 [IH]) greater than or equal to 40 years old without prior cardiovascular disease. Data across KPNC and IH were harmonized and grouped into presepsis (demographics, atherosclerotic cardiovascular disease scores, comorbidities) or intrasepsis factors (e.g., laboratory values, vital signs, organ support, infection source) with random split for training/internal validation datasets (75%/25%) within KPNC and IH. Models were bidirectionally, externally validated between healthcare systems. None. Changes to predictive accuracy (C-statistic) of cause-specific proportional hazards models predicting 1-year cardiovascular outcomes (atherosclerotic cardiovascular disease, heart failure, and atrial fibrillation events) were compared between models that did and did not contain intrasepsis factors. Among 39,590 KPNC and 16,388 IH sepsis survivors, 3,503 (8.8%) at Kaiser Permanente (KP) and 600 (3.7%) at IH experienced a cardiovascular event within 1-year after hospital discharge, including 996 (2.5%) at KP and 192 (1.2%) IH with an atherosclerotic event first, 564 (1.4%) at KP and 117 (0.7%) IH with a heart failure event, 2,310 (5.8%) at KP and 371 (2.3%) with an atrial fibrillation event. Death within 1 year after sepsis occurred for 7,948 (20%) KP and 2,085 (12.7%) IH patients. Combined models with presepsis and intrasepsis factors had better discrimination for cardiovascular events (KPNC C-statistic 0.783 [95% CI, 0.766-0.799]; IH 0.763 [0.726-0.801]) as compared with presepsis cardiovascular risk alone (KPNC: 0.666 [0.648-0.683], IH 0.660 [0.619-0.702]) during internal validation. External validation of models across healthcare systems showed similar performance (KPNC model within IH data C-statistic: 0.734 [0.725-0.744]; IH model within KPNC data: 0.787 [0.768-0.805]). Across two large healthcare systems, intrasepsis factors improved postsepsis cardiovascular risk prediction as compared with presepsis cardiovascular risk profiles. Further exploration of sepsis factors that contribute to postsepsis cardiovascular events is warranted for improved mechanistic and predictive models.

Authors: Walkey AJ; Myers LC; Go AS; Liu VX; et al.

Crit Care Explor. 2022 Apr;4(4):e0674. Epub 2022-04-08.

PubMed abstract

Evaluation of Outcomes Following Hospital-Wide Implementation of a Subcutaneous Insulin Protocol for Diabetic Ketoacidosis

Standard diabetic ketoacidosis care in the US includes intravenous insulin treatment in the intensive care unit. Subcutaneous (SQ) insulin could decrease intensive care unit need, but the data are limited. To assess outcomes after implementation of an SQ insulin protocol for treating diabetic ketoacidosis. This cohort study is a retrospective evaluation of a prospectively implemented SQ insulin protocol. The study was conducted at an integrated health care system in Northern California. Participants included hospitalized patients with diabetic ketoacidosis at 21 hospitals between January 1, 2010, and December 31, 2019. The preimplementation phase was 2010 to 2015, and the postimplementation phase was 2017 to 2019. Data analysis was performed from October 2020 to January 2022. An SQ insulin treatment protocol for diabetic ketoacidosis. Difference-in-differences evaluation of the need for intensive care, mortality, readmission, and length of stay at a single intervention site using an SQ insulin protocol from 2017 onward compared with 20 control hospitals using standard care. A total of 7989 hospitalizations for diabetic ketoacidosis occurred, with 4739 (59.3%) occurring before and 3250 (40.7%) occurring after implementation. The overall mean (SD) age was 42.3 (17.7) years, with 4137 hospitalizations (51.8%) occurring among female patients. Before implementation, SQ insulin was the first insulin used in 40 intervention (13.4%) and 651 control (14.7%) hospitalizations. After implementation, 98 hospitalizations (80.3%) received SQ insulin first at the intervention site compared with 402 hospitalizations (12.8%) at control sites. The adjusted rate ratio for intensive care unit admission was 0.43 (95% CI, 0.33-0.56) at the intervention sites, a 57% reduction compared with control sites, and was 0.50 (95% CI, 0.25-0.99) for 30-day hospital readmission, a 50% reduction. There were no significant changes in hospital length of stay and rates of death. These findings suggest that a protocol based on SQ insulin for diabetic ketoacidosis treatment was associated with significant decreases in intensive care unit need and readmission, with no evidence of increases in adverse events.

Authors: Rao, Priya; Jiang, Sheng-Fang; Kipnis, Patricia; Patel, Divyesh M; Katsnelson, Svetlana; Madani, Samineh; Liu, Vincent X

JAMA Netw Open. 2022 Apr 01;5(4):e226417. Epub 2022-04-01.

PubMed abstract

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

Communities of color have been disproportionately impacted by the COVID-19 epidemic in the USA. 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. 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. We examined the independent relationships of demographic, medical, and social factors on SARS-COV-2 testing and positivity between March 1, 2020, and November 30, 2020, by race/ethnicity. Findings were similar in the two cohorts, with Latino (16-18%), Asian (11-14%), and Black (11-12%) members having the highest prevalence of SARS-COV-2 infection (ORs adjusted for age, gender, and use of interpreter ranging from 1.68 to 2.23 compared to White member [7-8%], p < 0.001). Further adjustment for medical comorbidity (e.g., obesity, diabetes, chronic lung disease); neighborhood measures; and self-reported social risk factors (e.g., trouble paying for basics, food insecurity, housing concerns, transportation barriers) did not appreciably change these results. Compared to non-Latino White members, members of other race/ethnic groups had higher positivity rates that were only minimally reduced after controlling for medical and neighborhood conditions and self-reported social risk factors. These findings suggest that traditional infection transmission factors such as essential work roles and household size that have disproportionate representation among communities of color may be important contributors to SARS-COV-2 infection among insured adults.

Authors: McCloskey, Jodi K; Ellis, Jennifer L; Uratsu, Connie S; Drace, Melanie L; Ralston, James D; Bayliss, Elizabeth A; Grant, Richard W

J Gen Intern Med. 2022 04;37(5):1183-1190. Epub 2022-02-02.

PubMed abstract

Primary care telemedicine during the COVID-19 pandemic: patient’s choice of video versus telephone visit

The aim of this study is to examine the association between patient characteristics and primary care telemedicine choice among integrated delivery system patients self-scheduling visits during the COVID-19 pandemic. We used multivariate logistic regression to examine the association between the choice of video versus telephone and patient sociodemographic characteristics and technology access among patient-initiated primary care telemedicine visits scheduled online from March to October 2020. Among 978 272 patient-scheduled primary care telemedicine visits, 39% were video visits. Patients of Black or Hispanic race/ethnicity, or living in low socioeconomic status or low internet access neighborhoods were less likely to schedule video visits. Patients 65 years or older, with prior video visit experience or mobile portal access, or visiting their own personal provider were more likely to schedule video visits. While video adoption was substantial in all patient groups examined, differences in telemedicine choice suggest the persistence of a digital divide, emphasizing the importance of maintaining a telephone telemedicine option.

Authors: Huang, Jie; Graetz, Ilana; Millman, Andrea; Gopalan, Anjali; Lee, Catherine; Muelly, Emilie; Reed, Mary E

JAMIA Open. 2022 Apr;5(1):ooac002. Epub 2022-01-19.

PubMed abstract

Differences in Health Characteristics of Geographic Subgroups of Arab Americans in a Northern California Health Plan

Arab Americans are a diverse ethnic group originating from a large geographic area in the Middle East and North Africa (MENA). We aim to characterize differences in health between Arab Americans from different geographic subgroups within MENA. We used cross-sectional electronic health record (EHR) data for a subset of 4913 Arab Americans aged 20-84 in a 2016 Northern California health plan study cohort who could be assigned to one of 4 geographic subgroups (Gulf, African, Levant, and Other) based on EHR ethnicity data. We calculated age-adjusted prevalence estimates for men and women and used generalized linear models to compare Gulf, African, and Other subgroups to Levant Arabs on risk factors (obesity and smoking), chronic conditions (diabetes, hypertension, hyperlipidemia, and asthma), and mental health (depression and anxiety). Among women, prevalence of smoking was lower among Gulf, African, and Other Arabs than Levant Arabs. Among men, prevalence of obesity, diabetes, and hyperlipidemia was lower among Gulf, African, and Other Arabs than Levant Arabs, while prevalence of depression was higher for these subgroups than Levant Arabs. We found substantial differences in health characteristics across Arab Americans from different geographic subgroups. Our results suggest that more detailed race and ethnicity information should be collected on Arab Americans to better understand their diverse health risks.

Authors: Abuelezam, Nadia N; El-Sayed, Abdulrahman M; Galea, Sandro; Gordon, Nancy P

J Racial Ethn Health Disparities. 2022 Apr;9(2):399-405. Epub 2021-01-27.

PubMed abstract

All in the Family: A Qualitative Study of the Early Experiences of Adults with Younger Onset Type 2 Diabetes

Adults with type 2 diabetes diagnosed at a younger age are at increased risk for poor outcomes. We examined life stage-related facilitators and barriers to early self-management among younger adults with newly diagnosed type 2 diabetes. We conducted 6 focus groups that each met twice between November 2017 and May 2018. Participants (n = 41) were aged 21 to 44 years and diagnosed with type 2 diabetes during the prior 2 years. Transcripts were coded using thematic analysis and themes were mapped to the Capability-Opportunity-Motivation-Behavior framework. Participants were 38.4 (±5.8) years old; 10 self-identified as Latinx, 12 as Black, 12 as White, and 7 as multiple or other races. We identified 9 themes that fell into 2 categories: (1) the impact of having an adult family member with diabetes, and (2) the role of nonadult children. Family members with diabetes served as both positive and negative role models, and, for some, personal familiarity with the disease made adjusting to the diagnosis easier. Children facilitated their parents’ self-management by supporting self-management activities and motivating their parents to remain healthy. However, the stress and time demands resulting from parental responsibilities and the tendency to prioritize children’s needs were perceived as barriers to self-management. Our results highlight how the life position of younger-onset individuals with type 2 diabetes influences their early experiences. Proactively addressing perceived barriers to and facilitators of self-management in the context of family history and parenthood may aid in efforts to support these high-risk, younger patients.

Authors: Gopalan, Anjali; Blatchins, Maruta A; Xu, Karen K; Altschuler, Andrea; Marshall, Cassondra J; Hessler, Danielle M; Fernandez, Alicia; Grant, Richard W

J Am Board Fam Med. 2022 Mar-Apr;35(2):341-351.

PubMed abstract

Future of Teleoncology: Trends and Disparities in Telehealth and Secure Message Utilization in the COVID-19 Era

The COVID-19 pandemic created an imperative to re-examine the role of telehealth in oncology. We studied trends and disparities in utilization of telehealth (video and telephone visits) and secure messaging (SM; ie, e-mail via portal/app), before and during the pandemic. Retrospective cohort study of hematology/oncology patient visits (telephone/video/office) and SM between January 1, 2019, and September 30, 2020, at Kaiser Permanente Northern California. Among 334,666 visits and 1,161,239 SM, monthly average office visits decreased from 10,562 prepandemic to 1,769 during pandemic, telephone visits increased from 5,114 to 8,663, and video visits increased from 40 to 4,666. Monthly average SM increased from 50,788 to 64,315 since the pandemic began. Video visits were a significantly higher fraction of all visits (P < .01) in (1) younger patients (Generation Z 48%, Millennials 46%; Generation X 40%; Baby Boomers 34.4%; Silent Generation 24.5%); (2) patients with commercial insurance (39%) compared with Medicaid (32.7%) or Medicare (28.1%); (3) English speakers (33.7%) compared with those requiring an interpreter (24.5%); (4) patients who are Asian (35%) and non-Hispanic White (33.7%) compared with Black (30.1%) and Hispanic White (27.5%); (5) married/domestic partner patients (35%) compared with single/divorced/widowed (29.9%); (6) Charlson comorbidity index ≤ 3 (36.2%) compared with > 3 (31.3%); and (7) males (34.6%) compared with females (32.3%). Similar statistically significant SM utilization patterns were also seen. In the pandemic era, hematology/oncology telehealth and SM use rapidly increased in a manner that is feasible and sustained. Possible disparities existed in video visit and SM use by age, insurance plan, language, race, ethnicity, marital status, comorbidities, and sex.

Authors: Neeman, Elad; Lyon, Liisa; Sun, Hongxin; Conell, Carol; Reed, Mary; Kumar, Deepika; Kolevska, Tatjana; Kotak, Dinesh; Sundaresan, Tilak; Liu, Raymond

JCO Clin Cancer Inform. 2022 Mar;6:e2100160.

PubMed abstract

Comparison of cognitive function in older adults with type 1 diabetes, type 2 diabetes, and no diabetes: results from the Study of Longevity in Diabetes (SOLID)

The incidence of both type 1 diabetes (T1D) and type 2 diabetes (T2D) is increasing. Life expectancy is improving in T1D, resulting in a growing population of elderly adults with diabetes. While it is well established that older adults with T2D are at increased risk of cognitive impairment, little is known regarding cognitive aging in T1D and how their cognitive profiles may differ from T2D. We compared baseline cognitive function and low cognitive function by diabetes status (n=734 T1D, n=232 T2D, n=247 without diabetes) among individuals from the Study of Longevity in Diabetes (mean age=68). We used factor analysis to group cognition into five domains and a composite measure of total cognition. Using linear and logistic regression models, we examined the associations between diabetes type and cognitive function, adjusting for demographics, comorbidities, depression, and sleep quality. T1D was associated with lower scores on total cognition, language, executive function/psychomotor processing speed, and verbal episodic memory, and greater odds of low executive function/psychomotor processing speed (OR=2.99, 95% CI 1.66 to 5.37) and verbal episodic memory (OR=1.92, 95% CI 1.07 to 3.46), compared with those without diabetes. T2D was associated with lower scores on visual episodic memory. Compared with T2D, T1D was associated with lower scores on verbal episodic memory and executive function/psychomotor processing speed and greater odds of low executive function/psychomotor processing speed (OR=1.74, 95% CI 1.03 to 2.92). Older adults with T1D had significantly poorer cognition compared with those with T2D and those without diabetes even after accounting for a range of comorbidities. Future studies should delineate how to reduce risk in this vulnerable population who are newly surviving to old age.

Authors: Lacy, Mary E; Moran, Chris; Gilsanz, Paola; Beeri, Michal S; Karter, Andrew J; Whitmer, Rachel A

BMJ Open Diabetes Res Care. 2022 03;10(2).

PubMed abstract

The COVID-19 Pandemic Strikes Again and Again and Again

Authors: Myers, Laura C; Liu, Vincent X

JAMA Netw Open. 2022 03 01;5(3):e221760. Epub 2022-03-01.

PubMed abstract

Smoking and Risk of Premature Atherosclerotic Cardiovascular Disease

Authors: Rana, Jamal S; Moffet, Howard H; Liu, Jennifer Y; Nasir, Khurram; Blankstein, Ron; Karter, Andrew J; Sidney, Stephen

Am J Prev Med. 2022 03;62(3):466-468. Epub 2021-11-17.

PubMed abstract

Impact of the Affordable Care Act on Colorectal Cancer Incidence and Mortality

The Patient Protection and Affordable Care Act eliminated cost sharing for preventive services, including colorectal cancer screening for individuals aged 50-75 years with private health insurance. This study examines the impact of the Affordable Care Act’s removal of cost sharing for colorectal cancer screening on colorectal cancer incidence and mortality. Trends in colorectal cancer incidence and colorectal cancer‒related mortality were modeled among 2,113,283 Kaiser Permanente Northern California members aged ≥50 years between 2003 and 2016 using an interrupted time-series design. As a sensitivity analysis, a controlled analysis utilized a comparison group of members covered with pre‒Affordable Care Act zero cost sharing for colorectal cancer screening. Analyses were performed in 2019 and 2020. The colorectal cancer incidence dropped by 17% around the time the Affordable Care Act was enacted (change in level incidence rate ratio; 95% CI=0.77, 0.90, 2-sided p-value <0.0001), followed by a 3% further decrease per year (95% CI=0.93, 1.00, p=0.05). A similar pattern was observed for colorectal cancer‒related mortality. The controlled results indicated that the elimination of cost sharing for screening due to the Affordable Care Act was associated with greater improvements in colorectal cancer outcomes among members previously covered by health plans with out-of-pocket costs for screening than among those with health plans with zero cost sharing for screening before the Affordable Care Act. The elimination of cost sharing for colorectal cancer screening due to the Affordable Care Act was associated with a decrease in age-, race/ethnicity-, and sex-adjusted colorectal cancer incidence and colorectal cancer‒related mortality, implying that policies that remove barriers to screening, particularly financial burden from cost sharing, can result in improved colorectal cancer outcomes.

Authors: Lee, Catherine; Kushi, Lawrence H; Reed, Mary E; Eldridge, Elizabeth H; Lee, Jeffrey K; Zhang, Jie; Spiegelman, Donna

Am J Prev Med. 2022 03;62(3):387-394. Epub 2021-11-08.

PubMed abstract

Association of Intensive Care Unit Admission and Outcomes in Sepsis and Acute Respiratory Failure

Rationale: Many decisions to admit patients to the ICU are not grounded in evidence regarding who benefits from such triage, straining ICU capacity and limiting its cost-effectiveness. Objectives: To measure the benefits of ICU admission for patients with sepsis or acute respiratory failure. Methods: At 27 United States hospitals across two health systems from 2013 to 2018, we performed a retrospective cohort study using two-stage instrumental variable quantile regression with a strong instrument (hospital capacity strain) governing ICU versus ward admission among high-acuity patients (i.e., laboratory-based acute physiology score v2 ⩾ 100) with sepsis and/or acute respiratory failure who did not require mechanical ventilation or vasopressors in the emergency department. Measurements and Main Results: Among patients with sepsis (n = 90,150), admission to the ICU was associated with a 1.32-day longer hospital length of stay (95% confidence interval [CI], 1.01-1.63; P < 0.001) (when treating deaths as equivalent to long lengths of stay) and higher in-hospital mortality (odds ratio, 1.48; 95% CI, 1.13-1.88; P = 0.004). Among patients with respiratory failure (n = 45,339), admission to the ICU was associated with a 0.82-day shorter hospital length of stay (95% CI, -1.17 to -0.46; P < 0.001) and reduced in-hospital mortality (odds ratio, 0.75; 95% CI, 0.57-0.96; P = 0.04). In sensitivity analyses of length of stay, excluding, ignoring, or censoring death, results were similar in sepsis but not in respiratory failure. In subgroup analyses, harms of ICU admission for patients with sepsis were concentrated among older patients and those with fewer comorbidities, and the benefits of ICU admission for patients with respiratory failure were concentrated among older patients, highest-acuity patients, and those with more comorbidities. Conclusions: Among high-acuity patients with sepsis who did not require life support in the emergency department, initial admission to the ward, compared with the ICU, was associated with shorter length of stay and improved survival, whereas among patients with acute respiratory failure, triage to the ICU compared with the ward was associated with improved survival.

Authors: Anesi, George L; Liu, Vincent X; Chowdhury, Marzana; Small, Dylan S; Wang, Wei; Delgado, M Kit; Bayes, Brian; Dress, Erich; Escobar, Gabriel J; Halpern, Scott D

Am J Respir Crit Care Med. 2022 03 01;205(5):520-528.

PubMed abstract

Patient Experience and Satisfaction with Immediate Sequential and Delayed Sequential Bilateral Cataract Surgery

In bilaterally pseudophakic patients who received immediate or delayed sequential bilateral cataract surgery (ISBCS or DSBCS), we sought to determine patient experience, particularly related to the loss of opportunity to modify the surgical plan for the second eye. Cross-sectional. Patients who received ISBCS (n = 1818) and DSBCS (n = 1818) in the Kaiser Permanente Northern California system between 2017 and 2019 who actively used the electronic patient portal were randomly selected and sent a survey link. The survey inquired about reasons for choosing ISBCS or DSBCS, concerns about surgery, and whether the loss of opportunity to modify the surgical plan for the second eye affected the patient’s decision to undergo ISBCS. Participation was 18% among patients who received ISBCS and 17% among patients who received DSBCS. Of the patients who received ISBCS, 96% would choose ISBCS again while 80% of patients who received DSBCS would choose DSBCS again (P < .0001). Convenience was the leading reason patients chose ISBCS (65%), whereas surgeon recommendation was the primary reason patients chose DSBCS (68%). Sixteen percent of patients who received ISBCS and 38% of patients who received DSCBS reported that the possibility of modifying the surgical plan to reduce the need for corrective lenses in the second eye was an important consideration (P < .0001). Compared with patient who chose DSBCS, patients who chose ISBCS were more likely to choose ISBCS again and to recommend ISBCS to a family member or friend. The option to modify the surgical plan for the second eye to reduce need for glasses or contact lenses was not an important consideration for most of either group.

Authors: Carolan, James A; Amsden, Laura B; Lin, Andrew; Shorstein, Neal; Herrinton, Lisa J; Liu, Liyan; Carnahan, Matthew

Am J Ophthalmol. 2022 03;235:241-248. Epub 2021-09-25.

PubMed abstract

Outcomes After Implementation of a Benzodiazepine-Sparing Alcohol Withdrawal Order Set in an Integrated Health Care System

Alcohol withdrawal syndrome (AWS) is a common inpatient diagnosis managed primarily with benzodiazepines. Concerns about the adverse effects associated with benzodiazepines have spurred interest in using benzodiazepine-sparing treatments. To evaluate changes in outcomes after implementation of a benzodiazepine-sparing AWS inpatient order set that included adjunctive therapies (eg, gabapentin, valproic acid, clonidine, and dexmedetomidine). This difference-in-differences quality improvement study was conducted among 22 899 AWS adult hospitalizations from October 1, 2014, to September 30, 2019, in the Kaiser Permanente Northern California integrated health care delivery system. Data were analyzed from September 2020 through November 2021. Implementation of the benzodiazepine-sparing AWS order set on October 1, 2018. Adjusted rate ratios for medication use, inpatient mortality, length of stay, intensive care unit admission, and nonelective readmission within 30 days were calculated comparing postimplementation and preimplementation periods among hospitals with and without order set use. Among 904 540 hospitalizations in the integrated health care delivery system during the study period, AWS was present in 22 899 hospitalizations (2.5%), occurring among 16 323 unique patients (mean [SD] age, 57.1 [14.8] years; 15 764 [68.8%] men). Of these hospitalizations, 12 889 (56.3%) used an order set for alcohol withdrawal. Among hospitalizations with order set use, any benzodiazepine use decreased after implementation from 6431 hospitalizations (78.1%) to 2823 hospitalizations (60.7%) (P < .001), with concomitant decreases in the mean (SD) total dosage of lorazepam before vs after implementation (19.7 [38.3] mg vs 6.0 [9.1] mg; P < .001). There were also significant changes from before to after implementation in the use of adjunctive medications, including gabapentin (2413 hospitalizations [29.3%] vs 2814 hospitalizations [60.5%]; P < .001), clonidine (1476 hospitalizations [17.9%] vs 2208 hospitalizations [47.5%]; P < .001), thiamine (6298 hospitalizations [76.5%] vs 4047 hospitalizations [87.0%]; P < .001), valproic acid (109 hospitalizations [1.3%] vs 256 hospitalizations [5.5%]; P < .001), and phenobarbital (412 hospitalizations [5.0%] vs 292 hospitalizations [6.3%]; P = .003). Compared with AWS hospitalizations without order set use, use of the benzodiazepine-sparing order set was associated with decreases in intensive care unit use (adjusted rate ratio [ARR], 0.71; 95% CI, 0.56-0.89; P = .003) and hospital length of stay (ARR, 0.71; 95% CI, 0.58-0.86; P < .001). This study found that implementation of a benzodiazepine-sparing AWS order set was associated with decreased use of benzodiazepines and favorable trends in outcomes. These findings suggest that further prospective research is needed to identify the most effective treatments regimens for patients hospitalized with alcohol withdrawal.

Authors: Smith, Joshua T; Sage, Mary; Szeto, Herb; Myers, Laura C; Lu, Yun; Martinez, Adriana; Kipnis, Patricia; Liu, Vincent X

JAMA Netw Open. 2022 02 01;5(2):e220158. Epub 2022-02-01.

PubMed abstract

Chilblains and COVID-19-an Update on the Complexities of Interpreting Antibody Test Results, the Role of Interferon α, and COVID-19 Vaccines-Reply

Authors: McCleskey, Patrick E; Lieberman, Amara; Herrinton, Lisa J

JAMA Dermatol. 2022 02 01;158(2):218-219.

PubMed abstract

Differential Cardiometabolic Risk Factor Clustering Across U.S. Asian Ethnic Groups

Authors: Kizzee, Olivia P; Lo, Joan C; Ramalingam, Nirmala D; Rana, Jamal S; Gordon, Nancy P

Am J Prev Med. 2022 02;62(2):e129-e131. Epub 2021-10-07.

PubMed abstract

Connecting Research and Practice: Implementation of Suicide Prevention Strategies in Learning Health Care Systems

The health care systems affiliated with the Mental Health Research Network strive to be learning health care systems that identify and address evidence gaps of importance to clinicians, patients, and funders. This column describes how research guides clinical care and clinical care guides research in the area of suicide prevention as well as some of the challenges of conducting embedded research.

Authors: Rossom, Rebecca C; Sterling, Stacy; Liu, Vincent; Simon, Greg E; et al.

Psychiatr Serv. 2022 02 01;73(2):219-222. Epub 2021-06-30.

PubMed abstract

Performance of Predictive Models for 30-day Hospitalization and Mortality after COVID-19 Infection

Authors: Myers, Laura C; Kipnis, Patricia; O'Suilleabhain, Liam; Escobar, Gabriel; Liu, Vincent X

Ann Am Thorac Soc. 2022 01;19(1):131-134.

PubMed abstract

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

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. We investigated the barriers experienced by patients who persistently struggled to reach their CVD risk factor control goals. This qualitative study examined patient, clinician, and researcher observations of individuals’ experiences in a chronic disease management program. All participants (n = 332) were enrolled in a clinical trial testing a skills-based group intervention seeking to improve healthcare engagement. Data were analyzed through a general inductive approach and resulting themes were structured along the Capability-Opportunity-Motivation-Behavior framework. Analyses identified care engagement barriers related to participants’ communication skills and activation, care team relationship processes, and emotional factors. Although most participants reported benefitting from skills training, persistent barriers included distrust of their providers, shame about health challenges, and dissatisfaction with care team interactions that were described as impersonal or unresponsive. Efforts to support engagement in CVD risk factor management programs should address whether patients and their care team have the necessary skills, opportunities and confidence to proactively communicate health needs and engage in non-judgmental interactions for goal-setting, rapport-building, and shared decision-making.

Authors: Fang, Anya; Abdelgadir, Dana; Gopalan, Anjali; Ross, Thekla; Uratsu, Connie S; Sterling, Stacy A; Grant, Richard W; Iturralde, Esti

Patient Educ Couns. 2022 01;105(1):182-189. Epub 2021-05-04.

PubMed abstract

Did the 2015 USPSTF Abnormal Blood Glucose Recommendations Change Clinician Attitudes or Behaviors? A Mixed-Method Assessment

In 2015, the US Preventive Services Task Force (USPSTF) revised clinical recommendations to more broadly recommend abnormal blood glucose screening and more clearly recommend referral to behavioral interventions for adults with prediabetes. To assess the effects of the 2015 USPSTF recommendation changes on abnormal blood glucose screening and referral to behavioral interventions, and to examine physicians’ perceptions of the revised recommendation. We utilized a sequential, dependent mixed-methods triangulation design. A total of 33,444 patients meeting USPSTF abnormal blood glucose screening criteria within 15 health system-affiliated primary care practices and 20 primary care physicians in North Carolina. We assessed monthly abnormal blood glucose screening rate and monthly referral rate to behavioral interventions. To estimate trend changes in outcomes, we used segmented linear regression analysis of interrupted time-series data. We gathered physicians’ perspectives on the 2015 USPSTF abnormal blood glucose recommendation including awareness of, agreement with, adoption of, and adherence to the recommendation. To analyze qualitative data, we used directed content analysis. There was a slight significant change in trend in abnormal blood glucose screening rates post-recommendation. There was a slight, statistically significant decrease in referral rates to behavioral interventions post-recommendation. Physicians were generally unaware of the revisions to the 2015 USPSTF abnormal blood glucose recommendation; however, once the recommendations were described, physicians agreed with the screening recommendation but felt that the behavioral intervention referral recommendation was hard to implement. The 2015 USPSTF abnormal blood glucose guideline had little to no effect on abnormal blood glucose screening or referral to behavioral interventions in North Carolina practices. Potential interventions to improve these rates could include clinical decision tools embedded in the electronic health record and better referral systems for community-based diabetes prevention programs.

Authors: Thomas, Tainayah W; Golin, Carol E; Kinlaw, Alan C; Kirkman, M Sue; Golden, Shelley D; Lightfoot, Alexandra F; Samuel-Hodge, Carmen D

J Gen Intern Med. 2022 01;37(1):15-22. Epub 2021-04-07.

PubMed abstract

Precision communication: Physicians’ linguistic adaptation to patients’ health literacy

Authors: Schillinger, Dean; Duran, Nicholas D; McNamara, Danielle S; Crossley, Scott A; Balyan, Renu; Karter, Andrew J

Sci Adv. 2021 Dec 17;7(51):eabj2836. Epub 2021-12-17.

PubMed abstract

Oral Health Care: A Missing Pillar of Total Health Care?

Oral health is an important component of overall health, and preventive dental care is essential for maintaining good oral health. However, many patients face significant barriers to preventive dental care. We examined prevalence of and factors associated with no recent preventive dental care in an adult health plan population. For this cross-sectional study, we used data for 19,672 Kaiser Permanente members aged 25-85 who participated in the 2014/2015 or 2017 Member Health Survey (MHS) and 20,329 Medicaid members who completed an intake questionnaire. We estimated percentages of adults with no preventive dental care (teeth cleaning and examination by a dental professional) in the prior 12 months, overall and among four racial groups, by age, sex, education, income, and dental care cost factors. We used logistic regression to model associations of sociodemographic and cost factors with no preventive dental care. We also examined lack of preventive dental care in subgroups at elevated risk for periodontal disease. Overall prevalence of no preventive dental care was 21%, with significant differences by race (non-Hispanic White, 19.6%; African-American/Black, 29.3%; Latinx, 24.9%, Asian American/Pacific Islander, 19.6%). Adults with lower educational attainment and household income and dental care cost barriers were more likely to lack preventive dental care. Racial and socioeconomic factors remained significant in the multivariable models. Lack of preventive dental care was fairly common among adults with diabetes, prediabetes, hypertension, smokers, frequent consumption of sugary beverages, and Medicaid coverage. Oral health care should be better integrated with primary medical care to promote adult total health.

Authors: Gordon, Nancy P; Mosen, David M; Banegas, Matthew P

Perm J. 2021 12 03;25. Epub 2021-12-03.

PubMed abstract

ASO Author Reflections: Volume Matters-Longitudinal Retrospective Cohort Study of Outcomes Following Consultation and Standardization of Adrenal Surgery

Authors: Rahbari, Reza; Herrinton, Lisa J

Ann Surg Oncol. 2021 12;28(13):8861-8862. Epub 2021-06-29.

PubMed abstract

Hospital-specific Template Matching for Benchmarking Performance in a Diverse Multihospital System

Hospital-specific template matching is a newer method of hospital performance measurement that may be fairer than regression-based benchmarking. However, it has been tested in only limited research settings. The objective of this study was to test the feasibility of hospital-specific template matching assessments in the Veterans Affairs (VA) health care system and determine power to detect greater-than-expected 30-day mortality. Observational cohort study with hospital-specific template matching assessment. For each VA hospital, the 30-day mortality of a representative subset of hospitalizations was compared with the pooled mortality from matched hospitalizations at a set of comparison VA hospitals treating sufficiently similar patients. The simulation was used to determine power to detect greater-than-expected mortality. A total of 556,266 hospitalizations at 122 VA hospitals in 2017. A number of comparison hospitals identified per hospital; 30-day mortality. Each hospital had a median of 38 comparison hospitals (interquartile range: 33, 44) identified, and 116 (95.1%) had at least 20 comparison hospitals. In total, 8 hospitals (6.6%) had a significantly lower 30-day mortality than their benchmark, 5 hospitals (4.1%) had a significantly higher 30-day mortality, and the remaining 109 hospitals (89.3%) were similar to their benchmark. Power to detect a standardized mortality ratio of 2.0 ranged from 72.5% to 79.4% for a hospital with the fewest (6) versus most (64) comparison hospitals. Hospital-specific template matching may be feasible for assessing hospital performance in the diverse VA health care system, but further refinements are needed to optimize the approach before operational use. Our findings are likely applicable to other large and diverse multihospital systems.

Authors: Vincent, Brenda M; Molling, Daniel; Escobar, Gabriel J; Hofer, Timothy P; Iwashyna, Theodore J; Liu, Vincent X; Rosen, Amy K; Ryan, Andrew M; Seelye, Sarah; Wiitala, Wyndy L; Prescott, Hallie C

Med Care. 2021 12 01;59(12):1090-1098.

PubMed abstract

Assess COVID-19 prognosis … but be aware of your instrument’s accuracy!

Authors: Capuzzo, Maurizia; Amaral, Andre Carlos Kajdacsy-Balla; Liu, Vincent X

Intensive Care Med. 2021 12;47(12):1472-1474. Epub 2021-10-05.

PubMed abstract

Prior Immunosuppressive Therapy and Severe Illness Among Patients Diagnosed with SARS-CoV-2: a Community-Based Study

An estimated 10 million people in the USA are immunocompromised, a risk factor for severe COVID-19. Data informing whether immune-mediated medications lead to more severe infection are sparse. Determine whether outpatient immunosuppressive therapies that treat autoimmune inflammatory disease or prevent solid organ transplant rejection are associated with severe illness after diagnosis with SARS-CoV-2 DESIGN: Retrospective cohort study PARTICIPANTS: Adults with a positive PCR nasal swab for SARS-CoV-2 from February 25 to September 9, 2020, cared for within a large integrated health care organization MAIN MEASURES: Exposure was defined as an outpatient fill of prednisone, immunomodulator, small-molecule, or biologic therapy in the 105 days prior to a positive SARS-CoV-2 PCR test. The main outcome was either hospitalization, ICU admission, or death within 45 days after diagnosis of SARS-CoV-2. Multivariable logistic regression models were adjusted for age, race, gender, body mass index, comorbidities, and autoimmune disease. A total of 39,686 adults had a positive PCR test. In the primary analysis, prior prednisone use was associated with severe illness after diagnosis with SARS-CoV-2 (odds ratio (OR) 1.31; 95% confidence interval (CI) 1.08-1.60); however, immunomodulator (OR 0.88; 95% CI 0.57-1.34) and biologic/small-molecule therapy (OR 1.26; 95% CI 0.79-2.00) were not. Secondary analyses showed variable risk among therapies: Janus-kinase inhibitors had an increased odds of severe illness (OR 3.35; 95% CI 1.16-9.67), thiopurines/conventionaldisease-modifying antirheumatic drugs had a reduced odds (OR 0.53; 95% CI 0.32-0.88), and tumor necrosis factor inhibitors were not associated (OR 0.45; 95% CI 0.18-1.08). Outpatient use of prednisone is associated with severe illness after diagnosis of SARS-CoV-2. Immunomodulator and biologic/small-molecule therapy were not associated, but different risk subgroups were identified. Our findings can inform risk-benefit discussions in the clinic and risk-based recommendations for patients on these therapies.

Authors: Velayos, Fernando S; Dusendang, Jennifer R; Schmittdiel, Julie A

J Gen Intern Med. 2021 12;36(12):3794-3801. Epub 2021-09-28.

PubMed abstract

Racial and Ethnic Differences in Age at Diabetes Diagnosis-A Call for Action

Authors: Gopalan, Anjali; Habib, Anand R; Grant, Richard W

JAMA Intern Med. 2021 12 01;181(12):1560-1561.

PubMed abstract

Volume Matters: Longitudinal Retrospective Cohort Study of Outcomes Following Consultation and Standardization of Adrenal Surgery

Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting. In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010-2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics. In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9-3.1) to 4.1 (95% CI 3.5-4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6-3.1) to 9.9 (95% CI 4.9-14.9), while hospital volume increased from 3.5 (95% CI 2.3-4.6) to 15.4 (95% CI 6.9-24.0). Operative time was 34 (23-45) min faster in 2018-2019 compared with 2010-2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change. Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.

Authors: Rahbari, Reza; Herrinton, Lisa J; et al.

Ann Surg Oncol. 2021 Dec;28(13):8849-8860. Epub 2021-06-17.

PubMed abstract

Weight Outcomes of Sleeve Gastrectomy and Gastric Bypass Compared to Nonsurgical Treatment

To investigate weight trajectories among patients with severe obesity undergoing sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and nonsurgical treatment. Although bariatric procedures are associated with substantial weight loss, few studies have compared surgical outcomes to nonsurgical treatment, particularly for SG. In this retrospective, matched cohort study, adult patients with body mass index ≥35 kg/m2 who underwent RYGB or SG procedures from January 2005 through September 2015 were matched to 87,965 nonsurgical patients. Hierarchical linear models were used to investigate percent total weight loss (%TWL) and regain at 5 years among RYGB, SG, and nonsurgical patients, and at 10 years for RYGB and nonsurgical patients. Among 13,900 SG, 17,258 RYGB, and 87,965 nonsurgical patients, the 5-year follow-up rate was 70.9%, 72.0%, and 64.5%, respectively. At 1 year, RYGB patients had 28.4%TWL (95% confidence interval: 28.2, 28.5), SG 23.0%TWL (22.8, 23.2), and nonsurgical patients 0.2%TWL (0.1, 0.4). At 5 years, RYGB had 21.7%TWL (21.5, 22.0), SG 16.0%TWL (15.4, 16.6), and nonsurgical patients 2.2%TWL (2.0, 2.5). After 5 years, 3.7% of RYGB and 10.1% of SG patients had regained weight to within 5% of baseline. At 10 years, RYGB patients had 20.2%TWL (19.3, 21.0) and nonsurgical patients 4.8%TWL (4.0, 5.5). In this study, patients with severe obesity who underwent SG and RYGB lost significantly more weight at 5 years than nonsurgical patients. Weight regain was common after surgery but regain to within 5% of baseline was rare.

Authors: Arterburn DE; Johnson E; Coleman KJ; Herrinton LJ; Courcoulas AP; Fisher D; Li RA; Theis MK; Liu L; Fraser JR; Haneuse S

Ann Surg. 2021 12 01;274(6):e1269-e1276.

PubMed abstract

Computed Tomography Use in Children With Minor Head Trauma Presenting to 21 Community Emergency Departments Within an Integrated Health-Care System

Decreasing unnecessary cranial computed tomography (CT) use in pediatric head trauma patients remains important for emergency departments (EDs) across the US. Our study evaluated CT use in children with minor blunt head trauma in 21 community EDs within an integrated health-care system. We studied all children younger than 18 years old presenting to 21 community EDs between 2016 through 2018 with acute minor blunt head trauma, defined by an algorithm of ED chief complaints and diagnoses. We excluded patients with traumatic brain injuries diagnosed in the prior year, a CT within 24 hours prior to the ED visit, or an ED Glasgow Coma Scale score of less than 14. Among 39,792 pediatric minor head trauma ED visits, the aggregate CT use proportion across all EDs was 12.9% [95% confidence interval (CI), 12.6-13.3%; facility-level range, 5.4-21.6%]. The 7 facilities that had previously received a clinical decision support system intervention implementing the Pediatric Emergency Care Applied Research Network rules during 2013 through 2014 had an aggregate mean CT ordering rate of 11.2% (95% CI, 10.7-11.7%; facility-level range, 5.4-14.3%) compared to 14.1% (95% CI, 13.6-14.5%; facility-level range, 7.3-21.6%) for the nonintervention facilities. CT use for children with minor blunt head trauma in the community EDs of an integrated health-care system was low and stable across facilities from 2016 through 2018. This may be indicative of the safe stewardship of resources in the system, including the absence of financial or medicolegal incentives to scan very low-risk patients as well the availability of resources for close patient follow-up.

Authors: Shan, Judy; Warton, E Margaret; Reed, Mary E; Vinson, David R; Kuppermann, Nathan; Dayan, Peter S; Dalziel, Stuart R; Rauchwerger, Adina S; Ballard, Dustin W

Perm J. 2021 Nov 22;26(1):32-37. Epub 2021-11-22.

PubMed abstract

Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL:; Unique identifier: NCT03286179.

Authors: Mark, Dustin G; Ballard, Dustin W; Sax, Dana R; Vinson, David R; Reed, Mary E; Kaiser Permanente CREST Network Investigators [Link],; et al.

J Am Heart Assoc. 2021 11 16;10(22):e022539. Epub 2021-11-06.

PubMed abstract

Does NAFLD Mediate the Relationship Between Obesity and Type 2 Diabetes Risk? Evidence from the Multi-Ethnic Study of Atherosclerosis (MESA)

To estimate the effect of obesity on type 2 diabetes (T2DM) risk and evaluate to what extent non-alcoholic fatty liver disease (NAFLD) mediates this association. Data came from 4,522 adults ages 45-84 participating in the Multi-Ethnic Study of Atherosclerosis cohort. Baseline obesity was defined using established BMI categories. NAFLD was measured by CT scans at baseline and incident T2DM defined as fasting glucose ≥126 mg/dL or use of diabetes medications. Over a median 9.1 years of follow-up between 2000 and 2012, 557 new cases of T2DM occurred. After adjusting for age, sex, race/ethnicity, education, diet and exercise, those with obesity had 4.5 times the risk of T2DM compared to normal weight (hazard ratio [HR] = 4.5, 95% confidence interval [CI]: 3.0, 5.9). The mediation analysis suggested that NAFLD accounted for ~36% (95% CI: 27, 44) of the effect (direct effect HR = 3.2, 95% CI: 2.3, 4.6; indirect effect through NAFLD, HR = 1.4, 95% CI: 1.3, 1.5). These data suggest that the association between obesity and T2DM risk is partially explained by the presence of NAFLD. Future studies should evaluate if NAFLD could be an effective target to reduce the effect of obesity on T2DM.

Authors: Rodriguez, Luis A; Kanaya, Alka M; Shiboski, Stephen C; Fernandez, Alicia; Herrington, David; Ding, Jingzhong; Bradshaw, Patrick T

Ann Epidemiol. 2021 11;63:15-21. Epub 2021-07-19.

PubMed abstract

Disparities in Use of Video Telemedicine Among Patients With Limited English Proficiency During the COVID-19 Pandemic

Authors: Hsueh, Loretta; Huang, Jie; Millman, Andrea K; Gopalan, Anjali; Parikh, Rahul K; Teran, Silvia; Reed, Mary E

JAMA Netw Open. 2021 11 01;4(11):e2133129. Epub 2021-11-01.

PubMed abstract

Attitudes and Perceptions of Multidisciplinary Cancer Care Clinicians Toward Telehealth and Secure Messages

Telehealth use including secure messages has rapidly expanded since the COVID-19 pandemic, including for multidisciplinary aspects of cancer care. Recent reports described rapid uptake and various benefits for patients and clinicians, suggesting that telehealth may be in standard use after the pandemic. To examine attitudes and perceptions of multidisciplinary cancer care clinicians toward telehealth and secure messages. Cross-sectional specialty-specific survey (ie, some questions appear only for relevant specialties) among multidisciplinary cancer care clinicians, collected from April 29, 2020, to June 5, 2020. Participants were all 285 clinicians in the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation from all 21 community cancer centers of Kaiser Permanente Northern California. Clinician satisfaction, perceived benefits and challenges of telehealth, perceived quality of telehealth and secure messaging, preferred visit and communication types for different clinical activities, and preferences regarding postpandemic telehealth use. A total of 202 clinicians (71%) responded (104 of 128 medical oncologists, 34 of 37 radiation oncologists, 16 of 62 breast surgeons, 18 of 28 navigators, and 30 of 30 survivorship experts; 57% (116 of 202) were women; 73% [147 of 202] between ages 36-55 years). Seventy-six percent (n = 154) were satisfied with telehealth without statistically significant variations based on clinician characteristics. In-person visits were thought to promote a strong patient-clinician connection by 99% (n = 137) of respondents compared with 77% (n = 106) for video visits, 43% (n = 59) for telephone, and 14% (n = 19) for secure messages. The most commonly cited benefits of telehealth to clinicians included reduced commute (79%; n = 160), working from home (74%; n = 149), and staying on time (65%; n = 132); the most commonly cited negative factors included internet connection (84%; n = 170) or equipment problems (72%; n = 146), or physical examination needed (64%; n = 131). Most respondents (59%; n = 120) thought that video is adequate to manage the greater part of patient care in general; and most deemed various telehealth modalities suitable for any of the queried types of patient-clinician activities. For some specific activities, less than half of respondents thought that only an in-person visit is acceptable (eg, 49%; n = 66 for end-of-life discussion, 35%; n = 58 for new diagnosis). Most clinicians (82%; n = 166) preferred to maintain or increase use of telehealth after the pandemic. In this survey of multidisciplinary cancer care clinicians in the COVID-19 era, telehealth was well received and often preferred by most cancer care clinicians, who deemed it appropriate to manage most aspects of cancer care. As telehealth use becomes routine in some cancer care settings, video and telephone visits and use of asynchronous secure messaging with patients in cancer care has clear potential to extend beyond the pandemic period.

Authors: Neeman, Elad; Reed, Mary; Liu, Raymond; et al.

JAMA Netw Open. 2021 11 01;4(11):e2133877. Epub 2021-11-01.

PubMed abstract

Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System

Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up. To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events. This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018. Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics. This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type. In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Authors: Reed, Mary; Huang, Jie; Graetz, Ilana; Muelly, Emilie; Millman, Andrea; Lee, Catherine

JAMA Netw Open. 2021 11 01;4(11):e2132793. Epub 2021-11-01.

PubMed abstract

Clinical Outcomes Following Regionalization of Gastric Cancer Care in a US Integrated Health Care System

In 2016, Kaiser Permanente Northern California regionalized gastric cancer care, introducing a regional comprehensive multidisciplinary care team, standardizing staging and chemotherapy, and implementing laparoscopic gastrectomy and D2 lymphadenectomy for patients eligible for curative-intent surgery. This study evaluated the effect of regionalization on outcomes. The retrospective cohort study included gastric cancer cases diagnosed from January 2010 to May 2018. Information was obtained from the electronic medical record, cancer registry, state vital statistics, and chart review. Overall survival was compared in patients with all stages of disease, stage I-III disease, and curative-intent gastrectomy patients using annual inception cohorts. For the latter, the surgical approach and surgical outcomes were also compared. Among 1,429 eligible patients with gastric cancer with all stages of disease, one third were treated after regionalization, 650 had stage I-III disease, and 394 underwent curative-intent surgery. Among surgical patients, neoadjuvant chemotherapy utilization increased from 35% to 66% (P < .0001), laparoscopic gastrectomy increased from 18% to 92% (P < .0001), and D2 lymphadenectomy increased from 2% to 80% (P < .0001). Dissection of ≥ 15 lymph nodes increased from 61% to 95% (P < .0001). Surgical complication rates did not appear to increase after regionalization. Length of hospitalization decreased from 7 to 3 days (P < .001). Overall survival at 2 years was as follows: all stages, 32.8% pre and 37.3% post (P = .20); stage I-III cases with or without surgery, 55.6% and 61.1%, respectively (P = .25); and among surgery patients, 72.7% and 85.5%, respectively (P < .03). Regionalization of gastric cancer care within an integrated system allowed comprehensive multidisciplinary care, conversion to laparoscopic gastrectomy and D2 lymphadenectomy, increased overall survival among surgery patients, and no increase in surgical complications.

Authors: Teh, Swee H; Uong, Stephen; Lin, Teresa Y; Shiraga, Sharon; Li, Yan; Gong, I-Yeh; Herrinton, Lisa J; Li, Robert A

J Clin Oncol. 2021 10 20;39(30):3364-3376. Epub 2021-08-02.

PubMed abstract

Predictive Models for In-Hospital Deterioration in Ward Patients

Authors: Escobar, Gabriel J; Myers, Laura C; Liu, Vincent X

J Hosp Med. 2021 10;16(10):640.

PubMed abstract

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

To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs. Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two integrated health care delivery systems. Qualitative study using semi-structured interviews. We interviewed three groups of patients at Kaiser Permanente Washington and Kaiser Permanente Colorado representing three distinct profiles of complex care needs: Group A (“obesity, opioid prescription, and low-resourced neighborhood”), Group B (“older, high medical morbidity, emergency department, and hospital use”), and Group C (“older, mental and physical health concerns, and low-resourced neighborhood”). These profiles were identified based on prior work and prioritized by internal primary care stakeholders. Interview transcripts were analyzed using thematic analysis. Twenty-four patients participated; eight from each complex needs profile. Mean age across groups was 71 (range 48-86) years. We identified five themes common across the three groups that captured patients’ views regarding values-aligned care. These themes focused on the importance of care teams exploring and acknowledging a patient’s values, providing access to nonphysician providers who have different perspectives on care delivery, offering values-aligned mental health care, ensuring connection to community-based resources that support values and address needs, and providing care that supports the patient plus their family and caregivers. Our results suggest several opportunities to improve how care is delivered to patients with different complex medical, behavioral, and social needs. Future research is needed to better understand how to incorporate these opportunities into health care.

Authors: Tuzzio, Leah; Berry, Andrew L; Gleason, Kathy; Barrow, Jennifer; Bayliss, Elizabeth A; Gray, Marlaine Figueroa; Delate, Thomas; Bermet, Zoe; Uratsu, Connie S; Grant, Richard W; Ralston, James D

Health Serv Res. 2021 10;56 Suppl 1:1037-1044. Epub 2021-08-25.

PubMed abstract

Adjusting for selection bias due to missing data in electronic health records-based research

While electronic health records data provide unique opportunities for research, numerous methodological issues must be considered. Among these, selection bias due to incomplete/missing data has received far less attention than other issues. Unfortunately, standard missing data approaches (e.g. inverse-probability weighting and multiple imputation) generally fail to acknowledge the complex interplay of heterogeneous decisions made by patients, providers, and health systems that govern whether specific data elements in the electronic health records are observed. This, in turn, renders the missing-at-random assumption difficult to believe in standard approaches. In the clinical literature, the collection of decisions that gives rise to the observed data is referred to as the data provenance. Building on a recently-proposed framework for modularizing the data provenance, we develop a general and scalable framework for estimation and inference with respect to regression models based on inverse-probability weighting that allows for a hierarchy of missingness mechanisms to better align with the complex nature of electronic health records data. We show that the proposed estimator is consistent and asymptotically Normal, derive the form of the asymptotic variance, and propose two consistent estimators. Simulations show that naïve application of standard methods may yield biased point estimates, that the proposed estimators have good small-sample properties, and that researchers may have to contend with a bias-variance trade-off as they consider how to handle missing data. The proposed methods are motivated by an on-going, electronic health records-based study of bariatric surgery.

Authors: Peskoe, Sarah B; Arterburn, David; Coleman, Karen J; Herrinton, Lisa J; Daniels, Michael J; Haneuse, Sebastien

Stat Methods Med Res. 2021 10;30(10):2221-2238. Epub 2021-08-26.

PubMed abstract

Updated USPSTF Screening Recommendations for Diabetes: Identification of Abnormal Glucose Metabolism in Younger Adults

Authors: Grant, Richard W; Gopalan, Anjali; Jaffe, Marc G

JAMA Intern Med. 2021 10 01;181(10):1284-1286.

PubMed abstract

Algorithmic prognostication in critical care: a promising but unproven technology for supporting difficult decisions

Patients, surrogate decision makers, and clinicians face weighty and urgent decisions under uncertainty in the ICU, which could be aided by risk prediction. Although emerging artificial intelligence/machine learning (AI/ML) algorithms could reduce uncertainty surrounding these life and death decisions, certain criteria must be met to ensure their bedside value. Although ICU severity of illness scores have existed for decades, these tools have not been shown to predict well or to improve outcomes for individual patients. Novel AI/ML tools offer the promise of personalized ICU care but remain untested in clinical trials. Ensuring that these predictive models account for heterogeneity in patient characteristics and treatments, are not only specific to a clinical action but also consider the longitudinal course of critical illness, and address patient-centered outcomes related to equity, transparency, and shared decision-making will increase the likelihood that these tools improve outcomes. Improved clarity around standards and contributions from institutions and critical care departments will be essential. Improved ICU prognostication, enabled by advanced ML/AI methods, offer a promising approach to inform difficult and urgent decisions under uncertainty. However, critical knowledge gaps around performance, equity, safety, and effectiveness must be filled and prospective, randomized testing of predictive interventions are still needed.

Authors: Weissman, Gary E; Liu, Vincent X

Curr Opin Crit Care. 2021 10 01;27(5):500-505.

PubMed abstract

Ultrasound characteristics of early stage high-grade serous ovarian cancer

Survival from ovarian cancer is strongly dependent on the stage at diagnosis. Therefore, when confronted with a woman with an isolated adnexal mass, clinicians worry about missing the opportunity to detect cancer at an early stage. High-grade serous ovarian cancers account for 80% of ovarian cancer deaths, largely because of their tendency to be diagnosed at a late stage. Among adnexal masses, large size and the presence of solid areas on ultrasound examination have been found to be associated with cancer, but it is unclear whether these characteristics identify early-stage cases. This study aimed to evaluate the ultrasound findings associated with clinically detected early-stage high-grade serous ovarian cancer. This was a retrospective cohort study of women diagnosed with stage I or II high-grade serous ovarian or fallopian tube cancer measuring at least 1 cm at pathology from 2007 to 2017. Preoperative ultrasound examinations were independently reviewed by 3 radiologists. Adnexal masses were scored for size and volume; overall appearance; presence, thickness, and vascularity of septations; morphology and vascularity of other solid components; and degree of ascites. Characteristics were compared between masses of <5 cm and larger masses and between stage I and stage II cases. Interobserver variability was assessed. Among 111 women identified, 4 had bilateral ovarian involvement, for a total of 115 adnexal masses characterized by ultrasound examination. The mean age at diagnosis was 61.8 years (range, 42-91 years). The median mass size was 9.6 cm (range, 2.2-23.6 cm) with 87% of cases having a mass size of ≥5 cm. A mixed cystic and solid appearance was most common (77.4%), but a completely solid appearance was more frequently seen for tumors of <5 cm compared with larger tumors (26.7% vs 13.0%). Solid components other than septations were seen in 97.4% of cases. The characteristics of stage I and II cases were similar other than ascites, which was more commonly seen in stage II cases (18.0% vs 3.1%, respectively). Interobserver concordance was high for size and volume measurements (correlation coefficients, 0.96-0.99), with moderate agreement observed across the other ultrasound characteristics (Fleiss kappa, 0.45-0.58). In this community-based cohort, early-stage high-grade serous cancers rarely presented as masses of <5 cm or masses without solid components other than septations. Our findings provide additional support for the observation of small masses without solid areas on ultrasound examination.

Authors: Suh-Burgmann, Elizabeth; Brasic, Natasha; Jha, Priyanka; Hung, Yun-Yi; Goldstein, Ruth B

Am J Obstet Gynecol. 2021 10;225(4):409.e1-409.e8. Epub 2021-05-13.

PubMed abstract

Outcomes following interventions to sustain body weight in esophageal cancer patients starting preoperative therapy: a retrospective cohort study

To improve nutritional status and dysphagia, esophageal cancer patients starting neoadjuvant therapy in advance of curative-intent surgery may receive a jejunostomy tube (J-tube) or esophageal stent, or they may be managed without a feeding modality. We examined percent total weight loss (%TWL), reinterventions, and progression to surgery in relation to these options. The retrospective cohort study included stage II-III esophageal cancer patients diagnosed during 2010-2017 who received J-tube, stent, or nutritional counseling only, without a procedure, when starting chemotherapy or combined modality chemoradiation. Data were obtained from the electronic medical record and chart review. We compared median %TWL between intervention groups and reinterventions using Chi-square and Kruskal-Wallis tests. Among the 366 patients, median %TWL reached a nadir at 120 days, when it was 7% for patients with no procedure (N=307), 4% for J-tube (N=39), and 16% for stent (N=20) (P=0.01). Individual case analysis revealed 72-80% of the patients in the three groups started chemotherapy or chemoradiation as neoadjuvant curative-intent therapy (P difference =0.79). In J-tube patients, the reasons for intervention was anticipation of weight loss in 49% and mitigation of actual weight loss in 15%, whereas 95% of stent patients received the stent for dysphagia (P<0.001). A complication of the procedure was recorded in 85% of stent patients and 74% of J-tube patients (P<0.001). Among those who received no procedure initially, 25% received one later, compared with 15% of J-tube patients and 70% of stent patients who received a second procedure (P<0.001). Progression to surgery was observed in 65% of patients with no procedure, 51% of patients with J-tube, and 40% of stent patients, P=0.28). For stage II-III esophageal cancer patients starting chemotherapy, this study gives evidence that stents were associated with significant %TWL and risk of reintervention. Although J-tube patients returned to baseline weight sooner than those with no procedure, they experienced complications from their J-tubes. For esophageal cancer patients undergoing curative-intent treatment and with acceptable levels of weight loss, no procedure at all may be superior to placing a J-tube in terms of complications, weight loss, and progression to curative-intent surgery.

Authors: Velotta, Jeffrey B; Dusendang, Jennifer R; Kwak, Hyunjee; Huyser, Michelle; Patel, Ashish; Ashiku, Simon K; Herrinton, Lisa J

J Thorac Dis. 2021 Sep;13(9):5477-5486.

PubMed abstract

Association of Cardiovascular Outcomes and Mortality With Sustained Long-Acting Insulin Only vs Long-Acting Plus Short-Acting Insulin Treatment

Cardiovascular events and mortality are the principal causes of excess mortality and health care costs for people with type 2 diabetes. No large studies have specifically compared long-acting insulin alone with long-acting plus short-acting insulin with regard to cardiovascular outcomes. To compare cardiovascular events and mortality in adults with type 2 diabetes receiving long-acting insulin who do or do not add short-acting insulin. This retrospective cohort study emulated a randomized experiment in which adults with type 2 diabetes who experienced a qualifying glycated hemoglobin A1c (HbA1c) level of 6.8% to 8.5% with long-acting insulin were randomized to continuing treatment with long-acting insulin (LA group) or adding short-acting insulin within 1 year of the qualifying HbA1c level (LA plus SA group). Retrospective data in 4 integrated health care delivery systems from the Health Care Systems Research Network from January 1, 2005, to December 31, 2013, were used. Analysis used inverse probability weighting estimation with Super Learner for propensity score estimation. Analyses took place from April 1, 2018, to June 30, 2019. Long-acting insulin alone or with added short-acting insulin within 1 year from the qualifying HbA1c level. Mortality, cardiovascular mortality, acute myocardial infarction, stroke, and hospitalization for heart failure. Among 57 278 individuals (39 279 with data on cardiovascular mortality) with a mean (SD) age of 60.6 (11.5) years, 53.6% men, 43.5% non-Hispanic White individuals, and 4 years of follow-up (median follow-up of 11 [interquartile range, 5-20] calendar quarters), the LA plus SA group was associated with increased all-cause mortality compared with the LA group (hazard ratio, 1.27; 95% CI, 1.05-1.49) and a decreased risk of acute myocardial infarction (hazard ratio, 0.89; 95% CI, 0.81-0.97). Treatment with long-acting plus short-acting insulin was not associated with increased risks of congestive heart failure, stroke, or cardiovascular mortality. Findings of this retrospective cohort study suggested an increased risk of all-cause mortality and a decreased risk of acute myocardial infarction for the LA plus SA group compared with the LA group. Given the lack of an increase in major cardiovascular events or cardiovascular mortality, the increased all-cause mortality with long-acting plus short-acting insulin may be explained by noncardiovascular events or unmeasured confounding.

Authors: Schroeder, Emily B; Neugebauer, Romain; Schmittdiel, Julie A; O'Connor, Patrick J; et al.

JAMA Netw Open. 2021 09 01;4(9):e2126605. Epub 2021-09-01.

PubMed abstract

Temporal Trends and Hospital Variation in Time-to-Antibiotics Among Veterans Hospitalized With Sepsis

It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives. To examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system. This observational cohort study included 130 VA hospitals from 2013 to 2018. Participants included all patients admitted to the hospital via the emergency department with sepsis from 2013 to 2018, using a definition adapted from the Centers for Disease Control and Prevention Adult Sepsis Event definition, which requires evidence of suspected infection, acute organ dysfunction, and systemic antimicrobial therapy within 12 hours of presentation. Data were analyzed from October 6, 2020, to July 1, 2021. Time from presentation to antibiotic administration. The main outcome was differences in time-to-antibiotics across study periods, hospitals, and patient subgroups defined by presenting temperature and blood pressure. Temporal trends in time-to-antibiotics were measured overall and by subgroups. Hospital-level variation in time-to-antibiotics was quantified after adjusting for differences in patient characteristics using multilevel linear regression models. A total of 111 385 hospitalizations for sepsis were identified, including 107 547 men (96.6%) men and 3838 women (3.4%) with a median (interquartile range [IQR]) age of 68 (62-77) years. A total of 7574 patients (6.8%) died in the hospital, and 13 855 patients (12.4%) died within 30 days. Median (IQR) time-to-antibiotics was 3.9 (2.4-6.5) hours but differed by presenting characteristics. Unadjusted median (IQR) time-to-antibiotics decreased over time, from 4.5 (2.7-7.1) hours during 2013 to 2014 to 3.5 (2.2-5.9) hours during 2017 to 2018 (P < .001). In multilevel models adjusted for patient characteristics, median time-to-antibiotics declined by 9.0 (95% CI, 8.8-9.2) minutes per calendar year. Temporal trends in time-to-antibiotics were similar across patient subgroups, but hospitals with faster baseline time-to-antibiotics had less change over time, with hospitals in the slowest tertile decreasing time-to-antibiotics by 16.6 minutes (23.1%) per year, while hospitals in the fastest tertile decreased time-to-antibiotics by 7.2 minutes (13.1%) per year. In the most recent years (2017-2018), median time-to-antibiotics ranged from 3.1 to 6.7 hours across hospitals (after adjustment for patient characteristics), 6.8% of variation in time-to-antibiotics was explained at the hospital level, and odds of receiving antibiotics within 3 hours increased by 65% (95% CI, 56%-77%) for the median patient if moving to a hospital with faster time-to-antibiotics. This cohort study across nationwide VA hospitals found that time-to-antibiotics for sepsis has declined over time. However, there remains significant variability in time-to-antibiotics not explained by patient characteristics, suggesting potential unwarranted practice variation in sepsis treatment. Efforts to further accelerate time-to-antibiotics must be weighed against risks of overtreatment.

Authors: Wayne, Max T; Seelye, Sarah; Molling, Daniel; Wang, Xiao Qing; Donnelly, John P; Hogan, Cainnear K; Jones, Makoto M; Iwashyna, Theodore J; Liu, Vincent X; Prescott, Hallie C

JAMA Netw Open. 2021 09 01;4(9):e2123950. Epub 2021-09-01.

PubMed abstract

Association Between Troponin I Levels During Sepsis and Post-Sepsis Cardiovascular Complications

Rationale: Sepsis commonly results in elevated serum troponin levels and increased risk for postsepsis cardiovascular complications; however, the association between troponin levels during sepsis and cardiovascular complications after sepsis is unclear.Objectives: To evaluate the association between serum troponin levels during sepsis and 1 year after sepsis cardiovascular events.Methods: We analyzed adults aged ⩾40 years without preexisting cardiovascular disease within 5 years, admitted with sepsis across 21 hospitals from 2011 to 2017. Peak serum troponin I levels during sepsis were grouped as normal (⩽0.04 ng/ml) or tertiles of abnormal (>0.04 to ⩽0.09 ng/ml, >0.09 to ⩽0.42 ng/ml, or >0.42 ng/ml). Multivariable adjusted cause-specific Cox proportional hazards models with death as a competing risk were used to assess associations between peak troponin I levels and a composite cardiovascular outcome (atherosclerotic cardiovascular disease, atrial fibrillation, and heart failure) in the year following sepsis. Models were adjusted for presepsis and intrasepsis factors considered potential confounders.Measurements and Main Results: Among 14,046 eligible adults with troponin I measured, 2,012 (14.3%) experienced the composite cardiovascular outcome, including 832 (10.9%) patients with normal troponin levels, as compared with 370 (17.3%), 376 (17.6%), and 434 (20.3%) patients within each sequential abnormal troponin tertile, respectively (P < 0.001). Patients within the elevated troponin tertiles had increased risks of adverse cardiovascular events (adjusted hazard ratio [aHR]troponin0.04-0.09 = 1.37; 95% confidence interval [CI], 1.20-1.55; aHRtroponin0.09-0.42 = 1.44; 95% CI, 1.27-1.63; and aHRtroponin>0.42 = 1.77; 95% CI, 1.56-2.00).Conclusions: Among patients without preexisting cardiovascular disease, troponin elevation during sepsis identified patients at increased risk for postsepsis cardiovascular complications. Strategies to mitigate cardiovascular complications among this high-risk subset of patients are warranted.

Authors: Garcia, Michael A; Go, Alan S; Liu, Vincent X; Walkey, Allan J; et al.

Am J Respir Crit Care Med. 2021 09 01;204(5):557-565.

PubMed abstract

Reducing Readmissions for Chronic Obstructive Pulmonary Disease in Response to the Hospital Readmissions Reduction Program

Rationale: In August 2013, the Hospital Readmission Reduction Program announced financial penalties on hospitals with higher than expected risk-adjusted 30-day readmission rates for Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation. In October 2014, penalties were imposed. We hypothesized that penalties would be associated with decreased readmissions after COPD hospitalizations. Objectives: To determine whether the announcement and enactment of financial penalties for COPD were associated with decreases in hospital readmissions for COPD. Methods: We used data from California’s Office of Statewide Health Planning and Development to examine unplanned 30-day all-cause and COPD-related readmissions after COPD hospitalization. The preannouncement period was January 2010 to July 2013. The postannouncement period was August 2013 to September 2014. The postenactment period was October 2014 to December 2017. Using interrupted time series, we investigated the immediate change after the intervention (level change) and differences in the preintervention and postintervention trends (slope change). Results: We identified 333,429 index hospitalizations for COPD from 449 California hospitals. Overall, 69% of patients had Medicare insurance. For all-cause readmissions, the level change at announcement was 0.16% (95% confidence interval [CI], -1.07 to 1.38; P = 0.80); the change in slope between preannouncement and postannouncement periods was -0.01% (95% CI, -0.15 to 0.13; P = 0.92). The level change at enactment was 0.29% (95% CI, -1.11 to 1.69; P = 0.68); the change in slope between postannouncement and postenactment was 0.04% (95% CI, -0.10 to 0.18; P = 0.57). For patients with COPD-related readmissions, the level change at the time of the announcement was 0.09% (95% CI, -0.68 to 0.85; P = 0.83); the change in slope was 0.003% (95% CI, -0.08 to 0.09; P = 0.94). The level change at the time of the enactment was 0.22% (95% CI, -0.69 to 1.12; P = 0.64); the change in slope was -0.02% (95% CI, -0.10 to 0.07; P = 0.72). Conclusions: We did not detect decreases in either all-cause or COPD-related readmission rates at either time point. Although this would suggest that the Hospital Readmission Reduction Program penalty was ineffective for COPD, COPD readmissions had decreased at an earlier time point (October 2012) when penalties were announced for conditions other than COPD. Based on this, we believe early, broad interventions decreased readmissions, such that no difference was seen at this later time points despite institution of COPD-specific penalties.

Authors: Myers, Laura C; Cash, Rebecca; Liu, Vincent X; Camargo, Carlos A

Ann Am Thorac Soc. 2021 09;18(9):1506-1513.

PubMed abstract

Validation of Postpartum Hemorrhage Admission Risk Factor Stratification in a Large Obstetrics Population

This study aimed to evaluate the performance of the California Maternal Quality Care Collaborative (CMQCC) admission risk criteria for stratifying postpartum hemorrhage risk in a large obstetrics population. Using detailed electronic health record data, we classified 261,964 delivery hospitalizations from Kaiser Permanente Northern California hospitals between 2010 and 2017 into high-, medium-, and low-risk groups based on CMQCC criteria. We used logistic regression to assess associations between CMQCC risk groups and postpartum hemorrhage using two different postpartum hemorrhage definitions, standard postpartum hemorrhage (blood loss ≥1,000 mL) and severe postpartum hemorrhage (based on transfusion, laboratory, and blood loss data). Among the low-risk group, we also evaluated associations between additional present-on-admission factors and severe postpartum hemorrhage. Using the standard definition, postpartum hemorrhage occurred in approximately 5% of hospitalizations (n = 13,479), with a rate of 3.2, 10.5, and 10.2% in the low-, medium-, and high-risk groups. Severe postpartum hemorrhage occurred in 824 hospitalizations (0.3%), with a rate of 0.2, 0.5, and 1.3% in the low-, medium-, and high-risk groups. For either definition, the odds of postpartum hemorrhage were significantly higher in medium- and high-risk groups compared with the low-risk group. Over 40% of postpartum hemorrhages occurred in hospitalizations that were classified as low risk. Among the low-risk group, risk factors including hypertension and diabetes were associated with higher odds of severe postpartum hemorrhage. We found that the CMQCC admission risk assessment criteria stratified women by increasing rates of severe postpartum hemorrhage in our sample, which enables early preparation for many postpartum hemorrhages. However, the CMQCC risk factors missed a substantial proportion of postpartum hemorrhages. Efforts to improve postpartum hemorrhage risk assessment using present-on-admission risk factors should consider inclusion of other nonobstetrical factors.

Authors: Ruppel H; Liu VX; Gupta NR; Soltesz L; Escobar GJ

Am J Perinatol. 2021 09;38(11):1192-1200. Epub 2020-05-26.

PubMed abstract

Examining the Relationship Between the Lean Management System and Quality Improvement Care Management Processes.

