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Munro, Malcolm. "Acute Uterine Bleeding Unrelated to Pregnancy: A Southern California Permanente Medical Group Practice Guideline". Permanente Journal 17, n. 3 (1 agosto 2013): 43–56. http://dx.doi.org/10.7812/tpp/13-018.
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Ghochani, Mariam, Atieh Hajianpour, Abbas Padeganeh, Casey Brewer, Farzad Nooraie, Rezvan Habibian, Mike Moradian e Ruan Ramjit. "Cytogenomic microarray analysis as a first-tier clinical diagnostic test: Kaiser Permanente, Southern California Permanente Medical Group experience". Molecular Genetics and Metabolism 132 (aprile 2021): S287. http://dx.doi.org/10.1016/s1096-7192(21)00529-1.
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Tran, Hung. "QOL-57. SOUTHERN CALIFORNIA KAISER PERMANENTE PEDIATRIC NEURO-ONCOLOGY PROGRAM DEVELOPMENT". Neuro-Oncology 22, Supplement_3 (1 dicembre 2020): iii441. http://dx.doi.org/10.1093/neuonc/noaa222.710.
Testo completoAbstract (sommario):
Abstract KEY MESSAGE Standardization of care for subspecialty patients require centralization and support across multi-disciplinary groups within the Kaiser Permanente medical group, which is a large health maintenance organization (HMO) in the United States. BACKGROUND Prior to the development of a Pediatric Neuro-Oncology program, Southern California Kaiser Permanente pediatric neuro-oncology patients were routinely referred to respective regional academic centers for consultation. The process was not standard across the region, resulting in additional costs and differences in treatment recommendations, potentially affecting outcomes. METHODS A Pediatric Neuro-Oncology program was established, July 2017, based at the Kaiser Permanente Los Angeles Medical Center (LAMC), consisting of pediatric neuro-oncology, pediatric neurosurgery, pediatric neuro-radiology, pediatric radiation oncology, and pediatric neuro-oncology case management. RESULTS A Pediatric Neuro-Oncology tumor board was established to meet on a bi-monthly basis. Pediatric neuro-oncology patients across the Southern California now have their magnetic resonance imaging (MRI) reviewed by the same pediatric neuro radiologists. Neuropathology is standardized and sent to Children’s Hospital Los Angeles and reviewed at the molecular neuropathology tumor board attended by the pediatric neuro-oncologist. Cases discussions regarding the patients include the regional pediatric neurosurgeons, the pediatric radiation oncologists, and the pediatric neuro-oncologist, and treatment plans are recommended and recorded by the case manager. CONCLUSIONS Centralization of care has allowed for more consistent and standard care across the Southern California Region, but requires support from multi-disciplinary groups.
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Andryjowicz, E. "Implementation and Methodology for Expanding Minimally Invasive Surgery (MIS) for Hysterectomy within Southern California Permanente Medical Group". Journal of Minimally Invasive Gynecology 18, n. 6 (novembre 2011): S32. http://dx.doi.org/10.1016/j.jmig.2011.08.113.
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Cohen, David S., Jane E. Tongson-Ignacio, Christopher M. Lolachi, Vanessa S. Ghaderi, Babak Jahan-Parwar e Lester D. R. Thompson. "Rethinking Malignancy Risk in Indeterminate Thyroid Nodules with Positive Molecular Studies: Southern California Permanente Experience". Otolaryngology–Head and Neck Surgery 161, n. 3 (23 aprile 2019): 419–23. http://dx.doi.org/10.1177/0194599819842859.
Testo completoAbstract (sommario):
Objectives To recognize that thyroid nodules with atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS; Bethesda III) have different risks of malignancy based on genetic mutation and to consider molecular testing of nodules with AUS/FLUS to help avoid unnecessary morbidity or cost. Study Design Retrospective cohort study. Setting Multiple locations within Southern California Permanente Medical Group. Subjects and Methods Patients included those with indeterminate thyroid nodules and AUS/FLUS on 2 separate fine-needle aspirations with positive ThyGenX testing from 2014 to 2017 who underwent thyroid surgery. Patients were classified as having benign or malignant disease. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features was considered benign. Results A total of 231 patients had repeat AUS/FLUS with positive molecular testing and surgery. The most frequent type of malignancy was papillary carcinoma, followed by follicular carcinoma. The overall prevalence of malignancy in nodules with mutations was 74.0%, although there was considerable variation: BRAF = 100%, RET = 100%, PAX8-PPARγ = 84.6%, HRAS = 70.7%, NRAS = 63.4%, and KRAS = 33%—a statistically significant finding ( P < .001). Conclusions Not all molecular mutations in thyroid nodules with AUS/FLUS have a high risk of malignancy. Of note, patients with BRAF and RET mutations in our population had a 100% risk of malignancy. Patients with PAX, HRAS, or NRAS mutations had a high risk of malignancy, while patients with KRAS mutations had a lower risk of malignancy. Further studies are needed to determine if the presence of certain molecular mutations can help personalize care and aid in the decision for thyroid surgery.
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Jordan, Jennifer Lyn, e Robert Michael Cooper. "Prevalence of overweight and obesity in a population of childhood leukemia patients and survivors." Journal of Clinical Oncology 30, n. 34_suppl (1 dicembre 2012): 324. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.324.
Testo completoAbstract (sommario):
324 Background: Overweight and obesity (BMI>95 percentile) in the pediatric population has become a prominent problem. The prevalence of pediatric obesity has increased from 5% in 1976-1980 to 17% among children and adolescents in 2007-2008. The presence of obesity in survivors of certain childhood cancers has been identified as a late effect of therapy, especially in survivors of ALL and brain tumors. Obesity prevalence following treatment for ALL ranges from 11-57%. The long-term health consequences of obesity include diabetes mellitus, hypertension, cardiovascular disease, metabolic syndrome and certain cancers. Kaiser Permanente (KP) tracks pediatric BMI as part of routine health maintenance. There is an initiative to promote Healthy Eating and Active Living (HEAL) and reduce childhood obesity. As part of this initiative the HEAL clinic provides a multi-disciplinary weight management program for the general adolescent population at KP Los Angeles Medical Center (LAMC). Methods: A chart review was conducted using the electronic medical record system at LAMC. 99 records, 22 current patients and 77 survivors of ALL, were identified and reviewed for Body Mass Index (BMI) and compared to the general pediatric population of KP in Southern California. Results: See Table. 57 leukemia patients and survivors were identified as overweight or obese, which is a 57.5% prevalence rate. This is significantly higher than the rate of pediatric overweight and obesity of 37.1% in the KP Southern California general population. Conclusions: The use of an electronic medical record system confirms a higher prevalence of overweight and obesity in the ALL patients and survivors at KP LAMC than the general pediatric population in Southern California. The intervention piloted by the HEAL clinic has been adapted to treat this group of overweight and obese cancer patients and survivors. [Table: see text]
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Chang, Jason, Joseph E. Ahn, Nicholas Landsman, Katherine Rhee, Linda Chun e Kaushal Kevin Patel. "Efficacy of Contemporary Medical Management for Asymptomatic Carotid Artery Stenosis". American Surgeon 79, n. 10 (ottobre 2013): 987–91. http://dx.doi.org/10.1177/000313481307901006.
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In the Asymptomatic Carotid Artery Stenosis trial (1995), medical management was defined as aspirin in addition to adequate control of comorbidities. Since then, medical management of asymptomatic carotid artery stenosis (CAS) has progressed to include broader use of statins. Our purpose was to review the effect of contemporary medical management on stroke prevention. A retrospective review of the Kaiser Permanente, Southern California medical group database was performed. All patients with a diagnosis of asymptomatic CAS by International Classification of Diseases, 9th Revision codes from 2007 to 2011 were identified. Intervention for stroke prevention was the criteria for exclusion. Medications used were evaluated as was the rate of stroke. Asymptomatic CAS was noted in 7255 patients. Of these, 158 (2.2%) sustained a stroke within a mean follow-up of 37 months. Patients who were taking a statin had a statistically significant lower risk of stroke (1.6 vs 3.9%). The data support that contemporary medical management of asymptomatic CAS has decreased the incidence of stroke in comparison to previously published data. The use of statins was protective against the development of stroke. Future prospective randomized trials are needed to evaluate the efficacy of carotid intervention versus current medical management.
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Battaglia, Alex, Raoul Burchette, Jacob Hussman, Matthew A. Silver, Peter Martin e Paul Bernstein. "Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess". Otolaryngology–Head and Neck Surgery 158, n. 2 (7 novembre 2017): 280–86. http://dx.doi.org/10.1177/0194599817739277.
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Objective This study was performed to determine whether the efficacy and safety of medical management of uncomplicated peritonsillar abscess (PTA) presenting in the emergency department is equivalent to medical plus surgical therapy. Study Design Case series with chart review. Setting Southern California Permanente Medical Group (SCPMG). Subjects and Methods Upon successful completion of a prospective study comparing medical treatment (MT) to surgical treatment (ST) of PTA in 2008, MT was adopted by 12 SCPMG centers while 7 centers continued standard surgical drainage. Clinical outcomes are now reviewed on a random sampling of 211 patients with PTA treated with MT and 96 patients treated with ST between 2008 and 2013 at the respective medical centers. Patients were treated with intravenous (IV) fluids, weight-appropriate IV ceftriaxone, clindamycin, and dexamethasone, and then discharged on clindamycin × 10 days (MT). Patients in the ST group received MT but also surgical drainage. Primary end points were complication rates and failure rates. Results MT and ST resulted in no significant difference in treatment success or complications. However, patients in the MT group obtained significantly less liquid opioid prescriptions (MT, 30.8 ± 5.65; ST, 77.75 ± 13.41; P < .0001), reported fewer sore days (MT, 4.48 ± 0.27; ST, 5.77 ± 0.49; P = .0004), and required less days off from work (MT, 3.4 ± 0.44; ST, 4.9 ± 0.82; P = .044). Conclusions Compared to ST, MT appears to be equally safe and efficacious, with less pain, opioid use, and days off work, especially if patients with PTA present without trismus. MT for PTAs reduces the possibility of surgical complications, as well as the cost and inconvenience associated with ST.
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Bell, Elizabeth, Robert Michael Cooper e Lisa Mueller. "Using the electronic medical record to identify and follow survivors of pediatric malignancies." Journal of Clinical Oncology 30, n. 34_suppl (1 dicembre 2012): 302. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.302.
