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DiLena DD, Warton EM, Vinson DR, Siqueiros MH, Rauchwerger AS, Mark DG, Skarbinski J, Cholleti SM, Durant EJ, Reed ME, Ballard DW. Smells like a variant: How the association between COVID-19 and olfactory dysfunction changed between 2019 and 2022. J Intern Med 2024; 295:569-571. [PMID: 38091414 DOI: 10.1111/joim.13760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Affiliation(s)
- Daniel D DiLena
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - E Margaret Warton
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Kaiser Permanente Northern California, The Permanente Medical Group, Oakland, California, USA
| | - Marcos H Siqueiros
- Kaiser Permanente Northern California, The Permanente Medical Group, Oakland, California, USA
| | - Adina S Rauchwerger
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Dustin G Mark
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Kaiser Permanente Northern California, The Permanente Medical Group, Oakland, California, USA
| | - Jacek Skarbinski
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - S Madhavi Cholleti
- Kaiser Permanente Northern California, The Permanente Medical Group, Oakland, California, USA
| | - Edward J Durant
- Kaiser Permanente Northern California, The Permanente Medical Group, Oakland, California, USA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Dustin W Ballard
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Kaiser Permanente Northern California, The Permanente Medical Group, Oakland, California, USA
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Sax DR, Warton EM, Sofrygin O, Mark DG, Ballard DW, Kene MV, Vinson DR, Reed ME. Automated analysis of unstructured clinical assessments improves emergency department triage performance: A retrospective deep learning analysis. J Am Coll Emerg Physicians Open 2023; 4:e13003. [PMID: 37448487 PMCID: PMC10337523 DOI: 10.1002/emp2.13003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/11/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Objectives Efficient and accurate emergency department (ED) triage is critical to prioritize the sickest patients and manage department flow. We explored the use of electronic health record data and advanced predictive analytics to improve triage performance. Methods Using a data set of over 5 million ED encounters of patients 18 years and older across 21 EDs from 2016 to 2020, we derived triage models using deep learning to predict 2 outcomes: hospitalization (primary outcome) and fast-track eligibility (exploratory outcome), defined as ED discharge with <2 resource types used (eg, laboratory or imaging studies) and no critical events (eg, resuscitative medications use or intensive care unit [ICU] admission). We report area under the receiver operator characteristic curve (AUC) and 95% confidence intervals (CI) for models using (1) triage variables alone (demographics and vital signs), (2) triage nurse clinical assessment alone (unstructured notes), and (3) triage variables plus clinical assessment for each prediction target. Results We found 12.7% of patients were hospitalized (n = 673,659) and 37.0% were fast-track eligible (n = 1,966,615). The AUC was lowest for models using triage variables alone: AUC 0.77 (95% CI 0.77-0.78) and 0.70 (95% CI 0.70-0.71) for hospitalization and fast-track eligibility, respectively, and highest for models incorporating clinical assessment with triage variables for both hospitalization and fast-track eligibility: AUC 0.87 (95% CI 0.87-0.87) for both prediction targets. Conclusion Our findings highlight the potential to use advanced predictive analytics to accurately predict key ED triage outcomes. Predictive accuracy was optimized when clinical assessments were added to models using simple structured variables alone.
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Affiliation(s)
- Dana R Sax
- Department of Emergency Medicine Kaiser East Bay and Kaiser Permanente Northern California Division of Research Oakland California USA
| | - E Margaret Warton
- Kaiser Permanente Northern California Division of Research Oakland California USA
| | | | - Dustin G Mark
- Department of Emergency Medicine Kaiser East Bay and Kaiser Permanente Northern California Division of Research Oakland California USA
| | - Dustin W Ballard
- Department of Emergency Medicine Kaiser San Rafael and Kaiser Permanente Northern California Division of Research Oakland California USA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser San Rafael and Kaiser Permanente Northern California Division of Research Oakland California USA
| | - David R Vinson
- Department of Emergency Medicine Roseville, and Kaiser Permanente Northern California Division of Research Oakland California USA
| | - Mary E Reed
- Kaiser Permanente Northern California Division of Research Oakland California USA
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Vinson DR, Rauchwerger AS, Karadi CA, Shan J, Warton EM, Zhang JY, Ballard DW, Mark DG, Hofmann ER, Cotton DM, Durant EJ, Lin JS, Sax DR, Poth LS, Gamboa SH, Ghiya MS, Kene MV, Ganapathy A, Whiteley PM, Bouvet SC, Babakhanian L, Kwok EW, Solomon MD, Go AS, Reed ME. Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial). Trials 2023; 24:246. [PMID: 37004068 PMCID: PMC10064588 DOI: 10.1186/s13063-023-07230-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA.
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chandu A Karadi
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Judy Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer Y Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Dale M Cotton
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Edward J Durant
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
| | - James S Lin
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Dana R Sax
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Luke S Poth
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - Stephen H Gamboa
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meena S Ghiya
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
| | - Anuradha Ganapathy
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Patrick M Whiteley
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Sean C Bouvet
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | | | | | - Matthew D Solomon
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Cardiology, Oakland Medical Center, Oakland, CA, USA
| | - Alan S Go
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Sax DR, Warton EM, Mark DG, Vinson DR, Kene MV, Ballard DW, Vitale TJ, McGaughey KR, Beardsley A, Pines JM, Reed ME. Evaluation of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage. JAMA Netw Open 2023; 6:e233404. [PMID: 36930151 PMCID: PMC10024207 DOI: 10.1001/jamanetworkopen.2023.3404] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
IMPORTANCE Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI). OBJECTIVES To derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022. EXPOSURES Assigned ESI level. MAIN OUTCOMES AND MEASURES Rate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage. RESULTS A total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]). CONCLUSIONS AND RELEVANCE In this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.
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Affiliation(s)
- Dana R. Sax
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Dustin G. Mark
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - David R. Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California
| | - Mamata V. Kene
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, California
| | - Dustin W. Ballard
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Tina J. Vitale
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Katherine R. McGaughey
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Aaron Beardsley
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California
| | | | - Mary E. Reed
- Division of Research, Kaiser Permanente Northern California, Oakland
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Lieu TA, Altschuler A, Hsueh L, Warton EM, Levan C, Dixon M, San K, Awsare S, Chen YFI, Lee ER, Reed ME. Strategies Facilitating Video Visit Implementation by a Medical Group Serving a Diverse Population. Perm J 2022; 26:20-29. [PMID: 35939605 PMCID: PMC9676694 DOI: 10.7812/tpp/22.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022]
Abstract
IntroductionVideo visits have created new opportunities to enhance access to care, but limited information exists on strategies medical groups can employ to facilitate video visit use by higher-risk patients. Our objective was to identify generalizable strategies to facilitate successful delivery of video visits by systems serving highly diverse patient populations. MethodsThe authors conducted a qualitative study of physicians and staff members in a large group practice with 4.5 million patients with diverse race and ethnicity and socioeconomic status. Semi-structured interviews were conducted between January 2021 and April 2021, with key informants identified via purposive and snowball sampling. Video-recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. ResultsThe 42 key informants included regional and medical center leaders, primary care physicians, service managers, and medical assistants. Participants described clinical leadership in technology and multidisciplinary collaboration as crucial to sustained video care adoption. Strategies to facilitate real-time learning included local innovation, rapid communication channels, and psychological safety. The organization offered broad access to frequently updated data reports to help managers and practitioners understand processes, measure performance, and share best practices. Medical assistants and physicians developed new approaches to empathize, tailor interactions with patients, and overcome psychological and technical barriers to connecting via video. ConclusionsKey strategies for sustained video care adoption included clinical leadership articulating its purpose, multidisciplinary collaboration, local innovation, effective data use, empathy, and personalized care. These findings provide a model for how health care systems can foster robust adoption of technologies to serve diverse populations.
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Affiliation(s)
- Tracy A Lieu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- The Permanente Medical Group, Oakland, CA, USA
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Loretta Hsueh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Delivery Science Fellowship Program, Kaiser Permanente Northern California, Oakland, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | | | - Karen San
- The Permanente Medical Group, Oakland, CA, USA
- TPMG Consulting Services, Oakland, CA, USA
| | | | | | | | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Lieu TA, Warton EM, Levan C, San K, Hsueh L, Awsare S, Reed ME. Association of Medical Assistant-Supported Virtual Rooming With Successful Video Visit Connections. JAMA Intern Med 2022; 182:680-682. [PMID: 35404417 PMCID: PMC9002703 DOI: 10.1001/jamainternmed.2022.1032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/20/2022] [Indexed: 02/05/2023]
Affiliation(s)
| | | | | | - Karen San
- TPMG Consulting Services, Oakland, California
| | - Loretta Hsueh
- Delivery Science Fellowship Program, Kaiser Permanente Northern California, Oakland
| | | | - Mary E. Reed
- Division of Research, Kaiser Permanente Northern California, Oakland
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Asgari MM, Arron S, Warton EM, Quesenberry CP, Weisshaar D. Response to "Comments on sirolimus use and risk of cutaneous squamous cell carcinoma (SCC) in solid organ transplant recipients" (SOTRs). J Am Acad Dermatol 2022; 86:e205-e206. [PMID: 35430053 PMCID: PMC9904155 DOI: 10.1016/j.jaad.2016.01.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/30/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Maryam M. Asgari
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston;,Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sarah Arron
- Department of Dermatology, University of California at San Francisco
| | | | | | - Dana Weisshaar
- Department of Cardiology, Santa Clara, Kaiser Permanente Northern California
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8
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Shan J, Warton EM, Reed ME, Vinson DR, Kuppermann N, Dayan PS, Dalziel SR, Rauchwerger AS, Ballard DW. Computed Tomography Use in Children With Minor Head Trauma Presenting to 21 Community Emergency Departments Within an Integrated Health-Care System. Perm J 2021; 26:32-37. [PMID: 35609173 PMCID: PMC9126554 DOI: 10.7812/tpp/21.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Decreasing unnecessary cranial computed tomography (CT) use in pediatric head trauma patients remains important for emergency departments (EDs) across the US. Our study evaluated CT use in children with minor blunt head trauma in 21 community EDs within an integrated health-care system. METHODS We studied all children younger than 18 years old presenting to 21 community EDs between 2016 through 2018 with acute minor blunt head trauma, defined by an algorithm of ED chief complaints and diagnoses. We excluded patients with traumatic brain injuries diagnosed in the prior year, a CT within 24 hours prior to the ED visit, or an ED Glasgow Coma Scale score of less than 14. RESULTS Among 39,792 pediatric minor head trauma ED visits, the aggregate CT use proportion across all EDs was 12.9% [95% confidence interval (CI), 12.6-13.3%; facility-level range, 5.4-21.6%]. The 7 facilities that had previously received a clinical decision support system intervention implementing the Pediatric Emergency Care Applied Research Network rules during 2013 through 2014 had an aggregate mean CT ordering rate of 11.2% (95% CI, 10.7-11.7%; facility-level range, 5.4-14.3%) compared to 14.1% (95% CI, 13.6-14.5%; facility-level range, 7.3-21.6%) for the nonintervention facilities. CONCLUSION CT use for children with minor blunt head trauma in the community EDs of an integrated health-care system was low and stable across facilities from 2016 through 2018. This may be indicative of the safe stewardship of resources in the system, including the absence of financial or medicolegal incentives to scan very low-risk patients as well the availability of resources for close patient follow-up.