BACKGROUND AND OBJECTIVES: The United States has an underperforming health care system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the Lean Management System based on the Shingo principles originally developed by Toyota in Japan. Our objective was to examine the association between hospital use of the Lean Management System and evidence-based or recommended quality improvement care management processes. n METHODS: A cross-sectional analysis of data from 223 hospitals that responded to both the 2017 National Survey of Healthcare Organizations and Systems and the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals was conducted. n RESULTS: Controlling for hospital organizational and market characteristics, the number of years using Lean was positively associated with use of electronic health record-based decision support, use of quality-focused information management, use of evidence-based guidelines, and support for care transitions at the P < .05 level. The degree of education and training in Lean methods and processes was also positively associated (P < .05) with greater support for care transitions. The number of years using Lean was marginally associated with screening for clinical conditions at the P < .10 level. There was an unexpected negative association between education and training scores and screening for clinical conditions. n CONCLUSIONS: Greater experience in using the Lean Management System is positively associated with several evidence-based and/or recommended quality improvement care management processes.

Authors: Tierney, Aaron A;Shortell, Stephen M;Rundall, Thomas G;Blodgett, Janet C;Reponen, Elina

Qual Manag Health Care. 2021 Aug 26 doi: 10.1097/QMH.0000000000000318..

PubMed abstract

Exploratory and Confirmatory Bayesian Networks Identify the Central Role of Non-judging in Symptoms of Depression.

OBJECTIVES: Depression is a highly heterogeneous disorder, and meta-analyses of mindfulness-based interventions show moderate efficacy for reducing depressive symptoms. However, the mechanisms governing their efficacy remain unclear, highlighting the need for hypothesis-generating analyses to guide future research. METHODS: We used Bayesian network analysis in three cross-sectional samples (N = 1135) of undergraduates and participants from the community to identify links between individual symptoms of depression and specific facets of mindfulness. In two exploratory studies, we assessed depression using the Patient Health Questionnaire (n = 384) or the Depression Anxiety and Stress Scale (n = 350) and mindfulness using the Five-Facet Mindfulness Scale. RESULTS: Across these samples and measures, exploratory analyses indicated that non-judging was a central bridge between facets of mindfulness and symptoms of depression. We confirmed this finding in a pre-registered replication (n = 401) using a recently developed confirmatory testing framework for network analysis. Non-judging was consistently a central bridge in the networks and specifically linked to the symptoms of depression related to feelings of failure and worthlessness. CONCLUSIONS: These findings provide strong evidence that non-judging is an essential feature of mindfulness in the context of depression and provides direction for future research testing mindfulness-oriented treatment prescriptions for depression. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12671-021-01726-1.

Authors: Rubin M; Papini S; Dainer-Best J; Zaizar ED; Smits JAJ; Telch MJ

Mindfulness (N Y). 2021;12(10):2544-2551. doi: 10.1007/s12671-021-01726-1. Epub 2021 Aug 19.

PubMed abstract

Reduction in Long-term Mortality after Sleeve Gastrectomy and Gastric Bypass Compared to Non-surgical Patients with Severe Obesity

To separately compare the long-term risk of mortality among bariatric surgical patients undergoing either RYGB or SG to large, matched, population-based cohorts of patients with severe obesity who did not undergo surgery. Bariatric surgery has been associated with reduced long-term mortality compared to usual care for severe obesity which is particularly relevant in the COVID-19 era. Most prior studies involved the Roux-en-Y gastric bypass (RYGB) operation and there is less long-term data on the sleeve gastrectomy (SG). In this retrospective, matched cohort study, patients with a body mass index ≥35 kg/m2 who underwent bariatric surgery from January 2005 to September 2015 in three integrated health systems in the United States were matched to nonsurgical patients on site, age, sex, body mass index, diabetes status, insulin use, race/ethnicity, combined Charlson/Elixhauser comorbidity score, and prior health care utilization, with follow-up through September 2015. Each procedure (RYGB, SG) was compared to its own control group and the two surgical procedures were not directly compared to each other. Multivariable-adjusted Cox regression analysis investigated time to all-cause mortality (primary outcome) comparing each of the bariatric procedures to usual care. Secondary outcomes separately examined the incidence of cardiovascular-related death, cancer related-death, and diabetes related-death. Among 13,900 SG, 17,258 RYGB, and 87,965 nonsurgical patients, the 5-year follow-up rate was 70.9%, 72.0%, and 64.5%, respectively. RYGB and SG were each associated with a significantly lower risk of all-cause mortality compared to nonsurgical patients at 5-years of follow-up (RYGB: HR = 0.43; 95% CI: 0.35,0.54; SG: HR = 0.28; 95% CI: 0.13,0.57) Similarly, RYGB was associated with a significantly lower 5-year risk of cardiovascular- (HR = 0.27; 95% CI: 0.20, 0.37), cancer- (HR = 0.54; 95% CI: 0.39, 0.76), and diabetes-related mortality (HR = 0.23; 95% CI:0.15, 0.36). There was not enough follow-up time to assess 5-year cause-specific mortality in SG patients, but at 3-years follow up, there was significantly lower risk of cardiovascular- (HR = 0.33; 95% CI:0.19, 0.58), cancer- (HR = 0.26; 95% CI:0.11, 0.59), and diabetes-related (HR = 0.15; 95% CI:0.04, 0.53) mortality for SG patients. This study confirms and extends prior findings of an association with better survival following bariatric surgery in RYGB patients compared to controls and separately demonstrates that the SG operation also appears to be associated with lower mortality compared to matched control patients with severe obesity that received usual care. These results help to inform the trade-offs between long-term benefits and risks of bariatric surgery.

Authors: Courcoulas, Anita P; Fisher, David P; Coleman, Karen J; et al.

Ann Surg. 2021 Aug 13.

PubMed abstract

Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study

To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system. Observational study. 21 hospitals operated by Kaiser Permanente Northern California. 1 539 285 eligible index hospital admissions corresponding to 739 040 unique patients from June 2010 to December 2018. 411 507 patients were discharged post-implementation of the Transitions Program; 80 424 (19.5%) of these patients were at medium or high predicted risk and were assigned to receive the intervention after discharge. Patients admitted to hospital were automatically assigned to be followed by the Transitions Program in the 30 days post-discharge if their predicted risk of 30 day readmission or mortality was greater than 25% on the basis of electronic health record data. Non-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge. Difference-in-differences estimates indicated that the intervention was associated with significantly reduced odds of 30 day non-elective readmission (adjusted odds ratio 0.91, 95% confidence interval 0.89 to 0.93; absolute risk reduction 95% confidence interval -2.5%, -3.1% to -2.0%) but not with the odds of 30 day post-discharge mortality (1.00, 0.95 to 1.04). Based on the regression discontinuity estimate, the association with readmission was of similar magnitude (absolute risk reduction -2.7%, -3.2% to -2.2%) among patients at medium risk near the risk threshold used for enrollment. However, the regression discontinuity estimate of the association with post-discharge mortality (-0.7% -1.4% to -0.0%) was significant and suggested benefit in this subgroup of patients. In an integrated health system, the implementation of a comprehensive readmissions prevention intervention was associated with a reduction in 30 day readmission rates. Moreover, there was no association with 30 day post-discharge mortality, except among medium risk patients, where some evidence for benefit was found. Altogether, the study provides evidence to suggest the effectiveness of readmission prevention interventions in community settings, but further research might be required to confirm the findings beyond this setting.

Authors: Marafino, Ben J; Escobar, Gabriel J; Baiocchi, Michael T; Liu, Vincent X; Plimier, Colleen C; Schuler, Alejandro

BMJ. 2021 08 11;374:n1747. Epub 2021-08-11.

PubMed abstract

Distinct trajectories of depression symptoms in early and middle adolescence: Preliminary evidence from longitudinal network analysis.

Adolescent depression is a clinically relevant concern that has major implications for mental and physical health. The trajectory of depressive symptoms among adolescents suggests that there is likely variability throughout this developmental period. The aim of the study was to assess the longitudinal relationship between individual symptoms of depression among early and middle adolescents to provide guidance for future research investigating targeted intervention efforts. Data were extracted from electronic medical records (2015-2017) from a pediatric primary care clinic in an urban setting. Cross-Lagged Panel Network analysis was used to evaluate symptoms of depression measured with the Patient Health Questionnaire (PHQ-9) measured twice over a 1-year period among early adolescents (ages 11-13 years; n = 309) and middle adolescents (ages 14-16 years; n = 255). The sample was predominantly Hispanic (90%) and 56% female. The analyses highlighted key differences and similarities between early and middle adolescence, largely focused on the role of suicidal ideation and tightly linked with feelings of failure and appetitive disturbance. In early adolescence suicidal ideation was highly likely to lead to other symptoms. In middle adolescence, however, suicidal ideation no longer had connections to other symptoms and instead the strongest connections were toward suicidal ideation. Interestingly, across both early and middle adolescence feelings of failure and appetitive disturbance were highly likely to lead to suicidal ideation. These exploratory findings highlight several longitudinal associations between early and middle adolescence that provide insight into differences and similarities regarding how symptoms might progress within those developmental periods. Taken together these results can provide direction for future research to evaluate brief, targeted interventions for adolescents.

Authors: Rubin M; Bicki A; Papini S; Smits JAJ; Telch MJ; Gray JS

J Psychiatr Res. 2021 Oct;142:198-203. doi: 10.1016/j.jpsychires.2021.07.053. Epub 2021 Aug 4.

PubMed abstract

Evaluation of Vaccination Strategies to Compare Efficient and Equitable Vaccine Allocation by Race and Ethnicity Across Time

Identifying the most efficient COVID-19 vaccine allocation strategy may substantially reduce hospitalizations and save lives while ensuring an equitable vaccine distribution. To simulate the association of different vaccine allocation strategies with COVID-19-associated morbidity and mortality and their distribution across racial and ethnic groups. We developed and internally validated the risk of COVID-19 infection and risk of hospitalization models on randomly split training and validation data sets. These were used in a computer simulation study of vaccine prioritization among adult health plan members who were drawn from an integrated health care delivery system. The study was conducted from January 3, 2021, to June 1, 2021, in Oakland, California, and the data were analyzed during the same period. We simulated the association of different vaccine allocation strategies, including (1) random, (2) a US Centers for Disease Control and Prevention (CDC) proxy, (3) age based, and (4) combinations of models for the risk of adverse outcomes (CRS) and COVID-19 infection (PROVID), with COVID-19-related hospitalizations between May 1, 2020, and December 31, 2020, that were randomly permuted by month across 250 simulations and assessed vaccine allocation by race and ethnicity and the neighborhood deprivation index across time. The study included 3 202 679 adult patients (mean [SD] age, 48.2 [18.0] years; 1 677 637 women [52.4%]; 1 525 042 men [47.6%]; 611 154 Asian [19.1%], 206 363 Black [6.4%], 642 344 Hispanic [20.1%], and 1 390 638 White individuals [43.4%]), of whom 36 137 (1.1%) were positive for SARS-CoV-2. A risk-based strategy (CRS/PROVID) showed the largest avoidable hospitalization estimates (4954; 95% CI, 3452-5878) followed by age-based (4362; 95% CI, 2866-5175) and CDC proxy (4085; 95% CI, 2805-5109) strategies. Random vaccination showed substantially lower reductions in adverse outcomes. Risk-based strategies also showed the largest number of avoidable COVID-19 deaths (joint CRS/PROVID) and household transmissions. Risk-based (PROVID) and CDC proxy strategies were estimated to vaccinate the highest percentage of Hispanic and Black patients in 8 months (joint CRS/PROVID: 642 570 [100%] Hispanic, 185 530 [90%] Black; PROVID: 642 570 [100%] Hispanic, 198 480 [96%] Black; CDC proxy: 605 770 [95%] Hispanic and 151 772 [74%] Black) compared with an age-based approach (438 423 [68%] Hispanic, 154 714 [75%] Black). Overall, the PROVID and joint CRS/PROVID risk-based strategies were estimated to be followed by the most patients from areas with high neighborhood deprivation index being vaccinated early. In this simulation modeling study of adults from a large integrated health care delivery system, risk-based strategies were associated with the largest estimated reductions in COVID-19 hospitalizations, deaths, and household transmissions compared with the CDC proxy and age-based strategies, with a higher proportion of Hispanic and Black patients were estimated to be vaccinated early in the process compared with the CDC strategy.

Authors: Kipnis, Patricia; Soltesz, Lauren; Escobar, Gabriel J; Myers, Laura; Liu, Vincent X

JAMA Health Forum. 2021 08;2(8):e212095. Epub 2021-08-20.

PubMed abstract

Clinical characteristics of COVID-19 patients evaluated in the emergency department: A retrospective cohort study of 801 cases

Coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has extracted devastating tolls. Despite its pervasiveness, robust information on disease characteristics in the emergency department (ED) and how that information predicts clinical course remain limited. We conducted a retrospective cohort study of the first ED visit from SARS-CoV-2-positive patients in our health system, from February 21, 2020 to April 5, 2020. We reviewed each patient’s ED visit(s) and included the first visit with symptoms consistent with COVID-19. We collected demographic, clinical, and treatment variables from electronic health records and structured manual chart review. We used multivariable logistic regression to examine the association between patient characteristics and 2 primary outcomes: a critical outcome and hospitalization from index visit. Our critical outcome was defined as death or advanced respiratory support (high flow nasal cannula or greater) within 21 days. Of the first 1030 encounters, 801 met our inclusion criteria: 15% were over age 75 years, 47% were female, and 24% were non-Hispanic white. We found 161 (20%) had a critical outcome and 393 (49%) were hospitalized. Independent predictors of a critical outcome included a history of hypertension, abnormal chest x-ray, elevated neutrophil to lymphocyte ratio, elevated blood urea nitrogen (BUN), measured fever, and abnormal respiratory vital signs (respiratory rate, oxygen saturation). Independent predictors of hospitalization included abnormal pulmonary auscultation, elevated BUN, measured fever, and abnormal respiratory vital signs. In this large, diverse study of ED patients with COVID-19, we have identified numerous clinical characteristics that have independent associations with critical illness and hospitalization.

Authors: Cotton, Dale M; Vinson, David R; Ballard, Dustin W; Sax, Dana R; Mark, Dustin G; Reed, Mary E; Clinical Research on Emergency Services and Treatment (CREST) Network,; et al.

J Am Coll Emerg Physicians Open. 2021 Aug;2(4):e12538. Epub 2021-08-23.

PubMed abstract

Race/ethnicity moderates associations between depressive symptoms and diet composition among U.S. adults

Although depression is associated with poorer overall diet quality, few studies have examined its association with levels of particular macronutrients, and none have examined moderation by race/ethnicity. The present study examined (a) associations between depressive symptom severity and nine indices of diet composition and (b) whether race/ethnicity moderates these associations. Participants were 28,940 adults (mean age = 49 years, 52% female, 52% nonwhite) from NHANES 2005-2018. Depressive symptom severity was measured using the Patient Health Questionnaire-9 (PHQ-9). Nine diet composition indices were derived from the average of two 24-hr dietary recalls (e.g., total energy, total fat, saturated fat, total carbohydrate, sugar, fiber, and protein). Separate linear regression analyses revealed that PHQ-9 total was positively associated with saturated fat and sugar and negatively associated with protein and fiber. Moderation by race/ethnicity was observed (interaction ps < .05). Among non-Hispanic Whites, PHQ-9 total was positively associated with sugar and negatively associated with protein and fiber. Among non-Hispanic Blacks, PHQ-9 total was positively associated with total energy, total fat, saturated fat, monounsaturated fat, polyunsaturated fat, total carbohydrate, and sugar. Among Mexican Americans, PHQ-9 was positively associated with saturated fat. Among other Hispanics, PHQ-9 total was negatively associated with fiber, protein, and total, monounsaturated, and polyunsaturated fat. Findings from this large, nationally representative sample demonstrate that associations between depressive symptom severity and diet composition vary by race/ethnicity. Critically, an unhealthy diet composition pattern may be one mechanism explaining the excess risk of obesity and cardiometabolic diseases in individuals with depression, especially in non-Hispanic Blacks. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Authors: Vrany EA; Polanka BM; Hsueh L; Hill-Briggs F; Stewart JC

Health Psychol. 2021 Aug;40(8):513-522.

PubMed abstract

The Coming of Age of Implementation Science and Research in Critical Care Medicine

Authors: Barr, Juliana; Paulson, Shirley S; Kamdar, Biren; Ervin, Jennifer N; Lane-Fall, Meghan; Liu, Vincent; Kleinpell, Ruth

Crit Care Med. 2021 08 01;49(8):1254-1275.

PubMed abstract

Sodium-Glucose Cotransporter 2 Inhibitors vs Sulfonylureas: The Price of Prevention

Authors: Guduguntla, Vinay; Grant, Richard W

JAMA Intern Med. 2021 08 01;181(8):1054.

PubMed abstract

The Epic Sepsis Model Falls Short-The Importance of External Validation

Authors: Habib, Anand R; Lin, Anthony L; Grant, Richard W

JAMA Intern Med. 2021 08 01;181(8):1040-1041.

PubMed abstract

Epidemiologic Analysis of Chilblains Cohorts Before and During the COVID-19 Pandemic

Beginning in March 2020, case reports and case series linked the COVID-19 pandemic with an increased occurrence of chilblains, but this association has not been evaluated in an epidemiologic study. To assess whether a correlation exists between COVID-19 incidence and chilblains incidence. A retrospective cohort study was conducted within the Kaiser Permanente Northern California system from January 1, 2016, to December 31, 2020; health plan members of all ages were included. COVID-19 incidence in 207 location-months, representing 23 geographic locations in northern California across 9 months. Chilblains incidence was the main outcome. The association of chilblains incidence with COVID-19 incidence across the 207 location-months was measured using the Spearman rank correlation coefficient. Of 780 patients with chilblains reported during the pandemic, 464 were female (59.5%); mean (SD) age was 36.8 (21.8) years. COVID-19 incidence was correlated with chilblains incidence at 207 location-months (Spearman coefficient 0.18; P = .01). However, only 17 of 456 (3.7%) patients with chilblains tested during the pandemic were positive for SARS-CoV-2, and only 9 of 456 (2.0%) were positive for SARS-CoV-2 within 6 weeks of the chilblains diagnosis. Test results of 1 of 97 (1.0%) patients were positive for SARS-CoV-2 IgG antibodies. Latinx patients were disproportionately affected by COVID-19 but not by chilblains. This cohort study found that in northern California, the incidence of chilblains increased during the pandemic but was correlated weakly with the incidence of COVID-19 across 207 location-months. These findings may have resulted from a causal role of COVID-19, increased care-seeking by patients with chilblains during the pandemic, or changes in behavior during shelter in place.

Authors: McCleskey, Patrick E; Herrinton, Lisa J; et al.

JAMA Dermatol. 2021 08 01;157(8):947-953.

PubMed abstract

Pediatric Surgeons’ Adoption of an Innovative Laparoscopic Technique for Inguinal Hernia Repair: A Mixed Methods Study

Purpose: We studied adoption of an innovative laparoscopic technique for pediatric inguinal hernia repair by pediatric surgeons and pediatric urologists following dissemination of evidence for its benefits. Methods: This mixed methods study included children who received inguinal hernia repairs during 2017-2019 and their surgeons. We examined surgeons’ adoption and use of the innovative technique and rates of ipsilateral recurrence and metachronous contralateral repair. In-depth interviews with surgeons were used to identify themes regarding attitudes and practices regarding the adoption of surgical innovations. Results: No ipsilateral recurrences were noted among open repairs after 1.5 years of average follow-up, while 1.54% (7/453) of unilateral and 0.50% (3/606 sides) of bilateral innovative surgeries required ipsilateral repair after 1.3 years of average follow-up. Among unilateral cases, metachronous contralateral repairs were performed in 1.63% (8/490) of open and 0.44% (2/453) of innovative surgeries. Surgeon interviews identified approaches to continued learning and change; the role of departmental culture, norms, and resources; and technical issues specific to pediatric surgery and pediatric inguinal hernia repair. Conclusions: Outcomes may have improved over time as a consequence of learning. Differences among surgeons and departments influenced the speed of adoption. Surgeons linked the collegial model used when adopting the new technique to the apprenticeship model used during their training. We propose research into the collegial model to improve translation of evidence-based surgical innovations into practice. Level of Evidence: Level III.

Authors: Altschuler, Andrea; Chong, Albert J; Alavi, Mubarika; Herrinton, Lisa J

J Laparoendosc Adv Surg Tech A. 2021 Aug;31(8):947-953. Epub 2021-05-27.

PubMed abstract

Outcomes among acute heart failure emergency department patients by preserved vs. reduced ejection fraction

This study aimed to assess short-term outcomes among emergency department (ED) patients with acute heart failure (AHF) by preserved (≥50%) vs. reduced (<50%) ejection fraction (EF). We conducted a retrospective, multicentre study of adult ED patients with AHF from 2017 to 2018 in an integrated healthcare system with 21 hospitals. Among patients with known EF, our primary outcome was 30 day all-cause mortality, comparing patients with heart failure with preserved EF (HFpEF) and heart failure with reduced EF (HFrEF), adjusted for known risk factors. We ran separate multivariate regression models to compare 30 day mortality between HFpEF and HFrEF patients stratified by ED disposition (admit, observe, and discharge). Our secondary outcomes were adjusted 30 day all-cause return hospital admission and rates of non-fatal serious adverse events, including new intra-aorta balloon pump, endotracheal intubation, renal failure requiring dialysis, myocardial infarction, or coronary revascularization. We conducted a sensitivity analysis among patients with EF ≤ 40% and compared our primary and secondary outcomes among patients with EF ≤ 40% with those with EF ≥ 50%. Among the 26 050 total ED encounters for AHF, 15 275 (58.6%) had known EF and 62.4% had HFpEF. The mean age was 76, 49.6% were women, and 60.5% were white. We found that 62.4% of patients were admitted, 18.3% were observed, and 19.3% were discharged from the ED. The 30 day all-cause mortality rate was lowest among discharged patients (3.9%), intermediate among observed patients (5.9%), and highest among admitted patients (13.9%). Overall, the adjusted 30 day mortality rate was significantly higher among HFpEF patients compared with HFrEF patients (10.2% vs. 8.4%, P = 0.0004). HFpEF patients had higher mortality regardless of ED disposition, although the difference was only significant among admitted patients. The adjusted 30 day return hospital admission rates were not significantly different between HFpEF and HFrEF patients (17.9% vs. 17.8%, P = 0.89). The adjusted 30 day non-fatal serious adverse event rates were significantly higher among HFrEF patients compared with HFpEF patients (13.7% vs. 11.1%, P < 0.0001), driven by myocardial infarction and coronary revascularization. We found that 3692 patients had EF ≤ 40%. Patients with EF ≥ 50% had significantly higher adjusted 30 day mortality rates compared with those with EF ≤ 40% (10.2% vs. 8.4%, P < 0.05). In a contemporary population, almost three quarters of ED patients with AHF and known EF have HFpEF. These patients have higher 30 day adjusted mortality compared with those with HFrEF. Further studies might evaluate the underlying factors associated with this difference and target interventions to improve outcomes.

Authors: Sax, Dana R; Rana, Jamal S; Mark, Dustin G; Huang, Jie; Collins, Sean P; Liu, Dandan; Storrow, Alan B; Reed, Mary E; KP CREST Network,

ESC Heart Fail. 2021 08;8(4):2889-2898. Epub 2021-05-12.

PubMed abstract

Association of chronic anticoagulant and antiplatelet use on disease severity in SARS-COV-2 infected patients

Authors: Ho, Gwendolyn; Dusendang, Jennifer R; Schmittdiel, Julie; Kavecansky, Juraj; Tavakoli, Jahan; Pai, Ashok

J Thromb Thrombolysis. 2021 Aug;52(2):476-481. Epub 2021-02-01.

PubMed abstract

Development of a healthcare system COVID Hotspotting Score in California: an observational study with prospective validation

To examine the value of health systems data as indicators of emerging COVID-19 activity. Observational study of health system indicators for the COVID Hotspotting Score (CHOTS) with prospective validation. An integrated healthcare delivery system in Northern California including 21 hospitals and 4.5 million members. The CHOTS incorporated 10 variables including four major (cough/cold calls, emails, new positive COVID-19 tests, COVID-19 hospital census) and six minor (COVID-19 calls, respiratory infection and COVID-19 routine and urgent visits, and respiratory viral testing) indicators assessed with change point detection and slope metrics. We quantified cross-correlations lagged by 7-42 days between CHOTS and standardised COVID-19 hospital census using observational data from 1 April to 31 May 2020 and two waves of prospective data through 21 March 2021. Through 30 September 2020, peak cross-correlation between CHOTS and COVID-19 hospital census occurred with a 28-day lag at 0.78; at 42 days, the correlation was 0.69. Lagged correlation between medical centre CHOTS and their COVID-19 census was highest at 42 days for one facility (0.63), at 35 days for nine facilities (0.52-0.73), at 28 days for eight facilities (0.28-0.74) and at 14 days for two facilities (0.73-0.78). The strongest correlation for individual indicators was 0.94 (COVID-19 census) and 0.90 (new positive COVID-19 tests) lagged 1-14 days and 0.83 for COVID-19 calls and urgent clinic visits lagged 14-28 days. Cross-correlation was similar (0.73) with a 35-day lag using prospective validation from 1 October 2020 to 21 March 2021. Passively collected health system indicators were strongly correlated with forthcoming COVID-19 hospital census up to 6 weeks before three successive COVID-19 waves. These tools could inform communities, health systems and public health officials to identify, prepare for and mitigate emerging COVID-19 activity.

Authors: Liu, Vincent X; Thai, Khanh K; Galin, Jessica; Gerstley, Lawrence David; Myers, Laura C; Parodi, Stephen M; Chen, Yi-Fen Irene; Goler, Nancy; Escobar, Gabriel J; Kipnis, Patricia

BMJ Open. 2021 07 26;11(7):e048211. Epub 2021-07-26.

PubMed abstract

Singular and combined effects of transcranial infrared laser stimulation and exposure therapy on pathological fear: a randomized clinical trial.

BACKGROUND: Preclinical findings suggest that transcranial infrared laser stimulation (TILS) improves fear extinction learning and cognitive function by enhancing prefrontal cortex (PFC) oxygen metabolism. These findings prompted our investigation of treating pathological fear using this non-invasive stimulation approach either alone to the dorsolateral PFC (dlPFC), or to the ventromedial PFC (vmPFC) in combination with exposure therapy. METHODS: Volunteers with pathological fear of either enclosed spaces, contamination, public speaking, or anxiety-related bodily sensations were recruited for this randomized, single-blind, sham-controlled trial with four arms: (a) Exposure + TILS_vmPFC (n = 29), (b) Exposure + sham TILS_vmPFC (n = 29), (c) TILS_dlPFC alone (n = 26), or (d) Sham TILS _dlPFC alone (n = 28). Post-treatment assessments occurred immediately following treatment. Follow-up assessments occurred 2 weeks after treatment. RESULTS: A total of 112 participants were randomized [age range: 18-63 years; 96 females (85.71%)]. Significant interactions of Group x Time and Group x Context indicated differential treatment effects on retention (i.e. between time-points, averaged across contexts) and on generalization (i.e. between contexts, averaged across time-points), respectively. Among the monotherapies, TILS_dlPFC outperformed SHAM_dlPFC in the initial context, b = -13.44, 95% CI (-25.73 to -1.15), p = 0.03. Among the combined treatments, differences between EX + TILS_vmPFC and EX + SHAM_vmPFC were non-significant across all contrasts. CONCLUSIONS: TILS to the dlPFC, one of the PFC regions implicated in emotion regulation, resulted in a context-specific benefit as a monotherapy for reducing fear. Contrary to prediction, TILS to the vmPFC, a region implicated in fear extinction memory consolidation, did not enhance exposure therapy outcome.

Authors: Zaizar ED; Papini S; Gonzalez-Lima F; Telch MJ

Psychol Med. 2021 Jul 21:1-10. doi: 10.1017/S0033291721002270.

PubMed abstract

Pulmonary Rehabilitation and Readmission Rates for Medicare Beneficiaries with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Authors: Myers LC; Faridi MK; Hasegawa K; Camargo CA

Chronic Obstr Pulm Dis. 2021 Jul 16.

PubMed abstract

Equitably Allocating Resources During Crises: Racial Differences in Mortality Prediction Models

Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objectives: To test the prognostic accuracy of the SOFA score and version 2 of the Laboratory-based Acute Physiology Score (LAPS2) among Black and white patients. Methods: We included Black and white patients admitted for sepsis or acute respiratory failure at 27 hospitals. We calculated the discrimination and calibration for in-hospital mortality of SOFA, LAPS2, and modified versions of each, including categorical SOFA groups recommended in a popular CSC and a SOFA score without creatinine to reduce the influence of race. Measurements and Main Results: Of 113,158 patients, 27,644 (24.4%) identified as Black. The LAPS2 demonstrated higher discrimination (area under the receiver operating characteristic curve [AUC], 0.76; 95% confidence interval [CI], 0.76-0.77) than the SOFA score (AUC, 0.68; 95% CI, 0.68-0.69). The LAPS2 was also better calibrated than the SOFA score, but both underestimated in-hospital mortality for white patients and overestimated in-hospital mortality for Black patients. Thus, in a simulation using observed mortality, 81.6% of Black patients were included in lower-priority CSC categories, and 9.4% of all Black patients were erroneously excluded from receiving the highest prioritization. The SOFA score without creatinine reduced racial miscalibration. Conclusions: Using SOFA in CSCs may lead to racial disparities in resource allocation. More equitable mortality prediction scores are needed.

Authors: Ashana, Deepshikha Charan; Anesi, George L; Liu, Vincent X; Escobar, Gabriel J; Chesley, Christopher; Eneanya, Nwamaka D; Weissman, Gary E; Miller, William Dwight; Harhay, Michael O; Halpern, Scott D

Am J Respir Crit Care Med. 2021 07 15;204(2):178-186.

PubMed abstract

Linking racism and homonegativity to healthcare system distrust among young men of color who have sex with men: Evidence from the Healthy Young Men’s (HYM) study

Experiences with racism predict healthcare system distrust among people of color, but Black and Latino young men who have sex with men (YMSM) also experience overlapping forms of stigma associated with their sexual identities and behaviors (i.e., homonegativity and internalized homonegativity). These forms of minority stress may drive healthcare system distrust among Black and Latino YMSM but have received far less attention. To examine the associations of racism, homonegativity, and internalized homonegativity with healthcare system distrust among a community sample of Black and Latino YMSM. Data came from waves 2-4 (years 2017-2018) of the Healthy Young Men’s study, a longitudinal cohort study of Black and Latino YMSM living in Los Angeles County. Data across waves (n = 424, nobs = 1272) were combined and analyzed using a fixed effects approach and adjusting for repeated measures across participants. A series of regression models that added sets of covariates (demographics, syndemic indicators, and health-related factors) were tested to examine associations of racism, homonegativity, and internalized homonegativity with healthcare system distrust. Adjusting for demographics and syndemic indicators, racism, but not homonegativity or internalized homonegativity, was associated with healthcare system distrust. Adjustment for health-related factors had little impact on results. Among Black and Latino YMSM, greater exposure to racism is associated with greater healthcare system distrust. Efforts to strengthen healthcare system trust should explicitly target the institutional policies that disproportionately harm people of color.

Authors: Hsueh L; Layland EK; Kipke MD; Bray BC

Soc Sci Med. 2021 Jul 10;284:114219. Epub 2021-07-10.

PubMed abstract

ASO Visual Abstract: Volume Matters-Longitudinal Retrospective Cohort Study of Outcomes Following Consultation and Standardization of Adrenal Surgery

Authors: Rahbari, Reza; Herrinton, Lisa J; et al.

Ann Surg Oncol. 2021 Jul 03.

PubMed abstract

Retrospective Cohort Study Comparing Infliximab-dyyb and Infliximab in Biologic-Naive Patients With Inflammatory Bowel Disease in the United States

Real-world assessments of biosimilars are needed to understand their effectiveness and safety in practice settings that may differ from those seen in clinical trials or healthcare systems in different countries. To assess the effectiveness and safety of a biosimilar (infliximab-dyyb) and its reference product (infliximab) in patients with inflammatory bowel disease (IBD) in the United States. We conducted a retrospective cohort study of biologic-naive patients with IBD who started treatment with infliximab-dyyb or infliximab. The study included 3206 patients identified through electronic health records in a US integrated healthcare delivery system. The effectiveness outcome was a composite of IBD-related surgery, IBD-related emergency room visit, and IBD-related hospitalization within 12 months of initiation. Safety outcomes included incidence of any or serious infection, cancer, acute liver dysfunction, and tuberculosis. We used a non-inferiority test with an upper-limit margin of 10% to analyze effectiveness. Doubly robust methods incorporating Cox proportional hazard regression with standardized inverse probability of treatment weighting were used to analyze both effectiveness and safety outcomes. The composite effectiveness outcome occurred in 107 of 870 patients (12.3%) in the infliximab-dyyb and 379 of 2336 patients (16.2%) in the infliximab groups. Infliximab-dyyb was non-inferior (P < .01) and was not different (hazard ratio [HR] 0.81; confidence interval [CI] 0.65-1.01; P = .06) to infliximab. Safety outcomes were not different between infliximab-dyyb and infliximab for any infections (HR 1.01; CI 0.86-1.17; P = .95), serious infections (HR 0.83; CI 0.54-1.26; P = .38), cancers (HR 0.83; CI 0.44-1.54; P = .55), and tuberculosis (HR 0.59; CI 0.10-3.55; P = .57). Initiation of infliximab-dyyb was non-inferior to infliximab among biologic-naive patients with IBD in an US integrated healthcare delivery system.

Authors: Smith, Joshua T; Velayos, Fernando S; Niu, Fang; Liu, Vincent; Delate, Thomas; Pola, Suresh; Le, Kim; Hui, Rita L

Crohns Colitis 360. 2021 Jul;3(3):otab051. Epub 2021-07-29.

PubMed abstract

Reassessment of Glycemic Goals in Older Patients With Dementia-More Work Is Needed to Do Less

Authors: Claytor, Jennifer D; Grant, Richard W

JAMA Intern Med. 2021 07 01;181(7):994-995.

PubMed abstract

The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations

Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. Varied qualitative inquiry methods – in-depth interviews, participant-led neighborhood tours, and clinic visit observations – involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco’s public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM). Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients’ self-management. Health service providers leveraged these resources to address patients’ social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated. The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.

Authors: Nguyen, Kim Hanh; Fields, Jessica D; Cemballi, Anupama G; Desai, Riya; Gopalan, Anjali; Cruz, Tessa; Shah, Aekta; Akom, Antwi; Brown, William; Sarkar, Urmimala; Lyles, Courtney Rees

J Am Board Fam Med. 2021 Jul-Aug;34(4):698-708.

PubMed abstract

Incidence of 30-Day Venous Thromboembolism in Adults Tested for SARS-CoV-2 Infection in an Integrated Health Care System in Northern California

Authors: Roubinian, Nareg H; Dusendang, Jennifer R; Mark, Dustin G; Vinson, David R; Liu, Vincent X; Schmittdiel, Julie A; Pai, Ashok P

JAMA Intern Med. 2021 07 01;181(7):997-1000.

PubMed abstract

The effect of mail order pharmacy outreach on older patients with diabetes

Authors: Gong, Chelsea; Dyer, Wendy; Yassin, Maher; Neugebauer, Romain; Karter, Andrew J; Schmittdiel, Julie A

J Am Geriatr Soc. 2021 07;69(7):2028-2030. Epub 2021-03-26.

PubMed abstract

Endophthalmitis prophylaxis failures in patients injected with intracameral antibiotic during cataract surgery

To estimate the association of cefuroxime and moxifloxacin in relation to the occurrence of endophthalmitis following phacoemulsification cataract surgery. Retrospective clinical cohort study. We studied patients with noncomplex phacoemulsification cataract surgery in Kaiser Permanente Northern California during 2014-2019. Data were obtained for acute, postoperative endophthalmitis within 90 days of phacoemulsification, including culture and antibiogram results, intracameral and topical antibiotic agent, and dose. In a post hoc analysis, we also examined preoperative anterior chamber depth (ACD) and postoperative anterior chamber volume (ACV). Of 216,141 surgeries, endophthalmitis occurred in 0.020% of moxifloxacin-injected eyes and 0.013% of cefuroxime eyes (relative risk 1.62 with 95% CI 0.82-3.20, P = .16). Of the 34 (0.016%) cases of endophthalmitis, cefuroxime 1 mg was injected into 13 eyes and moxifloxacin 0.1% into 21 eyes. Organisms with antibiograms were identified in 12 (35%) cases. Of these, bacteria recovered from cefuroxime-injected eyes were resistant to cefuroxime in all cases (4/4), with Enterococcus comprising half of these. In eyes injected with moxifloxacin 0.1%, 6 out of 7 organisms were sensitive to moxifloxacin injected with 0.1 mL and in 1 eye injected with 1 mL. Streptococcus was the most common organism recovered (6/9) in moxifloxacin-injected eyes. Preoperative ACD and postoperative calculated ACV were higher in eyes injected with moxifloxacin. Endophthalmitis cases with positive cultures were generally related to organism resistance in cefuroxime eyes but to sensitive organisms in moxifloxacin eyes. Moxifloxacin doses may have been insufficient in eyes with larger ACV.

Authors: Shorstein, Neal H; Liu, Liyan; Carolan, James A; Herrinton, Lisa

Am J Ophthalmol. 2021 07;227:166-172. Epub 2021-02-08.

PubMed abstract

Developing and Testing Automatic Models of Patient Communicative Health Literacy Using Linguistic Features: Findings from the ECLIPPSE study

Patients with diabetes and limited health literacy (HL) may have suboptimal communication exchange with their health care providers and be at elevated risk of adverse health outcomes. These difficulties are generally attributed to patients’ reduced ability to both communicate and understand health-related ideas as well as physicians’ lack of skill in identifying those with limited HL. Understanding and identifying patients with barriers posed by lower HL to improve healthcare delivery and outcomes is an important research avenue. However, doing so using traditional methods has proven difficult and infeasible to scale. This study using corpus analyses, expert human ratings of HL, and natural language processing (NLP) approaches to estimate HL at the individual patient level. The goal of the study is to better understand HL from a linguistic perspective and to open new research areas to enhance population management and individualized care. Specifically, this study examines HL as a function of patients’ demonstrated ability to communicate health-related information to their providers via secure messages. The study develops an NLP-based HL model and validates the model by predicting patient-related events such as medical outcomes and hospitalizations. Results indicate that the developed model predicts human ratings of HL with ~80% accuracy. Validation indicates that lower HL patients are more likely to be nonwhite and have lower educational attainment. In addition, patients with lower HL suffered more negative health outcomes and had higher healthcare service utilization.

Authors: Crossley SA; Balyan R; Liu J; Karter AJ; McNamara D; Schillinger D

Health Commun. 2021 07;36(8):1018-1028. Epub 2020-03-02.

PubMed abstract

Racial/ethnic, gender, and age group differences in cardiometabolic risks among adults in a Northern California health plan: a cross-sectional study

In the U.S., the prevalence of diabetes and hypertension are higher among African American/Black (Black), Latinx, and Filipino adults than non-Hispanic White (White) and Chinese adults. We compared the racial/ethnic-specific prevalence of several modifiable cardiometabolic risks in an insured adult population to identify behaviors that may drive racial/ethnic differences in cardiometabolic health. This cross-sectional study used data for middle-aged (35-64) and older (65-79) Kaiser Permanente Northern California (KPNC) adult health plan members. Smoking status and BMI were derived from electronic health record data. Weighted pooled self-reported data from the 2014/2015 and 2017 KPNC Member Health Survey cycles were used to estimate daily number of servings of fruits/vegetables, general sodium avoidance, sugar-sweetened beverage (SSB) consumption frequency, alcohol use within daily recommended limit, weekly exercise frequency, and number of hours of sleep daily. Age-standardized estimates of all cardiometabolic risks were produced for middle-aged and older-aged women and men in the five racial/ethnic groups. Analyses focused on racial/ethnic differences within age-gender groups and gender and age group differences within racial/ethnic groups. In both age groups, Black, Latinx, and Filipino adults were more likely than White and Chinese adults to have overweight and obesity and were less likely to engage in health promoting dietary (fruit/vegetable and SSB consumption, sodium avoidance (women only)) and sleep behaviors. Middle-aged Black and Filipino men were more likely than White men to be current smokers. Less racial/ethnic variation was seen in exercise frequency. Significant gender differences were observed for dietary behaviors overall and within racial/ethnic groups, especially among middle-aged adults; however, these gender differences were smaller for sleep and exercise. Age differences within gender and racial/ethnic groups were less consistent. Racial/ethnic and gender differences in these behaviors were also seen in the subsample of adults with diabetes and/or hypertension and in the subsample of adults who reported they were trying to engage in health promoting behaviors. Black, Latinx, and Filipino adults were more likely than White and Chinese adults to report dietary and sleep behaviors associated with development and worsening of cardiometabolic conditions, with men exhibiting poorer dietary behaviors than women.

Authors: Gordon, Nancy P; Hsueh, Loretta

BMC Public Health. 2021 06 25;21(1):1227. Epub 2021-06-25.

PubMed abstract

Community-based smoking cessation treatment for adults with high anxiety sensitivity: a randomized clinical trial.

BACKGROUND AND AIMS: People with anxiety disorders are more likely to smoke and less likely to succeed when they try to quit. Anxiety sensitivity may underlie both phenomena, such that people with high anxiety sensitivity react to interoceptive distress by avoidance. This study aimed to test the efficacy of an exercise program that induced interoceptive distress and thereby created tolerance to this distress in a safe environment. DESIGN, SETTING AND PARTICIPANTS: Randomized clinical trial at four YMCA branches in Austin, Texas, USA. Participants [n = 150; 130 (86.7%) white; 101 (67.3%) female; meanage = 38.6, standard deviation (SD)age = 10.4] were adult, daily smokers with high anxiety sensitivity motivated to quit smoking, who reported no regular moderate-intensity exercise. INTERVENTIONS: Participants were assigned a YMCA personal trainer who guided them through a 15-week intervention aerobic exercise program. Participants assigned to the personalized intervention trained at 60-85% of their heart rate reserve (HRR), whereas participants assigned to the control intervention trained at 20-40% of their HRR. Participants in both groups received standard behavioral support and nicotine replacement therapy. MEASUREMENTS: The primary outcome was biologically verified 7-day point prevalence abstinence (PPA) at 6-month follow-up. FINDINGS: Sixty-one per cent of participants were available at the 6-month follow-up. PPA at 6 months was higher in the personalized intervention than the control intervention [27.6 versus 14.8%; odds ratio (OR) = 2.20, 95% confidence interval (CI) = 1.28, 3.80, P = 0.005], assuming missing at random. Anxiety sensitivity declined in both groups with no evidence that this differed between groups. CONCLUSIONS: An exercise program of high intensity increased abstinence from smoking in people with high anxiety sensitivity, but may not have done so by reducing anxiety sensitivity.

Authors: Smits JAJ; Zvolensky MJ; Rosenfield D; Brown RA; Otto MW; Dutcher CD; Papini S; Freeman SZ; DiVita A; Perrone A; Garey L

Addiction. 2021 Nov;116(11):3188-3197. doi: 10.1111/add.15586. Epub 2021 Jun 13.

PubMed abstract

Descriptive examination of secure messaging in a longitudinal cohort of diabetes patients in the ECLIPPSE study

The substantial expansion of secure messaging (SM) via the patient portal in the last decade suggests that it is becoming a standard of care, but few have examined SM use longitudinally. We examined SM patterns among a diverse cohort of patients with diabetes (N = 19 921) and the providers they exchanged messages with within a large, integrated health system over 10 years (2006-2015), linking patient demographics to SM use. We found a 10-fold increase in messaging volume. There were dramatic increases overall and for patient subgroups, with a majority of patients (including patients with lower income or with self-reported limited health literacy) messaging by 2015. Although more physicians than nurses and other providers messaged throughout the study, the distribution of health professions using SM changed over time. Given this rapid increase in SM, deeper understanding of optimizing the value of patient and provider engagement, while managing workflow and training challenges, is crucial.

Authors: Cemballi, Anupama Gunshekar; Karter, Andrew J; Schillinger, Dean; Liu, Jennifer Y; McNamara, Danielle S; Brown, William; Crossley, Scott; Semere, Wagahta; Reed, Mary; Allen, Jill; Lyles, Courtney Rees

J Am Med Inform Assoc. 2021 06 12;28(6):1252-1258.

PubMed abstract

Association of Real-time Continuous Glucose Monitoring With Glycemic Control and Acute Metabolic Events Among Patients With Insulin-Treated Diabetes

Continuous glucose monitoring (CGM) is recommended for patients with type 1 diabetes; observational evidence for CGM in patients with insulin-treated type 2 diabetes is lacking. To estimate clinical outcomes of real-time CGM initiation. Exploratory retrospective cohort study of changes in outcomes associated with real-time CGM initiation, estimated using a difference-in-differences analysis. A total of 41 753 participants with insulin-treated diabetes (5673 type 1; 36 080 type 2) receiving care from a Northern California integrated health care delivery system (2014-2019), being treated with insulin, self-monitoring their blood glucose levels, and having no prior CGM use were included. Initiation vs noninitiation of real-time CGM (reference group). Ten end points measured during the 12 months before and 12 months after baseline: hemoglobin A1c (HbA1c); hypoglycemia (emergency department or hospital utilization); hyperglycemia (emergency department or hospital utilization); HbA1c levels lower than 7%, lower than 8%, and higher than 9%; 1 emergency department encounter or more for any reason; 1 hospitalization or more for any reason; and number of outpatient visits and telephone visits. The real-time CGM initiators included 3806 patients (mean age, 42.4 years [SD, 19.9 years]; 51% female; 91% type 1, 9% type 2); the noninitiators included 37 947 patients (mean age, 63.4 years [SD, 13.4 years]; 49% female; 6% type 1, 94% type 2). The prebaseline mean HbA1c was lower among real-time CGM initiators than among noninitiators, but real-time CGM initiators had higher prebaseline rates of hypoglycemia and hyperglycemia. Mean HbA1c declined among real-time CGM initiators from 8.17% to 7.76% and from 8.28% to 8.19% among noninitiators (adjusted difference-in-differences estimate, -0.40%; 95% CI, -0.48% to -0.32%; P < .001). Hypoglycemia rates declined among real-time CGM initiators from 5.1% to 3.0% and increased among noninitiators from 1.9% to 2.3% (difference-in-differences estimate, -2.7%; 95% CI, -4.4% to -1.1%; P = .001). There were also statistically significant differences in the adjusted net changes in the proportion of patients with HbA1c lower than 7% (adjusted difference-in-differences estimate, 9.6%; 95% CI, 7.1% to 12.2%; P < .001), lower than 8% (adjusted difference-in-differences estimate, 13.1%; 95% CI, 10.2% to 16.1%; P < .001), and higher than 9% (adjusted difference-in-differences estimate, -7.1%; 95% CI, -9.5% to -4.6%; P < .001) and in the number of outpatient visits (adjusted difference-in-differences estimate, -0.4; 95% CI, -0.6 to -0.2; P < .001) and telephone visits (adjusted difference-in-differences estimate, 1.1; 95% CI, 0.8 to 1.4; P < .001). Initiation of real-time CGM was not associated with statistically significant changes in rates of hyperglycemia, emergency department visits for any reason, or hospitalizations for any reason. In this retrospective cohort study, insulin-treated patients with diabetes selected by physicians for real-time continuous glucose monitoring compared with noninitiators had significant improvements in hemoglobin A1c and reductions in emergency department visits and hospitalizations for hypoglycemia, but no significant change in emergency department visits or hospitalizations for hyperglycemia or for any reason. Because of the observational study design, findings may have been susceptible to selection bias.

Authors: Karter AJ; Parker MM; Moffet HH; Gilliam LK; Dlott R

JAMA. 2021 06 08;325(22):2273-2284.

PubMed abstract

Understanding differences within ethnic group designation: comparing risk factors and health indicators between Iranian and Arab Americans in Northern California

The Middle Eastern and North African (MENA) ethnic group is a diverse group composed of two primary subsets in the United States: Iranian and Arab Americans. We aimed to compare health risk factors, chronic health conditions, and mental health conditions of Iranian and Arab American adults in Northern California. We used cross-sectional electronic health record (EHR) data from a 2016 Northern California health plan study cohort to compare adults classified as Iranian or Arab American based on ethnicity, language, or surname. We produced age-standardized prevalence estimates of obesity, smoking, hyperlipidemia, prediabetes, diabetes, hypertension, depression, and anxiety for Iranian and Arab American men and women by age group (35-44, 45-64, and 65-84) and overall (35-84). We used generalized linear models to calculate prevalence ratios (PR) to compare Iranian and Arab American adults ages 35-84 on all health indicators. Compared to Arab Americans, Iranian Americans had a lower prevalence of obesity (PR: 0.77, 95% confidence interval, CI: 0.73, 0.82), current smoking (PR: 0.80, 95% CI: 0.73, 0.89), and ever smoking (PR: 0.95, 95% CI: 0.91, 0.99), but a higher prevalence of hyperlipidemia (PR: 1.09, 95% CI: 1.06, 1.12), prediabetes (PR: 1.12, 95% CI: 1.09, 1.16), depression (PR; 1.41, 95% CI: 1.30, 1.52), and anxiety (PR: 1.52, 95% CI: 1.42, 1.63). Similar patterns were observed for men and women. This work supports the need to collect granular data on race and ethnicity within the MENA ethnic group to improve identification in clinical care settings and population health reporting to better address the physical and mental health needs of different MENA subgroups.

Authors: Abuelezam, Nadia N; El-Sayed, Abdulrahman; Galea, Sandro; Gordon, Nancy P

BMC Public Health. 2021 06 05;21(1):1074. Epub 2021-06-05.

PubMed abstract

Association of Type 1 Diabetes and Hypoglycemic and Hyperglycemic Events and Risk of Dementia

To determine whether severe hypoglycemic and hyperglycemic events are associated with longitudinal dementia risk in older adults with type 1 diabetes. A longitudinal cohort study followed 2,821 members of an integrated healthcare delivery system with type 1 diabetes from 1997-2015. Hypoglycemic and hyperglycemic events requiring emergency room or hospitalization were abstracted from medical records beginning 1/1/1996 through cohort entry. Participants were followed for dementia diagnosis through 9/30/2015. Dementia risk was examined using Cox proportional hazard models adjusted for age (as timescale), sex, race/ethnicity, HbA1c, depression, stroke, and nephropathy. Among 2,821 older adults (mean age 56) with type 1 diabetes, 398 (14%) had a history of severe hypoglycemia, 335 (12%) severe hyperglycemia and 87 (3%) both. Over a mean 6.9 years of follow-up, 153 individuals (5.4%) developed dementia. In fully adjusted models, individuals with hypoglycemic events had 66% greater risk of dementia than those without a hypoglycemic event (HR=1.66; 95% CI: 1.09, 2.53), while those with hyperglycemic events had >2 times the risk (HR=2.11; 95% CI: 1.24, 3.59) than those without a hyperglycemic event. There was a 6-fold greater risk of dementia in individuals with both severe hypoglycemia and hyperglycemia versus those with neither (HR=6.20; 95% CI: 3.02, 12.70). For older individuals with type 1 diabetes, severe hypoglycemic and hyperglycemic events are associated with increased future risk of dementia.

Authors: Whitmer, Rachel A; Gilsanz, Paola; Quesenberry, Charles P; Karter, Andrew J; Lacy, Mary E

Neurology. 2021 Jun 02.

PubMed abstract

Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission

Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.

Authors: Yoo, Michael S; Liu, Vincent X; et al.

JAMA Netw Open. 2021 06 01;4(6):e216105. Epub 2021-06-01.

PubMed abstract

The Risks of Polycystic Ovary Syndrome and Diabetes Vary by Ethnic Subgroup Among Young Asian Women

Authors: Guo, Lynn; Gordon, Nancy P; Chandra, Malini; Dayo, Olumayowa; Lo, Joan C

Diabetes Care. 2021 06;44(6):e129-e130. Epub 2021-04-26.

PubMed abstract

Is Shelter-in-Place Policy Related to Mail Order Pharmacy Use and Racial/Ethnic Disparities for Patients With Diabetes?

Authors: Thomas, Tainayah W; Dyer, Wendy T; Yassin, Maher; Neugebauer, Romain; Karter, Andrew J; Schmittdiel, Julie A

Diabetes Care. 2021 06;44(6):e113-e114. Epub 2021-04-13.

PubMed abstract

Racial Disparities in COVID-19 Testing and Outcomes : Retrospective Cohort Study in an Integrated Health System

Racial disparities exist in outcomes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. To evaluate the contribution of race/ethnicity in SARS-CoV-2 testing, infection, and outcomes. Retrospective cohort study (1 February 2020 to 31 May 2020). Integrated health care delivery system in Northern California. Adult health plan members. Age, sex, neighborhood deprivation index, comorbid conditions, acute physiology indices, and race/ethnicity; SARS-CoV-2 testing and incidence of positive test results; and hospitalization, illness severity, and mortality. Among 3 481 716 eligible members, 42.0% were White, 6.4% African American, 19.9% Hispanic, and 18.6% Asian; 13.0% were of other or unknown race. Of eligible members, 91 212 (2.6%) were tested for SARS-CoV-2 infection and 3686 had positive results (overall incidence, 105.9 per 100 000 persons; by racial group, White, 55.1; African American, 123.1; Hispanic, 219.6; Asian, 111.7; other/unknown, 79.3). African American persons had the highest unadjusted testing and mortality rates, White persons had the lowest testing rates, and those with other or unknown race had the lowest mortality rates. Compared with White persons, adjusted testing rates among non-White persons were marginally higher, but infection rates were significantly higher; adjusted odds ratios [aORs] for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 2.01 (95% CI, 1.75 to 2.31), 3.93 (CI, 3.59 to 4.30), 2.19 (CI, 1.98 to 2.42), and 1.57 (CI, 1.38 to 1.78), respectively. Geographic analyses showed that infections clustered in areas with higher proportions of non-White persons. Compared with White persons, adjusted hospitalization rates for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 1.47 (CI, 1.03 to 2.09), 1.42 (CI, 1.11 to 1.82), 1.47 (CI, 1.13 to 1.92), and 1.03 (CI, 0.72 to 1.46), respectively. Adjusted analyses showed no racial differences in inpatient mortality or total mortality during the study period. For testing, comorbid conditions made the greatest relative contribution to model explanatory power (77.9%); race only accounted for 8.1%. Likelihood of infection was largely due to race (80.3%). For other outcomes, age was most important; race only contributed 4.5% for hospitalization, 12.8% for admission illness severity, 2.3% for in-hospital death, and 0.4% for any death. The study involved an insured population in a highly integrated health system. Race was the most important predictor of SARS-CoV-2 infection. After infection, race was associated with increased hospitalization risk but not mortality. The Permanente Medical Group, Inc.

Authors: Escobar, Gabriel J; Adams, Alyce S; Liu, Vincent X; Soltesz, Lauren; Chen, Yi-Fen Irene; Parodi, Stephen M; Ray, G Thomas; Myers, Laura C; Ramaprasad, Charulata M; Dlott, Richard; Lee, Catherine

Ann Intern Med. 2021 06;174(6):786-793. Epub 2021-02-09.

PubMed abstract

Disclosure of New Type 2 Diabetes Diagnoses to Younger Adults: a Qualitative Study

Adults diagnosed with type 2 diabetes at a younger age are at increased risk for poor outcomes. Yet, little is known about the early experiences of these individuals, starting with communication of the diagnosis. Addressing this knowledge gap is important as this initial interaction may shape subsequent disease-related perceptions and self-management. We examined diagnosis disclosure experiences and initial reactions among younger adults with newly diagnosed type 2 diabetes. Purposive sample of adult members of Kaiser Permanente Northern California, an integrated healthcare delivery system, diagnosed with type 2 diabetes before age 45 years. We conducted six focus groups between November 2017 and May 2018. Transcribed audio recordings were coded by two coders using thematic analysis. Participants (n = 41) were 38.4 (± 5.8) years of age; 10 self-identified as Latinx, 12 as Black, 12 as White, and 7 as multiple or other races. We identified variation in diagnosis disclosure experiences, centered on four key domains: (1) participants’ sense of preparedness for diagnosis (ranging from expectant to surprised); (2) disclosure setting (including in-person, via phone, via secure message, or via review of results online); (3) perceived provider tone (from nonchalant, to overly fear-centered, to supportive); and (4) participants’ emotional reactions to receiving the diagnosis (including acceptance, denial, guilt, and/or fear, rooted in personal and family experience). For younger adults, the experience of receiving a diabetes diagnosis varies greatly. Given the long-term consequences of inadequately managed diabetes and the need for early disease control, effective initial disclosure represents an opportunity to optimize initial care. Our results suggest several opportunities to improve the type 2 diabetes disclosure experience: (1) providing pre-test counseling, (2) identifying patient-preferred settings for receiving the news, and (3) developing initial care strategies that acknowledge and address the emotional distress triggered by this life-altering, chronic disease diagnosis.

Authors: Gopalan, Anjali; Blatchins, Maruta A; Altschuler, Andrea; Mishra, Pranita; Fakhouri, Issa; Grant, Richard W

J Gen Intern Med. 2021 06;36(6):1622-1628. Epub 2021-01-26.

PubMed abstract

Three Learning Organizations in Cataract Surgery: The Example of Intracameral Antibiotic Injection

The recent systematic adoption of intracameral antibiotic injection during cataract surgery in Sweden, India, and the US serves as a model for the successful transitioning of local quality improvement initiatives to organization-wide implementation. Although the delivery of eye care in the 3 countries is distinctly organized with differing governances and technological infrastructure, each contains elements of a learning organization (ie, an organization that has adopted a culture of creating, acquiring, and transferring knowledge into practice through system-level and clinician-level change). We describe a retrospective and organizational implementation study of intracameral antibiotic injection in Sweden, through the efforts of the National Cataract Registry; in the US by Kaiser Permanente; and in India by the Aravind Eye Hospital System. Leadership structure, training in problem solving, benchmarking, sharing of technical knowledge, and data and workforce engagement are compared. Each of the 3 organizations share the key elements of effective leadership, which values the exchange of ideas in the workforce, training and resourcing for change, and information management in the form of benchmarking and data sharing. In the case of intracameral antibiotic injection, a new technique was identified to improve quality and safety with a reduction in infections as evidence of the success of the programs. Committing to a culture of collective learning, and leveraging each stakeholder’s personal investment, health-care systems may improve care delivery and set new benchmarks in quality and safety.

Authors: Shorstein, Neal H; Montan, Per; Haripriya, Aravind; Lundström, Mats; Herrinton, Lisa

Perm J. 2021 05 19;25. Epub 2021-05-19.

PubMed abstract

Validity of a Computational Linguistics-Derived Automated Health Literacy Measure Across Race/Ethnicity: Findings from The ECLIPPSE Project

Limited health literacy (HL) partially mediates health disparities. Measurement constraints, including lack of validity assessment across racial/ethnic groups and administration challenges, have undermined the field and impeded scaling of HL interventions. We employed computational linguistics to develop an automated and novel HL measure, analyzing >300,000 messages sent by >9,000 diabetes patients via a patient portal to create a Literacy Profiles. We carried out stratified analyses among White/non-Hispanics, Black/non-Hispanics, Hispanics, and Asian/Pacific Islanders to determine if the Literacy Profile has comparable criterion and predictive validities. We discovered that criterion validity was consistently high across all groups (c-statistics 0.82-0.89). We observed consistent relationships across racial/ethnic groups between HL and outcomes, including communication, adherence, hypoglycemia, diabetes control, and ED utilization. While concerns have arisen regarding bias in AI, the automated Literacy Profile appears sufficiently valid across race/ethnicity, enabling HL measurement at a scale that could improve clinical care and population health among diverse populations.

Authors: Schillinger, Dean; Balyan, Renu; Crossley, Scott; McNamara, Danielle; Karter, Andrew

J Health Care Poor Underserved. 2021 05;32(2 Suppl):347-365.

PubMed abstract

Regionalization of Acute Myeloid Leukemia Treatment in a Community-Based Population: Implementation and Early Results

Regionalization of care for acute myeloid leukemia (AML) has not been described for community-based settings. In 2015, we shifted AML induction from 21 local centers to 3 regional centers. Using time-specific inception cohorts, we assessed whether regionalization was associated with the frequency of use of induction therapy, receipt of bone marrow transplantation, 60-day mortality (treatment toxicity), and 180-day mortality (treatment effectiveness). Information for all adult patients diagnosed with AML from 2013 to 2017 was obtained from the electronic health record. Multivariable methods were used to estimate the adjusted associations of induction, bone marrow transplantation, and death in relation to year of diagnosis before and after regionalization. Of 661 patients diagnosed during 2013 to 2017, 53% were ≥ 70 years, 22% were ≥ 80 years, and 10% died within the week following diagnosis. Comparing 2017 with 2013, the proportion of patients who received induction therapy increased 2.88 times (95% confidence interval [CI] = 1.55-5.35), and the proportion of non-acute promyelocytic leukemia patients receiving bone marrow transplantation increased 2.00 times (95% CI = 0.89-4.50). Regionalization was associated with lower 180-day mortality (hazard ratio [HR] = 0.64; 95% CI = 0.44-0.92), whereas change in 60-day mortality was not statistically significant (HR = 0.67; 95%CI = 0.43-1.04). In this community-based population, many patients were of advanced age yet benefitted from AML induction therapy delivered at a regionally specialized center. These early results suggest the benefit of regionalizing subspecialty leukemia care.

Authors: Law, Lisa Y; Uong, Stephen P; Vempaty, Hyma T; Nguyen, Vu H; Baer, David; Liu, Vincent X; Herrinton, Lisa J

Perm J. 2021 05;25.

PubMed abstract

Visit Content Analysis: Doctor-Patient Communication in Patients with Type 2 Diabetes

The primary care visit is an important opportunity to discuss and modify diabetes management. To gain insight into doctor-patient communication during primary care visits among English and Spanish speaking patients with type 2 diabetes and suboptimal glycemic control (HbA1c > 7%). We conducted a quantitative content analysis of audiotaped primary care visits in 2 patient cohorts. In Study 1 (31 English-speaking patients), we examined factors associated with management changes, and in Study 2 (20 Spanish-speaking patients and their Spanish-speaking providers), we examined the association of question asking with HbA1c control. This study was conducted between November 2017 and January 2020 across 8 primary care practices within Kaiser Permanente Northern California. In Study 1, the only factor significantly associated with a diabetes management change was patient identification of diabetes as a priority prior to the visit (91.7% had a management change vs 52.6% of patients who did not identify diabetes as a priority; p = 0.02). In Study 2, patients with poorer glycemic control (HbA1c ≥ 10.0) asked significantly fewer questions (3.4 ± 1.8 vs 10.7 ± 6.9 questions per 15 minutes; p = 0.004). Overall, despite receiving primary care from language-concordant providers, Spanish-speaking Study 2 patients asked fewer questions than English-speaking Study 1 patients (4.5 ± 2.9 vs 7.5 ± 3.7 questions per 15 minutes, respectively; p = 0.004). Our results highlight 2 potential strategies (preparing patients for their visits through identifying priorities and learning how to ask more questions during visits) for improving diabetes primary care.

Authors: Abdelgadir, Dana A; Rodriguez, Laurie M; Blatchins, Maruta A; Mishra, Pranita; Gopalan, Anjali; Grant, Richard W

Perm J. 2021 05;25.

PubMed abstract

Nonstationary Multivariate Gaussian Processes for Electronic Health Records

Advances in the modeling and analysis of electronic health records (EHR) have the potential to improve patient risk stratification, leading to better patient outcomes. The modeling of complex temporal relations across the multiple clinical variables inherent in EHR data is largely unexplored. Existing approaches to modeling EHR data often lack the flexibility to handle time-varying correlations across multiple clinical variables, or they are too complex for clinical interpretation. Therefore, we propose a novel nonstationary multivariate Gaussian process model for EHR data to address the aforementioned drawbacks of existing methodologies. Our proposed model is able to capture time-varying scale, correlation and smoothness across multiple clinical variables. We also provide details on two inference approaches: Maximum a posteriori and Hamilton Monte Carlo. Our model is validated on synthetic data and then we demonstrate its effectiveness on EHR data from Kaiser Permanente Division of Research (KPDOR). Finally, we use the KPDOR EHR data to investigate the relationships between a clinical patient risk metric and the latent processes of our proposed model and demonstrate statistically significant correlations between these entities.

Authors: Meng, Rui; Soper, Braden; Lee, Herbert K H; Liu, Vincent X; Greene, John D; Ray, Priyadip

J Biomed Inform. 2021 05;117:103698. Epub 2021-02-19.

PubMed abstract

Sepsis Subclasses: A Framework for Development and Interpretation

Sepsis is defined as a dysregulated host response to infection that leads to life-threatening acute organ dysfunction. It afflicts approximately 50 million people worldwide annually and is often deadly, even when evidence-based guidelines are applied promptly. Many randomized trials tested therapies for sepsis over the past 2 decades, but most have not proven beneficial. This may be because sepsis is a heterogeneous syndrome, characterized by a vast set of clinical and biologic features. Combinations of these features, however, may identify previously unrecognized groups, or “subclasses” with different risks of outcome and response to a given treatment. As efforts to identify sepsis subclasses become more common, many unanswered questions and challenges arise. These include: 1) the semantic underpinning of sepsis subclasses, 2) the conceptual goal of subclasses, 3) considerations about study design, data sources, and statistical methods, 4) the role of emerging data types, and 5) how to determine whether subclasses represent “truth.” We discuss these challenges and present a framework for the broader study of sepsis subclasses. This framework is intended to aid in the understanding and interpretation of sepsis subclasses, provide a mechanism for explaining subclasses generated by different methodologic approaches, and guide clinicians in how to consider subclasses in bedside care.

Authors: DeMerle, Kimberley M; Liu, Vincent; Seymour, Christopher W; et al.

Crit Care Med. 2021 05 01;49(5):748-759.

PubMed abstract

Investigating Bias from Missing Data in an Electronic Health Records-Based Study of Weight Loss After Bariatric Surgery

Missing data is common in electronic health records (EHR)-based obesity research. To avoid bias, it is critical to understand mechanisms that underpin missingness. We conducted a survey among bariatric surgery patients in three integrated health systems to (i) investigate predictors of disenrollment and (ii) examine differences in weight between disenrollees and enrollees at 5 years. We identified 2883 patients who had bariatric surgery between 11/2013 and 08/2014. Patients who disenrolled before their 5-year anniversary were invited to participate in a survey to ascertain reasons for disenrollment and current weight. Logistic regression was used to investigate predictors of disenrollment. Five-year percent weight change distributions were estimated using inverse-probability weighting to adjust for (un)availability of EHR weight data at 5 years among enrollees and survey (non-)response among disenrollees. Among 536 disenrolled patients, 104 (19%) completed the survey. Among 2347 patients who maintained enrollment, 384 (16%) had no weight measurement in the EHR near 5 years. Insurance, age, Hispanic ethnicity, and site predicted disenrollment. Disenrollees had slightly greater weight loss than enrollees. We found little evidence of weight loss differences by enrollment status. Collecting information through surveys can be an effective tool to investigate and adjust for missingness in EHR-based studies.

Authors: Koffman, Lily; Cooper, Julie; Haneuse, Sebastien; et al.

Obes Surg. 2021 05;31(5):2125-2135. Epub 2021-01-19.

PubMed abstract

Physician Stress During Electronic Health Record Inbox Work: In Situ Measurement With Wearable Sensors

Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day. The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress. Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model. Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2=98%). This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours.

Authors: Akbar F; Mark G; Prausnitz S; Warton EM; East JA; Moeller MF; Reed ME; Lieu TA

JMIR Med Inform. 2021 Apr 28;9(4):e24014. Epub 2021-04-28.

PubMed abstract

Physicians’ electronic inbox work patterns and factors associated with high inbox work duration

Electronic health record systems are increasingly used to send messages to physicians, but research on physicians’ inbox use patterns is limited. This study’s aims were to (1) quantify the time primary care physicians (PCPs) spend managing inboxes; (2) describe daily patterns of inbox use; (3) investigate which types of messages consume the most time; and (4) identify factors associated with inbox work duration. We analyzed 1 month of electronic inbox data for 1275 PCPs in a large medical group and linked these data with physicians’ demographic data. PCPs spent an average of 52 minutes on inbox management on workdays, including 19 minutes (37%) outside work hours. Temporal patterns of electronic inbox use differed from other EHR functions such as charting. Patient-initiated messages (28%) and results (29%) accounted for the most inbox work time. PCPs with higher inbox work duration were more likely to be female (P < .001), have more patient encounters (P < .001), have older patients (P < .001), spend proportionally more time on patient messages (P < .001), and spend more time per message (P < .001). Compared with PCPs with the lowest duration of time on inbox work, PCPs with the highest duration had more message views per workday (200 vs 109; P < .001) and spent more time on the inbox outside work hours (30 minutes vs 9.7 minutes; P < .001). Electronic inbox work by PCPs requires roughly an hour per workday, much of which occurs outside scheduled work hours. Interventions to assist PCPs in handling patient-initiated messages and results may help alleviate inbox workload.

Authors: Akbar, Fatema; Mark, Gloria; Warton, E Margaret; Reed, Mary E; Prausnitz, Stephanie; East, Jeffrey A; Moeller, Mark F; Lieu, Tracy A

J Am Med Inform Assoc. 2021 04 23;28(5):923-930.

PubMed abstract

Influence of patient immigrant status on physician trainee diabetes treatment decisions: a virtual patient experimental study

To determine the effect of patient immigrant status on physician trainees’ diabetes treatment decisions. Participants were 140 physician trainees (‘providers’). Providers viewed videos and vignettes of virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group and individual levels. Providers were less likely to refer foreign-born (vs. U.S.-born) patients to endocrinology. Individual-level results showed an almost even split between treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add oral hypoglycemic agent, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). Physician trainees are less likely to refer foreign-born patients to endocrinology. Half of individual-level decisions were influenced by patient immigrant status, but group-level analyses mask these differences. Systematic treatment differences based on non-relevant factors could lead to adverse outcomes for immigrants.

Authors: Hsueh L; Hirsh AT; Zapolski T; de Groot M; Mather KJ; Stewart JC

J Behav Med. 2021 Apr 16.