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302 Background: There are currently more than 328,000 survivors of pediatric malignancies in the United States (NCI, The Childhood Cancer Survivor Study: An Overview, http://www.cancer.gov/cancertopics/coping/ccss . 6/6/2012). These survivors are at risk for significant late effects from their cancer treatments (Childhood Cancer Survivors Study (Oeffinger, et al, NEJM 2006)). The Kaiser Permanente health care system has good insurance retention of patients treated for pediatric malignancies. Kaiser also uses an electronic medical record, which improves our ability to identify survivors and follow them over time to identify and manage late effects of cancer treatment. The Children’s Oncology Group (COG) has released a summary of cancer treatment form and specific guidelines for follow-up based on patients’ treatment. Methods: In 2010, we queried the Kaiser Permanente Southern California Cancer Registry for all patients who were diagnosed with a malignancy under the age of 18 from 1980 to 2009. This was cross-referenced with list of current Kaiser members as of 2010. We created a database of the current members and their diagnosis, treatment center, age at diagnosis, date of diagnosis, current age, years of survivorship, and sex. We divided the patients into priority groups: (1) more than 5 years from diagnosis and over age 18, (2) more than 5 years from diagnosis and less than age 18, and (3) less than 5 years from diagnosis. We began to prepare summaries of cancer treatment for the groups using the COG form. Results: We identified 1,267 survivors of pediatric malignancies who were Kaiser members in 2010. 54% are still Kaiser members 10 years after diagnosis. There were 611 in Group 1, 293 in Group 2, and 363 in Group 3. We have prepared summaries of cancer treatment including late effects for 400 of the survivors, 360 from Group 1, and 40 from Group 2. Conclusions: The combination of an electronic medical record and insurance retention allows us to identify and track survivors of pediatric malignancies into adulthood. With completed summaries of cancer treatment we will be able to quickly identify at-risk populations for monitoring and potential interventions.
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McDonough, Paul G., e Sylvain Fribourg. "Leuprolide Depot Before Myomectomy**This is a personal communication of the author’s and not to be construed as representing in any way either Kaiser Permanente or the Southern California Permanente Medical Group." Fertility and Sterility 53, n. 4 (aprile 1990): 754. http://dx.doi.org/10.1016/s0015-0282(16)53480-3.
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Chen, Gao L., Yasir Akmal, Andrew L. DiFronzo, Brooke Vuong e Victoria O'Connor. "Porcelain Gallbladder: No Longer an Indication for Prophylactic Cholecystectomy". American Surgeon 81, n. 10 (ottobre 2015): 936–40. http://dx.doi.org/10.1177/000313481508101005.
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Porcelain gallbladder (PG) was historically associated with gallbladder cancer (GBC), (range 12–62%, largest series n = 26). Presently, cholecystectomy is still performed in many patients with PG. The objective of this study was to determine the incidence of GBC in patients with radiographic diagnosis of PG. We conducted a retrospective chart review of the Kaiser Permanente southern California electronic medical record database and identified patients with radiographic diagnosis of PG between 2008 and 2013. Extracted were patient demographics, imaging modality, symptoms, surgical and observational outcomes, and pathology results. Out of 192 PG patients, 102 underwent cholecystectomy, and 90 were observed. None of the patients in the surgery group had GBC on pathology review, and none of the observed patients developed GBC during follow-up (mean 3.5 years). In the surgery group, 82 per cent of the patients were asymptomatic with a perioperative complication rate of 10.7 per cent. Among symptomatic patients, the complication rate was 16.7 per cent. Rate of conversion to open surgery was 5 per cent. Complications led to eight endoscopic or percutaneous interventions and five additional operations. PG is not associated with increased risk of GBC but is associated with high risk of postoperative complications. Cholecystectomy should not be recommended in asymptomatic patients with PG.
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Crain, Nikhil, e Talar Tejirian. "An Analysis of Early Postoperative Returns after Inguinal Hernia Surgery". American Surgeon 84, n. 10 (ottobre 2018): 1613–16. http://dx.doi.org/10.1177/000313481808401015.
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Although inguinal herniorrhaphy is low risk, patients still return to the urgent care or ED. We performed a retrospective study on 19,296 inguinal hernia operations across 14 Southern California Kaiser Permanente medical centers over five years. Unplanned returns within the first postoperative week were evaluated focusing on four potentially avoidable diagnoses (AD): pain, constipation, urinary retention, and nausea/vomiting. Overall, 1370 (7%) patients returned to the urgent care/emergency department, of which 537 (39%) had an AD. There was no difference in total returns (7.1 vs 7.4%, P = 0.33) or AD returns [2.8 vs 2.6%, ( P = 0.44)] for males vs females. Of the 537 total AD returns, there were 205 (38%) patients with pain, 191 (36%) with urinary retention, 112 (21%) with constipation, and 29 (5%) with nausea/vomiting. Most AD returns (78%) occurred within the first three postoperative days. Pain was greater in open operations [44 vs 26%, ( P < 0.05)], and urinary retention was greater in the laparoscopic group [27 vs 55%, ( P < 0.05)]. The overall rate of return was higher for laparoscopic compared with open unilateral operations [8 vs 6%, ( P < 0.05)], but similar between approaches for bilateral operations [11 vs 10%, ( P = 0.32)].
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Nguyen, Charles, Andrei Novac, Jessica Hazen, Pamela Howard, Ryan Tieu e Robert G. Bota. "Weight gain changes in patients with aripiprazole monotherapy compared with aripiprazole–antidepressant polypharmacy in an outpatient sample". Journal of Psychopharmacology 32, n. 4 (7 dicembre 2017): 423–29. http://dx.doi.org/10.1177/0269881117742659.
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Objective: This study seeks to evaluate the weight gain effect within a community-based population of patients with diagnoses of depression, mood disorder, and schizophrenia receiving aripiprazole over a period of at least 6 months. Method: The four million members of Kaiser Permanente of Southern California (KPSC) were queried for a four-year period between January 1, 2010 and December 31, 2013. The initial cohort comprised 25,682 KPSC members who received at least one dispense of aripiprazole. This initial cohort was split into those who received aripiprazole as a monotherapy (“Alone” group) and those who were given aripiprazole as part of a combination therapy. The group of patients that received aripiprazole and antidepressant with high serotonin reuptake inhibition we called “High” group while the group receiving aripiprazole and bupropion combination we called “Low” serotonin group. We compared the primary endpoint of mean percent weight change from baseline after 180 days of continuous treatment between the three groups. Three pairwise comparisons were made: High versus Alone, Low versus Alone, and Low versus High, using adjusted and unadjusted linear regression models. Results: Within this population, patients on aripiprazole monotherapy showed statistically significant weight gain in all three groups. However, there was no statistically significant difference in weight gain between the aripiprazole monotherapy, the high serotonergic combination group, and the low serotonergic combination group. This finding applied even within the subset of patients who were considered obese (body mass index > 30). Conclusions: The results suggest that weight gain is unchanged by combination treatments, but further research is required.
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Cooper, Robert Michael, e Erin Elizabeth Hahn. "Timeliness of care delivery for lung cancer patients in a vertically integrated health care system." Journal of Clinical Oncology 34, n. 7_suppl (1 marzo 2016): 127. http://dx.doi.org/10.1200/jco.2016.34.7_suppl.127.
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127 Background: A Kaiser Permanente Southern California (KPSC) organizational goal is to achieve optimal timeliness of cancer care delivery. The purpose of this report is to present a process used for a multi-disciplinary physician led performance improvement exercise at the at the Los Angeles Medical Center and share initial learnings. Methods: A CME approved Performance Improvement (PI) program to examine timeliness of care delivery for newly diagnosed patients with lung cancer was created for physicians. The multi-disciplinary core group met for 6 three hour blocks of time to process map the patient centered flow. The physicians evaluated current practice, developed a future state and made structural changes. The group focused on two time intervals: time from suspicion of malignancy until pathology resulted, and time from pathology until the start of treatment. Results: Initial learnings included, that the work was meaningful as shown by physicians using their dedicated education time and consistency of participation; an electronic medical record was useful for the initial process mapping and ongoing monitoring; patient flow is complex and patients followed many different paths to diagnosis and treatment. Participating in this project benefitted team building, improved understanding of the challenges throughout the system, enhanced empathy for their colleagues and patients, and educated physicians about performance improvement methodology. Preliminary review of timeliness of care delivery shows improvements in timeliness at the two time points both during the year of instituting a PI program and with the first interventions. Conclusions: A physician led multi-disciplinary approach to review of timeliness of care delivery is feasible and productive.
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Crain, Nikhil, e Armen Aboulian. "Unplanned Returns to Care within Seven Days after Anorectal Surgery: Can they be Avoided?" American Surgeon 85, n. 1 (gennaio 2019): 92–97. http://dx.doi.org/10.1177/000313481908500139.
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With rates up to 50 per cent, unanticipated returns after anorectal surgery remain a major issue. A retrospective analysis was performed on 5929 anorectal operations from January 2011 to December 2015 across 14 Kaiser Permanente Southern California medical centers. Data were gathered on the cause, frequency and timing of unplanned returns to the ED and urgent care. Of all patients, 246 (4%) returned with a nonavoidable diagnosis and 243 (4%) returned with one of four avoidable diagnoses: pain, constipation, urinary retention, and nausea/vomiting. Seventy four per cent of avoidable diagnoses returns occurred within the first four postoperative days, with 48 per cent between days 2 and 4. In patients older than 50 years of age, males showed higher urinary retention (P = 0.001), whereas females had higher constipation (P < 0.001). Contrarily, pain was higher for both males (P = 0.02) and females (P < 0.001) less than 50 years old. In a separate subanalysis on anesthesia type, both constipation (P = 0.03) and urinary retention (P = 0.01) showed double the return rate in the general versus local/monitored anesthesia care group, whereas pain (P = 0.15) and nausea/vomiting (P = 0.20) showed no differences. Half of returns fall into a category that is potentially avoidable with preemptive interventions.
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Cooper, Robert, Michaela Hull e Faisal N. Cheema. "Community Experience with Pediatric Inspired Treatment of Acute Lymphoblastic Leukemia in the Adolescent and Young Adult Population in Kaiser Permanente Northern and Southern California Regions". Blood 138, Supplement 1 (5 novembre 2021): 1212. http://dx.doi.org/10.1182/blood-2021-146677.
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Abstract Background: Pediatric inspired treatment for Acute Lymphoblastic Leukemia has been increasingly used for treatment of adolescents and young adults in the United States and Europe. In 2019 Dr. Stock published results of CALGB 10403 which showed that a pediatric inspired regimen was tolerable and efficacious in a population of ALL patients up to the age 40. Prior to that publication the use of pediatric inspired treatment was quite variable and mostly used in academic hospital systems. There was concern about tolerability, utilization and efficacy of pediatric inspired protocols. Kaiser Permanente is a vertically integrated care delivery system. The Northern and Southern California regions are the two largest regions each caring for approximately 4.5 million members and cared for in a network of medical offices and hospitals. Methods: We reviewed the Cancer Registries of the Kaiser Permanente Northern and Southern California regions for patients aged 15-39 diagnosed with acute lymphoblastic leukemia between 2010 - 2018. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. We examined the initial induction plan selected and determined if the induction used steroids, vincristine, an anthracycline and asparaginase and if so was classified as pediatric inspired. If not induction was classified as an adult protocol. Patients were characterized as pediatric inspired or adult then followed based on the initial induction plan selected. Neither the sub type of ALL, the molecular characteristics or the MRD status at the end of induction was reviewed. The selection of chemotherapy agents after the initial induction plan was not reviewed. The use of pediatric inspired induction over the time of the study was reviewed. The patients clinical course was reviewed for the next 6 months and utilization including hospital days, ICU days was reviewed. Patients were followed for toxicities of treatments including sepsis, lab abnormalities, and documented side effects of chemotherapy. The pattern of BMT referral was reviewed. The vital status known at the end of the evaluation was also reviewed. Results A total of 222 patients were evaluated. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. Over the study period 66.7 % of the patients received a pediatric inspired induction. The use of pediatric inspired treatments increased over the study period with 38% use in 2010 to 90% in 2018. For patients over age 21 in 2010 the use was 10% in 2018 84%. There was a significantly greater number of inpt days for patients initiated on adult protocols at months, 1, 3 and 6. There was no difference in ICU days. For outpatient utilization there was a significantly higher use of the ED at months 1,3,6 for patients initiated on adult treatments. For patients over 21 there was a significantly increased number of BMT consults during the first 6 months after diagnosis. There was no statistical difference in documented bacteremia, mucositis, pancreatitis, neuropathy or sepsis between the 2 groups. For patients over 26 there was a significant increase in peripheral neuropathy in the adult treated group. There was a significantly elevated risk of mortality at 2 years after diagnosis for the adult treated group. For patients over the age 26 the risk of mortality was similar at 2 years. Conclusion We saw a rapid increase of utilization of pediatric inspired inductions over the study period within the Kaiser Permanente California regions. Patients who initiated treatment on adult protocols had over the first 6 months more inpatient days, were more likely to utilize the ED, were more likely to have a BMT consult. Patients who received adult protocol treatments had higher mortality at 2 years after diagnosis. We conclude that adult oncologists now favor pediatric inspired treatment approaches and there do not seem to be any safety concerns with this approach and in fact pediatric inspired treatments may lead to lower utilization and decreased mortality. Disclosures No relevant conflicts of interest to declare.