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Affiliation(s)
- Judy Shan
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | | | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Kaiser Permanente Roseville, Roseville, CA, USA
| | - Nathan Kuppermann
- University of California Davis School of Medicine, Sacramento, CA, USA
| | - Peter S Dayan
- Columbia University College of Physicians and Surgeons, New York City, NY, USA
| | | | | | - Dustin W Ballard
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Kaiser Permanente San Rafael, San Rafael, CA, USA
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Akbar F, Mark G, Warton EM, Reed ME, Prausnitz S, East JA, Moeller MF, Lieu TA. Physicians' electronic inbox work patterns and factors associated with high inbox work duration. J Am Med Inform Assoc 2021; 28:923-930. [PMID: 33063087 DOI: 10.1093/jamia/ocaa229] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/05/2020] [Accepted: 09/03/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Electronic health record systems are increasingly used to send messages to physicians, but research on physicians' inbox use patterns is limited. This study's aims were to (1) quantify the time primary care physicians (PCPs) spend managing inboxes; (2) describe daily patterns of inbox use; (3) investigate which types of messages consume the most time; and (4) identify factors associated with inbox work duration. MATERIALS AND METHODS We analyzed 1 month of electronic inbox data for 1275 PCPs in a large medical group and linked these data with physicians' demographic data. RESULTS PCPs spent an average of 52 minutes on inbox management on workdays, including 19 minutes (37%) outside work hours. Temporal patterns of electronic inbox use differed from other EHR functions such as charting. Patient-initiated messages (28%) and results (29%) accounted for the most inbox work time. PCPs with higher inbox work duration were more likely to be female (P < .001), have more patient encounters (P < .001), have older patients (P < .001), spend proportionally more time on patient messages (P < .001), and spend more time per message (P < .001). Compared with PCPs with the lowest duration of time on inbox work, PCPs with the highest duration had more message views per workday (200 vs 109; P < .001) and spent more time on the inbox outside work hours (30 minutes vs 9.7 minutes; P < .001). CONCLUSIONS Electronic inbox work by PCPs requires roughly an hour per workday, much of which occurs outside scheduled work hours. Interventions to assist PCPs in handling patient-initiated messages and results may help alleviate inbox workload.
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Affiliation(s)
- Fatema Akbar
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, California, USA
| | - Gloria Mark
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, California, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Stephanie Prausnitz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jeffrey A East
- The Permanente Medical Group, Oakland, California, USA.,Department of Adult and Family Medicine, Kaiser Permanente Richmond, Richmond, California, USA
| | - Mark F Moeller
- The Permanente Medical Group, Oakland, California, USA.,Department of Adult and Family Medicine, Kaiser Permanente Napa, Napa, California, USA
| | - Tracy A Lieu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,The Permanente Medical Group, Oakland, California, USA
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Akbar F, Mark G, Prausnitz S, Warton EM, East JA, Moeller MF, Reed ME, Lieu TA. Physician Stress During Electronic Health Record Inbox Work: In Situ Measurement With Wearable Sensors. JMIR Med Inform 2021; 9:e24014. [PMID: 33908888 PMCID: PMC8116996 DOI: 10.2196/24014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/02/2021] [Accepted: 03/21/2021] [Indexed: 01/08/2023] Open
Abstract
Background Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day. Objective The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress. Methods Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model. Results Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2=98%). Conclusions This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours.
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Affiliation(s)
- Fatema Akbar
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, CA, United States
| | - Gloria Mark
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, CA, United States
| | - Stephanie Prausnitz
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Jeffrey A East
- The Permanente Medical Group, Oakland, CA, United States.,Department of Adult and Family Medicine, Kaiser Permanente, Richmond, CA, United States.,Department of Adult and Family Medicine, Kaiser Permanente, San Rafael, CA, United States
| | - Mark F Moeller
- The Permanente Medical Group, Oakland, CA, United States.,Department of Adult and Family Medicine, Kaiser Permanente, Napa, CA, United States
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Tracy A Lieu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States.,The Permanente Medical Group, Oakland, CA, United States
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11
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Kea B, Warton EM, Ballard DW, Mark DG, Reed ME, Rauchwerger AS, Offerman SR, Chettipally UK, Ramos PC, Le DD, Glaser DS, Vinson DR. Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study. J Atr Fibrillation 2021; 13:2355. [PMID: 34950330 PMCID: PMC8691349 DOI: 10.4022/jafib.2355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/12/2020] [Accepted: 01/05/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. METHODS This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. RESULTS Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. DISCUSSION Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.
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Affiliation(s)
- Bory Kea
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - E Margaret Warton
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Dustin W Ballard
- Kaiser Permanente Northern California Division of Research, Oakland, California
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Mary E Reed
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Steven R Offerman
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, California
| | - Patricia C Ramos
- Kaiser Permanente Sunnyside Medical Center, Northwest Permanente Physicians and Surgeons, Department of Emergency Medicine, Portland, Oregon
| | - Daphne D Le
- University of California, Berkeley, California
| | - David S Glaser
- Sisters of Charity of Leavenworth St. Joseph Hospital, Department of Emergency Medicine, Denver, Colorado
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, Oakland, California
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Sacramento Medical Center, Sacramento, California
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12
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Kharbanda AB, Vazquez-Benitez G, Ballard DW, Vinson DR, Chettipally UK, Dehmer SP, Ekstrom H, Rauchwerger AS, McMichael B, Cotton DM, Kene MV, Simon LE, Zhu J, Warton EM, O’Connor PJ, Kharbanda EO. Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial. JAMA Netw Open 2021; 4:e2036344. [PMID: 33560426 PMCID: PMC7873779 DOI: 10.1001/jamanetworkopen.2020.36344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis. OBJECTIVE To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis. DESIGN, SETTING, AND PARTICIPANTS In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019. INTERVENTIONS AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care. MAIN OUTCOMES AND MEASURES Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool. RESULTS We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group. CONCLUSIONS AND RELEVANCE In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02633735.
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Affiliation(s)
- Anupam B. Kharbanda
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - David R. Vinson
- The Permanente Medical Group, Oakland, California
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | | | - Steven P. Dehmer
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Heidi Ekstrom
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - Adina S. Rauchwerger
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Brianna McMichael
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | | | - Laura E. Simon
- The Kaiser Permanente Northern California Division of Research, Oakland, California
| | - Jingyi Zhu
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota
| | - E. Margaret Warton
- The Kaiser Permanente Northern California Division of Research, Oakland, California
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13
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Simon LE, Rauchwerger AS, Chettipally UK, Babakhanian L, Vinson DR, Warton EM, Reed ME, Kharbanda AB, Kharbanda EO, Ballard DW. Text message alerts to emergency physicians identifying potential study candidates increase clinical trial enrollment. J Am Med Inform Assoc 2021; 26:1360-1363. [PMID: 31340023 DOI: 10.1093/jamia/ocz118] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/05/2019] [Accepted: 06/11/2019] [Indexed: 12/25/2022] Open
Abstract
Prospective enrollment of research subjects in the fast-paced emergency department (ED) is challenging. We sought to develop a software application to increase real-time clinical trial enrollment during an ED visit. The Prospective Intelligence System for Clinical Emergency Services (PISCES) scans the electronic health record during ED encounters for preselected clinical characteristics of potentially eligible study participants and notifies the treating physician via mobile phone text alerts. PISCES alerts began 3 months into a cluster randomized trial of an electronic health record-based risk stratification tool for pediatric abdominal pain in 11 Northern California EDs. We compared aggregate enrollment before (2577 eligible patients, October 2016 to December 2016) and after (12 049 eligible patients, January 2017 to January 2018) PISCES implementation. Enrollment increased from 10.8% to 21.1% following PISCES implementations (P < .001). PISCES significantly increased study enrollment and can serve as a valuable tool to assist prospective research enrollment in the ED.
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Affiliation(s)
- Laura E Simon
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | | | - Uli K Chettipally
- Emergency Department, Kaiser Permanente South San Francisco Medical Center, South San Francisco, California, USA
| | | | - David R Vinson
- Division of Research, Kaiser Permanente, Oakland, California, USA.,Emergency Department, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | | | - Mary E Reed
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Anupam B Kharbanda
- Emergency Department, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Elyse O Kharbanda
- Division of Research, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Dustin W Ballard
- Division of Research, Kaiser Permanente, Oakland, California, USA.,Emergency Department, Kaiser Permanente San Rafael Medical Center, San Rafael, California, USA
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14
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Lieu TA, Warton EM, East JA, Moeller MF, Prausnitz S, Ballesca M, Mark G, Akbar F, Awsare S, Chen YFI, Reed ME. Evaluation of Attention Switching and Duration of Electronic Inbox Work Among Primary Care Physicians. JAMA Netw Open 2021; 4:e2031856. [PMID: 33475754 PMCID: PMC7821028 DOI: 10.1001/jamanetworkopen.2020.31856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Primary care physicians (PCPs) report multitasking during workdays while processing electronic inbox messages, but scant systematic information exists on attention switching and its correlates in the health care setting. OBJECTIVES To describe PCPs' frequency of attention switching associated with electronic inbox work, identify potentially modifiable factors associated with attention switching and inbox work duration, and compare the relative association of attention switching and other factors with inbox work duration. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of the work of 1275 PCPs in an integrated group serving 4.5 million patients used electronic health record (EHR) access logs from March 1 to 31, 2018, to evaluate PCPs' frequency of attention switching. Statistical analysis was performed from October 15, 2018, to August 28, 2020. MAIN OUTCOMES AND MEASURES Attention switching was defined as switching between the electronic inbox, other EHR work, and non-EHR periods. Inbox work duration included minutes spent on electronic inbox message views and related EHR tasks. Multivariable models controlled for the exposures. RESULTS The 1275 PCPs studied (721 women [56.5%]; mean [SD] age, 45.9 [8.5] years) had a mean (SD) of 9.0 (7.6) years of experience with the medical group and received a mean (SD) of 332.6 (148.3) (interquartile range, 252-418) new inbox messages weekly. On workdays, PCPs made a mean (SD) of 79.4 (21.8) attention switches associated with inbox work and did a mean (SD) 64.2 (18.7) minutes of inbox work over the course of 24 hours on workdays. In the model for attention switching, each additional patient secure message beyond the reference value was associated with 0.289 (95% CI, 0.217-0.362) additional switches, each additional results message was associated with 0.203 (95% CI, 0.127-0.278) additional switches, each additional request message was associated with 0.190 (95% CI, 0.124-0.257) additional switches, and each additional administrative message was associated with 0.262 (95% CI, 0.166-0.358) additional switches. Having a panel (a list of patients assigned to a primary care team) with more elderly patients (0.144 switches per percentage increase [95% CI, 0.009-0.278]) and higher inbox work duration (0.468 switches per additional minute of inbox work [95% CI, 0.411-0.524]) were also associated with higher attention switching involving the inbox. In the model for inbox work duration, each additional patient secure message beyond the reference value was associated with 0.151 (95% CI, 0.085-0.217) additional minutes, each additional results message was associated with 0.338 (95% CI, 0.272-0.404) additional minutes, each additional request message was associated with 0.101 (95% CI, 0.041-0.161) additional minutes, and each additional administrative message was associated with 0.179 (95% CI, 0.093-0.265) additional minutes. A higher percentage of the panel's patients initiating messages (0.386 minutes per percentage increase [95% CI, 0.026-0.745]) and attention switches (0.373 minutes per switch [95% CI, 0.328-0.419]) were also associated with higher inbox work duration. In addition, working at a medical center where all PCPs had high inbox work duration was independently associated with high or low inbox work duration. CONCLUSIONS AND RELEVANCE This study suggests that PCPs make frequent attention switches during workdays while processing electronic inbox messages. Message quantity was associated with both attention switching and inbox work duration. Physician and patient panel characteristics had less association with attention switching and inbox work duration. Assisting PCPs with message quantity might help modulate both attention switching and inbox work duration.