PubMed abstract

Prospective Validation and Comparative Analysis of Coronary Risk Stratification Strategies Among Emergency Department Patients With Chest Pain

Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as “rule-out” binary classification strategies, while others use graded-risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin-only strategies (fourth-generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA-ACS). The primary outcome was 60-day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all-cause mortality. There were 13 192 patient encounters included with a 60-day major adverse cardiac event incidence of 3.7%. RISTRA-ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03-0.10 and 0.07, 95% CI, 0.04-0.11, respectively) and the greatest net benefit across a range of low-risk thresholds. RISTRA-ACS demonstrated the highest discrimination for 60-day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91-0.94, P<0.0001). Conclusions RISTRA-ACS and HEART pathway were the optimal rule-out approaches, while RISTRA-ACS was the best-performing graded-risk approach. RISTRA-ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL:; Unique identifier: NCT03286179.

Authors: Mark, Dustin G; Sax, Dana R; Vinson, David R; Ballard, Dustin W; Reed, Mary E; Kaiser Permanente CREST Network Investigators,; et al.

J Am Heart Assoc. 2021 04 06;10(7):e020082. Epub 2021-03-31.

PubMed abstract

Acute Kidney Injury After CT in Emergency Patients with Chronic Kidney Disease: A Propensity Score-matched Analysis

Acute kidney injury (AKI) after intravenous contrast administration for computed tomography (CT) occurs infrequently, but certain patients may be susceptible. This study evaluated AKI incidence among emergency department (ED) patients with pre-existing chronic kidney disease (CKD) undergoing CT exams. This retrospective cohort study in an integrated healthcare system included ED patients previously diagnosed with CKD stages 3-5 (estimated glomerular filtration rate <60 milliliters per minute per 1.73 meters squared over at least three months), undergoing CT exams with or without intravenous contrast, from January 1, 2013-December 31, 2017. We excluded patients with CT prior to (30 days) or following (14 days) index CT and missing serum creatinine (sCr) measurements. We applied propensity score matching, and then multivariable regression adjustment for post-CT ED disposition and ED diagnosis, to calculate adjusted risk of AKI. Secondary patient-centered outcomes included 30-day mortality, end-stage renal disease (ESRD) diagnosis, and dialysis initiation. Among 103,573 eligible ED patients undergoing CT, propensity score matching yielded 5,589 pairs. Adjusted risk ratio (ARR) for AKI was higher overall for contrast-enhanced CT (1.60; 95% confidence interval [CI], 1.43-1.79). However, secondary outcomes were infrequent: 19/5,589 non-contrast vs 40/5,589 contrast patients with new dialysis initiation at 30 days (adjusted risk 0.3% vs 0.7%; adjusted risk reduction 0.4%; 95% CI, 0.1%-0.7%). In ED patients with chronic kidney disease undergoing CT, intravenous contrast was associated with higher overall adjusted risk of AKI, but patient-centered secondary outcomes were rare. The clinical significance of transient kidney injury after CT is unclear, although patients with advanced chronic kidney disease appear to have elevated risk.

Authors: Kene, Mamata; Arasu, Vignesh A; Mahapatra, Ajit K; Huang, Jie; Reed, Mary E

West J Emerg Med. 2021 Apr 02;22(3):614-622. Epub 2021-04-02.

PubMed abstract

Measurement of Sepsis in a National Cohort Using Three Different Methods to Define Baseline Organ Function

Rationale: In 2017, the U.S. Centers for Disease Control and Prevention (CDC) developed a new surveillance definition of sepsis, the adult sepsis event (ASE), to better track sepsis epidemiology. The ASE requires evidence of acute organ dysfunction and defines baseline organ function pragmatically as the best in-hospital value. This approach may undercount sepsis if new organ dysfunction does not resolve by discharge.Objectives: To understand how sepsis identification and outcomes differ when using the best laboratory values during hospitalization versus methods that use historical lookbacks to define baseline organ function.Methods: We identified all patients hospitalized at 138 Veterans Affairs hospitals (2013-2018) admitted via the emergency department with two or more systemic inflammatory response criteria, were treated with antibiotics within 48 hours (i.e., had potential infection), and completed 4+ days of antibiotics (i.e., had suspected infection). We considered the following three approaches to defining baseline renal, hematologic, and liver function: the best values during hospitalization (as in the Centers for Disease Control and Prevention’s ASE), the best values during hospitalization plus the prior 90 days (3-mo baseline), and the best values during hospitalization plus the prior 180 days (6-mo baseline). We determined how many patients met the criteria for sepsis by each approach, and then compared characteristics and outcomes of sepsis hospitalizations between the three approaches.Results: Among 608,128 hospitalizations with potential infection, 72.1%, 68.5%, and 58.4% had creatinine, platelet, and total bilirubin measured, respectively, in the prior 3 months. A total of 86.0%, 82.6%, and 74.8%, respectively, had these labs in the prior 6 months. Using the hospital baseline, 100,568 hospitalizations met criteria for community-acquired sepsis. By contrast, 111,983 and 117,435 met criteria for sepsis using the 3- and 6-month baselines, for a relative increase of 11% and 17%, respectively. Patient characteristics were similar across the three approaches. In-hospital mortality was 7.2%, 7.0%, and 6.8% for sepsis hospitalizations identified using the hospital, 3-month baseline, and 6-month baseline. The 30-day mortality was 12.5%, 12.7%, and 12.5%, respectively.Conclusions: Among veterans hospitalized with potential infection, the majority had laboratory values in the prior 6 months. Using 3- and 6-month lookbacks to define baseline organ function resulted in an 11% and 17% relative increase, respectively, in the number of sepsis hospitalizations identified.

Authors: Wayne, Max T; Molling, Daniel; Wang, Xiao Qing; Hogan, Cainnear K; Seelye, Sarah; Liu, Vincent X; Prescott, Hallie C

Ann Am Thorac Soc. 2021 04;18(4):648-655.

PubMed abstract

Five-year Longitudinal Cohort Study of Reinterventions After Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

To compare the long-term risks of reintervention following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in a large surgical cohort. The use of SG has increased dramatically relative to RYGB for the treatment of obesity. However, long-term risks following SG compared with RYGB have not been adequately defined in a large population-based study. A retrospective longitudinal cohort study of all adult health-plan members undergoing SG or RYGB for obesity in a multistate integrated health care system from January 2005 through September 2015. The risks of nutritional, endoscopic, radiologic, and surgical reintervention as well as the overall risk of any reinterventions at 1, 3, and 5 years were identified using diagnosis and procedure codes from comprehensive electronic medical records. The study included 15,319 patients who underwent SG and 19,954 patients who underwent RYGB with a follow-up of 79.2%. The overall risk of any reintervention at 5 years was 21.3% for SG and 28.3% for RYGB (P < 0.0001). After adjustment, SG was associated with fewer reinterventions through 5 years than RYGB (hazard ratio, 0.78; 95% confidence interval, 0.74-0.84). When comparing subcategories, SG also had a lower risk of nutritional, endoscopic, radiologic, and surgical reinterventions when examined versus RYGB. The findings for risks of reinterventions were consistent across clinical subgroups. SG has significantly lower risk of reintervention in all categories studied when compared with RYGB at 5-year follow-up. The long-term safety profile of LSG compared with RYGB should be an essential part of the discussion in patient-centered decision making when choosing between bariatric procedure options.

Authors: Li RA; Herrinton LJ; et al.

Ann Surg. 2021 04 01;273(4):758-765.

PubMed abstract

Smoking cessation treatment for individuals with comorbid diabetes and serious mental illness in an integrated health care delivery system

Smoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15-20 years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population. We conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N = 634) and without SMI (N = 18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility. Of the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52-2.13]; p < .001). For the SMI group, primary care providers wrote 80.24% of prescriptions, while psychiatrists wrote 8.81% of prescriptions. These findings offer an example of a delivery system with higher uptake of smoking cessation pharmacotherapy among people with SMI than without SMI, and highlight the opportunity to provide more smoking cessation interventions in mental health care settings.

Authors: Hwong AR; Schmittdiel J; Schillinger D; Newcomer JW; Essock S; Zhu Z; Dyer W; Young-Wolff KC; Mangurian C

Addict Behav. 2021 03;114:106697. Epub 2020-10-14.

PubMed abstract

The Presentation, Pace, and Profile of Infection and Sepsis Patients Hospitalized Through the Emergency Department: An Exploratory Analysis

To characterize the signs and symptoms of sepsis, compare them with those from simple infection and other emergent conditions and evaluate their association with hospital outcomes. A multicenter, retrospective cohort study of 408,377 patients hospitalized through the emergency department from 2012 to 2017 with sepsis, suspected infection, heart failure, or stroke. Infected patients were identified based on Sepsis-3 criteria, whereas noninfected patients were identified through diagnosis codes. Signs and symptoms were identified within physician clinical documentation in the first 24 hours of hospitalization using natural language processing. The time of sign and symptom onset prior to presentation was quantified, and sign and symptom prevalence was assessed. Using multivariable logistic regression, the association of each sign and symptom with four outcomes was evaluated: sepsis versus suspected infection diagnosis, hospital mortality, ICU admission, and time of first antibiotics (> 3 vs ≤ 3 hr from presentation). A total of 10,825 signs and symptoms were identified in 6,148,348 clinical documentation fragments. The most common symptoms overall were as follows: dyspnea (35.2%), weakness (27.2%), altered mental status (24.3%), pain (23.9%), cough (19.7%), edema (17.8%), nausea (16.9%), hypertension (15.6%), fever (13.9%), and chest pain (12.1%). Compared with predominant signs and symptoms in heart failure and stroke, those present in infection were heterogeneous. Signs and symptoms indicative of neurologic dysfunction, significant respiratory conditions, and hypotension were strongly associated with sepsis diagnosis, hospital mortality, and intensive care. Fever, present in only a minority of patients, was associated with improved mortality (odds ratio, 0.67, 95% CI, 0.64-0.70; p < 0.001). For common symptoms, the peak time of symptom onset before sepsis was 2 days, except for altered mental status, which peaked at 1 day prior to presentation. The clinical presentation of sepsis was heterogeneous and occurred with rapid onset prior to hospital presentation. These findings have important implications for improving public education, clinical treatment, and quality measures of sepsis care.

Authors: Liu, Vincent X; Bhimarao, Meghana; Greene, John D; Manickam, Raj N; Martinez, Adriana; Schuler, Alejandro; Barreda, Fernando; Escobar, Gabriel J

Crit Care Explor. 2021 Mar;3(3):e0344. Epub 2021-02-24.

PubMed abstract

Patient e-Visit Use and Outcomes for Common Symptoms in an Integrated Health Care Delivery System

Authors: Bhargava, Reena; Gayre, Gregg; Huang, Jie; Sievers, Evangeline; Reed, Mary

JAMA Netw Open. 2021 03 01;4(3):e212174. Epub 2021-03-01.

PubMed abstract

Characteristics and Outcomes of Clinic Visits Immediately Preceding Sepsis Hospitalization

Existing sepsis quality improvement initiatives focus on recognition and treatment of sepsis upon hospital admission. Yet many patients are evaluated in the clinic within 1 day of sepsis hospitalization. To determine the circumstances of clinic visits that precede sepsis hospitalization, including illness severity, whether patients are referred to the hospital, and time lapse and change in illness severity between clinic and hospital evaluation. In a retrospective cohort study at a tertiary academic medical center, data from electronic medical records were collected for all adult patients evaluated in an outpatient clinic within 1 day of sepsis hospitalization in 2017. Of 1450 patients hospitalized with sepsis, 118 had an established outpatient provider and a clinic visit within 1 day of admission and thus were included. During the clinic visit, 47 patients (39.8%) had a quick Sequential Organ Failure Assessment (qSOFA) score ≥1, and 59 (50.0%) had vital sign abnormalities. Most (74, 62.7%) were sent directly to the emergency department or hospital. Upon emergency department/hospital presentation, 62 patients (52.5%) had a worsening qSOFA score and/ or vital signs and 27 (22.9%) had worsening of multiple parameters. Median time lapse from clinic to emergency department/hospital evaluation was 3.2 hours. One in 10 patients hospitalized for sepsis had been evaluated in a clinic within 1 day of admission. At that clinic visit, most patients had an elevated qSOFA score or abnormal vital signs and a majority were sent directly to the emergency department/hospital. Half experienced clinical deterioration between the clinic visit and arrival in the emergency department/hospital.

Authors: Miller, H Catherine; Liu, Vincent X; Prescott, Hallie C

Am J Crit Care. 2021 03 01;30(2):135-139.

PubMed abstract

Reappraising Medical Syntax-Does Race Belong in the First Line of the Patient History?

Authors: Ikeme, Jesse C; Salazar, James W; Grant, Richard W

JAMA Intern Med. 2021 03 01;181(3):388-391.

PubMed abstract

Severe Hypoglycemia and Risk of Atherosclerotic Cardiovascular Disease in Patients With Diabetes

Authors: Rana, Jamal S; Moffet, Howard H; Liu, Jennifer Y; Karter, Andrew J

Diabetes Care. 2021 03;44(3):e40-e41. Epub 2021-01-20.

PubMed abstract

SARS-CoV-2 Clinical Outcomes in Patients with Cancer in a Large Integrated Health Care System in Northern California

The SARS-CoV-2 (COVID-19) pandemic continues to affect many lives globally. Patients with cancer undergoing potentially immunosuppressive therapies appear to be at particular risk for the disease and its complications. Here, we describe the experience of patients with cancer within Kaiser Permanente, a large, integrated health system in Northern California. Between February 25, 2020, and June 8, 2020, 4,627 patients were diagnosed with COVID-19, of whom 33 had active cancer treatment within 180 days and 214 had a history of cancer. Patients with active cancer treatment had a statistically higher risk of requiring noninvasive ventilation (odds ratio [OR], 2.57; confidence interval [CI], 1.10-6.01), and there was a nonsignificant trend toward higher risk of death (OR, 2.78; CI, 0.92-8.43). Those with a history of cancer had comparable outcomes to those without cancer. These data demonstrate an increased risk of complications from COVID-19 for patients with active cancer treatment.

Authors: Anantharaman, Archana; Dusendang, Jennifer R; Schmittdiel, Julie A; Harzstark, Andrea L

Oncologist. 2021 03;26(3):e500-e504. Epub 2020-12-03.

PubMed abstract

Preventing COPD readmissions under the Hospital Readmissions Reduction Program: How far have we come?

The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.

Authors: Press, Valerie G; Myers, Laura C; Feemster, Laura C

Chest. 2021 03;159(3):996-1006. Epub 2020-10-14.

PubMed abstract

Automated Identification of Adults at Risk for In-Hospital Clinical Deterioration. Reply

Authors: Escobar GJ; Liu VX; Kipnis P

N Engl J Med. 2021 02 04;384(5):486.

PubMed abstract

Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study

International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Authors: Kea, Bory; W Ballard, Dustin; G Mark, Dustin; E Reed, Mary; R Vinson, David; et al.

J Atr Fibrillation. 2021 Feb-Mar;13(5):2355. Epub 2021-02-28.

PubMed abstract

Implementation of a Multidisciplinary Expert Testicular Cancer Tumor Board Across a Large Integrated Healthcare Delivery System Via Early Case Ascertainment

In 2016, Kaiser Permanente Northern California began regionalizing testicular cancer care using population-based tumor board review. This mixed methods evaluation describes implementation outcomes and learnings. We conducted in-depth interviews with key stakeholders, administered surveys to local oncologists and urologists, and used clinical data to evaluate changes in care delivery during 2015-2018. An average of 135 patients with testicular cancer were diagnosed each year. Interviews with 16 key stakeholders provided several insights. Implementation resulted in high levels of satisfaction, was dependent on leadership and staff at various levels, and required technology and consulting solutions aligned to user agreements and clinical workflows. Of 123 local oncologists and urologists who completed surveys, 97% understood why care was regionalized and 89% agreed that tumor board review improved treatment decisions. Among 177 patients with stage I seminoma, the percentage appropriately observed rather than treated with adjuvant chemotherapy or radiation therapy increased from 48% (95% CI, 35 to 62) in 2015 to 87% (75 to 99) in 2018. Review altered care based on pathology and radiology re-review in 14.5 % of cases. Regionalization was feasible and effective.

Authors: Harzstark, Andrea L; Presti, Joseph C; Herrinton, Lisa J; et al.

JCO Clin Cancer Inform. 2021 02;5:187-193.

PubMed abstract

Sex-Based Differences Entangling With Electronic Health Record Documentation

Authors: Claytor, Jennifer; Grant, Richard W

JAMA Intern Med. 2021 02 01;181(2):290-291.

PubMed abstract

Association of anticoagulation use with SARS-CoV2 detection

Authors: Kavecansky, Juraj; Dusendang, Jennifer R; Tavakoli, Jahan; Schmittdiel, Julie; Ho, Gwendolyn; Loyles, Jodi; Pai, Ashok

Thromb Res. 2021 02;198:99-102. Epub 2020-12-02.

PubMed abstract

Use of Machine Learning to Develop a Risk-Stratification Tool for Emergency Department Patients With Acute Heart Failure

We use variables from a recently derived acute heart failure risk-stratification rule (STRATIFY) as a basis to develop and optimize risk prediction using additional patient clinical data from electronic health records and machine-learning models. Using a retrospective cohort design, we identified all emergency department (ED) visits for acute heart failure between January 1, 2017, and December 31, 2018, among adult health plan members of a large system with 21 EDs. The primary outcome was any 30-day serious adverse event, including death, cardiopulmonary resuscitation, balloon-pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization. Starting with the 13 variables from the STRATIFY rule (base model), we tested whether predictive accuracy in a different population could be enhanced with additional electronic health record-based variables or machine-learning approaches (compared with logistic regression). We calculated our derived model area under the curve (AUC), calculated test characteristics, and assessed admission rates across risk categories. Among 26,189 total ED encounters, mean patient age was 74 years, 51.7% were women, and 60.7% were white. The overall 30-day serious adverse event rate was 18.8%. The base model had an AUC of 0.76 (95% confidence interval 0.74 to 0.77). Incorporating additional variables led to improved accuracy with logistic regression (AUC 0.80; 95% confidence interval 0.79 to 0.82) and machine learning (AUC 0.85; 95% confidence interval 0.83 to 0.86). We found that 11.1%, 25.7%, and 48.9% of the study population had predicted serious adverse event risk of less than or equal to 3%, less than or equal to 5%, and less than or equal to 10%, respectively, and 28% of those with less than or equal to 3% risk were admitted. Use of a machine-learning model with additional variables improved 30-day risk prediction compared with conventional approaches.

Authors: Sax, Dana R; Mark, Dustin G; Huang, Jie; Sofrygin, Oleg; Rana, Jamal S; Collins, Sean P; Storrow, Alan B; Liu, Dandan; Reed, Mary E

Ann Emerg Med. 2021 02;77(2):237-248. Epub 2020-12-24.

PubMed abstract

Employing computational linguistics techniques to identify limited patient health literacy: Findings from the ECLIPPSE study

To develop novel, scalable, and valid literacy profiles for identifying limited health literacy patients by harnessing natural language processing. With respect to the linguistic content, we analyzed 283 216 secure messages sent by 6941 diabetes patients to physicians within an integrated system’s electronic portal. Sociodemographic, clinical, and utilization data were obtained via questionnaire and electronic health records. Retrospective study used natural language processing and machine learning to generate five unique “Literacy Profiles” by employing various sets of linguistic indices: Flesch-Kincaid (LP_FK); basic indices of writing complexity, including lexical diversity (LP_LD) and writing quality (LP_WQ); and advanced indices related to syntactic complexity, lexical sophistication, and diversity, modeled from self-reported (LP_SR), and expert-rated (LP_Exp) health literacy. We first determined the performance of each literacy profile relative to self-reported and expert-rated health literacy to discriminate between high and low health literacy and then assessed Literacy Profiles’ relationships with known correlates of health literacy, such as patient sociodemographics and a range of health-related outcomes, including ratings of physician communication, medication adherence, diabetes control, comorbidities, and utilization. LP_SR and LP_Exp performed best in discriminating between high and low self-reported (C-statistics: 0.86 and 0.58, respectively) and expert-rated health literacy (C-statistics: 0.71 and 0.87, respectively) and were significantly associated with educational attainment, race/ethnicity, Consumer Assessment of Provider and Systems (CAHPS) scores, adherence, glycemia, comorbidities, and emergency department visits. Since health literacy is a potentially remediable explanatory factor in health care disparities, the development of automated health literacy indicators represents a significant accomplishment with broad clinical and population health applications. Health systems could apply literacy profiles to efficiently determine whether quality of care and outcomes vary by patient health literacy; identify at-risk populations for targeting tailored health communications and self-management support interventions; and inform clinicians to promote improvements in individual-level care.

Authors: Schillinger, Dean; Balyan, Renu; Crossley, Scott A; McNamara, Danielle S; Liu, Jennifer Y; Karter, Andrew J

Health Serv Res. 2021 02;56(1):132-144. Epub 2020-09-23.

PubMed abstract

Predicting Non-Alcoholic Fatty Liver Disease for Adults Using Practical Clinical Measures: Evidence from the Multi-ethnic Study of Atherosclerosis.

BACKGROUND: Many adults have risk factors for non-alcoholic fatty liver disease (NAFLD). Screening all adults with risk factors for NAFLD using imaging is not feasible. OBJECTIVE: To develop a practical scoring tool for predicting NAFLD using participant demographics, medical history, anthropometrics, and lab values. DESIGN: Cross-sectional. PARTICIPANTS: Data came from 6194 white, African American, Hispanic, and Chinese American participants from the Multi-Ethnic Study of Atherosclerosis cohort, ages 45-85 years. MAIN MEASURES: NAFLD was identified by liver computed tomography ( 30% hepatic steatosis) and data on 14 predictors was assessed for predicting NAFLD. Random forest variable importance was used to identify the minimum subset of variables required to achieve the highest predictive power. This subset was used to derive (n = 4132) and validate (n = 2063) a logistic regression-based score (NAFLD-MESA Index). A second NAFLD-Clinical Index excluding laboratory predictors was also developed. KEY RESULTS: NAFLD prevalence was 6.2%. The model included eight predictors: age, sex, race/ethnicity, type 2 diabetes, smoking history, body mass index, gamma-glutamyltransferase (GGT), and triglycerides (TG). The NAFLD-Clinical Index model excluded GGT and TG. In the NAFLD-MESA model, the derivation set achieved an AUCNAFLD-MESA = 0.83 (95% CI, 0.81 to 0.86), and the validation set an AUCNAFLD-MESA = 0.80 (0.77 to 0.84). The NAFLD-Clinical Index model was AUCClinical = 0.78 [0.75 to 0.81] in the derivation set and AUCClinical = 0.76 [0.72 to 0.80] in the validation set (pBonferroni-adjusted < 0.01). CONCLUSIONS: The two models are simple but highly predictive tools that can aid clinicians to identify individuals at high NAFLD risk who could benefit from imaging.

Authors: Rodriguez LA; Shiboski SC; Bradshaw PT; Fernandez A; Herrington D; Ding J; Bradley RD; Kanaya AM

J Gen Intern Med. 2021 Sep;36(9):2648-2655. doi: 10.1007/s11606-020-06426-5. Epub 2021 Jan 26.

PubMed abstract

Evaluation of Attention Switching and Duration of Electronic Inbox Work Among Primary Care Physicians

Primary care physicians (PCPs) report multitasking during workdays while processing electronic inbox messages, but scant systematic information exists on attention switching and its correlates in the health care setting. To describe PCPs’ frequency of attention switching associated with electronic inbox work, identify potentially modifiable factors associated with attention switching and inbox work duration, and compare the relative association of attention switching and other factors with inbox work duration. This cross-sectional study of the work of 1275 PCPs in an integrated group serving 4.5 million patients used electronic health record (EHR) access logs from March 1 to 31, 2018, to evaluate PCPs’ frequency of attention switching. Statistical analysis was performed from October 15, 2018, to August 28, 2020. Attention switching was defined as switching between the electronic inbox, other EHR work, and non-EHR periods. Inbox work duration included minutes spent on electronic inbox message views and related EHR tasks. Multivariable models controlled for the exposures. The 1275 PCPs studied (721 women [56.5%]; mean [SD] age, 45.9 [8.5] years) had a mean (SD) of 9.0 (7.6) years of experience with the medical group and received a mean (SD) of 332.6 (148.3) (interquartile range, 252-418) new inbox messages weekly. On workdays, PCPs made a mean (SD) of 79.4 (21.8) attention switches associated with inbox work and did a mean (SD) 64.2 (18.7) minutes of inbox work over the course of 24 hours on workdays. In the model for attention switching, each additional patient secure message beyond the reference value was associated with 0.289 (95% CI, 0.217-0.362) additional switches, each additional results message was associated with 0.203 (95% CI, 0.127-0.278) additional switches, each additional request message was associated with 0.190 (95% CI, 0.124-0.257) additional switches, and each additional administrative message was associated with 0.262 (95% CI, 0.166-0.358) additional switches. Having a panel (a list of patients assigned to a primary care team) with more elderly patients (0.144 switches per percentage increase [95% CI, 0.009-0.278]) and higher inbox work duration (0.468 switches per additional minute of inbox work [95% CI, 0.411-0.524]) were also associated with higher attention switching involving the inbox. In the model for inbox work duration, each additional patient secure message beyond the reference value was associated with 0.151 (95% CI, 0.085-0.217) additional minutes, each additional results message was associated with 0.338 (95% CI, 0.272-0.404) additional minutes, each additional request message was associated with 0.101 (95% CI, 0.041-0.161) additional minutes, and each additional administrative message was associated with 0.179 (95% CI, 0.093-0.265) additional minutes. A higher percentage of the panel’s patients initiating messages (0.386 minutes per percentage increase [95% CI, 0.026-0.745]) and attention switches (0.373 minutes per switch [95% CI, 0.328-0.419]) were also associated with higher inbox work duration. In addition, working at a medical center where all PCPs had high inbox work duration was independently associated with high or low inbox work duration. This study suggests that PCPs make frequent attention switches during workdays while processing electronic inbox messages. Message quantity was associated with both attention switching and inbox work duration. Physician and patient panel characteristics had less association with attention switching and inbox work duration. Assisting PCPs with message quantity might help modulate both attention switching and inbox work duration.

Authors: Lieu, Tracy A; Warton, E Margaret; East, Jeffrey A; Moeller, Mark F; Prausnitz, Stephanie; Ballesca, Manuel; Mark, Gloria; Akbar, Fatema; Awsare, Sameer; Chen, Yi-Fen Irene; Reed, Mary E

JAMA Netw Open. 2021 01 04;4(1):e2031856. Epub 2021-01-04.

PubMed abstract

Frustrative nonreward and cannabinoid receptors: Chronic (but not acute) WIN 55,212-2 treatment increased resistance to change in two reward downshift tasks.

Assessing the role of cannabinoid (CB) receptors in behavior is relevant given the trend toward the legalization of medicinal and recreational marijuana. The present research aims at bridging a gap in our understanding of CB-receptor function in animal models of frustrative nonreward. These experiments were designed to (1) determine the effects of chronic administration of the nonselective CB1-receptor agonist WIN 55,212-2 (WIN) on reward downshift in rats and (2) determine whether the effects of chronic WIN were reducible to acute effects. In Experiment 1, chronic WIN (7 daily injections, 10 mg/kg, ip) accelerated the recovery of consummatory behavior after a 32-to-4% sucrose downshift relative to vehicle controls. In addition, chronic WIN eliminated the preference for an unshifted lever when the other lever was subject to a 12-to-2 pellet downshift in free-choice trials, but only in animals with previous experience with a sucrose downshift. In Experiment 2, acute WIN (1 mg/kg, ip) reduced consummatory behavior, but did not affect recovery from a 32-to-4% sucrose downshift. The antagonist SR 141716A (3 mg/kg, ip) also failed to interfere with recovery after the sucrose downshift. In Experiment 3, acute WIN administration (1 mg/kg, ip) did not affect free-choice behavior after a pellet downshift, although it reduced lever pressing and increased magazine entries relative to vehicle controls. The effects of chronic WIN on frustrative nonreward were not reducible to acute effects of the drug. Chronic WIN treatment in rats, like chronic marijuana use in humans, seems to increase resistance to the effects of frustrative nonreward.

Authors: Conrad SE; Davis D; Vilcek N; Thompson JB; Guarino S; Papini S; Papini MR

Pharmacol Biochem Behav. 2022 Feb;213:173320. doi: 10.1016/j.pbb.2021.173320. Epub 2022 Jan 3.

PubMed abstract

Development and Validation of an Obstetric Comorbidity Risk Score for Clinical Use

Background: A comorbidity summary score may support early and systematic identification of women at high risk for adverse obstetric outcomes. The objective of this study was to conduct the initial development and validation of an obstetrics comorbidity risk score for automated implementation in the electronic health record (EHR) for clinical use. Methods: The score was developed and validated using EHR data for a retrospective cohort of pregnancies with delivery between 2010 and 2018 at Kaiser Permanente Northern California, an integrated health care system. The outcome used for model development consisted of adverse obstetric events from delivery hospitalization (e.g., eclampsia, hemorrhage, death). Candidate predictors included maternal age, parity, multiple gestation, and any maternal diagnoses assigned in health care encounters in the 12 months before admission for delivery. We used penalized regression for variable selection, logistic regression to fit the model, and internal validation for model evaluation. We also evaluated prenatal model performance at 18 weeks of pregnancy. Results: The development cohort (n = 227,405 pregnancies) had an outcome rate of 3.8% and the validation cohort (n = 41,683) had an outcome rate of 2.9%. Of 276 candidate predictors, 37 were included in the final model. The final model had a validation c-statistic of 0.72 (95% confidence interval [CI] 0.70-0.73). When evaluated at 18 weeks of pregnancy, discrimination was modestly diminished (c-statistic 0.68 [95% CI 0.67-0.70]). Conclusions: The obstetric comorbidity score demonstrated good discrimination for adverse obstetric outcomes. After additional appropriate validation, the score can be automated in the EHR to support early identification of high-risk women and assist efforts to ensure risk-appropriate maternal care.

Authors: Ruppel, Halley; Liu, Vincent X; Kipnis, Patricia; Hedderson, Monique M; Greenberg, Mara; Forquer, Heather; Lawson, Brian; Escobar, Gabriel J

Womens Health Rep (New Rochelle). 2021;2(1):507-515. Epub 2021-11-02.

PubMed abstract

Health Risks and Chronic Health Conditions among Arab American and White Adults in Northern California

To characterize the prevalence of chronic cardiovascular conditions and risk factors among Arab American adults stratified by sex and compare these with non-Hispanic Whites. Cross-sectional study using electronic health record data from visits between January 2015 and December 2016. Age-adjusted prevalence estimates were calculated for men and women and compared using generalized linear models. Kaiser Permanente health plan in Northern California. Non-Hispanic White (N=969,566) and Arab American (N=18,072) adult members. Sex-stratified prevalence and prevalence ratios of diabetes, pre-diabetes, hypertension, and hyperlipidemia diagnosed by December 2016 and of obesity, ever smoking, and current smoking status. Arab American men had a significantly higher prevalence of ever smoking (41.8 vs 40.8%), diabetes (17.3 vs 12.5%), and hyperlipidemia (40.8 vs 34.7%) than White men, but a significantly lower prevalence of obesity (34.4 vs 37.8%) and hypertension (30.5 vs 33.3%). Arab American women had a significantly higher prevalence of diabetes (11.1 vs 8.7%) and hyperlipidemia (31.5 vs 28.3%) than White women but significantly lower prevalence of obesity (31.0 vs 34.2%), ever smoking (24.8 vs 34.5%), and hypertension (25.8 vs 28.4%). Hospital and health systems should intentionally collect data on Middle Eastern and North African ethnicity in electronic health records to identify and reduce the disparities this minority group faces.

Authors: Abuelezam, Nadia N; El-Sayed, Abdulrahman M; Galea, Sandro; Gordon, Nancy P

Ethn Dis. 2021 Spring;31(2):235-242. Epub 2021-04-15.

PubMed abstract

Challenges and solutions to employing natural language processing and machine learning to measure patients’ health literacy and physician writing complexity: The ECLIPPSE study

In the National Library of Medicine funded ECLIPPSE Project (Employing Computational Linguistics to Improve Patient-Provider Secure Emails exchange), we attempted to create novel, valid, and scalable measures of both patients’ health literacy (HL) and physicians’ linguistic complexity by employing natural language processing (NLP) techniques and machine learning (ML). We applied these techniques to > 400,000 patients’ and physicians’ secure messages (SMs) exchanged via an electronic patient portal, developing and validating an automated patient literacy profile (LP) and physician complexity profile (CP). Herein, we describe the challenges faced and the solutions implemented during this innovative endeavor. To describe challenges and solutions, we used two data sources: study documents and interviews with study investigators. Over the five years of the project, the team tracked their research process using a combination of Google Docs tools and an online team organization, tracking, and management tool (Asana). In year 5, the team convened a number of times to discuss, categorize, and code primary challenges and solutions. We identified 23 challenges and associated approaches that emerged from three overarching process domains: (1) Data Mining related to the SM corpus; (2) Analyses using NLP indices on the SM corpus; and (3) Interdisciplinary Collaboration. With respect to Data Mining, problems included cleaning SMs to enable analyses, removing hidden caregiver proxies (e.g., other family members) and Spanish language SMs, and culling SMs to ensure that only patients’ primary care physicians were included. With respect to Analyses, critical decisions needed to be made as to which computational linguistic indices and ML approaches should be selected; how to enable the NLP-based linguistic indices tools to run smoothly and to extract meaningful data from a large corpus of medical text; and how to best assess content and predictive validities of both the LP and the CP. With respect to the Interdisciplinary Collaboration, because the research required engagement between clinicians, health services researchers, biomedical informaticians, linguists, and cognitive scientists, continual effort was needed to identify and reconcile differences in scientific terminologies and resolve confusion; arrive at common understanding of tasks that needed to be completed and priorities therein; reach compromises regarding what represents “meaningful findings” in health services vs. cognitive science research; and address constraints regarding potential transportability of the final LP and CP to different health care settings. Our study represents a process evaluation of an innovative research initiative to harness “big linguistic data” to estimate patient HL and physician linguistic complexity. Any of the challenges we identified, if left unaddressed, would have either rendered impossible the effort to generate LPs and CPs, or invalidated analytic results related to the LPs and CPs. Investigators undertaking similar research in HL or using computational linguistic methods to assess patient-clinician exchange will face similar challenges and may find our solutions helpful when designing and executing their health communications research.

Authors: Brown, William; Karter, Andrew J; Lyles, Courtney; Schillinger, Dean; et al.

J Biomed Inform. 2021 01;113:103658. Epub 2020-12-11.

PubMed abstract

A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence in Patients with Diabetes

Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no large-scale intervention studies have assessed the effect of encouraging MOP use on medication adherence. To assess an intervention to encourage MOP services to increase its use and medication adherence. Randomized encouragement trial. 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12 months. Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicity-stratified analysis. During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients. This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider outreach interventions to actively promote MOP use among diabetes patients. registration number: NCT02621476.

Authors: Ramachandran, Bharathi; Neugebauer, Romain S; Brown, Susan D; Karter, Andrew J; Schmittdiel, Julie A; et al.

J Gen Intern Med. 2021 01;36(1):154-161. Epub 2020-10-01.

PubMed abstract

Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care

After implementation of the Surgical Home Recovery (SHR) initiative for mastectomy within a large, integrated health delivery system, most patients are discharged on the day of the procedure. We sought to identify predictors of SHR and unplanned return to care (RTC). Mastectomy cases with and without reconstruction from October 2017 to August 2019 were analyzed. Patient characteristics, operative variables, and multimodal pain management were compared between admitted patients and SHR patients using logistic regression. We identified predictors of RTC in SHR patients, defined as 7-day readmission, reoperation, or emergency department visit. Of 2,648 mastectomies, 1,689 (64%) were outpatient procedures and the mean age of patients was 58.5 years. Predictors of SHR included perioperative IV acetaminophen (odds ratio [OR] 1.59; 95% CI, 1.28 to 1.97), perioperative opiates (OR 1.47; 95% CI, 1.06 to 2.02), and operation performed by a high-volume breast surgeon (OR 2.12; 95% CI, 1.42 to 3.18). Bilateral mastectomies (OR 0.70; 95% CI, 0.54 to 0.91), immediate reconstruction (OR 0.52; 95% CI, 0.39 to 0.70), and American Society of Anesthesiologists class 3 to 4 (OR 0.69; 95% CI, 0.54 to 0.87) decreased the odds of SHR. Of SHR patients, 111 of 1,689 patients (7%) experienced RTC. Patients with American Society of Anesthesiologists class 3 to 4 (OR 2.01; 95% CI, 1.29 to 3.14) and African American race (OR 2.30; 95% CI, 1.38 to 4.91) were more likely to RTC; receiving IV acetaminophen (OR 0.56; 95% CI, 0.35 to 0.88) and filling an opiate prescription (OR 0.51; 95% CI, 0.34 to 0.77) decreased the odds of RTC. Surgeon volume and multimodal pain medication increased the odds of SHR. Within the SHR group, American Society of Anesthesiologists Class 3 to 4 and African American patients increased the likelihood of RTC. This study helps optimize patient selection and perioperative practice for successful SHR.

Authors: Vuong, Brooke; Dusendang, Jennifer R; Chang, Sharon B; Mentakis, Margaret Ann; Shim, Veronica C; Schmittdiel, Julie; Kuehner, Gillian

J Am Coll Surg. 2021 01;232(1):35-44. Epub 2020-10-03.

PubMed abstract

Understanding the Uptake of Digital Technologies for Health-Related Purposes in Frail Older Adults

Authors: Lee, David R; Lo, Joan C; Ramalingam, Nirmala; Gordon, Nancy P

J Am Geriatr Soc. 2021 01;69(1):269-272. Epub 2020-10-03.

PubMed abstract

The future of AI in critical care is augmented, not artificial, intelligence

Authors: Liu, Vincent X

Crit Care. 2020 12 02;24(1):673. Epub 2020-12-02.

PubMed abstract

Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles

Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. To define distinct patient clinical profiles among the most medically complex patients through clinical interpretation of analytically derived patient clusters. This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles. Complex patient profiles, 1-year health care utilization, and mortality outcomes by profile. The analysis included 104 869 individuals representing 3.3% of the adult population (mean [SD] age, 70.7 [14.5] years; 52.4% women; 39% non-White race/ethnicity). Latent class analysis resulted in a 7-class solution. Stakeholders defined the following complex patient profiles (prevalence): high acuity (9.4%), older patients with cardiovascular complications (15.9%), frail elderly (12.5%), pain management (12.3%), psychiatric illness (12.0%), cancer treatment (7.6%), and less engaged (27%). Patients in these groups had significantly different 1-year mortality rates (ranging from 3.0% for psychiatric illness profile to 23.4% for frail elderly profile; risk ratio, 7.9 [95% CI, 7.1-8.8], P < .001). Repeating the analysis using k-means clustering resulted in qualitatively similar groupings. Each clinical profile suggested a distinct collaborative care strategy to optimize management. The findings suggest that highly medically complex patient populations may be categorized into distinct patient profiles that are amenable to varying strategies for resource allocation and coordinated care interventions.

Authors: Grant, Richard W; McCloskey, Jodi; Hatfield, Meghan; Uratsu, Connie; Ralston, James D; Bayliss, Elizabeth; Kennedy, Chris J

JAMA Netw Open. 2020 12 01;3(12):e2029068. Epub 2020-12-01.

PubMed abstract

Predicting preventable hospital readmissions with causal machine learning

To assess both the feasibility and potential impact of predicting preventable hospital readmissions using causal machine learning applied to data from the implementation of a readmissions prevention intervention (the Transitions Program). Electronic health records maintained by Kaiser Permanente Northern California (KPNC). Retrospective causal forest analysis of postdischarge outcomes among KPNC inpatients. Using data from both before and after implementation, we apply causal forests to estimate individual-level treatment effects of the Transitions Program intervention on 30-day readmission. These estimates are used to characterize treatment effect heterogeneity and to assess the notional impacts of alternative targeting strategies in terms of the number of readmissions prevented. 1 539 285 index hospitalizations meeting the inclusion criteria and occurring between June 2010 and December 2018 at 21 KPNC hospitals. There appears to be substantial heterogeneity in patients’ responses to the intervention (omnibus test for heterogeneity p = 2.23 × 10-7 ), particularly across levels of predicted risk. Notably, predicted treatment effects become more positive as predicted risk increases; patients at somewhat lower risk appear to have the largest predicted effects. Moreover, these estimates appear to be well calibrated, yielding the same estimate of annual readmissions prevented in the actual treatment subgroup (1246, 95% confidence interval [CI] 1110-1381) as did a formal evaluation of the Transitions Program (1210, 95% CI 990-1430). Estimates of the impacts of alternative targeting strategies suggest that as many as 4458 (95% CI 3925-4990) readmissions could be prevented annually, while decreasing the number needed to treat from 33 to 23, by targeting patients with the largest predicted effects rather than those at highest risk. Causal machine learning can be used to identify preventable hospital readmissions, if the requisite interventional data are available. Moreover, our results suggest a mismatch between risk and treatment effects.

Authors: Marafino, Ben J; Schuler, Alejandro; Liu, Vincent X; Escobar, Gabriel J; Baiocchi, Mike

Health Serv Res. 2020 12;55(6):993-1002. Epub 2020-10-30.

PubMed abstract

Observational Study Design Challenges-The Case of Fluoroquinolones and Aortic Disease

Authors: DeGette, Raphaela Lipinsky; Grant, Richard William; Mph, M D

JAMA Intern Med. 2020 12 01;180(12):1605-1606.

PubMed abstract

60-day major adverse cardiac events in emergency department patients with non-low modified HEART scores

A low (0-3) History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score reliably identifies ED chest pain patients who are low risk for near-term major adverse cardiac events (MACE). To optimize sensitivity, many clinicians employ a modified HEART score by repeating troponin measurements and excluding patients with abnormal troponin values or ischemic electrocardiograms (ECGs). The residual MACE risk among patients with otherwise non-low (≥4) modified HEART scores is thus likely much lower than with non-low original HEART scores. To explore residual 60-day MACE risks among patients with non-low modified HEART scores. Secondary analysis of a retrospective cohort of ED patients presenting with chest pain to an integrated healthcare system between 2013 and 2015. Patients with serial troponin measurements within 6 h of ED arrival were considered for inclusion. Exclusions included an ischemic ECG, troponin values above the 99th percentile or a lack of continuous health plan coverage through the 60-day follow-up period. MACE was defined as a composite of myocardial infarction, cardiac arrest, cardiogenic shock or death. There were 22,976 study eligible patients encounters, 13,521 (59%) of which had non-low (≥4) modified HEART scores. The observed 60-day MACE risk among non-low HEART score patients was 2.0% (95% CI 1.8-2.3). When including all coronary revascularizations (MACE-R), the risk was 4.4% (95% CI 4.1-4.4). Risk of near-term MACE among patients with non-low modified HEART scores (excluding those with abnormal troponin or ischemic ECGs) appears to be much lower than in the original HEART score validation studies.

Authors: Mark DG; Huang J; Kennedy CJ; Vinson DR; Ballard DW; Reed ME; Kaiser Permanente CREST Network Investigators

Am J Emerg Med. 2020 12;38(12):2760.e5-2760.e8. Epub 2020-05-28.

PubMed abstract

Automated Identification of Adults at Risk for In-Hospital Clinical Deterioration

Hospitalized adults whose condition deteriorates while they are in wards (outside the intensive care unit [ICU]) have considerable morbidity and mortality. Early identification of patients at risk for clinical deterioration has relied on manually calculated scores. Outcomes after an automated detection of impending clinical deterioration have not been widely reported. On the basis of a validated model that uses information from electronic medical records to identify hospitalized patients at high risk for clinical deterioration (which permits automated, real-time risk-score calculation), we developed an intervention program involving remote monitoring by nurses who reviewed records of patients who had been identified as being at high risk; results of this monitoring were then communicated to rapid-response teams at hospitals. We compared outcomes (including the primary outcome, mortality within 30 days after an alert) among hospitalized patients (excluding those in the ICU) whose condition reached the alert threshold at hospitals where the system was operational (intervention sites, where alerts led to a clinical response) with outcomes among patients at hospitals where the system had not yet been deployed (comparison sites, where a patient’s condition would have triggered a clinical response after an alert had the system been operational). Multivariate analyses adjusted for demographic characteristics, severity of illness, and burden of coexisting conditions. The program was deployed in a staggered fashion at 19 hospitals between August 1, 2016, and February 28, 2019. We identified 548,838 non-ICU hospitalizations involving 326,816 patients. A total of 43,949 hospitalizations (involving 35,669 patients) involved a patient whose condition reached the alert threshold; 15,487 hospitalizations were included in the intervention cohort, and 28,462 hospitalizations in the comparison cohort. Mortality within 30 days after an alert was lower in the intervention cohort than in the comparison cohort (adjusted relative risk, 0.84, 95% confidence interval, 0.78 to 0.90; P<0.001). The use of an automated predictive model to identify high-risk patients for whom interventions by rapid-response teams could be implemented was associated with decreased mortality. (Funded by the Gordon and Betty Moore Foundation and others.).

Authors: Escobar, Gabriel J; Liu, Vincent X; Schuler, Alejandro; Lawson, Brian; Greene, John D; Kipnis, Patricia

N Engl J Med. 2020 11 12;383(20):1951-1960.

PubMed abstract

Expanding Post-discharge Readmission Metrics in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a common and costly reason for hospitalization and rehospitalization. The Hospital Readmissions Reduction Program penalizes hospitals for excess, non-elective, all-cause 30-day, inpatient rehospitalizations for COPD. We sought to determine how broadening the outcome definition would alter the numbers of patients being counted if observation stays and patients who died in the post-discharge period were included. We performed a retrospective cohort study of patients hospitalized for COPD between 6/1/2010 and 12/31/2017 from 21 hospitals in Kaiser Permanente Northern California. We classified encounters into three outcomes groups based on a 30-day post-discharge observation period: Group 1) non-elective, all-cause, inpatient rehospitalizations, which is the current metric, Group 2) composite outcome of Group 1 or all-cause mortality, and Group 3) composite outcome of Group 1 or non-elective, all-cause, observation rehospitalization. We used the Box-Cox method to find the transformation of the cumulative curves that resulted in the smallest mean standard error. We used the slope of the transformed curve against days to test for significant differences between pairs of cumulative density curves. Of 1,384,025 hospitalizations, 11,304 encounters from 8,097 patients met criteria to be index hospitalizations. The event rate for non-elective, all-cause, inpatient rehospitalizations was 17.1% (95% CI 10.4-26.5). The event rate for all-cause mortality was 4.7% (95% CI 3.1-7.7). The event rate for non-elective observation rehospitalizations was 3.9% (95% CI 1.7-7.0). The slope and standard error for Group 1 were 1.17 and 0.01, respectively, while the slope and standard error for Group 2 were 1.62 and 0.01, respectively (P=0.02 comparing Groups 1 and 2). The slope and standard error for Group 3 were 1.45 and 0.01, respectively (P=0.02 comparing Groups 1 and 3). We show that adding outcomes such as mortality and observation rehospitalizations would change the counts of patients contributing to the Hospital Readmission Reduction Program penalty for COPD if the outcome were broadened. Including mortality or observation stays in the quality incentive program might incentivize hospitals and providers to prevent these events in addition to inpatient rehospitalizations.

Authors: Myers, Laura C; Camargo, Carlos; Escobar, Gabriel; Liu, Vincent X

Chronic Obstr Pulm Dis. 2020 Nov 06.

PubMed abstract

Association of a Novel Index of Hospital Capacity Strain with Admission to Intensive Care Units

Rationale: Prior approaches to measuring healthcare capacity strain have been constrained by using individual care units, limited metrics of strain, or general, rather than disease-specific, populations.Objectives: We sought to develop a novel composite strain index and measure its association with intensive care unit (ICU) admission decisions and hospital outcomes.Methods: Using more than 9.2 million acute care encounters from 27 Kaiser Permanente Northern California and Penn Medicine hospitals from 2013 to 2018, we deployed multivariable ridge logistic regression to develop a composite strain index based on hourly measurements of 22 capacity-strain metrics across emergency departments, wards, step-down units, and ICUs. We measured the association of this strain index with ICU admission and clinical outcomes using multivariable logistic and quantile regression.Results: Among high-acuity patients with sepsis (n = 90,150) and acute respiratory failure (ARF; n = 45,339) not requiring mechanical ventilation or vasopressors, strain at the time of emergency department disposition decision was inversely associated with the probability of ICU admission (sepsis: adjusted probability ranging from 29.0% [95% confidence interval, 28.0-30.0%] at the lowest strain index decile to 9.3% [8.7-9.9%] at the highest strain index decile; ARF: adjusted probability ranging from 47.2% [45.6-48.9%] at the lowest strain index decile to 12.1% [11.0-13.2%] at the highest strain index decile; P < 0.001 at all deciles). Among subgroups of patients who almost always or never went to the ICU, strain was not associated with hospital length of stay, mortality, or discharge disposition (all P ≥ 0.13). Strain was also not meaningfully associated with patient characteristics.Conclusions: Hospital strain, measured by a novel composite strain index, is strongly associated with ICU admission among patients with sepsis and/or ARF. This strain index fulfills the assumptions of a strong within-hospital instrumental variable for quantifying the net benefit of admission to the ICU for patients with sepsis and/or ARF.

Authors: Anesi GL; Chowdhury M; Small DS; Delgado MK; Kohn R; Bayes B; Wang W; Dress E; Escobar GJ; Halpern SD; Liu VX

Ann Am Thorac Soc. 2020 11;17(11):1440-1447.

PubMed abstract

Smoking cessation treatment for individuals with comorbid diabetes and serious mental illness in an integrated health care delivery system

Smoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15-20 years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population. We conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N = 634) and without SMI (N = 18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility. Of the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52-2.13]; p < .001). For the SMI group, primary care providers wrote 80.24% of prescriptions, while psychiatrists wrote 8.81% of prescriptions. These findings offer an example of a delivery system with higher uptake of smoking cessation pharmacotherapy among people with SMI than without SMI, and highlight the opportunity to provide more smoking cessation interventions in mental health care settings.

Authors: Hwong AR; Schmittdiel J; Schillinger D; Newcomer JW; Essock S; Zhu Z; Dyer W; Young-Wolff KC; Mangurian C

Addict Behav. 2020 Oct 14:106697.

PubMed abstract

Network analysis reveals the associations of past quit experiences on current smoking behavior and motivation to quit.

INTRODUCTION: Smoking is a leading cause of morbidity and mortality in the United States. While most smokers endorse a desire to quit, achieving abstinence is notoriously difficult. Network analysis is a method for understanding the complex relationships of factors that maintain smoking behavior and impact motivation to quit. METHODS: This study examined self-report prescreen data from treatment-seeking smokers (N = 3913). The number of prior quit attempts and withdrawal symptoms experienced, as well as current smoking behavior and motivation to quit were modeled as interconnected nodes in a network. Two key network metrics were examined: 1) edge weights, which quantify the strength and direction of the associations of interest, and 2) the sum of each node’s edge weights, which quantifies the expected influence of a node on the overall network. RESULTS: The withdrawal symptom of craving, r = 0.10, 95% CI [0.07, 0.13] and digestive problems, r = -0.06, 95% CI [-0.09, -0.03], had the strongest positive and negative association with daily cigarettes, respectively. The number of prior quit attempts, r = 0.17, 95% CI [0.14, 0.20], concentration problems, r = -0.04, 95% CI [-0.027, -0.01], showed the strongest positive and negative associations, respectively, with current motivation to quit. Nodes with significant links to current smoking and motivation to quit were also among the most influential in the overall network. CONCLUSIONS: Findings suggest prior quit experiences and consequences associated with withdrawal symptoms may differentially relate to maintenance of smoking behavior and motivation to quit in treatment-seeking smokers. Interventions targeting key withdrawal symptoms may enhance motivation to quit.

Authors: Dutcher CD; Papini S; Gebhardt CS; Smits JAJ

Addict Behav. 2021 Feb;113:106689. doi: 10.1016/j.addbeh.2020.106689. Epub 2020 Oct 1.

PubMed abstract

The impact of prior and ongoing threat on the false alarm threshold for facial discrimination.

BACKGROUND AND OBJECTIVES: Perceptual adaptations that facilitate rapid responses to threats can also lead to false alarms, or the failure to discriminate safe stimuli from signals of threat. We examined the impact of varying degrees of threat on false alarms in the perceptual discrimination of faces along the dimension of emotion (Experiment 1) or identity (Experiment 2). METHODS: Participants first trained to discriminate between a target and nontarget face. Next, we tested their ability to identify the target in randomized presentations of the target, the nontarget, and nine novel stimuli morphed in 10% increments of similarity from the target to the nontarget. The task was completed under one of three randomized conditions: 1) Ongoing-Threat paired the target with an aversive outcome in both phases; 2) Prior-Threat paired the target with an aversive outcome in the training phase only; and 3) No-Threat paired the target with a neutral outcome in the training phase only. RESULTS: In Experiment 1 (N = 90), Ongoing-Threat lowered the false alarm threshold for facial discrimination based on anger intensity compared to Prior-Threat and No-Threat. In Experiment 2 (N = 90), Ongoing-Threat and Prior-Threat each lowered the false alarm threshold for identity-based discrimination compared to No-Threat. LIMITATIONS: The experiment did not measure generalization of threat responses. CONCLUSION: Associating a facial expression or identity with threat leads to faster but less accurate discrimination of faces with similar features, particularly under conditions of ongoing threat. These experiments provide an avenue for examining the parameters that impact false alarms, which play a key role in anxiety disorders.

Authors: Papini S; Dunsmoor JE; Smits JAJ

J Behav Ther Exp Psychiatry. 2021 Mar;70:101619. doi: 10.1016/j.jbtep.2020.101619. Epub 2020 Oct 1.

PubMed abstract

Estimates of Workload Associated With Suicide Risk Alerts After Implementation of Risk-Prediction Model

Authors: Kline-Simon, Andrea H; Sterling, Stacy; Young-Wolff, Kelly; Simon, Gregory; Lu, Yun; Does, Monique; Liu, Vincent

JAMA Netw Open. 2020 10 01;3(10):e2021189. Epub 2020-10-01.

PubMed abstract

Inpatient-outpatient shared electronic health records: telemedicine and laboratory follow-up after hospital discharge

Continuity of patient information across settings can improve transitions after hospital discharge, but outpatient clinicians often have limited access to complete information from recent hospitalizations. We examined whether providers’ timely access to clinical information through shared inpatient-outpatient electronic health records (EHRs) was associated with follow-up visits, return emergency department (ED) visits, or readmissions after hospital discharge in patients with diabetes. Stepped-wedge observational study. As an integrated delivery system staggered implementation of a shared inpatient-outpatient EHR, we studied 241,510 hospital discharges in patients with diabetes (2005-2011), examining rates of outpatient follow-up office visits, telemedicine (phone visits and asynchronous secure messages), laboratory tests, and return ED visits or readmissions (as adverse events). We used multivariate logistic regression adjusting for time trends, patient characteristics, and medical center and accounting for patient clustering to calculate adjusted follow-up rates. For patients with diabetes, provider use of a shared inpatient-outpatient EHR was associated with a statistically significant shift toward follow-up delivered through a combination of telemedicine and outpatient laboratory tests, without a traditional in-person visit (from 22.9% with an outpatient-only EHR to 27.0% with a shared inpatient-outpatient EHR; P < .05). We found no statistically significant differences in 30-day return ED visits (odds ratio, 1.02; 95% CI, 0.96-1.09) or readmissions (odds ratio, 0.98; 95% CI, 0.91-1.06) with the shared EHR compared with the outpatient-only EHR. Real-time clinical information availability during transitions between health care settings, along with robust telemedicine access, may shift the method of care delivery without adversely affecting patient health outcomes. Efforts to expand interoperability and information exchange may support follow-up care efficiency.

Authors: Reed, Mary; Huang, Jie; Brand, Richard; Graetz, Ilana; Jaffe, Marc G; Ballard, Dustin; Neugebauer, Romain; Fireman, Bruce; Hsu, John

Am J Manag Care. 2020 10 01;26(10):e327-e332. Epub 2020-10-01.

PubMed abstract

Assessment of Value of Neighborhood Socioeconomic Status in Models That Use Electronic Health Record Data to Predict Health Care Use Rates and Mortality

Prediction models are widely used in health care as a way of risk stratifying populations for targeted intervention. Most risk stratification has been done using a small number of predictors from insurance claims. However, the utility of diverse nonclinical predictors, such as neighborhood socioeconomic contexts, remains unknown. To assess the value of using neighborhood socioeconomic predictors in the context of 1-year risk prediction for mortality and 6 different health care use outcomes in a large integrated care system. Diagnostic study using data from all adults age 18 years or older who had Kaiser Foundation Health Plan membership and/or use in the Kaiser Permantente Northern California: a multisite, integrated health care delivery system between January 1, 2013, and June 30, 2014. Data were recorded before the index date for each patient to predict their use and mortality in a 1-year post period using a test-train split for model training and evaluation. Analyses were conducted in fall of 2019. One-year encounter counts (doctor office, virtual, emergency department, elective hospitalizations, and nonelective), total costs, and mortality. A total of 2 951 588 patients met inclusion criteria (mean [SD] age, 47.2 [17.4] years; 47.8% were female). The mean (SD) Neighborhood Deprivation Index was -0.32 (0.84). The areas under the receiver operator curve ranged from 0.71 for emergency department use (using the LASSO method and electronic health record predictors) to 0.94 for mortality (using the random forest method and electronic health record predictors). Neighborhood socioeconomic status predictors did not meaningfully increase the predictive performance of the models for any outcome. In this study, neighborhood socioeconomic predictors did not improve risk estimates compared with what is obtainable using standard claims data regardless of model used.

Authors: Schuler, Alejandro; O'Súilleabháin, Liam; Rinetti-Vargas, Gina; Kipnis, Patricia; Barreda, Fernando; Liu, Vincent X; Sofrygin, Oleg; Escobar, Gabriel J

JAMA Netw Open. 2020 10 01;3(10):e2017109. Epub 2020-10-01.

PubMed abstract

Endometrial Cancer Detection During the Coronavirus Disease 2019 (COVID-19) Pandemic

Authors: Suh-Burgmann EJ; Alavi M; Schmittdiel J

Obstet Gynecol. 2020 10;136(4):842-843.

PubMed abstract

Automated retrospective calculation of the EDACS and HEART scores in a multicenter prospective cohort of emergency department chest pain patients

Coronary risk scores are commonly applied to emergency department patients with undifferentiated chest pain. Two prominent risk score-based protocols are the Emergency Department Assessment of Chest pain Score Accelerated Diagnostic Protocol (EDACS-ADP) and the History, ECG, Age, Risk factors, and Troponin (HEART) pathway. Since prospective documentation of these risk determinations can be challenging to obtain, quality improvement projects could benefit from automated retrospective risk score classification methodologies. EDACS-ADP and HEART pathway data elements were prospectively collected using a Web-based electronic clinical decision support (eCDS) tool over a 24-month period (2018-2019) among patients presenting with chest pain to 13 EDs within an integrated health system. Data elements were also extracted and processed electronically (retrospectively) from the electronic health record (EHR) for the same patients. The primary outcome was agreement between the prospective/eCDS and retrospective/EHR data sets on dichotomous risk protocol classification, as assessed by kappa statistics (ĸ). There were 12,110 eligible eCDS uses during the study period, of which 66 and 47% were low-risk encounters by EDACS-ADP and HEART pathway, respectively. Agreement on low-risk status was acceptable for EDACS-ADP (ĸ = 0.73, 95% confidence interval [CI] = 0.72 to 0.75) and HEART pathway (ĸ = 0.69, 95% CI = 0.68 to 0.70) and for the continuous scores (interclass correlation coefficients = 0.87 and 0.84 for EDACS and HEART, respectively). Automated retrospective determination of low risk status by either the EDACS-ADP or the HEART pathway provides acceptable agreement compared to prospective score calculations, providing a feasible risk adjustment option for use in large data set analyses.

Authors: Mark DG; Sax DR; Vinson DR; Ballard DW; Reed ME; Kaiser Permanente CREST Network Investigators; et al.

Acad Emerg Med. 2020 10;27(10):1028-1038. Epub 2020-07-24.

PubMed abstract

Evaluation of automated computed tomography segmentation to assess body composition and mortality associations in cancer patients

Body composition from computed tomography (CT) scans is associated with cancer outcomes including surgical complications, chemotoxicity, and survival. Most studies manually segment CT scans, but Automatic Body composition Analyser using Computed tomography image Segmentation (ABACS) software automatically segments muscle and adipose tissues to speed analysis. Here, we externally evaluate ABACS in an independent dataset. Among patients with non-metastatic colorectal (n = 3102) and breast (n = 2888) cancer diagnosed from 2005 to 2013 at Kaiser Permanente, expert raters annotated tissue areas at the third lumbar vertebra (L3). To compare ABACS segmentation results to manual analysis, we quantified the proportion of pixel-level image overlap using Jaccard scores and agreement between methods using intra-class correlation coefficients for continuous tissue areas. We examined performance overall and among subgroups defined by patient and imaging characteristics. To compare the strength of the mortality associations obtained from ABACS’s segmentations to manual analysis, we computed Cox proportional hazards ratios (HRs) and 95% confidence intervals (95% CI) by tertile of tissue area. Mean ± SD age was 63 ± 11 years for colorectal cancer patients and 56 ± 12 for breast cancer patients. There was strong agreement between manual and automatic segmentations overall and within subgroups of age, sex, body mass index, and cancer stage: average Jaccard scores and intra-class correlation coefficients exceeded 90% for all tissues. ABACS underestimated muscle and visceral and subcutaneous adipose tissue areas by 1-2% versus manual analysis: mean differences were small at -2.35, -1.97 and -2.38 cm2 , respectively. ABACS’s performance was lowest for the <2% of patients who were underweight or had anatomic abnormalities. ABACS and manual analysis produced similar associations with mortality; comparing the lowest to highest tertile of skeletal muscle from ABACS versus manual analysis, the HRs were 1.23 (95% CI: 1.00-1.52) versus 1.38 (95% CI: 1.11-1.70) for colorectal cancer patients and 1.30 (95% CI: 1.01-1.66) versus 1.29 (95% CI: 1.00-1.65) for breast cancer patients. In the first study to externally evaluate a commercially available software to assess body composition, automated segmentation of muscle and adipose tissues using ABACS was similar to manual analysis and associated with mortality after non-metastatic cancer. Automated methods will accelerate body composition research and, eventually, facilitate integration of body composition measures into clinical care.

Authors: Cespedes Feliciano EM; Liu V; Caan BJ; et al.

J Cachexia Sarcopenia Muscle. 2020 10;11(5):1258-1269. Epub 2020-04-20.

PubMed abstract

Examining if the relationship between BMI and incident type 2 diabetes among middle-older aged adults varies by race/ethnicity: evidence from the Multi-Ethnic Study of Atherosclerosis (MESA).

AIMS: Disparities persist on the prevalence of undiagnosed type 2 diabetes in racial/ethnic minorities in the USA. This study evaluated the association between BMI and incident type 2 diabetes risk by racial/ethnic group, to determine whether BMI and presence of type 2 diabetes risk factors may help clinicians better target type 2 diabetes screening. METHODS: This prospective cohort analysis included 5659 adults free of type 2 diabetes at baseline from the Multi-Ethnic Study of Atherosclerosis (MESA), a population-based cohort (2000-2011). BMI was measured at baseline and time-updated at subsequent visits. Incident type 2 diabetes was defined as fasting glucose >/= 7.0 mmol/l, or use of any diabetes medications. RESULTS: The mean (sd) age was 62 (10) years and 42% of participants were white, 26% African American, 20% Hispanic and 12% Chinese American. During follow-up, 696 (12%) new type 2 diabetes cases were observed. In age- and sex-adjusted models, in the presence of one or more type 2 diabetes risk factors (the most common scenario), a 10% risk of incident type 2 diabetes was observed at a BMI of 21.7 kg/m(2) [95% confidence interval (CI) 20.1 to 22.8] in Chinese Americans, 23.8 kg/m(2) (22.7 to 24.9) in Hispanics, 24.7 kg/m(2) (23.7 to 25.6) in African Americans and 26.2 kg/m(2) (25.1 to 26.9) in white participants. CONCLUSIONS: This study supports including BMI and presence of type 2 diabetes risk factors as action points for clinicians to prioritize which adults aged >/= 45 years should be screened. The application of race/ethnicity-specific BMI thresholds may reduce the disparity of undiagnosed type 2 diabetes observed in minority groups.

Authors: Rodriguez LA; Bradshaw PT; Shiboski SC; Fernandez A; Vittinghoff E; Herrington D; Ding J; Kanaya AM

Diabet Med. 2021 May;38(5):e14377. doi: 10.1111/dme.14377. Epub 2020 Sep 22.

PubMed abstract

Changes in Management of Type 2 Diabetes Before and After Severe Hypoglycemia

Authors: Vijayakumar, Pavithra; Liu, Shuling; McCoy, Rozalina G; Karter, Andrew J; Lipska, Kasia J

Diabetes Care. 2020 Sep 17.

PubMed abstract

Associations of CYP2C9 and CYP2C19 pharmacogenetic variation with phenytoin-induced cutaneous adverse drug reactions

The role of cytochrome P450 (CYP)2C9 and CYP2C19 genetic variation in risk for phenytoin-induced cutaneous adverse drug events is not well understood independently of the human leukocyte antigen B (HLA-B)*15:02 risk allele. In the multi-ethnic resource for Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort, we identified 382 participants who filled a phenytoin prescription between 2005 and 2017. These participants included 21 people (5%) who self-identified as Asian, 18 (5%) as black, 29 (8%) as white Hispanic, and 308 (81%) as white non-Hispanic. We identified 264 (69%) CYP2C9*1/*1, 77 (20%) CYP2C9*1/*2, and 29 (8%) CYP2C9*1/*3. We also determined CYP2C19 genotypes, including 112 with the increased activity CYP2C19*17 allele. Using electronic clinical notes, we identified 32 participants (8%) with phenytoin-induced cutaneous adverse events recorded within 100 days of first phenytoin dispensing. Adjusting for age, sex, daily dose, and race/ethnicity, participants with CYP2C9*1/*3 or CYP2C9*2/*2 genotypes were more likely to develop cutaneous adverse events compared with CYP2C9*1/*1 participants (odds ratio 4.47; 95% confidence interval 1.64-11.69; P < 0.01). Among participants with low-intermediate and poor CYP2C9 metabolizer genotypes, eight (22%) who also had extensive and rapid CYP2C19 metabolizer genotypes experienced cutaneous adverse events, compared with none of those who also had intermediate CYP2C19 metabolizer genotypes (P = 0.17). Genetic variation reducing CYP2C9 metabolic activity may increase risk for phenytoin-induced cutaneous adverse events in the absence of the HLA-B*15:02 risk allele.

Authors: Fohner AE; Rettie AE; Thai KK; Ranatunga DK; Lawson BL; Liu VX; Schaefer CA

Clin Transl Sci. 2020 09;13(5):1004-1009. Epub 2020-04-18.

PubMed abstract

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years

Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.

Authors: Simon LE; Vinson DR; Reed ME; Mark DG; Sax DR; Ballard DW; et al.

Acad Emerg Med. 2020 09;27(9):821-831. Epub 2020-04-02.

PubMed abstract

Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay.

STUDY OBJECTIVE: Our objective is to describe the rates of diagnostic reclassification between conventional cardiac troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) and between combined and sex-specific hs-cTnT thresholds in adult emergency department (ED) patients in the United States. METHODS: We conducted a prospective, single-center, before-and-after, observational study of ED patients aged 18 years or older undergoing single or serial cardiac troponin testing in the ED for any reason before and after hs-cTnT implementation. Conventional cTnI and hs-cTnT results were obtained from a laboratory quality assurance database. Combined and sex-specific thresholds were the published 99th percentile upper reference limits for each assay. Cases underwent physician adjudication using the Fourth Universal Definition of Myocardial Infarction. Diagnostic reclassification occurred when a patient received a diagnosis of myocardial infarction or myocardial injury with one assay but not the other assay. Our primary outcome was diagnostic reclassification between the conventional cTnI and hs-cTnT assays. Diagnostic reclassification probabilities were assessed with sample proportions and 95% confidence intervals for binomial data. RESULTS: We studied 1,016 patients (506 men [50%]; median age 60 years [25th, 75th percentiles 49, 71]). Between the conventional cTnI and hs-cTnT assays, 6 patients (0.6%; 95% confidence interval 0.2% to 1.3%) underwent diagnostic reclassification regarding myocardial infarction (5/6 reclassified as no myocardial infarction) and 166 patients (16%; 95% confidence interval 14% to 19%) underwent diagnostic reclassification regarding myocardial injury (154/166 reclassified as having myocardial injury) by hs-cTnT. CONCLUSION: Compared with conventional cTnI, the hs-cTnT assay resulted in no clinically relevant change in myocardial infarction diagnoses but substantially more myocardial injury diagnoses.

Authors: Mumma BE; Casey SD; Dang RK; Polen MK; Kaur JC; Rodrigo J; Tancredi DJ; Narverud RA; Amsterdam EA; Tran N

Ann Emerg Med. 2020 Nov;76(5):566-579. doi: 10.1016/j.annemergmed.2020.06.047. Epub 2020 Aug 15.

PubMed abstract

Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART)

There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM). In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed. At least 296 participants and approximately 75 peer supporters will be enrolled. Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes. The registration number is NCT03689530.

Authors: Heisler M; Adams A; Hedderson M; Schmittdiel JA; et al.

Contemp Clin Trials. 2020 08;95:106048. Epub 2020-06-01.

PubMed abstract

A Transparent and Adaptable Method to Extract Colonoscopy and Pathology Data Using Natural Language Processing

Key variables recorded as text in colonoscopy and pathology reports have been extracted using natural language processing (NLP) tools that were not easily adaptable to new settings. We aimed to develop a reliable NLP tool with broad adaptability. During 1996-2016, Kaiser Permanente Northern California performed 401,566 colonoscopies with linked pathology. We randomly sampled 1000 linked reports into a Training Set and developed an NLP tool using SAS® PERL regular expressions. The NLP tool captured five colonoscopy and pathology variables: type, size, and location of polyps; extent of procedure; and quality of bowel preparation. We used a Validation Set (N = 3000) to confirm the variables’ classifications using manual chart review as the reference. Performance of the NLP tool was assessed using the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen’s κ. Cohen’s κ ranged from 93 to 99%. The sensitivity and specificity ranged from 95 to 100% across all categories. For categories with prevalence exceeding 10%, the PPV ranged from 97% to 100% except for adequate quality of preparation (prevalence 92%), for which the PPV was 65%. For categories with prevalence below 10%, the PPVs ranged from 62% to 100%. NPVs ranged from 94% to 100% except for the “complete” extent of procedure, for which the NPV was 73%. Using information from a large community-based population, we developed a transparent and adaptable NLP tool for extracting five colonoscopy and pathology variables. The tool can be readily tested in other healthcare settings.