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Lagana, Michele, Erin Elizabeth Hahn, Joanne E. Schottinger, Susan E. Kutner e Mark B. Littlewood. "The Kaiser Permanente Breast Cancer Survivorship National Clinical Algorithm: Regional variation in implementation processes/strategies within an integrated health care system." Journal of Clinical Oncology 34, n. 7_suppl (1 marzo 2016): 104. http://dx.doi.org/10.1200/jco.2016.34.7_suppl.104.
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104 Background: Kaiser Permanente (KP) is an integrated healthcare system providing comprehensive services to over 10 million members. The KP Interregional Breast Care Leaders, a multidisciplinary clinician group, developed a comprehensive evidence/consensus-based algorithm for breast cancer survivors, the KP Breast Cancer Survivorship National Clinical Algorithm (BCSNCA). The BCSNCA is intended to reduce variation in medical and psychosocial surveillance and improve outcomes by providing guidance to locally implemented survivorship programs, ie, recommendations for surveillance, late effects management, and risk reduction. As a quality improvement project, we evaluated regional/ facility level implementation. Methods: Qualitative data on BCSNCA implementation was collected from key informant interviews with oncology providers for 20 sites in 6 regions: Georgia, Colorado, Hawaii, Southern (KPSC) and Northern California (KPNC), and Mid-Atlantic, and by attending BCSNCA meetings. Implementation activities were recorded, categorized, and compared to BCSNCA. Results: Facilities in 3 regions implemented discrete BCSNCA components: Northwest and Georgia facilities implemented dedicated survivorship clinics; a KPSC facility piloted a nurse navigator standardized psychosocial assessment; KPNC implemented local guidelines, similar to the BCSNCA. One region has not implemented; Georgia implemented all BCSNCA components. There is variation within each region. Implementation drivers include available resources, competing QI priorities/leadership preferences, and adaptability of extant programs. Conclusions: We found variation between and within regions. The BCSNCA content accommodates variation in implementation, guided by a complex set of factors, including resource availability, leadership preferences, and local organizational goals. Even in integrated systems, the need for locally driven guideline adaptation is critical. Next step: assessment of BCSNCA components on patient-level outcomes.
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Spellman, Joseph, Ryan Sload, Paul Kim, Peter Martin e Gabriel Calzada. "Staging Neck Dissection and Transoral Robotic Surgery Treatment Algorithm in Palatine Tonsil Cancer". Otolaryngology–Head and Neck Surgery 158, n. 3 (21 novembre 2017): 479–83. http://dx.doi.org/10.1177/0194599817742615.
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Objective This study introduces a treatment algorithm based on staging neck dissection to identify patients with palatine tonsil squamous cell carcinoma who can be effectively treated with single-modality transoral robotic surgery while maintaining quality of life. Study Design Retrospective case series. Setting Kaiser Permanente Southern California Medical Group from 2012 to 2017. Subjects and Methods Patients with early-stage (T1/2) palatine tonsil squamous cell carcinoma with clinically and radiographically N0 necks underwent staging neck dissection. Those with pN2/3 disease or extracapsular extension on final pathology were triaged to definitive chemoradiation treatment. Patients with confirmed pN0/1 necks without extracapsular extension were treated definitively with transoral robotic surgery. Results Nineteen patients with cN0 disease underwent selective neck dissection. All were p16 positive. Of these, 14 had pathologically confirmed N0/1 necks without extracapsular extension and were treated with primary surgical resection via transoral robotic surgery. Clear margins were obtained on all patients. There were no significant intra- or postoperative complications. No patients required gastrostomy tube or tracheostomy placement. Mean and median follow-up was 28 months with no recurrences to date. Conclusion Up-front staging neck dissection accurately triages low-risk patients, determining candidates for single-modality definitive treatment with transoral robotic surgery. This approach provides excellent survival outcomes and minimal morbidity and maintains quality of life among appropriately selected patients with palatine tonsil cancer.
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Schottinger, Joanne E., Kristen L. Andrews, Gail X. Lindsay e Michael H. Kanter. "Use of electronic medical records on cancer screening rates: The proactive office encounter." Journal of Clinical Oncology 30, n. 34_suppl (1 dicembre 2012): 289. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.289.
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289 Background: The Southern California Permanente Medical Group cares for a diverse population of 3.5 million members. An electronic medical record supports the care of patients at each outpatient and inpatient encounter. In the US, only about 55% of Americans receive recommended preventive care services. Methods: The Proactive Office Encounter (POE) was developed to proactively address care gaps in preventive or chronic care needs at the point of service with every visit to either primary or specialty care. Prior to a visit, the staff identify missing labs or screening procedures and provides the patient with pre-visit instructions. With a standardized workflow and checklist used during any office visit, care gaps are identified from decision support tools in the electronic record and office staff pend necessary orders to the physician. The room is prepared for any procedures necessary (Pap), iFOBT kits are made ready for use if indicated, and on exiting, the patient receives an after visit summary that includes any necessary follow up instructions. Successful Completion Opportunity Reports are produced for every department to measure the improvement of closing care gaps. A small financial incentive is applied for specialists for these successful comp-letions (P4P). Back office work flow reports measure the elements of POE at the individual staff level. Performance on screening rates is reported bimonthly for feedback. Results: Within two years of implementation, pre and post POE cancer screening rates increased from 85.6 to 88.7 (3.1%) for breast cancer; 82.0 to 86.6 (4.6%) for cervical cancer; and 52.5 to 69.7 (17.4%) for colorectal cancer. Rates for advising smokers to quit smoking increased from 53 to 68 (15%). Conclusions: Use of evidence-based logic integrated in an electronic medical record combined with standard work flows deployed in primary and specialty care reliably ensures that patients receive needed services at every visit. This contributed to sharp rises in preventive care quality measures. Care shifts from being reactive to team-based and proactive and is no longer dependent on a physician remembering all the needed elements of care.
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Schottinger, Joanne E., Farah Brasfield, Andrew DiFronzo, Helen Lau, Kerry C. Litman, Gary Edward Schwartz e Michael H. Kanter. "Reducing colorectal cancer mortality: The e-Autopsy tool." Journal of Clinical Oncology 32, n. 30_suppl (20 ottobre 2014): 60. http://dx.doi.org/10.1200/jco.2014.32.30_suppl.60.
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60 Background: Colorectal cancer (CRC) remains the second leading cause of cancer death in the US, despite the availability of highly effective screening and treatment modalities. Kaiser Permanente Southern California is a non profit integrated health care organization that serves 3.7 million socio-economically diverse members. Our region has developed a goal to reduce colorectal cancer mortality by 50% in the next decade, from our baseline measurement of 13.8 deaths/100,00 members to 6.9 deaths/100,000 members. Methods: A literature search was conducted by the evidence based services unit to identify interventions demonstrated in published literature to reduce CRC mortality. These interventions were used to develop a spread sheet to guide the e-Autopsy, an electronic medical records review of 50 cases of recent death with CRC that was conducted by a multi-specialty group of reviewers: physicians in primary care, medical and surgical oncology, and pathology. Records of patients who died were compared to the best practices identified in the literature review to measure how often care was not matching the best practices. Review and comments were tallied by a quality nurse and reviewed by a multi-disciplinary steering group. Results: Electronic record review revealed multiple areas of opportunity for focus: Improve screening rates; Reduce diagnostic errors in evaluation of anemia/abdominal complaints; Improve care co-ordination to reduce time to surgery and chemotherapy administration; Evaluate metastatic disease for resection; Improve rates of delivery of adjuvant chemotherapy; Engage patients in lifestyle modifications. Ongoing system wide metrics and a dashboard have been developed to monitor progress in each of these areas. The relevant chiefs of service groups have developed goals and work plans to improve these metrics, which are also monitored by a central quality steering committee. Conclusions: Electronic medical record "autopsy" review of deaths in the system can be used to find and demonstrate multiple areas of focus for quality improvement projects that will help support the ultimate big region wide goal of halving the deaths from colorectal cancer.
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An, Jaejin, Dennis Hwang, Jiaxiao Shi, Amy Sawyer, Aiyu Chen, Diego Mazzotti, Greg Maislin et al. "447 Cost-Effectiveness of a 3-Year Tele-OSA Intervention". Sleep 44, Supplement_2 (1 maggio 2021): A177. http://dx.doi.org/10.1093/sleep/zsab072.446.
Testo completoAbstract (sommario):
Abstract Introduction Trial-based tele-obstructive sleep apnea (OSA) cost-effectiveness analyses have often been inconclusive due to small sample sizes and short follow-up. In this study, we report the cost-effectiveness of Tele-OSA using a larger sample from a 3-month trial that was augmented with 2.75 additional years of epidemiologic follow-up. Methods The Tele-OSA study was a 3-month randomized trial conducted in Kaiser Permanente Southern California that demonstrated improved adherence in patients receiving automated feedback messaging regarding their positive airway pressure (PAP) use when compared to usual care. At the end of the 3 months, participants in the intervention group pseudo-randomly either stopped or continued receiving messaging. This analysis included those participants who had moderate-severe OSA (Apnea Hypopnea Index >=15) and compared the cost-effectiveness of 3 groups: 1) no messaging, 2) messaging for 3 months only, and 3) messaging for 3 years. Costs were derived by multiplying medical service use from electronic medical records times costs from Federal fee schedules. Effects were average nightly hours of PAP use. We report the incremental cost per incremental hour of PAP use as well as the fraction acceptable. Results We included 256 patients with moderate-severe OSA (Group 1, n=132; Group 2, n=79; Group 3, n=45). Group 2, which received the intervention for 3 months only, had the highest costs and fewest hours of use and was dominated by the other two groups. Average 1-year costs for groups 1 and 3 were $6035 (SE, $477) and $6154 (SE, $575), respectively; average nightly hours of PAP use were 3.07 (SE, 0.23) and 4.09 (SE, 0.42). Compared to no messaging, messaging for 3 years had an incremental cost ($119, p=0.86) per incremental hour of use (1.02, p=0.03) of $117. For a willingness-to-pay (WTP) of $500 per year ($1.37/night), 3-year messaging has a 70% chance of being acceptable. Conclusion Long-term Tele-OSA messaging was more effective than no messaging for PAP use outcomes but also highly likely cost-effective with an acceptable willingness-to-pay threshold. Epidemiologic evidence suggests that this greater use will yield both clinical and additional economic benefits. Support (if any) Tele-OSA study was supported by the AASM Foundation SRA Grant #: 104-SR-13
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An, Jaejin, Henry Glick, Jiaxiao Shi, Aiyu Chen, Jessica Arguelles, Brendan Keenan, Greg Maislin et al. "448 Association between Positive Airway Pressure Adherence and Healthcare Costs". Sleep 44, Supplement_2 (1 maggio 2021): A177. http://dx.doi.org/10.1093/sleep/zsab072.447.
