Group Health Research Institute Research Articles

A systematic multidisciplinary initiative for reducing the risk of complications in adult scoliosis surgery.

OBJECTIVE Systematic multidisciplinary approaches to improving quality and safety in complex surgical care have shown promise. Complication rates from complex spine surgery range from 10% to 90% for all surgeries, and the overall mortality rate is 1%-4%. These rates suggest the need for improved perioperative complex spine surgery processes designed to minimize risk and improve quality. METHODS The Group Health Research Institute and Virginia Mason Medical Center implemented a systematic multidisciplinary protocol, the Seattle Spine Team Protocol, in 2010. This protocol involves the following elements: 1) a comprehensive multidisciplinary conference including clinicians from neurosurgery, anesthesia, orthopedics, internal medicine, behavioral health, and nursing, collaboratively deciding on each patient's suitability for surgery; 2) a mandatory patient education course that reviews the risks of surgery, preparation for the surgery, and postoperative care; 3) a dual-attending-surgeon approach involving 1 neurosurgeon and 1 orthopedic spine surgeon; 4) a dedicated specialist complex spine anesthesia team; and 5) rigorous intraoperative monitoring of a patient's blood loss and coagulopathy. The authors identified 71 patients who underwent complex spine surgery involving fusion of 6 or more levels before implementation of the protocol (surgery between 2008 and 2010) and 69 patients who underwent complex spine surgery after the implementation of the protocol (2010 and 2012). All patient demographic variables, including age, sex, body mass index, smoking status, diagnosis of diabetes and/or osteoporosis, previous surgery, and the nature of the spinal deformity, were comprehensively assessed. Also comprehensively assessed were surgical variables, including operative time, number of levels fused, and length of stay. The authors assessed overall complication rates at 30 days and 1 year and detailed deaths, cardiovascular events, infections, instrumentation failures, and CSF leaks. Chi-square and Wilcoxon rank-sum tests were used to assess differences in patient characteristics for patients with a procedure in the preimplementation period from those in the postimplementation period under a Poisson distribution model. RESULTS Patients who underwent surgery after implementation of the Seattle Spine Team Protocol had a statistically significant reduction (relative risk 0.49 [95% CI 0.30-0.78]) in all measured complications, including cardiovascular events, wound infections, other perioperative infections, and implant failures within 30 days after surgery; the analysis was adjusted for age and Charlson comorbidity score. A trend toward fewer deaths in this group was also found. CONCLUSIONS This type of systematic quality improvement strategy can improve quality and patient safety and might be applicable to other complex surgical disciplines. Implementation of these strategies in the treatment of adult spinal deformity will likely lead to better patient outcomes.

Health Outcomes of Population-Based Pharmacy Outreach to Increase Statin Use for Prevention of Cardiovascular Disease in Patients with Diabetes.

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

Confronting the Need for Evidence Regarding Prevention.

* Abbreviations: AAP — : American Academy of Pediatrics USPSTF — : US Preventive Services Task Force When both of us entered pediatrics, we learned that screening dipstick urinalyses was a standard part of well-child care, even though data from at least the 1970s questioned its rationale based on the high false-positive rate and the identification of self-limited disease.1 Screening seemed sensible and innocuous, and neither of us questioned it at the time. Although we were both aware of the debate about benefit, we do not recall hearing about the potential harms of dipstick screening. Over time, the evidence regarding the lack of benefit grew and the recommendation for screening urinalysis was limited to the 5-year-olds2 and then eventually dropped.3 Here is the question: Should a screening test that seems effective be adopted into routine practice with the expectation that evidence would eventually affirm its use or remove it from clinical care? Do we “do first, ask later?” We all know practices in our communities that still routinely use screening urinalyses out of concern about missing a “case” regardless of the potential harm and questionable benefit. How much do we need to know about a preventive screening test before it is recommended as “standard of care?” When do we know enough to either start or stop a service provided to all? How well do we stop a preventive service after it is shown to be ineffective? Preventive care services delivery is the cornerstone of pediatrics. From the newborn visit through adolescence, the American Academy of Pediatrics (AAP) and Bright Futures recommend 31 well-child care visits, each with specific discrete preventive services.4 We are often asked by our trainees in clinic how we decide what services to provide within the limited available time. We were taught by skilled and talented clinicians based on their personal knowledge, experience, and expert opinion about what … Address correspondence to David C. Grossman, MD, MPH, Group Health Cooperative, Group Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101. E-mail: grossman.d{at}ghc.org