Authors: Fevrier, Helene B; Liu, Liyan; Herrinton, Lisa J; Li, Dan

J Med Syst. 2020 Jul 31;44(9):151. Epub 2020-07-31.

PubMed abstract

Reply to Letter to the Editor

Authors: Chong AJ; Herrinton L; Fevrier H

J Pediatr Surg. 2020 07;55(7):1421. Epub 2020-03-28.

PubMed abstract

Hospitalization is less common in ambulatory patients with acute pulmonary embolism diagnosed before emergency department referral than after arrival

Emergency department (ED) patients with acute pulmonary embolism (PE) may undergo diagnostic pulmonary imaging as an outpatient before referral to the ED for definitive management. This population has not been well characterized. This retrospective cohort study included ambulatory adults with acute objectively confirmed PE across 21 EDs in an integrated health care system from January 1, 2013, through April 30, 2015. We excluded patients arriving by ambulance. We compared outpatients with diagnostic pulmonary imaging in the 12 hours prior to ED arrival (the clinic-based cohort) with those receiving imaging for PE only after ED arrival. We reported adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for hospitalization, adjusted for race, presyncope or syncope, proximal clot location, and PE Severity Index class. Among 2,352 eligible ED patients with acute PE, 344 (14.6%) had a clinic-based diagnosis. This cohort had lower PE Severity Index classification and were less likely to be hospitalized than their counterparts with an ED-based diagnosis: 80.8% vs. 92.0% (p < 0.0001). The inverse association with hospitalization persisted after adjusting for the above patient characteristics with aOR of 0.36 (95% CI = 0.26 to 0.50). In the study setting, ambulatory outpatients with acute PE are commonly diagnosed before ED arrival. A clinic-based diagnosis of PE identifies ED patients less likely to be hospitalized. Research is needed to identify which patients with a clinic-based PE diagnosis may not require transfer to the ED before home discharge.

Authors: Vinson DR; Bath H; Huang J; Reed ME; Mark DG; CREST Network

Acad Emerg Med. 2020 07;27(7):588-599. Epub 2020-07-05.

PubMed abstract

Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review.

BACKGROUND: Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience). n METHODS: We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes. n RESULTS: Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands. n DISCUSSION: Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

Authors: Haverfield, Marie C;Zulman, Donna M;et al.

J Gen Intern Med. 2020 Jul;35(7):2107-2117. doi: 10.1007/s11606-019-05525-2. Epub 2020 Jan 9.

PubMed abstract

Design of a cluster-randomized trial of the effectiveness and cost-effectiveness of metformin on prevention of type 2 diabetes among prediabetic Mexican adults (the PRuDENTE initiative of Mexico City).

INTRODUCTION: Type 2 diabetes (T2D) is a global epidemic, and nations are struggling to implement effective healthcare strategies to reduce the burden. While efficacy studies demonstrate that metformin can reduce incident T2D by half among younger, obese adults with prediabetes, its real-world effectiveness are understudied, and its use for T2D prevention in primary care is low. We describe the design of a pragmatic trial to evaluate the incremental effectiveness of metformin, as an adjunct to a simple lifestyle counseling. METHODS: The “Prevencion de la Diabetes con Ejercicio, Nutricion y Tratamiento” [Diabetes Prevention with Exercise, Nutrition and Treatment; PRuDENTE, (Spanish acronym)] is a cluster-randomized trial in Mexico City’s public primary healthcare system. The study randomly assigns 51 clinics to deliver one of two interventions for 36months: 1) lifestyle only; 2) lifestyle plus metformin, to 3060 patients ages 30-65 with impaired fasting glucose and obesity. The primary endpoint is incident T2D (fasting glucose >/=126mg/dL, or HbA1c >/=6.5%). We will also measure a range of implementation-related process outcomes at the clinic-, clinician- and patient-levels to inform interpretations of effectiveness and enable efforts to refine, adapt, adopt and disseminate the model. We will also estimate the cost-effectiveness of metformin as an adjunct to lifestyle counseling in Mexico. DISCUSSION: Findings from this pragmatic trial will generate new translational knowledge in Mexico and beyond, both with respect to metformin’s real-world effectiveness among an ‘at-risk’ population, and uncovering facilitators and barriers to the reach, adoption and implementation of metformin preventive therapy in public primary care settings. TRIAL REGISTRATION: This trial is registered at (NCT03194009).

Authors: Rodriguez LA; Barquera S; Aguilar-Salinas CA; Sepulveda-Amor J; Sanchez-Romero LM; Denova-Gutierrez E; Balderas N; Moreno-Loaeza L; Handley MA; Basu S; Lopez-Arellano O; Gallardo-Hernandez A; Schillinger D

Contemp Clin Trials. 2020 Aug;95:106067. doi: 10.1016/j.cct.2020.106067. Epub 2020 Jun 21.

PubMed abstract

Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.

Authors: Molling D; Vincent BM; Wiitala WL; Escobar GJ; Hofer TP; Liu VX; Rosen AK; Ryan AM; Seelye S; Prescott HC

Medicine (Baltimore). 2020 Jun 12;99(24):e20385.

PubMed abstract

Characteristics of Hospitalized Adults With COVID-19 in an Integrated Health Care System in California

Authors: Myers LC; Parodi SM; Escobar GJ; Liu VX

JAMA. 2020 Jun 02;323(21):2195-2198.

PubMed abstract

Differences in Diet Quality among Multiple US Racial/Ethnic Groups from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study and the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Diet quality is an important risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). Little is known about the diet quality of South Asians in the United States, a group with higher rates of T2D and CVD compared with other racial/ethnic groups. OBJECTIVE: This study determined whether diet quality differs between South Asian adults in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study and whites, Chinese Americans, African Americans, and Hispanics in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS: Cross-sectional data from 3926 participants free of CVD from MESA visit 5 (2010-2011) and 889 South Asian participants from MASALA visit 1 (2010-2013) were pooled. Diet quality was assessed using the Alternative Healthy Eating Index (AHEI-2010) derived using FFQs. Multivariable linear regression models adjusted for age, sex, and total energy intake were used to compare mean differences in diet quality between the racial/ethnic groups. RESULTS: MESA participants were, on average, 14 y older than MASALA participants. The adjusted mean (95% CI) scores for the AHEI-2010 were 70.2 (69.5, 70.9) among South Asians, 66.2 (66.3, 68.2) among Chinese Americans, 61.1 (60.7, 61.6) among whites, 59.0 (58.4, 59.7) among Hispanics, and 57.5 (56.9, 58.1) among African Americans. The mean AHEI scores among South Asians were 3.1 (1.8, 4.3), 9.2 (8.3, 10.1), 11.2 (10.2, 12.3), and 12.8 (11.8, 13.7) points higher compared with Chinese Americans, whites, Hispanics, and African Americans, respectively. CONCLUSIONS: South Asian adults in the United States have a higher diet quality compared with other racial/ethnic groups. This paradoxical finding is not consistent with the observed higher rates of T2D and CVD compared with other groups. This is further evidence of the importance of studying the South Asian population to better understand the causes of chronic disease not explained by diet quality.

Authors: Rodriguez LA; Jin Y; Talegawkar SA; Otto MCO; Kandula NR; Herrington DM; Kanaya AM

J Nutr. 2020 Jun 1;150(6):1509-1515. doi: 10.1093/jn/nxaa050.

PubMed abstract

Dose Timing of D-Cycloserine to Augment Exposure Therapy for Social Anxiety Disorder: A Randomized Clinical Trial.

Importance: Findings suggest that the efficacy of D-cycloserine (DCS) for enhancing exposure therapy may be strongest when administered after sessions marked by low fear at the conclusion of exposure practice. These findings have prompted investigation of DCS dosing tailored to results of exposure sessions. Objective: To compare tailored postsession DCS administration with presession DCS administration, postsession DCS administration, and placebo augmentation of exposure therapy for social anxiety disorder. Design, Setting, and Participants: This double-blind randomized clinical trial involved adults with social anxiety disorder enrolled at 3 US university centers. Symptom severity was assessed at baseline, weekly during treatment, and at 1-week and 3-month follow-up. Data analysis was performed from September 2019 to March 2020. Interventions: Participants completed a 5-session treatment and received pills commensurate with their condition assignment at sessions 2 through 5, which emphasized exposure practice. Main Outcomes and Measures: Symptom severity was evaluated by the Liebowitz Social Anxiety Scale and Social Phobic Disorders-Severity Form as administered by independent evaluators. Results: A total of 152 participants were enrolled (mean [SD] age, 29.24 [10.16] years; 84 men [55.26%]). Compared with placebo, presession and postsession conditions showed greater symptom improvement (b = -0.25; 95% CI, -0.37 to -0.13; P < .001; d = 1.07; and b = -0.20; 95% CI, -0.32 to -0.07; P = .002; d = 0.85) and lower symptom severity (b = -0.51; 95% CI, -0.81 to -0.21; P < .001; d = 0.76; and b = -0.49; 95% CI, -0.80 to -0.18; P = .002; d = 0.72) at 3-month follow-up. No differences were found between presession and postsession conditions. The tailored condition showed no advantage over placebo. Compared with the tailored condition, presession and postsession conditions evidenced greater decreases (b = -0.22; 95% CI, -0.34 to -0.10; P < .001; d = 0.94; and b = -0.17, 95% CI, -0.29 to -0.04; P = .008; d = 0.72) and lower symptom severity (b = -0.44, 95% CI, -0.73 to -0.14; P = .004; d = 0.64; and b = -0.41, 95% CI, -0.72 to -0.11; P = .008; d = 0.61) at 3-month follow-up. Conclusions and Relevance: Administration of DCS enhanced exposure therapy for social anxiety disorder when given before or after the exposure session. However, the study failed to achieve the aim to develop a tailored clinical application. Trial Registration: Identifier: NCT02066792.

Authors: Smits JAJ; Pollack MH; Rosenfield D; Otto MW; Dowd S; Carpenter J; Dutcher CD; Lewis EM; Witcraft SM; Papini S; Curtiss J; Andrews L; Kind S; Conroy K; Hofmann SG

JAMA Netw Open. 2020 Jun 1;3(6):e206777. doi: 10.1001/jamanetworkopen.2020.6777.

PubMed abstract

Behavioural and psychosocial factors associated with 5-year weight trajectories within the PORTAL Overweight/Obesity Cohort

The purpose of this study was to model weight trajectories over a 5-year time period (2012-2016) and their association with behavioural and psychosocial characteristics and health care-related experiences using data from the Patient Outcomes Research to Advance Learning (PORTAL) overweight/obesity cohort. Weight trajectories for each eligible patient in the PORTAL overweight/obesity cohort (n = 2864) were identified first using growth modelling; trajectories were then grouped using a hierarchical cluster analysis. Weight trajectory clusters that emerged were compared on demographics, and predictors of cluster membership were examined. Clusters were also compared on responses to a survey assessing health behaviours, quality of life, and health care experience completed in 2015 by 49% of the total sample (n = 1391). Seven distinct weight trajectory clusters were identified: (a) significant weight loss then maintenance; (b) higher stable weight; (c) moderate stable weight; (d) steady weight loss then relapse; (e) weight gain then weight loss; (f) steady weight gain then maintenance; and (g) lower stable weight. Age, sex, race/ethnicity, and body mass index at baseline predicted patient’s weight trajectory (P < .001). Over two thirds of patients maintained their weight over the 5-year period. Significant weight loss then maintenance, weight gain then weight loss, and higher stable weight patients were more likely to report receiving weight counselling from their provider. Patients in the significant weight loss then maintenance and lower stable weight clusters were more likely to be physically active than the other clusters. Findings suggest variability in patterns of weight change among adults with overweight or obesity who have access to health care and that these patterns differ on demographic, behavioural and psychosocial factors, and health care experience.

Authors: Fitzpatrick SL; Rosales AG; Brown SD; Arterburn DE; Daley MF; Horberg M; Koebnick C; Oshiro C; Young DR

Obes Sci Pract. 2020 Jun;6(3):272-281. Epub 2020-02-27.

PubMed abstract

Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians

Video or telephone telemedicine can offer patients access to a clinician without arranging for transportation or spending time in a waiting room, but little is known about patient characteristics associated with choosing between telemedicine or office visits. To examine patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. This cross-sectional study included data from 1 131 722 patients who scheduled a primary care appointment through the Kaiser Permanente Northern California patient portal between January 1, 2016, and May 31, 2018. All completed primary care appointments booked via the patient portal were identified. Only index visits without any other clinical visits within 7 days were included to define a relatively distinct patient-initiated care-seeking episode. Visits for routine physical, which are not telemedicine-eligible, were excluded. Data were analyzed from July 1, 2018, to December 31, 2019. Patient choice between an office, video, or telephone visit. Relative risk ratios (RRRs) for patient sociodemographic characteristics (age, sex, race/ethnicity, neighborhood socioeconomic status, language preference), technology access (neighborhood residential internet, mobile portal use), visiting the patient’s own personal primary care clinician, and in-person visit barriers (travel-time, parking, cost-sharing), associated with choice of video or telephone telemedicine (vs office visit). Of 2 178 440 patient-scheduled primary care visits scheduled by 1 131 722 patients, 86% were scheduled as office visits and 14% as telemedicine visits, with 7% of the telemedicine visits by video. Choosing telemedicine was statistically significantly associated with patient sociodemographic characteristics. For example, patients aged 65 years and over were less likely than patients aged 18 to 44 years to choose telemedicine (RRR, 0.24; 95% CI, 0.22-0.26 for video visit; RRR 0.55; 95% CI, 0.54-0.57 for telephone visit). Choosing telemedicine was also statistically significantly associated with technology access (patients living in a neighborhood with high rates of residential internet access were more likely to choose a video visit than patients whose neighborhoods had low internet access: RRR, 1.10; 95% CI, 1.06-1.14); as well as in-person visit barriers (patients whose clinic had a paid parking structure were more likely to choose a telemedicine visit than patients whose facility had free parking: RRR, 1.70; 95% CI, 1.41-2.05 for video visit; and RRR, 1.73, 95% CI, 1.61-1.86 for telephone visit). In this cross-sectional study, patients usually chose an in-person visit when scheduling an appointment online through the portal. Telemedicine may offer the potential to reach vulnerable patient groups and improve access for patients with transportation, parking, or cost barriers to clinic visits.

Authors: Reed ME; Huang J; Graetz I; Lee C; Muelly E; Kennedy C; Kim E

JAMA Netw Open. 2020 06 01;3(6):e205873. Epub 2020-06-01.

PubMed abstract

Recurrent diabetic ketoacidosis and cognitive function among older adults with type 1 diabetes: findings from the Study of Longevity in Diabetes

Diabetic ketoacidosis (DKA) is a serious complication of diabetes. DKA is associated with poorer cognition in children with type 1 diabetes (T1D), but whether this is the case in older adults with T1D is unknown. Given the increasing life expectancy in T1D, understanding the role of DKA on brain health in older adults is crucial. We examined the association of DKA with cognitive function in 714 older adults with T1D from the Study of Longevity in Diabetes. Participants self-reported lifetime exposure to DKA resulting in hospitalization; DKA was categorized into 0 hospitalization, 1 hospitalization or ≥2 hospitalizations (recurrent DKA). Global and domain-specific cognition (language, executive function/psychomotor speed, episodic memory and simple attention) were assessed. The association of DKA with cognitive function was evaluated via linear and logistic regression models. Twenty-eight percent of participants (mean age=67 years; mean age at diagnosis=28 years; average duration of diabetes=39 years) reported a lifetime history of DKA resulting in hospitalization (18.5% single DKA; 9.7% recurrent DKA). In fully adjusted models, those with recurrent DKA had lower global cognitive function (β=-0.13; 95% CI -0.22 to 0.02) and lower scores on the executive function/psychomotor speed domain (β=-0.34; 95% CI -0.51 to 0.17). Individuals with recurrent DKA were also more likely to have the lowest level of cognitive function on the executive function/psychomotor speed domain (defined as 1.5 SD below the population mean; OR=3.26, 95% CI 1.43 to 7.42). Among 714 older adults with T1D, recurrent DKA was associated with lower global cognitive function, lower scores on the executive function/psychomotor speed domain and 3.3 times greater risk of having the lowest level of cognitive function in our sample on the executive function/psychomotor speed domain. These findings suggest that recurrent DKA may negatively impact the brain health of older patients with T1D and highlight the importance of DKA prevention.

Authors: Lacy ME; Gilsanz P; Eng CW; Beeri MS; Karter AJ; Whitmer RA

BMJ Open Diabetes Res Care. 2020 06;8(1).

PubMed abstract

Telehealth in Oncology During the COVID-19 Outbreak: Bringing the House Call Back Virtually

Authors: Liu R; Sundaresan T; Reed ME; Trosman JR; Weldon CB; Kolevska T

JCO Oncol Pract. 2020 06;16(6):289-293. Epub 2020-05-04.

PubMed abstract

Incidence, clinical outcomes, and transmission dynamics of severe coronavirus disease 2019 in California and Washington: prospective cohort study

To understand the epidemiology and burden of severe coronavirus disease 2019 (covid-19) during the first epidemic wave on the west coast of the United States. Prospective cohort study. Kaiser Permanente integrated healthcare delivery systems serving populations in northern California, southern California, and Washington state. 1840 people with a first acute hospital admission for confirmed covid-19 by 22 April 2020, among 9 596 321 healthcare plan enrollees. Analyses of hospital length of stay and clinical outcomes included 1328 people admitted by 9 April 2020 (534 in northern California, 711 in southern California, and 83 in Washington). Cumulative incidence of first acute hospital admission for confirmed covid-19, and subsequent probabilities of admission to an intensive care unit (ICU) and mortality, as well as duration of hospital stay and ICU stay. The effective reproduction number (RE ) describing transmission dynamics was estimated for each region. As of 22 April 2020, cumulative incidences of a first acute hospital admission for covid-19 were 15.6 per 100 000 cohort members in northern California, 23.3 per 100 000 in southern California, and 14.7 per 100 000 in Washington. Accounting for censoring of incomplete hospital stays among those admitted by 9 April 2020, the estimated median duration of stay among survivors was 9.3 days (with 95% staying 0.8 to 32.9 days) and among non-survivors was 12.7 days (1.6 to 37.7 days). The censoring adjusted probability of ICU admission for male patients was 48.5% (95% confidence interval 41.8% to 56.3%) and for female patients was 32.0% (26.6% to 38.4%). For patients requiring critical care, the median duration of ICU stay was 10.6 days (with 95% staying 1.3 to 30.8 days). The censoring adjusted case fatality ratio was 23.5% (95% confidence interval 19.6% to 28.2%) among male inpatients and 14.9% (11.8% to 18.6%) among female inpatients; mortality risk increased with age for both male and female patients. Reductions in RE were identified over the study period within each region. Among residents of California and Washington state enrolled in Kaiser Permanente healthcare plans who were admitted to hospital with covid-19, the probabilities of ICU admission, of long hospital stay, and of mortality were identified to be high. Incidence rates of new hospital admissions have stabilized or declined in conjunction with implementation of social distancing interventions.

Authors: Lewnard JA; Liu VX; Bellows J; et al.

BMJ. 2020 May 22;369:m1923. Epub 2020-05-22.

PubMed abstract

COVID-19: Long-term Planning for Procedure-based Specialties During Extended Mitigation and Suppression Strategies

Authors: Rouillard S; Liu VX; Corley DA

Gastroenterology. 2020 May 18.

PubMed abstract

The Impact of Step-Down Unit Care on Patient Outcomes After ICU Discharge

To examine whether and how step-down unit admission after ICU discharge affects patient outcomes. Retrospective study using an instrumental variable approach to remove potential biases from unobserved differences in illness severity for patients admitted to the step-down unit after ICU discharge. Ten hospitals in an integrated healthcare delivery system in Northern California. Eleven-thousand fifty-eight episodes involving patients who were admitted via emergency departments to a medical service from July 2010 to June 2011, were admitted to the ICU at least once during their hospitalization, and were discharged from the ICU to the step-down unit or the ward. None. Using congestion in the step-down unit as an instrumental variable, we quantified the impact of step-down unit care in terms of clinical and operational outcomes. On average, for ICU patients with lower illness severity, we found that availability of step-down unit care was associated with an absolute decrease in the likelihood of hospital readmission within 30 days of 3.9% (95% CI, 3.6-4.1%). We did not find statistically significant effects on other outcomes. For ICU patients with higher illness severity, we found that availability of step-down unit care was associated with an absolute decrease in in-hospital mortality of 2.5% (95% CI, 2.3-2.6%), a decrease in remaining hospital length-of-stay of 1.1 days (95% CI, 1.0-1.2 d), and a decrease in the likelihood of ICU readmission within 5 days of 3.6% (95% CI, 3.3-3.8%). This study shows that there exists a subset of patients discharged from the ICU who may benefit from care in an step-down unit relative to that in the ward. We found that step-down unit care was associated with statistically significant improvements in patient outcomes especially for high-risk patients. Our results suggest that step-down units can provide effective transitional care for ICU patients.

Authors: Lekwijit S; Chan CW; Green LV; Liu VX; Escobar GJ

Crit Care Explor. 2020 May;2(5):e0114. Epub 2020-05-06.

PubMed abstract

Comparison of Early Warning Scoring Systems for Hospitalized Patients With and Without Infection at Risk for In-Hospital Mortality and Transfer to the Intensive Care Unit

Risk scores used in early warning systems exist for general inpatients and patients with suspected infection outside the intensive care unit (ICU), but their relative performance is incompletely characterized. To compare the performance of tools used to determine points-based risk scores among all hospitalized patients, including those with and without suspected infection, for identifying those at risk for death and/or ICU transfer. In a cohort design, a retrospective analysis of prospectively collected data was conducted in 21 California and 7 Illinois hospitals between 2006 and 2018 among adult inpatients outside the ICU using points-based scores from 5 commonly used tools: National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Between the Flags (BTF), Quick Sequential Sepsis-Related Organ Failure Assessment (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS). Data analysis was conducted from February 2019 to January 2020. Risk model discrimination was assessed in each state for predicting in-hospital mortality and the combined outcome of ICU transfer or mortality with area under the receiver operating characteristic curves (AUCs). Stratified analyses were also conducted based on suspected infection. The study included 773 477 hospitalized patients in California (mean [SD] age, 65.1 [17.6] years; 416 605 women [53.9%]) and 713 786 hospitalized patients in Illinois (mean [SD] age, 61.3 [19.9] years; 384 830 women [53.9%]). The NEWS exhibited the highest discrimination for mortality (AUC, 0.87; 95% CI, 0.87-0.87 in California vs AUC, 0.86; 95% CI, 0.85-0.86 in Illinois), followed by the MEWS (AUC, 0.83; 95% CI, 0.83-0.84 in California vs AUC, 0.84; 95% CI, 0.84-0.85 in Illinois), qSOFA (AUC, 0.78; 95% CI, 0.78-0.79 in California vs AUC, 0.78; 95% CI, 0.77-0.78 in Illinois), SIRS (AUC, 0.76; 95% CI, 0.76-0.76 in California vs AUC, 0.76; 95% CI, 0.75-0.76 in Illinois), and BTF (AUC, 0.73; 95% CI, 0.73-0.73 in California vs AUC, 0.74; 95% CI, 0.73-0.74 in Illinois). At specific decision thresholds, the NEWS outperformed the SIRS and qSOFA at all 28 hospitals either by reducing the percentage of at-risk patients who need to be screened by 5% to 20% or increasing the percentage of adverse outcomes identified by 3% to 25%. In all hospitalized patients evaluated in this study, including those meeting criteria for suspected infection, the NEWS appeared to display the highest discrimination. Our results suggest that, among commonly used points-based scoring systems, determining the NEWS for inpatient risk stratification could identify patients with and without infection at high risk of mortality.

Authors: Liu VX; Escobar GJ; Churpek MM; et al.

JAMA Netw Open. 2020 May 01;3(5):e205191. Epub 2020-05-01.

PubMed abstract

Racial and Ethnic Disparities in Diabetes Care Quality among Women of Reproductive Age in an Integrated Delivery System

Diabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined. This retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures-glycemic testing, glycemic control, and medication adherence-among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use. In this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar. Our findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.

Authors: Marshall CJ; Rodriguez HP; Dyer W; Schmittdiel JA

Womens Health Issues. 2020 May - Jun;30(3):191-199. Epub 2020-04-25.

PubMed abstract

Continuation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in the Face of Kidney Disease Progression-Safe and Possibly Life Saving

Authors: DeJong C; Grant RW

JAMA Intern Med. 2020 05 01;180(5):727.

PubMed abstract

Initial Glycemic Control and Care Among Younger Adults Diagnosed With Type 2 Diabetes

The prevalence of type 2 diabetes is increasing among adults under age 45. Onset of type 2 diabetes at a younger age increases an individual’s risk for diabetes-related complications. Given the lasting benefits conferred by early glycemic control, we compared glycemic control and initial care between adults with younger onset (21-44 years) and mid-age onset (45-64 years) of type 2 diabetes. Using data from a large, integrated health care system, we identified 32,137 adults (aged 21-64 years) with incident diabetes (first HbA1c ≥6.5% [≥48 mmol/mol]). We excluded anyone with evidence of prior type 2 diabetes, gestational diabetes mellitus, or type 1 diabetes. We used generalized linear mixed models, adjusting for demographic and clinical variables, to examine differences in glycemic control and care at 1 year. Of identified individuals, 26.4% had younger-onset and 73.6% had mid-age-onset type 2 diabetes. Adults with younger onset had higher initial mean HbA1c values (8.9% [74 mmol/mol]) than adults with onset in mid-age (8.4% [68 mmol/mol]) (P < 0.0001) and lower odds of achieving an HbA1c <7% (<53 mmol/mol) 1 year after the diagnosis (adjusted odds ratio [aOR] 0.70 [95% CI 0.66-0.74]), even after accounting for HbA1c at diagnosis. Adults with younger onset had lower odds of in-person primary care contact (aOR 0.82 [95% CI 0.76-0.89]) than those with onset during mid-age, but they did not differ in telephone contact (1.05 [0.99-1.10]). Adults with younger onset had higher odds of starting metformin (aOR 1.20 [95% CI 1.12-1.29]) but lower odds of adhering to that medication (0.74 [0.69-0.80]). Adults with onset of type 2 diabetes at a younger age were less likely to achieve glycemic control at 1 year following diagnosis, suggesting the need for tailored care approaches to improve outcomes for this high-risk patient population.

Authors: Gopalan A; Mishra P; Alexeeff SE; Blatchins MA; Kim E; Man A; Karter AJ; Grant RW

Diabetes Care. 2020 05;43(5):975-981. Epub 2020-03-04.

PubMed abstract

Response-to-Treatment for Comorbid Post-Traumatic Stress and Substance Use Disorders: The Value of Combining Person- and Variable-Centered Approaches.

Optimizing treatment for co-occurring post-traumatic stress disorder and substance use disorder (PTSD+SUD) is critically important. Whereas treatments have been designed that target PTSD+SUD with some success, these treatments do not benefit all. Data-driven approaches that combine person- and variable-centered methods, such as parallel process latent class growth analysis (PP-LCGA) can be used to identify response-to-treatment trajectories across both PTSD symptoms and substance use. The current study employed PP-LCGA separately in two randomized clinical trials (study 1 n = 81, Mean age = 40.4 years, SD = 10.7; study 2 n = 59, Mean age = 44.7 years, SD = 9.4) to examine PTSD symptom response and percentage of days using substances across treatment trials comparing Concurrent Treatment of PTSD and SUD using Prolonged Exposure and Relapse Prevention. Results revealed four PTSD+SUD profiles for study one and three PTSD+SUD profiles for study two. For PTSD symptoms, response trajectories could be broadly classified into treatment responders and non-responders across both studies. For substance use, response trajectories could be broadly classified into declining, moderately stable, and abstaining profiles. When considering PTSD symptoms and substance use trajectories together, profiles emerged that would have been missed had these treatment outcomes been considered separately.

Authors: Allan NP; Lopez-Castro T; Hien DA; Papini S; Killeen TK; Gros DF; Ruglass LM; Barrett E; Back SE

J Psychopathol Behav Assess. 2020 Dec;42(4):725-738. doi: 10.1007/s10862-020-09803-w. Epub 2020 Apr 28.

PubMed abstract

Isradipine enhancement of virtual reality cue exposure for smoking cessation: Rationale and study protocol for a double-blind randomized controlled trial.

Cigarette smoking remains a leading cause of preventable death in the United States, contributing to over 480,000 deaths each year. Although significant strides have been made in the development of effective smoking cessation treatments, most established interventions are associated with high relapse rates. One avenue for increasing the effectiveness of smoking cessation interventions is to design focused, efficient, and rigorous experiments testing engagement of well-defined mechanistic targets. Toward this aim, the current protocol will apply a pharmacologic augmentation strategy informed by basic research in animal models of addiction. Our goal is to evaluate the enhancing effect of isradipine, an FDA-approved calcium channel blocker, on the extinction of craving-a key mechanism of drug relapse after periods of abstinence. To activate craving robustly in human participants, we will use multimodal smoking cues including novel 360 degrees video environments developed for this project and delivered through consumer virtual reality headsets. Adult smokers will take either isradipine or placebo and complete the cue exposure protocol in a double-blind randomized control trial. In order to test the hypothesis that isradipine will enhance retention of craving extinction, participants will repeat cue exposure 24h later without the administration of isradipine or placebo. The study will be implemented in a primary care setting where adult smokers receive healthcare, and smoking behavior will be tracked throughout the trial with ecological momentary assessment.

Authors: Papini S; Young CC; Gebhardt CS; Perrone A; Morikawa H; Otto MW; Roache JD; Smits JAJ

Contemp Clin Trials. 2020 Jul;94:106013. doi: 10.1016/j.cct.2020.106013. Epub 2020 Apr 24.

PubMed abstract

From Containment to Mitigation of COVID-19 in the US

Authors: Parodi SM; Liu VX

JAMA. 2020 04 21;323(15):1441-1442.

PubMed abstract

Exploiting nonsystematic covariate monitoring to broaden the scope of evidence about the causal effects of adaptive treatment strategies

In studies based on electronic health records (EHR), the frequency of covariate monitoring can vary by covariate type, across patients, and over time, which can limit the generalizability of inferences about the effects of adaptive treatment strategies. In addition, monitoring is a health intervention in itself with costs and benefits, and stakeholders may be interested in the effect of monitoring when adopting adaptive treatment strategies. This paper demonstrates how to exploit nonsystematic covariate monitoring in EHR-based studies to both improve the generalizability of causal inferences and to evaluate the health impact of monitoring when evaluating adaptive treatment strategies. Using a real world, EHR-based, comparative effectiveness research (CER) study of patients with type II diabetes mellitus, we illustrate how the evaluation of joint dynamic treatment and static monitoring interventions can improve CER evidence and describe two alternate estimation approaches based on inverse probability weighting (IPW). First, we demonstrate the poor performance of the standard estimator of the effects of joint treatment-monitoring interventions, due to a large decrease in data support and concerns over finite-sample bias from near-violations of the positivity assumption (PA) for the monitoring process. Second, we detail an alternate IPW estimator using a no direct effect assumption. We demonstrate that this estimator can improve efficiency but at the potential cost of increase in bias from violations of the PA for the treatment process.

Authors: Kreif N; Sofrygin O; Schmittdiel JA; Adams AS; Grant RW; Zhu Z; van der Laan MJ; Neugebauer R

Biometrics. 2020 Apr 15.

PubMed abstract

Presyncope Is Associated with Intensive Care Unit Admission in Emergency Department Patients with Acute Pulmonary Embolism

Syncope is common among emergency department (ED) patients with acute pulmonary embolism (PE) and indicates a higher acuity and worse prognosis than in patients without syncope. Whether presyncope carries the same prognostic implications has not been established. We compared incidence of intensive care unit (ICU) admission in three groups of ED PE patients: those with presyncope; syncope; and neither. This retrospective cohort study included all adults with acute, objectively confirmed PE in 21 community EDs from January 2013-April 2015. We combined electronic health record extraction with manual chart abstraction. We used chi-square test for univariate comparisons and performed multivariate analysis to evaluate associations between presyncope or syncope and ICU admission from the ED, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Among 2996 PE patients, 82 (2.7%) had presyncope and 109 (3.6%) had syncope. ICU admission was similar between groups (presyncope 18.3% vs syncope 25.7%) and different than their non-syncope counterparts (either 22.5% vs neither 4.7%; p<0.0001). On multivariate analysis, both presyncope and syncope were independently associated with ICU admission, controlling for demographics, higher-risk PE Severity Index (PESI) class, ventilatory support, proximal clot location, and submassive and massive PE classification: presyncope, aOR 2.79 (95% CI, 1.40, 5.56); syncope, aOR 4.44 (95% CI 2.52, 7.80). These associations were only minimally affected when excluding massive PE from the model. There was no significant interaction between either syncope or presyncope and PESI, submassive or massive classification in predicting ICU admission. Presyncope appears to carry similar strength of association with ICU admission as syncope in ED patients with acute PE. If this is confirmed, clinicians evaluating patients with acute PE may benefit from including presyncope in their calculus of risk assessment and site-of-care decision-making.

Authors: Vinson DR; Reed ME; Mark DG; et al.

West J Emerg Med. 2020 Apr 13;21(3):703-713. Epub 2020-04-13.

PubMed abstract

Reservations Regarding O-RADS Recommendations

Authors: Suh-Burgmann E; Flanagan T; Brasic N

Radiology. 2020 04;295(1):248-249. Epub 2020-02-25.

PubMed abstract

Impact of the Affordable Care Act on Colorectal Cancer Outcomes: A Systematic Review

The Patient Protection and Affordable Care Act increases healthcare access and includes provisions that directly impact access to and cost of evidence-based colorectal cancer screening. The Affordable Care Act’s removal of cost sharing for colorectal cancer screening as well as Medicaid expansion have been hypothesized to increase screening and improve other health outcomes. However, since its passage in 2010, there is little consensus on the Affordable Care Act’s impact. Data from March 2010 to June 2019 were reviewed and 21 relevant studies were identified; 19 studies examined colorectal cancer screening with most finding increased screening rates. Eleven studies found significant increases, 5 found nonsignificant increases, 3 found nonsignificant decreases, and 1 study found a significant decrease in colorectal cancer screening. Three studies examined the impact on colorectal cancer incidence and stage of diagnosis, where a significant 2.4% increase in early diagnosis was found in one and a nonsignificant increase in incidence in another. However, survival improved after Medicaid expansion. Free preventive colorectal cancer screening and Medicaid expansion because of passage of the Affordable Care Act have been, in general, positively associated with modest improvements in screening rates across the country. Future studies are needed that investigate the longer-term impact of the Affordable Care Act on colorectal cancer morbidity and mortality rates, as screening is only the first step in treatment of cancerous and precancerous lesions, preventing them from progressing. Moreover, more studies examining subpopulations are needed to better assess where gaps in care remain.

Authors: Xu MR; Kelly AMB; Kushi LH; Reed ME; Koh HK; Spiegelman D

Am J Prev Med. 2020 04;58(4):596-603. Epub 2020-01-31.

PubMed abstract

The Role of Professional Organizations in Fostering the Early Career Development of Academic Intensivists

Authors: Vail EA; Nadig NR; Sahetya SK; Vande Vusse LK; Walkey AJ; Liu V; Mathews KS

Ann Am Thorac Soc. 2020 04;17(4):412-418.

PubMed abstract

Red blood cell transfusions for emergency department patients with gastrointestinal bleeding within an integrated health system

To assess trends over time in red blood cell (RBC) transfusion practice among emergency department (ED) patients with gastrointestinal (GI) bleeding within an integrated healthcare system, inclusive of 21 EDs. Retrospective cohort of ED patients diagnosed with GI bleeding between July 1st, 2012 and September 30th, 2016. The primary outcome was receipt of an RBC transfusion in the ED. Secondary outcomes included 90-day rates of RBC transfusion, repeat ED visits, rehospitalization, and all-cause mortality. Logistic regression was used to obtain confounder-adjusted outcome rates. A total of 24,868 unique patient encounters were used for the primary analysis. The median hemoglobin level in the ED prior to RBC transfusion decreased from 7.5 g/dl to 6.9 g/dl in the first versus last twelve months of the study period (p < 0.0001). A small trend was observed in the overall adjusted rate of ED RBC transfusion (absolute quarterly change of -0.1%, R2 = 0.18, p = 0.0001) largely attributable to the subgroup of patients with hemoglobin nadirs between 7.0 and 9.9 g/dl (absolute quarterly change of -0.4%, R2 = 0.38, p < 0.0001). Rates of RBC transfusions through 90 days likewise decreased (absolute quarterly change of -0.4%, R2 = 0.85, p < 0.0001) with stable to decreased corresponding rates of repeat ED visits, rehospitalizations and mortality. Rates of ED RBC transfusion decreased over time among patients with GI bleeding, particularly in those with hemoglobin nadirs between 7.0 and 9.9 g/dl. These findings suggest that ED providers are willing to adopt evidence-based restrictive RBC transfusion recommendations for patients with GI bleeding.

Authors: Mark DG; Huang J; Plimier C; Reed ME; Escobar GJ; Vinson DR; Roubinian NH

Am J Emerg Med. 2020 04;38(4):746-753. Epub 2019-06-10.

PubMed abstract

Advancing Evidence Synthesis from Effectiveness to Implementation: Integration of Implementation Measures into Evidence Reviews.

BACKGROUND: In order to close the gap between discoveries that could improve health, and widespread impact on routine health care practice, there is a need for greater attention to the factors that influence dissemination and implementation of evidence-based practices. Evidence synthesis projects (e.g., systematic reviews) could contribute to this effort by collecting and synthesizing data relevant to dissemination and implementation. Such an advance would facilitate the spread of high-value, effective, and sustainable interventions. n OBJECTIVE: The objective of this paper is to evaluate the feasibility of extracting factors related to implementation during evidence synthesis in order to enhance the replicability of successes of studies of interventions in health care settings. n DESIGN: Drawing on the implementation science literature, we suggest 10 established implementation measures that should be considered when conducting evidence synthesis projects. We describe opportunities to assess these constructs in current literature and illustrate these methods through an example of a systematic review. n SUBJECTS: Twenty-nine studies of interventions aimed at improving clinician-patient communication in clinical settings. n KEY RESULTS: We identified acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, intervention complexity, penetration, reach, and sustainability as factors that are feasible and appropriate to extract during an evidence synthesis project. n CONCLUSIONS: To fully understand the potential value of a health care innovation, it is important to consider not only its effectiveness, but also the process, demands, and resource requirements involved in downstream implementation. While there is variation in the degree to which intervention studies currently report implementation factors, there is a growing demand for this information. Abstracting information about these factors may enhance the value of systematic reviews and other evidence synthesis efforts, improving the dissemination and adoption of interventions that are effective, feasible, and sustainable across different contexts.

Authors: A Tierney, Aaron;C Haverfield, Marie;P McGovern, Mark;M Zulman, Donna

J Gen Intern Med. 2020 Apr;35(4):1219-1226. doi: 10.1007/s11606-019-05586-3. Epub 2019 Dec 17.

PubMed abstract

Diabetes and cardiovascular disease mortality among a population-based cohort of women with and without breast cancer.

PURPOSE: We investigated whether the relationship between diabetes and all-cause and CVD-related mortality differed between women with and without breast cancer among a cohort drawn from the same source population. METHODS: We interviewed 1,363 women newly diagnosed with breast cancer in 1996-1997, and 1,358 age-matched women without breast cancer, to assess history of physician-diagnosed diabetes. All-cause (n = 631) and CVD-specific mortality (n = 234) was determined by the National Death Index through 2009. We estimated multivariable-adjusted hazard ratios (HRs) for the rates of all-cause and CVD-specific mortality and, to account for competing causes of death, and subdistribution HRs (sHRs) for risk of CVD-related death. RESULTS: Among women with and without breast cancer, respectively, diabetes was associated with: all-cause mortality [HR (95% CI) 1.52 (1.13, 2.05) and 2.17 (1.46, 3.22)]; CVD-specific deaths [1.74 (1.06, 2.84) and 2.06 (1.11, 3.84)]; and risk of CVD-related death [sHR 1.36 (0.81, 2.27) and 1.79 (0.94, 3.40)]. Differences in effect estimates between women with and without breast cancer did not reach statistical significance (p-interaction > 0.10). CONCLUSION: We found that the positive association between a history of physician-diagnosed diabetes and risk of all-cause and CVD-related mortality is of similar magnitude among a population-based cohort of women with or without breast cancer.

Authors: Rodriguez LA; Bradshaw PT; Parada H; Khankari NK; Wang T; Cleveland RJ; Teitelbaum SL; Neugut AI; Gammon MD

Cancer Causes Control. 2020 May;31(5):517-524. doi: 10.1007/s10552-020-01292-2. Epub 2020 Mar 7.

PubMed abstract

Testing patient-informed approaches for visually depicting the hemoglobin A1c value to patients with poorly controlled diabetes: a randomized, controlled trial

Patients’ understanding of the hemoglobin A1c (HbA1c) has been linked to better diabetes care outcomes (glycemic control, self-care). This is concerning given low documented rates of HbA1c understanding. In this non-blinded, randomized trial, we compared two formats for communicating the HbA1c, selected based on input from people with diabetes, to standard presentation to assess their impact on participants’ glycemic control and diabetes-related perceptions. To design the tested formats, we interviewed 25 patients with diabetes and reviewed a range of possible formats, including color-based scales and graphs. The interviews were recorded, transcribed, and subjected to thematic analysis. Synthesizing interviewees’ feedback, we selected two formats, one using a combination of words and colors (Words) and one using a color-coded graph (Graph), for further evaluation. We then randomized adults with poorly controlled diabetes to receive mailed information on their current diabetes control in one of three ways: 1) standard lab report (control), 2) Words format, or 3) Graph format. The primary outcome was HbA1c change at 6 months. Also examined were changes in participants’ diabetes-related perceptions and choice of participation incentive. Of the 234 enrolled participants, 76.9% were Black, and their median baseline HbA1c was 9.1% (interquartile range 8.4-10.4). There were no between-arm differences in HbA1c change (- 1.04% [SD 2.2] Control vs. -0.59% [SD 2.0] Words vs. -0.54% [SD 2.1] Graph, p > 0.05 for all comparisons). Participants in the Words arm had an increase in the accuracy of their perceptions of diabetes seriousness (p = 0.04) and in the number of participants reporting a diabetes management goal (p = 0.01). The two patient-informed communication formats did not differentially impact glycemic control among adults with inadequately controlled diabetes. However, a significant proportion of participants in the Words arm had an increase in the accuracy of their perception of diabetes seriousness, a potential mediating factor in positive diabetes-related behavioral changes. With increasing use of patient-facing online portals, thoughtfully designed approaches for visually communicating essential, but poorly understood, information like the HbA1c to patients have the potential to facilitate interpretation and support self-management. Prospectively registered as NCT01886170.

Authors: Gopalan A; Suttner L; Troxel AB; McDonough K; Schapira MM

BMC Health Serv Res. 2020 Mar 06;20(1):178. Epub 2020-03-06.

PubMed abstract

Assessment of Electronic Health Record Search Patterns and Practices by Practitioners in a Large Integrated Health Care System

The electronic health record (EHR) is a source of practitioner dissatisfaction in part because of challenges with information retrieval. To improve data accessibility, a better understanding of practitioners’ information needs within individual patient records is needed. To assess EHR users’ searches using data from a large integrated health care system. This retrospective cross-sectional analysis used EHR search data from Kaiser Permanente Northern California, an integrated health care delivery system with more than 4.4 million members. Users’ EHR search activity data were obtained from April 1, 2018, to May 15, 2019. Search term frequency was grouped by user and practitioner types. Network analyses were performed of co-occurring search terms within a single search episode, and centrality measures for search terms (degree and betweenness centrality) were calculated. A total of 12 313 047 search activities (including 4 328 330 searches and 7 984 717 result views) conducted by 34 735 unique users within 977 160 unique patient EHRs were identified. In aggregate, users searched for 208 374 unique search terms and conducted a median of 4 searches (interquartile range, 1-28 searches). Of all 97 367 active EHR users, 34 735 (35.7%) conducted at least 1 search. However, of all 12 968 active EHR physician users, 9801 (75.6%) conducted at least 1 search, and of all 1908 active pharmacist users, 1402 (73.5%) conducted at least 1 search. The top 3 most commonly searched terms were statin (75 017 searches [1.7%]), colonoscopy (73 545 [1.7%]), and pft (54 990 [1.3%]). However, wide variation in top searches were noted across practitioner groups. Terms searched most often with another term in a single linked search episode included statin, lisinopril, colonoscopy, gabapentin, and aspirin. Although physicians and pharmacists were the most active users of EHR searches, search volume and frequently searched terms varied considerably by and within user role. Further customization of the EHR interface may help leverage users’ search content and patterns to improve targeted information retrieval.

Authors: Ruppel H; Bhardwaj A; Manickam RN; Adler-Milstein J; Flagg M; Ballesca M; Liu VX

JAMA Netw Open. 2020 03 02;3(3):e200512. Epub 2020-03-02.

PubMed abstract

Cytological sampling of fallopian tubes using a hysteroscopic catheter: A multi-center study

To assess the feasibility of a novel hysteroscopic catheter to collect fallopian tube cytologic samples and to correlate cytologic findings with histopathology. This was a prospective, multicenter, single-arm pilot study. Women undergoing salpingo-oophorectomy for a pelvic mass suspicious for malignancy or for prevention of cancer for BRCA mutation carriers were recruited from 3 gynecologic oncology centers (October 2016-August 2017). Cytologic samples were collected from the fallopian tube using a novel FDA-cleared hysteroscopic catheter and evaluated by a pathologist blinded to surgical or pathologic findings. The correlation between cytologic results and final surgical pathology was assessed. Of the 50 patients enrolled, 42 were eligible. Hysteroscopies were completed in 40 patients with 78 fallopian tubes, of which 65 ostia (83%) were identified. Of these, 61 (72%) were successfully catheterized resulting in 44 (68%) cytology samples adequate for further evaluation: 5 were classified as positive (3 neoplastic and 2 malignant) and 39 as negative (34 benign and 5 reactive/atypical). A comparison of cytology results with fallopian tube histopathology showed a concordance rate of 95% (42/44). Of the two samples with discordant results, both had positive cytology but negative tubal pathology, and both were stage I ovarian cancers with malignant ovary histology. Deployment of the device yielded an evaluable cytologic sample in 68% of cases with a high rate of concordance with histopathology. Further evaluation of the device’s ability to detect malignancy in high risk populations is warranted.

Authors: Powell CB; Littell RD; Landen CN; Pramanik S; Hamilton IC; Suh-Burgmann EJ

Gynecol Oncol. 2020 03;156(3):636-640. Epub 2020-01-07.

PubMed abstract

Educational Program for Physiologic Monitor Use and Alarm Systems Safety: A Toolkit

Clinical alarm systems safety is a national healthcare concern in the United States. Physiologic monitors are the medical devices associated with the highest number of false and clinically insignificant alarms, producing alarm fatigue and a challenge to meet the national clinical alarm systems safety goal. Modern physiologic monitors are high-tech complex devices with multimeasurement modalities and high sensitivity for alarms. This complexity hinders safe operation of the monitors by nurses and appropriate management of associated alarms. Nurses need to integrate cognitive knowledge, psychomotor skills, and critical thinking to safely operate the monitors and support clinical decisions. Limited resources are available to support clinical education for nurses on physiologic monitor use and alarm management. This toolkit presents an educational framework for physiologic monitor use and alarm safety guided by adult learning principles. The components of the program are (1) knowledge, skills, and attitude of physiologic monitor use; (2) scenario-based learning model to support the knowledge, skills, and attitude necessary for safe monitor use; and (3) a framework for evaluating the educational program. Education should be ongoing and customized per facility to ensure safe use of complex technology and to decrease alarm fatigue, the leading cause of alarm-related sentinel events.

Authors: Phillips J; Sowan A; Ruppel H; Magness R

Clin Nurse Spec. 2020 Mar/Apr;34(2):50-62.

PubMed abstract

Primary Care Practitioners’ Perspectives on Burnout and What to Do About It

Authors: Grant RW; Goitein L

JAMA Intern Med. 2020 03 01;180(3):345-346.

PubMed abstract

Severe Hypoglycemia and Cognitive Function in Older Adults With Type 1 Diabetes: The Study of Longevity in Diabetes (SOLID)

In children with type 1 diabetes (T1D), severe hypoglycemia (SH) is associated with poorer cognition, but the association of SH with cognitive function in late life is unknown. Given the increasing life expectancy in people with T1D, understanding the role of SH in brain health is crucial. We examined the association between SH and cognitive function in 718 older adults with T1D from the Study of Longevity in Diabetes (SOLID). Subjects self-reported recent SH (previous 12 months) and lifetime history of SH resulting in inpatient/emergency department utilization. Global and domain-specific cognition (language, executive function, episodic memory, and simple attention) were assessed. The associations of SH with cognitive function and impaired cognition were evaluated via linear and logistic regression models, respectively. Thirty-two percent of participants (mean age 67.2 years) reported recent SH and 50% reported lifetime SH. Compared with those with no SH, subjects with a recent SH history had significantly lower global cognition scores. Domain-specific analyses revealed significantly lower scores on language, executive function, and episodic memory with recent SH exposure and significantly lower executive function with lifetime SH exposure. Recent SH was associated with impaired global cognition (odds ratio [OR] 3.22, 95% CI 1.30, 7.94) and cognitive impairment on the language domain (OR 3.15, 95% CI 1.19, 8.29). Among older adults with T1D, recent SH and lifetime SH were associated with worse cognition. Recent SH was associated with impaired global cognition. These findings suggest a deleterious role of SH on the brain health of older patients with T1D and highlight the importance of SH prevention.

Authors: Lacy ME; Gilsanz P; Eng C; Beeri MS; Karter AJ; Whitmer RA

Diabetes Care. 2020 03;43(3):541-548. Epub 2019-12-27.

PubMed abstract

Sounds good: the bright future of clinical alarm management initiatives

Authors: Ruppel H; Bonafide CP

BMJ Qual Saf. 2020 Feb 21.

PubMed abstract

What Do We Do After the Pilot Is Done? Implementation of a Hospital Early Warning System at Scale

Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning system (EWS), based on a very large database, that provides RRTs with 12 hours lead time to mount a response. Results from a 2-hospital pilot were encouraging, so leadership decided to deploy the Advance Alert Monitor (AAM) program in 19 more hospitals. How can one deploy an RRS using an automated EWS at scale? EWS displays were removed from frontline clinicians’ hospital electronic dashboards, and a Virtual Quality Team (VQT) RN was interposed between the EWS and the RRT. VQT RNs monitor the EWS remotely-when alerts are issued, they conduct a preliminary chart review and contact hospital RRT RNs. VQT and RRT RNs review the cases jointly. The RRT RNs then consult with hospitalists regarding clinical rescue and/or palliative care workflows. Subsequently, VQT RNs monitor patient charts, ensuring adherence to RRS practice standards. To enable this process, the project team developed a governance structure, clinical workflows, palliative care workflows, and documentation standards. The AAM Program now functions in 21 Kaiser Permanente Northern California hospitals. VQT RNs monitor EWS alerts 24 hours a day, 7 days a week. The AAM Program handles ∼16,000 alerts per year. Its implementation has resulted in standardization of RRT staffing, clinical rescue workflows, and in-hospital palliative care.

Authors: Paulson SS; Dummett BA; Green J; Scruth E; Reyes V; Escobar GJ

Jt Comm J Qual Patient Saf. 2020 Jan 21.

PubMed abstract

Risk of atherosclerotic cardiovascular disease by cardiovascular health metric categories in approximately 1 million patients

Authors: Rana JS; Liu JY; Moffet HH; Karter AJ; Nasir K; Solomon MD; Jaffe MG; Ambrosy AP; Go AS; Sidney S

Eur J Prev Cardiol. 2020 Feb 10:2047487320905025.

PubMed abstract

Risk of atherosclerotic cardiovascular disease by cardiovascular health metric categories in approximately 1 million patients

Authors: Rana, Jamal S; Liu, Jennifer Y; Moffet, Howard H; Karter, Andrew J; Nasir, Khurram; Solomon, Matthew D; Jaffe, Marc G; Ambrosy, Andrew P; Go, Alan S; Sidney, Stephen

Eur J Prev Cardiol. 2020 Feb 07.

PubMed abstract

Association of Mobile Patient Portal Access With Diabetes Medication Adherence and Glycemic Levels Among Adults With Diabetes

Online patient portals support self-management, and mobile devices expand portal access, but whether this translates to improvements in diabetes outcomes is unclear. To examine the association of adding mobile patient portal access with diabetes medication adherence and glycemic levels among adults with diabetes. This retrospective cohort study included patients with diabetes treated at Kaiser Permanente Northern California, a large, integrated health care delivery system, from April 1, 2015, to December 31, 2017. Inclusion criteria were adults with diabetes with an oral diabetes prescription at baseline and no insulin use. Data were analyzed from March 2018 to March 2019. Patient portal access status for each calendar month from April 2015 to December 2017, categorized as never used, used from a computer only, used from a mobile device only, or used from both computer and mobile device. Medication adherence, measured by monthly percentage of days covered (PDC), and glycemic levels, measured by changes in glycated hemoglobin A1c (HbA1c) levels. The association of portal access with study outcomes was assessed using linear regression with patient-level fixed effects and adjusting for time-changing variables, stratified by baseline HbA1c level. Among 111 463 included patients (mean [SD] age, 63.79 [12.93] years; 59 918 [53.76%] men), the number of patients using the portal from both a computer and mobile device increased over time from 38 371 patients (34.42%) in April 2015 to 57 920 patients (61.71%) in December 2017. Among patients with no prior portal access, adding computer-only portal access was associated with an increase in PDC of 1.16 (95% CI, 0.63 to 1.70) percentage points and a change of -0.06 (95% CI, -0.08 to -0.03) percentage points in HbA1c level, and adding both mobile and computer portal access was associated with an increase in PDC of 1.67 (95% CI, 1.10 to 2.23) percentage points and a change of -0.13 (95% CI, -0.16 to -0.10) percentage points in HbA1c level. Among patients with higher baseline HbA1c level (>8.0%), changing from no portal access to both computer and mobile access was associated with an increase in PDC of 5.09 (95% CI, 3.78 to 6.40) percentage points and a change of -0.19 (95% CI, -0.27 to -0.15) percentage points in HbA1c level. These findings suggest that providing patients with computer patient portal access and combining it with mobile patient portal access are associated with significantly improved diabetes medication adherence and glycemic control, with greater benefits among patients with more clinical need. Convenient access to portal self-management tools through a mobile device could significantly improve diabetes management.

Authors: Graetz I; Huang J; Muelly ER; Fireman B; Hsu J; Reed ME

JAMA Netw Open. 2020 02 05;3(2):e1921429. Epub 2020-02-05.

PubMed abstract

Pretreatment Posttraumatic Stress Disorder Symptom Network Metrics Predict the Strength of the Association Between Node Change and Network Change During Treatment.

Network analysis has been increasingly applied in an effort to understand complex interactions among symptoms in posttraumatic stress disorder (PTSD). Although methods that initially focused on identifying central symptoms in cross-sectional networks have been extended to longitudinal data that can reveal the relative roles of acute symptoms in the emergence of the PTSD syndrome, the association between network metrics and symptom change during treatment have yet to be explored in PTSD. To address this gap, we estimated pretreatment PTSD symptom networks in a sample of patients from a multisite clinical trial for women with full or subthreshold PTSD and substance use. We tested the hypothesis that node metrics calculated in the pretreatment network would be predictive of the strength of the association between a symptom’s change and the change in the severity of all other symptoms through the course of treatment. A symptom node’s strength and predictability in the pretreatment network were each strongly correlated with the association between that symptom’s change and overall change across the symptom network, r(15) = .79, p < .001 and r(15) = .75, p < .001, respectively, whereas a symptom's mean severity at pretreatment was not, r(15) = .27, p = .292. These findings suggest that a node's centrality prior to treatment engagement is a predictor of its association with overall symptom change throughout the treatment process.

Authors: Papini S; Rubin M; Telch MJ; Smits JAJ; Hien DA

J Trauma Stress. 2020 Feb;33(1):64-71. doi: 10.1002/jts.22379. Epub 2019 Jul 25.

PubMed abstract

Risk of Cardiovascular Events in Statin-Treated Patients with Type 2 Diabetes and Metabolic Dyslipidemia without Prevalent Atherosclerotic Cardiovascular Disease

The relationship between achieved low-density lipoprotein cholesterol (LDL-C) levels and risk of incident atherosclerotic cardiovascular disease events among patients with diabetes and metabolic dyslipidemia has not been well described. We conducted an observational cohort study of statin-treated adults (ages 21-90 years) with type 2 diabetes without established atherosclerotic cardiovascular disease (as of January 1, 2006) who had metabolic dyslipidemia (elevated triglycerides ?150 mg/dL and low high-density lipoprotein cholesterol, <50 mg/dL [women] and <40 mg/dL [men]). All subjects were members of Kaiser Permanente Northern California, an integrated health care delivery system. Adjusted multivariable Cox models were specified to estimate hazard ratios (HRs) for incident atherosclerotic cardiovascular disease events by achieved LDL-C levels (<50, 50-<70, 70-<100, and ?100 mg/dL). Incident atherosclerotic cardiovascular disease events were defined as a composite of nonfatal myocardial infarction, ischemic stroke, or coronary heart disease death through December 31, 2013. A total of 19,095 individuals met the selection criteria. Mean age was 63.4 years, 53.5% were women, and the mean follow-up was 5.9 years. Unadjusted rates of atherosclerotic cardiovascular disease events were not significantly different across specified LDL-C categories. In models adjusted for demographics and clinical characteristics, the risk was significantly lower with decreasing achieved LDL-C levels (P <0.0001 for trend). Relative to achieved LDL-C ?100 mg/dL, LDL-C <50 mg/dL had an hazard ratio of 0.66 (95% confidence interval [CI] 0.52-0.82). In a large, contemporary cohort of statin-treated patients with type 2 diabetes and metabolic dyslipidemia without established atherosclerotic cardiovascular disease, lower achieved LDL-C levels were associated with a monotonically lower risk of incident atherosclerotic cardiovascular disease events. The benefits of achieving very-low LDL-C (<50 mg/dL) in this population requires further evaluation in prospective interventional studies.

Authors: Rana JS; Liu JY; Moffet HH; Sanchez RJ; Khan I; Karter AJ

Am J Med. 2020 02;133(2):200-206. Epub 2019-07-22.

PubMed abstract

Enhancing panic and smoking reduction treatment with D-Cycloserine: A pilot randomized clinical trial.

In this placebo-controlled randomized clinical trial, we examined the efficacy of 250 mg d-cycloserine (DCS) for enhancing the effects of cognitive behavior therapy targeting anxiety sensitivity reduction in the context of smoking cessation treatment among adults with a history of panic attacks. We hypothesized that DCS would enhance treatment of our mechanistic targets-anxiety sensitivity and panic and related symptoms-and result in greater smoking abstinence. A total of 53 smokers were randomized to a 7-week integrated treatment and received study medication (DCS or placebo) prior to sessions 3-5; these sessions emphasized interoceptive exposure practice. Nicotine replacement therapy was initiated at session 5 (quit date). We found that DCS augmentation led to greater reductions of one (anxiety sensitivity) of two of our mechanistic targets at early but not late assessments, and that engaging that target predicted better smoking outcomes. However, there was no evidence of group (DCS vs. placebo) differences in smoking cessation success at treatment endpoint or follow-up evaluations. Hence, although we found that DCS can enhance treatment targeting a smoking maintaining factor, additional strategies appear to be needed to significantly affect smoking outcomes.

Authors: Smits JAJ; Zvolensky MJ; Otto MW; Piper ME; Baird SO; Kauffman BY; Lee-Furman E; Alavi N; Dutcher CD; Papini S; Rosenfield B; Rosenfield D

Drug Alcohol Depend. 2020 Mar 1;208:107877. doi: 10.1016/j.drugalcdep.2020.107877. Epub 2020 Jan 22.

PubMed abstract

Web Exclusive. Annals for Hospitalists Inpatient Notes – The Role of Hospitalists in the Creation of Learning Healthcare Systems

Authors: Gilmartin HM; Liu VX; Burke RE

Ann Intern Med. 2020 01 21;172(2):HO2-HO3.

PubMed abstract

‘No growth to date’? Predicting positive blood cultures in critical illness

Authors: Liu VX; Wiens J

Intensive Care Med. 2020 Jan 21.

PubMed abstract

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter.

IMPORTANCE: Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction. n OBJECTIVE: To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients. n EVIDENCE REVIEW: Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their “top 5” practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes. n FINDINGS: The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient’s emotions). n CONCLUSIONS AND RELEVANCE: This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

Authors: Zulman, Donna M;Schwartz, Rachel;Verghese, Abraham;et al.

JAMA. 2020 Jan 07;323(1):70-81. doi: 10.1001/jama.2019.19003..

PubMed abstract

Goldilocks, the Three Bears and Intensive Care Unit Utilization: Delivering Enough Intensive Care But Not Too Much. A Narrative Review

Professional societies have developed recommendations for patient triage protocols, but wide variations in triage patterns for many acute conditions exist among hospitals in the United States. Differences in hospitals’ triage patterns can be attributed to factors such as physician behavior, hospital policy and real-time conditions such as intensive care unit capacity. The patient safety concern is that patients evaluated for admission to the intensive care unit during times of high intensive care unit capacity may have adverse outcomes related to delays in care. Because standardization of a national triage policy is not feasible due to differing resources available at each hospital, local guidelines should prevail that take into account hospitals’ local resources. The goal would be to better match intensive care unit bed supply with demand.

Authors: Myers LC; Escobar G; Liu VX

Pulm Ther. 2020 Jan 03.

PubMed abstract

Comparison of Mortality and Major Cardiovascular Events Among Adults With Type 2 Diabetes Using Human vs Analogue Insulins

The comparative cardiovascular safety of analogue and human insulins in adults with type 2 diabetes who initiate insulin therapy in usual care settings has not been carefully evaluated using machine learning and other rigorous analytic methods. To examine the association of analogue vs human insulin use with mortality and major cardiovascular events. This retrospective cohort study included 127 600 adults aged 21 to 89 years with type 2 diabetes at 4 health care delivery systems who initiated insulin therapy from January 1, 2000, through December 31, 2013. Machine learning and rigorous inference methods with time-varying exposures were used to evaluate associations of continuous exposure to analogue vs human insulins with mortality and major cardiovascular events. Data were analyzed from September 1, 2017, through June 30, 2018. On the index date (first insulin dispensing), participants were classified as using analogue insulin with or without human insulin or human insulin only. Overall mortality, mortality due to cardiovascular disease (CVD), myocardial infarction (MI), stroke or cerebrovascular accident (CVA), and hospitalization for congestive heart failure (CHF) were evaluated. Marginal structural modeling (MSM) with inverse probability weighting was used to compare event-free survival in separate per-protocol analyses. Adjusted and unadjusted hazard ratios and cumulative risk differences were based on logistic MSM parameterizations for counterfactual hazards. Propensity scores were estimated using a data-adaptive approach (machine learning) based on 3 nested covariate adjustment sets. Sensitivity analyses were conducted to address potential residual confounding from unmeasured differences in risk factors across delivery systems. The 127 600 participants (mean [SD] age, 59.4 [12.6] years; 68 588 men [53.8%]; mean [SD] body mass index, 32.3 [7.1]) had a median follow-up of 4 quarters (interquartile range, 3-9 quarters) and experienced 5464 deaths overall (4.3%), 1729 MIs (1.4%), 1301 CVAs (1.0%), and 3082 CHF hospitalizations (2.4%). There were no differences in adjusted hazard ratios for continuous analogue vs human insulin exposure during 10 quarters for overall mortality (1.15; 95% CI, 0.97-1.34), CVD mortality (1.26; 95% CI, 0.86-1.66), MI (1.11; 95% CI, 0.77-1.45), CVA (1.30; 95% CI, 0.81-1.78), or CHF hospitalization (0.93; 95% CI, 0.75-1.11). Insulin-naive adults with type 2 diabetes who initiate and continue treatment with human vs analogue insulins had similar observed rates of major cardiovascular events, CVD mortality, and overall mortality.

Authors: Neugebauer R; Schmittdiel JA; O'Connor PJ; et al.

JAMA Netw Open. 2020 01 03;3(1):e1918554. Epub 2020-01-03.

PubMed abstract

Predicting the readability of physicians’ secure messages to improve health communication using novel linguistic features: Findings from the ECLIPPSE study

Low literacy skills impact important aspects of communication, including health-related information exchanges. Unsuccessful communication on the part of physician or patient contributes to lower quality of care, is associated with poorer chronic disease control, jeopardizes patient safety and can lead to unfavorable healthcare utilization patterns. To date, very little research has focused on digital communication between physicians and patients, such as secure messages sent via electronic patient portals. The purpose of the current study is to develop an automated readability formula to better understand what elements of physicians’ digital messages make them more or less difficult to understand. The formula is developed using advanced natural language processing (NLP) to predict human ratings of physician text difficulty. The results indicate that NLP indices that capture a diverse set of linguistic features predict the difficulty of physician messages better than classic readability tools such as Flesch Kincaid Grade Level. Our results also provide information about the textual features that best explain text readability. Implications for how the readability formula could provide feedback to physicians to improve digital health communication by promoting linguistic concordance between physician and patient are discussed.

Authors: Crossley, Scott A; Balyan, Renu; Liu, Jennifer; Karter, Andrew J; McNamara, Danielle; Schillinger, Dean

J Commun Healthc. 2020;13(4):1-13. Epub 2020-09-24.

PubMed abstract

Context is Key: Using the Audit Log to Capture Contextual Factors Affecting Stroke Care Processes

High quality patient care through timely, precise and efficacious management depends not only on the clinical presentation of a patient, but the context of the care environment to which they present. Understanding and improving factors that affect streamlined workflow, such as provider or department busyness or experience, are essential to improving these care processes, but have been difficult to measure with traditional approaches and clinical data sources. In this exploratory data analysis, we aim to determine whether such contextual factors can be captured for important clinical processes by taking advantage of non-traditional data sources like EHR audit logs which passively track the electronic behavior of clinical teams. Our results illustrate the potential of defining multiple measures of contextual factors and their correlation with key care processes. We illustrate this using thrombolytic (tPA) treatment for ischemic stroke as an example process, but the measurement approaches can be generalized to multiple scenarios.

Authors: Noshad, Morteza; Rose, Christian C; Thombley, Robert; Chiang, Jonathan; Corbin, Conor K; Nguyen, Minh; Liu, Vincent X; Adler-Milstein, Julia; Chen, Jonathan H

AMIA Annu Symp Proc. 2020;2020:953-962. Epub 2021-01-25.

PubMed abstract

Racial-ethnic differences in prevalence of social determinants of health and social risks among middle-aged and older adults in a Northern California health plan

Social determinants of health (SDoHs) and social risks (SRs) have been associated with adverse health and healthcare utilization and racial/ethnic disparities. However, there is limited information about the prevalence of SRs in non-“safety net” adult populations and how SRs differ by race/ethnicity, age, education, and income. We analyzed weighted survey data for 16,247 White, 1861 Black, 2895 Latino, 1554 Filipino, and 1289 Chinese adults aged 35 to 79 who responded to the 2011 or 2014/2015 Kaiser Permanente Northern California Member Health Survey. We compared age-standardized prevalence estimates of SDoHs (education, household income, marital status) and SRs (financial worry, cost-related reduced medication use and fruit/vegetable consumption, chronic stress, harassment/discrimination, health-related beliefs) across racial/ethnic groups for ages 35 to 64 and 65 to 79. SDoHs and SRs differed by race/ethnicity and age group, and SRs differed by levels of education and income. In both age groups, Blacks, Latinos, and Filipinos were more likely than Whites to be in the lower income category and be worried about their financial situation. Compared to Whites, cost-related reduced medication use was higher among Blacks, and cost-related reduced fruit/vegetable consumption was higher among Blacks and Latinos. Younger adults were more likely than older adults to experience chronic stress and financial worry. Racial/ethnic disparities in income were observed within similar levels of education. Differences in prevalence of SRs by levels of education and income were wider within than across racial/ethnic groups. In this non-“safety net” adult health plan population, Blacks, Latinos, and Filipinos had a higher prevalence of social risks than Whites and Chinese, and prevalence of social risks differed by age group. Our results support the assessment and EHR documentation of SDoHs and social risks and use of this information to understand and address drivers of racial/ethnic disparities in health and healthcare use.

Authors: Gordon, Nancy P; Banegas, Matthew P; Tucker-Seeley, Reginald D

PLoS One. 2020;15(11):e0240822. Epub 2020-11-04.

PubMed abstract

Association Between Peripheral Blood Oxygen Saturation (SpO2)/Fraction of Inspired Oxygen (FiO2) Ratio Time at Risk and Hospital Mortality in Mechanically Ventilated Patients

Acute respiratory failure requiring mechanical ventilation is a leading cause of mortality in the intensive care unit. Although single peripheral blood oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) ratios of hypoxemia have been evaluated to risk-stratify patients with acute respiratory distress syndrome, the utility of longitudinal SpO2/FiO2 ratios is unknown. To assess time-based SpO2/FiO2 ratios ≤ 150-SpO2/FiO2 time at risk (SF-TAR)-for predicting mortality in mechanically ventilated patients. Retrospective, observational cohort study of mechanically ventilated patients at 21 community and 2 academic hospitals. Association between the SF-TAR in the first 24 hours of ventilation and mortality was examined using multivariable logistic regression and compared with the worst recorded isolated partial pressure of arterial oxygen/fraction of inspired oxygen (P/F) ratio. In 28,758 derivation cohort admissions, every 10% increase in SF-TAR was associated with a 24% increase in adjusted odds of hospital mortality (adjusted odds ratio = 1.24; 95% confidence interval [CI] = 1.23-1.26); a similar association was observed in validation cohorts. Discrimination for mortality modestly improved with SF-TAR (area under the receiver operating characteristic curve [AUROC] = 0.81; 95% CI = 0.81-0.82) vs the worst P/F ratio (AUROC = 0.78; 95% CI = 0.78-0.79) and worst SpO2/FiO2 ratio (AUROC = 0.79; 95% CI = 0.79-0.80). The SF-TAR in the first 6 hours offered comparable discrimination for hospital mortality (AUROC = 0.80; 95% CI = 0.79-0.80) to the 24-hour SF-TAR. The SF-TAR can identify ventilated patients at increased risk of death, offering modest improvements compared with single SpO2/FiO2 and P/F ratios. This longitudinal, noninvasive, and broadly generalizable tool may have particular utility for early phenotyping and risk stratification using electronic health record data in ventilated patients.