Testo completoAbstract (sommario):
Abstract Introduction The impact of positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA) on healthcare costs is uncertain. We explored the relationship between 3-year PAP adherence and direct healthcare cost utilizing the Tele-OSA study cohort. Methods The Tele-OSA randomized clinical trial demonstrated improved PAP adherence in patients receiving automated feedback messaging regarding their PAP use versus usual care. The study enrolled patients at Kaiser Permanente Southern California, a large integrated healthcare system, from 2014–2015. Patients with moderate-severe OSA (Apnea Hypopnea Index [AHI] ≥15) from all study arms were consolidated, then stratified into PAP adherence groups based on mean PAP hours and PAP use patterns over 3-year follow-up period: (a) high adherence (consistent ≥4 hours/night); (b) moderate adherence (2–3.9 hours/night or inconsistent ≥4 hours/night); (c) low adherence (<2 hours/night). Healthcare costs (2020 US dollars) were derived by assigning costs from Federal fee schedules to healthcare utilization extracted from electronic health records. The 6-month mean healthcare costs during follow-up were estimated using generalized linear models adjusting for patient demographics, comorbidities, Medicaid coverage, prior healthcare cost, and AHI. Results Of 374 patients (mean age 50 years, 63% male), 22% were categorized into high adherence, 18% moderate adherence, and 60% low adherence to PAP therapy. Mean (SD) hours of PAP use were 6.5 (1.1) hours, 3.7 (1.3) hours, and 0.3 (0.5) hours for high, moderate, and low adherence groups, respectively. The high adherence group had the lowest average (SE) adjusted 6-month healthcare costs compared with other groups (High: $2,991 [$234]; Moderate: $3,604 [$412]; Low: $3,854 [$300]). Cost savings of high vs low adherence were $862 (95% CI $1540, $185). Cost savings of moderate vs low adherence were $250 (95% CI -$694, $1,193). Conclusion Better PAP adherence was associated with significantly lower healthcare costs over 3 years in patients with moderate-severe OSA. Findings support the importance of care strategies to enhance long-term PAP adherence for OSA therapy. Support (if any) The Tele-OSA Study was supported by AASM Foundation SRA Grant #: 104-SR-13
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Nguyen, Huong Q., Lewei Duan, Janet S. Lee, Thomas G. Winn, Annet Arakelian, Jaime Akiyama-Ciganek, Dan N. Huynh, Della D. Williams e Bing Han. "Association of a Medicare Advantage Posthospitalization Home Meal Delivery Benefit With Rehospitalization and Death". JAMA Health Forum 4, n. 6 (25 giugno 2023): e231678. http://dx.doi.org/10.1001/jamahealthforum.2023.1678.
Testo completoAbstract (sommario):
ImportanceThe 2018 Chronic Care Act allowed Medicare Advantage plans to have greater flexibility in offering supplemental benefits, such as meals and services, to address unmet needs of beneficiaries with certain chronic conditions. Based on earlier studies of community-based nutritional support, such programs may result in reduced use.ObjectiveTo evaluate the association of a 4-week posthospitalization home-delivered meals benefit with 30-day all-cause rehospitalization and mortality in patients admitted for heart failure (HF) and other acute medical conditions (non-HF).Design, Setting, and ParticipantsIn this cohort study, patients who received meals (the meals group) were compared with 2 controls: (1) no meals in the 2019 historical cohort who would have been eligible for the benefit (the no meals–2019 group) and (2) no meals in the 2021 and 2022 concurrent cohort who were referred but did not receive the meals due to unsuccessful contacts and active declines (the no meals–2021/2022 group). This study took place in a large integrated health care system in southern California among Medicare Advantage members with a hospitalization for HF or other acute medical conditions at 15 Kaiser Permanente hospitals discharged to home.ExposureThe exposure was receipt of at least 1 and up to 4 shipments of home-delivered meals (total of 56 to 84 meals) after hospital discharge.Main Outcomes and MeasuresThe main outcomes were 30-day all-cause composite rehospitalization and death.ResultsA total of 4032 adults with admission to the hospital for HF (mean [SD] age, 79 [9] years; 1951 [48%] White; 2001 [50%] female) and 7944 with non-HF admissions (mean [SD] age, 78 [8] years; 3890 [49%] White; 4149 [52%] female) were included in the analyses. Unadjusted rates of 30-day death and rehospitalization for the meals, no meals–2019, and no meals–2021/2022 cohorts were as follows: HF: 23.3%, 30.1%, and 38.5%; non-HF: 16.5%, 22.4%, and 32.9%, respectively. For HF, exposure to meals was significantly associated with lower odds of 30-day death and rehospitalization compared with the no meals–2021/2022 cohort (OR, 0.55; 95% CI, 0.43-0.71; P &lt; .001) but was not significant compared with the no meals–2019 cohort (OR, 0.86; 95% CI, 0.72-1.04; P = .12). For non-HF, exposure to meals was associated with significantly lower odds of 30-day death and rehospitalization when compared with the no meals–2019 (OR, 0.64; 95% CI, 0.52-0.79; P &lt; .001) and the no meals–2021/2022 (OR, 0.48; 95% CI, 0.37-0.62; P &lt; .001) cohorts.Conclusions and RelevanceIn this cohort study, exposure to posthospitalization home-delivered meals was associated with lower 30-day rehospitalization and mortality; randomized clinical trials are needed to confirm these findings.
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Haque, Reina, Lie H. Chen, Karen Kwan, Nina Oestreicher, Rowan T. Chlebowski e Deepa Lalla. "Abstract P2-11-02: Subsequent breast cancer among women with HER2+ disease in a large integrated healthcare system". Cancer Research 82, n. 4_Supplement (15 febbraio 2022): P2–11–02—P2–11–02. http://dx.doi.org/10.1158/1538-7445.sabcs21-p2-11-02.
Testo completoAbstract (sommario):
Abstract BACKGROUND: Women with breast cancer are living longer, including those with risk factors like HER2+ tumors or diagnosed at later stages, but a dearth of information exists on patients’ outcomes beyond clinical trials. We aimed to describe the risk of subsequent breast cancer (recurrence, second primary breast cancer, breast cancer-specific death) in women with HER2+ disease in a large community health plan. METHODS: We assembled a cohort of 3550 women (≥18 years) with HER2+ breast cancer (Stages I-III) during 2009-2017 whom were Kaiser Permanente Southern California members and followed them through December 2018. Subjects were identified from the plan’s NCI-SEER tumor registry. Data elements were captured from the tumor registry, pathology reports, and electronic health records. Hormone receptor (HR, ER and/or PR+), and HER2 status were assessed by immunohistochemistry or FISH. Subsequent breast cancer (SBC) events were identified from pathology report review (2/3 of cohort) or a validated computerized algorithm (1/3 of cohort without pathology reports). We computed SBC rates by trastuzumab use, HR status and tumor size and followed women from the index date to the date of SBC, disenrollment, death, or end of study in December 2018, whichever occurred first. Multivariable Cox proportional hazards regression was used to estimated adjusted hazard ratios (HR) and 95% confidence intervals. RESULTS: Of the 3550 women, the median age at diagnosis was 57 years. The cohort comprised 46% White; 13% Black; 16% Asian/Pacific Islander; and 24% Hispanic. 83% had stage I-II disease and 68% were HR+. Among these women, 81% received adjuvant trastuzumab; 3% other chemotherapy only and 16% neither. Less than 20 women used neoadjuvant trastuzumab. The cohort was followed a mean of 4.1 years (IQR: 1.5-6.3), with a maximum of 10 years. In the trastuzumab treated group, the cumulative 1-, 3-, 5-, and 10-year SBC risk were: 9.8%, 24.6%, 27.8%, and 30.4%, respectively. The mean time to SBC was 2.0 years (IQR: 0.9-2.5). SBC rate was lower in women who had trastuzumab (73.5/1,000 PY) therapy than those who did not (90.8/1,000 PY), corresponding to 22% reduced risk (adjusted HR=0.78, 95% CI: 0.66-0.91) (Table 1). Compared to women diagnosed at stage I, those with stage II-III disease were 1.19 times (adj HR=1.19, 95% CI: 1.01-1.40) more likely to develop SBC. Tumor size≥2cm was associated with a 23% greater risk of SBC (adj HR=1.23, 95% CI: 1.00-1.51) versus tumors<2cm. The multivariable analyses included these covariates: trastuzumab use; diagnosis age and year; stage; race/ethnicity; geocoded income; ER/PR; surgery type; other adjuvant therapy (endocrine, radiation, chemotherapy); lymph node status; histology; BMI; comorbidity; neoadjuvant trastuzumab, and other chemotherapy. CONCLUSION: This population-based study using one of the most comprehensive electronic medical records in California, we observed that the cumulative SBC risk persists, and was 30.4% at 10 years in women with HER2+ breast cancer treated with trastuzumab. Further, the SBC risk was greater in those with higher stages, large tumors (≥2 cm) and lymph node positive, even after accounting for trastuzumab use. Table. Multivariable HRs (95% CI) for subsequent breast-cancer in women with HER2+ invasive diseaseTotal Women*SBCSBC rates per 1,000 woman-yearsCrude modelMultivariable modelNNHR (95% CI)HR (95% CI)All Women 3550110176.5 TrastuzumabNo67522790.81.00 (ref)1.00 (ref)Yes287587473.50.86 (0.74-0.99)0.78 (0.66-0.91) Stage at dxI147138862.31.00 (ref)1.00 (ref)II-III207971387.31.45 (1.28-1.65)1.19 (1.01-1.40) Tumor sizeTumors<2 cm53012657.11.00 (ref)1.00 (ref)Tumors≥2 cm291094380.11.51 (1.25-1.83)1.23 (1.00-1.51) Lymph NodesPositive (ref)117043387.11.00 (ref)1.00 (ref)Negative206254363.90.69 (0.61-0.79)0.75 (0.65-0.88)*Some variables do not sum to N=3550 due to missing Citation Format: Reina Haque, Lie H Chen, Karen Kwan, Nina Oestreicher, Rowan T. Chlebowski, Deepa Lalla. Subsequent breast cancer among women with HER2+ disease in a large integrated healthcare system [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-02.
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Greene, Ingrid, e Denise Ferguson. "Targeting Internal Publics During the 2014 Ebola Outbreak: An Analysis of Kaiser Permanente’s Crisis Communication Strategy". Proceedings of the International Crisis and Risk Communication Conference 1 (marzo 2018): 30–33. http://dx.doi.org/10.30658/icrcc.2018.9.