Integrating Chronic Care for AUDs Into Primary Care Settings

Integrating Chronic Care for AUDs Into Primary Care Settings

Study Points to Risk Factors Predictive of Suicide After Emergency Visit

Study Points to Risk Factors Predictive of Suicide After Emergency Visit

Dose Matters: An Approach to Strengthening Community Health Strategies to Achieve Greater Impact

Dose Matters describes the concept of “population dose”—an approach to strengthening and evaluating the impact of complex multisector, multilevel, place-based initiatives. This discussion paper reports on what is promising about the approach while recognizing the measurement and other challenges that still lie ahead. The concept emerged from ongoing evaluations of Kaiser Permanente’s Community Health Initiative investments, conducted by the Center for Community Health and Evaluation (CCHE) at the Group Health Research Institute in collaboration with partners at the University of California. Following an overview of the Community Health Initiative, this report describes the concept in more detail and explains how it can be used to estimate the population-level impact of a set of related interventions. The estimated impact or dose of an intervention is the product of reach (the number of people touched by the intervention) and strength (the effect size or impact on each person reached). The dose concept can also be used in planning and implementation to yield greater impact. We hope that Dose Matters will introduce the concept of population dose in enough detail that a broad audience of community health researchers, evaluators, practitioners, and planners will be both prepared and eager to apply these analyses and approaches to their own work. Additional guidance is available in the form of an interactive toolkit developed by CCHE and Kaiser Permanente (see the Related Resources box). Together, Dose Matters and the toolkit will describe in detail the uses of dose for both evaluators and researchers, who will use the quantitative calculations, and community-based organizations and funders, who will apply the overall concept to strengthen every phase of improving community health outcomes, from planning to implementation to evaluation.

Applying a Neutropenia Risk Model to Cancer Patients Using VDW Data: A CRN Pilot Study

Background/Aims: Neutropenia, an extreme reduction in infection-fighting white blood cells, is a dangerous side effect of cytotoxic chemotherapy for cancer treatment, especially when accompanied by fever. Neutropenia and febrile neutropenia are associated with treatment delays, chemotherapy dose reductions, hospitalizations, antibiotic use, death and high costs. The granulocyte-colony stimulating factors (G-CSFs), filgrastim, pegfilgrastim and tbo-filgrastim, reduce the risk of neutropenia and febrile neutropenia; however, they are also associated with additional patient visits, side effects and high treatment-related costs. G-CSF use was found to be inconsistent with recommended clinical guidelines (overuse among those at low risk and underuse among those at high risk for neutropenia), thus making it part of the Choosing Wisely campaign. Individual patient factors are associated with increased risk for neutropenia and febrile neutropenia beyond that of the prescribed chemotherapy. No study has investigated the effect of providing medical oncologists with neutropenia risk predictions in real time to optimize the use of G-CSF and reduce neutropenia/febrile neutropenia outcomes among patients. The ongoing work will assess the feasibility of applying an existing patient neutropenia risk model developed by Lyman et al. to existing electronic data files. This work builds upon feasibility work currently being conducted at HealthPartners Institute, Minneapolis, MN, and adds two more CRN sites (Group Health Research Institute, Seattle, WA, and Henry Ford Health System, Detroit, MI).