Authors: Adams JY; Rogers AJ; Schuler A; Marelich GP; Fresco JM; Taylor SL; Riedl AW; Baker JM; Escobar GJ; Liu VX

Perm J. 2020;24. Epub 2020-01-31.

PubMed abstract

Sleep Quality and Cognitive Function in Type 1 Diabetes: Findings From the Study of Longevity in Diabetes (SOLID)

The objective was to examine the association between sleep quality and global and domain-specific cognitive function among older individuals with type 1 diabetes (T1D). We evaluated 695 individuals with T1D aged 60 years or above who participated in the baseline assessment of the Study of Longevity in Diabetes (SOLID), which captured subjective sleep quality (Pittsburgh Sleep Quality Index) and global and domain-specific (language, executive function, episodic memory, and simple attention) cognitive function. Multivariable linear regressions estimated the associations between sleep quality quartiles and overall and domain-specific cognitive function adjusting for age, sex, race/ethnicity, education, depressive symptoms, and severe hypoglycemic episodes. Sensitivity analyses examined the associations between aspects of sleep quality and global cognitive function. The worst sleep quality quartile was associated with lower global cognition (β=-0.08; 95% confidence interval: -0.17, -0.01) and lower executive function (β=-0.17, 95% confidence interval: -0.30, -0.03) compared with the best quartile of sleep quality adjusting for demographics and comorbidities. Sleep quality was not associated with language, episodic memory, or simple attention. Sleep medications and daytime dysfunction were most strongly associated with global cognition. Our results suggest that sleep quality may be a modifiable risk factor for global cognitive function and executive function among elderly individuals with T1D.

Authors: Gilsanz P; Lacy ME; Beeri MS; Karter AJ; Eng CW; Whitmer RA

Alzheimer Dis Assoc Disord. 2020 Jan-Mar;34(1):18-24.

PubMed abstract

ICU Utilization for Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Noninvasive Ventilation.

OBJECTIVES: We investigated whether patients with chronic obstructive pulmonary disease could safely receive noninvasive ventilation outside of the ICU.DESIGN: Retrospective cohort study.SETTING: Twelve states with ICU utilization flag from the State Inpatient Database from 2014.PATIENTS: Patients greater than or equal to 18 years old with primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease and secondary diagnosis of respiratory failure who received noninvasive ventilation.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Multilevel logistic regression models were used to obtain hospital-level ICU utilization rates. We risk-adjusted using both patient/hospital characteristics. The primary outcome was in-hospital mortality; secondary outcomes were invasive monitoring (arterial/central catheters), hospital length of stay, and cost. We examined 5,081 hospitalizations from 424 hospitals with ICU utilization ranging from 0.05 to 0.98. The overall median in-hospital mortality was 2.62% (interquartile range, 1.72-3.88%). ICU utilization was not significantly associated with in-hospital mortality (β = 0.01; p = 0.05) or length of stay (β = 0.18; p = 0.41), which was confirmed by Spearman correlation (ρ = 0.06; p = 0.20 and ρ = 0.02; p = 0.64, respectively). However, lower ICU utilization was associated with lower rates of invasive monitor placement by linear regression (β = 0.05; p < 0.001) and Spearman correlation (ρ = 0.28; p < 0.001). Lower ICU utilization was also associated with significantly lower cost by linear regression (β = 14.91; p = 0.02) but not by Spearman correlation (ρ = 0.09; p = 0.07).CONCLUSIONS: There is wide variability in the rate of ICU utilization for noninvasive ventilation across hospitals. Chronic obstructive pulmonary disease patients receiving noninvasive ventilation had similar in-hospital mortality across the ICU utilization spectrum but a lower rate of receiving invasive monitors and probably lower cost when treated in lower ICU-utilizing hospitals. Although the results suggest that noninvasive ventilation can be delivered safely outside of the ICU, we advocate for hospital-specific risk assessment if a hospital were considering changing its noninvasive ventilation delivery policy.

Authors: Myers, Laura C; Faridi, Mohammad Kamal; Currier, Paul; Camargo, Carlos A

Critical care medicine. 2019 05 20;47(5):677-684. Epub 2019-12-20.

PubMed abstract

The Hospital Readmissions Reduction Program and Readmissions for Chronic Obstructive Pulmonary Disease, 2006-2015.

RATIONALE: In October 2012, the initial phase of the Hospital Readmission Reduction Program (HRRP) imposed financial penalties on hospitals with higher than expected risk-adjusted 30-day readmission rates for Medicare beneficiaries with congestive heart failure, myocardial infarction, and pneumonia. We hypothesized that these penalties may also be associated with decreased readmissions for chronic obstructive pulmonary disease (COPD) in the general population before COPD became a target condition (October 2014).OBJECTIVE: To determine if implementation of the initial financial penalties for other conditions was associated with a decrease in hospital readmissions for COPD.METHODS: We used population-level data to examine patients readmitted for any reason or for COPD within 30 days after an initial hospitalization for COPD. The data source was seven states in the State Inpatient Database. The pre-implementation period included calendar years 2006-2012. The post-implementation period included 2013-2015. Using interrupted time series, the level change was examined, which reflected the difference between the expected and actual readmission rates in 2013. The difference in slopes between the pre- and post-implementation periods was also examined.RESULTS: We identified 805,764 hospitalizations for COPD from 904 hospitals. Overall, 26% of patients had primary insurance other than Medicare. After the intervention, patients had lower rates of all-cause 30-day readmissions (level change -0.93%, 95% CI -1.44, -0.43, P=0.004), which was driven by fewer early readmissions (0-7 days). The post-implementation slope became positive; the difference in slopes was 0.39% (95% CI 0.28, 0.50, PCONCLUSIONS: In patients with COPD and any insurance status, there was an association between the initial phase of the HRRP and a decrease in both all-cause and COPD-related readmissions even before COPD became a target diagnosis. The large amount of money at risk to hospitals likely resulted in broad behavioral change. Future research is needed to test which levers can effectively reduce readmission rates for COPD.

Authors: Myers, Laura C; Faridi, Mohammad K; Hasegawa, Kohei; Hanania, Nicola A; Camargo, Carlos A

Annals of the American Thoracic Society. 2019 Dec 20;():. Epub 2019-12-20.

PubMed abstract

An Examination of Medical Malpractice Claims Involving Physician Trainees.

PURPOSE: To identify patient-, provider- and claim-related factors of medical malpractice claims in which physician trainees were directly involved in the harm events.METHOD: The authors performed a case-control study using medical malpractice claims closed between 2012-2016 and contributed to the Comparative Benchmarking System database by teaching hospitals. Using the service extender flag, they classified claims as cases if physician trainees were directly involved in the harm events. They classified claims as controls if they were from the same facilities but trainees were not directly involved in the harm events. They performed multivariable regression with predictor variables being patient and provider characteristics. The outcome was physician trainee involvement in harm events.RESULTS: From the original pool of 30,973 claims, there were 581 cases and 2,610 controls. The majority of cases involved residents (471, 81%). Cases had a statistically significant higher rate of having a trainee named as defendants than controls (184, 32% vs 233, 9%, P < .001). The most common final diagnosis for cases was puncture or laceration during surgery (62, 11%). Inadequate supervision was a contributing factor in 140 (24%) cases overall, with the majority (104, 74%) of these claims being procedure-related. Multivariable regression analysis revealed trainees were most likely to be involved in harm events in specialties such as oral surgery/dentistry and obstetrics/gynecology (odds ratio [OR] = 7.99, 95% confidence interval [CI] 2.93, 21.83 and OR = 1.85, 95% CI 1.24, 2.66), when performing procedures (OR = 1.58, 95% CI 1.27, 1.96), or when delivering care in the emergency room (OR = 1.65, 95% CI 1.43, 1.91).CONCLUSIONS: Among claims involving physician trainees, procedures were common and often associated with inadequate supervision. Training directors of procedural specialties can use this information to improve resident supervision policies. The goal is to reduce the likelihood of future events.

Authors: Myers, Laura C; Gartland, Rajshri M; Skillings, Jillian; Heard, Lisa; Bittner, Edward A; Einbinder, Jonathan; Metlay, Joshua P; Mort, Elizabeth

Academic medicine : journal of the Association of American Medical Colleges. 2019 Dec 10;47(5):677-684. Epub 2019-12-10.

PubMed abstract

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. Eligible participants had ≥1 uncontrolled CVD risk factors (hyperlipidemia, hypertension, or diabetes mellitus) for at least 2 years before study enrollment. The control group (n=315) received usual care within an existing CVD population-based disease management program. The intervention group (n=332) received usual care plus a group-based behavioral intervention focused on patient activation and engagement. Study outcomes included patient activation and patient-centered care processes (6 months) and healthcare system engagement, medication adherence, and control of CVD risk factors (12 months). Compared with the control group at follow-up, the intervention group had greater improvement in patient activation (adjusted mean difference=2.8, P=0.01), patient-centered care (adjusted mean difference=0.19, P=0.003), and 2 out of 3 measures of healthcare system engagement (eg, secure messages exchanged with a population health manager; adjusted incidence rate ratio=1.7, P=0.01). Intervention and control arms did not differ on improvement in 1-year CVD risk factor control. Conclusions Further work is needed to more effectively connect increased patient activation and engagement to downstream changes in risk factor control. Clinical Trial Registration URL: Unique identifier: NCT02302612.

Authors: Iturralde E; Sterling SA; Uratsu CS; Mishra P; Ross TB; Grant RW

J Am Heart Assoc. 2019 12 03;8(23):e014021. Epub 2019-11-30.

PubMed abstract

Primary Care Physicians’ Experiences With and Strategies for Managing Electronic Messages

The increasing use of electronic communications has enhanced access to physicians for patients and clinical staff. Primary care physicians (PCPs) have anecdotally identified electronic inbox management as a new source of work-related stress. To describe PCPs’ experiences managing their electronic inboxes and to characterize the array of management strategies developed by individual physicians and practice groups. This qualitative study was conducted in 8 medical centers of a large group practice with more than 4 million patients in diverse settings and a mature electronic health record. The group encourages patients to use portal secure messaging to enhance access to their physicians and the care experience. Semistructured interviews were conducted with 24 internists and family medicine physicians identified via snowball sampling. Interviews were conducted July through November 2018. Data analysis was conducted between November 2018 and April 2019. Audio recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. The 24 participants (12 women [50.0%]; mean [SD] age, 45.5 [6.5] years), including 9 department chiefs and 15 PCPs, had a mean (SD) of 16.8 (7.8) years since medical school graduation. Participants described substantial changes in medical practice due to electronic communication, including perceived patient expectations to receive rapid responses to portal secure messages. They described portal secure messaging as useful for building relationships with patients, but also reported that electronic message management has created new stressors, including erosion of work-life boundaries and anxiety associated with unlimited inbox volume. Individual PCPs used a diverse array of strategies, including multitasking during and outside work and delegating to medical assistants. Chiefs described group-level strategies, including reserving clinic time for inbox management, coverage systems for vacation and sick days, physician-to-physician training, and interdisciplinary teams to share messaging work. Individual physicians and local practice groups have developed a wide array of strategies for electronic inbox management. The volume of electronic messages and PCPs’ perceptions that patients expect rapid responses have created new stressors in primary care practice. Medical groups and health systems can support PCPs by facilitating knowledge transfer among physicians about inbox management strategies and further developing team structures for inbox coverage.

Authors: Lieu TA; Altschuler A; Weiner JZ; East JA; Moeller MF; Prausnitz S; Reed ME; Warton EM; Goler N; Awsare S

JAMA Netw Open. 2019 12 02;2(12):e1918287. Epub 2019-12-02.

PubMed abstract

Multiyear Rehospitalization Rates and Hospital Outcomes in an Integrated Health Care System

Since the introduction of the rehospitalization rate as a quality measure, multiple changes have taken place in the US health care delivery system. Interpreting rehospitalization rates without taking a global view of these changes and new data elements from comprehensive electronic medical records yields a limited assessment of the quality of care. To examine hospitalization outcomes from a broad perspective, including the implications of numerator and denominator definitions, all adult patients with all diagnoses, and detailed clinical data. This cohort study obtained data from 21 hospitals in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system that serves patients with Medicare Advantage plans, Medicaid, and/or Kaiser Foundation Health Plan. The KPNC electronic medical record system was used to capture hospitalization data for adult patients who were 18 years of age or older; discharged from June 1, 2010, through December 31, 2017; and hospitalized for reasons other than childbirth. Hospital stays for transferred patients were linked using public and internal sources. Hospitalization type (inpatient, for observation only), comorbidity burden, acute physiology score, and care directives. Mortality (inpatient, 30-day, and 30-day postdischarge), nonelective rehospitalization, and discharge disposition (home, home with home health assistance, regular skilled nursing facility, or custodial skilled nursing facility). In total, 1 384 025 hospitalizations were identified, of which 1 155 034 (83.5%) were inpatient and 228 991 (16.5%) were for observation only. These hospitalizations involved 679 831 patients (mean [SD] age, 61.4 [18.1] years; 362 582 female [53.3%]). The number of for-observation-only hospitalizations increased from 16 497 (9.4%) in the first year of the study to 120 215 (20.5%) in the last period of the study, whereas inpatient hospitalizations with length of stay less than 24 hours decreased by 33% (from 12 008 [6.9%] to 27 108 [4.6%]). Illness burden measured using administrative data or acute physiology score increased significantly. The proportion of patients with a Comorbidity Point Score of 65 or higher increased from 20.5% (range across hospitals, 18.4%-26.4%) to 28.8% (range, 22.3%-33.0%), as did the proportion with a Charlson Comorbidity Index score of 4 or higher, which increased from 28.8% (range, 24.6%-35.0%) to 38.4% (range, 31.9%-43.4%). The proportion of patients at or near critical illness (Laboratory-based Acute Physiology Score [LAPS2] ≥110) increased by 21.4% (10.3% [range across hospitals, 7.4%-14.7%] to 12.5% [range across hospitals, 8.3%-16.6%]; P < .001), reflecting a steady increase of 0.07 (95% CI, 0.04-0.10) LAPS2 points per month. Unadjusted inpatient mortality in the first year of the study was 2.78% and in the last year was 2.71%; the corresponding numbers for 30-day mortality were 5.88% and 6.15%, for 30-day postdischarge mortality were 3.94% and 4.22%, and for nonelective rehospitalization were 12.00% and 12.81%, respectively. All outcomes improved after risk adjustment. Compared with the first month, the final observed to expected ratio was 0.79 (95% CI, 0.73-0.84) for inpatient mortality, 0.86 (95% CI, 0.82-0.89) for 30-day mortality, 0.90 (95% CI, 0.85-0.95) for 30-day nonelective rehospitalization, and 0.87 (95% CI, 0.83-0.92) for 30-day postdischarge mortality. The proportion of nonelective rehospitalizations meeting public reporting criteria decreased substantially over the study period (from 58.0% in 2010-2011 to 45.2% in 2017); most of this decrease was associated with the exclusion of observation stays. This study found that in this integrated system, the hospitalization rate decreased and risk-adjusted hospital outcomes improved steadily over the 7.5-year study period despite worsening case mix. The comprehensive results suggest that future assessments of care quality should consider the implications of numerator and denominator definitions, display multiple metrics concurrently, and include all hospitalization types and detailed data.

Authors: Escobar GJ; Plimier C; Greene JD; Liu V; Kipnis P

JAMA Netw Open. 2019 12 02;2(12):e1916769. Epub 2019-12-02.

PubMed abstract

Use and Discontinuation of Insulin Treatment Among Adults Aged 75 to 79 Years With Type 2 Diabetes

Among older individuals with type 2 diabetes, those with poor health have greater risk and derive less benefit from tight glycemic control with insulin. To examine whether insulin treatment is used less frequently and discontinued more often among older individuals with poor health compared with those in good health. This longitudinal cohort study included 21 531 individuals with type 2 diabetes followed for up to 4 years starting at age 75 years. Electronic health record data from the Kaiser Permanente Northern California Diabetes Registry was collected to characterize insulin treatment and glycemic control over time. Data were collected from January 1, 2009, through December 31, 2017, and analyzed from February 2, 2018, through June 30, 2019. Health status was defined as good (<2 comorbid conditions or 2 comorbidities but physically active), intermediate (>2 comorbidities or 2 comorbidities and no self-reported weekly exercise), or poor (having end-stage pulmonary, cardiac, or renal disease; diagnosis of dementia; or metastatic cancer). Insulin use prevalence at age 75 years and discontinuation among insulin users over the next 4 years (or 6 months prior to death if <4 years). Of 21 531 patients, 10 396 (48.3%) were women, and the mean (SD) age was 75 (0) years. Nearly one-fifth of 75-year-olds (4076 [18.9%]) used insulin. Prevalence and adjusted risk ratios (aRRs) of insulin use at age 75 years were higher in individuals with poor health (29.4%; aRR, 2.03; 95% CI, 1.87-2.20; P < .01) and intermediate health (27.5%; aRR, 1.85; 95% CI, 1.74-1.97; P < .01) relative to good health (10.5% [reference]). One-third (1335 of 4076 [32.7%]) of insulin users at age 75 years discontinued insulin within 4 years of cohort entry (and at least 6 months prior to death). Likelihood of continued insulin use was higher among individuals in poor health (aRR, 1.47; 95% CI, 1.27-1.67; P < .01) and intermediate health (aRR, 1.16; 95% CI, 1.05-1.30; P < .01) compared with good health (reference). These same prevalence and discontinuation patterns were present in the subset with tight glycemic control (hemoglobin A1c <7.0%). In older individuals with type 2 diabetes, insulin use was most prevalent among those in poor health, whereas subsequent insulin discontinuation after age 75 years was most likely in healthier patients. Changes are needed in current practice to better align with guidelines that recommend reducing treatment intensity as health status declines.

Authors: Weiner JZ; Gopalan A; Mishra P; Lipska KJ; Huang ES; Laiteerapong N; Karter AJ; Grant RW

JAMA Intern Med. 2019 12 01;179(12):1633-1641.

PubMed abstract

Assessing clinical heterogeneity in sepsis through treatment patterns and machine learning

To use unsupervised topic modeling to evaluate heterogeneity in sepsis treatment patterns contained within granular data of electronic health records. A multicenter, retrospective cohort study of 29 253 hospitalized adult sepsis patients between 2010 and 2013 in Northern California. We applied an unsupervised machine learning method, Latent Dirichlet Allocation, to the orders, medications, and procedures recorded in the electronic health record within the first 24 hours of each patient’s hospitalization to uncover empiric treatment topics across the cohort and to develop computable clinical signatures for each patient based on proportions of these topics. We evaluated how these topics correlated with common sepsis treatment and outcome metrics including inpatient mortality, time to first antibiotic, and fluids given within 24 hours. Mean age was 70 ± 17 years with hospital mortality of 9.6%. We empirically identified 42 clinically recognizable treatment topics (eg, pneumonia, cellulitis, wound care, shock). Only 43.1% of hospitalizations had a single dominant topic, and a small minority (7.3%) had a single topic comprising at least 80% of their overall clinical signature. Across the entire sepsis cohort, clinical signatures were highly variable. Heterogeneity in sepsis is a major barrier to improving targeted treatments, yet existing approaches to characterizing clinical heterogeneity are narrowly defined. A machine learning approach captured substantial patient- and population-level heterogeneity in treatment during early sepsis hospitalization. Using topic modeling based on treatment patterns may enable more precise clinical characterization in sepsis and better understanding of variability in sepsis presentation and outcomes.

Authors: Fohner AE; Greene JD; Lawson BL; Chen JH; Kipnis P; Escobar GJ; Liu VX

J Am Med Inform Assoc. 2019 12 01;26(12):1466-1477.

PubMed abstract

The number needed to benefit: estimating the value of predictive analytics in healthcare

Predictive analytics in health care has generated increasing enthusiasm recently, as reflected in a rapidly growing body of predictive models reported in literature and in real-time embedded models using electronic health record data. However, estimating the benefit of applying any single model to a specific clinical problem remains challenging today. Developing a shared framework for estimating model value is therefore critical to facilitate the effective, safe, and sustainable use of predictive tools into the future. We highlight key concepts within the prediction-action dyad that together are expected to impact model benefit. These include factors relevant to model prediction (including the number needed to screen) as well as those relevant to the subsequent action (number needed to treat). In the simplest terms, a number needed to benefit contextualizes the numbers needed to screen and treat, offering an opportunity to estimate the value of a clinical predictive model in action.

Authors: Liu VX; Bates DW; Wiens J; Shah NH

J Am Med Inform Assoc. 2019 12 01;26(12):1655-1659.

PubMed abstract

Postoperative Opioid Use Before and After Enhanced Recovery After Surgery Program Implementation

Authors: Liu VX; Eaton A; Lee DC; Reyes VM; Paulson SS; Campbell CI; Avins AL; Parodi SM

Ann Surg. 2019 12;270(6):e69-e71.

PubMed abstract

Aggregation of Asian-American subgroups masks meaningful differences in health and health risks among Asian ethnicities: an electronic health record based cohort study

Few large cohort studies have examined the prevalence of diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), obesity, and smoking among middle-aged and older adults in the major Asian-American ethnic groups and Native Hawaiian/Pacific Islanders (PIs). The aim of this study was to evaluate how prevalence of these conditions and risk factors differs across Asian-American and PI ethnic groups and compares with an aggregated All Asian-American racial group. This study used a cohort of 1.4 million adults aged 45 to 84 who were Kaiser Permanente Northern California health plan members during 2016. The cohort included approximately 274,910 Asian-Americans (Chinese, Filipino, Japanese, Korean, Southeast Asian, South Asian, other), 8450 PIs, 795,080 non-Hispanic whites, 107,200 blacks, and 210,050 Latinos. We used electronic health record data to produce age-standardized prevalence estimates of DM, HTN, CAD, obesity (using standard and Asian thresholds), and smoking for men and women in all racial/ethnic subgroups and compared these subgroups to an aggregated All Asian-American racial group and to whites, blacks, and Latinos. We found large differences in health burden across Asian-American ethnic subgroups. For both sexes, there were 16 and > 22 percentage point differences between the lowest and highest prevalence of DM and HTN, respectively. Obesity prevalence among Asian subgroups (based on an Asian BMI ≥ 27.5 kg/m2 threshold) ranged from 14 to 39% among women and 21 to 45% among men. Prevalence of smoking ranged from 1 to 4% among women and 5 to 14% among men. Across all conditions and risk factors, prevalence estimates for Asian-American and PI ethnic groups significantly differed from those for the All Asian-American group. In general, Filipinos and PIs had greater health burden than All Asians, with prevalence estimates approaching those of blacks. In a population of middle-aged and older adult Northern California health plan members, we found substantive differences in prevalence of chronic cardiovascular conditions, obesity, and smoking across Asian-American ethnic groups and between Asian-American ethnic groups and an aggregated All Asian racial group. Our study confirms that reporting statistics for an aggregated Asian-American racial group masks meaningful differences in Asian-American ethnic group health.

Authors: Gordon NP; Lin TY; Rau J; Lo JC

BMC Public Health. 2019 Nov 25;19(1):1551. Epub 2019-11-25.

PubMed abstract

“They were just waiting for me to mess up”: A critical discourse analysis of immigrant Latinx teens’ perceptions of power dynamics.

This paper explores Latinx adolescents’ perceptions of power dynamics with authority around them. We seek to inform how community-based professionals engage with and seek to understand members of this population. We conducted a critical discourse analysis of data collected during a community action photovoice project with 13 Latinx adolescents living in a metropolitan region of the southeastern United States. Participants felt they were under greater surveillance scrutiny by authority figures in social and academic spaces than their non-Latino peers. They discussed ways their movements were at times constrained because others presumed they were deviant, and how that affected their identity development. Judgments and assumptions held by both powerful adults and oppressed groups alike serve to reinscribe social stratification that places Latinx adolescents at a power disadvantage relative to their white peers. These experiences and understandings of power relations shape the circuitous racial dispossession of youth.

Authors: Merino, Yesenia Y; Thomas, Tainayah T; Lightfoot, Alexandra A; Eng, Eugenia E; Simán, Florence F; Thatcher, Kari K; Chapman, Mimi M

Journal of community psychology. 2019 Nov 09;():. Epub 2019-11-09.

PubMed abstract

Comorbid Diabetes and Severe Mental Illness: Outcomes in an Integrated Health Care Delivery System

Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood. To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI. Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring. Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21-1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87-0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02-1.05, p < .001; aRR 1.02; 95% CI 1.00-1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02-1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71-0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control. Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control.

Authors: Mangurian C; Schillinger D; Newcomer JW; Vittinghoff E; Essock S; Zhu Z; Dyer W; Young-Wolff KC; Schmittdiel J

J Gen Intern Med. 2019 Nov 08.

PubMed abstract

What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection.

OBJECTIVE: We sought to investigate the concept and practices of ‘clinician presence’, exploring how physicians and professionals create connection, engage in interpersonal interaction, and build trust with individuals across different circumstances and contexts. n DESIGN: In 2017-2018, we conducted qualitative semistructured interviews with 10 physicians and 30 non-medical professionals from the fields of protective services, business, management, education, art/design/entertainment, social services, and legal/personal services. n SETTING: Physicians were recruited from primary care clinics in an academic medical centre, a Veterans Affairs clinic, and a federally qualified health centre. n PARTICIPANTS: Participants were 55% men and 45% women; 40% were non-white. n RESULTS: Qualitative analyses yielded a definition of presence as n CONCLUSIONS: Clinician presence involves learning to step back, pause, and be prepared to receive a patient’s story. Building on strategies from physicians and non-medical professionals, clinician presence is best enacted through purposeful intention to connect, conscious navigation of time, and proactive management of technology and the environment to focus attention on the patient. Everyday practice or ritual supporting these strategies could support physician self-care as well as physician-patient connection.

Authors: Brown-Johnson, Cati;Schwartz, Rachel;Maitra, Amrapali;Haverfield, Marie C;Tierney, Aaron;Shaw, Jonathan G;Zionts, Dani L;Safaeinili, Nadia;Thadaney Israni, Sonoo;Verghese, Abraham;Zulman, Donna M

BMJ Open. 2019 Nov 03;9(11):e030831. doi: 10.1136/bmjopen-2019-030831..

PubMed abstract

Detection of early stage ovarian cancer in a large community cohort

Although detecting ovarian cancer at early stage is a highly meaningful clinical goal, no studies have evaluated early stage disease presentation in a large community-based population and how it differs from that of late stage disease. Electronic medical records were evaluated for women diagnosed with ovarian or fallopian tube cancer in 2016 and 2017 to identify the first imaging study to detect disease. Women being followed prior to diagnosis for known genetic risk from BRCA or other mutation were excluded. The visit in which the imaging test was ordered and related encounters were reviewed to determine the indication for imaging. Patient characteristics, presenting symptoms and duration, and modality of first abnormal imaging were compared for early vs late stage ovarian cancer and by provider specialty. Of 540 women with ovarian cancer, 190 (35%) were diagnosed with early stage disease, of whom 141 (74%) were symptomatic, with 45% of women presenting to internists, 33% to gynecologists, and 20% to emergency medicine physicians. Pelvic ultrasonography detected only 23% of late stage cases whereas pelvic ultrasonography and abdominal pelvic computed tomography (CT) each detected 47% of early stage cases. While abdominal pain and bloating were common to both women with early and late stage cancer, women with early stage disease were younger (58 vs 64 years, P < .0001), more likely to present to gynecologists (33% vs 15%, P < .001) and complained more often of a palpable mass (17% vs 6%, P < .0001) or postmenopausal bleeding (11% vs 5%, P < .001). Excluding women with genetic predisposition to ovarian cancer known prior to diagnosis, approximately three out of four cases of early stage ovarian cancer are detected as the result of evaluation of symptoms and one in four cases are detected incidentally. Abdominal pelvic CT and pelvic ultrasonography each detect an equal proportion of early stage cases. In contrast to late stage presentation, women diagnosed with early stage disease present more often with complaints of a palpable mass or postmenopausal bleeding, particularly to gynecologists.

Authors: Suh-Burgmann EJ; Alavi M

Cancer Med. 2019 11;8(16):7133-7140. Epub 2019-09-30.

PubMed abstract

Proton Pump Inhibitors, H2 Blocker Use, and Risk of Inflammatory Bowel Disease in Children

Evidence suggests use of proton pump inhibitors (PPIs) and H2 blockers may provoke disease flares in individuals with established inflammatory bowel disease (IBD); however, there are no studies investigating the relationship of these medications with risk of developing pediatric IBD. The hypothesis was that use of acid suppression therapy in children might be associated with development of pediatric IBD. This was a nested case-control study of 285 Kaiser Permanente Northern California members, age ≤21 years diagnosed with IBD from 1996 to 2016. Four controls without IBD were matched to each case on age, race, and membership status at the case’s index date. Disease risk scores (DRS) were computed for each subject. Odds ratios and 95% confidence intervals were calculated by using conditional logistic regression models adjusted for DRS. The children’s mean age was 15.1 ± 2.6 years and 49.5% were female. Six cases (n = 3 Crohn’s disease [CD], n = 3 ulcerative colitis [UC]) and 6 controls were prescribed PPIs and 10 cases (n = 7 CD, n = 3 UC) and 28 controls were prescribed H2 blockers. The OR for the association of at least 1 PPI or H2 blocker prescription with subsequent IBD was 3.6 (95% CI, 1.1-11.7) for PPIs and 1.6 (95% CI, 0.7-3.7) for H2 blockers. Early-life PPI use appears to be associated with subsequent IBD risk. These findings have implications for clinical treatment of children with gastrointestinal symptoms and warrant further investigation in a larger cohort.

Authors: Schwartz NRM; Hutfless S; Herrinton LJ; Amsden LB; Fevrier HB; Giefer M; Lee D; Suskind DL; Delaney JAC; Phipps AI

J Pediatr Pharmacol Ther. 2019 Nov-Dec;24(6):489-496.

PubMed abstract

Secure Messaging with Physicians by Proxies for Patients with Diabetes: Findings from the ECLIPPSE Study

Little is known about patients who have caregiver proxies communicate with healthcare providers via portal secure messaging (SM). Since proxy portal use is often informal (e.g., sharing patient accounts), novel methods are needed to estimate the prevalence of proxy-authored SMs. (1) Develop an algorithm to identify proxy-authored SMs, (2) apply this algorithm to estimate predicted proxy SM (PPSM) prevalence among patients with diabetes, and (3) explore patient characteristics associated with having PPSMs. Retrospective cohort study. We examined 9856 patients from Diabetes Study of Northern California (DISTANCE) who sent ??1 English-language SM to their primary care physician between July 1, 2006, and Dec. 31, 2015. Using computational linguistics, we developed ProxyID, an algorithm that identifies phrases frequently found in registered proxy SMs. ProxyID was validated against blinded expert categorization of proxy status among an SM sample, then applied to identify PPSM prevalence across patients. We examined patients’ sociodemographic and clinical characteristics according to PPSM penetrance, “none” (0%), “low” (??0-50%), and “high” (??50-100%). Only 2.3% of patients had ??1 registered proxy-authored SM. ProxyID demonstrated moderate agreement with expert classification (??=?0.58); 45.7% of patients had PPSMs (40.2% low and 5.5% high). Patients with high percent PPSMs were older than those with low percent and no PPSMs (66.5 vs 57.4 vs 56.2 years, p?

Authors: Semere W; Crossley S; Karter AJ; Lyles CR; Brown W; Reed M; McNamara DS; Liu JY; Schillinger D

J Gen Intern Med. 2019 11;34(11):2490-2496. Epub 2019-08-19.

PubMed abstract

Text message alerts to emergency physicians identifying potential study candidates increase clinical trial enrollment

Prospective enrollment of research subjects in the fast-paced emergency department (ED) is challenging. We sought to develop a software application to increase real-time clinical trial enrollment during an ED visit. The Prospective Intelligence System for Clinical Emergency Services (PISCES) scans the electronic health record during ED encounters for preselected clinical characteristics of potentially eligible study participants and notifies the treating physician via mobile phone text alerts. PISCES alerts began 3 months into a cluster randomized trial of an electronic health record-based risk stratification tool for pediatric abdominal pain in 11 Northern California EDs. We compared aggregate enrollment before (2577 eligible patients, October 2016 to December 2016) and after (12 049 eligible patients, January 2017 to January 2018) PISCES implementation. Enrollment increased from 10.8% to 21.1% following PISCES implementations (P?

Authors: Simon LE; Rauchwerger AS; Chettipally UK; Babakhanian L; Vinson DR; Warton EM; Reed ME; Kharbanda AB; Kharbanda EO; Ballard DW

J Am Med Inform Assoc. 2019 11 01;26(11):1360-1363.

PubMed abstract

Effect of d-cycloserine on fear extinction training in adults with social anxiety disorder.

Preclinical and clinical data have shown that D-cycloserine (DCS), a partial agonist at the N-methyl-d-aspartate receptor complex, augments the retention of fear extinction in animals and the therapeutic learning from exposure therapy in humans. However, studies with non-clinical human samples in de novo fear conditioning paradigms have demonstrated minimal to no benefit of DCS. The aim of this study was to evaluate the effects of DCS on the retention of extinction learning following de novo fear conditioning in a clinical sample. Eighty-one patients with social anxiety disorder were recruited and underwent a previously validated de novo fear conditioning and extinction paradigm over the course of three days. Of those, only 43 (53%) provided analyzable data. During conditioning on Day 1, participants viewed images of differently colored lamps, two of which were followed by with electric shock (CS+) and a third which was not (CS-). On Day 2, participants were randomly assigned to receive either 50 mg DCS or placebo, administered in a double-blind manner 1 hour prior to extinction training with a single CS+ in a distinct context. Day 3 consisted of tests of extinction recall and renewal. The primary outcome was skin conductance response to conditioned stimuli, and shock expectancy ratings were examined as a secondary outcome. Results showed greater skin conductance and expectancy ratings in response to the CS+ compared to CS- at the end of conditioning. As expected, this difference was no longer present at the end of extinction training, but returned at early recall and renewal phases on Day 3, showing evidence of return of fear. In contrast to hypotheses, DCS had no moderating influence on skin conductance response or expectancy of shock during recall or renewal phases. We did not find evidence of an effect of DCS on the retention of extinction learning in humans in this fear conditioning and extinction paradigm.

Authors: Hofmann SG; Papini S; Carpenter JK; Otto MW; Rosenfield D; Dutcher CD; Dowd S; Lewis M; Witcraft S; Pollack MH; Smits JAJ

PLoS One. 2019 Oct 17;14(10):e0223729. doi: 10.1371/journal.pone.0223729. eCollection 2019.

PubMed abstract

Assessing the clinical impact of CYP2C9 pharmacogenetic variation on phenytoin prescribing practice and patient response in an integrated health system

To assess the impact of CYP2C9 variation on phenytoin patient response and clinician prescribing practice where genotype was unknown during treatment. A retrospective analysis of Resource on Genetic Epidemiology Research on Adult Health and Aging cohort participants who filled a phenytoin prescription between 1996 and 2017. We used laboratory test results, medication dispensing records, and medical notes to identify associations of CYP2C9 genotype with phenytoin blood concentration, neurologic side effects, and medication dispensing patterns reflecting clinician prescribing practice and patient response. Among 993 participants, we identified 69% extensive, 20% high-intermediate, 10% low-intermediate, and 2% poor metabolizers based on CYP2C9 genotypes. Compared with extensive metabolizer genotype, low-intermediate/poor metabolizer genotype was associated with increased dose-adjusted phenytoin blood concentration [21.3 pg/mL, 95% confidence interval (CI): 13.6-29.0 pg/mL; P < 0.01] and increased risk of neurologic side effects (hazard ratio: 2.40, 95% CI: 1.24-4.64; P < 0.01). Decreased function CYP2C9 genotypes were associated with medication dispensing patterns indicating dose decrease, use of alternative anticonvulsants, and worse adherence, although these associations varied by treatment indication for phenytoin. CYP2C9 variation was associated with clinically meaningful differences in clinician prescribing practice and patient response, with potential implications for healthcare utilization and treatment efficacy.

Authors: Fohner AE; Ranatunga DK; Thai KK; Lawson BL; Risch N; Oni-Orisan A; Jelalian AT; Rettie AE; Liu VX; Schaefer CA

Pharmacogenet Genomics. 2019 10;29(8):192-199.

PubMed abstract

More Than We Bargained For: The “Dominating” Cost Effectiveness of Sepsis Quality Improvement?

Authors: Peltan ID; Liu VX

Crit Care Med. 2019 10;47(10):1464-1467.

PubMed abstract

Portal Use Among Patients With Chronic Conditions: Patient-reported Care Experiences

Personal health records offer patients access to view their own health information and to manage their care online through secure patient portal tools. Little is known about the patient-reported experience in using health portals to manage chronic conditions. In a patient-centered research study, we examined how using portal tools affects patient health care experiences among patients with chronic conditions. We also examined barriers among nonportal users. A cross-sectional patient survey. Patients with a chronic condition in an integrated delivery system offering a patient portal. Respondents reported barriers, preferences, and experiences in using the patient portal, and whether using the portal changed their overall health. Among all the 1824 respondents (70% response rate), portal nonusers reported preferring in-person health care (54%) or experiencing internet access barriers (41%). Portal users reported that using the portal was convenient (90%), the information available was useful (92%), and that it integrated well with other health care (92%). Among users, 31% reported that using the portal had improved their overall health. After adjustment, patients were significantly more likely to report that portal use improved their health if they had also reported convenience, information usefulness, or integration with other care (P<0.05). Reassuringly, patient-reported impacts on overall health did not vary by patient characteristics (including age, race, sex, education, income, complex conditions). Patients with chronic conditions using the portal reported convenience, information usefulness, and integration of the patient portal with their health care; these may act as potential pathways improving health.

Authors: Reed ME; Huang J; Millman A; Graetz I; Hsu J; Brand R; Ballard DW; Grant R

Med Care. 2019 10;57(10):809-814.

PubMed abstract

Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting

The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child’s probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS). We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC. We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS. The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.

Authors: Cotton DM; Vinson DR; Reed ME; Mark DG; Sax DR; Ballard DW; Clinical Research on Emergency Services and Treatments (CREST) Network; et al.

Ann Emerg Med. 2019 10;74(4):471-480. Epub 2019-06-19.

PubMed abstract

Understanding Non-Adherence with Hydroxychloroquine Therapy in Systemic Lupus Erythematosus

Hydroxychloroquine (HCQ) is a cornerstone to managing systemic lupus erythematosus (SLE), yet adherence to medication is poor. We sought to measure the association of adherence with 5 “dimensions of adherence” as articulated by the World Health Organization for chronic conditions: the patient’s socioeconomic status, and patient-, condition-, therapy-, and healthcare system-related factors. Our longterm goal is to generate evidence to design effective interventions to increase adherence. The retrospective cohort study included Kaiser Permanente Northern California patients ≥ 18 years old during 2006-2014, with SLE and ≥ 2 consecutive prescriptions for HCQ. Adherence was calculated from the medication possession ratio and dichotomized as < 80% versus ≥ 80%. Predictor variables were obtained from the electronic medical record and census data. We used multivariable logistic regression to estimate adjusted OR and 95% CI. The study included 1956 patients. Only 58% of patients had adherence ≥ 80%. In adjusted analyses, socioeconomic variables did not predict adherence. Increasing age (65-89 yrs compared with ≤ 39 yrs: OR 1.44, 95% CI 1.07-1.93), white race (p < 0.05), and the number of rheumatology visits in the year before baseline (≥ 3 compared with 0 or 1: OR 1.47, 95% CI 1.18-1.83) were positively associated with adherence. The rheumatologist and medical center providing care were not associated with adherence. At our setting, as in other settings, about half of patients with SLE were not adherent to HCQ therapy. Differences in adherence by race/ethnicity suggest the possibility of using tailored interventions to increase adherence. Qualitative research is needed to elucidate patient preferences for adherence support.

Authors: Liu LH; Fevrier HB; Goldfien R; Hemmerling A; Herrinton LJ

J Rheumatol. 2019 10;46(10):1309-1315. Epub 2019-02-01.

PubMed abstract

Effect of donor, component and recipient characteristics on hemoglobin increments following red blood cell transfusion

Significant research has focused individually on blood donors, product preparation and storage, and optimal transfusion practice. To better understand the interplay between these factors on measures of red blood cell (RBC) transfusion efficacy, we conducted a linked analysis of blood donor and component data with patients who received single-unit RBC transfusions between 2008 and 2016. Hemoglobin levels before and after RBC transfusions and at 24- and 48-hour intervals after transfusion were analyzed. Generalized estimating equation linear regression models were fit to examine hemoglobin increments after RBC transfusion adjusting for donor and recipient demographic characteristics, collection method, additive solution, gamma irradiation, and storage duration. We linked data on 23?194 transfusion recipients who received one or more single-unit RBC transfusions (n = 38?019 units) to donor demographic and component characteristics. Donor and recipient sex, Rh-D status, collection method, gamma irradiation, recipient age and body mass index, and pretransfusion hemoglobin levels were significant predictors of hemoglobin increments in univariate and multivariable analyses (P < .01). For hemoglobin increments 24 hours after transfusion, the coefficient of determination for the generalized estimating equation models was 0.25, with an estimated correlation between actual and predicted values of 0.5. Collectively, blood donor demographic characteristics, collection and processing methods, and recipient characteristics accounted for significant variation in hemoglobin increments related to RBC transfusion. Multivariable modeling allows the prediction of changes in hemoglobin using donor-, component-, and patient-level characteristics. Accounting for these factors will be critical for future analyses of donor and component factors, including genetic polymorphisms, on posttransfusion increments and other patient outcomes.

Authors: Roubinian NH; Plimier C; Woo JP; Lee C; Bruhn R; Liu VX; Escobar GJ; Kleinman SH; Triulzi DJ; Murphy EL; Busch MP

Blood. 2019 09 26;134(13):1003-1013. Epub 2019-07-26.

PubMed abstract

Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting.

This multidisciplinary consensus update aligns prior Society of Radiologists in Ultrasound (SRU) guidelines on simple adnexal cysts with recent large studies showing exceptionally low risk of cancer associated with simple adnexal cysts. Most small simple cysts do not require follow-up. For larger simple cysts or less well-characterized cysts, follow-up or second opinion US help to ensure that solid elements are not missed and are also useful for assessing growth of benign tumors. In postmenopausal women, reporting of simple cysts greater than 1 cm should be done to document their presence in the medical record, but such findings are common and follow-up is recommended only for simple cysts greater than 3-5 cm, with the higher 5-cm threshold reserved for simple cysts with excellent imaging characterization and documentation. For simple cysts in premenopausal women, these thresholds are 3 cm for reporting and greater than 5-7 cm for follow-up imaging. If a cyst is at least 10%-15% smaller at any time, then further follow-up is unnecessary. Stable simple cysts at initial follow-up may benefit from a follow-up at 2 years due to measurement variability that could mask growth. Simple cysts that grow are likely cystadenomas. If a previously suspected simple cyst demonstrates papillary projections or solid areas at follow-up, then the cyst should be described by using standardized terminology. These updated SRU consensus recommendations apply to asymptomatic patients and to those whose symptoms are not clearly attributable to the cyst. These recommendations can reassure physicians and patients regarding the benign nature of simple adnexal cysts after a diagnostic-quality US examination that allows for confident diagnosis of a simple cyst. Patients will benefit from less costly follow-up, less anxiety related to these simple cysts, and less surgery for benign lesions.

Authors: Levine D; Suh-Burgmann EJ; Brown DL; et al.

Radiology. 2019 Nov;293(2):359-371. doi: 10.1148/radiol.2019191354. Epub 2019 Sep 24.

PubMed abstract

Neonatal Sepsis Evaluation: Facing the Certainty of Uncertainty

Authors: Puopolo KM; Escobar GJ

JAMA Pediatr. 2019 Sep 03.

PubMed abstract

Enhanced Recovery After Surgery to Change Process Measures and Reduce Opioid Use After Cesarean Delivery: A Quality Improvement Initiative

To evaluate implementation of an enhanced recovery after surgery (ERAS) program for patients undergoing elective cesarean delivery by comparing opioid exposure, multimodal analgesia use, and other process and outcome measures before and after implementation. An ERAS program was implemented among patients undergoing elective cesarean delivery in a large integrated health care delivery system. We conducted a pre-post study of ERAS implementation to compare changes in process and outcome measures during the 12 months before and 12 months after implementation. The study included 4,689 patients who underwent an elective cesarean delivery in the 12 months before (pilot sites: March 1, 2015-February 29, 2016, all other sites: October 1, 2015-September 30, 2016), and 4,624 patients in the 12 months after (pilot sites: April 1, 2016-March 31, 2017, all other sites: November 1, 2016-October 31, 2017) ERAS program implementation. After ERAS implementation mean inpatient opioid exposure (average daily morphine equivalents) decreased from 10.7 equivalents (95% CI 10.2-11.3) to 5.4 equivalents (95% CI 4.8-5.9) controlling for age, race-ethnicity, prepregnancy body mass index, patient reported pain score, and medical center. The use of multimodal analgesia (ie, acetaminophen and neuraxial anesthesia) increased from 9.7% to 88.8%, the adjusted risk ratio (RR) for meeting multimodal analgesic goals was 9.13 (RR comparing post-ERAS with pre-ERAS; 95% CI 8.35-10.0) and the proportion of time patients reported acceptable pain scores increased from 82.1% to 86.4% (P<.001). Outpatient opioids dispensed at hospital discharge decreased from 85.9% to 82.2% post-ERAS (P<.001) and the average number of dispensed pills decreased from 38 to 26 (P<.001). The hours to first postsurgical ambulation decreased by 2.7 hours (95% CI -3.1 to -2.4) and the hours to first postsurgical solid intake decreased by 11.1 hours (95% CI -11.5 to -10.7). There were no significant changes in hospital length of stay, surgical site infections, hospital readmissions, or breastfeeding rates. Implementation of an ERAS program in patients undergoing elective cesarean delivery was associated with a reduction in opioid inpatient and outpatient exposure and with changes in surgical process measures of care without worsened surgical outcomes.

Authors: Hedderson M; Campbell C; Quesenberry C; Liu V; et al.

Obstet Gynecol. 2019 09;134(3):511-519.

PubMed abstract

Considerations for Identifying Social Needs in Health Care Systems: A Commentary on the Role of Predictive Models in Supporting a Comprehensive Social Needs Strategy

Authors: Nau C; Adams JL; Roblin D; Schmittdiel J; Schroeder E; Steiner JF

Med Care. 2019 09;57(9):661-666.

PubMed abstract

Do no harm: a roadmap for responsible machine learning for health care

Interest in machine-learning applications within medicine has been growing, but few studies have progressed to deployment in patient care. We present a framework, context and ultimately guidelines for accelerating the translation of machine-learning-based interventions in health care. To be successful, translation will require a team of engaged stakeholders and a systematic process from beginning (problem formulation) to end (widespread deployment).

Authors: Wiens J; Liu VX; Goldenberg A; et al.

Nat Med. 2019 09;25(9):1337-1340. Epub 2019-08-19.

PubMed abstract

Identifying Common Predictors of Multiple Adverse Outcomes Among Elderly Adults With Type-2 Diabetes

As part of a multidisciplinary team managing patients with type-2 diabetes, pharmacists need a consistent approach of identifying and prioritizing patients at highest risk of adverse outcomes. Our objective was to identify which predictors of adverse outcomes among type-2 diabetes patients were significant and common across 7 outcomes and whether these predictors improved the performance of risk prediction models. Identifying such predictors would allow pharmacists and other health care providers to prioritize their patient panels. Our study population included 120,256 adults aged 65 years or older with type-2 diabetes from a large integrated health system. Through an observational retrospective cohort study design, we assessed which risk factors were associated with 7 adverse outcomes (hypoglycemia, hip fractures, syncope, emergency department visit or hospital admission, death, and 2 combined outcomes). We split (50:50) our study cohort into a test and training set. We used logistic regression to model outcomes in the test set and performed k-fold validation (k=5) of the combined outcome (without death) within the validation set. The most significant predictors across the 7 outcomes were: age, number of medicines, prior history of outcome within the past 2 years, chronic kidney disease, depression, and retinopathy. Experiencing an adverse outcome within the prior 2 years was the strongest predictor of future adverse outcomes (odds ratio range: 4.15-7.42). The best performing models across all outcomes included: prior history of outcome, physiological characteristics, comorbidities and pharmacy-specific factors (c-statistic range: 0.71-0.80). Pharmacists and other health care providers can use models with prior history of adverse event, number of medicines, chronic kidney disease, depression and retinopathy to prioritize interventions for elderly patients with type-2 diabetes.

Authors: Kabue S; Liu V; Dyer W; Raebel M; Nichols G; Schmittdiel J

Med Care. 2019 09;57(9):702-709.

PubMed abstract

Association of Anxiety With High-Cost Health Care Use Among Individuals With Type 2 Diabetes

People with type 2 diabetes vary greatly in their use of high-cost health care resources. We examined the association of anxiety with high-cost use after accounting for depression and medical comorbidity. Using electronic health record data, we assessed past anxiety diagnosis, health care use and costs, demographics, comorbidities, and diabetes control status and complications during 2008-2012 for 143,573 adult members of an integrated health care system with type 2 diabetes. Multivariable regression models estimated associations between anxiety and emergency department (ED) use, total hospitalization costs, and high-cost status (i.e., incurring total health care costs in the top 20% among all system members). During 2008-2011, 12.9% of participants received a diagnosis of anxiety, of whom 52.9% also had received a depression diagnosis. After adjustment for covariates including depression, anxiety was positively related to the number of ED visits in 2012 (incidence rate ratio 1.27; 95% CI 1.21, 1.34), the likelihood of visiting the ED on a chronic, frequent basis during 2010-2012 (odds ratio 2.55; 95% CI 1.90, 3.44), and high-cost status in 2012 (odds ratio 1.29; 95% CI 1.23, 1.36), but anxiety was not related to total hospitalization costs in 2012 (relative cost ratio 1.06; 95% CI 0.94, 1.21; P = 0.33). Anxiety is highly comorbid with depression among individuals with type 2 diabetes and is independently associated with high-cost resource use. Strategies to improve anxiety management among people with diabetes hold the potential to also reduce health care costs.

Authors: Iturralde E; Chi FW; Grant RW; Weisner C; Van Dyke L; Pruzansky A; Bui S; Madvig P; Pearl R; Sterling SA

Diabetes Care. 2019 09;42(9):1669-1674. Epub 2019-06-18.

PubMed abstract

To catch a killer: electronic sepsis alert tools reaching a fever pitch?

Authors: Ruppel H; Liu V

BMJ Qual Saf. 2019 09;28(9):693-696. Epub 2019-04-23.

PubMed abstract

Patient-Provider Video Telemedicine Integrated With Clinical Care: Patient Experiences

Authors: Reed ME; Huang J; Parikh R; Millman A; Ballard DW; Barr I; Wargon C

Ann Intern Med. 2019 08 06;171(3):222-224. Epub 2019-04-30.

PubMed abstract

Preventing Diabetes in High-Risk Patients: Time for a System-Level Approach to Disease Prevention

Authors: Schmittdiel JA; Adams AS; Dlott R

J Gen Intern Med. 2019 08;34(8):1367-1368.

PubMed abstract

A Seat at the Table: Strategic Engagement in Service Activities for Early Career Faculty From Underrepresented Groups in the Academy

Many academic institutions strive to promote more diverse and inclusive campuses for faculty, staff, and students. As part of this effort, these institutions seek to include individuals from historically underrepresented groups (URGs)-such as women, people from racial/ethnic minority populations, persons with disabilities-on committees and in other service activities. However, given the low number of faculty members from URGs at many institutions, these faculty members tend to receive more requests to provide service to the institution or department (e.g., serving on committees, mentoring) than their counterparts from majority groups. Faculty members from URGs, especially early-career faculty, thus risk becoming overburdened with providing service at the expense of working on other scholarly activities required for promotion and tenure (i.e., conducting research, publishing). Although many scholars and others have written about this “minority tax” and its implications for early-career faculty from underrepresented racial/ethnic minority groups, fewer have published about how this tax extends beyond racial/ethnic minorities to women and persons with disabilities. Further, the literature provides scant practical advice on how to avoid overburdening early-career faculty from URGs. Here, a group of multidisciplinary early- and mid-career faculty members from URGs seek to provide their peers from URGs with practical strategies for both evaluating the appropriateness of service requests and declining those that are not a good fit. The authors also provide institutional leaders with actionable recommendations to prevent early-career faculty from URGs from becoming overburdened with service.

Authors: Carson TL; Aguilera A; Brown SD; Peña J; Butler A; Dulin A; Jonassaint CR; Riley I; Vanderbom K; Molina KM; Cené CW

Acad Med. 2019 08;94(8):1089-1093.

PubMed abstract

High-Need Patients’ Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program.

BACKGROUND: Healthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients’ personal goals and factors associated with goal progress. n OBJECTIVE: To describe high-need patients’ goals, and to identify factors associated with their goal progress DESIGN: Retrospective cohort study PARTICIPANTS: A total of 113 high-need patients participated in a single-site Veterans Affairs intensive outpatient care program. n MAIN MEASURES: Two independent reviewers examined patients’ goals recorded in the electronic health record, categorized each goal into one of three domains (medical, behavioral, or social), and determined whether patients attained goal progress during program participation. Logistic regression was used to determine factors associated with goal progress. n RESULTS: The majority (n = 72, 64%) of the 113 patients attained goal progress. Among the 100 (88%) patients with at least one identified goal, 58 set goal(s) in the medical domain; 60 in the behavioral domain; and 52 in the social domain. Within each respective domain, 41 (71%) attained medical goal progress; 34 (57%) attained behavioral goal progress; and 32 (62%) attained social goal progress. Patients with mental health condition(s) (aOR 0.3; 95% CI 0.1-0.9; p = 0.03) and those living alone (aOR 0.4; 95% CI 0.1-1.0; p = 0.05) were less likely to attain goal progress. Those with mental health condition(s) and those who were living alone were least likely to attain goal progress (interaction aOR 0.1 compared to those with neither characteristic; 95% CI 0.0-0.7; p = 0.02). n CONCLUSIONS: Among high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.

Authors: Hsu, Kristie Y;Slightam, Cindie;Shaw, Jonathan G;Tierney, Aaron;Hummel, Debra L;Goldstein, Mary K;Chang, Evelyn T;Boothroyd, Derek;Zulman, Donna M

J Gen Intern Med. 2019 Aug;34(8):1564-1570. doi: 10.1007/s11606-019-05010-w. Epub 2019 May 28.

PubMed abstract

Targeted learning with daily EHR data

Electronic health records (EHR) data provide a cost- and time-effective opportunity to conduct cohort studies of the effects of multiple time-point interventions in the diverse patient population found in real-world clinical settings. Because the computational cost of analyzing EHR data at daily (or more granular) scale can be quite high, a pragmatic approach has been to partition the follow-up into coarser intervals of pre-specified length (eg, quarterly or monthly intervals). The feasibility and practical impact of analyzing EHR data at a granular scale has not been previously evaluated. We start filling these gaps by leveraging large-scale EHR data from a diabetes study to develop a scalable targeted learning approach that allows analyses with small intervals. We then study the practical effects of selecting different coarsening intervals on inferences by reanalyzing data from the same large-scale pool of patients. Specifically, we map daily EHR data into four analytic datasets using 90-, 30-, 15-, and 5-day intervals. We apply a semiparametric and doubly robust estimation approach, the longitudinal Targeted Minimum Loss-Based Estimation (TMLE), to estimate the causal effects of four dynamic treatment rules with each dataset, and compare the resulting inferences. To overcome the computational challenges presented by the size of these data, we propose a novel TMLE implementation, the “long-format TMLE,” and rely on the latest advances in scalable data-adaptive machine-learning software, xgboost and h2o, for estimation of the TMLE nuisance parameters.

Authors: Sofrygin O; Zhu Z; Schmittdiel JA; Adams AS; Grant RW; van der Laan MJ; Neugebauer R

Stat Med. 2019 07 20;38(16):3073-3090. Epub 2019-04-25.

PubMed abstract

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

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. Using data from a recent clinical trial (Aligning Patients and Providers, NCT02707146), we examined the association between patient-defined visit priorities and subsequent provider actions taken during and after the visit. We tested the hypothesis that psychosocial concerns (eg, stress, anxiety, caregiving demands) are less likely to be addressed than traditional medical concerns. We analyzed 147 patient-defined visit priorities submitted just before the visit by 109 patients (mean age, 59.0 ± 12.7 years; including 73.4% women, 47.7% non-White race/ethnicity). Nearly one quarter of patient-defined visit priorities were related to psychosocial concerns (35/147; 23.8%). In models adjusting for age, gender, race/ethnicity, and familiarity with PCP, patients’ psychosocial priorities were significantly less likely than medical priorities to be addressed during the visit (63% vs. 88%; adjusted odds ratio [aOR], 0.16; 95% CI, 0.06 to 0.41; P < .001), to receive clinical action (51% vs. 82%; aOR, 0.15; 95% CI, 0.06 to 0.38; P < .001), or to receive post visit information from the primary care doctor (17% vs. 32%; aOR, 0.39; 95% CI, 0.14 to 1.08; P = .07). Patient-defined psychosocial priorities are less likely to be addressed during (or immediately after) primary care visits compared with patient-defined medical priorities.

Authors: Santo EC; Vo MT; Uratsu CS; Grant RW

J Am Board Fam Med. 2019 Jul-Aug;32(4):513-520.

PubMed abstract

Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields.

BACKGROUND: While barriers to physician wellness have been well detailed, concrete solutions are lacking. n OBJECTIVE: We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness. n DESIGN: We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals. n PARTICIPANTS: Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor). n APPROACH: Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach. n KEY RESULTS: Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment. n LIMITATIONS: In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings. n CONCLUSION: Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.

Authors: Schwartz, Rachel;Haverfield, Marie C;Brown-Johnson, Cati;Maitra, Amrapali;Tierney, Aaron;Bharadwaj, Shreyas;Shaw, Jonathan G;Azimpour, Farzad;Thadaney Israni, Sonoo;Verghese, Abraham;Zulman, Donna M

J Gen Intern Med. 2019 Jul;34(7):1251-1257. doi: 10.1007/s11606-019-04913-y. Epub 2019 Apr 29.

PubMed abstract

Opportunities to encourage mail order pharmacy delivery service use for diabetes prescriptions: a qualitative study

Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional “brick and mortar” pharmacies to refill prescriptions. We conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. A total of 28 diabetes patients participated. Participants’ average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of ‘Opportunity.’ Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions. This study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.

Authors: Schmittdiel JA; Marshall CJ; Wiley D; Chau CV; Trinacty CM; Wharam JF; Duru OK; Karter AJ; Brown SD

BMC Health Serv Res. 2019 Jun 25;19(1):422. Epub 2019-06-25.

PubMed abstract

Lack of Standardized Terminology in Ultrasound Reports for Ovarian Cysts

Authors: Suh-Burgmann E; Herrinton L

JAMA Intern Med. 2019 06 01;179(6):847-848.

PubMed abstract

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

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. 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. 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. Eligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c)?>?=?8.0%, and were registered users of the KPNC online patient portal. Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care. Glycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences. During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n?=?457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p?=?0.048) and being given treatment choices to consider (81% vs 73%, p?=?0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56%?±?1.45%), with no significant differences between arms. A “light touch” email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation. NCT02375932.

Authors: Vo MT; Uratsu CS; Estacio KR; Altschuler A; Kim E; Alexeeff SE; Adams AS; Schmittdiel JA; Heisler M; Grant RW

J Gen Intern Med. 2019 06;34(6):831-838. Epub 2019-02-11.

PubMed abstract

Primary Care Physician Stress Driven by Social and Financial Needs of Complex Patients

Authors: Weiner JZ; McCloskey JK; Uratsu CS; Grant RW

J Gen Intern Med. 2019 06;34(6):818-819.

PubMed abstract

Use of financial incentives and text message feedback to increase healthy food purchases in a grocery store cash back program: a randomized controlled trial

The HealthyFood (HF) program offers members up to 25% cash back monthly on healthy food purchases. In this randomized controlled trial, we tested the efficacy of financial incentives combined with text messages in increasing healthy food purchases among HF members. Members receiving the lowest (10%) cash back level were randomized to one of six arms: Arm 1 (Usual Care): 10% cash back, no weekly text, standard monthly text; Arm 2: 10% cash back, generic weekly text, standard monthly text; Arm 3: 10% cash back, personalized weekly text, standard monthly text; Arm 4: 25% cash back, personalized weekly text, standard monthly text; Arm 5: 10 + 15%NET cash back, personalized weekly text, standard monthly text; and, Arm 6: 10 + 15%NET cash back, personalized weekly text, unbundled monthly text. In the 10 + 15%NET cash back, the cash back amount was the baseline 10% plus 15% of the net difference between healthy and unhealthy spending. The generic text included information on HF and healthy eating, while the personalized text had individualized feedback on purchases. The standard monthly text contained the cash back amount. The unbundled monthly text included the amount lost due to unhealthy purchases. The primary outcome was the average monthly percent healthy food spending. Secondary outcomes were the percent unhealthy food spending, and the percent healthy and unhealthy food items. Of the members contacted, 20 opted out, and 2841 met all inclusion criteria. There were no between-arm differences in the examined outcomes. The largest mean (standard deviation) difference in percent healthy spending was between Arm 1 (24.8% [11%]) and Arm 2 (26.8% [13%]), and the largest mean difference in percent unhealthy spending was also between Arm 1 (24.4% [20%]) and Arm 2 (21.7% [17%]), but no differences were statistically significant after correction for multiple comparisons. None of the tested financial incentive structures or text strategies differentially affected food purchasing. Notably, more than doubling the cash back amount and introducing a financial disincentive for unhealthy purchases did not affect purchasing. These findings speak to the difficulty of changing shopping habits and to the need for innovative strategies to shift complex health behaviors. NCT02486588 Increasing Engagement with a Healthy Food Benefit. The trial was prospectively registered on July 1, 2015.

Authors: Gopalan A; Shaw PA; Lim R; Paramanund J; Patel D; Zhu J; Volpp KG; Buttenheim AM

BMC Public Health. 2019 May 31;19(1):674. Epub 2019-05-31.

PubMed abstract

Medical Malpractice Involving Pulmonary/Critical Care Physicians.

BACKGROUND: Medical malpractice data can be leveraged to understand specialty-specific risk.METHODS: Malpractice claims were examined from the Comparative Benchmarking System (2007-2016), a national database containing > 30% of claims data in the United States. Claims were identified with either internal medicine or pulmonary/critical care (PCC) physicians as the primary provider involved in the harm. Claim characteristics were compared according to specialty and care setting (inpatient vs outpatient), and multiple regression analysis was performed to predict claim payment.RESULTS: Claims involving PCC physicians differed from those involving internal medicine physicians in terms of harm severity, allegation, final diagnosis, procedure involvement, payment rate, and contributing factors. The majority of claims involving PCC physicians resulted from inpatient care (63%), of which only 26% occurred delivering intensive care. Eighty-one percent were from harm events that resulted in death/permanent injury. The most common diagnosis was laceration during a procedure for inpatient claims (6%) and lung cancer for outpatient claims (28%). Thirty-one percent of claims overall involved procedures. Although only 26% were paid, the median indemnity per paid claim of $285,769 ranked PCC as the twelfth highest of 69 specialties. The two variables associated with indemnity payment were outpatient care (OR, 1.70; 95% CI, 1.01-2.86) and temporary harm (OR, 0.36; 95% CI, 0.15-0.87).CONCLUSIONS: Malpractice claims involving PCC physicians were distinct from claims involving internal medicine physicians. Although only one-quarter of claims was paid, the indemnity per claim was high among specialties. Specialty-specific prevention strategies must be developed to mitigate both patient harm and provider malpractice risk.

Authors: Myers, Laura C; Skillings, Jillian; Heard, Lisa; Metlay, Joshua P; Mort, Elizabeth

Chest. 2019 Nov 10;156(5):907-914. Epub 2019-05-15.

PubMed abstract

Association of Social and Behavioral Risk Factors With Earlier Onset of Adult Hypertension and Diabetes

The National Academy of Medicine has recommended incorporating information on social and behavioral factors associated with health, such as educational level and exercise, into electronic health records, but questions remain about the clinical value of doing so. To examine whether National Academy of Medicine-recommended social and behavioral risk factor domains are associated with earlier onset of hypertension and/or diabetes in a clinical population. This prospective cohort study used data collected from April 1, 2005, to December 31, 2016, from a population-based sample of 41 745 patients from 4 cycles of Kaiser Permanente Northern California’s Adult Member Health Survey, administered to members at 19 Kaiser Permanente Northern California medical center service populations. The study used Kaplan-Meier survival tables and Cox proportional hazards regression analysis to estimate the onset of hypertension and diabetes among patients with no indication of disease at baseline. Data analysis was performed from June 2, 2017, to March 26, 2019. Race/ethnicity, educational level, financial worry, partnership status, stress, intimate partner violence, concentrated neighborhood poverty, depressive symptoms, infrequent exercise, smoking, heavy alcohol consumption, and cumulative social and behavioral risk. Onset of hypertension and diabetes during the 3.5 years after survey administration. The study included 18 133 people without baseline hypertension (mean [SD] age, 48.1 [15.3] years; 10 997 [60.7%] female; and 11 503 [63.4%] white) and 35 788 people without baseline diabetes (mean [SD] age, 56.2 [16.9] years; 20 191 [56.4%] female; and 24 351 [68.0%] white). There was a dose-response association between the number of social and behavioral risk factors and likelihood of onset of each condition. Controlling for age, sex, race/ethnicity, body mass index, and survey year, hazard ratios (HRs) comparing those with 3 or more risk factors with those with 0 risk factor were 1.41 (95% CI, 1.17-1.71) for developing hypertension and 1.53 (95% CI, 1.29-1.82) for developing diabetes. When the same covariates were adjusted for, having less than a high school educational level (hazard ratio [HR], 1.84; 95% CI, 1.40-2.43), being widowed (HR, 1.38; 95% CI, 1.11-1.71), concentrated neighborhood poverty (HR, 1.26; 95% CI, 1.00-1.59), infrequent exercise (HR, 1.22; 95% CI, 1.08-1.38), and smoking (HR, 1.35; 95% CI, 1.10-1.67) were significantly associated with hypertension onset. Having less than a high school educational level (HR, 1.58; 95% CI, 1.26-1.97), financial worry (HR, 1.29; 95% CI, 1.13-1.46), being single or separated (HR, 1.24; 95% CI, 1.08-1.42), high stress (HR, 1.28; 95% CI, 1.09-1.51), intimate partner violence (HR, 1.68; 95% CI, 1.14-2.48), concentrated neighborhood poverty (HR, 1.31; 95% CI, 1.07-1.60), depressive symptoms (HR, 1.28; 95% CI, 1.10-1.50), and smoking (HR, 1.53; 95% CI, 1.27-1.86) were significantly associated with diabetes onset, although heavy alcohol consumption was associated with protection (HR, 0.75; 95% CI, 0.66-0.85) rather than risk. Independent of traditional risk factors, individual and cumulative social and behavioral risk factor exposures were associated with onset of hypertension and diabetes within 3.5 years in a clinical setting. The findings support the value of assessing social and behavioral risk factors to help identify high-risk patients and of providing targets for intervention.

Authors: Pantell MS; Prather AA; Downing JM; Gordon NP; Adler NE

JAMA Netw Open. 2019 05 03;2(5):e193933. Epub 2019-05-03.

PubMed abstract

Evidence supports prediabetes treatment

Authors: Neumiller JJ; Kalyani RR; Herman WH; Grant RW; Wysham CH; Inzucchi SE; Hirsch IB; Fonseca VA; Buse JB; Barrett EJ

Science. 2019 04 26;364(6438):341-342.

PubMed abstract

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

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. 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. We adapted the English-language Visit Planner mobile app for Spanish-speaking Latino patients. We applied culturally defined themes derived from prior published research and input by both skilled linguists and potential end users. Initial changes were iteratively reviewed and edited by a team of writers, health care educators, subject matter experts, patients, and providers. The trans-creation process resulted in the following key culturally mediated changes to the tool: replacing the “provider” actors with “patient” actors; changing the choice of “Stress at Home or Work” (represented by an icon of a house) to “Mi Familia” (translation: my family; icon is an outline of family members holding hands); replacing the English terms “anxiety” and “depression” with “Me siento desanimado”(translation: I am feeling down) to avoid mental health stigma; and using more concise text translation to ensure the wording fit the available on-screen space. The trans-creation process of cultural and linguistic adaptation led to several design changes that would not have been implemented if we had simply translated the words from English to Spanish.

Authors: Ruvalcaba D; Nagao Peck H; Lyles C; Uratsu CS; Escobar PR; Grant RW

JMIR Mhealth Uhealth. 2019 04 05;7(4):e12457. Epub 2019-04-05.