Testo completoAbstract (sommario):
Issues management in today’s quickly changing world can be complex and unpredictable, and in the case of the spread of Ebola, carry lethal implications. Kaiser Permanente (KP) faced a potential internal crisis due to the involvement of medical staff during the spread of the disease in the United States. In addition, KP needed to ensure the safety of the patients the healthcare provider serves. This case study examines how the corporate communications team at KP in Southern California communicated the necessary messages during this crisis in the U.S. in the fall of 2014. The methodology of this case is a textual analysis of the internal corporate communications within Kaiser Permanente during the 2014 Ebola outbreak in the U.S.
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Kawatkar, A. A., L. H. Chu, W. Chen, L. Yen, M. H. Erder, P. Hodgkins, R. Iyer e G. Longstreth. "PGI3 Validation of Algorithms to Identify Diverticulitis Through Electronic Medical Records in Kaiser Permanente Southern California (KPSC)". Value in Health 15, n. 4 (giugno 2012): A135. http://dx.doi.org/10.1016/j.jval.2012.03.730.
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Luu, Mitchell N., Paul Y. Wada, Tory Levine-Hall, Leo Hurley, Nirmala Ramalingam, H. Nicole Tran e Sally B. Slome. "Using a report card to increase HIV screening in a large primary care group practice". BMJ Open Quality 10, n. 1 (gennaio 2021): e000988. http://dx.doi.org/10.1136/bmjoq-2020-000988.
Testo completoAbstract (sommario):
BackgroundDespite increased efforts to promote HIV screening, a large proportion of the US population have never been tested for HIV.ObjectiveTo determine whether provider education and personalised HIV screening report cards can increase HIV screening rates within a large integrated healthcare system.DesignThis quality improvement study provided a cohort of primary care physicians (PCPs) a brief educational intervention and personalised HIV screening report cards with quarterly performance data.ParticipantsParticipants included a volunteer cohort of 20 PCPs in the department of adult and family medicine.Main measuresPer cent of empaneled patients screened for HIV by cohort PCPs compared with PCPs at the Kaiser Permanente Oakland Medical Center (KPOAK) and the non-Oakland Medical Centers in Northern California region (Kaiser Permanente Northern California (KPNC)).Key resultsOf the 20 participating PCPs, 13 were female and 7 were male. Thirteen were internal medicine and seven family medicine physicians. The average age was 40 years and average practice experience was 9 years after residency. During the 12-month intervention, the estimated increase in HIV screening in the cohort PCP group was 2.6% as compared with 1.9% for KPOAK and 1.8% for KPNC.ConclusionsThese findings suggest that performance-related report cards are associated with modestly increased rates of HIV screening by PCPs.
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VUGIA, DUC J., CAROL L. PETERSON, HILDY B. MEYERS, KWANG SIK KIM, ANTONIO ARRIETA, PATRICK M. SCHLIEVERT, EDWARD L. KAPLAN, S. BENSON WERNER e LAURENE MASCOLA. "Invasive group A streptococcal infections in children with varicella in Southern California". Pediatric Infectious Disease Journal 15, n. 2 (febbraio 1996): 146–50. http://dx.doi.org/10.1097/00006454-199602000-00011.
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Becerra-Culqui, Tracy A., Darios Getahun, Vicki Chiu, Lina S. Sy e Hung Fu Tseng. "The Association of Prenatal Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccination With Attention-Deficit/Hyperactivity Disorder". American Journal of Epidemiology 189, n. 10 (7 maggio 2020): 1163–72. http://dx.doi.org/10.1093/aje/kwaa074.
Testo completoAbstract (sommario):
Abstract As prenatal vaccinations become more prevalent, it is important to assess potential safety events. In a retrospective cohort study of Kaiser Permanente Southern California (Pasadena, California) mother-child pairs with birth dates during January 1, 2011–December 31, 2014, we investigated the association between prenatal tetanus, diphtheria, and acellular pertussis (Tdap) vaccination and risk of attention-deficit/hyperactivity disorder (ADHD) in offspring. Information on Tdap vaccination during pregnancy was obtained from electronic medical records. ADHD was defined by International Classification of Diseases codes (Ninth or Tenth Revision) and dispensed ADHD medication after age 3 years. Children were followed to the date of their first ADHD diagnosis, the end of Kaiser Permanente membership, or the end of follow-up (December 31, 2018). In Cox proportional hazards models, we estimated unadjusted and adjusted hazard ratios for the association between maternal Tdap vaccination and ADHD, with inverse probability of treatment weighting (IPTW) used to adjust for confounding. Of 128,756 eligible mother-child pairs, 85,607 were included in the final sample. The ADHD incidence rate was 3.41 per 1,000 person-years in the Tdap-vaccinated women and 3.93 per 1,000 person-years in the unvaccinated (hazard ratio = 1.01, 95% confidence interval: 0.88, 1.16). The IPTW-adjusted analyses showed no association between prenatal Tdap vaccination and ADHD in offspring (hazard ratio = 1.00, 95% confidence interval: 0.88, 1.14). In this study, prenatal Tdap vaccination was not associated with ADHD risk in offspring, supporting recommendations to vaccinate pregnant women.
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Pan, Minggui, Andrew Fang, Maihgan Kavanagh, Brian Kim, Jason D. Lee, Craig McCormick, Lee Jae Morse et al. "Improving care quality for patients with soft tissue and bone sarcoma by establishing a national virtual tumor board and electronic consultation platform." Journal of Clinical Oncology 34, n. 7_suppl (1 marzo 2016): 211. http://dx.doi.org/10.1200/jco.2016.34.7_suppl.211.
Testo completoAbstract (sommario):
211 Background: Bone and soft tissue sarcomas are relatively uncommon and their management is extremely complex requiring coordinated multidisciplinary expertise for optimal care. Because Kaiser Permanente operates across many geographic regions in the country, in-person tumor board is not practical. Methods: The Kaiser Permanente Northern California medical oncology team has developed a system-based virtual tumor board (VTB) and electronic consultation (EC) platform comprised of experts from several key disciplines including musculoskeletal/surgical oncology, musculoskeletal radiology, pathology, radiation oncology, brachytherapy, medical adult and pediatric oncology. The VTB and EC cases are physician referral-based. The VTB occurs once every two weeks via video conferencing reviewing imaging studies and pathology while EC is available for more urgent cases whenever requested. This platform is available to Kaiser Permanente physicians in Northern and Southern California and other states including Hawaii, Mid-Atlantic, Northwest, Colorado, and Georgia. We conducted a survey targeting referring physicians to assess the value of this service platform in improving sarcoma care. Results: From March 2013 to October 2015, approximately 500 cases have been referred to the VTB and EC. Approximately 2/3 of the cases were referred to the VTB and 1/3 to the EC. The cases include a vast spectrum of bone and soft tissue sarcoma cases that were either newly diagnosed or at the time of relapse or progression. The physician survey on the quality and utilization of this sarcoma platform provided very positive feedback, with 100% responses stating that VTB and EC improved patient care and their confidence in managing patients with sarcoma, 90% stating VTB and EC changed their management to a certain extent. Approximately 90% responders rated VTB and EC very to extremely helpful. Conclusions: We conclude that a system-based VTB and EC can provide an excellent platform for improving quality of care and physician confidence in managing patients with bone and soft tissue sarcoma in an integrated healthcare system.
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Negriff, Sonya, Mercie J. DiGangi, Adam L. Sharp e Jun Wu. "Medical Visits From Birth to 6 Months Predict Child Maltreatment Diagnoses Up to Age 5". Clinical Pediatrics 59, n. 14 (22 luglio 2020): 1258–64. http://dx.doi.org/10.1177/0009922820941630.
Testo completoAbstract (sommario):
Electronic health record data for pediatric members of Kaiser Permanente Southern California were used to identify key variables (ie, the number of emergency department visits and the number of providers) available in early infancy (0-6 months) placing children at higher risk of a maltreatment diagnosis in the first 5 years of life. The analytic sample included 96 462 children age 0 to 5 years born from January 1, 2009, to June 30, 2018. Poisson regression showed that children with ≥2 emergency department visits from birth to 6 months were at twice the risk of a maltreatment diagnosis before age 2 and 5 years compared with those children with no emergency department visits. Children with more continuity of primary care providers (0-5 providers) in the first 6 months of life were at lower risk of a maltreatment diagnosis at 2 years and 5 years than those children who saw multiple providers (6+). Information about medical utilization in early infancy may help physicians and other medical providers identify children at higher risk of maltreatment and prevent future incidents.
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Chao, Chun, Lanfang Xu, Smita Bhatia, Robert Cooper, Somjot Brar, F. Lennie Wong e Saro H. Armenian. "Cardiovascular Disease Risk Profiles in Survivors of Adolescent and Young Adult (AYA) Cancer: The Kaiser Permanente AYA Cancer Survivors Study". Journal of Clinical Oncology 34, n. 14 (10 maggio 2016): 1626–33. http://dx.doi.org/10.1200/jco.2015.65.5845.
Testo completoAbstract (sommario):
Purpose To describe the epidemiology and risk factors for cardiovascular disease (CVD) in survivors of adolescent and young adult (AYA) cancer. Methods We identified a retrospective cohort of 2-year survivors of AYA cancer who were diagnosed between the ages of 15 to 39 years (1998 to 2009) at Kaiser Permanente Southern California. A comparison group without cancer was selected and matched 10:1 to cancer survivors on the basis of age, sex, Kaiser Permanente Southern California membership, and calendar year. Patients were followed through December 31, 2012, for coronary artery disease, heart failure, and stroke. Time-dependent Poisson regression was used to evaluate the effect that cancer survivorship had on the risk of developing CVD, adjusted for cardiovascular risk factors (CVRFs; ie, diabetes, hypertension, and dyslipidemia), ethnicity, smoking, and overweight/obesity. Among cancer survivors, mortality risk by CVD status was examined using Cox regression. Results A total of 5,673 2-year survivors of AYA cancer and 57,617 comparison patients were included, representing 24,839 and 239,073 person-years of follow-up, respectively. Overall, cancer survivors had more than two-fold risk of developing CVD (adjusted incidence rate ratio, 2.37; 95% CI, 1.93 to 2.93) when compared with patients without cancer; survivors of leukemia and breast cancer were at the highest risk (adjusted incidence rate ratio, 4.23; 95% CI, 1.73 to 10.31; and 3.63; 95% CI, 2.41 to 5.47, respectively) of developing CVD. Having any of the CVRFs increased the risk of CVD in cancer survivors. Cancer survivors who developed CVD had an 11-fold increased overall mortality risk (hazard ratio, 10.9; 95% CI, 8.1 to 14.8) when compared with survivors without CVD. Conclusion Survivors of AYA cancer are at increased risk for developing CVD. Survival after CVD onset is compromised, and CVRFs are independent modifiers of CVD risk. These data form the basis for identifying high-risk individuals and proactive management of CVRFs.
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Gregory, J., J. E. Mattison e C. Linde. "Naming Notes: Transitions from Free Text to Structured Entry". Methods of Information in Medicine 34, n. 01/02 (1995): 57–67. http://dx.doi.org/10.1055/s-0038-1634580.