Big Trial Tests Suicidality and Prevention in Real World

Back to table of contents Previous article Next article Full AccessBig Trial Tests Suicidality and Prevention in Real WorldAaron LevinAaron LevinSearch for more papers by this authorPublished Online:2 Dec 2014https://doi.org/10.1176/appi.pn.2014.11b2AbstractThe Collaboratory is a new approach to large-scale clinical trials intended to move interventions with major public health significance rapidly into clinical practice.What works in a clinical trial and what works in the clinic can be two different things. Of necessity, clinical trials must test an intervention in a narrowly defined population to minimize confounders, but patients encountered in the real world are rarely packaged so neatly.Now a new multisite trial seeks to enroll 19,500 patients to test suicide prevention programs out where patients live.The online suicide prevention intervention was in part designed by people who had experienced suicidality or suicide attempts, said Rebecca Rossom, M.D., M.S.HealthPartners“This is a very pragmatic clinical trial,” said investigator Rebecca Rossom, M.D., M.S., a clinical research associate at HealthPartners Institute for Education and Research in Bloomington, Minn., and an adjunct assistant professor of psychiatry at the University of Minnesota.The project is one of the seven initial demonstration projects chosen by the National Institutes of Health (NIH) to be part of its Health Care Systems Research Collaboratory. The Collaboratory’s goal is “to revamp the nation’s clinical trials system to produce cost-effective, large-scale research studies and put the results of those studies into clinical practice as quickly as possible.”The trial uses a simple screening procedure to recruit patients. “We are taking on all comers, as long as they score a 2 or 3 on the PHQ-9,” Rossom told Psychiatric News. “We want to see how these interventions work with real, live people.”The trial will study patients at three major health systems: Kaiser Permanente, Group Health Cooperative in Washington state, and Minnesota’s HealthPartners. The PHQ-9 asks about “thoughts that you would be better off dead or of hurting yourself in some way,” a general inquiry that can help clinicians identify people who are at elevated risk for suicide.Collectively, the three systems generate 1.8 million PHQ-9s every year. Investigators will screen the reports every week to determine who would benefit from the interventions.Patients are randomized before they are invited to participate, said Rossom. The control group will get treatment as usual. A second group will be invited join a risk-assessment and care-management program based on the Perfect Depression Care model developed at the Henry Ford Health System in Michigan. That includes outreach using secure messaging and encouraging follow-up care.A third cohort will use a multimedia approach, an online training program called “Now Matters Now” to help patients develop skills to manage painful emotions and stressful situations; patients will be supported by outreach messages from an online coach. This intervention is based on the dialectical behavioral therapy developed by Marsha Linehan, Ph.D., a professor of psychology and an adjunct professor of psychiatry and behavioral sciences at the University of Washington.“The online skills training method was designed with significant input from people with suicidal ideation,” said Rossom.Researchers will track each patient for 18 months, and the trial is expected to last for five years. The primary outcome is time to a first suicide attempt.From its pilot studies, the Group Health researchers came to view suicidality as an “enduring vulnerability rather than a short-term emergency.” Such risk seemed to continue for about a year after the first elevation of the PHQ-9. Risk declined after the first year—as long as patients were engaged in treatment.A score of 2 or 3 (on a 0-to-3 scale of the PHQ-9) is a predictor of heightened risk for a suicide attempt. “If you scored zero, you had a 0.4 percent chance of a suicide attempt in the following year. And if you scored a 3, which means you’re thinking about suicide almost every day, your risk goes up to 4 percent,” said Rossom.“We hope that we are able to test three questions,” said study leader Gregory Simon, M.D., M.P.H., a Group Health Research Institute senior investigator and a research professor in psychiatry and behavioral sciences at the University of Washington, in a statement. “Are we truly able to identify people who are at high risk? Do these programs help prevent suicide attempts? And will people accept these new programs?”“This new trial is very exciting and has the potential to make a great difference in people’s lives [through] timely identification and appropriate treatment of mental disorders,” said Eve Moscicki, Sc.D., M.P.H., director of the Practice Research Network at the American Psychiatric Foundation. This will be a chance to gather the data to test that proposition, she said. ■“Gregory Simon on the Collaboratory and How to Improve Suicide Prevention Programs” can be accessed here. “Does Response on the PHQ-9 Depression Questionnaire Predict Subsequent Suicide Attempt or Suicide Death?” is available here. ISSUES NewArchived