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Affiliation(s)
- Tracy A. Lieu
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Oakland, California
| | | | - Jeffrey A. East
- The Permanente Medical Group, Oakland, California
- Department of Adult and Family Medicine, Kaiser Permanente, Richmond, California
- Department of Adult and Family Medicine, Kaiser Permanente, San Rafael, California
| | - Mark F. Moeller
- The Permanente Medical Group, Oakland, California
- Department of Adult and Family Medicine, Kaiser Permanente, Napa, California
| | | | - Manuel Ballesca
- The Permanente Medical Group, Oakland, California
- Department of Adult and Family Medicine, Kaiser Permanente, Napa, California
| | - Gloria Mark
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California, Irvine
| | - Fatema Akbar
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California, Irvine
| | | | | | - Mary E. Reed
- Division of Research, Kaiser Permanente Northern California, Oakland
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15
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Simon LE, Kene MV, Warton EM, Rauchwerger AS, Vinson DR, Reed ME, Chettipally UK, Mark DG, Sax DR, McLachlan DI, Cotton DM, Lin JS, Vazquez-Benitez G, Kharbanda AB, Kharbanda EO, Ballard DW. Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years. Acad Emerg Med 2020; 27:821-831. [PMID: 32239713 PMCID: PMC8310728 DOI: 10.1111/acem.13931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. METHODS This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. RESULTS Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). CONCLUSION Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.
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Affiliation(s)
- Laura E. Simon
- Division of Research, Kaiser Permanente, Oakland, CA
- University of California San Diego School of Medicine, La Jolla, CA
| | - Mamata V. Kene
- The Permanente Medical Group, Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | | | | | - David R. Vinson
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Mary E. Reed
- Division of Research, Kaiser Permanente, Oakland, CA
| | - Uli K. Chettipally
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dustin G. Mark
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Dana R. Sax
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - D. Ian McLachlan
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dale M. Cotton
- The Permanente Medical Group, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA
| | - James S. Lin
- The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | | | | | - Dustin W. Ballard
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente San Rafael Medical Center, San Rafael, CA
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16
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Lieu TA, Altschuler A, Weiner JZ, East JA, Moeller MF, Prausnitz S, Reed ME, Warton EM, Goler N, Awsare S. Primary Care Physicians' Experiences With and Strategies for Managing Electronic Messages. JAMA Netw Open 2019; 2:e1918287. [PMID: 31880798 PMCID: PMC6991215 DOI: 10.1001/jamanetworkopen.2019.18287] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE The increasing use of electronic communications has enhanced access to physicians for patients and clinical staff. Primary care physicians (PCPs) have anecdotally identified electronic inbox management as a new source of work-related stress. OBJECTIVES To describe PCPs' experiences managing their electronic inboxes and to characterize the array of management strategies developed by individual physicians and practice groups. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted in 8 medical centers of a large group practice with more than 4 million patients in diverse settings and a mature electronic health record. The group encourages patients to use portal secure messaging to enhance access to their physicians and the care experience. Semistructured interviews were conducted with 24 internists and family medicine physicians identified via snowball sampling. Interviews were conducted July through November 2018. Data analysis was conducted between November 2018 and April 2019. MAIN OUTCOMES AND MEASURES Audio recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. RESULTS The 24 participants (12 women [50.0%]; mean [SD] age, 45.5 [6.5] years), including 9 department chiefs and 15 PCPs, had a mean (SD) of 16.8 (7.8) years since medical school graduation. Participants described substantial changes in medical practice due to electronic communication, including perceived patient expectations to receive rapid responses to portal secure messages. They described portal secure messaging as useful for building relationships with patients, but also reported that electronic message management has created new stressors, including erosion of work-life boundaries and anxiety associated with unlimited inbox volume. Individual PCPs used a diverse array of strategies, including multitasking during and outside work and delegating to medical assistants. Chiefs described group-level strategies, including reserving clinic time for inbox management, coverage systems for vacation and sick days, physician-to-physician training, and interdisciplinary teams to share messaging work. CONCLUSIONS AND RELEVANCE Individual physicians and local practice groups have developed a wide array of strategies for electronic inbox management. The volume of electronic messages and PCPs' perceptions that patients expect rapid responses have created new stressors in primary care practice. Medical groups and health systems can support PCPs by facilitating knowledge transfer among physicians about inbox management strategies and further developing team structures for inbox coverage.
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Affiliation(s)
- Tracy A. Lieu
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Oakland, California
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jonathan Z. Weiner
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Oakland, California
| | - Jeffrey A. East
- The Permanente Medical Group, Oakland, California
- Department of Adult and Family Medicine, Kaiser Permanente Richmond, Richmond, California
| | - Mark F. Moeller
- The Permanente Medical Group, Oakland, California
- Department of Adult and Family Medicine, Kaiser Permanente Napa, Napa, California
| | | | - Mary E. Reed
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Nancy Goler
- The Permanente Medical Group, Oakland, California
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17
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Cotton DM, Vinson DR, Vazquez-Benitez G, Margaret Warton E, Reed ME, Chettipally UK, Kene MV, Lin JS, Mark DG, Sax DR, McLachlan ID, Rauchwerger AS, Simon LE, Kharbanda AB, Kharbanda EO, Ballard DW. Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting. Ann Emerg Med 2019; 74:471-480. [PMID: 31229394 PMCID: PMC8364751 DOI: 10.1016/j.annemergmed.2019.04.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/21/2019] [Accepted: 04/19/2019] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS). METHODS We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC. RESULTS We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS. CONCLUSION The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.
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Affiliation(s)
- Dale M Cotton
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, South Sacramento Medical Center, Sacramento, CA.
| | - David R Vinson
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, Sacramento Medical Center, Sacramento, CA
| | | | | | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, CA
| | - Uli K Chettipally
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, South San Francisco Medical Center, South San Francisco, CA
| | - Mamata V Kene
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, San Leandro Medical Center, San Leandro, CA
| | - James S Lin
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Santa Clara Medical Center, Santa Clara, CA
| | - Dustin G Mark
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, Oakland Medical Center, Oakland, CA
| | - Dana R Sax
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Oakland Medical Center, Oakland, CA
| | - Ian D McLachlan
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, San Francisco Medical Center, San Francisco, CA
| | | | - Laura E Simon
- Kaiser Permanente, Division of Research, Oakland, CA
| | - Anupam B Kharbanda
- Children's Hospitals and Clinics of Minnesota, Department of Pediatric Emergency Medicine, Minneapolis, MN
| | | | - Dustin W Ballard
- Permanente Medical Group, Oakland, CA; Kaiser Permanente, Division of Research, Oakland, CA; Kaiser Permanente, San Rafael Medical Center, San Rafael, CA
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Karter AJ, Warton EM, Moffet HH, Ralston JD, Huang ES, Miller DR, Lipska KJ. Revalidation of the Hypoglycemia Risk Stratification Tool Using ICD-10 Codes. Diabetes Care 2019; 42:e58-e59. [PMID: 30765427 PMCID: PMC6429629 DOI: 10.2337/dc18-2154] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/16/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA .,Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA.,Departments of Epidemiology and Health Services, University of Washington, Seattle, WA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Elbert S Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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Fernandez A, Warton EM, Schillinger D, Moffet HH, Kruger J, Adler N, Karter AJ. Language barriers and LDL-C/SBP control among Latinos with diabetes. Am J Manag Care 2018; 24:405-410. [PMID: 30222919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Language barriers in healthcare are associated with worse glycemic control among Latino patients with limited English proficiency and diabetes. We examined the association of patient-physician language concordance with lipid (low-density lipoprotein cholesterol [LDL-C]) and systolic blood pressure (SBP) control. STUDY DESIGN Retrospective cohort study. METHODS Data were obtained from a survey and the electronic health records of Latino and white patients with diabetes receiving care within 1 integrated health plan with interpreter services available. Limited English proficiency and patient-physician language concordance were defined by patient report. Outcomes were poor lipid control (LDL-C >100 mg/dL) and poor SBP control (SBP >140 mm Hg). RESULTS In total, 3463 Latino (2921 who spoke English and 542 who were limited English proficient [LEP]) and 3896 English-speaking white patients participated. One-third of the patients had poor lipid control and one-fifth had poor SBP control. English-speaking white patients were slightly less likely to have poor lipid control than English-speaking Latino patients, but the difference did not persist after adjustment for age and sex. Among Latinos, LEP patients were less likely to have poor lipid control than English-speaking patients (odds ratio, 0.71; 95% CI, 0.54-0.93), with no difference by LEP patient-physician language concordance. Poor SBP control did not differ by ethnicity, primary language, or patient-physician language concordance. CONCLUSIONS We found no evidence that ethnicity or language barriers in healthcare were associated with poorer lipid or blood pressure control among Latino and white patients with diabetes receiving care in settings with professional interpreters.