Testo completoAbstract (sommario):
Abstract:To practice medicine in the near future, health care providers in the USA need an information infrastructure they do not yet have. We offer a contribution from social science research to discussions of current medical records practices and how health care activity systems may be transformed by the advent of electronic health records. The goal of the paper is to set forth a framework that connects over-arching questions concerning medical informatics systems development with the practical, cultural and conceptual issues involved in transitions from handwritten and other free text documentation to structured entry of medical records to build patient profiles. The research is broadly framed by an interest in how reciprocal modifications of the design and use of an electronic health record are negotiated in an iterative prototyping project. It is conducted as part of a complex multi-disciplinary research and development effort to create an electronic health record prototype for use in the integrated health care delivery environment of the Southern California Kaiser Permanente Medical Care Program.
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Quinn, Virginia P., Rebecca Nash, Enid Hunkeler, Richard Contreras, Lee Cromwell, Tracy A. Becerra-Culqui, Darios Getahun et al. "Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people". BMJ Open 7, n. 12 (dicembre 2017): e018121. http://dx.doi.org/10.1136/bmjopen-2017-018121.
Testo completoAbstract (sommario):
PurposeThe Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population.ParticipantsA stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016.Findings to dateAbout 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%–5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers.Future plansSTRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg, polycythemia and bone density), overall and in relation to gender affirmation therapy.
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Hu, E., S. Hufford, R. Lukes, M. Bernstein-Singer, G. Sobel, P. Gill, L. Pinter-Brown, M. Rarick, P. Rosen e R. Brynes. "Third-World Hodgkin's disease at Los Angeles County-University of Southern California Medical Center." Journal of Clinical Oncology 6, n. 8 (agosto 1988): 1285–92. http://dx.doi.org/10.1200/jco.1988.6.8.1285.
Testo completoAbstract (sommario):
The reported experience with Hodgkin's disease (HD) in the United States has come primarily from large referral centers that attract a predominantly white population of high socioeconomic status (SES). The majority of these patients had the nodular sclerosis (NS) histologic subtype and asymptomatic stage I/II disease. We have reviewed the records of 178 patients with HD seen within the past 17 years at Los Angeles County-University of Southern California Medical Center (LAC/USC), which is a nonreferral, government-operated facility. Our patient population was found to be heterogeneous, with 38% white, 22% black, and 36% Hispanic. Systemic "B" symptoms were noted in 62% of patients at diagnosis, and 63% had advanced disease (stage III or IV). NS pathologic subtype was present in only 52% of the group. Comparison between the races revealed: (1) Hispanics had a higher incidence of lymphocyte depleted subtype and less NS than whites (P less than .06); (2) whites had equal distribution between stages I/II and III/IV; (3) blacks and Hispanics presented more frequently with stage III/IV (P = .10); and (4) extranodal involvement occurred most often in bone in whites, and was equally distributed between liver, lung, and bone in blacks and Hispanics. We conclude that the lower SES, mixed racial population seen at our institution more closely resembles the reports of HD in Third-World countries and is characterized by advanced symptomatic disease. Further, the clinical pathologic characteristics of HD in the United States may vary significantly, depending upon the precise ethnic and socioeconomic status of the patients being served.
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Rafique, Amana, e Sunny C. Jiang. "Genetic diversity of human polyomavirus JCPyV in Southern California wastewater". Journal of Water and Health 6, n. 4 (1 marzo 2008): 533–38. http://dx.doi.org/10.2166/wh.2008.067.
Testo completoAbstract (sommario):
JC Polyomavirus (JCPyV) has the potential to be used as a viral marker for human waste contamination because at least 40% of the human population excretes this virus through its urine. In addition, each of 6 known subtypes of JCPyV is associated with a specific human ethnicity group, which has allowed for tracing of human migration. This study aims to explore the possibility of linking the genetic diversity of JCPyV with source of human waste. Primary sewage effluent from Irvine Ranch Water District (IRWD) sewage treatment facility was collected and examined for the presence of JCPyV using polymerase chain reaction (PCR). JCPyV was detected by nested PCR using primers specific to the conservative regulatory region in 100% of the 13 samples collected monthly over a year. Only 5 samples were amplifiable by the primers specific to the diverse intergenic region of the virus. Sequence analyses of cloned amplicons from the intergenic region indicated that JCPyV matched subtypes of European, Asian, African and African-American origins. A genotype that is unique from previously identified clinical sample is also revealed. This research suggests the diversity of JCPyV subtypes can be used as a tool to trace the source of human waste contamination.
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Fassett, Michael J., Lawrence D. Lurvey, Lyn Yasumura, Marielle Nguyen, Joseph J. Colli, Marianna Volodarskiy, Jonathan C. Gullett et al. "Universal SARS-Cov-2 Screening in Women Admitted for Delivery in a Large Managed Care Organization". American Journal of Perinatology 37, n. 11 (3 luglio 2020): 1110–14. http://dx.doi.org/10.1055/s-0040-1714060.
Testo completoAbstract (sommario):
Objective The coronavirus disease 2019 (COVID-19) pandemic has created a need for data regarding the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnant women. After implementing universal screening for COVID-19 in women admitted for delivery, we sought to describe the characteristics of COVID-19 in this large cohort of women. Study Design An observational study of women admitted to labor and delivery units in Kaiser Permanente Southern California (KPSC) hospitals between April 6 and May 11, 2020 who were universally offered testing for SARS-CoV-2 infection (n = 3,963). Hospital inpatient and outpatient physician encounter, and laboratory records were used to ascertain universal testing levels, test results, and medical and obstetrical histories. The prevalence of SARS-CoV-2 infection was estimated from the number of women who tested positive during labor per 100 women delivered. Results Of women delivered during the study period, 3,923 (99.0%) underwent SARS-CoV-2 testing. A total of 17 (0.43%; 95% confidence interval: 0.23–0.63%) women tested positive, and none of them were symptomatic on admission. There was no difference in terms of characteristics between SARS-CoV-2 positive and negative tested women. One woman developed a headache attributed to COVID-19 3 days postpartum. No neonates had a positive test at 24 hours of life. Conclusion The findings suggest that in pregnant women admitted for delivery between April 6 and May 11, 2020 in this large integrated health care system in Southern California, prevalence of SARS-CoV-2 test positive was very low and all patients were asymptomatic on admission. Key Points
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Al-Temimi, Mohammed H., Charles Trujillo, Mital Shah, Sriram Rangarajan, Edwin Kim, Bindupryia Chandrasekaran, David Handman e Samir Johna. "Same-Day versus Conventional Different-Day Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: A Multi-Center Retrospective Study". American Surgeon 84, n. 10 (ottobre 2018): 1679–83. http://dx.doi.org/10.1177/000313481808401029.
Testo completoAbstract (sommario):
Same-day endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy (LC) could potentially reduce hospital length of stay (HLOS). Patients undergoing same-day procedures (N = 164) between 2012 and 2014 were compared with different-day procedures performed in the second half of 2014 (N = 276), in the Kaiser Permanente Southern California database. Both groups had comparable baseline characteristics. ERCP success rate (97.5% vs 93.5%), overall postoperative morbidity (3.66% vs 3.99%), and retained stones (2.5% vs 5.8%) were not different between groups ( P > 0.05); however, HLOS was shorter in the same-day group (2.99 ± 2.34 vs 3.84 ± 2.52 days, P < 0.001). Morbidity, procedure success, and HLOS were not different in the same-day group, whether ERCP was performed before or after LC ( P > 0.05). In the same-day group, those undergoing single anesthesia had higher BMI (40.1 ± 10.8 vs 30.3 ± 6.6) and were more likely to have gastric bypass (30% vs 0%) than those undergoing separate anesthesia sessions ( P < 0.01). Longer HLOS (4.8 ± 3.5 vs 2.9 ± 2.2 days) and higher estimated blood loss (65 ± 90 mL vs 20 ± 29 mL) were also associated with the single-anesthetic session ( P < 0.01). ERCP performed on the same day of LC reduces HLOS without increasing morbidity. This approach does not affect postoperative morbidity and ERCP success rate, whether ERCP was performed before or after LC.
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Chang, Allen, Armen Derboghossians, Jennifer Kaswick, Brian Kim, Howard Jung, Jeff Slezak, Melanie Wuerstle, Stephen G. Williams e Gary W. Chien. "Achieving proficiency with robot-assisted radical prostatectomy: Laparoscopic-trained versus robotics-trained surgeons". Canadian Urological Association Journal 7, n. 11-12 (8 novembre 2013): 711. http://dx.doi.org/10.5489/cuaj.360.
Testo completoAbstract (sommario):
Background: Initiating a robotics program is complex, in regards to achieving favourable outcomes, effectively utilizing an expensive surgical tool, and granting console privileges to surgeons. We report the implementation of a community-based robotics program among minimally-invasive surgery (MIS) urologists with and without formal robotics training.Methods: From August 2008 to December 2010 at Kaiser Permanente Southern California, 2 groups of urologists performing robot-assisted radical prostatectomy (RARP) were followed since the time of robot acquisition at a single institution. The robotics group included 4 surgeons with formal robotics training and the laparoscopic group with another 4 surgeons who were robot-naïve, but skilled in laparoscopy. The laparoscopic group underwent an initial 7-day mentorship period. Surgical proficiency was measured by various operative and pathological outcome variables. Data were evaluated using comparative statistics and multivariate analysis.Results: A total of 420 and 549 RARPs were performed by the robotics and laparoscopic groups, respectively. Operative times were longer in the laparoscopic group (p = 0.002), but estimated blood loss was similar. The robotics group had a significantly better overall positive surgical margin rate of 19.9% compared to the laparoscopic group (27.8%) (p = 0.005). Both groups showed improvements in operative and pathological parameters as they accrued experience, and achieved similar results towards the end of the study.Conclusions: Robot-naïve laparoscopic surgeons may achieve similar outcomes to robotic surgeons relatively early after a graduated mentorship period. This study may apply to a community-based practice in which multiple urologists with varied training backgrounds are granted robot privileges.
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Al-Temimi, Mohammed H., Charles N. Trujillo, Scott Mahlberg, Joseph Ruan, Patrick Nguyen, Robert Yuhan e Joseph C. Carmichael. "Surgical Intervention for Right-Side Diverticulitis: A Case-Matched Comparison with Left-Side Diverticulitis". American Surgeon 84, n. 10 (ottobre 2018): 1608–12. http://dx.doi.org/10.1177/000313481808401014.
Testo completoAbstract (sommario):
Right-side diverticulitis (RSD) is an uncommon disease in Western countries. We conducted a case-matched comparison of surgically managed right-side and left-side diverticulitis (LSD) from the Southern California Kaiser Permanente database (2007–2014). Of 995 patients undergoing emergent surgery for diverticulitis, 33 RSD (3.3%) met our inclusion criteria and were matched (1:1) to LSD based on age, gender, year of diagnosis, and Hinchey class. Mean age of the RSD group was 56 ± 13.9 years, and 24.2 per cent were Asian. RSD was classified as Hinchey class III or IV in 28.1 per cent and 9.4 per cent of cases, respectively. Right hemicolectomy was performed in 87.9 per cent and laparoscopy was used in 24.2 per cent of the cases. Surgically managed RSD patients were more likely to be Asian (25% vs 3.1%, P = 0.03) and have body mass index < 25 (31.3% vs 6.3%, P = 0.02) compared with LSD patients. Diverting stoma was less common in the RSD (6.3% vs 62.5%) ( P < 0.001). Hospital stay was shorter in RSD (7.6 ± 4.2 vs 12.8 ± 9.4 days, P = 0.006) and more common in the RSD group ( P < 0.01). Open surgery (90.6% vs 71.9%) and postoperative complications (37.5% vs 25%) were more common in the LSD group, but that was not statistically significant ( P > 0.05). Surgery for complicated RSD was associated with shorter hospital stay and decreased likelihood of diverting ostomy.
