KP AIM-HI Program: Augmented Intelligence in Medicine and Healthcare Initiative
The Moore Foundation will fund a RFP for health system prospective evaluation of machine learning-based diagnostic decision support tools for 3 to 5 external applicants over 3 years each. KP DOR will act as the coordinating center for designing, executing,…
Machine Learning Applied to EHR Data as a Means of Improving Biosurveillance and Diagnostic Excellence: A Pilot Project
We aim to develop and extend methods of probabilistic modeling of temporal electronic health record (EHR) data, using non-stationary Gaussian processes, hidden Markov models, and composite mixture models, to identify opportunities to conduct clinical biosurveillance and to achieve diagnostic excellence.…
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.
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…
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…
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…
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…
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…
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.
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…
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…
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…
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…
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…
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…
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…
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…
Blood clots in hospitalized patients tied to worse outcomes
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…
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…
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…
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.…
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…
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…
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…
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.…
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…
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…
Exposure to small children linked to lower risk of severe COVID-19
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…
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
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…
Early antibiotics for sepsis supported in new study
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…
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…
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…
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.…
National recognition for Kaiser Permanente early alert system
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…
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])…
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…
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…
Evaluation of Risk-Based Predictive Models to Inform the Efficiency of Perioperative Systems
We previously developed an automated electronic health record-based risk stratification tool, called the Comorbidity Assessment and Surgical Triage (CAST) score, which we implemented in KP HealthConnect to improve triage of elective surgical patients to perioperative medicine clinic visit types in…
Turning back the clock on sepsis: Defining the epidemiology and opportunities of pre-sepsis
We intend to determine the epidemiology of pre-sepsis, including ambulatory and prehospital care settings, to identify modifiable care delays, opportunities for primary sepsis prevention, and to improve early sepsis care for vulnerable populations. The objectives include determining the epidemiology of…
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…
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…
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…
Risk score assigns surgery patients to best level of preoperative counseling
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…
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…
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…
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…
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…
Predictive model paired with case management reduced rate of readmitted hospital patients
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.…
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…
New tool for early identification of COVID-19 surges
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…
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…
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)…
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…
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…
Effectiveness and safety of treatments for hospitalized patients with COVID-19
Examine the safety and effectiveness of current treatments for hospitalized patients with COVID-19 and identify patient characteristics and time periods during the disease course that are associated with more favorable treatment response.
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…
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…
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…
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…
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…
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,…
Analysis confirms racial disparities in COVID-19 infection
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…
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…
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…
Real-time in-hospital alerts associated with lower patient mortality
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…
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…
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,…
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…
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…
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…
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…
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…
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…
Population-level estimates show wide age range of adults hospitalized with COVID-19
Can knowing common search terms lead to better usability of electronic health records?
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'…
Investigator pursues compelling questions about a poorly understood killer of hospital patients
Understanding and Informing Early Hospital Antibiotic Prescribing for Potential Infection
The goals of this study are to (1) examine temporal trends in early hospital antibiotic prescribing patterns over the past 5 years, to assess for unintended consequences associated with earlier antibiotics in severe sepsis/septic shock; (2) quantify the patient-level harm…
Sepsis on FHIR
Overall goal is to define and refine the current epidemiology, clinical characteristics, and treatment practices in respiratory failure in late and moderately preterm infants. Specific aims are to determine that incidence and epidemiology of respiratory failure in neonates born 32-36…
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,…
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…
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…
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…
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…
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…
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…
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…
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…
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,…
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…
Kaiser Permanente machine learning analysis of sepsis illustrates condition’s complexity
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…
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…
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…
Using EHR Audit Logs to Capture Diagnostic Pathways and Time to Diagnosis
Rapid expansions in the use of electronic health record (EHR) systems also contribute to large expansions in the availability of metadata. These highly granular metadata may prove particularly useful for understanding how frontline clinicians interact with clinical information when making…
Targeting Cardiovascular Events to Improve Patient Outcomes After Sepsis
Sepsis is the most common illness leading to hospitalization in the United States, affecting more than 1 million Americans each year. While short-term mortality has improved over prior decades, sepsis survivors face numerous post-hospital sequelae that negatively impact long-term morbidity…
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…
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…
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…
Benchmarking Hospital Quality – Template Matching
In this study, Kaiser Permanente Northern California researchers will serve as consultants for U.S. Department of Veterans Affairs (VA) researchers to evaluate the utility of template matching techniques, compared with standard regression techniques, for comparing hospital quality.