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Affiliation(s)
- Alicia Fernandez
- UCSF Box 1364, DGIM Zuckerberg San Francisco General Hospital, San Francisco, CA 94143.
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20
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Pachucki MC, Karter AJ, Adler NE, Moffet HH, Warton EM, Schillinger D, O'Connell BH, Laraia B. Eating with others and meal location are differentially associated with nutrient intake by sex: The Diabetes Study of Northern California (DISTANCE). Appetite 2018; 127:203-213. [PMID: 29601920 DOI: 10.1016/j.appet.2018.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 11/23/2017] [Accepted: 03/23/2018] [Indexed: 02/07/2023]
Abstract
Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating - frequencies of eating meals with others, meals prepared at home, and meals outside the home - are associated with nutrient intake. Because diet improvement can reduce complications of diabetes mellitus, we surveyed a multi-ethnic cohort of persons with type 2 diabetes (n = 770) about social aspects of diet (based on 24-hour recalls). Sex-stratified multiple regression analyses adjusted for confounders assessed the relationship between frequency of eating with others and nutrient intake (total energy, energy from fat, energy from carbohydrates, Healthy Eating Index/HEI, Dietary Approaches to Stop Hypertension/DASH score). Although there was slight variation in men's versus women's propensity to share meals, after adjustment for confounders, there was no consistently significant association between meals with others and the 5 nutrient intake measures for either men or women. The directions of association between categories of eating with others and diet quality (HEI and DASH scores) - albeit not significant - were different for men (positive) and women (mostly negative), which warrants further investigation. The next analyses estimated nutrient intake associated with meals prepared at home, and meals consumed outside the home. Analyses indicated that greater meal frequency at home was associated with significantly better scores on diet quality indices for men (but not women), while meal frequency outside the home was associated with poorer diet quality and energy intake for women (but not men). Better measurement of social dimensions of eating may inform ways to improve nutrition, especially for persons with diabetes for whom diet improvement can result in better disease outcomes.
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Affiliation(s)
- Mark C Pachucki
- Department of Sociology and Computational Social Science Institute, University of Massachusetts, Amherst, 200 Hicks Way, Thompson Hall, Amherst, MA 01003-9277, United States.
| | - Andrew J Karter
- Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612, United States
| | - Nancy E Adler
- Center for Health and Community, University of California, San Francisco, 3333 California Street, Suite 465, San Francisco, CA 94118, United States
| | - Howard H Moffet
- Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612, United States
| | - E Margaret Warton
- Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612, United States
| | - Dean Schillinger
- Department of Medicine, University of California, San Francisco, Box 1364, SFGH Bldg 10, Ward 13 1310, San Francisco, CA 94143, United States
| | | | - Barbara Laraia
- School of Public Health, University of California, Berkeley, 207-B University Hall, Berkeley, CA 94720-97360, United States
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21
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Vinson DR, Warton EM, Mark DG, Ballard DW, Reed ME, Chettipally UK, Singh N, Bouvet SZ, Kea B, Ramos PC, Glaser DS, Go AS. Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department. West J Emerg Med 2018; 19:346-360. [PMID: 29560065 PMCID: PMC5851510 DOI: 10.5811/westjem.2017.9.35671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/23/2017] [Accepted: 09/05/2017] [Indexed: 12/18/2022] Open
Abstract
Introduction Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED). Methods This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation. Results Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm. Conclusion Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
| | | | - Dustin G Mark
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Oakland Medical Center, Department of Emergency Medicine, Oakland, California
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente San Rafael Medical Center, Department of Emergency Medicine, San Rafael, California
| | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, California
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente South San Francisco Medical Center, Department of Emergency Medicine, San Francisco, California
| | - Nimmie Singh
- Mercy Redding Family Practice Residency Program, Redding, California
| | - Sean Z Bouvet
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente Walnut Creek Medical Center, Department of Emergency Medicine, Walnut Creek, California
| | - Bory Kea
- Oregon Health and Science University, Department of Emergency Medicine, Portland, Oregon
| | - Patricia C Ramos
- Kaiser Permanente Sunnyside Medical Center, Northwest Permanente Physicians and Surgeons, Department of Emergency Medicine, Portland, Oregon
| | - David S Glaser
- Sisters of Charity of Leavenworth St. Joseph Hospital, Department of Emergency Medicine, Denver, Colorado
| | - Alan S Go
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,University of California, San Francisco, Departments of Epidemiology, Biostatistics, and Medicine, San Francisco, California.,Stanford University School of Medicine, Department of Health Research and Policy, Palo Alto, California
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22
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Karter AJ, Warton EM, Lipska KJ, Ralston JD, Moffet HH, Jackson GG, Huang ES, Miller DR. Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use. JAMA Intern Med 2017; 177:1461-1470. [PMID: 28828479 PMCID: PMC5624849 DOI: 10.1001/jamainternmed.2017.3844] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable. OBJECTIVE To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D. DESIGN, SETTING, AND PARTICIPANTS Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D. EXPOSURES Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records. MAIN OUTCOMES AND MEASURES Hypoglycemia-related ED or hospital use during 12 months of follow-up. RESULTS The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (>5%), intermediate (1%-5%), or low (<1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79). CONCLUSIONS AND RELEVANCE This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.
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Affiliation(s)
- Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of General Internal Medicine, University of California, San Francisco.,Department of Epidemiology, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Elbert S Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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Abstract
OBJECTIVE To estimate the rate, characteristics, and dispositions of hypoglycemia events among persons who received care from Alameda County, California, Emergency Medical Services (EMS). METHODS This study was based on data for 601,077 Alameda County EMS encounters during 2013-15. Subjects were defined as having hypoglycemia if EMS personnel recorded a primary impression of hypoglycemia or low blood glucose (<60 mg/dl or "unspecified low"). The outcome of interest was patient transport or non-transport to an emergency department or other care setting; we excluded 33,177 (6%) encounters which lacked clear disposition outcomes. RESULTS Among 567,900 eligible encounters, 8,332 (1.47%) were attributed to hypoglycemia, of which 1,125 (13.5%) were not transported. Non-transport was more likely among males, adult patients age <60, initial blood glucose >60 mg/dl or EMS arrival time 18:00-6:00. CONCLUSIONS Without an understanding of EMS encounters and non-transport rates, surveillance based solely on emergency department and hospital data will significantly underestimate rates of severe hypoglycemia. Additionally, given that hypoglycemia is often safely and effectively treated by non-physicians, EMS protocols should provide guidance for non-transport of hypoglycemic patients whose blood glucose levels have normalized.
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Zhang YT, Mujahid MS, Laraia BA, Warton EM, Blanchard SD, Moffet HH, Downing J, Karter AJ. Association Between Neighborhood Supermarket Presence and Glycated Hemoglobin Levels Among Patients With Type 2 Diabetes Mellitus. Am J Epidemiol 2017; 185:1297-1303. [PMID: 28510620 DOI: 10.1093/aje/kwx017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 05/23/2016] [Indexed: 11/14/2022] Open
Abstract
We estimated associations between neighborhood supermarket gain or loss and glycemic control (assessed by glycated hemoglobin (HbA1c) values) in patients from the Kaiser Permanente Northern California Diabetes Registry (n = 434,806 person-years; 2007-2010). Annual clinical measures were linked to metrics from a geographic information system for each patient's address of longest residence. We estimated the association between change in supermarket presence (gain, loss, or no change) and change in HbA1c value, adjusting for individual- and area-level attributes and according to baseline glycemic control (near normal, <6.5%; good, 6.5%-7.9%; moderate, 8.0%-8.9%; and poor, ≥9.0%). Supermarket loss was associated with worse HbA1c trajectories for those with good, moderate, and poor glycemic control at baseline, while supermarket gain was associated with marginally better HbA1c outcomes only among patients with near normal HbA1c values at baseline. Patients with the poorest baseline HbA1c values (≥9.0%) had the worst associated changes in glycemic control following either supermarket loss or gain. Differences were not clinically meaningful relative to no change in supermarket presence. For patients with type 2 diabetes mellitus, gaining neighborhood supermarket presence did not benefit glycemic control in a substantive way. The significance of supermarket changes on health depends on a complex interaction of resident, neighborhood, and store characteristics.
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Affiliation(s)
- Y. Tara Zhang
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Mahasin S. Mujahid
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Barbara A. Laraia
- Division of Public Health Nutrition, School of Public Health, University of California, Berkeley, Berkeley, California
| | | | - Samuel D. Blanchard
- Department of Environmental Science, Policy and Management, University of California, Berkeley, Berkeley, California
| | | | - Janelle Downing
- Center for Health and Community, University of California, San Francisco, San Francisco, California
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25
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Laraia BA, Downing JM, Zhang YT, Dow WH, Kelly M, Blanchard SD, Adler N, Schillinger D, Moffet H, Warton EM, Karter AJ. Food Environment and Weight Change: Does Residential Mobility Matter?: The Diabetes Study of Northern California (DISTANCE). Am J Epidemiol 2017; 185:743-750. [PMID: 28387785 DOI: 10.1093/aje/kww167] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 03/29/2016] [Indexed: 12/17/2022] Open
Abstract
Associations between neighborhood food environment and adult body mass index (BMI; weight (kg)/height (m)2) derived using cross-sectional or longitudinal random-effects models may be biased due to unmeasured confounding and measurement and methodological limitations. In this study, we assessed the within-individual association between change in food environment from 2006 to 2011 and change in BMI among adults with type 2 diabetes using clinical data from the Kaiser Permanente Diabetes Registry collected from 2007 to 2011. Healthy food environment was measured using the kernel density of healthful food venues. Fixed-effects models with a 1-year-lagged BMI were estimated. Separate models were fitted for persons who moved and those who did not. Sensitivity analysis using different lag times and kernel density bandwidths were tested to establish the consistency of findings. On average, patients lost 1 pound (0.45 kg) for each standard-deviation improvement in their food environment. This relationship held for persons who remained in the same location throughout the 5-year study period but not among persons who moved. Proximity to food venues that promote nutritious foods alone may not translate into clinically meaningful diet-related health changes. Community-level policies for improving the food environment need multifaceted strategies to invoke clinically meaningful change in BMI among adult patients with diabetes.