PubMed abstract

Digital Information Technology Use and Patient Preferences for Internet-Based Health Education Modalities: Cross-Sectional Survey Study of Middle-Aged and Older Adults With Chronic Health Conditions

Health information, patient education, and self-management (health information and advice, HIA) tools are increasingly being made available to adults with chronic health conditions through internet-based health and mobile health (mHealth) digital information technologies. However, there is limited information about patient preferences for using specific types of health information and advice resources and how preferences and usage differ by age group and education. The objective of this study was to examine how use of digital information technologies and preferred methods for obtaining health information and advice varies by age group and education among middle-aged and older adults with chronic health conditions. The study used cross-sectional survey data for 9005 Kaiser Permanente Northern California members aged 45 to 85 years who responded to a mailed and Web-based health survey conducted during 2014 and 2015 and indicated having at least 1 chronic health condition. Bivariate analyses and logistic regression models with weighted data were used to estimate and compare the prevalence of digital information technology use, past-year use of internet-based health information and advice resources, and preferences for using internet-based, mHealth, and traditional health information and advice modalities for adults aged 45 to 65 years, 66 to 75 years, and 76 to 85 years. The percentages of adults who used digital information technologies (computers, smartphones, internet, email, and apps), had obtained health information and advice from an internet-based resource in the past year, and who were interested in using internet-based and mHealth modalities for obtaining health information and advice declined with age. Within age group, prevalence of digital information technologies use and interest in internet-based and mHealth modalities was lower among adults with no college education versus college graduates. Differences in preferences for internet-based health information and advice modalities between the oldest and younger groups and those with lower versus higher education were substantially diminished when we restricted analyses to internet users. Health care providers and organizations serving middle-aged and older adults with chronic health conditions should not assume that patients, especially those who are older and less educated, want to engage with internet-based and mHealth resources. In addition, increasing the engagement of nonutilizers of digital devices and the internet with internet-based health information and advice and mHealth apps might require both instrumental (eg, providing digital information technology devices, internet, and skills training) and social support. As part of patient-centered care, it is important for providers to ascertain their patients’ use of digital information technologies and preferences for obtaining health information and patient education rather than routinely referring them to internet-based resources. It is also important for health care providers and consumer health organizations to user test their Web-based resources to make sure they are easy for older and less educated adults to use and to make sure that it remains easy for adults with chronic conditions to obtain health information and patient education using offline resources.

Authors: Gordon NP; Crouch E

JMIR Aging. 2019 Apr 04;2(1):e12243. Epub 2019-04-04.

PubMed abstract

Association between Inpatient Delirium and Hospital Readmission in Patients ≥ 65 Years of Age: A Retrospective Cohort Study

Delirium affects more than seven million hospitalized adults in the United States annually. However, its impact on postdischarge healthcare utilization remains unclear. To determine the association between delirium and 30-day hospital readmission. A retrospective cohort study. A general community medical and surgical hospital. All adults who were at least 65 years old, without a history of delirium or alcohol-related delirium, and were hospitalized from September 2010 to March 2015. The patients deemed at risk for or displaying symptoms of delirium were screened by nurses using the Confusion Assessment Method with a followup by a staff psychiatrist for a subset of screen-positive patients. Patients with delirium confirmed by a staff psychiatrist were compared with those without delirium. The primary outcome was the 30-day readmission rate. The secondary outcomes included emergency department (ED) visits 30 days postdischarge, mortality during hospitalization and 30 days postdischarge, and discharge location. The cohort included 718 delirious patients and 7,927 nondelirious patients. Using an unweighted multivariable logistic regression, delirium was determined to be significantly associated with the increased odds of readmission within 30 days of discharge (odds ratio (OR): 2.60; 95% CI, 1.96-3.44; P < .0001). Delirium was also significantly (P < .0001) associated with ED visits within 30 days postdischarge (OR: 2.18; 95% CI: 1.77-2.69) and discharge to a facility (OR: 2.52; 95% CI: 2.09-3.01). Delirium is a significant predictor of hospital readmission, ED visits, and discharge to a location other than home. Delirious patients should be targeted to reduce postdischarge healthcare utilization.

Authors: LaHue SC; Douglas VC; Kuo T; Conell CA; Liu VX; Josephson SA; Angel C; Brooks KB

J Hosp Med. 2019 04;14(4):201-206.

PubMed abstract

The Impact of Pharmacy-specific Predictors on the Performance of 30-Day Readmission Risk Prediction Models

Pharmacists are an expensive and limited resource in the hospital and outpatient setting. A pharmacist can spend up to 25% of their day planning. Time spent planning is time not spent delivering an intervention. A readmission risk adjustment model has potential to be used as a universal outcome-based prioritization tool to help pharmacists plan their interventions more efficiently. Pharmacy-specific predictors have not been used in the constructs of current readmission risk models. We assessed the impact of adding pharmacy-specific predictors on performance of readmission risk prediction models. We used an observational retrospective cohort study design to assess whether pharmacy-specific predictors such as an aggregate pharmacy score and drug classes would improve the prediction of 30-day readmission. A model of age, sex, length of stay, and admission category predictors was used as the reference model. We added predictor variables in sequential models to evaluate the incremental effect of additional predictors on the performance of the reference. We used logistic regression to regress the outcomes on predictors in our derivation dataset. We derived and internally validated our models through a 50:50 split validation of our dataset. Our study population (n=350,810) was of adult admissions at hospitals in a large integrated health care delivery system. Individually, the aggregate pharmacy score and drug classes caused a nearly identical but moderate increase in model performance over the reference. As a single predictor, the comorbidity burden score caused the greatest increase in model performance when added to the reference. Adding the severity of illness score, comorbidity burden score and the aggregate pharmacy score to the reference caused a cumulative increase in model performance with good discrimination (c statistic, 0.712; Nagelkerke R, 0.112). The best performing model included all predictors: severity of illness score, comorbidity burden score, aggregate pharmacy score, diagnosis groupings, and drug subgroups. Adding the aggregate pharmacy score to the reference model significantly increased the c statistic but was out-performed by the comorbidity burden score model in predicting readmission. The need for a universal prioritization tool for pharmacists may therefore be potentially met with the comorbidity burden score model. However, the aggregate pharmacy score and drug class models still out-performed current Medicare readmission risk adjustment models. Pharmacists have a great role in preventing readmission, and therefore can potentially use one of our models: comorbidity burden score model, aggregate pharmacy score model, drug class model or complex model (a combination of all 5 major predictors) to prioritize their interventions while exceeding Medicare performance measures on readmission. The choice of model to use should be based on the availability of these predictors in the health care system.

Authors: Kabue S; Greene J; Kipnis P; Lawson B; Rinetti-Vargas G; Liu V; Escobar G

Med Care. 2019 04;57(4):295-299.

PubMed abstract

Visual outcomes after cataract surgery in patients with type 2 diabetes

To assess the relation between diabetic retinopathy (DR) severity, duration of diabetes, insulin dependence, and preoperative hemoglobin A1c (HbA1c) with visual outcome after phacoemulsification for cataract in patients with type 2 diabetes. Kaiser Permanente Northern California, USA. Retrospective case series. Information was obtained from the electronic medical record for patients, June 1, 2010, through May 31, 2015. Confounding factors and clustering of eyes within patients were controlled for using linear mixed-effects regression models for continuous outcomes and general estimating equations for dichotomous outcomes. The study included 65 370 patients; 28% had type 2 diabetes without DR, 5% nonproliferative DR, and 1.2% proliferative DR. Patients with diabetes and no DR were as likely as those without diabetes to achieve a corrected distance visual acuity (CDVA) of 20/20 (odds ratio, 1.01; 95% confidence interval, 0.94-1.10). The odds of a postoperative CDVA of 20/25 or worse increased with the severity of retinopathy duration of diabetes and insulin dependence, but not with the preoperative HbA1c. Although the odds of a postoperative CDVA of 20/20 was lower in patients with DR, every DR group averaged 4 lines of CDVA improvement, the same as patients without diabetes. A longer duration of diabetes, insulin dependence, and elevated HbA1c were not associated with worse postoperative outcomes. Patients with DR and cataracts were less likely to achieve a CDVA of 20/20 vision but gained as many lines of CDVA from phacoemulsification as patients without diabetes, showing no evidence that cataract surgery should be delayed in diabetic patients with elevated HbA1c.

Authors: Liu L; Herrinton LJ; Alexeeff S; Karter AJ; Amsden LB; Carolan J; Shorstein NH

J Cataract Refract Surg. 2019 04;45(4):404-413. Epub 2019-01-09.

PubMed abstract

Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience

Widespread adoption of electronic health records (EHRs) in medical care has resulted in increased physician documentation workload and decreased interaction with patients. Despite the increasing use of medical scribes for EHR documentation assistance, few methodologically rigorous studies have examined the use of medical scribes in primary care. To evaluate the association of use of medical scribes with primary care physician (PCP) workflow and patient experience. This 12-month crossover study with 2 sequences and 4 periods was conducted from July 1, 2016, to June 30, 2017, in 2 medical center facilities within an integrated health care system and included 18 of 24 eligible PCPs. The PCPs were randomly assigned to start the first 3-month period with or without scribes and then alternated exposure status every 3 months for 1 year, thereby serving as their own controls. The PCPs completed a 6-question survey at the end of each study period. Patients of participating PCPs were surveyed after scribed clinic visits. PCP-reported perceptions of documentation burden and visit interactions, objective measures of time spent on EHR activity and required for closing encounters, and patient-reported perceptions of visit quality. Of the 18 participating PCPs, 10 were women, 12 were internal medicine physicians, and 6 were family practice physicians. The PCPs graduated from medical school a mean (SD) of 13.7 (6.5) years before the study start date. Compared with nonscribed periods, scribed periods were associated with less self-reported after-hours EHR documentation (<1 hour daily during week: adjusted odds ratio [aOR], 18.0 [95% CI, 4.7-69.0]; <1 hour daily during weekend: aOR, 8.7; 95% CI, 2.7-28.7). Scribed periods were also associated with higher likelihood of PCP-reported spending more than 75% of the visit interacting with the patient (aOR, 295.0; 95% CI, 19.7 to >900) and less than 25% of the visit on a computer (aOR, 31.5; 95% CI, 7.3-136.4). Encounter documentation was more likely to be completed by the end of the next business day during scribed periods (aOR, 2.8; 95% CI, 1.2-7.1). A total of 450 of 735 patients (61.2%) reported that scribes had a positive bearing on their visits; only 2.4% reported a negative bearing. Medical scribes were associated with decreased physician EHR documentation burden, improved work efficiency, and improved visit interactions. Our results support the use of medical scribes as one strategy for improving physician workflow and visit quality in primary care.

Authors: Mishra P; Kiang JC; Grant RW

JAMA Intern Med. 2018 11 01;178(11):1467-1472.

PubMed abstract

Building Toward a Population-Based Approach to Diabetes Screening and Prevention for US Adults

Evidence-based treatments for prediabetes can prevent and delay the development of type 2 diabetes in adults. In this review, we propose a framework for population-based diabetes prevention that links screening and prevention activities across key stakeholders. We also discuss gaps in current practice, while highlighting opportunities to improve diabetes screening and prevention efforts population-wide. Awareness of diabetes risk is low, and many adults with prediabetes are not identified through existing screening efforts. Accumulating evidence and policies support expansion of the Diabetes Prevention Program (DPP) into clinical and community settings. However, the infrastructure to facilitate referrals and promote data exchange among patients, clinical settings, and community-based DPP programs is lacking. Development of evidence-driven, scalable processes for assessing diabetes risk, screening eligible adults, and delivering preventive treatments are needed to effectively improve the glycemic health of the US adult population.

Authors: Bowen ME; Schmittdiel JA; Kullgren JT; Ackermann RT; O'Brien MJ

Curr Diab Rep. 2018 09 19;18(11):104. Epub 2018-09-19.

PubMed abstract

Prevalence and Factors Influencing Use of Internet and Electronic Health Resources by Middle-Aged and Older Adults in a US Health Plan Population: Cross-Sectional Survey Study

Health care organizations are increasingly using electronic health (eHealth) platforms to provide and exchange health information and advice (HIA). There is limited information about how factors beyond internet access affect use of eHealth resources by middle-aged and older adults. We aimed to estimate prevalence of use of the internet, health plan patient portal, and Web-based HIA among middle-aged and older adults; investigate whether similar sociodemographic-related disparities in eHealth resource use are found among middle-aged and older adults; and examine how sociodemographic and internet access factors drive disparities in eHealth resource use among adults who use the internet. We analyzed cross-sectional survey data for 10,920 Northern California health plan members aged 45 to 85 years who responded to a mailed and Web-based health survey (2014-2015). We used bivariate and multivariable analyses with weighted data to estimate prevalence of and identify factors associated with internet use and self-reported past year use of the health plan’s patient portal and Web-based HIA resources by middle-aged adults (aged 45 to 65 years; n=5520), younger seniors (aged 65 to 75 years; n=3014), and older seniors (aged 76 to 85 years; n=2389). Although approximately 96% of middle-aged adults, 92% of younger seniors, and 76% of older seniors use the internet to obtain information, about 4%, 9%, and 16%, respectively, require someone’s help to do so. The percentages who used the patient portal and Web-based HIA resources were similar for middle-aged adults and younger seniors but lower among older seniors (59.6%, 61.4%, and 45.0% and 47.9%, 48.4%, and 37.5%, respectively). Disparities in use of the internet, patient portal, and Web-based HIA across levels of education and between low and higher income were observed in all age groups, with wider disparities between low and high levels of education and income among seniors. Multivariable analyses showed that for all 3 age groups, educational attainment, ability to use the internet without help, and having 1 or more chronic condition were significant predictors of patient portal and Web-based HIA use after controlling for gender, race/ethnicity, and internet use. Internet use, and especially use without help, significantly declines with age, even within a middle-aged group. Educational attainment is significantly associated with internet use, ability to use the internet without help, and use of patient portal and Web-based HIA resources by middle-aged and older adults. Even among middle-aged and older adult internet users, higher educational attainment and ability to use the internet without help are positively associated with patient portal and Web-based HIA use. Organizations serving middle-aged and older adults should take into account target population characteristics when developing and evaluating uptake of eHealth resources and should consider offering instruction and support services to boost patient engagement.

Authors: Crouch E; Gordon NP

JMIR Aging. 2019 Mar 26;2(1):e11451. Epub 2019-03-26.

PubMed abstract

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

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. 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. We tested this tool in a cluster-randomized controlled trial with usual care as the control. Eligible patients had at least 1 clinical care gap (eg, overdue for cancer screening, suboptimal chronic disease risk factor control, or medication nonadherence). The study (conducted March 31, 2016 through December 31, 2017) included 750 English- or Spanish-speaking patients. Compared with usual care patients, intervention patients more often reported “definitely” preparing questions for their doctor (59.5% vs 45.1%, P <.001) and "definitely" expressing their top concerns at the beginning of the visit (91.3% vs 83.3%, P = .005). Patients in both arms reported high levels of satisfaction with their care (86.8% vs 89.9%, P = .20). With 6 months of follow-up, prevalence of clinical care gaps was reduced by a similar amount in each study arm. A simple waiting room-based tool significantly improved visit communication. Patients using the Visit Planner were more prepared and more likely to begin the visit by communicating their top priorities. These changes did not, however, lead to further reduction in aggregate clinical care gaps beyond the improvements seen in the usual care arm.

Authors: Grant RW; Lyles C; Uratsu CS; Vo MT; Bayliss EA; Heisler M

Ann Fam Med. 2019 03;17(2):141-149.

PubMed abstract

Statistical Modeling and Aggregate-Weighted Scoring Systems in Prediction of Mortality and ICU Transfer: A Systematic Review

The clinical deterioration of patientsin general hospital wards is an important safety issue. Aggregate-weighted early warning systems (EWSs) may not detect risk until patients present with acute decline. We aimed to compare the prognostic test accuracy and clinical workloads generated by EWSs using statistical modeling (multivariable regression or machine learning) versus aggregate-weighted tools. We searched PubMed and CINAHL using terms that described clinical deterioration and use of an advanced EWS. The outcome was clinical deterioration (intensive care unit transfer or death) of adult patients on general hospital wards. We included studies published from January 1, 2012 to September 15, 2018. Following 2015 PRIMSA systematic review protocol guidelines; 2015 TRIPOD criteria for predictive model evaluation; and the Cochrane Collaboration guidelines, we reported model performance, adjusted positive predictive value (PPV), and conducted simulations of workup-to-detection ratios. Of 285 articles, six studies reported the model performance of advanced EWSs, and five were of high quality. All EWSs using statistical modeling identified at-risk patients with greater precision than aggregate-weighted EWSs (mean AUC 0.80 vs 0.73). EWSs using statistical modeling generated 4.9 alerts to find one true positive case versus 7.1 alerts in aggregate-weighted EWSs; a nearly 50% relative workload increase for aggregate-weighted EWSs. Compared with aggregate-weighted tools, EWSs using statistical modeling consistently demonstrated superior prognostic performance and generated less workload to identify and treat one true positive case. A standardized approach to reporting EWS model performance is needed, including outcome definitions, pretest probability, observed and adjusted PPV, and workup-to-detection ratio.

Authors: Linnen DT; Escobar GJ; Hu X; Scruth E; Liu V; Stephens C

J Hosp Med. 2019 Mar;14(3):161-169.

PubMed abstract

The Legacy Effect in Type 2 Diabetes: Impact of Early Glycemic Control on Future Complications (the Diabetes & Aging Study)

To examine for a legacy effect of early glycemic control on diabetic complications and death. This cohort study of managed care patients with newly diagnosed type 2 diabetes and 10 years of survival (1997-2013, average follow-up 13.0 years, N = 34,737) examined associations between HbA1c <6.5% (<48 mmol/mol), 6.5% to <7.0% (48 to <53 mmol/mol), 7.0% to <8.0% (53 to <64 mmol/mol), 8.0% to <9.0% (64 to <75 mmol/mol), or ≥9.0% (≥75 mmol/mol) for various periods of early exposure (0-1, 0-2, 0-3, 0-4, 0-5, 0-6, and 0-7 years) and incident future microvascular (end-stage renal disease, advanced eye disease, amputation) and macrovascular (stroke, heart disease/failure, vascular disease) events and death, adjusting for demographics, risk factors, comorbidities, and later HbA1c. Compared with HbA1c <6.5% (<48 mmol/mol) for the 0-to-1-year early exposure period, HbA1c levels ≥6.5% (≥48 mmol/mol) were associated with increased microvascular and macrovascular events (e.g., HbA1c 6.5% to <7.0% [48 to <53 mmol/mol] microvascular: hazard ratio 1.204 [95% CI 1.063-1.365]), and HbA1c levels ≥7.0% (≥53 mmol/mol) were associated with increased mortality (e.g., HbA1c 7.0% to <8.0% [53 to <64 mmol/mol]: 1.290 [1.104-1.507]). Longer periods of exposure to HbA1c levels ≥8.0% (≥64 mmol/mol) were associated with increasing microvascular event and mortality risk. Among patients with newly diagnosed diabetes and 10 years of survival, HbA1c levels ≥6.5% (≥48 mmol/mol) for the 1st year after diagnosis were associated with worse outcomes. Immediate, intensive treatment for newly diagnosed patients may be necessary to avoid irremediable long-term risk for diabetic complications and mortality.

Authors: Laiteerapong N; Ham SA; Gao Y; Moffet HH; Liu JY; Huang ES; Karter AJ

Diabetes Care. 2019 03;42(3):416-426. Epub 2018-08-13.

PubMed abstract

Long-term follow-up of pediatric open and laparoscopic inguinal hernia repair

Pediatric laparoscopic inguinal hernia repair is not widely accepted. Children 0-14 years who underwent inguinal hernia repair during 2010-2016 at Kaiser Permanente Northern California were classified into five groups: (1) open unilateral repair without contralateral exploration; (2) open unilateral repair with contralateral laparoscopic exploration ("open+explore"); (3) open bilateral repair; (4) laparoscopic unilateral repair; and (5) laparoscopic bilateral repair. Outcomes included ipsilateral reoperation, metachronous contralateral repair, incision time, and complications. The study included 1697 children. Follow-up averaged 3.6 years after open (N = 1156) and 2.6 years after laparoscopic (N = 541) surgery. Metachronous contralateral repair was performed in 3.8% (26/683) of patients with open unilateral surgery without contralateral exploration, 0.7% (2/275) of open+explore patients, and 0.9% (3/336) of laparoscopic unilateral patients (p 

Authors: Chong AJ; Fevrier HB; Herrinton LJ

J Pediatr Surg. 2019 Feb 27.

PubMed abstract

Revalidation of the Hypoglycemia Risk Stratification Tool Using ICD-10 Codes

Authors: Karter AJ; Warton EM; Moffet HH; Ralston JD; Huang ES; Miller DR; Lipska KJ

Diabetes Care. 2019 Feb 14.

PubMed abstract

Sexual Orientation Disparities in Physical Activity: Results From Insured Adults in California

The majority of adults in the United States fail to meet the Centers for Disease Control and Prevention (CDC) physical activity (PA) guideline recommendations for health promotion. Despite evidence of disparities by sexual orientation in adverse health outcomes related to PA, little is known about whether PA patterns and the likelihood of meeting these guidelines differ between heterosexual and sexual minority (SM) men and women. In 2018, we pooled unweighted respondent data from Kaiser Permanente Northern California Member Health Surveys conducted in 2008, 2011, and 2014/15 (N=42,534) to compare PA patterns among heterosexual and SM men and women. In total, 38.8% of heterosexual men, 43.4% of SM men, 32.9% of heterosexual women, and 40.0% of SM women meet the CDC PA guidelines, yet there was no statistically significant difference in the adjusted odds of meeting these guidelines. Compared with heterosexual women, SM women engage in PA more frequently [odds ratio=0.81; 95% confidence interval (CI), 0.74-0.89], for more minutes per week on average (12.71; 95% CI, 4.85-20.57), and at higher levels of intensity (relative risk ratio=1.26; 95% CI, 1.02-1.56). Compared with heterosexual men, SM men engage in PA more frequently (OR=0.85; 95% CI, 0.74-0.98), for fewer minutes per week on average (-12.89; 95% CI, -25.84 to 0.06), and at lower levels of intensity (relative risk ratio=0.83; 95% CI, 0.67-0.99). We find that SMs get more frequent PA than their heterosexual peers, which suggests that the higher prevalence of obesity and other PA-related adverse health outcomes among SMs may be due to factors other than PA patterns.

Authors: Fricke J; Gordon N; Downing J

Med Care. 2019 02;57(2):138-144.

PubMed abstract

Pill, patch, or ring? A mixed methods analysis of provider counseling about combined hormonal contraception

In this study we aimed to investigate the content and process of contraceptive counseling surrounding combined hormonal contraceptive (CHC) methods (combined oral contraceptives, the ring, and the patch). We performed a mixed methods analysis of data collected as part of the Patient-Provider Communication about Contraception study, in which reproductive age women and their providers were recruited at several San Francisco Bay Area clinics from 2009-2012. Participants completed pre- and post-visit surveys, and had their visits audio recorded and transcribed. We performed descriptive and bivariate analyses of the entire cohort to examine associations between demographic characteristics and pre-existing method preferences with method selection and counseling content, and coded transcripts of a subset of the sample for salient themes related to content and process of counseling about combined hormonal contraceptive methods using a directed content analysis approach. The overall sample included 342 women, with 152 women (44%) having a preference for a specific CHC prior to their visit, 127 women (37%) had a preference for a non-CHC method, and 63 (18%) having no existing method preference. Of the women who reported preferring a CHC in their pre-visit survey, the majority (72%) chose that method. We found that women were inconsistently counseled about the range of CHC methods. For example, women who had no pre-visit method preference (52%) or who preferred the ring (54%) or the patch (73%) were more likely to receive comprehensive counseling about the three CHC methods than were women who preferred combined oral contraceptives (35%) or non-CHC methods (33%). Providers mentioned the patch the least often, and in qualitative analysis indicated discomfort with prescribing this method. Side effects and benefits of methods, as well as strategies to enhance successful use of the chosen method, were inconsistently discussed. In only 73% of visits in which a woman chose a CHC did the provider assess the patient’s ability to use the chosen method correctly, and in 66% of all visits in which women chose a CHC method, providers discussed what to do if she was dissatisfied with the method. Counseling about combined hormonal contraceptive methods often does not include information about all available methods, or comprehensive information about side effects, benefits, or logistics of use. As this counseling can impact patient’s satisfaction with and continuation of their chosen method of contraception, future work should focus on designing interventions to improve providers’ ability to meet patients’ needs. Short acting hormonal contraception is widely used, but counseling for these methods often neglects key features. Comprehensive counseling about all methods and their individual features can improve contraceptive selection and use.

Authors: Craig AD; Steinauer J; Kuppermann M; Schmittdiel JA; Dehlendorf C

Contraception. 2019 02;99(2):104-110. Epub 2018-09-15.

PubMed abstract

Response to Comment on Laiteerapong et al. The Legacy Effect in Type 2 Diabetes: Impact of Early Glycemic Control on Future Complications (The Diabetes & Aging Study). Diabetes Care 2019;42:XXXX-XXXX

Authors: Laiteerapong N; Ham SA; Huang ES; Karter AJ

Diabetes Care. 2019 Jan 24.

PubMed abstract

Automated Early Detection of Obstetric Complications: Theoretical and Methodological Considerations

Compared to adults admitted to general medical-surgical wards, women admitted to labor and delivery services are at much lower risk of experiencing unexpected critical illness. Nonetheless, critical illness and other complications that put either the mother or fetus at risk do occur. One potential approach to prevention is to use automated early warning systems such as those used for non-pregnant adults. Predictive models using data extracted in real time from electronic records constitute the cornerstone of such systems. This article addresses several issues involved in the development of such predictive models: specification of temporal characteristics, choice of denominator, selection of outcomes for model calibration, potential uses of existing adult severity of illness scores, approaches to data processing, statistical considerations, validation, and options for instantiation. These have not been explicitly addressed in the obstetrics literature, which has focused on the use of manually assigned scores. In addition, this article provides some results from work in progress to develop two obstetric predictive models using data from 262,071 women admitted to a labor and delivery service at 15 Kaiser Permanente Northern California hospitals between 2010 and 2017.

Authors: Escobar GJ; Gupta NR; Walsh EM; Soltesz L; Terry SM; Kipnis P

Am J Obstet Gynecol. 2019 Jan 22.

PubMed abstract

Long-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia: A Retrospective Cohort Study

Randomized clinical trial findings support decreased red blood cell (RBC) transfusion and short-term tolerance of in-hospital anemia. However, long-term outcomes related to changes in transfusion practice have not been described. To describe the prevalence of anemia at and after hospital discharge and associated morbidity and mortality events. Retrospective cohort study. Integrated health care delivery system with 21 hospitals serving 4 million members. 445 371 surviving adults who had 801 261 hospitalizations between January 2010 and December 2014. Hemoglobin levels and RBC transfusion, rehospitalization, and mortality events within 6 months of hospital discharge. Generalized estimating equations were used to examine trends over time, accounting for correlated observations and patient-level covariates. From 2010 to 2014, the prevalence of moderate anemia (hemoglobin levels between 7 and 10 g/dL) at hospital discharge increased from 20% to 25% (P < 0.001) and RBC transfusion declined by 28% (39.8 to 28.5 RBC units per 1000 patients; P < 0.001). The proportion of patients whose moderate anemia had resolved within 6 months of hospital discharge decreased from 42% to 34% (P < 0.001), and RBC transfusion and rehospitalization within 6 months of hospital discharge decreased from 19% to 17% and 37% to 33%, respectively (P < 0.001 for both). During this period, the adjusted 6-month mortality rate decreased from 16.1% to 15.6% (P = 0.004) in patients with moderate anemia, in parallel with that of all others. Possible unmeasured confounding. Anemia after hospitalization increased in parallel with decreased RBC transfusion. This increase was not accompanied by a rise in subsequent RBC use, rehospitalization, or mortality within 6 months of hospital discharge. Longitudinal analyses support the safety of practice recommendations to limit RBC transfusion and tolerate anemia during and after hospitalization. National Heart, Lung, and Blood Institute.

Authors: Roubinian NH; Murphy EL; Mark DG; Triulzi DJ; Carson JL; Lee C; Kipnis P; Kleinman S; Liu VX; Escobar GJ

Ann Intern Med. 2019 01 01;170(1):80.

PubMed abstract

Patients with complex chronic conditions: Health care use and clinical events associated with access to a patient portal

For patients with diabetes, many with multiple complex chronic conditions, using a patient portal can support self-management and coordination of health care services, and may impact the frequency of in-person health care visits. To examine the impact of portal access on the number of outpatient visits, emergency visits, and preventable hospitalizations. Observational study comparing patients’ visit rates with and without portal access, using marginal structural modeling with inverse probability weighting estimates to account for potential bias due to confounding and attrition. Large integrated delivery system which implemented a patient portal (2006-2007). We examined 165,447 patients with diabetes defined using clinical registries. Our study included both patients with diabetes-only and patients with multiple complex chronic conditions (diabetes plus asthma, congestive artery disease, congestive heart failure, or hypertension). We examined rates of outpatient office visits, emergency room visits, and preventable hospitalizations (for ambulatory care sensitive conditions). Access to a patient portal was associated with significantly higher rates of outpatient office visits, in both patients with diabetes only and in patients with multiple complex conditions (p<0.05). In patients with multiple complex chronic conditions, portal use was also associated with significantly fewer emergency room visits (3.9 fewer per 1,000 patients per month, p<0.05) and preventable hospital stays (0.8 fewer per 1,000 patients per month, p<0.05). In patients with only diabetes, the results were directionally consistent but not statistically significantly associated with emergency room visits and preventable hospital stays. Observational study in an integrated delivery system. Access to a patient portal can increase engagement in outpatient visits, potentially addressing unmet clinical needs, and reduce downstream health events that lead to emergency and hospital care, particularly among patients with multiple complex conditions.

Authors: Reed ME; Huang J; Brand RJ; Neugebauer R; Graetz I; Hsu J; Ballard DW; Grant R

PLoS One. 2019;14(6):e0217636. Epub 2019-06-19.

PubMed abstract

Diagnostic thresholds for pregnancy hyperglycemia, maternal weight status and the risk of childhood obesity in a diverse Northern California cohort using health care delivery system data

To estimate the risk of childhood obesity associated with the various criteria proposed for diagnosis of gestational diabetes (GDM), and the joint effects with maternal BMI. Cohort study of 46,396 women delivering at the Kaiser Permanente Northern California health care delivery system in 1995-2004 and their offspring, followed through 5-7 years of age. Pregnancy hyperglycemia was categorized according to the screening and oral glucose tolerance test values proposed for the diagnosis of GDM by the International Association of the Diabetes and Pregnancy Study Group (IADPSG), Carpenter Coustan (CC), and the National Diabetes Data Group (NDDG). Childhood obesity was defined by the International Obesity Task Force’s age and sex-specific BMI cut-offs. Poisson regression models estimated the risks of childhood obesity associated with each category of pregnancy glycemia compared to normal screening, and the joint effects of maternal BMI category and GDM by the CC and the IADPSG criteria. Compared with normal screening, increased risks of childhood obesity were observed for abnormal screening [RR (95% CI): 1.30 (1.22, 1.38)], 1+ abnormal values by the IADPSG or CC [1.47 (1.36, 1.59) and 1.48 (1.37, 1.59), respectively], and 2+ values by CC or NDDG [1.52 (1.39, 1.67) and 1.60 (1.43, 1.78), respectively]. Compared to obese women without GDM, obese women with GDM defined by the CC criteria had significantly increased risk of childhood obesity [1.20 (1.07, 1.34)], which was also observed for GDM by the IADSPG [1.18 (1.07, 1.30)], though GDM did not significantly increase the risk of childhood obesity among normal weight or overweight women. The risk of childhood obesity starts to increase at levels of pregnancy glycemia below those used to diagnose GDM and the effect of GDM on childhood obesity risk appears more pronounced in women with obesity. Interventions to reduce obesity and pregnancy hyperglycemia are warranted.

Authors: Ehrlich SF; Hedderson MM; Xu F; Ferrara A

PLoS One. 2019;14(5):e0216897. Epub 2019-05-10.

PubMed abstract

Clinical Response to Real-Time Patient-Reported Diabetic Peripheral Neuropathy Symptoms

To assess clinician response to real-time patient-reported data about diabetic peripheral neuropathy (DPN) symptoms, we analyzed DPN diagnosis and treatment patterns after administration of a 4-question symptom questionnaire in a large vertically integrated health care system. Retrospective cohort study to analyze data from 160,852 patients screened for DPN symptoms from April 2012 to March 2014. Electronic medical record data were used to study changes in DPN diagnosis, treatment initiation, and treatment intensification. We used logistic regression to study the association of patient characteristics with the odds of clinical response. Of patients queried, 50,684 (31.5%) reported symptoms. Patients reporting DPN symptoms experienced a greater increase in new DPN diagnoses (16 percentage points; p < 0.0001) and medication use (4 percentage points; p < 0.0001) compared with those denying symptoms. Among patients reporting symptoms, women and nonwhite patients were less likely to receive a DPN diagnosis, whereas older patients were more likely to receive a DPN diagnosis. Overall, patients who were older, were Asian (hazard ratio = 0.67, 95% confidence interval = 0.63-0.77), and had lower socioeconomic status (hazard ratio = 0.89, 95% confidence interval = 0.80-0.99) were less likely to be treated. However, these racial and socioeconomic differences were not statistically significant for patients with preexisting DPN diagnoses. Patients' real-time reports of DPN symptoms were associated with increased clinical activity. Patient- and clinician-level factors associated with the likelihood of receiving a DPN diagnosis need further study because a formal diagnosis may be associated with more equitable treatment.

Authors: Banerjee S; Kim E; Parker MM; Gilliam LK; Dlott R; Adams A

Perm J. 2019;23.

PubMed abstract

Sociodemographic Determinants of Health and Well-Being Among Adults Residing in the Combined Kaiser Permanente Regions

Kaiser Permanente commissioned a health and well-being (HWB) survey of adult members and nonmembers in its 8 Regions. To estimate the prevalence of HWB indicators and evaluate differences in prevalence of excellent/very good (E/VG) health and thriving overall in life (thriving) by race/ethnicity, age group, sex, education, and financial situation. Cross-sectional survey conducted by email and phone during Winter 2016-2017 with a racial/ethnic group-stratified quota sample. Participants (N = 26,304) provided sociodemographic characteristics and ratings for 6 HWB indicators. Using population-weighted data, we estimated the prevalence of HWB indicators and used logistic regression models to test for differences in E/VG health and thriving by sociodemographic factors. Overall health and overall life evaluation. Of adults, 52% were in E/VG health and 63% were thriving. Blacks were less likely to be in E/VG health than whites, Hispanics, and Asian/Pacific Islanders, but there was little racial/ethnic variation in those who were thriving. E/VG health and thriving varied significantly by level of education and financial situation. Across all racial/ethnic groups, large differences in percentages were observed in E/VG health and thriving between the lowest and highest levels of education and financial situation but little racial/ethnic variation within education and financial situation strata. Differences in health status and life evaluation are associated very strongly with financial situation and educational attainment, and these social determinants partially explain racial/ethnic disparities in HWB. The lack of strong correlation of health status and life evaluation suggests these are different domains of well-being.

Authors: Stiefel MC; Gordon NP; Wilson-Anumudu FJ; Arsen EL

Perm J. 2019;23.

PubMed abstract

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

Latinos face unique challenges engaging with their health care providers for risk management of cardiovascular disease (CVD). To better understand differences in how Latinos and non-Latino whites (NLWs) experience CVD care. We examined self-reported activation, engagement, confidence, and communication comparing Latinos (n = 194) and NLWs (n = 208). Data were taken from baseline survey assessments of participants in the CREATE Wellness Study (NCT02302612), designed to help patients with poorly controlled CVD risk factors more actively engage in their care. The groups were compared using ?2 tests and separate logistic regression models adjusting for age, age and income, and age and educational attainment. Latinos in this cohort were younger, were less educated, and had lower incomes than did NLWs. In age-adjusted models, Latinos were significantly less likely to report knowing how to ask good questions about their health (71.1% vs 83.7% for NLW, p < 0.01; adjusted odds ratio = 0.49, 95% confidence interval = 0.29-0.83). Further adjustment by educational attainment or income did not attenuate this association. Latinos were also significantly more likely to report positive experiences and confidence with several measures of chronic illness care (adjusted odds ratio range = 1.57-2.01). Further adjustment by educational attainment eliminated these associations. We found notable differences between Latinos and NLWs in their experience of health care. These results provide insights into how CVD risk management programs can be tailored for Latinos. Interventions to improve patient activation and engagement for Latinos with CVD should emphasize question-asking skills.

Authors: Torres DX; Lu WY; Uratsu CS; Sterling SA; Grant RW

Perm J. 2019;23.

PubMed abstract

Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and drug treatment initiation and engagement among people living with the human immunodeficiency virus (HIV) and patients without an HIV diagnosis

Background: Problematic use of alcohol and other drugs (AOD) is highly prevalent among people living with the human immunodeficiency virus (PLWH), and untreated AOD use disorders have particularly detrimental effects on human immunodeficiency virus (HIV) outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement are important benchmarks for access to AOD use disorder treatment. To inform improved patient care, we compared HEDIS measures of AOD use disorder treatment initiation and engagement and health care utilization among PLWH and patients without an HIV diagnosis. Methods: Patients with a new AOD use disorder diagnosis documented between October 1, 2014, and August 15, 2015, were identified using electronic health records (EHR) and insurance claims data from 7 health care systems in the United States. Demographic characteristics, clinical diagnoses, and health care utilization data were also obtained. AOD use disorder treatment initiation and engagement rates were calculated using HEDIS measure criteria. Factors associated with treatment initiation and engagement were examined using multivariable logistic regression models. Results: There were 469 PLWH (93% male) and 86,096 patients without an HIV diagnosis (60% male) in the study cohort. AOD use disorder treatment initiation was similar in PLWH and patients without an HIV diagnosis (10% vs. 11%, respectively). Among those who initiated treatment, few engaged in treatment in both groups (9% PLWH vs. 12% patients without an HIV diagnosis). In multivariable analysis, HIV status was not significantly associated with either AOD use disorder treatment initiation or engagement. Conclusions: AOD use disorder treatment initiation and engagement rates were low in both PLWH and patients without an HIV diagnosis. Future studies need to focus on developing strategies to efficiently integrate AOD use disorder treatment with medical care for HIV.

Authors: Hechter RC; Weisner C; Campbell CI; Satre DD; et al.

Subst Abus. 2019;40(3):302-310. Epub 2019-03-25.

PubMed abstract

Patient characteristics associated with treatment initiation and engagement among individuals diagnosed with alcohol and other drug use disorders in emergency department and primary care settings

Background: Treatment initiation and engagement rates for alcohol and other drug (AOD) use disorders differ depending on where the AOD use disorder was identified. Emergency department (ED) and primary care (PC) are 2 common settings where patients are identified; however, it is unknown whether characteristics of patients who initiate and engage in treatment differ between these settings. Methods: Patients identified with an AOD disorder in ED or PC settings were drawn from a larger study that examined Healthcare Effectiveness Data and Information Set (HEDIS) AOD treatment initiation and engagement measures across 7 health systems using electronic health record data (n = 54,321). Multivariable generalized linear models, with a logit link, clustered on health system, were used to model patient factors associated with initiation and engagement in treatment, between and within each setting. Results: Patients identified in the ED had higher odds of initiating treatment than those identified in PC (adjusted odds ratio [aOR] = 1.89, 95% confidence interval [CI] = 1.73-2.07), with no difference in engagement between the settings. Among those identified in the ED, compared with patients aged 18-29, older patients had higher odds of treatment initiation (age 30-49: aOR = 1.25, 95% CI = 1.12-1.40; age 50-64: aOR = 1.42, 95% CI = 1.26-1.60; age 65+: aOR = 1.27, 95% CI = 1.08-1.49). However, among those identified in PC, compared with patients aged 18-29, older patients were less likely to initiate (age 30-49: aOR = 0.81, 95% CI = 0.71-0.94; age 50-64: aOR = 0.68, 95% CI = 0.58-0.78; age 65+: aOR = 0.47, 95% CI = 0.40-0.56). Women identified in ED had lower odds of initiating treatment (aOR = 0.80, 95% CI = 0.72-0.88), whereas sex was not associated with treatment initiation in PC. In both settings, patients aged 65+ had lower odds of engaging compared with patients aged 18-29 (ED: aOR = 0.61, 95% CI = 0.38-0.98; PC: aOR = 0.42, 95% CI = 0.26-0.68). Conclusion: Initiation and engagement in treatment differed by sex and age depending on identification setting. This information could inform tailoring of future AOD interventions.

Authors: Kline-Simon AH; Campbell CI; Weisner C; Sterling SA; Yarborough BJH; et al.

Subst Abus. 2019;40(3):278-284. Epub 2019-01-31.

PubMed abstract

Using natural language processing and machine learning to classify health literacy from secure messages: The ECLIPPSE study

Limited health literacy is a barrier to optimal healthcare delivery and outcomes. Current measures requiring patients to self-report limitations are time-consuming and may be considered intrusive by some. This makes widespread classification of patient health literacy challenging. The objective of this study was to develop and validate “literacy profiles” as automated indicators of patients’ health literacy to facilitate a non-intrusive, economic and more comprehensive characterization of health literacy among a health care delivery system’s membership. To this end, three literacy profiles were generated based on natural language processing (combining computational linguistics and machine learning) using a sample of 283,216 secure messages sent from 6,941 patients to their primary care physicians. All patients were participants in Kaiser Permanente Northern California’s DISTANCE Study. Performance of the three literacy profiles were compared against a gold standard of patient self-reported health literacy. Associations were analyzed between each literacy profile and patient demographics, health outcomes and healthcare utilization. T-tests were used for numeric data such as A1C, Charlson comorbidity index and healthcare utilization rates, and chi-square tests for categorical data such as sex, race, poor adherence and severe hypoglycemia. Literacy profiles varied in their test characteristics, with C-statistics ranging from 0.61-0.74. Relations between literacy profiles and health outcomes revealed patterns consistent with previous health literacy research: patients identified via literacy profiles indicative of limited health literacy: (a) were older and more likely of minority status; (b) had poorer medication adherence and glycemic control; and (c) exhibited higher rates of hypoglycemia, comorbidities and healthcare utilization. This represents the first successful attempt to employ natural language processing to estimate health literacy. Literacy profiles can offer an automated and economical way to identify patients with limited health literacy and greater vulnerability to poor health outcomes.

Authors: Balyan R; Crossley SA; Brown W; Karter AJ; McNamara DS; Liu JY; Lyles CR; Schillinger D

PLoS ONE. 2019;14(2):e0212488. Epub 2019-02-22.

PubMed abstract

The association between medical comorbidity and Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement for alcohol and other drug use disorders

Background: Medical comorbidity may influence treatment initiation and engagement for alcohol and other drug (AOD) use disorders. We examined the association between medical comorbidity and Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement measures.Methods: We used electronic health record and insurance claims data from 7 US health care systems to identify patients with AOD use disorders between October 1, 2014, and August 15, 2015 (N = 86,565). Among patients identified with AOD use disorders in outpatient and emergency department (ED) settings, we examined how Charlson/Deyo comorbidity index scores and medical complications of AOD use were associated with treatment initiation. Among those who initiated treatment in inpatient and outpatient/ED settings, we also examined how comorbidity and AOD use-related medical complications were associated with treatment engagement. Analyses were conducted using generalized estimating equation logistic regression modeling.Results: Among patients identified as having an AOD diagnosis in outpatient and ED settings (n = 69,965), Charlson/Deyo comorbidity index scores of 2 or more were independently associated with reduced likelihood of initiation (risk ratio [RR] = 0.80, 95% confidence interval [CI] = 0.74, 0.86; reference score = 0), whereas prior-year diagnoses of cirrhosis (RR = 1.25, 95% CI = 1.12, 1.35) and pancreatic disease (RR = 1.34, 95% CI = 1.15, 1.56) were associated with greater likelihood of initiation. Among those who were identified in outpatient/ED settings and initiated, higher comorbidity scores were associated with lower likelihood of engagement (score 1: RR = 0.85, 95% CI = 0.76, 0.94; score 2+: RR = 0.61, 95% CI = 0.53, 0.71).Conclusion: Medical comorbidity was associated with lower likelihood of initiating or engaging in AOD treatment, but cirrhosis and pancreatic disease were associated with greater likelihood of initiation. Interventions to improve AOD treatment initiation and engagement for patients with comorbidities are needed, such as integrating medical and AOD treatment.

Authors: Binswanger IA; Campbell CI; Satre DD; Weisner C; Lapham GT; et al.

Subst Abus. 2019;40(3):292-301. Epub 2019-01-24.

PubMed abstract

Factors associated with Healthcare Effectiveness Data and Information Set (HEDIS) alcohol and other drug measure performance in 2014-2015

Background: Only 10% of patients with alcohol and other drug (AOD) disorders receive treatment. The AOD Initiation and Engagement in Treatment (AOD-IET) measure was added to the national Healthcare Effectiveness Data and Information Set (HEDIS) to improve access to care. This study identifies factors related to improving AOD-IET rates. Methods: We include data from 7 health systems with differing geographic, patient demographic, and organizational characteristics; all used a common Virtual Data Warehouse containing electronic health records and insurance claims data. Multilevel logistic regression models examined AOD-IET among adults (18+). Results: A total of 86,565 patients had an AOD diagnosis qualifying for the HEDIS denominator. Initiation rates varied from 26% to 46%; engagement rates varied from 14% to 29%. Women versus men (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.76-0.86); Hispanics (OR = 0.85, 95% CI = 0.79-0.91), black/African Americans (OR = 0.82, 95% CI = 0.75-0.90), and Asian Americans (OR = 0.83, 95% CI = 0.72-0.95) versus whites; and patients aged 65+ versus 18-29 (OR = 0.82, 95% CI = 0.74-0.90) had lower odds of initiation. Patients aged 30-49 versus 18-29 (OR = 1.11, 95% CI = 1.04-1.19) and those with prior psychiatric (OR = 1.26, 95% CI = 1.18-1.35) and medical (OR = 1.18, 95% CI = 1.10-1.26) conditions had higher odds of engagement. Identification in primary care versus other departments was related to lower odds of initiation (emergency department [ED]: OR = 1.55, 95% CI = 1.45-1.66; psychiatry/AOD treatment: OR = 3.58, 95% CI = 3.33-3.84; other outpatient: OR = 1.19, 95% CI = 1.06-1.32). Patients aged 30-49 versus 18-29 had higher odds of engagement (OR = 1.26, 95% CI = 1.10-1.43). Patients aged 65+ versus 18-29 (OR = 0.51, 95% CI = 0.43-0.62) and black/African Americans versus whites (OR = 0.64, 95% CI = 0.53-0.77) had lower odds. Those initiating treatment in psychiatry/AOD treatment versus primary care (OR = 7.02, 95% CI = 5.93-8.31) had higher odds of engagement; those in inpatient (OR = 0.40, 95% CI = 0.32-0.50) or other outpatient (OR = 0.73, 95% CI = 0.59-0.91) settings had lower odds. Discussion: Rates of initiation and engagement varied but were low. Findings identified age, race/ethnicity, co-occurring conditions, and department of identification as key factors associated with AOD-IET. Focusing on these could help programs develop interventions that facilitate AOD-IET for those less likely to receive care.

Authors: Weisner C; Campbell CI; Sterling SA; Satre DD; Kline-Simon AH; et al.

Subst Abus. 2019;40(3):318-327. Epub 2019-01-24.

PubMed abstract

The prevalence of Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement in treatment among patients with cannabis use disorders in 7 US health systems

Background: Cannabis use disorders (CUDs) have increased with more individuals using cannabis, yet few receive treatment. Health systems have adopted the Healthcare Effectiveness Data and Information Set (HEDIS) quality measures of initiation and engagement in alcohol and other drug (AOD) dependence treatment, but little is known about the performance of these among patients with CUDs. Methods: This cohort study utilized electronic health records and claims data from 7 health care systems to identify patients with documentation of a new index CUD diagnosis (no AOD diagnosis ≤60 days prior) from International Classification of Diseases, Ninth revision, codes (October 1, 2014, to August 31, 2015). The adjusted prevalence of each outcome (initiation, engagement, and a composite of both) was estimated from generalized linear regression models, across index identification settings (inpatient, emergency department, primary care, addiction treatment, and mental health/psychiatry), AOD comorbidity (patients with CUD only and CUD plus other AOD diagnoses), and patient characteristics. Results: Among 15,202 patients with an index CUD diagnosis, 30.0% (95% confidence interval [CI]: 29.2-30.7%) initiated, 6.9% (95% CI: 6.2-7.7%) engaged among initiated, and 2.1% (95% CI: 1.9-2.3%) overall both initiated and engaged in treatment. The adjusted prevalence of outcomes varied across index identification settings and was highest among patients diagnosed in addiction treatment, with 25.0% (95% CI: 22.5-27.6%) initiated, 40.9% (95% CI: 34.8-47.0%) engaged, and 12.5% (95% CI: 10.0-15.1%) initiated and engaged. The adjusted prevalence of each outcome was generally highest among patients with CUD plus other AOD diagnosis at index diagnosis compared with those with CUD only, overall and across index identification settings, and was lowest among uninsured and older patients. Conclusion: Among patients with a new CUD diagnosis, the proportion meeting HEDIS criteria for initiation and/or engagement in AOD treatment was low and demonstrated variation across index diagnosis settings, AOD comorbidity, and patient characteristics, pointing to opportunities for improvement.

Authors: Lapham GT; Campbell CI; Yarborough BJH; Hechter RC; Ahmedani BK; Haller IV; Kline-Simon AH; Satre DD; Loree AM; Weisner C; Binswanger IA

Subst Abus. 2019;40(3):268-277. Epub 2019-01-18.

PubMed abstract

Psychiatric comorbidity and Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and other drug treatment initiation and engagement across 7 health care systems

Background: Psychiatric comorbidity is common among patients with alcohol and other drug (AOD) use disorders. To better understand how psychiatric comorbidity influences AOD treatment access in health care systems, the present study examined treatment initiation and engagement among a large, diverse sample of patients with comorbid psychiatric and AOD use disorders. Methods: This study utilized data from a multisite observational study examining Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement in treatment (IET) among patients with AOD use disorders from 7 health care systems. Participants were aged 18 or older with at least 1 AOD index diagnosis between October 1, 2014, and August 15, 2015. Data elements extracted from electronic health records and insurance claims data included patient demographic characteristics, ICD-9 (International Classification of Diseases, Ninth Revision) diagnostic codes, and procedure codes. Descriptive analyses and multivariate logistic regression models were used to examine the relationship between patient-level factors and IET measures. Results: Across health care systems, out of a total of 86,565 patients who had at least 1 AOD index diagnosis during the study period, 66.2% (n = 57,335) patients also had a comorbid psychiatric disorder. Among patients with a comorbid psychiatric disorder, 34.9% (n = 19,998) initiated AOD treatment, and of those, 10.3% (n = 2,060) engaged in treatment. After adjusting for age, sex, and race/ethnicity, patients with comorbid psychiatric disorders were more likely to initiate (odds ratio [OR] = 3.20, 95% confidence interval [CI] = 3.08, 3.32) but no more likely to engage (OR = 0.56, 95% CI = 0.51, 0.61) in AOD treatment, compared with those without a comorbid psychiatric disorder. Conclusions: Findings suggest that identification of comorbid psychiatric disorders may increase initiation in AOD treatment. However, innovative efforts are needed to enhance treatment engagement both generally and especially for individuals without diagnosed psychiatric conditions.

Authors: Loree AM; Satre DD; Campbell CI; Weisner C; Ahmedani BK; et al.

Subst Abus. 2019;40(3):311-317. Epub 2019-01-25.

PubMed abstract

Predictors of Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement among patients with opioid use disorder across 7 health systems

Background: The prevalence of opioid use disorder (OUD) has increased rapidly in the United States and improving treatment access is critical. Among patients with OUD, we examined factors associated with the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures of alcohol and other drug (AOD) treatment initiation and engagement. Methods: Electronic health record and claims data between October 1, 2014, and August 15, 2015, from 7 health systems were used to identify patients (n = 11,490) with a new index OUD diagnosis (no AOD diagnosis prior <60 days) based on International Classification of Diseases (ICD)-9 codes. Multivariable generalized linear models with a logit link clustered on health system were used to examine the associations of patient demographic and clinical characteristics, and department of index diagnosis, with HEDIS measures of treatment initiation and engagement. Results: The prevalence of OUD among all AOD diagnoses varied across health systems, as did rates of AOD initiation (5.7%-21.6%) and engagement (7.6%-24.6%). Those diagnosed in the emergency department (adjusted odds ratio [aOR] = 1.58, 95% confidence interval [CI] = 1.27,1.97) or psychiatry/AOD treatment (aOR = 2.92, 95% CI = 2.47,3.46) were more likely to initiate treatment compared with primary care. Older patients were less likely to initiate (age 50-64 vs. age 18-29: aOR = 0.42, 95% CI = 0.35, 0.51; age 65+ vs. age 18-29: aOR = 0.34, 95% CI = 0.26, 0.43), as were women (aOR = 0.72, 95% CI = 0.62, 0.85). Patients diagnosed in psychiatry/AOD treatment (aOR = 2.67, 95% CI = 1.98, 3.60) compared with primary care were more likely to engage in treatment. Those identified in an inpatient setting (aOR = 0.19, 95% CI = 0.14, 0.27 vs. primary care), those with medical comorbidity (aOR = 0.70, 95% CI = 0.52, 0.95), and older patients (age 50-64 vs. 18-29: aOR = 0.64, 95% CI = 0.46, 0.88; age 65+ vs. 18-29: aOR = 0.36, 95% CI = 0.22, 0.57) were less likely to engage in treatment. Conclusions: Rates of initiation and engagement for OUD patients vary widely with noticeable room for improvement, particularly in this critical time of the opioid crisis. Targeting patient and system factors may improve health system performance, which is key to improving patient outcomes.

Authors: Campbell CI; Weisner C; Binswanger IA; Lapham GT; Ahmedani BK; Yarborough BJH; Haller IV; Altschuler A; Hechter RC; Loree AM; Kline-Simon AH

Subst Abus. 2019;40(3):328-334. Epub 2019-01-24.

PubMed abstract

Inpatient electronic health record maintenance from 2010 to 2015

To describe the scale and scope of inpatient electronic health record (EHR) maintenance following initial implementation. A retrospective study reviewing EHR change documentation within an integrated healthcare delivery system that has 21 hospitals. Between 2010 and 2015, we identified and categorized all significant changes made to the inpatient EHR, as documented within monthly EHR communication updates. We categorized EHR changes as updates to existing functionality or upgrades to new functionality. We grouped changes within larger functional domains as orders, alerts and customization, surgical and emergency department (ED), data review, reports and health information management, and other. We also identified the clinical areas and user roles targeted by these changes. Over a 6-year period, 5551 unique changes were made to the inpatient EHR, with a median of 72 changes per month. Changes most frequently targeted orders (44.7% of 2190 change documents) and order sets (29.9% of documents). In total, changes affected 135 EHR functions. A total of 151 unique user roles were affected by these changes, with the most frequent roles including nurses (30.6%), physicians (26.6%), and other clinical staff (22.7%). The clinical areas most targeted by changes included surgical areas and the ED. Over 6 years, EHR maintenance for clinical functionality was substantial and varied with pervasive impacts, requiring persistent attention, diverse expertise, and interdisciplinary collaboration.

Authors: Liu VX; Haq N; Chan IC; Hoberman B

Am J Manag Care. 2019 01;25(1):18-21.

PubMed abstract

The health information technology special issue: new real-world evidence and practical lessons

As technology applications in healthcare continue to grow, electronic health records are maturing, interoperability is developing, and patient-facing technology use is expanding.

Authors: Reed ME

Am J Manag Care. 2019 01;25(1):12.

PubMed abstract

Shake Rattle & Roll – Design and rationale for a pragmatic trial to improve blood pressure control among blacks with persistent hypertension

In Kaiser Permanente Northern California (KPNC), members had similar access to care and a very high overall rate of hypertension control. However, blacks had poorer blood pressure (BP) control than whites. The Shake Rattle & Roll (SRR) trial aimed to improve BP control rates in blacks and to reduce disparities in hypertension control. SRR was a cluster randomized controlled trial conducted at an urban medical center. All 98 adult primary care physicians (PCP) and their panels of hypertensive black patients were randomized, stratified by panel size, to one of three arms: 1) Usual Care (n?=?33 PCPs, N?=?1129 patients); 2) Enhanced Monitoring arm with an emphasis on improving pharmacotherapy protocol adherence (n?=?34 PCPs, N?=?349 patients); or 3) Lifestyle arm with a culturally tailored diet and lifestyle coaching intervention focusing on the Dietary Approaches to Stop Hypertension eating plan (n?=?31 PCPs, N?=?286 patients). The intervention period was for 12-months post-enrollment. Follow-up was planned for one and three years post-intervention completion. Primary outcome measure was the proportion of participants with controlled BP, defined as <140/90?mmHg, at 12-months post-enrollment. Secondary outcome included adverse cardiovascular events. An intention-to-treat analysis was carried out as the primary analysis. SRR was a uniquely designed trial that included components from both pragmatic and explanatory methods. The pragmatic aspects allow for a more cost-effective way to conduct a clinical trial and easier implementation of successful interventions into clinical practice. However, there were also challenges of having mixed methodology with regards to trial conduction and analysis.

Authors: Nguyen-Huynh MN; Young JD; Alexeeff S; Hatfield MK; Sidney S

Contemp Clin Trials. 2019 01;76:85-92. Epub 2018-11-28.

PubMed abstract

Automated symptom and treatment side effect monitoring for improved quality of life among adults with diabetic peripheral neuropathy in primary care: a pragmatic, cluster, randomized, controlled trial

To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy. We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment. Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes. Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy. (NCT02056431).

Authors: Adams AS; Schmittdiel JA; Neugebauer R; Grant RW; et al.

Diabet Med. 2019 01;36(1):52-61. Epub 2018-11-07.

PubMed abstract

Immersive 3D exposure-based treatment for spider fear: A randomized controlled trial.

Stereoscopic 3D gives the viewer the same shape, size, perspective and depth they would experience viewing the real world and could mimic the perceptual threat cues present in real life. This is the first study to investigate whether an immersive stereoscopic 3D video exposure-based treatment would be effective in reducing fear of spiders. Participants with a fear of spiders (N = 77) watched two psychoeducational videos with facts about spiders and phobias. They were then randomized to a treatment condition that watched a single session of a stereoscopic 3D immersive video exposure-based treatment (six 5-minute exposures) delivered through a virtual reality headset or a psychoeducation only control condition that watched a 30-minute neutral video (2D documentary) presented on a computer monitor. Assessments of spider fear (Fear of Spiders Questionnaire [FSQ], Behavioral Approach Task [BAT], & subjective ratings of fear) were completed pre- and post-treatment. Consistent with prediction, the stereoscopic 3D video condition outperformed the control condition in reducing fear of spiders showing a large between-group change effect size on the FSQ (Cohen’s d = 0.85) and a medium between-group effect size on the BAT (Cohen’s d = 0.47). This provides initial support for stereoscopic 3D video in treating phobias.

Authors: Minns S; Levihn-Coon A; Carl E; Smits JAJ; Miller W; Howard D; Papini S; Quiroz S; Lee-Furman E; Telch M; Carlbring P; Xanthopoulos D; Powers MB

J Anxiety Disord. 2019 Jan;61:37-44. doi: 10.1016/j.janxdis.2018.12.003. Epub 2018 Dec 21.

PubMed abstract

Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial

Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. Controlled pragmatic trial. ( NCT03601676). All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). Adult ED patients with acute PE. Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. Lack of random allocation. Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.

Authors: Vinson DR; Mark DG; Reed ME; Ballard DW; eSPEED Investigators of the KP CREST Network; et al.

Ann Intern Med. 2018 12 18;169(12):855-865. Epub 2018-11-13.

PubMed abstract

Vegetarian Diets Are Associated with Selected Cardiometabolic Risk Factors among Middle-Older Aged South Asians in the United States.

Background: Following a vegetarian diet is considered to be beneficial for overall health and is associated with a lower risk of chronic disease. Objective: This study examined whether South Asians in the United States who consume a vegetarian diet have a lower prevalence of cardiometabolic risk factors. Methods: Data from the Mediators of Atherosclerosis in South Asians Living in America study, which included 892 South Asians (47% women), with an age range of 40-83 y and a mean +/- SD age of 55 +/- 9.4 y, were used. Participants were classified as vegetarian if they reported no consumption of meat, poultry, or fish in the previous year on a validated and culturally appropriate food-frequency questionnaire. Adjusted linear and logistic regression models were used to examine associations of a vegetarian diet with cardiometabolic risk factors. Results: Thirty-eight percent of the cohort participants were classified as vegetarian. Vegetarians reported more frequent weekly eating occasions of whole grains (median frequency/wk: 10 compared with 9, P = 0.012) and beans and legumes (median frequency/wk: 8.5 compared with 5.1, P < 0.001), and less frequent weekly eating occasions of sweets and desserts (median frequency/wk: 1.9 compared with 2.3, P < 0.001). Consuming a vegetarian diet was associated with lower body mass index (P = 0.023), fasting glucose (P = 0.015), insulin resistance (P = 0.003), total cholesterol (P = 0.027), and LDL cholesterol (P = 0.004) and lower odds of fatty liver (OR: 0.43; 95% CI: 0.23, 0.78, P = 0.006). The odds of having any coronary artery calcium were lower for vegetarian men (OR: 0.53; 95% CI: 0.32, 0.87, P = 0.013); however, no significant associations were observed among women. Conclusions: Among US South Asians, a vegetarian diet was associated with fewer cardiometabolic risk factors overall and with less subclinical atherosclerosis among men.

Authors: Jin Y; Kanaya AM; Kandula NR; Rodriguez LA; Talegawkar SA

J Nutr. 2018 Dec 1;148(12):1954-1960. doi: 10.1093/jn/nxy217.

PubMed abstract

Tele-Triage Outcomes For Patients With Chest Pain: Comparing Physicians And Registered Nurses

We took advantage of a change in protocol in an integrated delivery system’s telephone consultation service-routing callers complaining of chest pain to physicians instead of registered nurses, whenever feasible-to explore whether tele-triage outcomes differed by staffing type. Comparing outcomes of 11,315 physician-directed calls to those of an equal number of nurse-directed calls in 2013, we found that the physician-directed calls were briefer (eight minutes versus thirteen minutes), produced fewer ED referrals (10 percent versus 16 percent), and resulted in higher patient adherence to the providers’ site-of-care recommendation (86 percent versus 82 percent). Mortality rates at seven days were low for both physician- and nurse-directed calls (0.1 percent). We suspect that providers’ immediate access to callers’ comprehensive electronic health records and patients’ rapid access to outpatient care likely contributed to the program’s success. Our findings suggest that tele-triage can be used to safely and effectively manage an emergent complaint, and that physicians’ expertise may bring additional efficiency to the process.

Authors: Sax DR; Vinson DR; Yamin CK; Huang J; Falck TM; Bhargava R; Amaral DJ; Reed ME

Health Policy Plan. 2019 Jul 01;34(6):450-460.

PubMed abstract

Patterns of medication adherence in a multi-ethnic cohort of prevalent statin users diagnosed with breast, prostate, or colorectal cancer

To investigate the implications of a cancer diagnosis on medication adherence for pre-existing comorbid conditions, we explored statin adherence patterns prior to and following a new diagnosis of breast, colorectal, or prostate cancer among a multi-ethnic cohort. We identified adults enrolled at Kaiser Permanente Northern California who were prevalent statin medication users, newly diagnosed with breast, colorectal, or prostate cancer between 2000 and 2012. Statin adherence was measured using the proportion of days covered (PDC) during the 2-year pre-cancer diagnosis and the 2-year post-cancer diagnosis. Adherence patterns were assessed using generalized estimating equations, for all cancers combined and stratified by cancer type and race/ethnicity, adjusted for demographic, clinical, and tumor characteristics. Among 10,177 cancer patients, statin adherence decreased from pre- to post-cancer diagnosis (adjusted odds ratio (ORadj):0.91, 95% confidence interval (95% CI):0.88-0.94). Statin adherence decreased from pre- to post-cancer diagnosis among breast (ORadj:0.94, 95% CI:0.90-0.99) and colorectal (ORadj:0.79, 95% CI:0.74-0.85) cancer patients. No difference in adherence was observed among prostate cancer patients (ORadj:1.01, 95% CI:0.97-1.05). Prior to cancer diagnosis, adherence to statins was generally higher among non-Hispanic whites and multi-race patients than other groups. However, statin adherence after diagnosis decreased only among these two populations (ORadj:0.85, 95% CI:0.85-0.92 and ORadj:0.86, 95% CI:0.76-0.97), respectively. We found substantial variation in statin medication adherence following diagnosis by cancer type and race/ethnicity among a large cohort of prevalent statin users in an integrated health care setting. Improving our understanding of comorbidity management and polypharmacy across diverse cancer patient populations is warranted to develop tailored interventions that improve medication adherence and reduce disparities in health outcomes.

Authors: Banegas MP; Emerson MA; Adams AS; Achacoso NS; Chawla N; Alexeeff S; Habel LA

J Cancer Surviv. 2018 12;12(6):794-802. Epub 2018-10-18.

PubMed abstract

Characteristics of patients with substance use disorder before and after the Affordable Care Act

The Affordable Care Act (ACA) offered an unprecedented opportunity to expand insurance coverage to patients with substance use disorders (SUDs). We explored the expectations of key stakeholders for the ACA’s impact on SUD care, and examined how clinical characteristics of newly enrolled patients with SUD in a large healthcare delivery system differed pre- and post- ACA implementation. In this mixed-methods study, qualitative interviews were conducted with health system leaders to identify themes regarding how the health system prepared for the ACA. Electronic health record data were used to examine demographics, as well as specific SUD, psychiatric, and medical diagnoses in cohorts of pre-ACA (2012, n = 6066) vs. post-ACA (2014, n = 7099) newly enrolled patients with SUD. Descriptive statistics and logistic regression models were employed to compare pre-ACA and post-ACA measures. Interviewees felt much uncertainty, but anticipated having to care for more SUD patients, who might have greater severity. Quantitative findings affirmed these expectations, with post-ACA SUD patients having higher rates of cannabis and amphetamine use disorders, and more psychiatric and medical conditions, compared to their pre-ACA counterparts. The post-ACA SUD cohort also had more Medicaid patients and greater enrollment in high-deductible plans. Post-ACA, SUD patients had more comorbidities as well as and more financial barriers to care. As federal healthcare policy continues to evolve, with potentially more restrictive coverage criteria, it is essential to continue examining how health systems adapt to changing health policy and its impact on SUD care.

Authors: Campbell CI; Parthasarathy S; Altschuler A; Young-Wolff KC; Satre DD

Drug Alcohol Depend. 2018 12 01;193:124-130. Epub 2018-10-06.

PubMed abstract

Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study

To examine the prevalence and person-level predictors of undiagnosed Type 2 diabetes among adults with elevated HbA1c values. We identified adults without diabetes who had a first elevated HbA1c (index HbA1c ≥ 48 mmol/mol; ≥ 6.5%) between January 2014 and December 2015, and classified them by Type 2 diabetes diagnosis status at 1 year following this result. Multilevel modelling techniques were used to examine the association of individual demographic, clinical, and utilization characteristics with remaining undiagnosed. We quantified differences in early Type 2 diabetes care between diagnosed and undiagnosed individuals. Of the 18 356 adults with a first elevated index HbA1c , 30.2% remained undiagnosed with Type 2 diabetes 1 year later. Individuals with lower index HbA1c values [adjusted odds ratio (aOR) 5.95, 95% confidence interval (CI) 5.21-6.78 for 48 to <53 mmol/mol (6.5% to 7.0%); referent 53 to <64 mmol/mol (7.0% to <8.0%)], who were ≥ 70 years old (aOR 1.40, 95% CI 1.24-1.59; referent 50-59 years), and who had a prior prediabetes diagnosis (aOR 1.35, 95% CI 1.24-1.47; referent no prediabetes) had increased odds of remaining undiagnosed. After adjusting for age, race, and index HbA1c , remaining undiagnosed was associated with lower odds of initiating metformin (aOR 0.06, 95% CI 0.05-0.07). Almost one-third of adults with an elevated HbA1c value were not diagnosed with Type 2 diabetes within 1 year. Undiagnosed Type 2 diabetes, in turn, was associated with differences in early care. Strategies that leverage the electronic health record to facilitate earlier diagnosis may help reduce delays and allow for early intervention towards the goal of improved outcomes.

Authors: Gopalan A; Mishra P; Alexeeff SE; Blatchins MA; Kim E; Man AH; Grant RW

Diabet Med. 2018 12;35(12):1655-1662. Epub 2018-09-21.

PubMed abstract

Central Obesity Increases the Risk of Gestational Diabetes Partially Through Increasing Insulin Resistance

This study examined the associations of central obesity measures, waist to hip ratio (WHR) and waist circumference (WC), in early pregnancy with subsequent risk of gestational diabetes mellitus (GDM) and evaluated the potential mediating role of insulin resistance markers. Within the prospective Pregnancy Environment and Lifestyle Study cohort of 1,750 women, WC and hip circumference were measured at gestational weeks 10 to 13. In a nested case-control study within the cohort, 115 GDM cases and 230 controls had fasting serum insulin, homeostatic model assessment of insulin resistance (HOMA-IR), and adiponectin measurements at gestational weeks 16 to 19. Poisson and conditional logistic regression models were used, adjusting for established risk factors for GDM, including prepregnancy overweight or obesity. For women with WHR 

Authors: Zhu Y; Hedderson MM; Quesenberry CP; Feng J; Ferrara A

Obesity (Silver Spring). 2018 Nov 21.

PubMed abstract

Advancing Health Policy and Program Research in Diabetes: Findings from the Natural Experiments for Translation in Diabetes (NEXT-D) Network

To advance our understanding of the impacts of policies and programs aimed at improving detection, engagement, prevention, and clinical diabetes management in the USA, we synthesized findings from a network of studies that used natural experiments to evaluate diabetes health policies and programs. Studies from the Natural EXperiments for Translation in Diabetes (NEXT-D) network used rigorous longitudinal quasi-experimental study designs (e.g., interrupted time series) and analytical methods (e.g., difference-in-differences) to augment causal inference. Investigators partnered with health system stakeholders to evaluate whether glucose testing rates changed from before-to-after clinic interventions (e.g., integrating electronic screening decision prompts in New York City) or employer programs (e.g., targeted messaging and waiving copayments for at-risk employees). Other studies examined participation and behavior change in low- (e.g., wellness coaching) or high-intensity lifestyle modification programs (e.g., diabetes prevention program-like interventions) offered by payers or employers. Lastly, studies assessed how employer health insurance benefits impacted healthcare utilization, adherence, and outcomes among people with diabetes. NEXT-D demonstrated that low-intensity interventions to facilitate glucose testing and enhance engagement in lifestyle modification were associated with small improvements in weight but large improvements in screening and testing when supported by electronic health record-based decision-support. Regarding high-intensity diabetes prevention program-like lifestyle programs offered by payers or employers, enrollment was modest and led to weight loss and marginally lower short-term health expenditures. Health plans that incentivize patient behaviors were associated with increases in medication adherence. Meanwhile, shifting patients to high-deductible health plans was associated with no change in medication use and preventive screenings, but patients with diabetes delayed accessing healthcare for acute complications (e.g., cellulitis). Findings were more pronounced among lower-income patients, who experienced increased rates and acuity of emergency department visits for diabetes complications and other high-severity conditions. Findings from NEXT-D studies provide informative data that can guide programs and policies to facilitate detection, prevention, and treatment of diabetes in practice.