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Gill, Tajinder H., Fred Hauter e Mitchell A. Pelter. "Conversions from Captopril to Lisinopril at a Dosage Ratio of 5:1 Result in Comparable Control of Hypertension". Annals of Pharmacotherapy 30, n. 1 (gennaio 1996): 7–11. http://dx.doi.org/10.1177/106002809603000101.
Testo completoAbstract (sommario):
OBJECTIVE: To provide clinical support that conversion from Captopril to lisinopril at a daily oral dosage ratio of 5:1 maintains comparable therapeutic efficacy, and to estimate retrospectively cost savings because of conversion from Captopril to lisinopril therapy at the study site and with the associated overall drug conversion program instituted by Kaiser Permanente. DESIGN: An open-label, randomized, prospective, parallel study was performed in 56 patients with mild-to-moderate hypertension. In a 4-week prerandomization period, oral maintenance dosages of Captopril were established. Patients then were randomly assigned either to continue taking Captopril or to change to lisinopril at an initial conversion ratio of Captopril 5 mg to lisinopril 1 mg. Blood pressures were evaluated 2, 4, 8, and 12 weeks postrandomization. If necessary, dosages were adjusted to maintain adequate efficacy (i.e., systolic pressure <160 mm Hg and diastolic pressure <90 mm Hg in the prerandomization period; diastolic pressure <90 mm Hg postrandomization). Cost savings for the study site and to the overall program with respect to conversion from Captopril were defined as the difference between the estimated drug costs and the drug costs projected if the conversion had not been made. SETTING: Woodland Hills Medical Center of the Southern California Region of Kaiser Permanente Medical Care Program. MAIN OUTCOME MEASURES: The main outcome measures were systolic and diastolic blood pressure. The measure for the retrospective cost savings analysis was estimated cost savings based on the number of prescriptions written for Captopril and lisinopril from December 1988 through December 1993, and the average wholesale price. PARTICIPANTS: Members of the Kaiser Permanente Medical Care Program who were diagnosed with mild-to-moderate hypertension and whose hypertension was controlled by Captopril alone. Retrospectively, mild-to-moderate hypertension would have been classified as stages 1–3, based on the current guidelines of the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. RESULTS: The blood pressures of patients in whom Captopril therapy was switched to lisinopril therapy were maintained throughout the entire study within the defined acceptable limits of control when the conversion was initiated at a daily oral dosage ratio of 5:1. The final dosage conversion ratio was not significantly different statistically from the theoretical dosage conversion ratio of 5:1. CONCLUSIONS: The conversion from Captopril (in equally divided daily doses) to lisinopril (once daily) at a dosage ratio of 5:1 maintained comparable control of mild-to-moderate hypertension with no increase in adverse effects. In addition, the cost savings associated with an overall drug conversion program were substantial, and the conversion provided a preferred once-daily dosing regimen.
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Ackerson, Bradley, Hung Fu Tseng, Lina S. Sy, Zendi Solano, Jeff Slezak, Yi Luo, Christine A. Fischetti e Vivek Shinde. "Severe Morbidity and Mortality Associated With Respiratory Syncytial Virus Versus Influenza Infection in Hospitalized Older Adults". Clinical Infectious Diseases 69, n. 2 (19 novembre 2018): 197–203. http://dx.doi.org/10.1093/cid/ciy991.
Testo completoAbstract (sommario):
Abstract Background Respiratory syncytial virus (RSV) is an important cause of serious respiratory illness in older adults. Comparison of RSV and influenza infection in hospitalized older adults may increase awareness of adult RSV disease burden. Methods Hospitalized adults aged ≥60 years who tested positive for RSV or influenza between 1 January 2011 and 30 June 2015 were identified from Kaiser Permanente Southern California electronic medical records. Baseline characteristics, comorbidities, utilization, and outcomes were compared. Results The study included 645 RSV- and 1878 influenza-infected hospitalized adults. Patients with RSV were older than those with influenza (mean, 78.5 vs 77.4 years; P = .035) and more likely to have congestive heart failure (35.3% vs 24.5%; P < .001) and chronic obstructive pulmonary disease (COPD) (29.8% vs 24.3%; P = .006) at baseline. In adjusted analyses, RSV infection was associated with greater odds of length of stay ≥7 days (odds ratio [OR] = 1.5; 95% confidence interval [CI], 1.2–1.8; P < .001); pneumonia (OR = 2.7; 95% CI, 2.2–3.2; P < .001); intensive care unit admission (OR = 1.3; 95% CI, 1.0–1.7; P = .023); exacerbation of COPD (OR = 1.7; 95% CI, 1.3–2.4; P = .001); and greater mortality within 1 year of admission (OR = 1.3; 95% CI, 1.0–1.6; P = .019). Conclusions RSV infection may result in greater morbidity and mortality among older hospitalized adults than influenza. Increased recognition of adult RSV disease burden will be important in the evaluation and use of new RSV vaccines and antivirals.
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Crain, Nikhil, e Talar Tejirian. "Impact of Intraoperative Foley Catheters on Postoperative Urinary Retention after Inguinal Hernia Surgery". American Surgeon 85, n. 10 (ottobre 2019): 1099–103. http://dx.doi.org/10.1177/000313481908501005.
Testo completoAbstract (sommario):
Foley catheters (FCs) are often used during inguinal hernia operations; however, the impact of intraoperative FC use on postoperative urinary retention (POUR) is not well understood. We reviewed unplanned returns to the urgent care or ED for 27,012 inguinal hernia operations across 15 Southern California Kaiser Permanente medical centers over 6.5 years. In total, 239 (0.88%) patients returned to urgent care/ED with POUR [235 (98%) men versus 4 (2%) women]. Overall, POUR increased with age ( P < 0.00001). POUR was higher in open repairs using general anesthesia versus local with monitored anesthesia care (0.7% vs 0.3%, P < 0.0001). Of 5,017 laparoscopic operations, 28 per cent had FC use. Although POUR was greater for laparoscopic versus open operations (2.21 vs 0.58%, P < 0.00001), there was no difference in POUR for intraoperative FC versus no FC use in the laparoscopic approach (2.36% vs 2.15%, P = 0.33). For all laparoscopic operations, there was no difference in urinary tract infection within 7 or 30 days when comparing intra-operative FC versus no FC use ( P = 0.28). POUR can be minimized by avoiding general anesthesia for open inguinal hernia repairs, but intraoperative FC use does not affect POUR or urinary tract infection rates for laparoscopic inguinal hernia repair.
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Bruxvoort, Katia J., Zoe Bider-Canfield, Joan A. Casey, Lei Qian, Alice Pressman, Anna S. Liang, Sarah Robinson, Steven J. Jacobsen e Sara Y. Tartof. "Outpatient Urinary Tract Infections in an Era of Virtual Healthcare: Trends From 2008 to 2017". Clinical Infectious Diseases 71, n. 1 (22 agosto 2019): 100–108. http://dx.doi.org/10.1093/cid/ciz764.
Testo completoAbstract (sommario):
Abstract Background Urinary tract infections (UTIs) occur commonly, but recent data on UTI rates are scarce. It is unknown how the growth of virtual healthcare delivery affects outpatient UTI management and trends in the United States. Methods From 1 January 2008 to 31 December 2017, UTIs from outpatient settings (office, emergency, and virtual visits) were identified from electronic health records at Kaiser Permanente Southern California using multiple UTI definitions. Annual rates estimated by Poisson regression were stratified by sex, care setting, age, and race/ethnicity. Annual trends were estimated by linear or piecewise Poisson regression. Results UTIs occurred in 1 065 955 individuals. Rates per 1000 person-years were 53.7 (95% confidence interval [CI], 50.6–57.0) by diagnosis code with antibiotic and 25.8 (95% CI, 24.7–26.9) by positive culture. Compared to office and emergency visits, UTIs were increasingly diagnosed in virtual visits, where rates by diagnosis code with antibiotic increased annually by 21.2% (95% CI, 16.5%–26.2%) in females and 29.3% (95% CI, 23.7%–35.3%) in males. Only 32% of virtual care diagnoses had a culture order. Overall, UTI rates were highest and increased the most in older adults. Rates were also higher in Hispanic and white females and black and white males. Conclusions Outpatient UTI rates increased from 2008 to 2017, especially in virtual care and among older adults. Virtual care is important for expanding access to health services, but strategies are needed in all outpatient care settings to ensure accurate UTI diagnosis and reduce inappropriate antibiotic treatment.
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Tseng, Hung-Fu, Lei Qian, Jun Wu, Yi Luo, Lina S. Sy, Katia Bruxvoort e Bradley Ackerson. "19. Completion of Two-Dose Recombinant Zoster Vaccine Series in Adults 50 Years and Older". Open Forum Infectious Diseases 7, Supplement_1 (1 ottobre 2020): S32—S33. http://dx.doi.org/10.1093/ofid/ofaa439.064.
Testo completoAbstract (sommario):
Abstract Background In 2017, the Advisory Committee on Immunization Practices preferentially recommended adjuvanted recombinant zoster vaccine (RZV) for adults ≥ 50 years as a two-dose series 2–6 months apart.1 We evaluated two-dose RZV completion and factors associated with completion. Methods The study included Kaiser Permanente Southern California members ≥ 50 years who received an RZV dose during April-November 2018 and had continuous membership 12 months before to 9 months after the 1st RZV dose (RZV1). Completion was defined as receipt of the 2nd dose ≥4 weeks to 9 months after RZV1 (allowing a 3-month grace period). Characteristics including age at RZV1, sex, race/ethnicity, Medicaid status, neighborhood level income and education, distance from home to medical office, comorbidities, history of herpes zoster, health care utilization before and after RZV1, receipt of influenza vaccine, vaccination month (supply shortage proxy), concomitant vaccine, department administering RZV1, medical center, and medically attended local or systemic reaction, pain, or gout after RZV1 were compared between completers and non-completers. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) for factors associated with completion were estimated by multivariable logistic regression. Results Among 31,120 RZV1 recipients, 67.2% completed the series within 9 months. In adjusted analyses, higher completion was associated with White compared with Black or Hispanic race/ethnicity, higher neighborhood income and education, no chronic pulmonary disease, diabetes, or dementia, more outpatient visits and fewer emergency department visits before or after RZV1, no hospitalizations after RZV1, receipt of influenza vaccine, receipt of RZV1 in June-November rather than April-May 2018, no concomitant vaccine with RZV1, and receipt of RZV1 in Family Practice rather than Internal Medicine. Systemic reactions or pain after RZV1 was not associated with completion. Table 2. RZV Series Completion by Selected Characteristics During Follow-up of Members Aged ≥50 Years Who Received at Least One Dose of RZV at Kaiser Permanente Southern California in April-November 2018 Table 2. RZV Series Completion by Selected Characteristics During Follow-up of Members Aged ≥ 50 Years Who Received at Least One Dose of RZV at KPSC in April-November 2018 Figure 1. Factors Associated with RZV Series Completion of Members Aged ≥ 50 Years Who Received at Least One Dose of RZV at KPSC in April-November 2018 Conclusion Completion of RZV series appears moderate in the early phase of implementation. Despite similar accessibility in a health care system, completion varied by race/ethnicity, socioeconomic status, health status, and care seeking behavior, suggesting areas to target for improvement. Disclosures Hung-Fu Tseng, MPH, PhD, GlaxoSmithKlein (Research Grant or Support) Lei Qian, PhD, GlaxoSmithKlein (Research Grant or Support) Jun Wu, MD, MS, GlaxoSmithKlein (Research Grant or Support) Yi Luo, PhD, GlaxoSmithKlein (Research Grant or Support) Lina S. Sy, MPH, GlaxoSmithKlein (Research Grant or Support) Katia Bruxvoort, PhD, MPH, GlaxoSmithKlein (Research Grant or Support) Bradley Ackerson, MD, GlasoSmithKlein (Research Grant or Support)
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Kolevska, Tatjana, Farah M. Brasfield, Dinesh Kotak, Joseph Presti, Andrea Harzstark, Jennifer Fu Carney, Violeta Rabrenovich et al. "Implementation of a national cancer subspecialist virtual consult pilot in an integrated health system." JCO Oncology Practice 19, n. 11_suppl (novembre 2023): 143. http://dx.doi.org/10.1200/op.2023.19.11_suppl.143.