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26
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Downing J, Laraia B, Rodriguez H, Dow WH, Adler N, Schillinger D, Warton EM, Karter AJ. Beyond the Great Recession: Was the Foreclosure Crisis Harmful to the Health of Individuals With Diabetes? Am J Epidemiol 2017; 185:429-435. [PMID: 28184432 DOI: 10.1093/aje/kww171] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 07/28/2016] [Indexed: 12/20/2022] Open
Abstract
The housing foreclosure crisis was harmful to the financial well-being of many households. In the present study, we investigated the health effects of the housing foreclosure crisis on glycemic control within a population of patients with diabetes. We hypothesized that an increase in the neighborhood foreclosure rate could worsen glycemic control by activating stressors such as higher neighborhood crime, lower housing prices, and erosion of neighborhood social cohesion. To test this, we linked public foreclosure records at the census-block level with clinical records from 2006 to 2009 of patients with diabetes. We specified individual fixed-effects models and controlled for individual time-invariant confounders and area-level time-varying confounders, including housing prices and unemployment rate, to estimate the effect of the foreclosure rate per census-block group on glycated hemoglobin. We found no statistically significant relationship between changes in the neighborhood foreclosure rate per block group in the prior year and changes in glycated hemoglobin. There is no evidence that increased foreclosure rates worsened glycemic control in this continuously insured population with diabetes. More research is needed to inform our knowledge of the role of insurance and health-care delivery systems in protecting the health of diabetic patients during times of economic stress.
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27
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Downing J, Laraia B, Rodriguez H, Dow WH, Adler N, Schillinger D, Warton EM, Karter AJ. Downing et al. Respond to "Foreclosures and Health in a Neighborhood Context". Am J Epidemiol 2017; 185:440-441. [PMID: 28184427 DOI: 10.1093/aje/kww170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/09/2016] [Indexed: 11/12/2022] Open
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28
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Reed ME, Warton EM, Kim E, Solomon MD, Karter AJ. Value-Based Insurance Design Benefit Offsets Reductions In Medication Adherence Associated With Switch To Deductible Plan. Health Aff (Millwood) 2017; 36:516-523. [DOI: 10.1377/hlthaff.2016.1316] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Mary E. Reed
- Mary E. Reed ( ) is a research scientist in the Division of Research at Kaiser Permanente, in Oakland, California
| | - E. Margaret Warton
- E. Margaret Warton is a consulting data analyst in the Division of Research at Kaiser Permanente
| | - Eileen Kim
- Eileen Kim is chief of outpatient quality in the East Bay service area at Kaiser Permanente
| | - Matthew D. Solomon
- Matthew D. Solomon is a physician researcher in the Department of Cardiology at Kaiser Permanente
| | - Andrew J. Karter
- Andrew J. Karter is a research scientist in the Division of Research at Kaiser Permanente
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29
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Tamayo A, Mujahid MS, Laraia B, Warton EM, Blanchard SD, Kelly M, Moffet HH, Adler N, Schillinger D, Karter AJ. Police-Recorded Crime and Perceived Stress among Patients with Type 2 Diabetes: the Diabetes Study of Northern California (DISTANCE). J Urban Health 2016; 93:745-757. [PMID: 27613180 PMCID: PMC5052144 DOI: 10.1007/s11524-016-0069-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
While stress has been linked to poor health outcomes, little is known about the impact of objective measures of neighborhood crime on stress in patients with chronic disease. Using the Kaiser Permanente Diabetes Study of Northern California (DISTANCE), we examined associations between police-recorded crime (2005-2007) and stress (Perceived Stress Scale-4) in four large Northern California cities (Oakland, Sacramento, San Francisco, and San Jose). We performed stratified analysis by gender and race/ethnicity using generalized linear regression models. In our study sample (n = 3188, mean age 59, range 30-77), 10 % reported high stress. In adjusted analyses, higher neighborhood all crimes rate was associated with modest increase in high stress for African-American (OR = 1.10; 95 % CI 1.02-1.22) and Latina women (OR = 1.36; 95 % CI 1.10-1.67) and property crime showed similar associations with stress for these groups of women. Visible crime was associated with stress only for Latina women (OR = 1.43; 95 % CI 1.14-1.78). We found no association between crime and stress among men or other racial/ethnic groups of women. High crime levels may disproportionately impact health among certain subpopulations. Studies using additional measures of stress are necessary to differentiate the health impact of crime-related stress from other forms of stressors among individuals living with diabetes.
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Affiliation(s)
- Aracely Tamayo
- School of Public Health, Division of Epidemiology, University of California Berkeley, 101 Haviland Hall, Berkeley, CA, 94720-7358, USA
| | - Mahasin S Mujahid
- School of Public Health, Division of Epidemiology, University of California Berkeley, 101 Haviland Hall, Berkeley, CA, 94720-7358, USA.
| | - Barbara Laraia
- Berkeley School of Public Health, Division of Public Health Nutrition, University of California, 207B University Hall, Berkeley, CA, 94720, USA
| | - E Margaret Warton
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Samuel D Blanchard
- Berkeley Department of Environmental Science, Policy and Management, University of California, 130 Mulford Hall, Berkeley, CA, 94720-3114, USA
| | - Maggi Kelly
- Berkeley Department of Environmental Science, Policy and Management, University of California, 130 Mulford Hall, Berkeley, CA, 94720-3114, USA
| | - Howard H Moffet
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Nancy Adler
- San Francisco Center for Health and Community, University of California, 3333 California St. Laurel Heights, San Francisco, CA, 94118, USA
| | - Dean Schillinger
- San Francisco Center for Vulnerable Populations at San Francisco General Hospital, University of California, 1001 Portero Ave, SFGH 10, San Francisco, CA, 94110, USA
| | - Andrew J Karter
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
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30
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Sarkar U, Lyles C, Steinman M, Huang ES, Moffet HH, Whitmer RA, Warton EM, Karter AJ. Changes in Medication Use After Dementia Diagnosis in an Observational Cohort of Individuals with Diabetes Mellitus. J Am Geriatr Soc 2016; 65:77-82. [PMID: 27642180 DOI: 10.1111/jgs.14429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess changes in medication use after a diagnosis of dementia in individuals with type 2 diabetes mellitus. DESIGN Difference-in-differences analysis of changes in the number of dispensed chronic medications between individuals with and without newly diagnosed dementia. SETTING Integrated healthcare delivery system, Kaiser Permanente Northern California. PARTICIPANTS Individuals aged 50 and older without prevalent dementia with type 2 diabetes mellitus enrolled in a baseline survey. During 5 years of follow-up, 193 individuals with a new diagnosis of dementia were identified, and risk-set sampling was used to randomly select five reference subjects per case matched on 5-year age categories and sex (965 matched participants), resulting in an analytical sample of 1,158. MEASUREMENTS The exposure was new diagnosis of dementia. The primary outcome was change in number of current chronic medications (total, cardiovascular (blood pressure and lipid control), diabetes mellitus) at three times: 1 year before index date (preindex date), date of diagnosis of dementia or matched reference date (index date), and up to 1 year after index date or end of follow-up if censored before 1 year (postindex date). RESULTS After adjustment, the number of chronic medications and the subset of cardiovascular medications declined after a dementia diagnosis in the overall cohort and in age-, sex-, and time-matched reference individuals, but the decline was significantly greater in the group with dementia (0.71 medications fewer than the reference group, P = .02). The number of diabetes mellitus medications declined in both groups, but the declines were not statistically different (0.18 medications fewer than the reference group, P = .008). CONCLUSIONS Use of cardiometabolic medications fell after a diagnosis of dementia, as recommended in national guidelines.
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Affiliation(s)
- Urmimala Sarkar
- Center for Vulnerable Populations, Division of General Internal Medicine, University of California San Francisco, San Francisco, California
| | - Courtney Lyles
- Center for Vulnerable Populations, Division of General Internal Medicine, University of California San Francisco, San Francisco, California
| | - Michael Steinman
- Division of Geriatrics, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Elbert S Huang
- School of Medicine, University of Chicago, Chicago, Illinois
| | - Howard H Moffet
- Division of Research, Kaiser Permanente, Oakland, California
| | | | | | - Andrew J Karter
- Division of Research, Kaiser Permanente, Oakland, California
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Zhang YT, Laraia BA, Mujahid MS, Blanchard SD, Warton EM, Moffet HH, Karter AJ. Is a reduction in distance to nearest supermarket associated with BMI change among type 2 diabetes patients? Health Place 2016; 40:15-20. [PMID: 27160530 DOI: 10.1016/j.healthplace.2016.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/09/2016] [Accepted: 04/22/2016] [Indexed: 11/27/2022]
Abstract
We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009 and 2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes.
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Affiliation(s)
- Y Tara Zhang
- University of California Berkeley, School of Public Health, Division of Epidemiology, Haviland Hall, Berkeley, CA 94720-7358, United States
| | - Barbara A Laraia
- University of California, Berkeley School of Public Health, Division of Public Health Nutrition, 207B University Hall, Berkeley, CA 94720, United States
| | - Mahasin S Mujahid
- University of California Berkeley, School of Public Health, Division of Epidemiology, Haviland Hall, Berkeley, CA 94720-7358, United States.
| | - Samuel D Blanchard
- University of California, Berkeley College of Natural Resources, Department of Environmental Science, Policy and Management, 130 Mulford Hall, Berkeley, CA 94720-3114, United States
| | - E Margaret Warton
- Kaiser Permanente Division of Research, 2000 Broadway Oakland, CA 94612, United States
| | - Howard H Moffet
- Kaiser Permanente Division of Research, 2000 Broadway Oakland, CA 94612, United States
| | - Andrew J Karter
- Kaiser Permanente Division of Research, 2000 Broadway Oakland, CA 94612, United States
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Tamayo A, Karter AJ, Mujahid MS, Warton EM, Moffet HH, Adler N, Schillinger D, Hendrickson O'Connell B, Laraia B. Associations of perceived neighborhood safety and crime with cardiometabolic risk factors among a population with type 2 diabetes. Health Place 2016; 39:116-21. [PMID: 27060870 DOI: 10.1016/j.healthplace.2016.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 02/18/2016] [Accepted: 03/24/2016] [Indexed: 11/18/2022]
Abstract
Little is known about how neighborhood crime may relate to health in diabetes patients. We examined associations between individuals' perceptions of neighborhood safety or violent crime and stress, physical activity, body mass index (BMI) or hemoglobin A1c (HbA1c) in a sample (n=721) of adults (mean age:63) with diabetes. Self-reported neighborhood safety, violent crime, physical activity, and stress were collected and linked to clinical measures of BMI and HbA1c. Approximately 54% and 15% of patients reported neighborhood safety concerns and violent crimes, respectively. Any neighborhood safety concerns (β=1.14, 95% C.I. 0.04-2.24) and violent crime (β=2.04, 95% C.I. 0.34-3.73) were associated with BMI in adjusted analysis. Any violent crime was associated with class II-III obesity (BMI≥35) (OR=1.34, 95% C.I.: 1.02, 1.75). There were no significant associations between neighborhood safety concerns or violent crime with stress, physical activity, or HbA1c. Neighborhood safety is associated with BMI and obesity. Further studies, including longitudinal designs, are needed to study how people with diabetes may be influenced by a sense of poor personal safety in their neighborhoods.