Authors: Ali MK; Wharam F; Kenrik Duru O; Schmittdiel J; Ackermann RT; Albu J; Ross-Degnan D; Hunter CM; Mangione C; Gregg EW; NEXT-D Study Group

Curr Diab Rep. 2018 11 20;18(12):146. Epub 2018-11-20.

PubMed abstract

Bias-contingent attention bias modification and attention control training in treatment of PTSD: a randomized control trial.

BACKGROUND: Randomized control trials (RCTs) comparing attention control training (ACT) and attention bias modification (ABM) in posttraumatic stress disorder (PTSD) have shown mixed results. The current RCT extends the extant literature by comparing the efficacy of ACT and a novel bias-contingent-ABM (BC-ABM), in which direction of training is contingent upon the direction of pre-treatment attention bias (AB), in a sample of civilian patients with PTSD. METHODS: Fifty treatment-seeking civilian patients with PTSD were randomly assigned to either ACT or BC-ABM. Clinician and self-report measures of PTSD and depression, as well as AB and attention bias variability (ABV), were acquired pre- and post-treatment. RESULTS: ACT yielded greater reductions in PTSD and depressive symptoms on both clinician-rated and self-reported measures compared with BC-ABM. The BC-ABM condition successfully shifted ABs in the intended training direction. In the ACT group, there was no significant change in ABV or AB from pre- to post-treatment. CONCLUSIONS: The current RCT extends previous results in being the first to apply ABM that is contingent upon AB at pre-treatment. This personalized BC-ABM approach is associated with significant reductions in symptoms. However, ACT produces even greater reductions, thereby emerging as a promising treatment for PTSD.

Authors: Lazarov A; Suarez-Jimenez B; Abend R; Naim R; Shvil E; Helpman L; Zhu X; Papini S; Duroski A; Rom R; Schneier FR; Pine DS; Bar-Haim Y; Neria Y

Psychol Med. 2019 Oct;49(14):2432-2440. doi: 10.1017/S0033291718003367. Epub 2018 Nov 12.

PubMed abstract

Scaling Up Diabetes Prevention Programs in North Carolina: Perceptions of Demand From Potential Program Recipients and Providers.

Authors: Thomas, Tainayah T; Samuel-Hodge, Carmen D CD; Porterfield, Deborah S DS; Alva, Maria L ML; Leeman, Jennifer J

The Diabetes educator. 2019 02 09;45(1):116-124. Epub 2018-11-09.

PubMed abstract

Examining the role of access to care: Racial/ethnic differences in receipt of resection for early-stage non-small cell lung cancer among integrated system members and non-members

To examine the role of uniform access to care in reducing racial/ethnic disparities in receipt of resection for early stage non-small cell lung cancer (NSCLC) by comparing integrated health system member patients to demographically similar non-member patients. Using data from the California Cancer Registry, we conducted a retrospective cohort study of patients from four racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander), aged 21-80, with a first primary diagnosis of stage I or II NSCLC between 2004 and 2011, in counties served by Kaiser Permanente Northern California (KPNC) at diagnosis. Our cohort included 1565 KPNC member and 4221 non-member patients. To examine the relationship between race/ethnicity and receipt of surgery stratified by KPNC membership, we used modified Poisson regression to calculate risk ratios (RR) adjusted for patient demographic and tumor characteristics. Black patients were least likely to receive surgery regardless of access to integrated care (64-65% in both groups). The magnitude of the black-white difference in the likelihood of surgery receipt was similar for members (RR: 0.82, 95% CI: 0.73-0.93) and non-members (RR: 0.86, 95% CI: 0.80-0.94). Among members, roughly equal proportions of Hispanic and White patients received surgery; however, among non-members, Hispanic patients were less likely to receive surgery (non-members, RR: 0.93, 95% CI: 0.86-1.00; members, RR: 0.98, 95% CI: 0.89-1.08). Disparities in surgical treatment for NSCLC were not reduced through integrated health system membership, suggesting that factors other than access to care (e.g., patient-provider communication) may underlie disparities. Future research should focus on identifying such modifiable factors.

Authors: Check DK; Albers KB; Uppal KM; Suga JM; Adams AS; Habel LA; Quesenberry CP; Sakoda LC

Lung Cancer. 2018 Nov;125:51-56. Epub 2018-09-11.

PubMed abstract

Exploring how patients understand and assess their diabetes control

Poor understanding of diabetes management targets is associated with worse disease outcomes. Patients may use different information than providers to assess their diabetes control. In this study, we identify the information patients use to gauge their current level of diabetes control and explore patient-perceived barriers to understanding the hemoglobin A1c value (HbA1c). Adults who self-reported a diagnosis of diabetes were recruited from outpatient, academically-affiliated, Internal Medicine clinics. Semi-structured interviews were conducted with participants and collected data were analyzed using thematic analysis. The mean age of the 25 participants was 56.8 years. HbA1c was one of several types of information participants used to assess diabetes control. Other information included perceived self-efficacy and adherence to self-care, the type and amount of medications taken, the presence or absence of symptoms attributed to diabetes, and feedback from self-monitoring of blood glucose. Most participants reported familiarity with the HbA1c (22 of 25), though understanding of the value’s meaning varied significantly. Inadequate diabetes education and challenges with patient-provider communication were cited as common barriers to understanding the HbA1c. In addition to the HbA1c, several categories of information influenced participants’ assessments of their diabetes control. Increased provider awareness of the factors that influence patients’ perceptions of diabetes control can inform effective, patient-centered approaches for communicating vital diabetes-related information, facilitating behavior change towards improved patient outcomes.

Authors: Gopalan A; Kellom K; McDonough K; Schapira MM

BMC Endocr Disord. 2018 Nov 06;18(1):79. Epub 2018-11-06.

PubMed abstract

Emergency Department Patient Satisfaction with Treatment of Low-risk Pulmonary Embolism

Many emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I-III). This phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2-8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated. Survey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all). ED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.

Authors: Simon LE; Iskin HR; Vemula R; Huang J; Rauchwerger AS; Reed ME; Ballard DW; Vinson DR

West J Emerg Med. 2018 Nov;19(6):938-946. Epub 2018-10-18.

PubMed abstract

Prospective Validation of a Standardized Ultrasonography-Based Ovarian Cancer Risk Assessment System

To evaluate the performance of a system that standardizes ovarian cancer risk assessment and reporting on ultrasonography. We conducted a prospective community-based cohort study of average-risk women undergoing ultrasonography in 2016 using a reporting system that requires adnexal masses to be categorized as 1, 2, 3, or X based on standardized ultrasound criteria including size, presence of solid components, and vascularity assessed by Doppler. With a median follow-up of 18 months, the risk of ovarian cancer or borderline tumor diagnosis for each category was determined. Among 43,606 women undergoing ultrasonography, 6,838 (16%) had an abnormal adnexal mass reported: 70% were category 1, 21% category 2, 3.7% category 3, and 5.4% category X. Among these women, 89 (1.3%) were subsequently diagnosed with ovarian cancer and 59 (0.9%) with borderline tumors. The risks of ovarian cancer diagnosis associated with masses reported as categories 1, 2, 3, and X were 0.2% (95% CI 0.05-0.3%), 1.3% (95% CI 0.7-1.9%), 6.0% (95% CI 3.0-8.9%), and 13.0% (95% CI 9.5-16.4%), respectively; risks of either ovarian cancer or borderline tumor were 0.4% (95% CI 0.2-0.6%), 2.3% (95% CI 1.6-3.1%), 10.4% (95% CI 6.6-14.1%), and 18.9% (95% CI 14.9-23.0%) respectively. Among 36,768 (84%) women with normal or benign adnexal findings reported, 38 women were diagnosed with ovarian cancer, for a risk of 0.1% (95% CI 0.07-0.14%). In a community-based setting with low ovarian cancer prevalence, our standardized reporting system differentiated adnexal masses into four categories with distinct levels of risk with 9-10% of women having higher risk masses and 70% of women having masses associated with a risk of cancer similar to that of normal ultrasound findings. The system supports risk-based management by providing clinicians a more consistent assessment of risk based on ultrasound characteristics.

Authors: Suh-Burgmann E; Flanagan T; Osinski T; Alavi M; Herrinton L

Obstet Gynecol. 2018 11;132(5):1101-1111.

PubMed abstract

Evaluating the Impact of Eliminating Copayments for Tobacco Cessation Pharmacotherapy

We examined the impact of the Affordable Care Act-mandated elimination of tobacco cessation pharmacotherapy (TCP) copayments on patient use of TCP, overall and by income. Electronic health record data captured any and combination (eg, nicotine gum plus patch) TCP use among adult smokers newly enrolled in Kaiser Permanente Northern California (KPNC). KPNC eliminated TCP copayments in 2015. We included current smokers newly enrolled in the first 6 months of 2014 (before copayment elimination, N=16,199) or 2015 (after elimination, N=16,469). Multivariable models estimated 1-year changes in rates of any TCP fill, and of combination TCP fill, and tested for differences by income (<$50k, $50?75k, ?$75k). Through telephone surveys in 2016 with a subset of smokers newly enrolled in 2014 (n=306), we assessed barriers to TCP use, with results stratified by income. Smokers enrolled in KPNC in 2015 versus 2014 were more likely to have a TCP fill (9.1% vs. 8.2%; relative risk, 1.19; 95% confidence interval, 1.11-1.27), and combination TCP fill, among those with any fill (42.3% vs. 37.9%; relative risk, 1.12; 95% confidence interval, 1.02-1.23); findings were stronger for low-income smokers. Low-income patients (<$50k) were less likely to report that clinicians discussed smoking treatments with them (58%) compared with higher income smokers ($50?75k, 67%; ?$75k, 83%), and were less aware that TCP was free (40% vs. 53% and 69%, respectively, P-values<0.05). The Affordable Care Act's copayment elimination was associated with a modest increase in TCP use and a greater effect among low-income smokers. Uptake may have been enhanced if promoted to patients directly and via providers.

Authors: Young-Wolff KC; Adams SR; Klebaner D; Adams AS; Campbell CI; Satre DD; Prochaska JJ

Med Care. 2018 11;56(11):912-918.

PubMed abstract

Associations of ICU Capacity Strain with Disposition and Outcomes of Patients with Sepsis Presenting to the Emergency Department

Intensive care unit (ICU) capacity strain refers to the potential limits placed on an ICU’s ability to provide high-quality care for all patients who may need it at a given time. Few studies have investigated how fluctuations in ICU capacity strain might influence care outside the ICU. To determine whether ICU capacity strain is associated with initial level of inpatient care and outcomes for emergency department (ED) patients hospitalized for sepsis. We performed a retrospective cohort study of patients with sepsis admitted from the ED to a medical ward or ICU at three hospitals within the University of Pennsylvania Health System between 2012 and 2015. Patients were excluded if they required life support therapies, defined as invasive or noninvasive ventilatory support or vasopressors, at the time of admission. The exposures were four measures of ICU capacity strain at the time of the ED disposition decision: ICU occupancy, ICU turnover, ICU census acuity, and ward occupancy. The primary outcome was the decision to admit to a ward or to an ICU. Secondary analyses assessed the association of ICU capacity strain with in-hospital outcomes, including mortality. Among 77,142 hospital admissions from the ED, 3,067 patients met the study’s eligibility criteria. The ICU capacity strain metrics varied between and within study hospitals over time. In unadjusted analyses, ICU occupancy, ICU turnover, ICU census acuity, and ward occupancy were all negatively associated with ICU admission. In the fully adjusted model including patient-level covariates, only ICU occupancy remained associated with ICU admission (odds ratio, 0.87; 95% confidence interval, 0.79-0.96; P = 0.005), such that a 10% increase in ICU occupancy (e.g., one additional patient in a 10-bed ICU) was associated with a 13% decrease in the odds of ICU admission. Among the subset of patients admitted initially from the ED to a medical ward, ICU occupancy at the time of admission was associated with increased odds of hospital mortality (odds ratio, 1.61; 95% confidence interval, 1.21-2.14; P = 0.001). The odds that patients in the ED with sepsis who do not require life support therapies will be admitted to the ICU are reduced when those ICUs experience high occupancy but not high levels of other previously explored measures of capacity strain. Patients with sepsis admitted to the wards during times of high ICU occupancy had increased odds of hospital mortality.

Authors: Anesi GL; Liu VX; Gabler NB; Delgado MK; Kohn R; Weissman GE; Bayes B; Escobar GJ; Halpern SD

Ann Am Thorac Soc. 2018 11;15(11):1328-1335.

PubMed abstract

Ensemble machine learning prediction of posttraumatic stress disorder screening status after emergency room hospitalization.

Posttraumatic stress disorder (PTSD) develops in a substantial minority of emergency room admits. Inexpensive and accurate person-level assessment of PTSD risk after trauma exposure is a critical precursor to large-scale deployment of early interventions that may reduce individual suffering and societal costs. Toward this aim, we applied ensemble machine learning to predict PTSD screening status three months after severe injury using cost-effective and minimally invasive data. Participants (N = 271) were recruited at a Level 1 Trauma Center where they provided variables routinely collected at the hospital, including pulse, injury severity, and demographics, as well as psychological variables, including self-reported current depression, psychiatric history, and social support. Participant zip codes were used to extract contextual variables including population total and density, average annual income, and health insurance coverage rates from publicly available U.S. Census data. Machine learning yielded good prediction of PTSD screening status 3 months post-hospitalization, AUC = 0.85 95% CI [0.83, 0.86], and significantly outperformed all benchmark comparison models in a cross-validation procedure designed to yield an unbiased estimate of performance. These results demonstrate that good prediction can be attained from variables that individually have relatively weak predictive value, pointing to the promise of ensemble machine learning approaches that do not rely on strong isolated risk factors.

Authors: Papini S; Pisner D; Shumake J; Powers MB; Beevers CG; Rainey EE; Smits JAJ; Warren AM

J Anxiety Disord. 2018 Dec;60:35-42. doi: 10.1016/j.janxdis.2018.10.004. Epub 2018 Oct 30.

PubMed abstract

Mobile-accessible personal health records increase the frequency and timeliness of PHR use for patients with diabetes

Personal health records (PHRs) offer patients a portal to view lab results, communicate with their doctors, and refill medications. Expanding PHR access to mobile devices could increase patients’ engagement with their PHRs. We examined whether access to a mobile-optimized PHR changed the frequency and timeliness of PHR use among adult patients with diabetes in an integrated delivery system. Among patients originally using the PHR only by computer, PHR use frequency increased with mobile access. Non-White patients were more likely to view their lab results within 7 days if they had computer and mobile access compared with computer only; however, there were no statistically significant differences among White patients. More frequent and timely mobile access to PHR data and tools may lead to convenient and effective PHR engagement to support patient self-management. Future studies should evaluate whether PHR use with a mobile device is associated with changes in self-management and outcomes.

Authors: Graetz I; Huang J; Brand R; Hsu J; Reed ME

J Am Med Inform Assoc. 2018 Oct 24.

PubMed abstract

Understanding functional and social risk characteristics of frail older adults: a cross-sectional survey study

Frailty is a condition of increasing importance, given the aging adult population. With an anticipated shortage of geriatricians, primary care physicians will increasingly need to manage care for frail adults with complex functional risks and social-economic circumstances. We used cross-sectional data from 4551 adults ages 65-90 who responded to the 2014/2015 cycle of the Kaiser Permanente Northern California Member Health Survey (MHS), a self-administered survey that covers multiple health and social characteristics, to create a deficits accumulation model frailty index, classify respondents as frail or non-frail, and then compare prevalence of functional health issues including Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL) and social determinants of health (SDOHs) by frailty status. The overall prevalence of frailty was 14.3%, higher for women than men, increased with age, and more common among those with low levels of education and income. Frail older adults were more likely than non-frail to have ≥ 3 chronic diseases (55.9% vs. 10.1%), obesity (32.7% vs. 22.8%), insomnia (36.4% vs. 8.8%), oral health problems (25.1% vs. 4.7%), balance or walking problems (54.2% vs. 4.9%), ≥ 1 fall (56.1% vs. 19.7%), to use ≥ 1 medication known to increase fall risk (56.7% vs. 26.0%), and to need help with ≥2 ADLs (15.8% vs. 0.8%) and ≥ 2 IADLs (38.4% vs. 0.8%). They were more likely to feel financial strain (26.9% vs. 12.6%) and to use less medication than prescribed (7.4% vs. 3.6%), less medical care than needed (8.3% vs 3.7%), and eat less produce (9.5% vs. 3.2%) due to cost. Nearly 20% of frail adults were unpaid caregivers for an adult with frailty, serious illness or disability. This study examined the prevalence of frailty and identified modifiable and non-modifiable risk factors of health. The frail older adult population is heterogeneous and requires a patient-centered assessment of their circumstances by healthcare providers and caregivers to improve their quality of life, avoid adverse health events, and slow physical and mental decline. The characteristics identified in this study can be proactively used for the assessment of patient health, quality of life, and frailty prevention.

Authors: Lee DR; Santo EC; Lo JC; Ritterman Weintraub ML; Patton M; Gordon NP

BMC Fam Pract. 2018 10 19;19(1):170. Epub 2018-10-19.

PubMed abstract

Omega 3 polyunsaturated fatty acids and healthy ageing

Authors: Zhu Y; Ferrara A; Forman MR

BMJ. 2018 10 17;363:k4263. Epub 2018-10-17.

PubMed abstract

Prevalence of infant bronchiolitis-coded healthcare encounters attributable to RSV

We sought to determine the proportion of bronchiolitis episodes attributable to respiratory syncytial virus (RSV) among ICD-9 coded infant bronchiolitis episodes which were tested for RSV. Bronchiolitis healthcare encounters were extracted from Kaiser Permanente Northern California databases for years 2006 to 2009. We used ICD-9 codes for bronchiolitis to capture bronchiolitis-related healthcare encounters including hospital admissions (Hospitalization), emergency department visits (EDV), and outpatient visits (OPV). We reported the monthly proportion of RSV-positive bronchiolitis episodes among tested bronchiolitis episodes. We used logistic regression to assess association between bronchiolitis episodes and patient demographic and health care characteristics. We also used logistic regression to assess association between decision to test and patient demographics and health care characteristics. Among 10,411 ICD-9 coded infant bronchiolitis episodes, 29% were RSV tested. Fifty one percent of those tested were RSV positive. Between December and February, and in infants ≤6 months, the proportion of bronchiolitis episodes that were attributable to RSV was 77.2% among hospitalized episodes, 78.3% among EDV episodes, and 60.9% among OPV episodes, respectively. The proportion of RSV-positive bronchiolitis episodes varied based upon infant age at diagnosis, level of health care service used, and time of the year of the episode. Estimation of the proportion of ICD-9 coded bronchiolitis episodes attributable to RSV is more specific when restricting to bronchiolitis episodes during peak months, younger infant age, and those requiring higher level of healthcare.

Authors: Turi KN; Wu P; Escobar GJ; Gebretsadik T; Ding T; Walsh EM; Li SX; Carroll KN; Hartert TV

Health Sci Rep. 2018 Dec;1(12):e91. Epub 2018-10-12.

PubMed abstract

Real-Time Patient-Provider Video Telemedicine Integrated with Clinical Care

Authors: Reed ME; Parikh R; Huang J; Ballard DW; Barr I; Wargon C

N Engl J Med. 2018 10 11;379(15):1478-1479.

PubMed abstract

Lagged effects of substance use on PTSD severity in a randomized controlled trial with modified prolonged exposure and relapse prevention.

OBJECTIVE: To advance understanding of the effectiveness of evidence-based treatments for comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD), research must provide a more nuanced picture of how substance use affects change in PTSD symptoms over the course of treatments and whether prolonged exposure techniques can be efficacious during active substance use. A data set that included patients with PTSD/subthreshold-PTSD and SUD treated with an exposure-based intervention provided an opportunity to conduct a secondary analysis to test how patients’ substance use impacted PTSD change over treatment. METHOD: We applied growth models to week-to-week PTSD symptom and substance use changes during treatment and follow-up of a randomized controlled trial of two cognitive-behavioral treatments for PTSD and SUD: Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE) and Relapse Prevention Therapy (RPT). Cross-lagged analyses were used to determine whether prior week substance use impacted subsequent PTSD symptom severity. RESULTS: Both treatments evidenced significant reductions in PTSD symptom severity. In the context of continued substance use, results suggest that individuals still benefit from exposure-based treatment. CONCLUSION: Results provide evidence that RPT and COPE both led to significant reductions in PTSD, providing further support that exposure-based techniques tailored for SUD can be conducted without jeopardizing PTSD or SUD outcomes. Implications for clinical decision making around treatment selection are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Authors: Hien DA; Smith KZ; Owens M; Lopez-Castro T; Ruglass LM; Papini S

J Consult Clin Psychol. 2018 Oct;86(10):810-819. doi: 10.1037/ccp0000345.

PubMed abstract

Reducing risk of Clostridium difficile infection and overall use of antibiotic in the outpatient treatment of urinary tract infection

Risk of community-acquired Clostridium difficile infection (CA-CDI) following antibiotic treatment specifically for urinary tract infection (UTI) has not been evaluated. We conducted a nested case-control study at Kaiser Permanente Northern California, 2007-2010, to assess antibiotic prescribing and other factors in relation to risk of CA-CDI in outpatients with uncomplicated UTI. Cases were diagnosed with CA-CDI within 90 days of antibiotic use. We used matched controls and confirmed case-control eligibility through chart review. Antibiotics were classified as ciprofloxacin (most common), or low risk (nitrofurantoin, sulfamethoxazole/trimethoprim), moderate risk, or high risk (e.g. cefpodoxime, ceftriaxone, clindamycin) for CDI. We computed the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the relationship of antibiotic treatment for uncomplicated UTI and history of relevant gastrointestinal comorbidity (including gastrointestinal diagnoses, procedures, and gastric acid suppression treatment) with risk of CA-CDI using logistic regression analysis. Despite the large population, only 68 cases were confirmed with CA-CDI for comparison with 112 controls. Female sex [81% of controls, adjusted odds ratio (OR) 6.3, CI 1.7-24), past gastrointestinal comorbidity (prevalence 39%, OR 2.3, CI 1.1-4.8), and nongastrointestinal comorbidity (prevalence 6%, OR 2.8, CI 1.4-5.6) were associated with increased CA-CDI risk. Compared with low-risk antibiotic, the adjusted ORs for antibiotic groups were as follows: ciprofloxacin, 2.7 (CI 1.0-7.2); moderate-risk antibiotics, 3.6 (CI 1.2-11); and high-risk antibiotics, 11.2 (CI 2.4-52). Lower-risk antibiotics should be used for UTI whenever possible, particularly in patients with a gastrointestinal comorbidity. However, UTI can be managed through alternative approaches. Research into the primary prevention of UTI is urgently needed.

Authors: Ge IY; Fevrier HB; Conell C; Kheraj MN; Flint AC; Smith DS; Herrinton LJ

Ther Adv Urol. 2018 Oct;10(10):283-293. Epub 2018-06-22.

PubMed abstract

Association between Inhaled Corticosteroid Use and Pulmonary Nontuberculous Mycobacterial Infection

Nontuberculous mycobacterial (NTM) pulmonary disease prevalence is increasing. To determine the association between the use of inhaled corticosteroids and the likelihood of NTM pulmonary infection among individuals with treated airway disease. We conducted a case-control study of subjects with airway disease with and without NTM pulmonary infection (based on mycobacterial respiratory cultures) between 2000 and 2010 in northern California. We quantified the use of inhaled corticosteroids, other airway disease medications, and healthcare use within 6 months of NTM pulmonary infection identification. We used 1:10 case-control matching and conditional logistic regression to evaluate the association between the duration and cumulative dosage of inhaled corticosteroid use and NTM pulmonary infection. We identified 248 cases with NTM pulmonary infection with an estimated rate of 16.4 cases per 10,000 subjects treated for airway disease. The median interval between treated airway disease cohort entry (defined as date of patient filling the third airway disease treatment prescription) and NTM case identification was 1,217 days. Compared with control subjects, subjects with NTM pulmonary infection were more likely to use airway disease medications including systemic steroids; they were also more likely to use health care. Any inhaled corticosteroids use between 120 days and 2 years before cohort entry was associated with substantially increased odds of NTM infection. For example, the adjusted odds ratio for NTM infection among inhaled corticosteroid users in a 2-year interval was 2.51 (95% confidence interval, 1.40-4.49; P?

Authors: Liu VX; Winthrop KL; Lu Y; Sharifi H; Nasiri HU; Ruoss SJ

Ann Am Thorac Soc. 2018 10;15(10):1169-1176.

PubMed abstract

Review of Metformin Use for Type 2 Diabetes Prevention

Prediabetes is prevalent and significantly increases lifetime risk of progression to type 2 diabetes. This review summarizes the evidence surrounding metformin use for type 2 diabetes prevention. Articles published between 1998 and 2017 examining metformin use for the primary indication of diabetes prevention available on MEDLINE. Forty articles met inclusion criteria and were summarized into four general categories: (1) RCTs of metformin use for diabetes prevention (n=7 and n=2 follow-up analyses); (2) observational analyses examining metformin use in heterogeneous subgroups of patients with prediabetes (n=9 from the Diabetes Prevention Program, n=1 from the biguanides and the prevention of the risk of obesity [BIGPRO] trial); (3) observational analyses examining cost effectiveness of metformin use for diabetes prevention (n=11 from the Diabetes Prevention Program, n=1 from the Indian Diabetes Prevention Program); and (4) real-world assessments of metformin eligibility or use for diabetes prevention (n=9). Metformin was associated with reduced relative risk of incident diabetes, with the strongest evidence for use in those at highest risk (i.e., aged <60 years, BMI ≥35, and women with histories of gestational diabetes). Metformin was also deemed cost effective in 11 economic analyses. Recent studies highlighted low rates of metformin use for diabetes prevention in real-world settings. Two decades of evidence support metformin use for diabetes prevention among higher-risk patients. However, metformin is not widely used in real-world practice, and enhancing the translation of this evidence to real-world practice has important implications for patients, providers, and payers.

Authors: Moin T; Schmittdiel JA; Flory JH; Yeh J; Karter AJ; Kruge LE; Schillinger D; Mangione CM; Herman WH; Walker EA

Am J Prev Med. 2018 10;55(4):565-574. Epub 2018-08-17.

PubMed abstract

Research to Change Health Delivery Systems: On the Outside Looking in?

Authors: Gopalan A; Grant RW

J Gen Intern Med. 2018 10;33(10):1592-1593.

PubMed abstract

The Implementation of Performance Management Systems in U.S. Physician Organizations

Performance management systems (PMSYS) aid in improving the quality and efficiency of care, but little is known about factors that influence more robust PMSYS among physician organizations. Using a nationally representative survey of U.S. medical practices, we examined the extent to which organizational capabilities and external factors were associated with more developed PMSYS. Linear regression estimated the relative impact of these factors on PMSYS. On average, practices implemented a minority (32 points out of 100) of the PMSYS processes assessed. Practices evaluated ( p < .01) or financially incentivized by external entities ( p < .01), receiving data from health plans ( p < .01), participating in an accountable care organization ( p < .01), affiliating with an independent practice association and/or physician-hospital organization ( p < .01), and using health information technology ( p < .01) and chronic disease registries ( p < .01) to greater degrees had more robust PMSYS. PMSYS of medical practices are underdeveloped, although both external incentives and organizational capabilities may support PMSYS development.

Authors: Pimperl AF; Rodriguez HP; Schmittdiel JA; Shortell SM

Med Care Res Rev. 2018 10;75(5):562-585. Epub 2017-03-08.

PubMed abstract

Traumatic brain injury associated with dementia risk among people with type 1 diabetes

To examine the association between traumatic brain injury (TBI) and dementia risk among a cohort of middle-aged and elderly individuals with type 1 diabetes (T1D). We evaluated 4,049 members of an integrated health care system with T1D ≥50 years old between January 1, 1996, and September 30, 2015. Dementia and TBI diagnoses throughout the study period were abstracted from medical records. Cox proportional hazards models estimated associations between time-dependent TBI and dementia adjusting for demographics, HbA1c, nephropathy, neuropathy, stroke, peripheral artery disease, depression, and dysglycemic events. Fine and Gray regression models evaluated the association between baseline TBI and dementia risk accounting for competing risk of death. A total of 178 individuals (4.4%) experienced a TBI and 212 (5.2%) developed dementia. In fully adjusted models, TBI was associated with 3.6 times the dementia risk (hazard ratio [HR] 3.64; 95% confidence interval [CI] 2.34, 5.68). When accounting for the competing risk of death, TBI was associated with almost 3 times the risk of dementia (HR 2.91; 95% CI 1.29, 5.68). This study demonstrates a marked increase in risk of dementia associated with TBI among middle-aged and elderly people with T1D. Given the complexity of self-care for individuals with T1D, and the comorbidities that predispose them to trauma and falls, future work is needed on interventions protecting brain health in this vulnerable population, which is now living to old age.

Authors: Gilsanz P; Albers K; Beeri MS; Karter AJ; Quesenberry CP; Whitmer RA

Neurology. 2018 Sep 26.

PubMed abstract

Exposure-based therapy changes amygdala and hippocampus resting-state functional connectivity in patients with posttraumatic stress disorder.

BACKGROUND: Recent research suggests that posttraumatic stress disorder (PTSD) is associated with altered amygdala and hippocampal resting-state functional connectivity (rsFC). However, less research has examined whether Prolonged Exposure (PE), a first line exposure-based treatment for PTSD, has the potential to alter resting state neural networks. METHODS: A total of 24 patients with PTSD and 26 matched trauma-exposed healthy controls (TEHCs) underwent resting-state functional magnetic resonance imaging (fMRI) at baseline. PTSD patients were scanned a second time after completing 10-session PE in which patients narrated a detailed trauma account (imaginal exposure) and confronted trauma reminders (in vivo exposure) to extinguish trauma-related fear responses. TEHC were scanned again following a 10-week waiting period. Seed regions of interest (ROIs) included centromedial amygdala (CMA), basolateral amygdala (BLA), and the hippocampus. RESULTS: Post- versus pretreatment comparisons indicated increased rsFC of the BLA and CMA with the orbitofrontal cortex (OFC), and hippocampus-medial prefrontal cortex (mPFC) among patients with PTSD, but not among TEHC participants. CONCLUSIONS: Enhanced amygdala and hippocampus rsFC with prefrontal cortical regions following PE could underlie improved capacity for inhibition and re-evaluation of threat, and heightened memory encoding and retrieval ability, respectively. These findings encourage further investigation of this circuitry as a therapeutic target in PTSD.

Authors: Zhu X; Suarez-Jimenez B; Lazarov A; Helpman L; Papini S; Lowell A; Durosky A; Lindquist MA; Markowitz JC; Schneier F; Wager TD; Neria Y

Depress Anxiety. 2018 Oct;35(10):974-984. doi: 10.1002/da.22816. Epub 2018 Sep 10.

PubMed abstract

Long-term Glycemic Control and Dementia Risk in Type 1 Diabetes

Individuals with type 1 diabetes have experienced an increase in life expectancy; yet, it is unknown what level of glycemic control is ideal for maintaining late-life brain health. We investigated the association of long-term glycemic control with dementia in older individuals with type 1 diabetes. We followed 3,433 members of a health care system with type 1 diabetes, ages ≥50 years, from 1996 to 2015. Repeated measurements of hemoglobin A1c (HbA1c), dementia diagnoses, and comorbidities were ascertained from health records. Cox proportional hazards models were fit to evaluate the association of time-varying glycemic exposure with dementia, with adjustment for age, sex, race/ethnicity, baseline health conditions, and frequency of HbA1c measurement. Over a mean follow-up of 6.3 years, 155 individuals (4.5%) were diagnosed with dementia. Patients with ≥50% of HbA1c measurements at 8-8.9% (64-74 mmol/mol) and ≥9% (≥75 mmol/mol) had 65% and 79% higher risk of dementia, respectively, compared with those with

Authors: Lacy ME; Gilsanz P; Karter AJ; Quesenberry CP; Pletcher MJ; Whitmer RA

Diabetes Care. 2018 Sep 04.

PubMed abstract

The Effect of Age and Comorbidities on the Association Between the Medicare STAR Oral Antihyperglycemic Adherence Metric and Glycemic Control

The Medicare STAR program for Medicare Advantage Plans that include drug benefits provides monetary incentives for health plans to achieve good adherence to oral antihyperglycemic (OAH) agents but does not account for differential case mix that could affect the ability of health plans to achieve the required quality metrics. To determine whether OAH adherence varies by age and comorbidities among patients aged 65 years or older and the extent to which adherence affects glycemic control across age and comorbidity strata. We studied 54,480 patients with diabetes aged > 65 years from the Colorado, Northwest, and Northern California regions of Kaiser Permanente who received OAH agents but not insulin in 2010. We calculated adherence using the proportion of days covered (PDC) method. Per the STAR program, hemoglobin A1c < 8% defined good glycemic control. We also defined poor control as A1c > 9%. We used modified Poisson regression to identify predictors of adherence and to determine its effects on A1c across age and comorbidity strata, adjusting for sociodemographics and medication-related variables. The risk of being adherent to OAH declined moderately with an increasing number of comorbidities (risk ratio [RR] = 0.99, 95% CI = 0.98-1.00 for 1 comorbidity and RR = 0.90, 95% CI = 0.88-0.91 for 4 or more comorbidities). Adherence to OAH agents was associated with a 0%-3% increased risk of A1c < 8% across age and comorbidity categories, as well as a large decreased risk (RR = 0.55-0.73) of A1c > 9% for patients aged < 80 years or with < 3 comorbidities. Among patients with diabetes aged > 65 years, having multiple comorbidities affects adherence. Adherence reduces the risk of poor A1c control among patients aged 65-79 years or with 2 or fewer comorbidities. Our results suggest that health plan case mix minimally influenced the Medicare STAR OAH adherence metric, but it may affect glycemic control quality measures, especially if a HEDIS-like measure of poor control were adopted. This study was supported by grant number 1R21DK103146-01A1 from the National Institute of Diabetes and Digestive and Kidney Disorders. Nichols currently receives grant funding from Boehringer-Ingelheim, Sanofi, Amarin Pharma, and Janssen Pharmaceuticals for other unrelated research projects. The other authors declare no conflicts of interest. This study was presented at the American Diabetes Association’s 77th Scientific Sessions; June 9-13, 2017; San Diego, CA.

Authors: Nichols GA; Raebel MA; Dyer W; Schmittdiel JA

J Manag Care Spec Pharm. 2018 Sep;24(9):856-861.

PubMed abstract

Language barriers and LDL-C/SBP control among Latinos with diabetes

Language barriers in healthcare are associated with worse glycemic control among Latino patients with limited English proficiency and diabetes. We examined the association of patient-physician language concordance with lipid (low-density lipoprotein cholesterol [LDL-C]) and systolic blood pressure (SBP) control. Retrospective cohort study. Data were obtained from a survey and the electronic health records of Latino and white patients with diabetes receiving care within 1 integrated health plan with interpreter services available. Limited English proficiency and patient-physician language concordance were defined by patient report. Outcomes were poor lipid control (LDL-C >100 mg/dL) and poor SBP control (SBP >140 mm Hg). In total, 3463 Latino (2921 who spoke English and 542 who were limited English proficient [LEP]) and 3896 English-speaking white patients participated. One-third of the patients had poor lipid control and one-fifth had poor SBP control. English-speaking white patients were slightly less likely to have poor lipid control than English-speaking Latino patients, but the difference did not persist after adjustment for age and sex. Among Latinos, LEP patients were less likely to have poor lipid control than English-speaking patients (odds ratio, 0.71; 95% CI, 0.54-0.93), with no difference by LEP patient-physician language concordance. Poor SBP control did not differ by ethnicity, primary language, or patient-physician language concordance. We found no evidence that ethnicity or language barriers in healthcare were associated with poorer lipid or blood pressure control among Latino and white patients with diabetes receiving care in settings with professional interpreters.

Authors: Fernandez A; Warton EM; Schillinger D; Moffet HH; Kruger J; Adler N; Karter AJ

Am J Manag Care. 2018 09;24(9):405-410.

PubMed abstract

Risk of Incident Atherosclerotic Cardiovascular Disease Events by Achieved Atherogenic Lipid Levels Among 62,428 Statin-Treated Individuals With Diabetes Mellitus

The relevance of low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C) goals for primary prevention of atherosclerotic cardiovascular disease (ASCVD) among patients with diabetes was assessed. This retrospective cohort study included patients with type 2 diabetes, age 21 to 90years, taking statins, with no history of ASCVD as of January 1, 2006, in Kaiser Permanente Northern California, an integrated healthcare delivery system. Multivariate cox models were utilized to estimate hazard ratios (HRs) for incident ASCVD events by achieved LDL-C and non-HDL-C levels with adjustment for potential confounders. Incident ASCVD events were defined as a composite of myocardial infarction, ischemic stroke, or coronary heart disease death. A cohort of 62,428 patients, with mean age of 64.1years, 46.9% women, and mean follow-up of 6.0 years, was identified. After adjustment, the risk of incident ASCVD for these statin-treated patients was monotonically lower with decreasing achieved LDL-C levels (p<0.0001 for trend) and non-HDL-C levels (p <0.0001 for trend). Relative to achieved LDL-C ≥130 mg/dl, LDL-C <50 mg/dl had HR = 0.58 (95% confidence interval 0.49 to 0.69). Relative to achieved non-HDL-C ≥160mg/dl, non-HDL-C <80 mg/dl had HR = 0.59 (95% confidence interval 0.51 to 0.68). In a large cohort of statin-treated diabetic patients without ASCVD, a monotonically lower risk of incident ASCVD events was associated with lower achieved lipid levels. These findings support the use of LDL-C ornon-HDL-C treatment goals for ASCVD primary prevention in diabetic patients.

Authors: Rana JS; Liu JY; Moffet HH; Boklage SH; Khan I; Karter AJ

Am J Cardiol. 2018 09 01;122(5):762-767. Epub 2018-06-02.

PubMed abstract

Association of behavioral health factors and social determinants of health with high and persistently high healthcare costs

A high proportion of U.S. health care costs are attributable to a relatively small proportion of patients. Understanding behavioral and social factors that predict initial and persistent high costs for these “high utilizers” is critical for health policy-makers. This prospective observational study was conducted at Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system with 4.1 million members. A stratified random sample of high-cost vs. non-high-cost adult KPNC members matched by age, gender, race/ethnicity, type of health insurance, and medical severity (N = 378) was interviewed between 3/14/2013 and 3/20/2014. Data on health care costs and clinical diagnoses between 1/1/2008 and 12/31/2012 were derived from the electronic health record (EHR). Social-economic status, depression symptoms, adverse childhood experiences (ACEs), interpersonal violence, financial stressors, neighborhood environment, transportation access, and patient activation and engagement were obtained through telephone interviews. Initial and subsequent high-cost status were defined as being classified in top 20% cost levels over 1/1/2009-12/31/2011 and 1/1/2012-12/31/2012, respectively. Psychiatric diagnosis (OR 2.55, 95% CI 1.52-4.29, p < 0.001), financial stressors (OR 1.97, 95% CI 1.19-3.26, p = 0.009), and ACEs (OR 1.10, 95% CI 1.00-1.20, p = 0.051) predicted initial high-cost status. ACEs alone predicted persistent high-cost status in the subsequent year (OR 1.12, 95% CI 1.00-1.25, p = 0.050). Non-medical factors such as psychiatric problems, financial stressors and adverse childhood experiences contribute significantly to the likelihood of high medical utilization and cost. Efforts to predict and reduce high utilization must include measuring and potentially addressing these factors.

Authors: Sterling S; Chi F; Weisner C; Grant R; Pruzansky A; Bui S; Madvig P; Pearl R

Prev Med Rep. 2018 Sep;11:154-159. Epub 2018-06-27.

PubMed abstract

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

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. To characterize factors that best identify which complex patients are most suited for intensive care management. We conducted a mixed-methods study involving 35 care managers (CMs; 10 licensed social workers and 25 registered nurses) working in intensive care management programs within Kaiser Permanente Northern California (KPNC) outpatient medical centers. We asked CMs to review a randomly selected list of up to 50 patients referred to them in the prior year and to categorize each patient as either (1) “good candidates” for care management, (2) “not needing” intensive care management, or (3) “needing more” than traditional care management could provide. We then conducted semi-structured interviews to understand how CMs separated patients into these three groups. CMs assigned 1178 patients into the 3 referral categories. Less than two thirds (62%, n = 736) of referred patients were considered good candidates, with 18% (n = 216) categorized as not needing care management and 19% (n = 226) as needing more. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 for not needing and 69.8 for needing more, p < 0.001), prescribed more medications (p = 0.02) and had more prior year outpatient visits (p = 0.04), while the number of prior year hospital and emergency room admissions were greater than not needing but less than needing more (p < 0.001). A logistic regression model using available electronic record data predicted good candidate designation with a c statistic of 0.75. Several qualitative themes emerged that helped define appropriateness for referral, including availability of social support, patient motivation, non-medical transitions, recent trajectory of medical condition, and psychiatric or substance use issues. Many apparently complex patients are not good candidates for intensive care management. Current electronic medical records do not capture several of the most salient characteristics that determine appropriateness for care management. Our findings suggest that systematic collection of social support, patient motivation, and recent non-medically related life change information may help identify which complex patients are most likely to benefit from care management.

Authors: Garcia ME; Uratsu CS; Sandoval-Perry J; Grant RW

J Gen Intern Med. 2018 09;33(9):1454-1460. Epub 2018-05-24.

PubMed abstract

Collaborative research and actions on both sides of the US-Mexico border to counteract type 2 diabetes in people of Mexican origin.

BACKGROUND: Type 2 Diabetes (T2D) is now a massive epidemic in both California and Mexico, with serious consequences for social and economic well-being. A large proportion of these populations share common ethnic backgrounds. Yet diverse environmental and social conditions across regions create unique opportunities to explore the ways that T2D risk, incidence, management and outcomes manifest. MAIN TEXT: An action-oriented research consortium headed up by the University of California and Universidad Nacional Autonoma de Mexico was constituted to set priorities for bi-national translational research, in an attempt to implement and evaluate clinical, public health and policy actions to decrease the burden of T2D for people of Mexican origin. In this paper, we describe the epidemiology of T2D in Mexico and California, review current efforts to combat the epidemic, highlight gaps in knowledge and identify urgent areas of opportunity for collaboration. The group has developed a common research agenda and funding has been obtained to evaluate biological samples from the 2016 Mexican Health Survey, collaborate in a telemedicine-based retinopathy project, implement interventions in food banks, promote a communications campaign, and design a large-scale diabetes prevention effectiveness trial. CONCLUSIONS: T2D has caused a state of emergency in Mexico and is a major health problem among Mexican populations on both sides of the border. Understanding the commonalities and differences between California and Mexico for those of Mexican origin with respect to T2D, when combined with a sharing of knowledge and advances, can produce a bi-national translational research agenda to inform relevant policy and practice. Amidst economic and political uncertainty and limited healthcare budgets, this collaboration can contribute to the development of scientific evidence to inform policies and interventions. This may provide a promising collaborative model that could be expanded to other health conditions and regions of the world.

Authors: Barquera S; Schillinger D; Aguilar-Salinas CA; Schenker M; Rodriguez LA; Hernandez-Alcaraz C; Sepulveda-Amor J

Global Health. 2018 Aug 22;14(1):84. doi: 10.1186/s12992-018-0390-5.

PubMed abstract

Brief Commentary: Glycemic Targets for Older Adults With Type 2 Diabetes

Authors: Schroeder EB; Karter AJ

Ann Intern Med. 2018 08 21;169(4):250-251. Epub 2018-06-26.

PubMed abstract

Diagnosis-based cohort augmentation using laboratory results data: The case of chronic kidney disease

In this report, we use data from FDA’s Sentinel System to focus on how augmenting a diagnosis-based chronic kidney disease cohort with patients identified through laboratory results impacts cohort characteristics and outcomes. We used data from 2 Data Partners. Patients were eligible if they were health plan members on January 1, 2012. We classified chronic kidney disease patients into mutually exclusive categories according to the hierarchy of (1) ICD-9-CM diagnosis (DXGroup), or (2) two estimated glomerular filtration rates <60 mL/min/1.73m2 , separated by at least 90 days (2-LabGroup), or (3) a single estimated glomerular filtration rates <60 mL/min/1.73m2 (1-LabGroup). We compared the groups on demographic, clinical, and health care utilization characteristics using pairwise standardized differences. We used Cox regression to compare the groups on mortality, adjusting for baseline covariates. We identified 209 864 patients: 107 607 in DxGroup (51%) and 102 257 (49%) from laboratory data alone. For every characteristic, the DxGroup was the sickest, followed by the 2-LabGroup and then the 1-LabGroup. The DxGroup was more likely to die than 2-LabGroup (hazard ratio [HR], 1.47; 95% CI, 1.22-1.77) at Site 1; that effect was observed, but attenuated, at Site 2 (HR, 1.16; 95% CI, 1.07-1.25). The DxGroup was more likely to die than the 1-LabGroup at Site 1 (HR, 1.36; 95% CI, 1.20-1.55), but not at Site 2 (HR, 0.94; 95% CI, 0.89-1.00). We suggest that drug safety researchers consider whether the method of cohort identification contributes to generalizability of safety findings.

Authors: Smith DH; Shetterly S; Flory J; Haynes K; Lu CY; Gagne JJ; Herrinton L; Nyirenda C; Patorno E; Shoaibi A; Raebel MA

Pharmacoepidemiol Drug Saf. 2018 08;27(8):872-877. Epub 2018-06-22.

PubMed abstract

Immediate sequential bilateral cataract surgery: surgeon preferences and concerns

We surveyed cataract surgeons to gain insight into their perceptions of and attitudes about immediate sequential bilateral cataract surgery (ISBCS). Cross-sectional. All active cataract surgeons in Kaiser Permanente Northern California in 2016. Online survey that asked cataract surgeons why they did or did not perform ISBCS, their interest in offering ISBCS, concerns about the procedure, and desired supports. Of the 165 active cataract surgeons, 107 (65%) participated in the survey, of whom 92 (86%) responded that they currently practiced ISBCS and 15 (14%) reported that they did not. For ISBCS surgeons, patient convenience (95%) and patient request (91%) were the top reasons for performing the procedure. For surgeons who do not perform ISBCS, the most commonly cited concerns were not having the postoperative refractive outcome from the first eye to guide intraocular lens selection in the second eye (80%) and risk of bilateral vision loss (73%). Among those who do not perform ISBCS, 9 (60%) identified the need for evidence-based patient selection criteria to support a decision to adopt the procedure. In addition, many surgeons in both groups wanted streamlined patient education materials and established protocols. Patient centeredness is a key construct of contemporary health care delivery, and in an era of low complication risk, many patients request ISBCS; the number of these surgeries has increased. In our capitated health care system, the great majority of surgeons perform ISBCS for the convenience of their patients. Providing surgeons with guidelines and tools to support ISBCS likely would increase adoption.

Authors: Amsden LB; Shorstein NH; Fevrier H; Liu L; Carolan J; Herrinton LJ

Can J Ophthalmol. 2018 08;53(4):337-341. Epub 2017-12-27.

PubMed abstract

Eating with others and meal location are differentially associated with nutrient intake by sex: The Diabetes Study of Northern California (DISTANCE)

Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating – frequencies of eating meals with others, meals prepared at home, and meals outside the home – are associated with nutrient intake. Because diet improvement can reduce complications of diabetes mellitus, we surveyed a multi-ethnic cohort of persons with type 2 diabetes (n = 770) about social aspects of diet (based on 24-hour recalls). Sex-stratified multiple regression analyses adjusted for confounders assessed the relationship between frequency of eating with others and nutrient intake (total energy, energy from fat, energy from carbohydrates, Healthy Eating Index/HEI, Dietary Approaches to Stop Hypertension/DASH score). Although there was slight variation in men’s versus women’s propensity to share meals, after adjustment for confounders, there was no consistently significant association between meals with others and the 5 nutrient intake measures for either men or women. The directions of association between categories of eating with others and diet quality (HEI and DASH scores) – albeit not significant – were different for men (positive) and women (mostly negative), which warrants further investigation. The next analyses estimated nutrient intake associated with meals prepared at home, and meals consumed outside the home. Analyses indicated that greater meal frequency at home was associated with significantly better scores on diet quality indices for men (but not women), while meal frequency outside the home was associated with poorer diet quality and energy intake for women (but not men). Better measurement of social dimensions of eating may inform ways to improve nutrition, especially for persons with diabetes for whom diet improvement can result in better disease outcomes.

Authors: Pachucki MC; Karter AJ; Adler NE; Moffet HH; Warton EM; Schillinger D; O'Connell BH; Laraia B

Appetite. 2018 08 01;127:203-213. Epub 2018-03-27.

PubMed abstract

Association of Initiation of Basal Insulin Analogs vs Neutral Protamine Hagedorn Insulin With Hypoglycemia-Related Emergency Department Visits or Hospital Admissions and With Glycemic Control in Patients With Type 2 Diabetes

In clinical trials of patients with type 2 diabetes, long-acting insulin analogs modestly reduced the risk of nocturnal hypoglycemia compared with human neutral protamine Hagedorn (NPH) insulin, but cost 2 to 10 times more. Outcomes in clinical practice may differ from trial results. To compare the rates of hypoglycemia-related emergency department (ED) visits or hospital admissions associated with initiation of long-acting insulin analogs vs human NPH insulin in patients with type 2 diabetes. A retrospective observational study using data from Kaiser Permanente of Northern California from January 1, 2006, through September 30, 2015. Patients with type 2 diabetes who initiated a long-acting insulin analog or NPH insulin were included and censored at death, loss of health plan coverage, change in insulin treatment, or study end on September 30, 2015. Initiation of basal insulin analogs (glargine or detemir) vs NPH insulin. The primary outcome was the time to a hypoglycemia-related ED visit or hospital admission and the secondary outcome was the change in hemoglobin A1c level within 1 year of insulin initiation. There were 25 489 patients with type 2 diabetes who initiated basal insulin therapy (mean age, 60.2 [SD, 11.8] years; 51.9% white; 46.8% female). During a mean follow-up of 1.7 years, there were 39 hypoglycemia-related ED visits or hospital admissions among 1928 patients who initiated insulin analogs (11.9 events [95% CI, 8.1 to 15.6] per 1000 person-years) compared with 354 hypoglycemia-related ED visits or hospital admissions among 23 561 patients who initiated NPH insulin (8.8 events [95% CI, 7.9 to 9.8] per 1000 person-years) (between-group difference, 3.1 events [95% CI, -1.5 to 7.7] per 1000 person-years; P = .07). Among 4428 patients matched by propensity score, the adjusted hazard ratio was 1.16 (95% CI, 0.71 to 1.78) for hypoglycemia-related ED visits or hospital admissions associated with insulin analog use. Within 1 year of insulin initiation, hemoglobin A1c level decreased from 9.4% (95% CI, 9.3% to 9.5%) to 8.2% (95% CI, 8.1% to 8.2%) after initiation of insulin analogs and from 9.4% (95% CI, 9.3% to 9.5%) to 7.9% (95% CI, 7.9% to 8.0%) after initiation of NPH insulin (adjusted difference-in-differences for glycemic control, -0.22% [95% CI, -0.09% to -0.37%]). Among patients with type 2 diabetes, initiation of a basal insulin analog compared with NPH insulin was not associated with a reduced risk of hypoglycemia-related ED visits or hospital admissions or with improved glycemic control. These findings suggest that the use of basal insulin analogs in usual practice settings may not be associated with clinical advantages for these outcomes.

Authors: Lipska KJ; Parker MM; Moffet HH; Huang ES; Karter AJ

JAMA. 2018 07 03;320(1):53-62.

PubMed abstract

Influence of a New Diabetes Diagnosis on the Health Behaviors of the Patient’s Partner

When a person is given a diagnosis of diabetes, the changes in his or her health behaviors may influence the behaviors of his or her partner. The diabetes diagnosis may affect household members’ perceptions of their own health risks, which could trigger behavioral change. The purpose of this study was to assess whether partners of persons with newly diagnosed diabetes changed their health behaviors compared with partners of persons without diabetes. The study population consisted of Kaiser Permanente Northern California health plan members from 2007 to 2011. This cohort study assessed differences in change of 8 health behaviors. The study compared coresiding partners of persons with newly diagnosed diabetes before and after a diabetes diagnosis with a 5 to 1 matched sample of coresiding partners of persons without diabetes. A total of 180,910 couples were included in the analysis. After adjusting for baseline characteristics, partners of persons with newly diagnosed diabetes had significantly higher rates of participation in weight management-related health education classes (risk ratio [RR] = 1.50; 95% CI, 1.39-1.63); smoking cessation medication use (RR = 1.25; 95% CI, 1.05-1.50); glucose screening (RR = 1.07; 95% CI, 1.05-1.08); clinically meaningful weight loss (RR = 1.06; 95% CI, 1.02-1.11); lipid screening (RR = 1.05; 95% CI, 1.04-1.07); influenza vaccination (RR = 1.03; 95% CI, 1.02-1.04); and blood pressure screening (RR = 1.02; 95% CI, 1.02-1.03) compared with partners of persons without diabetes. There were small but significant differences in health-related behavioral changes among partners of persons with newly diagnosed diabetes compared with partners of persons without diabetes, even when no intervention occurred. This finding suggests a diabetes diagnosis within a family may be a teachable moment to improve health behaviors at the household level.

Authors: Schmittdiel JA; Cunningham SA; Adams SR; Nielsen J; Ali MK

Ann Fam Med. 2018 07;16(4):290-295.

PubMed abstract

Risk Adjustment for Hospital Characteristics Reduces Unexplained Hospital Variation in Pressure Injury Risk

Research investigating risk factors for hospital-acquired pressure injury (HAPI) has primarily focused on the characteristics of patients and nursing staff. Limited data are available on the association of hospital characteristics with HAPI. We aimed to quantify the association of hospital characteristics with HAPI and their effect on residual hospital variation in HAPI risk. We employed a retrospective cohort study design with split validation using hierarchical survival analysis. This study extends the analysis “Hospital-Acquired Pressure Injury (HAPI): Risk Adjusted Comparisons in an Integrated Healthcare Delivery System” by Rondinelli et al. (2018) to include hospital-level factors. We analyzed 1,661 HAPI episodes among 728,266 adult hospitalization episodes across 35 California Kaiser Permanente hospitals, an integrated healthcare delivery system between January 1, 2013, and June 30, 2015. After adjusting for patient-level and hospital-level variables, 2 out of 12 candidate hospital variables were statistically significant predictors of HAPI. The hazard for HAPI decreased by 4.8% for every 0.1% increase in a hospital’s mean mortality ([6.3%, 2.6%], p < .001), whereas every 1% increase in a hospital's proportion of patients with a history of diabetes increased HAPI hazard by 5% ([-0.04%, 10.0%], p = .072). Addition of these hierarchical variables decreased unexplained hospital variation of HAPI risk by 35%. We found hospitals with higher patient mortality had lower HAPI risk. Higher patient mortality may decrease the pool of patients who live to HAPI occurrence. Such hospitals may also provide more resources (specialty staff) to care for frail patient populations. Future research should aim to combine hospital data sets to overcome power limitations at the hospital level and should investigate additional measures of structure and process related to HAPI care.

Authors: Linnen DT; Kipnis P; Rondinelli J; Greene JD; Liu V; Escobar GJ

Nurs Res. 2018 Jul/Aug;67(4):314-323.

PubMed abstract

Toward the “Plateau of Productivity”: Enhancing the Value of Machine Learning in Critical Care

Authors: Liu VX

Crit Care Med. 2018 07;46(7):1196-1197.

PubMed abstract

Diabetes and Prediabetes Prevalence by Race and Ethnicity Among People With Severe Mental Illness

Authors: Mangurian CV; Schillinger D; Newcomer JW; Vittinghoff E; Essock SM; Zhu Z; Dyer WT; Schmittdiel JA

Diabetes Care. 2018 07;41(7):e119-e120. Epub 2018-06-13.

PubMed abstract

The Relationship Between Prescription Copayments and Contraceptive Adherence in a New-user Cohort

Contraceptive nonadherence is an important contributor to unintended pregnancy in the United States. While the elimination of patient cost sharing has been cited as means to improve contraceptive access, little is known about the relationship between cost sharing and ongoing adherence and continuation of chosen methods. The purpose of this study was to examine the relationship between copayment amount and adherence to pharmacy-dispensed contraception in young women. We conducted a retrospective cohort study of 39,142 women ages 19-29 with a new prescription for the contraceptive pill, patch, or ring at Kaiser Permanente Northern California during 2011-2014. We examined 12-month nonadherence as measured by timely prescription refills and used multivariable Cox proportional hazards models to assess the association between copayment amount and the risk of nonadherence. Ninety-four percent of women used the pill, and 6% used the patch or ring. Forty percent of patients had no copayment and 25% had a copayment of ≥$30. Nearly 75% of women were nonadherent during the study period. In 2013 and 2014, women with a copayment had a 9% increased risk of nonadherence (adjusted hazard ratio, 1.09; 95% confidence interval, 1.04, 1.14) compared with women with no copayment. Prescription copayments may serve as a barrier to adherence of pharmacy-dispensed contraception. Given recent changes to Affordable Care Act contraceptive coverage requirement, these findings can be used to support state-level and health system-level policies for no-cost contraception, and to determine the potential public health impact of this policy change.

Authors: Marshall C; Schmittdiel J; Chandra M; Calhoun A; Raine-Bennett T

Med Care. 2018 07;56(7):577-582.

PubMed abstract

Surveillance of Hypoglycemia-Limitations of Emergency Department and Hospital Utilization Data

Authors: Karter AJ; Moffet HH; Liu JY; Lipska KJ

JAMA Intern Med. 2018 07 01;178(7):987-988.

PubMed abstract

Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes

Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge. The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5-day pulmonary embolism-related return visits and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5-day pulmonary embolism-related return visit. Thirty-day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All-cause 30-day mortality was lower in the home discharge group (1.1% versus 4.4%). Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes.

Authors: Vinson DR; Ballard DW; Reed ME; Sax DR; Mark DG; MAPLE Investigators of the KP CREST Network; et al.

Ann Emerg Med. 2018 07;72(1):62-72.e3. Epub 2017-12-13.

PubMed abstract

Adherence to Cardio-protective Medications Prescribed for Secondary Prevention after an Acute Coronary Syndrome Hospitalization Compared to Usual Care

Secondary prevention after an acute coronary syndrome (ACS) hospitalization is critical to prevent additional morbidity and mortality. While poor adherence to prescribed cardio-protective medications is a known problem;1;2 it is unknown whether an ACS event might motivate patients to achieve better adherence. In a large integrated health care population; we examined initiation and adherence to newly prescribed cardio-protective medications among post-ACS event patients compared to patients who were prescribed these same medications in usual care.Strengths of this study include the large cohort with 12–15 months of follow-up and a robust adherence methodology based on pharmacy dispensing records in this closed health care system. We did not assess adherence to aspirin, an essential medication for this patient population, because it is often obtained over-the-counter and thus not reliably measurable from pharmacy dispensing.Adherence to newly prescribed cardio-protective medications was excellent among ACS patients discharged from the hospital, and substantially better than patients prescribed the same medications in usual care, suggesting that experiencing an ACS event may motivate patients to be more adherent to medications prescribed at discharge than they might be in usual care. However, despite having had an ACS event, and although better adherence than a similar, previously reported study,4 adherence over time among ACS patients remained suboptimal.Our study in a large real world contemporary population illustrates that post-ACS medication adherence was much better than that observed among patients receiving the same medications in usual care, perhaps due to motivation conferred by the ACS event itself. Nonetheless, medication adherence was suboptimal even in ACS patients, limiting the potential benefits of these proven treatments. Multifactorial interventions that address the various psychosocial, socioeconomic, and behavioral patient barriers are needed to improve adherence in these high-risk patients.

Authors: Rana JS; Parker MM; Liu JY; Moffet HH; Karter AJ

J Gen Intern Med. 2018 Jun 07.

PubMed abstract

Immersive 3D exposure-based treatment for spider fear: A randomized controlled trial.

Stereoscopic 3D gives the viewer the same shape, size, perspective and depth they would experience viewing the real world and could mimic the perceptual threat cues present in real life. This is the first study to investigate whether an immersive stereoscopic 3D video exposure-based treatment would be effective in reducing fear of spiders. Participants with a fear of spiders (N=77) watched two psychoeducational videos with facts about spiders and phobias. They were then randomized to a treatment condition that watched a single session of a stereoscopic 3D immersive video exposure-based treatment (six 5-min exposures) delivered through a virtual reality headset or a psychoeducation only control condition that watched a 30-min neutral video (2D documentary) presented on a computer monitor. Assessments of spider fear (Fear of Spiders Questionnaire [FSQ], Behavioral Approach Task [BAT], & subjective ratings of fear) were completed pre- and post-treatment. Consistent with prediction, the stereoscopic 3D video condition outperformed the control condition in reducing fear of spiders showing a large between-group effect size on the FSQ (Cohen’s d=0.85) and a medium between-group effect size on the BAT (Cohen’s d=0.47). This provides initial support for stereoscopic 3D video in treating phobias.

Authors: Minns S; Levihn-Coon A; Carl E; Smits JAJ; Miller W; Howard D; Papini S; Quiroz S; Lee-Furman E; Telch M; Carlbring P; Xanthopoulos D; Powers MB

J Anxiety Disord. 2018 Aug;58:1-7. doi: 10.1016/j.janxdis.2018.05.006. Epub 2018 Jun 4.

PubMed abstract

Improved Cardiovascular Risk Factors Control Associated with a Large-Scale Population Management Program Among Diabetes Patients

Optimal cardiovascular risk factors control among individuals with diabetes remains a challenge. We evaluated changes in glucose, lipid, and blood pressure control among diabetes patients after implementation of a large-scale population management program, known as Preventing Heart Attacks and Strokes Everyday, at Kaiser Permanente Northern California (KPNC), during 2004-2013. We used National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set cut points to identify prevalence of poor glycemic (hemoglobin A1c > 9%) control, good lipid control (low-density lipoprotein cholesterol < 100 mg/dL), and good blood pressure control (blood pressure < 140/90 mm Hg) in each year (N range = 98,345 to 122,177 over the entire period). We assessed trends in risk factor control based on Joinpoint regression and average annual percentage change (AAPC) compared with published National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set commercial rates. We found that the prevalence of poor glycemic control (hemoglobin A1c > 9%) declined in both KPNC and nationally, but was statistically significant only in KPNC (AAPC = -4.8; P < .05). The prevalence of good lipid control (low-density lipoprotein cholesterol < 100 mg/dL) increased significantly in KPNC (47% to 71%; AAPC = +4.3; P < .05), but there was no significant improvement nationally (40% to 44%; AAPC = +1.4; P = .2). The prevalence of blood pressure control (<140/90 mm Hg) was higher in KPNC (77% to 82%; AAPC = +1.1; P < .05) versus nationally (57% to 62%; AAPC = +1.9; P < .05) during the reported years 2007-2013. Relative to national benchmarks, a substantially greater improvement in risk factor control among adults with diabetes was observed after implementation of a comprehensive population management program.

Authors: Rana JS; Karter AJ; Liu JY; Moffet HH; Jaffe MG

Am J Med. 2018 06;131(6):661-668. Epub 2018-03-22.

PubMed abstract

Food Insecurity, Food “Deserts,” and Glycemic Control in Patients With Diabetes: A Longitudinal Analysis

Both food insecurity (limited food access owing to cost) and living in areas with low physical access to nutritious foods are public health concerns, but their relative contribution to diabetes management is poorly understood. This was a prospective cohort study. A random sample of patients with diabetes in a primary care network completed food insecurity assessment in 2013. Low physical food access at the census tract level was defined as no supermarket within 1 mile in urban areas and 10 miles in rural areas. HbA1c measurements were obtained from electronic health records through November 2016. The relationship among food insecurity, low physical food access, and glycemic control (as defined by HbA1c) was analyzed using hierarchical linear mixed models. Three hundred and ninety-one participants were followed for a mean of 37 months. Twenty percent of respondents reported food insecurity, and 31% resided in an area of low physical food access. In adjusted models, food insecurity was associated with higher HbA1c (difference of 0.6% [6.6 mmol/mol], 95% CI 0.4-0.8 [4.4-8.7], P < 0.0001), which did not improve over time (P = 0.50). Living in an area with low physical food access was not associated with a difference in HbA1c (difference 0.2% [2.2 mmol/mol], 95% CI -0.2 to 0.5 [-2.2 to 5.6], P = 0.33) or with change over time (P = 0.07). Food insecurity is associated with higher HbA1c, but living in an area with low physical food access is not. Food insecurity screening and interventions may help improve glycemic control for vulnerable patients.

Authors: Berkowitz SA; Karter AJ; Corbie-Smith G; Seligman HK; Ackroyd SA; Barnard LS; Atlas SJ; Wexler DJ

Diabetes Care. 2018 06;41(6):1188-1195. Epub 2018-03-19.

PubMed abstract

The Impact of Acute Organ Dysfunction on Long-Term Survival in Sepsis

To estimate the impact of each of six types of acute organ dysfunction (hepatic, renal, coagulation, neurologic, cardiac, and respiratory) on long-term mortality after surviving sepsis hospitalization. Multicenter, retrospective study. Twenty-one hospitals within an integrated healthcare delivery system in Northern California. Thirty thousand one hundred sixty-three sepsis patients admitted through the emergency department between 2010 and 2013, with mortality follow-up through April 2015. None. Acute organ dysfunction was quantified using modified Sequential Organ Failure Assessment scores. The main outcome was long-term mortality among sepsis patients who survived hospitalization. The estimates of the impact of each type of acute organ dysfunction on long-term mortality were based on adjusted Cox proportional hazards models. Sensitivity analyses were conducted based on propensity score-matching and adjusted logistic regression. Hospital mortality was 9.4% and mortality was 31.7% at 1 year. Median follow-up time among sepsis survivors was 797 days (interquartile range: 384-1,219 d). Acute neurologic (odds ratio, 1.86; p < 0.001), respiratory (odds ratio, 1.43; p < 0.001), and cardiac (odds ratio, 1.31; p < 0.001) dysfunction were most strongly associated with short-term hospital mortality, compared with sepsis patients without these organ dysfunctions. Evaluating only patients surviving their sepsis hospitalization, acute neurologic dysfunction was also most strongly associated with long-term mortality (odds ratio, 1.52; p < 0.001) corresponding to a marginal increase in predicted 1-year mortality of 6.0% for the presence of any neurologic dysfunction (p < 0.001). Liver dysfunction was also associated with long-term mortality in all models, whereas the association for other organ dysfunction subtypes was inconsistent between models. Acute sepsis-related neurologic dysfunction was the organ dysfunction most strongly associated with short- and long-term mortality and represents a key mediator of long-term adverse outcomes following sepsis.

Authors: Schuler A; Wulf DA; Lu Y; Iwashyna TJ; Escobar GJ; Shah NH; Liu VX

Crit Care Med. 2018 06;46(6):843-849.

PubMed abstract

A Two-Step Method to Identify Positive Deviant Physician Organizations of Accountable Care Organizations with Robust Performance Management Systems

To identify positive deviant (PD) physician organizations of Accountable Care Organizations (ACOs) with robust performance management systems (PMSYS). Third National Survey of Physician Organizations (NSPO3, n = 1,398). Organizational and external factors from NSPO3 were analyzed. Linear regression estimated the association of internal and contextual factors on PMSYS. Two cutpoints (75th/90th percentiles) identified PDs with the largest residuals and highest PMSYS scores. A total of 65 and 41 PDs were identified using 75th and 90th percentiles cutpoints, respectively. The 90th percentile more strongly differentiated PDs from non-PDs. Having a high proportion of vulnerable patients appears to constrain PMSYS development. Our PD identification method increases the likelihood that PD organizations selected for in-depth inquiry are high-performing organizations that exceed expectations.

Authors: Pimperl AF; Rodriguez HP; Schmittdiel JA; Shortell SM

Health Serv Res. 2018 06;53(3):1851-1869. Epub 2017-04-06.

PubMed abstract

Add-On Antihypertensive Medications to Angiotensin-Aldosterone System Blockers in Diabetes: A Comparative Effectiveness Study

In individuals with diabetes, the comparative effectiveness of add-on antihypertensive medications added to an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker on the risk of significant kidney events is unknown. We used an observational, multicenter cohort of 21,897 individuals with diabetes to compare individuals who added β-blockers, dihydropyridine calcium channel blockers, loop diuretics, or thiazide diuretics to angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. We examined the hazard of significant kidney events, cardiovascular events, and death using Cox proportional hazard models with propensity score weighting. The composite significant kidney event end point was defined as the first occurrence of a ≥30% decline in eGFR to an eGFR<60 ml/min per 1.73 m2, initiation of dialysis, or kidney transplant. The composite cardiovascular event end point was defined as the first occurrence of hospitalization for acute myocardial infarction, acute coronary syndrome, stroke, or congestive heart failure; coronary artery bypass grafting; or percutaneous coronary intervention, and it was only examined in those free of cardiovascular disease at baseline. Over a maximum of 5 years, there were 4707 significant kidney events, 1498 deaths, and 818 cardiovascular events. Compared with thiazide diuretics, hazard ratios for significant kidney events for β-blockers, calcium channel blockers, and loop diuretics were 0.81 (95% confidence interval, 0.74 to 0.89), 0.67 (95% confidence interval, 0.58 to 0.78), and 1.19 (95% confidence interval, 1.00 to 1.41), respectively. Compared with thiazide diuretics, hazard ratios of mortality for β-blockers, calcium channel blockers, and loop diuretics were 1.19 (95% confidence interval, 0.97 to 1.44), 0.73 (95% confidence interval, 0.52 to 1.03), and 1.67 (95% confidence interval, 1.31 to 2.13), respectively. Compared with thiazide diuretics, hazard ratios of cardiovascular events for β-blockers, calcium channel blockers, and loop diuretics compared with thiazide diuretics were 1.65 (95% confidence interval, 1.39 to 1.96), 1.05 (95% confidence interval, 0.80 to 1.39), and 1.55 (95% confidence interval, 1.05 to 2.27), respectively. Compared with thiazide diuretics, calcium channel blockers were associated with a lower risk of significant kidney events and a similar risk of cardiovascular events.