Testo completoAbstract (sommario):
143 Background: Over 65,000 new cancer patients are diagnosed nationally each year at Kaiser Permanente (KP), with 12.7 million members in 9 states and the District of Columbia. KP developed the Cancer Expert Review Program (the Program) to connect oncologists with cancer subspecialists across the enterprise. The Program provides consultation and a chart note viewable by the patient within 2 business days. Methods: The Program was piloted from October 2022 to June 2023 for medical oncology patients with breast, gastrointestinal (GI), genitourinary (GU), sarcoma, thoracic, hematology, central nervous system (CNS), melanoma, head & neck, and gynecologic oncology (GYN) diagnoses or a need for molecular/genomic testing. Medical oncologists from Hawaii, Georgia, and Southern California submitted requests for virtual consults to designated cancer subspecialists using HealthConnect, KP’s EPIC system. Consulting physicians had direct access to the medical records for each patient, including pathology and imaging. Oncologists informed patients of the service and discussed the rendered opinion as part of shared decision-making. Implementation outcomes of feasibility and acceptability were evaluated. Providers were surveyed about perceptions of the service using an internally developed questionnaire. The time from consult request to completion was measured. Results: 108 consults (67.5%) were provided by individual subspecialists, while 22 consults (14%) were reviewed by multiple experts or a multidisciplinary team. 140 consults (87.5%) were completed within 2 business days. Of the 44 oncologists who requested a consult, 12 responded to a physician survey. 85% of physicians rated satisfaction with the service as “satisfied” or “extremely satisfied”. 75% said the advice helped to develop the treatment plan. Half of physicians reported the advice changed the original treatment or approach either “somewhat” or “to a great extent.” Half of physicians indicated that if this internal program were not available, they would have referred their patient to a non-Kaiser Permanente provider for a consultation. Conclusions: Implementation of a national cancer subspecialist virtual consult pilot within an integrated health system demonstrated the feasibility and acceptability of timely expert consults with high physician satisfaction. The Program facilitates subspecialist care in collaboration with the patient’s trusted general oncologist, keeping care close to home.Additional research is needed to understand the long-term implementation and quality outcomes of the Program.[Table: see text]
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Koebnick, Corinna, Sara Y. Tartof, Margo A. Sidell, Emily Rozema, Joanie Chung, Vicki Y. Chiu, Zackary W. Taylor, Anny H. Xiang e Darios Getahun. "Effect of In-Utero Antibiotic Exposure on Childhood Outcomes: Methods and Baseline Data of the Fetal Antibiotic EXposure (FAX) Cohort Study". JMIR Research Protocols 8, n. 7 (30 luglio 2019): e12065. http://dx.doi.org/10.2196/12065.
Testo completoAbstract (sommario):
Background The widespread use of antepartum and intrapartum antibiotics has raised concerns about the possible disruption of the child’s gut microbiota and effects on the maturation from the infant to the adult microbiome. The Fetal Antibiotic EXposure (FAX) study provides a cohort to examine the association between in-utero exposure to antibiotics and adverse childhood outcomes including body weight, atopic diseases, and autism spectrum disorders and to investigate the role of other potential factors mitigating or moderating the risk for adverse outcomes. Objective The aim of this paper was to describe the methods, cohort characteristics, and retention of infants included in the study cohort. Methods For this retrospective cohort study, we included children born in Kaiser Permanente Southern California (KPSC) hospitals between January 1, 2007, and December 31, 2015, within 22 to 44 completed weeks of gestation with KPSC insurance coverage during the first year of life. Follow-up data collection was performed through electronic medical records. Results The study cohort was comprised 223,431 children of which 65.7% (146,720/223,431) were exposed to antibiotics in-utero: 19.0% (42,511/223,431) were exposed during the antepartum period, 30.0% (66,896/223,431) during the intrapartum period, and 16.7% (37,313/223,431) exposed during both the antepartum and intrapartum periods. Conclusions This cohort of children will provide a unique opportunity to address key questions regarding the long-term sequelae of in-utero exposure to antibiotics using real-world data. The high retention and multiple medical visits over time allow us to model the trajectories of body mass index over time. International Registered Report Identifier (IRRID) DERR1-10.2196/12065
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Vadheim, Constance M., David P. Greenberg, Susan Partridge, Jennie Jing e Joel I. Ward. "Effectiveness and Safety of an Haemophilus influenzae Type b Conjugate Vaccine (PRP-T) in Young Infants". Pediatrics 92, n. 2 (1 agosto 1993): 272–79. http://dx.doi.org/10.1542/peds.92.2.272.
Testo completoAbstract (sommario):
Objective. To study the safety, immunogenicity, and protective efficacy of the Haemophilus influenzae capsular polysaccharide tetanus conjugate vaccine (PRP-T). Design. Randomized, double-blind, controlled clinical trial. Setting. Southern California Kaiser-Permanente Health Plan. Participants. 10 317 infants 6 to 15 weeks of age, with no known immune dysfunction, exposure to hepatitis B, or contraindication to diphtheria-tetanus-pertussis (DTP) vaccination were enrolled between August 1989 and September 1990. Intervention. Infants were randomized to receive either PRP-T or a recombinant hepatitis B control vaccine (in addition to DTP at approximately 2, 4, and 6 months of age. Outcome measures. Adverse reactions occurring during the first 72 hours and between doses (including hospitalizations and outpatient visits) were measured using parental reporting/interviews and review of records. Invasive disease caused by H influenzae was ascertained from the time of enrollment until December 31, 1990. Results. In October 1990, the study was prematurely terminated because of licensure of other H influenzae vaccines recommended for routine infant use. The rates of systemic and local reactions occurring within 72 hours of each vaccine dose were generally similar for infants given PRP-T and hepatitis B, but some reaction rates (local reactions, fever ≥ 120°F, irritability, crying) were significantly higher in the PRP-T group. In the month following receipt of vaccine, PRP-T-vaccinated infants experienced five definite seizures compared with three in the hepatitis B control group. Within 48 hours of vaccination, three seizures (two definite and one possible), which were thought to be related to vaccination, occurred in the PRP-T group, compared with none in the control group (P < .13). Overall morbidity, mortality and hospitalization rates were similar in the two vaccine groups. Three cases of invasive disease caused by H influenzae occurred in the control group; none occurred in the PRP-T group. Conclusions. The PRP-T vaccine is safe and appears to be effective in preventing invasive disease caused by H influenzae type b.
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Flores, Glenda M., e Maricela Bañuelos. "Gendered Deference: Perceptions of Authority and Competence among Latina/o Physicians in Medical Institutions". Gender & Society 35, n. 1 (18 gennaio 2021): 110–35. http://dx.doi.org/10.1177/0891243220979655.
Testo completoAbstract (sommario):
Prior studies note that gender- and race-based discrimination routinely inhibit women’s advancement in medical fields. Yet few studies have examined how gendered displays of deference and demeanor are interpreted by college-educated and professional Latinas/os who are making inroads into prestigious and masculinized nontraditional fields such as medicine. In this article, we elucidate how gender shapes perceptions of authority and competence among the same pan-ethnic group, and we use deference and demeanor as an analytical tool to examine these processes. Our analysis underscores three main points of difference: (1) gendered cultural taxation; (2) microaggressions from women nurses and staff and; (3) the questioning of authority and competence to elucidate how gendered racism manifests for Latina/o doctors. Taking demonstrations of gendered deference and demeanors are vital to transforming medical schools and creating more inclusive spaces for all physicians and patients. Conclusions are based on experiences reported in interviews with 48 Latina/o physicians and observation in their places of work in Southern California.
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Kershberg, Hilary B., Monica Alvarado, Jaime L. Natoli, Emily Parkhurst, Hui Zhou e George E. Tiller. "Use of the electronic medical record (EMR) to identify women at increased risk for hereditary breast and ovarian cancer (HBOC)." Journal of Clinical Oncology 31, n. 31_suppl (1 novembre 2013): 236. http://dx.doi.org/10.1200/jco.2013.31.31_suppl.236.
Testo completoAbstract (sommario):
236 Background: Diagnosis of breast cancer at a young age is an indication for genetic counseling and possible BRCA testing. However, not all women with this early diagnosis are referred for genetic counseling, especially if they do not have a family history of breast or ovarian cancer. Methods: The genetics department in Kaiser Permanente Southern California (KPSC) provides clinical genetic services in an integrated health care system serving over 3.6 million members. Using data from the KPSC tumor registry, the KPSC EMR system, and a departmental cancer test results database, we identified 454 women diagnosed with early breast cancer (<46 years) between September 2005 and September 2010 who had not received genetic counseling. We contacted these women with a letter and/or phone call offering a genetics consultation, and we offered BRCA testing to all those who came for counseling. Results: 142 women (31%) came in for genetic counseling, and 312 women (69%) declined, did not keep their appointment, or never responded. Hispanics were more likely to schedule and keep an appointment than Caucasians (OR=1.35, 95% CI, 0.79-2.31), although this was not statistically significant. Of those who came in for counseling, African Americans were significantly less likely to accept genetic testing than Caucasians (OR=0.31, 95% CI, 0.10-0.98).Of the 142 patients who were counseled, 122 (86%) accepted testing. We identified 6 patients (5%) who were positive for a deleterious BRCA mutation and 6 patients (5%) who had a variant of uncertain significance. Of the 6 women with deleterious mutations, only 1 had a first-degree relative with breast or ovarian cancer, and 4 had mutation probabilities <10%. Conclusions: This project demonstrates how an integrated care approach and EMR system provide an opportunity to identify and contact women who are at increased risk for inherited cancer susceptibility.