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Affiliation(s)
- Aracely Tamayo
- University of California, Berkeley School of Public Health, Division of Epidemiology, 101 Haviland Hall Berkeley, CA 94720-7358, United States.
| | - Andrew J Karter
- Kaiser Permanente, Division of Research Oakland, CA, United States
| | - Mahasin S Mujahid
- UC Berkeley, School of Public Health, Division of Epidemiology Berkeley, CA, United States
| | | | - Howard H Moffet
- Kaiser Permanente, Division of Research Oakland, CA, United States
| | - Nancy Adler
- University of California, San Francisco, Center for Health and Community San Francisco, CA, United States
| | - Dean Schillinger
- San Francisco General Hospital, University of California, San Francisco, Division of General Internal Medicine, Center for Vulnerable Populations San Francisco, CA, United States
| | | | - Barbara Laraia
- UC Berkeley SPH, Community Health and Human Development Berkeley, CA, United States
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Ballard DW, Reed ME, Singh N, Rauchwerger AS, Hamity CA, Warton EM, Chettipally UK, Mark DG, Vinson DR. Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit. Ann Emerg Med 2015; 66:646-654.e2. [DOI: 10.1016/j.annemergmed.2015.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 03/14/2015] [Accepted: 04/06/2015] [Indexed: 11/29/2022]
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Moore MM, Geller AC, Warton EM, Schwalbe J, Asgari MM. Multiple primary melanomas among 16,570 patients with melanoma diagnosed at Kaiser Permanente Northern California, 1996 to 2011. J Am Acad Dermatol 2015; 73:630-6. [PMID: 26298295 DOI: 10.1016/j.jaad.2015.06.059] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Published rates of cutaneous multiple primary melanoma (MPM) vary widely. OBJECTIVE We examined incidence of and risk factors associated with MPMs among Kaiser Permanente Northern California members. METHODS We estimated MPM incidence among 16,570 patients with melanoma from 1996 through 2011. We compared characteristics between patients with MPMs and single primary melanomas and estimated crude and adjusted hazard ratios of MPMs using Cox models. RESULTS In all, 15,448 patients had a single melanoma and 1122 had MPMs. Patients with MPMs were older and more often male, non-Hispanic white, and partnered. Subsequent primary melanomas were diagnosed after a mean of 3.83 (SD 3.61, median 2.82) years and were more likely in situ and thinner than initial tumors. The risk of a subsequent melanoma decreased from 2% in the first year after diagnosis to a stable approximately 1% rate through 15 years of follow-up. LIMITATIONS We lacked data on some known melanoma risk factors and had small numbers of non-white patients and certain tumor subtypes. CONCLUSIONS The risk of MPMs, although highest in the first year after diagnosis, remains stable thereafter. Those at highest risk of MPMs are older, male, white, and partnered. Clinicians should be aware of the rate of MPMs and recognize high-risk subgroups.
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Affiliation(s)
- Megan M Moore
- Department of Dermatology, The Permanente Medical Group, Walnut Creek, California.
| | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Joan Schwalbe
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Maryam M Asgari
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Dermatology, The Permanente Medical Group, Walnut Creek, California
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Asgari MM, Arron ST, Warton EM, Quesenberry CP, Weisshaar D. Sirolimus use and risk of cutaneous squamous cell carcinoma (SCC) in solid organ transplant recipients (SOTRs). J Am Acad Dermatol 2015; 73:444-50. [DOI: 10.1016/j.jaad.2015.05.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 05/14/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
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Paulson KG, Iyer JG, Simonson WT, Blom A, Thibodeau RM, Schmidt M, Pietromonaco S, Sokil M, Warton EM, Asgari MM, Nghiem P. CD8+ lymphocyte intratumoral infiltration as a stage-independent predictor of Merkel cell carcinoma survival: a population-based study. Am J Clin Pathol 2014; 142:452-8. [PMID: 25239411 DOI: 10.1309/ajcpikdzm39crpnc] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Intratumoral CD8+ lymphocytes (IT-CD8s) have shown promise as a prognostic indicator for Merkel cell carcinoma (MCC). We tested whether IT-CD8s predict survival among a population-based MCC cohort. METHODS One hundred thirty-seven MCC cases that had not previously been analyzed for IT-CD8s were studied. RESULTS Three-year MCC-specific survival rates were 56%, 72%, and 100% for patients with absent (n = 46), low (n = 85), and moderate or strong (n = 6) IT-CD8s, respectively. Increased IT-CD8s were associated with improved MCC-specific survival in a multivariate competing risk-regression analysis including stage, age, and sex (hazard ratio [HR] = 0.5; 95% confidence interval [CI] = 0.3-0.9). Although a similar trend was observed for overall survival, statistical significance was not reached (HR = 0.8; 95% CI = 0.6-1.0), likely because of the high rate of non-MCC deaths among older patients. CONCLUSIONS This study of prospectively captured MCC cases supports the concept that cellular immunity is important in MCC outcome and that CD8+ lymphocyte infiltration adds prognostic information to conventional staging.
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Affiliation(s)
- Kelly G. Paulson
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
| | - Jayasri G. Iyer
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
| | - William T. Simonson
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
| | - Astrid Blom
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
| | - Renee M. Thibodeau
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
| | - Miranda Schmidt
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
| | - Stephanie Pietromonaco
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
| | - Monica Sokil
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Maryam M. Asgari
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Paul Nghiem
- Department of Medicine/Dermatology and Pathology at the University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle WA
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Asgari MM, Sokil MM, Warton EM, Iyer J, Paulson KG, Nghiem P. Effect of host, tumor, diagnostic, and treatment variables on outcomes in a large cohort with Merkel cell carcinoma. JAMA Dermatol 2014; 150:716-23. [PMID: 24807619 DOI: 10.1001/jamadermatol.2013.8116] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Merkel cell carcinoma (MCC) is a rare, aggressive, neuroendocrine-derived skin cancer with high rates of recurrence and associated mortality. Few published studies have used comprehensive patient data and long-term follow-up to examine factors that predict MCC outcomes. OBJECTIVE To characterize MCC in a large defined-population cohort and analyze predictors of disease recurrence and survival. SETTING, DESIGN, AND PARTICIPANTS Retrospective cohort study of 218 patients with MCC from the cancer registry of Kaiser Permanente Northern California, a large integrated health care delivery system. Patients were diagnosed as having MCC and followed up from January 1, 1995, through December 31, 2009. We examined host (age, sex, race, and immunosuppression), tumor (anatomic site, size, and extent), diagnostic (results of imaging and pathologic nodal evaluation), and treatment (surgery, radiation therapy, and chemotherapy) variables for their association with MCC outcomes. EXPOSURE Host, tumor, diagnostic, and treatment factors. MAIN OUTCOMES AND MEASURES Recurrence (locoregional and distant) of MCC and patient survival (overall and MCC specific). RESULTS We estimated adjusted hazard ratios (AHRs) and 95% CIs for outcomes using Cox proportional hazards regression models. After adjustment for host, tumor, diagnostic, and treatment variables, tumor extent (categorized as local, regional, and distant) remained significantly associated with all outcomes. Immunosuppression was associated with higher MCC-specific mortality (AHR, 4.9 [95% CI, 1.7-14.4]), and an unknown primary site was associated with a lower risk for distant metastasis (0.1 [0.0-0.7]) and improved survival (0.4 [0.2-0.9]). Pathological nodal evaluation was associated with a lower risk for metastasis (AHR, 0.2 [95% CI, 0.0-1.0]) and improved survival. Radiation treatment was associated with a decreased risk for locoregional recurrence (AHR, 0.3 [95% CI, 0.1-0.6]), whereas chemotherapy was not associated with any alteration in outcomes. CONCLUSIONS AND RELEVANCE Tumor site and extent, results of pathologic nodal evaluation, and the presence of radiation treatment were associated with MCC recurrence. Immunosuppression, tumor extent, and results of pathologic nodal evaluation were associated with MCC-specific survival, whereas chemotherapy was not associated with any outcomes. Our findings may help to inform diagnostic and therapeutic management of MCCs.
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Affiliation(s)
- Maryam M Asgari
- Division of Research, Kaiser Permanente Northern California, Oakland2Department of Dermatology, University of California at San Francisco
| | - Monica M Sokil
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jayasri Iyer
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Paul Nghiem
- Fred Hutchinson Cancer Research Center, Seattle, Washington4Division of Dermatology, Department of Medicine, University of Washington, Seattle
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Asgari MM, Warton EM, Quesenberry CP, Koralek DO, Taylor M. Risk of subsequent cutaneous squamous cell carcinoma in patients with melanoma. J Am Acad Dermatol 2014; 71:521-8. [DOI: 10.1016/j.jaad.2014.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 11/30/2022]
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Ahmed AT, Warton EM, Schaefer CA, Shen L, McIntyre RS. The effect of bariatric surgery on psychiatric course among patients with bipolar disorder. Bipolar Disord 2013; 15:753-63. [PMID: 23909994 PMCID: PMC3844030 DOI: 10.1111/bdi.12109] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 03/29/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Bariatric surgery is the most effective therapy for severe obesity. People with bipolar disorder have increased risk of obesity, yet are sometimes considered ineligible for bariatric surgery due to their bipolar disorder diagnosis. This study aimed to determine if bariatric surgery alters psychiatric course among stable patients with bipolar disorder. METHODS A matched cohort study (2006-2009) with mean follow-up of 2.17 years was conducted within Kaiser Permanente Northern California, a group practice integrated health services delivery organization that provides medical and psychiatric care to 3.3 million people. Participants were 144 severely obese patients with bipolar disorder who underwent bariatric surgery, and 1,440 control patients with bipolar disorder, matched for gender, medical center, and contemporaneous health plan membership. Controls met referral criteria for bariatric surgery. Hazard ratio for psychiatric hospitalization, and change in rate of outpatient psychiatric utilization from baseline to Years 1 and 2, were compared between groups. RESULTS A total of 13 bariatric surgery patients (9.0%) and 153 unexposed to surgery (10.6%) had psychiatric hospitalization during follow-up. In multivariate Cox models adjusting for potential confounding factors, the hazard ratio of psychiatric hospitalization associated with bariatric surgery was 1.03 [95% confidence interval (CI): 0.83-1.23]. In fully saturated multivariate general linear models, change in outpatient psychiatric utilization was not significantly different for surgery patients versus controls, from baseline to Year 1 (-0.4 visits/year, 95% CI: -0.5 to 0.4) or baseline to Year 2 (0.4 visits/year, 95% CI: -0.1 to 1.0). CONCLUSIONS Bariatric surgery did not affect psychiatric course among stable patients with bipolar disorder. The results of this study suggest that patients with bipolar disorder who have been evaluated as stable can be considered for bariatric surgery.