Identifying Pre-Sepsis Opportunities for Early, Targeted Intervention
Early evidence suggests there will be ongoing waves of COVID-19 outbreak that can be mitigated through effective community-level prediction models and intervention. This project will Identify pre-sepsis opportunities for early, targeted intervention to inform community-level mitigation strategies of upcoming COVID19…
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…
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…
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…
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…
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…
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.…
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…
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…
Benefits of Intensive Care Unit Admission for Patients with Acute Respiratory Failure or Sepsis
Ideal and optimally efficient use of intensive care unit (ICU) resources would create benefits across the health care system. Ideal use of ICU resources requires a needs assessment to determine which categories of patients commonly admitted to ICUs derive true…
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…
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…
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…
Prediction of Recurrent Clostridium Difficile Infection Using Comprehensive Electronic Medical Records in an Integrated Healthcare Delivery System
BACKGROUND Predicting recurrent Clostridium difficile infection (rCDI) remains difficult. We employed a retrospective cohort design. Granular electronic medical record (EMR) data had been collected from patients hospitalized at 21 Kaiser Permanente Northern California hospitals. The derivation dataset (2007-2013) included data…
Individual and health system variation in rehospitalizations the year after pneumonia
Little is known about variation in patterns of recovery among patients discharged alive from hospitalizations for pneumonia.The aim of the is observational cohort study was to characterize the variation in patterns of hospital readmission and survival in the year after…
Innovation and Technology: Electronic Intensive Care Unit Diaries
Hospitalization in the intensive care unit can be a stressful time for patients and their family members. Patients' family members often have difficulty processing all of the information that is given to them. Therefore, an intensive care unit diary can…
Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System
Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective…
Data-Driven Precision Medicine in Sepsis
Sepsis is a common and costly disease which contributes to nearly 1 in 2 hospital deaths in our healthcare system. While aggressive early treatment with quantitative resuscitation has demonstrated benefit, many other interventions have not demonstrated efficacy likely resulting from…
Utilization of Health Services Among Adults With Recurrent Clostridium difficile Infection: A 12-Year Population-Based Study
BACKGROUND Considerable efforts have been dedicated to developing strategies to prevent and treat recurrent Clostridium difficile infection (rCDI); however, evidence of the impact of rCDI on patient healthcare utilization and outcomes is limited. OBJECTIVE To compare healthcare utilization and 1-year…
The Kaiser Permanente Northern California Enhanced Recovery After Surgery Program: Design, Development, and Implementation
Complications are common after surgery, highlighting the need for innovations that reduce postsurgical morbidity and mortality. In this report, we describe the design, development, and implementation of an Enhanced Recovery After Surgery program in the Kaiser Permanente Northern California integrated…
Incorporating an Early Detection System Into Routine Clinical Practice in Two Community Hospitals
Efforts to improve outcomes of patients who deteriorate outside the intensive care unit have included the use of rapid response teams (RRTs) as well as manual and automated prognostic scores. Although automated early warning systems (EWSs) are starting to enter…
Piloting electronic medical record-based early detection of inpatient deterioration in community hospitals
Patients who deteriorate in the hospital outside the intensive care unit (ICU) have higher mortality and morbidity than those admitted directly to the ICU. As more hospitals deploy comprehensive inpatient electronic medical records (EMRs), attempts to support rapid response teams…
Data that drive: Closing the loop in the learning hospital system
The learning healthcare system describes a vision of US healthcare that capitalizes on science, information technology, incentives, and care culture to drive improvements in the quality of health care. The inpatient setting, one of the most costly and impactful domains…
In-hospital mortality following treatment with red blood cell transfusion or inotropic therapy during early goal-directed therapy for septic shock: a retrospective propensity-adjusted analysis
We sought to investigate whether treatment of subnormal (
Towards Smarter Lumping and Smarter Splitting: Rethinking Strategies for Sepsis and ARDS Clinical Trial Design
Both quality improvement and clinical research efforts over the past few decades have focused on consensus definition of sepsis and acute respiratory distress syndrome (ARDS). Although clinical definitions based on readily available clinical data have advanced recognition and timely use…
Multicenter Implementation of a Treatment Bundle for Sepsis Patients with Intermediate Lactate Values
Treatments for patients with sepsis with intermediate lactate values (?2 and
Developing a framework for implementing intensive care unit diaries: a focused review of the literature
Intensive care unit diaries have been shown to improve post-critical illness recovery, however, prior reports of diary implementation are heterogeneous. We sought to construct a common framework for designing and implementing Intensive Care Unit diaries based on prior studies. We…
The Natural History of Changes in Preferences for Life-Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults
To compare changes in preferences for life-sustaining treatments (LSTs) and subsequent mortality of younger and older inpatients. Retrospective cohort study. Kaiser Permanente Northern California (KPNC). Individuals hospitalized at 21 KPNC hospitals between 2008 and 2012 (N = 227,525). Participants were divided according…
Evaluation Following Staggered Implementation of the “Rethinking Critical Care” ICU Care Bundle in a Multicenter Community Setting