Authors: Schroeder EB; Chonchol M; Shetterly SM; Powers JD; Adams JL; Schmittdiel JA; Nichols GA; O'Connor PJ; Steiner JF

Clin J Am Soc Nephrol. 2018 05 07;13(5):727-734. Epub 2018-03-23.

PubMed abstract

Impact of emergency physician-provided patient education about alternative care venues

Interventions that focus on educating patients appear to be the most effective in directing healthcare utilization to more appropriate venues. We sought to evaluate the effects of mailed information and a brief scripted educational phone call from an emergency physician (EP) on subsequent emergency department (ED) utilization by low-risk adults with a recent treat-and-release ED visit. Patients were randomized into 3 groups for post-ED follow-up: EP phone call with mailed information, mailed information only, and no educational intervention. Each intervention group was compared with a set of matched controls. We undertook this study in 6 EDs within an integrated healthcare delivery system. Overall, 9093 patients were identified; the final groups were the phone group (n = 609), mail group (n = 771), and matched control groups for each (n = 1827 and n = 1542, respectively). Analysis was stratified by age (<65 and ≥65 years). Patients were educated about available venues of care delivery for their future medical needs. The primary outcome was the rate of 6-month ED utilization after the intervention compared with the 6-month utilization rate preceding the intervention. Compared with matched controls, subsequent ED utilization decreased by 22% for patients 65 years or older in the phone group (P = .04) and by 27% for patients younger than 65 years in the mail group (P = .03). ED utilization subsequent to a low-acuity ED visit decreased after a brief post-ED education intervention by an EP explaining alternative venues of care for future medical needs. Response to the method of communication (phone vs mail) varied significantly by patient age.

Authors: Patel PB; Vinson DR; Gardner MN; Wulf DA; Kipnis P; Liu V; Escobar GJ

Am J Manag Care. 2018 05;24(5):225-231.

PubMed abstract

Acute Pulmonary Embolism in Emergency Department Patients Despite Therapeutic Anticoagulation

Emergency department (ED) patients with acute pulmonary embolism (PE) despite therapeutic anticoagulation at the time of diagnosis are uncommonly encountered and present a diagnostic and management challenge. Their characterization and outcomes are poorly described. We sought to describe the prevalence and characteristics of therapeutically anticoagulated patients among a population of patients with acute PE in a community setting and to describe treatment changes and 30-day outcomes. From a large retrospective cohort of adults with acute, objectively-confirmed PE across 21 EDs between 01/2013 and 04/2015, we identified patients who arrived on direct oral or injectable anticoagulants, or warfarin with an initial ED international normalized ratio (INR) value ≥2.0. Patients were excluded from the larger cohort if they had received a diagnosis of venous thromboembolism (VTE) in the prior 30 days. We gathered demographic and clinical variables from electronic health records and structured manual chart review. We report discharge anticoagulation regimens and major 30-day adverse outcomes. Among 2,996 PE patients, 36 (1.2%) met study criteria. Mean age was 63 years. Eleven patients (31%) had active cancer and 25 (69%) were high risk on the PE Severity Index (Classes III-V), comparable to the larger cohort (p>0.1). Reasons for pre-arrival anticoagulation were VTE treatment or prevention (n=21), and atrial fibrillation or flutter (n=15). All patients arrived on warfarin and one was also on enoxaparin: 32 had a therapeutic INR (2.0-3.0) and four had a supratherapeutic INR (>3.0). Fifteen patients (42%) had at least one subtherapeutic INR (<2.0) in the 14 days preceding their diagnostic visit. Two patients died during hospitalization. Of the 34 ultimately discharged, 22 underwent a change in anticoagulation drug or dosing, 19 of whom received injectables, either to replace or to supplement warfarin. Four patients also received inferior vena cava filters. Thirty-day outcomes included one major hemorrhage and one additional death. No patients experienced recurrent or worsening VTE. We found a low prevalence of therapeutic anticoagulation at the time of acute PE diagnosis. Most patients with breakthrough PE underwent a change in therapy, though management varied widely. Subtherapeutic anticoagulation levels in the preceding weeks were common and support the importance of anticoagulation adherence.

Authors: Liu MY; Ballard DW; Huang J; Rauchwerger AS; Reed ME; Bouvet SC; Vinson DR

West J Emerg Med. 2018 May;19(3):510-516. Epub 2018-04-06.

PubMed abstract

Identifying Geographic Disparities in Diabetes Prevalence Among Adults and Children Using Emergency Claims Data

Geographic surveillance can identify hotspots of disease and reveal associations between health and the environment. Our study used emergency department surveillance to investigate geographic disparities in type 1 and type 2 diabetes prevalence among adults and children. Using all-payer emergency claims data from 2009 to 2013, we identified unique New York City residents with diabetes and geocoded their location using home addresses. Geospatial analysis was performed to estimate diabetes prevalence by New York City Census tract. We also used multivariable regression to identify neighborhood-level factors associated with higher diabetes prevalence. We estimated type 1 and type 2 diabetes prevalence at 0.23% and 10.5%, respectively, among adults and 0.20% and 0.11%, respectively, among children in New York City. Pediatric type 1 diabetes was associated with higher income (P = 0.001), whereas adult type 2 diabetes was associated with lower income (P < 0.001). Areas with a higher proportion of nearby restaurants categorized as fast food had a higher prevalence of all types of diabetes (P < 0.001) except for pediatric type 2 diabetes. Type 2 diabetes among children was only higher in neighborhoods with higher proportions of African American residents (P < 0.001). Our findings identify geographic disparities in diabetes prevalence that may require special attention to address the specific needs of adults and children living in these areas. Our results suggest that the food environment may be associated with higher type 1 diabetes prevalence. However, our analysis did not find a robust association with the food environment and pediatric type 2 diabetes, which was predominantly focused in African American neighborhoods.

Authors: Lee DC; Gallagher MP; Gopalan A; Osorio M; Vinson AJ; Wall SP; Ravenell JE; Sevick MA; Elbel B

J Endocr Soc. 2018 May 01;2(5):460-470. Epub 2018-04-17.

PubMed abstract

Large-Scale Implementation of Structured Reporting of Adnexal Masses on Ultrasound

The aim of this article is to describe the development and implementation of structured reporting of adnexal mass findings on pelvic ultrasound in a large integrated health care delivery system. A structured reporting system that includes standardized terminology for describing adnexal masses on ultrasound was developed by a multidisciplinary team of radiologists, gynecologists, and gynecologic oncologists on the basis of literature review and internal data. The system uses a reporting template that requires radiologists to assign abnormal adnexal masses to one of five possible categories on the basis of standardized criteria: category 0, 1, 2, or 3 for masses <10 cm, to reflect increasing concern for malignancy, and category X for masses >10 cm. Unique predefined hashtags were linked to each category to enable electronic data extraction, and a hard stop feature was installed that prevents reports from being finalized without a category designation. In 2014, after a 3-month pilot study, large-scale implementation was supported by an educational campaign consisting of web-based conferences, e-mail announcements, and local presentations. Clinical management recommendations on the basis of category and other clinical factors were provided in a separate practice resource for clinicians. Analysis of adherence revealed that 93% of the approximately 12,000 reports describing abnormal adnexal masses in 2016 included category designations. Feedback from referring providers via an anonymous survey indicated high levels of satisfaction with reports. Multidisciplinary collaboration and leveraging of technology enabled large-scale implementation of structured reporting with high levels of adherence among radiologists and improved satisfaction among referring providers.

Authors: Suh-Burgmann EJ; Flanagan T; Lee N; Osinski T; Sweet C; Lynch M; Caponigro M; Mehta J; Alavi M; Herrinton LJ

J Am Coll Radiol. 2018 May;15(5):755-761. Epub 2018-03-20.

PubMed abstract

Mortality Measures to Profile Hospital Performance for Patients With Septic Shock

Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions. Retrospective cohort study. U.S. acute care hospitals. Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes. None. We used hierarchical logistic regression models to determine hospital risk-standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk-standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4-33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2-38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16-70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30-0.58]). Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure.

Authors: Walkey AJ; Shieh MS; Liu VX; Lindenauer PK

Crit Care Med. 2018 Apr 30.

PubMed abstract

Depression in type 1 diabetes and risk of dementia

Depression afflicts 14% of individuals with type 1 diabetes (T1D). Depression is a robust risk factor for dementia but it is unknown if this holds true for individuals with T1D, who recently started living to an age conferring dementia risk. We examined if depression is a dementia risk factor among elderly individuals with T1D. 3,742 individuals with T1D age ≥50 were followed for dementia from 1/1/96-9/30/2015. Depression, dementia, and comorbidities were abstracted from electronic medical records. Cox proportional hazard models estimated the association between depression and dementia adjusting for demographics, glycosylated hemoglobin, severe dysglycemic epidsodes, stroke, heart disease, nephropathy, and end stage renal disease. The cumulative incidence of dementia by depression was estimated conditional on survival dementia-free to age 55. Five percent (N = 182) were diagnosed with dementia and 20% had baseline depression. Depression was associated with a 72% increase in dementia (fully adjusted HR = 1.72; 95% CI:1.12-2.65). The 25-year cumulative incidence of dementia was more than double for those with versus without depression (27% vs. 12%). For people with T1D, depression significantly increases dementia risk. Given the pervasiveness of depression in T1D, this has major implications for successful aging in this population recently living to old age.

Authors: Gilsanz P; Schnaider Beeri M; Karter AJ; Quesenberry CP; Adams AS; Whitmer RA

Aging Ment Health. 2018 Apr 10:1-7.

PubMed abstract

Healthcare Utilization and Infection in the Week Prior to Sepsis Hospitalization

To quantify healthcare utilization in the week preceding sepsis hospitalization to identify potential opportunities to improve the recognition and treatment of sepsis prior to admission. Retrospective study. Two large integrated healthcare delivery systems in the United States. Hospitalized sepsis patients. None. We quantified clinician-based encounters in each of the 7 days preceding sepsis admission, as well as on the day of admission, and categorized them as: hospitalization, subacute nursing facility, emergency department, urgent care, primary care, and specialty care. We identified the proportion of encounters with diagnoses for acute infection based on 28 single-level Clinical Classification Software categories. We also quantified the use of antibiotics over the same interval and used linear regression to evaluate time trends. We included a total of 14,658 Kaiser Permanente Northern California sepsis hospitalizations and 31,369 Veterans Health Administration sepsis hospitalizations. Over 40% of patients in both cohorts required intensive care. A total of 7,747 Kaiser Permanente Northern California patients (52.9%) and 14,280 Veterans Health Administration patients (45.5%) were seen by a clinician in the week before sepsis. Prior to sepsis, utilization of subacute nursing facilities remained steady, whereas hospital utilization declined. Primary care, specialty care, and emergency department visits increased, particularly at admission day. Among those with a presepsis encounter, 2,648 Kaiser Permanente Northern California patients (34.2%) and 3,858 Veterans Health Administration patients (27.0%) had at least one acute infection diagnosis. An increasing percentage of outpatient encounters also had infectious diagnoses (3.3%/d; 95% CI, 1.5%-5.1%; p < 0.01), particularly in primary and specialty care settings. Prior to sepsis hospitalization, the use of antibiotics also increased steadily (2.1%/d; 95% CI, 1.1%-3.1%; p < 0.01). Over 45% of sepsis patients had clinician-based encounters in the week prior to hospitalization with an increasing frequency of diagnoses for acute infection and antibiotic use in the outpatient setting. These presepsis encounters offer several potential opportunities to improve the recognition, risk stratification, and treatment prior to sepsis hospitalization.

Authors: Liu VX; Escobar GJ; Chaudhary R; Prescott HC

Crit Care Med. 2018 04;46(4):513-516.

PubMed abstract

Accuracy of international classification of diseases, ninth revision, codes for postpartum hemorrhage among women undergoing cesarean delivery

Determining the accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes for postpartum hemorrhage (PPH) is vital for reaching valid conclusions about the epidemiology of PPH. Our primary objectives were to assess the performance characteristics of ICD-9 PPH codes against a reference standard using estimated blood loss (EBL) among a cohort undergoing Cesarean delivery. We analyzed maternal discharge and EBL data from women who underwent Cesarean delivery at Kaiser Permanente Northern California facilities between 2010 and 2013. We defined PPH as an EBL of at least 1000 mL. In a secondary analysis, ICD-9 performance characteristics were assessed using an EBL of at least 1500 mL to classify severe PPH. We identified 35,614 hospitalizations for Cesarean delivery. Using EBL of at least 1000 mL as the “gold standard,” PPH codes had a sensitivity of 27.8%, specificity of 97%, positive predictive value (PPV) of 74.5%, and a negative predictive value (NPV) of 80.9%. The prevalence of a PPH code (9%) was lower than the prevalence using a blood loss of at least 1000 mL (24%). Using a reference standard of EBL of at least 1500 mL, PPH codes had a sensitivity of 61.7%, specificity of 93.8%, PPV of 34.2%, and NPV of 97.9%. PPH ICD-9 codes have high specificity, moderately high PPVs and NPVs, and low sensitivity. An EBL of at least 1500 mL as a reference standard has higher sensitivity. Our findings suggest that, for women undergoing Cesarean delivery, quality improvement efforts are needed to enhance PPH ICD-9 coding accuracy in administrative data sets.

Authors: Butwick AJ; Walsh EM; Kuzniewicz M; Li SX; Escobar GJ

Transfusion. 2018 04;58(4):998-1005. Epub 2018-01-26.

PubMed abstract

Effect of Out-of-Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE)

To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes. Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012. Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence. Adherence and OOP costs were based on pharmacy dispensing records and benefits. Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day’s supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months). Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.

Authors: Karter AJ; Parker MM; Solomon MD; Lyles CR; Adams AS; Moffet HH; Reed ME

Health Serv Res. 2018 04;53(2):1227-1247. Epub 2017-05-05.

PubMed abstract

Association of Inflammatory Markers with Disease Progression in Patients with Metastatic Melanoma Treated with Immune Checkpoint Inhibitors

We investigated the effect of inflammatory biomarkers (neutrophil, platelet, and lymphocyte counts) on risk of progression in patients with metastatic melanoma treated with an immune checkpoint inhibitor targeting programmed cell death protein-1 (PD-1). This retrospective cohort study included 108 patients with malignant melanoma treated with an anti-PD-1 checkpoint inhibitor from August 2014 through December 2015. The outcome was disease progression noted on imaging or clinical examination. Follow-up began on the date of initiation of anti-PD-1 therapy and ended on the date of progression, disenrollment, death of causes other than malignant melanoma, or the end of the study in February 2017. The median time from initiating therapy with an anti-PD-1 checkpoint inhibitor (nivolumab or pembrolizumab) to the end of follow-up was 118 days. After adjustment, baseline neutrophil and platelet counts were associated with progression. The hazard ratio (HR) for neutrophil counts ≥ 5501/μL vs ≤ 3900/μL was 2.3 (95% confidence interval [CI] = 1.2-4.6, p < 0.05). For platelet counts ≥ 304,000 vs ≤ 215,000/μL, the HR was 2.0 (CI = 1.0-3.9, p < 0.05). For lymphocyte counts ≥ 1716/μL vs ≤ 1120/μL, the HR was 0.5 (CI = 0.2-1.0, p = 0.05). For patients with metastatic melanoma treated with nivolumab or pembrolizumab, higher neutrophil or platelet counts, or lower lymphocyte counts, are associated with higher risk of progression. For these patients, we recommend more frequent assessment for progression and closer follow-up, especially for patients with substantial comorbidities or poor physical performance.

Authors: Pan M; Alavi M; Herrinton LJ

Perm J. 2018 Mar 30;22.

PubMed abstract

Older adults’ readiness to engage with eHealth patient education and self-care resources: a cross-sectional survey

This study examined access to digital technologies, skills and experience, and preferences for using web-based and other digital technologies to obtain health information and advice among older adults in a large health plan. A primary aim was to assess the extent to which digital divides by race/ethnicity and age group might affect the ability of a large percentage of seniors, and especially those in vulnerable groups, to engage with online health information and advice modalities (eHIA) and mobile health (mHealth) monitoring tools. A mailed survey was conducted with age-sex stratified random samples of English-speaking non-Hispanic white, African-American/black (black), Hispanic/Latino (Latino), Filipino-American (Filipino), and Chinese-American (Chinese) Kaiser Permanente Northern California members who were aged 65-79 years. Respondent data were weighted to the study population for the cross-sectional analyses. Older seniors and black, Latino, and Filipino seniors have less access to digital tools, less experience performing a variety of online tasks, and are less likely to believe that they would be capable of going online for health information and advice compared to younger and white Non-Hispanic seniors. Consequently, they are also less likely to be interested in using eHIA modalities. The same subgroups of seniors that have previously been shown to have higher prevalence of chronic conditions and greater difficulties with healthcare access are also less likely to adopt use of eHIA and mHealth monitoring technologies. At the patient population level, this digital divide is important to take into account when planning health information and chronic disease management programs. At the individual patient level, to provide good patient-centered care, it is important for providers to assess rather than assume digital access, eHealth skills, and preferences prior to recommending use of web-based resources and mHealth tools.

Authors: Gordon NP; Hornbrook MC

BMC Health Serv Res. 2018 03 27;18(1):220. Epub 2018-03-27.

PubMed abstract

Effect of cognitive bias modification-memory on depressive symptoms and autobiographical memory bias: two independent studies in high-ruminating and dysphoric samples.

Memory bias is a risk factor for depression. In two independent studies, the efficacy of one CBM-Memory session on negative memory bias and depressive symptoms was tested in vulnerable samples. We compared positive to neutral (control) CBM-Memory trainings in highly-ruminating individuals (N = 101) and individuals with elevated depressive symptoms (N = 100). In both studies, participants studied positive, neutral, and negative Swahili words paired with their translations. In five study-test blocks, they were then prompted to retrieve either only the positive or neutral translations. Immediately following the training and one week later, we tested cued recall of all translations and autobiographical memory bias; and also measured mood, depressive symptoms, and rumination. Retrieval practice resulted in training-congruent recall both immediately after and one week after the training. Overall, there was no differential decrease in symptoms or difference in autobiographical memory bias between the training conditions. In the dysphoric but not in the high-ruminating sample, the positive training resulted in positive autobiographical bias only in dysphoric individuals with positive pre-existing bias. We conclude that one session of positive retrieval-based CBM-Memory may not be enough to yield symptom change and affect autobiographical memory bias in vulnerable individuals.

Authors: Vrijsen JN; Dainer-Best J; Witcraft SM; Papini S; Hertel P; Beevers CG; Becker ES; Smits JAJ

Cogn Emot. 2019 Mar;33(2):288-304. doi: 10.1080/02699931.2018.1450225. Epub 2018 Mar 15.

PubMed abstract

Sex, race, and insurance status differences in hospital treatment and outcomes following out-of-hospital cardiac arrest.

BACKGROUND: Sex, race, and insurance status are associated with treatment and outcomes in several cardiovascular diseases. These disparities, however, have not been well-studied in out-of-hospital cardiac arrest (OHCA). OBJECTIVE: Our objective was to evaluate the association of patient sex, race, and insurance status with hospital treatments and outcomes following OHCA. METHODS: We studied adult patients in the 2011-2015 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database with a “present on admission” diagnosis of cardiac arrest (ICD-9-CM 427.5). Insurance status was classified as private, Medicare, and Medi-Cal/government/self-pay. Our primary outcome was good neurologic recovery at hospital discharge, which was determined by discharge disposition. Secondary outcomes were survival to hospital discharge, treatment at a 24/7 percutaneous coronary intervention (PCI) center, “do not resuscitate” orders within 24h of admission, and cardiac catheterization during hospitalization. Data were analyzed with hierarchical multiple logistic regression models. RESULTS: We studied 38,163 patients in the OSHPD database. Female sex, non-white race, and Medicare insurance status were independently associated with worse neurologic recovery [OR 0.94 (0.89-0.98), 0.93 (0.88-0.98), and 0.85 (0.79-0.91), respectively], lower rates of treatment at a 24/7 PCI center [OR 0.89 (0.85-0.93), 0.88 (0.85-0.93), and 0.87 (0.82-0.94), respectively], and lower rates of cardiac catheterization [OR 0.61 (0.57-0.65), 0.90 (0.84-0.97), and 0.44 (0.40-0.48), respectively]. Female sex, white race, and Medicare insurance were associated with DNR orders within 24h of admission [OR 1.16 (1.10-1.23), 1.14 (1.07-1.21), and 1.25 (1.15-1.36), respectively]. CONCLUSIONS: Sex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.

Authors: Casey SD; Mumma BE

Resuscitation. 2018 May;126:125-129. doi: 10.1016/j.resuscitation.2018.02.027. Epub 2018 Mar 5.

PubMed abstract

Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department

Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED). This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation. Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82-0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10-3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35-5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm. Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.

Authors: Vinson DR; Mark DG; Ballard DW; Reed ME; Go AS; et al.

West J Emerg Med. 2018 Mar;19(2):346-360. Epub 2018-02-12.

PubMed abstract

Exploring young women’s decisional needs for contraceptive method choice: A qualitative study

Assisting women with choosing contraceptive methods that meet their needs and preferences is essential to providing patient-centered care, but research to inform interventions supporting method choice is lacking. An assessment of patient decisional needs for contraceptive method choice may provide insight into patient-centered ways to support decision making. Using the Ottawa Decision Support Framework as a guide, we conducted a qualitative study with semistructured interviews to identify women’s decisional needs for choosing a contraceptive method. The sample consisted of 21 women aged 18-29 from an integrated health care delivery system. We employed thematic analysis to identify common themes in the participants’ experience. Overall, participants perceived choosing a contraceptive method to be a somewhat difficult decision and described feeling hesitant and unsure. Lack of knowledge of and familiarity with methods and the unpredictability of side effects contributed to participants’ hesitancy. Women considered method choice in the context of their lives and their values for various contraceptive attributes, particularly side effects. Participants identified several sources for contraceptive information. Information from friends and family was highly influential. Participants desired both factual and experiential information. Contraceptive method choice may be difficult for many young women, suggesting a need for decision support. Interventions supporting method choice may be more relevant if they directly address knowledge gaps and uncertainty as well as provide both factual and experiential information on a comprehensive set of contraceptive attributes.

Authors: Marshall C; Kandahari N; Raine-Bennett T

Contraception. 2018 03;97(3):243-248. Epub 2017-10-13.

PubMed abstract

Incorporating Longitudinal Comorbidity and Acute Physiology Data in Template Matching for Assessing Hospital Quality: An Exploratory Study in an Integrated Health Care Delivery System

We sought to build on the template-matching methodology by incorporating longitudinal comorbidities and acute physiology to audit hospital quality. Patients admitted for sepsis and pneumonia, congestive heart failure, hip fracture, and cancer between January 2010 and November 2011 at 18 Kaiser Permanente Northern California hospitals. We generated a representative template of 250 patients in 4 diagnosis groups. We then matched between 1 and 5 patients at each hospital to this template using varying levels of patient information. Data were collected retrospectively from inpatient and outpatient electronic records. Matching on both present-on-admission comorbidity history and physiological data significantly reduced the variation across hospitals in patient severity of illness levels compared with matching on administrative data only. After adjustment for longitudinal comorbidity and acute physiology, hospital rankings on 30-day mortality and estimates of length of stay were statistically different from rankings based on administrative data. Template matching-based approaches to hospital quality assessment can be enhanced using more granular electronic medical record data.

Authors: Hu W; Chan CW; Zubizarreta JR; Escobar GJ

Med Care. 2018 Feb 26.

PubMed abstract

Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department

Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1%) for major adverse cardiac events (MACE). The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates. The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs. A total of 118,822 patients with possible ACS were included. The 3 risk scores' accuracies were optimized using the lower limit of cTnI quantitation (<0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p < 0.0001). Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.

Authors: Mark DG; Huang J; Chettipally U; Kene MV; Anderson ML; Hess EP; Ballard DW; Vinson DR; Reed ME; Kaiser Permanente CREST Network Investigators

J Am Coll Cardiol. 2018 02 13;71(6):606-616.

PubMed abstract

Flexible, Cluster-Based Analysis of the Electronic Medical Record of Sepsis with Composite Mixture Models

The widespread adoption of electronic medical records (EMRs) in healthcare has provided vast new amounts of data for statistical machine learning researchers in their efforts to model and predict patient health status, potentially enabling novel advances in treatment. In the case of sepsis, a debilitating, dysregulated host response to infection, extracting subtle, uncataloged clinical phenotypes from the EMR with statistical machine learning methods has the potential to impact patient diagnosis and treatment early in the course of their hospitalization. However, there are significant barriers that must be overcome to extract these insights from EMR data. First, EMR datasets consist of both static and dynamic observations of discrete and continuous-valued variables, many of which may be missing, precluding the application of standard multivariate analysis techniques. Second, clinical populations observed via EMRs and relevant to the study and management of conditions like sepsis are often heterogeneous; properly accounting for this heterogeneity is critical. Here, we describe an unsupervised, probabilistic framework called a composite mixture model that can simultaneously accommodate the wide variety of observations frequently observed in EMR datasets, characterize heterogeneous clinical populations, and handle missing observations. We demonstrate the efficacy of our approach on a large-scale sepsis cohort, developing novel techniques built on our model-based clusters to track patient mortality risk over time and identify physiological trends and distinct subgroups of the dataset associated with elevated risk of mortality during hospitalization.

Authors: Mayhew MB; Petersen BK; Sales AP; Greene JD; Liu VX; Wasson TS

J Biomed Inform. 2018 02;78:33-42. Epub 2017-12-02.

PubMed abstract

A systematic review of care management interventions targeting multimorbidity and high care utilization

Evidence supporting the effectiveness of care management programs for complex patients has been inconclusive. However, past reviews have not focused on complexity primarily defined by multimorbidity and healthcare utilization. We conducted a systematic review of care management interventions targeting the following three patient groups: adults with two or more chronic medical conditions, adults with at least one chronic medical condition and concurrent depression, and adults identified based solely on high past or predicted healthcare utilization. Eligible studies were identified from PubMed, published between 06/01/2005 and 05/31/2015, and reported findings from a randomized intervention that tested a comprehensive, care management intervention. Identified interventions were grouped based on the three “complex” categories of interest (described above). Two investigators extracted data using a structured abstraction form and assessed RCT quality. We screened 989 article titles for eligibility from which 847 were excluded. After reviewing the remaining 142 abstracts, 83 articles were excluded. We reviewed the full-text of 59 full-text articles and identified 15 unique RCTs for the final analysis. Of these 15 studies, two focused on patients with two or more chronic medical conditions, seven on patients with at least one chronic medical condition and depression, and six on patients with high past or predicted healthcare utilization. Measured outcomes included utilization, chronic disease measures, and patient-reported outcomes. The seven studies targeting patients with at least one chronic medical condition and depression demonstrated significant improvement in depression symptoms (ranging from 9.2 to 48.7% improvement). Of the six studies that focused on high utilizers, two showed small reductions in utilization. The quality of the research methodology in most of the studies (12/15) was rated fair or poor. Interventions were more likely to be successful when patients were selected based on having at least one chronic medical condition and concurrent depression, and when patient-reported outcomes were assessed. Future research should focus on the role of mental health in complex care management, finding better methods for identifying patients who would benefit most from care management, and determining which intervention components are needed for which patients.

Authors: Baker JM; Grant RW; Gopalan A

BMC Health Serv Res. 2018 01 30;18(1):65. Epub 2018-01-30.

PubMed abstract

Effectiveness of Respiratory Syncytial Virus Immunoprophylaxis on Bronchiolitis Hospitalizations among High-risk Infants

We sought to determine the real-world effectiveness of respiratory syncytial virus (RSV) immunoprophylaxis in a population-based cohort to inform policy. The study population included infants born 1996-2008 and enrolled in Kaiser Permanente Northern California. During the RSV season (November-March), RSV immunoprophylaxis administration and the following 30 days were defined as RSV immunoprophylaxis protected period(s), and all other days as unprotected period(s). Bronchiolitis hospitalizations were determined using the International Classification of Diseases Ninth Revision codes during RSV season. We used proportional hazard model to estimate bronchiolitis hospitalization risk comparing infants’ protected period(s) with unprotected period(s). Infants who ever received RSV immunoprophylaxis had a 32% decreased risk of bronchiolitis hospitalization (adjusted hazard ratio = 0.68, 95% confidence interval: 0.46, 1.00) when comparing protected periods to unprotected periods. Infants with chronic lung disease (CLD) had a 52% decreased risk in bronchiolitis hospitalization (adjusted hazard ratio = 0.48, 95% confidence interval: 0.25, 0.94). Under the new 2014 American Academy of Pediatrics (AAP) guidelines, 48% of infants eligible based on in-place AAP guidelines at birth would no longer be eligible, but nearly all with CLD remain eligible. RSV immunoprophylaxis is effective in decreasing hospitalization. This association is greatest for infants with CLD, a group still recommended for receipt under the new AAP guidelines.

Authors: Wu P; Escobar GJ; Gebretsadik T; Carroll KN; Li SX; Walsh EM; Mitchel EF; Sloan C; Dupont WD; Yu C; Horner JR; Hartert TV

Am J Epidemiol. 2018 Jan 17.

PubMed abstract

Six-Year Diabetes Incidence After Genetic Risk Testing and Counseling: A Randomized Clinical Trial

Authors: Vassy JL; He W; Florez JC; Meigs JB; Grant RW

Diabetes Care. 2018 Jan 05.

PubMed abstract

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

Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions. 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. 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. A range of factors were identified that undermined the ability of patient and physicians to establish an efficient working agenda: the most prominent were time pressure and short visit lengths, but also included differing visit expectations, patient hesitancy to bring up embarrassing concerns, electronic medical record/documentation requirements, differences balancing current symptoms versus future medical risk, nonactionable items, differing philosophies about medications and lifestyle interventions, and difficulty by patients in prioritizing their top concerns. Primary care patients and their physicians adopt a range of different strategies to address the time constraints during visits. The primary factor that supported well-aligned visits was the ability for patients and physicians to proactively negotiate the visit agenda at the beginning of the visit. Efforts to optimize care within time-constrained systems should focus on helping patients more effectively prepare for visits. Physicians should ask for the patient’s agenda early, explain visit parameters, establish a reasonable number of concerns that can be discussed, and collaborate on a plan to deal with concerns that cannot be addressed during the visit.

Authors: Kowalski, Christine P; McQuillan, Deanna B; Chawla, Neetu; Lyles, Courtney; Altschuler, Andrea; Uratsu, Connie S; Bayliss, Elizabeth A; Heisler, Michele; Grant, Richard W

J Am Board Fam Med. 2018 Jan-Feb;31(1):29-37.

PubMed abstract

Using Neighborhood-Level Census Data to Predict Diabetes Progression in Patients with Laboratory-Defined Prediabetes

Research on predictors of clinical outcomes usually focuses on the impact of individual patient factors, despite known relationships between neighborhood environment and health. To determine whether US census information on where a patient resides is associated with diabetes development among patients with prediabetes. Retrospective cohort study of all 157,752 patients aged 18 years or older from Kaiser Permanente Northern California with laboratory-defined prediabetes (fasting plasma glucose, 100 mg/dL-125 mg/dL, and/or glycated hemoglobin, 5.7%-6.4%). We assessed whether census data on education, income, and percentage of households receiving benefits through the US Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP) was associated with diabetes development using logistic regression controlling for age, sex, race/ethnicity, blood glucose levels, and body mass index. Progression to diabetes within 36 months. Patients were more likely to progress to diabetes if they lived in an area where less than 16% of adults had obtained a bachelor’s degree or higher (odds ratio [OR] =1.22, 95% confidence interval [CI] = 1.09-1.36), where median annual income was below $79,999 (OR = 1.16 95% CI = 1.03-1.31), or where SNAP benefits were received by 10% or more of households (OR = 1.24, 95% CI = 1.1-1.4). Area-level socioeconomic and food assistance data predict the development of diabetes, even after adjusting for traditional individual demographic and clinical factors. Clinical interventions should take these factors into account, and health care systems should consider addressing social needs and community resources as a path to improving health outcomes.

Authors: Schmittdiel JA; Dyer WT; Marshall CJ; Bivins R

Perm J. 2018;22:18-096.

PubMed abstract

Liver Enzymes in Early to Mid-pregnancy, Insulin Resistance, and Gestational Diabetes Risk: A Longitudinal Analysis

Background: Liver enzymes may be implicated in glucose homeostasis; liver enzymes progressively change during pregnancy but longitudinal data during pregnancy in relation to insulin resistance and gestational diabetes (GDM) risk are lacking. We investigated longitudinal associations of γ-glutamyl transferase (GGT) and alanine aminotransferase (ALT) with insulin secretion and resistance markers across early to mid-pregnancy and subsequent GDM risk. Methods: Within the prospective Pregnancy Environment and Lifestyle Study cohort, 117 GDM cases were ascertained and matched to 232 non-GDM controls in a nested case-control study. Fasting blood samples were collected at two clinic visits (CV1, gestational weeks 10-13; CV2, gestational weeks 16-19). Linear mixed model and conditional logistic regression were used, adjusting for major risk factors for GDM. Results: In repeated measure analysis, after adjusting for confounders including body mass index and waist-to-hip ratio, GGT per standard deviation increment was associated with elevated fasting glucose and HOMA-IR (% change = 1.51%, 95% CI 0.56-2.46% and 7.43%, 95% CI 1.76-13.11%, respectively) and decreased adiponectin (% change = -2.86%, 95% CI-5.53 to -0.20%) from CV1 to CV2. At CV1 and CV2, GGT levels comparing the highest versus lowest quartile were associated with 3.01-fold (95% CI 1.32-6.85) and 3.51-fold (95% CI 1.37-8.97) increased risk of GDM, respectively. Progressively increased (

Authors: Zhu Y; Hedderson MM; Quesenberry CP; Feng J; Ferrara A

Front Endocrinol (Lausanne). 2018;9:581. Epub 2018-10-02.

PubMed abstract

An Observational Study of Cardiovascular Risks Associated with Rheumatoid Arthritis Therapies: A Comparison of Two Analytical Approaches

Comparative safety studies typically use hierarchical treatment categories that lump monotherapy and combination therapy. The consequence of this approach on study results is not clear. For example, studies of tumor necrosis factor inhibitors usually lump users regardless of whether they are using the drug alone or in combination with other agents. This study explored the importance of lumping vs splitting users of monotherapy and combination therapy. We also explored whether the timing of disenrollment from Health Plan membership was informative as an outcome variable when interpreting unmeasured, time-varying confounding. This observational cohort study included Kaiser Permanente Northern California 2003 to 2013 members with rheumatoid arthritis who started methotrexate. The study end point was a major cardiovascular event. In Cox proportional hazards analysis, we compared treatment classifications using five lumped categories with treatment classification using nine split categories. We also studied disenrollment as an outcome. Among 5885 patients, 238 experienced serious cardiovascular events during an average follow-up of 4.25 years. Analysis of drug treatments using 5 lumped categories was difficult to interpret because treatment effects and drug users were mixed. In contrast, analysis of 9 drug categories that split monotherapies from combination therapy was easier to interpret, although confidence intervals were wider. Analysis of drug treatment in relation to disenrollment provided useful information with which to assess study validity, although the power of the analysis was limited. In comparative safety studies, we recommend greater transparency in classifying treatment and evaluating disenrollment.

Authors: Herrinton LJ; Ray GT; Curtis JR; Wu JJ; Fireman B; Liu L; Goldfien R

Perm J. 2018;22:17-101.

PubMed abstract

Improving the quality of care and patient experience of care during the diagnosis of lupus: a qualitative study of primary care

Purpose To better understand diagnostic delay and doctor-patient communication during the diagnosis of systemic lupus erythematous in patients without malar rash, we conducted a qualitative study of primary care providers’ perceptions. Methods We conducted in-depth interviews with a purposive sample of eight primary care physicians in Kaiser Permanente Northern California. Telephone interviews were recorded, transcribed, reviewed, and coded for domains and themes. Results We identified five domains related to diagnosis: initial assessment and tests, initial diagnosis and empiric treatment, timeliness of diagnosis, communicating with the patient, and opportunities for improvement. In the absence of malar rash, the lupus manifestations are common while the disease is rare. Once the primary care provider believes that the disease may be autoimmune, they work with a rheumatologist, but this could take months. Initially, the physician assesses whether the condition is self-limiting or responds to empiric treatments. Over time, as empiric treatments fail or additional lupus manifestations emerge, the primary care provider makes a referral. Doctor-patient communication is critical to help the physician make sense of the symptoms, maintain trust, and assure the patient that he or she is receiving appropriate care. Patient persistence and communication are critically important. Continuing education was deemed essential by each physician. Conclusion In the absence of malar rash, a lupus diagnosis can be difficult. Enhanced doctor-patient communication, patient persistence, physician access to rheumatology and continuing education of primary care might improve time to diagnosis and the patient’s experience with primary care. This knowledge is transferable to other rare, complex diseases.

Authors: Amsden LB; Davidson PT; Fevrier HB; Goldfien R; Herrinton LJ

Lupus. 2018 Jan 01:961203318763082.

PubMed abstract

Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk

Patient reports of their adherence behaviors, concerns about statins, and perceptions of atherosclerotic cardiovascular disease (ASCVD) risk could inform approaches for improving adherence to statin therapy. We examined these factors and their associations with adherence. We conducted telephone interviews among a stratified random sample of adults receiving statins within an integrated delivery system (N = 730, 81% response rate) in 2010. We sampled equal numbers of individuals in three clinical risk categories: those with 1) coronary artery disease; 2) diabetes or other ASCVD diagnosis; and 3) no diabetes or ASCVD diagnoses. We assessed 15 potential concerns about and barriers to taking statins, and perceived risk of having a heart attack in the next 10 years (0-10 scale). We calculated the proportion of days covered (PDC) by statins in the last 12 months using dispensing data and used multivariate logistic regression to examine the characteristics associated with non-adherence (PDC<80%). Analyses were weighted for sampling proportions. Sixty-one percent of patients with PDC<50% reported not filling a new prescription, splitting or skipping statins, or stopping refilling statins in the last 12 months vs. 15% of those with PDC≥80% (p<0.05). The most commonly reported concerns about statins were preferring to lower cholesterol with lifestyle changes (66%), disliking medications in general (59%), and liver or kidney problems (31%); having trouble remembering to take statins (9%) was the most common reason for taking less than prescribed. In multivariate analyses, clinical risk categories were not significantly associated with odds of non-adherence; however, those with higher perceived risk of heart attack were less likely to be non-adherent. Patient-reported medication-taking behaviors were correlated with statin PDC and those with lower perceived cardiovascular risk were less likely to be adherent. These findings highlight the importance of eliciting from and educating patients on their adherence behaviors and ASCVD risks.

Authors: Fung V; Graetz I; Reed M; Jaffe MG

PLoS ONE. 2018;13(2):e0191817. Epub 2018-02-08.

PubMed abstract

Diabetes Screening among Antipsychotic-Treated Adults with Severe Mental Illness in an Integrated Delivery System: A Retrospective Cohort Study

Severe mental illness (SMI) is associated with increased risk for type 2 diabetes, partly due to adverse metabolic effects of antipsychotic medications. In public health care settings, annual screening rates are 30%. We measured adherence to national diabetes screening guidelines for patients taking antipsychotic medications. To estimate diabetes screening prevalence among patients with SMI within an integrated health care system, and to assess characteristics associated with lack of screening. Retrospective cohort study. Antipsychotic-treated adults with SMI. We excluded participants with known diabetes. Primary outcome was screening via fasting glucose test or hemoglobin A1c during a 1-year period. In 2014, 16,754 patients with SMI diagnoses were receiving antipsychotics. Seventy-four percent of these patients’ providers ordered diabetes screening tests that year, but only 55% (9247/16,754) received screening. When the observation time frame was extended to 2 years, 73% (12,250/16,754) were screened. Adjusting for sex and race/ethnicity, young adults (aged 18-29 years) were less likely to receive screening than older age groups [adjusted RR (aRR) 1.23-1.57, p < 0.0001]. Compared to whites, screening was more common for Asians (aRR 1.141, 95% CI 1.089-1.195, p < 0.0001), less common for blacks (aRR 0.946, 95% CI 0.898-0.997, p < 0.0375), and no different for Hispanics (aRR 1.030, 95% CI 0.988-1.074, p = 0.165). Smokers were less likely to be screened than non-smokers (aRR 0.93, 95% CI 0.89-0.97, p < 0.0008). Utilization of either mental health or primary care services increased the likelihood of screening. While almost three-fourths of adults with SMI taking antipsychotic medications received a lab order for diabetes screening, only 55% received screening within a 12-month period. Young adults and smokers were less likely to be screened, despite their disproportionate metabolic risk. Future studies should assess the barriers and facilitators with regard to diabetes screening in this vulnerable population at the patient, provider, and system levels.

Authors: Mangurian C; Schillinger D; Newcomer JW; Vittinghoff E; Essock S; Zhu Z; Dyer W; Schmittdiel J

J Gen Intern Med. 2018 01;33(1):79-86. Epub 2017-10-31.

PubMed abstract

Crossing the Research to Quality Chasm: A Checklist for Researchers and Clinical Leadership Partners

Authors: Schmittdiel JA; Grant RW

J Gen Intern Med. 2018 01;33(1):9-10. Epub 2017-10-02.

PubMed abstract

Hospital-Acquired Pressure Injury: Risk-Adjusted Comparisons in an Integrated Healthcare Delivery System

Although healthcare organizations have decreased hospital-acquired pressure injury (HAPI) rates, HAPIs are not eliminated, driving further examination in both nursing and health services research. The objective was to describe HAPI incidence, risk factors, and risk-adjusted hospital variation within a California integrated healthcare system. Inpatient episodes were included in this retrospective cohort if patients were hospitalized between January 1, 2013, and June 30, 2015. The primary outcome was development of a HAPI over time. Predictors included cited HAPI risk factors in addition to incorporation of a longitudinal comorbidity burden (Comorbidity Point Score, Version 2 [COPS2]), a severity-of-illness score (Laboratory-Based Acute Physiology Score, Version 2 [LAPS2]), and the Braden Scale for Predicting Pressure Ulcer Risk. Analyses included HAPI inpatient episodes (n = 1661) and non-HAPI episodes (n = 726,605). HAPI incidence was 0.57 per 1,000 patient days (95% CI [0.019, 3.805]) and 0.2% of episodes. A multivariate Cox proportional hazards model showed significant (p < .001) hazard ratios (HRs) for the change from the 25th to the 75th percentile for age (HR = 1.36, 95% CI [1.25, 1.45]), higher COPS2 scores (HR = 1.10, 95% CI [1.04, 1.16]), and higher LAPS2 scores (HR = 1.38, 95% CI [1.28, 1.50]). Female gender, an emergency room admission for a medical reason, and higher Braden scores showed significant protective HRs (HR < 1.00, p < .001). After risk adjustment, significant variation remained among the 35 hospitals. Results prompt the consideration of age, severity of illness (LAPS2), comorbidity indexes (COPS2), and the Braden score as important predictors for HAPI risk. HAPI rates may be low; however, because of significant individual site variation, HAPIs remain an area to explore through both research and quality improvement initiatives.

Authors: Rondinelli J; Zuniga S; Kipnis P; Kawar LN; Liu V; Escobar GJ

Nurs Res. 2018 Jan/Feb;67(1):16-25.

PubMed abstract

Rectal Cancer Survivors’ Participation in Productive Activities

Rectal cancer and its treatment impair survivors’ productivity. To assess determinants of market and nonmarket employment, job search, volunteering, and homemaking among survivors five years or longer after diagnosis. We mailed questionnaires to 1063 survivors who were members of (Northern California, Northwest) during 2010 and 2011. Productive activities, functional health status, and bowel management at the time of the survey. Response rate was 60.5% (577/953). Higher comorbidity burdens were associated with lower productivity for men and women rectal cancer survivors. Productive survivors were younger and had lower disease stage and age at diagnosis, higher household income and educational attainment, and fewer comorbidity burdens and workplace adjustments than did nonproductive survivors (p < 0.05 each; 2-sided). Productive rectal cancer survivors were evenly split by sex. Staying productive is associated with better mental health for rectal cancer survivors. Rectal cancer survivors with multiple chronic conditions, higher disease stage, lower productive activities, and older age need better access to medical care and closer monitoring of the quality of their care, including self-care. To capture the full extent of the involvement of survivors in all types of productive activities, research should routinely include measures of employment, searching for employment, homemaking, and volunteering. Counting market and nonmarket productive activities is innovative and recognizes the continuum of contributions survivors make to families and society. Health care systems should routinely monitor rectal cancer survivors' medical care access, comorbidities, health-related quality of life, and productive activities.

Authors: Hornbrook MC; Grant M; Wendel C; Bulkley JE; Mcmullen CK; Altschuler A; Temple LK; Herrinton LJ; Krouse RS

Perm J. 2017;22.

PubMed abstract

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

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. Informed by published evidence, relevant theoretical frameworks, stakeholder advice, and patient input, we developed a group-based intervention (Changing Results: Engage and Activate to Enhance Wellness; “CREATE Wellness”) to address the complex needs of patients with elevated or unmeasured CVD-related risk factors. We are testing this intervention in a randomized trial among patients with persistent (i.e > 2 years) sub-optimal risk factor control despite being enrolled in an advanced and highly successful CVD disease management program. The CREATE Wellness intervention is designed as a 3 session, group-based intervention combining proven elements of patient activation, health system engagement skills training, shared decision making, care planning, and identification of lifestyle change barriers. Our key learnings in designing the intervention included the value of multi-level stakeholder input and the importance of pragmatic skills training to address barriers to care. The CREATE Wellness intervention represents an evidence-based, patient-centered approach for patients not responding to traditional disease management. The trial is currently underway at three medical facilities within Kaiser Permanente Northern California and next steps include an evaluation of efficacy, adaptation for non-English speaking patient populations, and modification of the curriculum for web- or phone-based versions. NCT02302612.

Authors: Miller-Rosales C; Sterling SA; Grant RW; et al.

Contemp Clin Trials Commun. 2017 Dec;8:140-146. Epub 2017-10-04.

PubMed abstract

Effects of Transitioning to Medicare Part D on Access to Drugs for Medical Conditions among Dual Enrollees with Cancer

To evaluate the impact of transitioning from Medicaid to Medicare Part D drug coverage on the use of noncancer treatments among dual enrollees with cancer. We leveraged a representative 5% national sample of all fee-for-service dual enrollees in the United States (2004-2007) to evaluate the impact of the removal of caps on the number of reimbursable prescriptions per month (drug caps) under Part D on 1) prevalence and 2) average days’ supply dispensed for antidepressants, antihypertensives, and lipid-lowering agents overall and by race (white and black). The removal of drug caps was associated with increased use of lipid-lowering medications (days’ supply 3.63; 95% confidence interval [CI] 1.57-5.70). Among blacks in capped states, we observed increased use of lipid-lowering therapy (any use 0.08 percentage points; 95% CI 0.05-0.10; and days’ supply 4.01; 95% CI 2.92-5.09) and antidepressants (days’ supply 2.20; 95% CI 0.61-3.78) and increasing trends in antihypertensive use (any use 0.01 percentage points; 95% CI 0.004-0.01; and days’ supply 1.83; 95% CI 1.25-2.41). The white-black gap in the use of lipid-lowering medications was immediately reduced (-0.09 percentage points; 95% CI -0.15 to -0.04). We also observed a reversal in trends toward widening white-black differences in antihypertensive use (level -0.08 percentage points; 95% CI -0.12 to -0.05; and trend -0.01 percentage points; 95% CI -0.02 to -0.01) and antidepressant use (-0.004 percentage points; 95% CI -0.01 to -0.0004). Our findings suggest that the removal of drug caps under Part D had a modest impact on the treatment of hypercholesterolemia overall and may have reduced white-black gaps in the use of lipid-lowering and antidepressant therapies.

Authors: Adams AS; Madden JM; Zhang F; Lu CY; Ross-Degnan D; Lee A; Soumerai SB; Gilden D; Chawla N; Griggs JJ

Value Health. 2017 Dec;20(10):1345-1354. Epub 2017-07-06.

PubMed abstract

Overcoming barriers to diabetic polyneuropathy management in primary care

Diabetic polyneuropathy is a highly prevalent and costly complication of diabetes that is frequently underdiagnosed and undertreated in primary care settings. In this article, we discuss challenges in the management of diabetic polyneuropathy symptoms, including diagnostic complexity, the limited efficacy and high side effect rates associated with available treatments and the time constrained primary care visit. We call for the development of novel patient-centric, system-level strategies that engage patients between physician visits in order to facilitate timely communication of symptoms and treatment response and to promote patient-centered care.

Authors: Adams AS; Callaghan B; Grant RW

Healthc (Amst). 2017 Dec;5(4):171-173. Epub 2016-12-07.

PubMed abstract

Communicating Through a Patient Portal to Engage Family Care Partners

Authors: Reed ME; Huang J; Brand R; Ballard D; Yamin C; Hsu J; Grant R

JAMA Intern Med. 2017 Nov 20.

PubMed abstract

Physical activity, bowel function, and quality of life among rectal cancer survivors

Physical activity (PA) is positively associated with numerous health benefits among cancer survivors. This study examined insufficiently investigated relationships among PA, health-related quality of life (HRQOL), and bowel function (BF) in rectal cancer survivors. RC survivors (n = 1063) ≥5 years from diagnosis in two Kaiser permanente regions were mailed a multidimensional survey to assess HRQOL and BF. PA was assessed by a modified Godin Leisure-Time Exercise Questionnaire. PA minutes were categorized into weighted categories based on guidelines: (1) not active (zero PA minutes); (2) insufficiently active (1-149 PA minutes); (3) meeting guidelines (150-299 PA minutes); and (4) above guidelines (≥300 PA minutes). Relationships of PA with HRQOL and BF were evaluated using multiple linear regression, stratified by sex and ostomy status for BF. Types of PA identified as helpful for BF and symptoms addressed were summarized. Response rate was 60.5%. Of 557 participants, 40% met or exceeded PA guidelines, 34% were not active, and 26% were insufficiently active. Aerobic activities, specifically walking and cycling, were most commonly reported to help BF. Higher PA was associated with better psychological wellbeing and multiple SF12 scales, worse BF scores in men with ostomies, and better BF scores in women. Meeting or exceeding PA guidelines was associated with higher HRQOL. Although the BF findings are exploratory, they suggest women may benefit from increased PA, whereas men with ostomies may face challenges that require more study. Identifying PA strategies that will lead to improved patient compliance and benefit are needed.

Authors: Krouse RS; Wendel CS; Garcia DO; Grant M; Temple LKF; Going SB; Hornbrook MC; Bulkley JE; McMullen CK; Herrinton LJ

Qual Life Res. 2017 11;26(11):3131-3142. Epub 2017-07-04.

PubMed abstract

Machine Learning and Sepsis: On the Road to Revolution

Authors: Liu VX; Walkey AJ

Crit Care Med. 2017 11;45(11):1946-1947.

PubMed abstract

Predictors of Bowel Function in Long-term Rectal Cancer Survivors with Anastomosis

Bowel function in long-term rectal cancer survivors with anastomosis has not been characterized adequately. We hypothesized that bowel function is associated with patient, disease, and treatment characteristics. The cohort study included Kaiser Permanente members who were long-term (≥5 years) rectal cancer survivors with anastomosis. Bowel function was scored using the self-administered, 14-item Memorial Sloan-Kettering Cancer Center Bowel Function Index. Patient, cancer, and treatment variables were collected from the electronic medical chart. We used multiple regression to assess the relationship of patient- and treatment-related variables with the bowel function score. The study included 381 anastomosis patients surveyed an average 12 years after their rectal cancer surgeries. The total bowel function score averaged 53 (standard deviation, 9; range, 31-70, higher scores represent better function). Independent factors associated with worse total bowel function score included receipt of radiation therapy (yes vs. no: 5.3-unit decrement, p < 0.0001), tumor distance from the anal verge (≤6 cm vs. >6 cm: 3.2-unit decrement, p < 0.01), and history of a temporary ostomy (yes vs. no: 4.0-unit decrement, p < 0.01). One factor measured at time of survey was also associated with worse total bowel function score: ever smoking (2.3-unit decrement, p < 0.05). The regression model explained 20% of the variation in the total bowel function score. Low tumor location, radiation therapy, temporary ostomy during initial treatment, and history of smoking were linked with decreased long-term bowel function following an anastomosis. These results should improve decision-making about surgical options.

Authors: Alavi M; Wendel CS; Krouse RS; Temple L; Hornbrook MC; Bulkley JE; McMullen CK; Grant M; Herrinton LJ

Ann Surg Oncol. 2017 Nov;24(12):3596-3603. Epub 2017-08-07.

PubMed abstract

Opportunities to Reduce Diabetes Risk in Women of Reproductive Age: Assessment and Treatment of Prediabetes within a Large Integrated Delivery System

Preventing diabetes before pregnancy may be important to improve maternal and infant outcomes. Although the preconception period is a crucial time to focus on chronic disease prevention, little is known about preventive services for reproductive-aged women at risk of developing diabetes. Using electronic health record data from patients at Kaiser Permanente Northern California, we identified 21,965 nonpregnant women aged 18 to 44 with incident prediabetes (PDM; fasting plasma glucose [FPG] = 100-125 or glycated hemoglobin A1c = 5.7%-6.4%) between 2007 and 2010. We looked for evidence of a “clinical response” to PDM in the 6 months after laboratory testing, defined as retesting of blood glucose levels, referral or attendance to health education, diagnosis of PDM, metformin initiation, or a clinical note of discussion of PDM. Multilevel models were used to examine the relationship between patient characteristics and clinical response, and to assess provider-level variation. Fewer than one-half of women had a documented clinical response to the PDM-range laboratory result. Women with higher FPG values and body mass indexes were more likely to have a PDM diagnosis (FPG 120-125 vs. 100-119: OR, 1.96; 95% CI, 1.78-2.17; body mass index, 30-34 kg/m2 vs. <25 kg/m2: OR, 1.30; 95% CI, 1.13-1.48) and have 'PDM' recorded in the notes (FPG 120-125 vs. 100-119: OR, 1.15; 95% CI, 1.06-1.26; body mass index: 30-34 kg/m2 vs. <25 kg/m2: OR, 1.58; 95% CI, 1.44-1.74). Provider-level variation was modest, except for metformin initiation (intraclass correlation coefficient, 0.8; p < .01). Low clinical response to PDM among women of reproductive age suggests there are missed opportunities for diabetes prevention among this vulnerable population.

Authors: Marshall C; Adams S; Dyer W; Schmittdiel J

Womens Health Issues. 2017 Nov - Dec;27(6):666-672. Epub 2017-07-08.

PubMed abstract

Emotion dysregulation moderates the effect of cognitive behavior therapy with prolonged exposure for co-occurring PTSD and substance use disorders.

A goal of clinical trials is to identify unique baseline characteristics that can inform treatment planning. One such target is emotion dysregulation (ED), which contributes to the maintenance of co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) and may be a potential moderator of treatment response. We examined the moderating impact of ED severity on treatment outcomes in an urban, socioeconomically disadvantaged, and racially/ethnically diverse sample with complex trauma and severe SUDs. Participants with co-occurring PTSD and SUD (PTSD+SUD) were randomized to Concurrent Treatment with Prolonged Exposure (COPE, n=39), Relapse Prevention Therapy (RPT, n=43), or an active monitoring control group (AMCG, n=28). Baseline ED severity moderated treatment outcomes such that high ED was associated with greater reduction in PTSD severity among those who received COPE relative to RPT and AMCG. In contrast, low ED was associated with greater reduction in substance use among those in RPT relative to COPE and AMCG. Implications for individualizing and optimizing treatment selection for PTSD+SUD are discussed.

Authors: Hien DA; Lopez-Castro T; Papini S; Gorman B; Ruglass LM

J Anxiety Disord. 2017 Dec;52:53-61. doi: 10.1016/j.janxdis.2017.10.003. Epub 2017 Oct 16.

PubMed abstract

Comparing Hospital Processes and Outcomes in California Medicare Beneficiaries: Simulation Prompts Reconsideration

This article is not a traditional research report. It describes how conducting a specific set of benchmarking analyses led us to broader reflections on hospital benchmarking. We reexamined an issue that has received far less attention from researchers than in the past: How variations in the hospital admission threshold might affect hospital rankings. Considering this threshold made us reconsider what benchmarking is and what future benchmarking studies might be like. Although we recognize that some of our assertions are speculative, they are based on our reading of the literature and previous and ongoing data analyses being conducted in our research unit. We describe the benchmarking analyses that led to these reflections. The Centers for Medicare and Medicaid Services’ Hospital Compare Web site includes data on fee-for-service Medicare beneficiaries but does not control for severity of illness, which requires physiologic data now available in most electronic medical records.To address this limitation, we compared hospital processes and outcomes among Kaiser Permanente Northern California’s (KPNC) Medicare Advantage beneficiaries and non-KPNC California Medicare beneficiaries between 2009 and 2010. We assigned a simulated severity of illness measure to each record and explored the effect of having the additional information on outcomes. We found that if the admission severity of illness in non-KPNC hospitals increased, KPNC hospitals’ mortality performance would appear worse; conversely, if admission severity at non-KPNC hospitals’ decreased, KPNC hospitals’ performance would appear better. Future hospital benchmarking should consider the impact of variation in admission thresholds.

Authors: Escobar GJ; Baker JM; Turk BJ; Draper D; Liu V; Kipnis P

Perm J. 2017;21.

PubMed abstract

The Delivery Science Rapid Analysis Program: A Research and Operational Partnership at Kaiser Permanente Northern California

Health care researchers and delivery system leaders share a common mission to improve health care quality and outcomes. However, differing timelines, incentives, and priorities are often a barrier to research and operational partnerships. In addition, few funding mechanisms exist to generate and solicit analytic questions that are of interest to both research and to operations within health care settings, and provide rapid results that can be used to improve practice and outcomes. The Delivery Science Rapid Analysis Program (RAP) was formed in 2013 within the Kaiser Permanente Northern California Division of Research, sponsored by The Permanente Medical Group. A Steering Committee consisting of both researchers and clinical leaders solicits and reviews proposals for rapid analytic projects that will use existing data and are feasible within 6 months and with up to $30,000 (approximately 25-50% full-time equivalent) of programmer/analyst effort. Review criteria include the importance of the analytic question for both research and operations, and the potential for the project to have a significant impact on care delivery within 12 months of completion. The RAP funded 5 research and operational analytic projects between 2013 and 2017. These projects spanned a wide range of clinical areas, including lupus, pediatric obesity, diabetes, e-cigarette use, and hypertension. The hypertension RAP project, which focused on optimizing thiazide prescribing in Black/African-American patients with hypertension, led to new insights that inform an equitable care quality metric designed to reduce blood pressure control disparities throughout the KPNC region. Programs that actively encourage research and operational analytic partnerships have significant potential to improve care, enhance research collaborations, and contribute to the building and sustaining of learning health care systems.

Authors: Schmittdiel JA; Dlott R; Young JD; Rothmann MB; Dyer W; Adams AS

Learn Health Syst. 2017 Oct;1(4). Epub 2017-07-12.

PubMed abstract

The Incidence and Prevalence of Systemic Lupus Erythematosus in San Francisco County, California: The California Lupus Surveillance Project

Estimates of the incidence and prevalence of systemic lupus erythematosus (SLE) in the US have varied widely. The purpose of this study was to conduct the California Lupus Surveillance Project (CLSP) to determine credible estimates of SLE incidence and prevalence, with a special focus on Hispanics and Asians. The CLSP, which is funded by the Centers for Disease Control and Prevention, is a population-based registry of individuals with SLE residing in San Francisco County, CA, from January 1, 2007 through December 31, 2009. Data sources included hospitals, rheumatologists, nephrologists, commercial laboratories, and a state hospital discharge database. We abstracted medical records to ascertain SLE cases, which we defined as patients who met ≥4 of the 11 American College of Rheumatology classification criteria for SLE. We estimated crude and age-standardized incidence and prevalence, which were stratified by sex and race/ethnicity. The overall age-standardized annual incidence rate was 4.6 per 100,000 person-years. The average annual period prevalence was 84.8 per 100,000 persons. The age-standardized incidence rate in women and men was 8.6 and 0.7 per 100,000 person-years, respectively. This rate was highest among black women (30.5), followed by Hispanic women (8.9), Asian women (7.2), and white women (5.3). The age-standardized prevalence in women per 100,000 persons was 458.1 in blacks, 177.9 in Hispanics, 149.7 in Asians, and 109.8 in whites. Capture-recapture modeling estimated 33 additional incident cases and 147 additional prevalent cases. Comprehensive methods that include intensive case-finding provide more credible estimates of SLE in Hispanics and Asians, and confirm racial and ethnic disparities in SLE. The disease burden of SLE is highest in black women, followed by Hispanic women, Asian women, and white women.

Authors: Dall'Era M; Cisternas MG; Snipes K; Herrinton LJ; Gordon C; Helmick CG

2017 Oct;69(10):1996-2005. Epub 2017-09-10.

PubMed abstract

Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use

Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable. To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D. Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D. Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records. Hypoglycemia-related ED or hospital use during 12 months of follow-up. The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (>5%), intermediate (1%-5%), or low (<1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79). This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.

Authors: Karter AJ; Warton EM; Lipska KJ; Ralston JD; Moffet HH; Jackson GG; Huang ES; Miller DR

JAMA Intern Med. 2017 Oct 01;177(10):1461-1470.

PubMed abstract

Identifying Distinct Subgroups of ICU Patients: A Machine Learning Approach

Identifying subgroups of ICU patients with similar clinical needs and trajectories may provide a framework for more efficient ICU care through the design of care platforms tailored around patients’ shared needs. However, objective methods for identifying these ICU patient subgroups are lacking. We used a machine learning approach to empirically identify ICU patient subgroups through clustering analysis and evaluate whether these groups might represent appropriate targets for care redesign efforts. We performed clustering analysis using data from patients’ hospital stays to retrospectively identify patient subgroups from a large, heterogeneous ICU population. Kaiser Permanente Northern California, a healthcare delivery system serving 3.9 million members. ICU patients 18 years old or older with an ICU admission between January 1, 2012, and December 31, 2012, at one of 21 Kaiser Permanente Northern California hospitals. None. We used clustering analysis to identify putative clusters among 5,000 patients randomly selected from 24,884 ICU patients. To assess cluster validity, we evaluated the distribution and frequency of patient characteristics and the need for invasive therapies. We then applied a classifier built from the sample cohort to the remaining 19,884 patients to compare the derivation and validation clusters. Clustering analysis successfully identified six clinically recognizable subgroups that differed significantly in all baseline characteristics and clinical trajectories, despite sharing common diagnoses. In the validation cohort, the proportion of patients assigned to each cluster was similar and demonstrated significant differences across clusters for all variables. A machine learning approach revealed important differences between empirically derived subgroups of ICU patients that are not typically revealed by admitting diagnosis or severity of illness alone. Similar data-driven approaches may provide a framework for future organizational innovations in ICU care tailored around patients’ shared needs.

Authors: Vranas KC; Jopling JK; Sweeney TE; Ramsey MC; Milstein AS; Slatore CG; Escobar GJ; Liu VX

Crit Care Med. 2017 Oct;45(10):1607-1615.

PubMed abstract

Reply to the Timing of Early Antibiotics and Hospital Mortality in Sepsis – Playing Devil’s Advocate

Authors: X Liu V; Fielding-Singh V; Iwashyna TJ; Bhattacharya J; Escobar GJ

Am J Respir Crit Care Med. 2017 10 01;196(7):935-936.

PubMed abstract

The Timing of Early Antibiotics and Hospital Mortality in Sepsis

Prior sepsis studies evaluating antibiotic timing have shown mixed results. To evaluate the association between antibiotic timing and mortality among patients with sepsis receiving antibiotics within 6 hours of emergency department registration. Retrospective study of 35,000 randomly selected inpatients with sepsis treated at 21 emergency departments between 2010 and 2013 in Northern California. The primary exposure was antibiotics given within 6 hours of emergency department registration. The primary outcome was adjusted in-hospital mortality. We used detailed physiologic data to quantify severity of illness within 1 hour of registration and logistic regression to estimate the odds of hospital mortality based on antibiotic timing and patient factors. The median time to antibiotic administration was 2.1 hours (interquartile range, 1.4-3.1 h). The adjusted odds ratio for hospital mortality based on each hour of delay in antibiotics after registration was 1.09 (95% confidence interval [CI], 1.05-1.13) for each elapsed hour between registration and antibiotic administration. The increase in absolute mortality associated with an hour’s delay in antibiotic administration was 0.3% (95% CI, 0.01-0.6%; P = 0.04) for sepsis, 0.4% (95% CI, 0.1-0.8%; P = 0.02) for severe sepsis, and 1.8% (95% CI, 0.8-3.0%; P = 0.001) for shock. In a large, contemporary, and multicenter sample of patients with sepsis in the emergency department, hourly delays in antibiotic administration were associated with increased odds of hospital mortality even among patients who received antibiotics within 6 hours. The odds increased within each sepsis severity strata, and the increased odds of mortality were greatest in septic shock.

Authors: Liu VX; Fielding-Singh V; Greene JD; Baker JM; Iwashyna TJ; Bhattacharya J; Escobar GJ

Am J Respir Crit Care Med. 2017 Oct 01;196(7):856-863.

PubMed abstract

Ibutilide Effectiveness and Safety in the Cardioversion of Atrial Fibrillation and Flutter in the Community Emergency Department

Little is known about the use of ibutilide for cardioversion in atrial fibrillation and flutter outside of clinical trials. We seek to describe patient characteristics, ibutilide administration patterns, cardioversion rates, and adverse outcomes in the community emergency department (ED) setting. We also evaluate potential predictors of cardioversion success. Using a retrospective cohort of adults who received ibutilide in 21 community EDs between January 2009 and June 2015, we gathered demographic and clinical variables from electronic health records and structured manual chart review. We calculated rates of cardioversion and frequency of ventricular tachycardia within 4 hours and estimated adjusted odds ratios (aOR) in a multivariate regression model for potential predictors of cardioversion. Among 361 patients, the median age was 61 years (interquartile range 53 to 71 years) and most had recent-onset atrial fibrillation and flutter (98.1%). Five percent of the cohort had a history of heart failure. The initial QTc interval was prolonged (>480 ms) in 29.4% of patients, and 3.1% were hypokalemic (<3.5 mEq/L). The mean ibutilide dose was 1.5 mg (SD 0.5 mg) and the rate of ibutilide-related cardioversion within 4 hours was 54.8% (95% confidence interval [CI] 49.6% to 60.1%), 50.5% for atrial fibrillation and 75.0% for atrial flutter. Two patients experienced ventricular tachycardia (0.6%), both during their second ibutilide infusion. Age (in decades) (aOR 1.3; 95% CI 1.1 to 1.5), atrial flutter (versus atrial fibrillation) (aOR 2.7; 95% CI 1.4 to 5.1), and no history of atrial fibrillation and flutter (aOR 2.0; 95% CI 1.2 to 3.1) were associated with cardioversion. The effectiveness and safety of ibutilide in this community ED setting were consistent with clinical trial results despite less stringent patient selection criteria.

Authors: Vinson DR; Lugovskaya N; Warton EM; Rome AM; Stevenson MD; Reed ME; Nagam MR; Ballard DW; Pharm CAFÉ Investigators of the CREST Network

Ann Emerg Med. 2017 Sep 29.

PubMed abstract

A randomized controlled study of power posing before public speaking exposure for social anxiety disorder: No evidence for augmentative effects.

This manuscript details a randomized controlled study designed to test the efficacy of power posing (i.e., briefly holding postures associated with dominance and power) as an augmentative strategy for exposure therapy for social anxiety disorder (SAD). Seventy-three individuals diagnosed with SAD were assigned to one of three conditions: power posing, submissive posing, or rest (no posing) prior to participating in an exposure therapy session. Participants were assessed for between-group differences in pre- and post-manipulation salivary hormone levels, within-session subjective experiences of fear, and pre- and 1-week post-treatment SAD severity outcome measures. Though the intervention resulted in decreased SAD symptom severity one week later, analyses revealed no significant between-group differences on any tested variables. Accordingly, this study provides no evidence to suggest that power posing impacts hormone levels or exposure therapy outcomes.

Authors: Davis ML; Papini S; Rosenfield D; Roelofs K; Kolb S; Powers MB; Smits JAJ

J Anxiety Disord. 2017 Dec;52:1-7. doi: 10.1016/j.janxdis.2017.09.004. Epub 2017 Sep 18.

PubMed abstract

Navigating the research-clinical interface in genomic medicine: analysis from the CSER Consortium

PurposeThe Clinical Sequencing Exploratory Research (CSER) Consortium encompasses nine National Institutes of Health-funded U-award projects investigating translation of genomic sequencing into clinical care. Previous literature has distinguished norms and rules governing research versus clinical care. This is the first study to explore how genomics investigators describe and navigate the research-clinical interface.MethodsA CSER working group developed a 22-item survey. All nine U-award projects participated. Descriptive data were tabulated and qualitative analysis of text responses identified themes and characterizations of the research-clinical interface.ResultsSurvey responses described how studies approached the research-clinical interface, including in consent practices, recording results, and using a research versus clinical laboratory. Responses revealed four characterizations of the interface: clear separation between research and clinical care, interdigitation of the two with steps to maintain separation, a dynamic interface, and merging of the two. All survey respondents utilized at least two different characterizations. Although research has traditionally been differentiated from clinical care, respondents pointed to factors blurring the distinction and strategies to differentiate the domains.ConclusionThese results illustrate the difficulty in applying the traditional bifurcation of research versus clinical care to translational models of clinical research, including in genomics. Our results suggest new directions for ethics and oversight.Genetics in Medicine advance online publication, 31 August 2017; doi:10.1038/gim.2017.137.

Authors: Wolf SM; Amendola LM; Berg JS; Chung WK; Clayton EW; Green RC; Harris-Wai J; Henderson GE; Jarvik GP; Koenig BA; Lehmann LS; McGuire AL; O'Rourke P; Somkin C; Wilfond BS; Burke W

Genet Med. 2017 Aug 31.

PubMed abstract

Prediction of Recurrent Clostridium Difficile In