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Affiliation(s)
- Ameena T Ahmed
- Department of Internal Medicine, The Permanente Medical Group, San Francisco
| | | | | | - Ling Shen
- Kaiser Permanente Division of Research, Oakland CA, USA
| | - Roger S McIntyre
- Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, Ontario, Canada
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Lipska KJ, Warton EM, Huang ES, Moffet HH, Inzucchi SE, Krumholz HM, Karter AJ. HbA1c and risk of severe hypoglycemia in type 2 diabetes: the Diabetes and Aging Study. Diabetes Care 2013; 36:3535-42. [PMID: 23900589 PMCID: PMC3816866 DOI: 10.2337/dc13-0610] [Citation(s) in RCA: 176] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We examined the association between HbA1c level and self-reported severe hypoglycemia in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Type 2 diabetic patients in a large, integrated healthcare system, who were 30-77 years of age and treated with glucose-lowering therapy, were asked about severe hypoglycemia requiring assistance in the year prior to the Diabetes Study of Northern California survey conducted in 2005-2006 (62% response rate). The main exposure of interest was the last HbA1c level collected in the year preceding the observation period. Poisson regression models adjusted for selected demographic and clinical variables were specified to evaluate the relative risk (RR) of severe hypoglycemia across HbA1c levels. We also tested whether the HbA1c-hypoglycemia association differed across potential effect modifiers (age, diabetes duration, and category of diabetes medication). RESULTS Among 9,094 eligible survey respondents (mean age 59.5 ± 9.8 years, mean HbA1c 7.5 ± 1.5%), 985 (10.8%) reported experiencing severe hypoglycemia. Across HbA1c levels, rates of hypoglycemia were 9.3-13.8%. Compared with those with HbA1c of 7-7.9%, the RR of hypoglycemia was 1.25 (95% CI 0.99-1.57), 1.01 (0.87-1.18), 0.99 (0.82-1.20), and 1.16 (0.97-1.38) among those with HbA1c <6, 6-6.9, 8-8.9, and ≥9%, respectively, in a fully adjusted model. Age, diabetes duration, and category of diabetes medication did not significantly modify the HbA1c-hypoglycemia relationship. CONCLUSIONS Severe hypoglycemia was common among patients with type 2 diabetes across all levels of glycemic control. Risk tended to be higher in patients with either near-normal glycemia or very poor glycemic control.
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Jones-Smith JC, Karter AJ, Warton EM, Kelly M, Kersten E, Moffet HH, Adler N, Schillinger D, Laraia BA. Obesity and the food environment: income and ethnicity differences among people with diabetes: the Diabetes Study of Northern California (DISTANCE). Diabetes Care 2013; 36:2697-705. [PMID: 23637355 PMCID: PMC3747875 DOI: 10.2337/dc12-2190] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE It is unknown whether any association between neighborhood food environment and obesity varies according to individual income and/or race/ethnicity. The objectives of this study were to test whether there was an association between food environments and obesity among adults with diabetes and whether this relationship differed according to individual income or race/ethnicity. RESEARCH DESIGN AND METHODS Subjects (n = 16,057) were participants in the Diabetes Study of Northern California survey. Kernel density estimation was used to create a food environment score for each individual's residence address that reflected the mix of healthful and unhealthful food vendors nearby. Logistic regression models estimated the association between the modeled food environment and obesity, controlling for confounders, and testing for interactions between food environment and race/ethnicity and income. RESULTS The authors found that more healthful food environments were associated with lower obesity in the highest income groups (incomes 301-600% and >600% of U.S. poverty line) among whites, Latinos, and Asians. The association was negative, but smaller and not statistically significant, among high-income blacks. On the contrary, a more healthful food environment was associated with higher obesity among participants in the lowest-income group (<100% poverty threshold), which was statistically significant for black participants in this income category. CONCLUSIONS These findings suggest that the availability of healthful food environments may have different health implications when financial resources are severely constrained.
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Affiliation(s)
- Jessica C Jones-Smith
- Center for Health and Community, University of California, San Francisco, San Francisco, California, USA.
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Stoddard PJ, Laraia BA, Warton EM, Moffet HH, Adler NE, Schillinger D, Karter AJ. Neighborhood deprivation and change in BMI among adults with type 2 diabetes: the Diabetes Study of Northern California (DISTANCE). Diabetes Care 2013; 36:1200-8. [PMID: 23275367 PMCID: PMC3631838 DOI: 10.2337/dc11-1866] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare associations between neighborhood deprivation and measures of BMI change among adults with type 2 diabetes. RESEARCH DESIGN AND METHODS Using data from the Kaiser Permanente Diabetes Study of Northern California (DISTANCE) survey, we estimated the association between neighborhood deprivation and two measures of BMI change over 3 years: 1) a continuous measure and 2) a categorical measure of clinically substantive BMI loss or gain (≥7% of baseline BMI) versus stable BMI. The sample included 13,609 adults. RESULTS On average, there was little change in BMI (-0.12, SD 3.07); 17.0 and 16.1% had clinically substantive BMI loss or gain, respectively, at follow-up. There was a positive association between neighborhood deprivation and BMI change for adults in the most versus least-deprived quartile of neighborhood deprivation (β = 0.22, P = 0.02) in adjusted models. In addition, relative to the least-deprived quartile (Q1), adults in more-deprived quartiles of neighborhood deprivation were more likely to experience either substantive BMI loss (Q2 relative risk ratio 1.19, 95% CI 1.00-1.41; Q3 1.20, 1.02-1.42; Q4 1.30, 1.08-1.55) or gain (Q2 1.25, 1.04-1.49; Q3 1.24, 1.04-1.49; Q4 1.45, 1.20-1.75). CONCLUSIONS Greater neighborhood deprivation was positively associated with BMI change among adults with diabetes as well as with clinically substantive BMI loss or gain. Findings stress the importance of allowing for simultaneous associations with both gain and loss in future longitudinal studies of neighborhood deprivation and weight change, which may be particularly true for studies of patients with diabetes for whom both weight loss and gain have health implications.
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Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, Moffet HH, Adler N, Warton EM, Schillinger D. Communication and medication refill adherence: the Diabetes Study of Northern California. JAMA Intern Med 2013; 173:210-8. [PMID: 23277199 PMCID: PMC3609434 DOI: 10.1001/jamainternmed.2013.1216] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Poor medication refill adherence contributes to poor cardiometabolic control and diabetes outcomes. Studies linking communication between patients and health care providers to adherence often use self-reported adherence and have not explored differences across communication domains or therapeutic indications. METHODS To investigate associations between patient communication ratings and cardiometabolic medication refill adherence, we conducted a cross-sectional analysis of 9377 patients in the Diabetes Study of Northern California (DISTANCE), a race-stratified, random sample of Kaiser Permanente survey respondents. Eligible participants received 1 or more oral hypoglycemic, lipid-lowering, or antihypertensive medication in the 12 months preceding the survey. Communication was measured with a 4-item Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) score and 4 items from the Trust in Physicians and Interpersonal Processes of Care instruments. Poor adherence was classified as greater than a 20% continuous medication gap for ongoing medication therapies. Using modified least squares regression, we calculated differences in poor adherence prevalence for a 10-point decrease in CAHPS score and compared higher vs lower communication ratings on other items, adjusting for necessary sociodemographic and medical confounders derived from a directed acyclic graph. RESULTS In this cohort, 30% had poor cardiometabolic medication refill adherence. For each 10-point decrease in CAHPS score, the adjusted prevalence of poor adherence increased by 0.9% (P=.01). Compared with patients offering higher ratings, patients who gave health care providers lower ratings for involving patients in decisions, understanding patients' problems with treatment, and eliciting confidence and trust were more likely to have poor adherence, with absolute differences of 4% (P=.04), 5% (P=.02), and 6% (P=.03), respectively. Associations between communication and adherence were somewhat larger for hypoglycemic medications than for other medications. CONCLUSIONS Poor communication ratings were independently associated with objectively measured inadequate cardiometabolic medication refill adherence, particularly for oral hypoglycemic medications. Future studies should investigate whether improving communication skills among clinicians with poorer patient communication ratings could improve their patients' cardiometabolic medication refill adherence and outcomes.
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Affiliation(s)
- Neda Ratanawongsa
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco (UCSF), San Francisco, CA 94110, USA.
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Silverberg MJ, Leyden W, Warton EM, Quesenberry CP, Engels EA, Asgari MM. HIV infection status, immunodeficiency, and the incidence of non-melanoma skin cancer. J Natl Cancer Inst 2013; 105:350-60. [PMID: 23291375 DOI: 10.1093/jnci/djs529] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background The incidence of non-melanoma skin cancers (NMSCs), including basal cell (BCC) or squamous cell carcinoma (SCC), is not well documented among HIV-positive (HIV(+)) individuals. Methods We identified 6560 HIV(+) and 36 821 HIV-negative (HIV(-)) non-Hispanic white adults who were enrolled and followed up in Kaiser Permanente Northern California from 1996 to 2008. The first biopsy-proven NMSCs diagnosed during follow-up were identified from pathology records. Poisson models estimated rate ratios that compared HIV(+) (overall and stratified by recent CD4 T-cell counts and serum HIV RNA levels) with HIV(-) subjects and were adjusted for age, sex, smoking history, obesity diagnosis history, and census-based household income. Sensitivity analyses were adjusted for outpatient visits (ie, a proxy for screening). All statistical tests were two-sided. Results The NMSC incidence rate was 1426 and 766 per 100 000 person-years for HIV(+) and HIV(-) individuals, respectively, which corresponds with an adjusted rate ratio of 2.1 (95% confidence interval [CI] = 1.9 to 2.3). Similarly, the adjusted rate ratio for HIV(+) vs HIV(-) subjects was 2.6 (95% CI = 2.1 to 3.2) for SCCs, and it was 2.1 (95% CI = 1.8 to 2.3) for BCCs. There was a statistically significant trend of higher rate ratios with lower recent CD4 counts among HIV(+) subjects compared with HIV(-) subjects for SCCs (P trend < .001). Adjustment for number of outpatient visits did not affect the results. Conclusion HIV(+) subjects had a twofold higher incidence rate of NMSCs compared with HIV(-) subjects. SCCs but not BCCs were associated with immunodeficiency.