To evaluate process metrics and outcomes after implementation of the "Rethinking Critical Care" ICU care bundle in a community setting. Retrospective interrupted time-series analysis. Three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system. ICU patients admitted between…
Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
Septic shock currently refers to a state of acute circulatory failure associated with infection. Emerging biological insights and reported variation in epidemiology challenge the validity of this definition. To develop a new definition and clinical criteria for identifying septic shock…
Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
The Third International Consensus Definitions Task Force defined sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection." The performance of clinical criteria for this sepsis definition is unknown. To evaluate the validity of clinical criteria to…
Treatment of Alcohol Withdrawal Syndrome with and without Dexmedetomidine
Studies suggest that dexmedetomidine-an intravenous central-acting ?2-adrenergic agonist that effectively reduces anxiety among critically ill patients-is being used in patients with severe alcohol withdrawal. However, evidence supporting its use is limited, and it is not approved for this indication. To…
Consensus Statement on Electronic Health Predictive Analytics: A Guiding Framework to Address Challenges
The recent explosion in available electronic health record (EHR) data is motivating a rapid expansion of electronic health care predictive analytic (e-HPA) applications, defined as the use of electronic algorithms that forecast clinical events in real time with the intent…
Variation in the Contents of Sepsis Bundles and Quality Measures: A Systematic Review
Sepsis contributes to one in every two to three inpatient hospital deaths. Early recognition and treatment are instrumental in reducing mortality, yet there are substantial quality gaps. Sepsis bundles containing quality metrics are often used in efforts to improve outcomes.…
Impact of Relative Contraindications to Home Management in Emergency Department Patients with Low-Risk Pulmonary Embolism
Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of…
The Accuracy of an Electronic Pulmonary Embolism Severity Index Auto-Populated from the Electronic Health Record: Setting the stage for computerized clinical decision support
The Pulmonary Embolism (PE) Severity Index identifies emergency department (ED) patients with acute PE that can be safely managed without hospitalization. However, the Index comprises 11 weighted variables, complexity that can impede its integration into contextual workflow. We designed a…
Trends in red blood cell transfusion and 30-day mortality among hospitalized patients
Blood conservation strategies have been shown to be effective in decreasing red blood cell (RBC) utilization in specific patient groups. However, few data exist describing the extent of RBC transfusion reduction or their impact on transfusion practice and mortality in…
Hospital readmission and healthcare utilization following sepsis in community settings
Sepsis, the most expensive cause of hospitalization in the United States, is associated with high morbidity and mortality. However, healthcare utilization patterns following sepsis are poorly understood. To identify patient-level factors that contribute to postsepsis mortality and healthcare utilization. A…
Increased one-year health care utilization in survivors of severe sepsis
Hospitalizations for severe sepsis are common, and a growing number of patients survive to hospital discharge. Nonetheless, little is known about survivors' post-discharge healthcare use. To measure inpatient healthcare use of severe sepsis survivors compared with patients' own presepsis resource…
Accuracy of hospital standardized mortality rates: effects of model calibration
Risk-adjusted mortality rates are commonly used in quality report cards to compare hospital performance. The risk adjustment depends on models that are assessed for goodness-of-fit using various discrimination and calibration measures. However, the relationship between model fit and the accuracy…
Predicting red blood cell transfusion in hospitalized patients: role of hemoglobin level, comorbidities, and illness severity
Randomized controlled trial evidence supports a restrictive strategy of red blood cell (RBC) transfusion, but significant variation in clinical transfusion practice persists. Patient characteristics other than hemoglobin levels may influence the decision to transfuse RBCs and explain some of this…
Fluid Volume, Lactate Values, and Mortality in Sepsis Patients with Intermediate Lactate Values
Patients with severe sepsis without shock or tissue hypoperfusion face substantial mortality; however, treatment guidelines are lacking. To evaluate the association between intravenous fluid resuscitation, lactate clearance, and mortality in patients with "intermediate" lactate values of 2 mmol/L or greater…
Automated identification of pneumonia in chest radiograph reports in critically ill patients
Prior studies demonstrate the suitability of natural language processing (NLP) for identifying pneumonia in chest radiograph (CXR) reports, however, few evaluate this approach in intensive care unit (ICU) patients. From a total of 194,615 ICU reports, we empirically developed a…
Visitation policies and practices in United States intensive care units
Prior reports suggest that restrictive ICU visitation policies can negatively impact patients and their loved ones. However, visitation practices in US ICUs, and the hospital factors associated with them, are not well described. A telephone survey was made of ICUs,…
An electronic simplified acute physiology score-based risk adjustment score for critical illness in an integrated healthcare system*
OBJECTIVE: Risk adjustment is essential in evaluating the performance of an ICU; however, assigning scores is time-consuming. We sought to create an automated ICU risk adjustment score, based on the Simplified Acute Physiology Score 3, using only data available within…
Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system
BACKGROUND: Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions. DESIGN, SETTING, PATIENTS: Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival…
The association between sepsis and potential medical injury among hospitalized patients
BACKGROUND: Patient safety remains a national priority, but the role of disease-specific characteristics in safety is not well characterized. METHODS: We identified potentially preventable medical injuries using patient safety indicators (PSIs) and annual data from the Nationwide Inpatient Sample between…