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Asgari MM, Eide MJ, Warton EM, Fletcher SW. Validation of a large basal cell carcinoma registry. J Registry Manag 2013; 40:65-69. [PMID: 24002130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The epidemiological study of basal cell carcinomas (BCCs) is difficult because BCCs lack distinct disease codes and are excluded from most cancer registries. OBJECTIVE To develop and validate a large BCC registry based on electronically assigned Systematized Nomenclature of Medicine (SNOMED) codes and text-string searches of electronic pathology reports from Kaiser Permanente Northern California. METHODS AND MATERIALS Potential BCCs were identified from electronic pathology reports (n=39,026) in 2005 and were reviewed by a dermatologist who assigned case/non-case status (gold-standard). A subset of the records (n=9,428) was independently reviewed by a second dermatologist to ascertain reliability of case assignment. In addition, a subset of excluded electronic pathology reports from 2005 (n=2,700) was reviewed to determine whether inclusion criteria had missed potential BCCs. We calculated the positive predictive value (PPV) of 3 different algorithms for identifying BCCs from electronic pathology data. RESULTS BCC-specific SNOMED codes had the highest PPV for identifying BCCs, 0.992 (95 percent CI: 0.991-0.993). Inter-rater reliability for case assignment was high (kappa=0.92, 95 percent CI: 0.91-0.93). Standardized incidence rates were consistent with previously published rates in the United States. CONCLUSIONS We created and validated a large BCC registry to serve as a unique resource for studying BCCs.
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Abstract
BACKGROUND In screening pharmaceuticals for possible carcinogenic effects we noted an association between lip cancer risk and the photosensitizing antihypertensive drugs hydrochlorothiazide and nifedipine. In this study, we further characterized the risk of lip cancer associated with these and other commonly used antihypertensive drugs. METHODS In a comprehensive medical care program, we evaluated prescriptions dispensed and cancer occurrence from August 1, 1994, to February 29, 2008. We identified 712 patients with lip cancer (cases) and 22,904 comparison individuals (controls) matched for age, sex, and cohort year of entry in the susceptible group, non-Hispanic whites. We determined use, at least 2 years before diagnosis or control index date, of the commonly prescribed diuretics hydrochlorothiazide and hydrochlorothiazide combined with triamterene, the angiotensin-converting enzyme inhibitor lisinopril, the calcium channel blocker nifedipine, and the β-adrenergic blocker atenolol, the only nonphotosensitizer agent studied. We analyzed the use of each drug exclusively and regardless of use of the others, and focused on duration of use. Conditional logistic regression was used for analysis of matched case-control sets, with control for cigarette smoking. RESULTS At least a 5-year supply of a drug yielded the following odds ratios (95% CIs), respectively, compared with no use: hydrochlorothiazide, 4.22 (2.82-6.31); hydrochlorothiazide-triamterene, 2.82 (1.74-4.55); lisinopril, 1.42 (0.95-2.13); nifedipine, 2.50 (1.29-4.84); and atenolol, 1.93 (1.29-2.91). When the other drugs were excluded, the odds ratio for atenolol was reduced to 0.54 (0.07-4.08). CONCLUSION These data support an increased risk of lip cancer in non-Hispanic whites receiving treatment for hypertension with long-term use of photosensitizing drugs.
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Affiliation(s)
- Gary D Friedman
- Division of Research, Kaiser Permanente Medical Care Program, Oakland, California, USA
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Laraia BA, Karter AJ, Warton EM, Schillinger D, Moffet HH, Adler N. Place matters: neighborhood deprivation and cardiometabolic risk factors in the Diabetes Study of Northern California (DISTANCE). Soc Sci Med 2012; 74:1082-90. [PMID: 22373821 DOI: 10.1016/j.socscimed.2011.11.036] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 09/01/2011] [Accepted: 11/25/2011] [Indexed: 11/26/2022]
Abstract
While neighborhood deprivation is associated with prevalence of chronic diseases, it is not well understood whether neighborhood deprivation is also associated with cardiometabolic risk factors among adults with chronic disease. Subjects (n = 19,804) from the Diabetes Study of Northern California (DISTANCE) cohort study, an ethnically-stratified, random sample of members of Kaiser Permanente Northern California (KPNC), an integrated managed care consortium, with type 2 diabetes who completed a survey between 2005 and 2007 and who lived in a 19 county study area were included in the analyses. We estimated the association between a validated neighborhood deprivation index (NDI) and four cardiometabolic risk factors: body mass index (BMI = kg/m2), glycosylated hemoglobin (A1c), low density lipoproteins (LDL) and systolic blood pressure (SBP) using multi-level models. Outcomes were modeled in their continuous form and as binary indicators of poor control (severe obesity: BMI ≥35, poor glycemic control: A1c ≥9%, hypercholesterolemia: LDL ≥130 mg/dL, and hypertension: SBP ≥140 mmHg). BMI, A1c and SBP increased monotonically across quartiles of NDI (p < 0.001 in each case); however, LDL was significantly associated with NDI only when comparing the most to the least deprived quartile. NDI remained significantly associated with BMI and A1c after adjusting for individual level factors including income and education. A linear trend (p < 0.001) was observed in the relative risk ratios for dichotomous indicators of severe obesity, poor glycemic control, and 2 or more poorly controlled cardiometabolic risk factors across NDI quartile. In adjusted models, higher levels of neighborhood deprivation were positively associated with indicators of cardiometabolic risk among adults with diabetes, suggesting that neighborhood level deprivation may influence individual outcomes. However, longitudinal data are needed to test the causal direction of these relationships.
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Affiliation(s)
- Barbara A Laraia
- Department of Medicine, Division of Prevention Sciences, University of California, San Francisco, CA, USA.
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Asgari MM, Warton EM, Neugebauer R, Chren MM. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol 2011; 147:1387-94. [PMID: 22184760 PMCID: PMC3620041 DOI: 10.1001/archdermatol.2011.319] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To identify preoperative, intraoperative, and postoperative variables that predict higher short- and long-term patient satisfaction with Mohs surgery. DESIGN Prospective cohort study. SETTING A university-based dermatology practice and the affiliated Veterans Affairs medical center dermatology clinic. PATIENTS A total of 339 consecutive patients treated with Mohs surgery in 1999 and 2000. MAIN OUTCOME MEASURES Short-term satisfaction at 1 week and long-term satisfaction at 1 year. We used directed acyclic graphs to determine appropriate confounding adjustment for preoperative, intraoperative, and postoperative variables that influence satisfaction with Mohs surgery in logistic regression models. RESULTS Better preoperative skin-related quality of life (measured using Skindex) and more intraoperative Mohs stages were the most salient predictors of higher short- and long-term satisfaction; these odds ratios (ORs) were 2.33 (95% CI, 1.01-5.35) and 5.19 (1.66-16.29), respectively, for preoperative skin-related quality of life and 7.06 (2.02-24.67) and 5.30 (1.24-22.64), respectively, for more intraoperative Mohs stages. Patients not bothered by postoperative bleeding were more likely to be satisfied short term (OR, 2.25; 95% CI, 1.25-4.05), as were those who considered themselves involved in decision making about their treatment (3.05; 1.52-6.10). Higher long-term satisfaction with Mohs surgery was observed among patients who were married (2.36; 1.10-5.09). CONCLUSIONS Higher short- and long-term satisfaction with Mohs surgery is predicted by better preoperative skin-related quality of life and by more intraoperative Mohs stages. The effect of postoperative variables wanes over time, suggesting that factors influencing satisfaction can vary depending on the time frame when satisfaction is measured. Our results may help clinicians identify patients who are at higher risk of dissatisfaction following Mohs surgery.
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Affiliation(s)
- Maryam M Asgari
- Division of Research, Kaiser Permanente Northern California, Oakland , California 94612, USA.
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Asgari MM, Chren MM, Warton EM, Friedman GD, White E. Supplement use and risk of cutaneous squamous cell carcinoma. J Am Acad Dermatol 2011; 65:1145-51. [PMID: 21664718 PMCID: PMC3184340 DOI: 10.1016/j.jaad.2010.09.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Revised: 08/17/2010] [Accepted: 09/12/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Laboratory and epidemiologic studies suggest that certain dietary supplements may alter risk of cutaneous squamous cell carcinoma (SCC). OBJECTIVE We sought to examine the association between supplement use and SCC risk. METHODS Cases (n = 415) were defined as Kaiser Permanente Northern California members with a pathology-verified SCC in 2004 and control subjects (n = 415) were age-, sex-, and race-matched members with no history of skin cancer. Supplement use and SCC risk factors were ascertained by questionnaire. Associations of SCC with use of multivitamins; vitamins A, C, D, and E; and grape seed extract were estimated as odds ratios and 95% confidence intervals using conditional logistic regression. Models were adjusted for SCC risk factors and other supplement use. RESULTS Grape seed extract users had a significantly decreased risk of cutaneous SCC (adjusted odds ratio 0.26, confidence interval 0.08-0.89, P = .031). Multivitamin use was associated with a borderline significant reduction in SCC risk (adjusted odds ratio 0.71, confidence interval 0.51-1.00, P = .049). Use of vitamins A, C, D, and E was not associated with SCC risk. LIMITATIONS The data may be prone to recall and selection bias because of the case-control design. No information was obtained on dose or duration of supplement use. CONCLUSIONS Use of grape seed extract may be associated with a decreased risk of cutaneous SCC. The other supplements included in our study did not reveal clear associations with SCC risk.
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Affiliation(s)
- Maryam M Asgari
- Division of Research, Kaiser Permanente Northern California, Oakland, California 94612, USA.
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Abstract
Laboratory and epidemiologic studies suggest a protective effect of tea consumption on risk of cutaneous squamous cell carcinoma (SCC). We designed a case-control study to examine the association between putative protective exposures, including tea consumption, and SCC risk using a large health maintenance organization population. Cases (n=415) were defined as Kaiser Permanente Northern California (KPNC) members with a pathology-verified SCC in 2004 and controls (n=415) were age-, gender-, and race-matched members with no previous history of skin cancer. Tea consumption and SCC risk factors were ascertained by questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using conditional logistic regression to estimate the association of SCC with regular use, as well as dose and duration of tea consumption. Risk factor adjusted models included education, smoking, hair and eye color, skin type, family history of skin cancer, and history of freckling, sunburns, sun exposure, and tanning bed use. Adjusted analyses showed no reduction in SCC risk with regular consumption of tea (OR=1.11, 95% CI: 0.81-1.54). Examining duration, dose, and combined duration and dose exposure variables did not alter findings. We found no evidence that tea consumption was associated with cutaneous SCC risk.
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Affiliation(s)
- Maryam M Asgari
- Division of Research, Kaiser Permanente Northern California, Oakland, California 94612, USA.
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