Toward personalizing treatment for depression: predicting diagnosis and severity

ObjectiveDepression is a prevalent disorder difficult to diagnose and treat. In particular, depressed patients exhibit largely unpredictable responses to treatment. Toward the goal of personalizing treatment for depression, we develop and evaluate computational models that use electronic health record (EHR) data for predicting the diagnosis and severity of depression, and response to treatment.Materials and methodsWe develop regression-based models for predicting depression, its severity, and response to treatment from EHR data, using structured diagnosis and medication codes as well as free-text clinical reports. We used two datasets: 35 000 patients (5000 depressed) from the Palo Alto Medical Foundation and 5651 patients treated for depression from the Group Health Research Institute.ResultsOur models are able to predict a future diagnosis of depression up to 12 months in advance (area under the receiver operating characteristic curve (AUC) 0.70–0.80). We can differentiate patients with severe baseline depression from those with minimal or mild baseline depression (AUC 0.72). Baseline depression severity was the strongest predictor of treatment response for medication and psychotherapy.ConclusionsIt is possible to use EHR data to predict a diagnosis of depression up to 12 months in advance and to differentiate between extreme baseline levels of depression. The models use commonly available data on diagnosis, medication, and clinical progress notes, making them easily portable. The ability to automatically determine severity can facilitate assembly of large patient cohorts with similar severity from multiple sites, which may enable elucidation of the moderators of treatment response in the future.

PS1-17: Organization-wide Collaboration to Convert Binary Clinical Notes to Research-ready Text

Background/Aims Clinical text is an integral part of research at Group Health Research Institute (GHRI), supporting ongoing projects and new research proposals. Our clinical notes are stored in a single, full-text-indexed table that is populated nightly with all new notes in Group Health’s Electronic Medical Record (EMR). These notes include those generated internally and those received from partner organizations via electronic interfaces. Recently one of our partners changed its interface from sending formatted text to sending binary PDF files. While this had little effect on clinical users, it made a significant amount of text data inaccessible for computerized processing. This text was crucial to ongoing research, so we needed to find a way to preserve access.

ABCC9 gene polymorphism is associated with hippocampal sclerosis of aging pathology.

Hippocampal sclerosis of aging (HS-Aging) is a high-morbidity brain disease in the elderly but risk factors are largely unknown. We report the first genome-wide association study (GWAS) with HS-Aging pathology as an endophenotype. In collaboration with the Alzheimer's Disease Genetics Consortium, data were analyzed from large autopsy cohorts: (#1) National Alzheimer's Coordinating Center (NACC); (#2) Rush University Religious Orders Study and Memory and Aging Project; (#3) Group Health Research Institute Adult Changes in Thought study; (#4) University of California at Irvine 90+ Study; and (#5) University of Kentucky Alzheimer's Disease Center. Altogether, 363 HS-Aging cases and 2,303 controls, all pathologically confirmed, provided statistical power to test for risk alleles with large effect size. A two-tier study design included GWAS from cohorts #1-3 (Stage I) to identify promising SNP candidates, followed by focused evaluation of particular SNPs in cohorts #4-5 (Stage II). Polymorphism in the ATP-binding cassette, sub-family C member 9 (ABCC9) gene, also known as sulfonylurea receptor 2, was associated with HS-Aging pathology. In the meta-analyzed Stage I GWAS, ABCC9 polymorphisms yielded the lowest p values, and factoring in the Stage II results, the meta-analyzed risk SNP (rs704178:G) attained genome-wide statistical significance (p=1.4×10(-9)), with odds ratio (OR) of 2.13 (recessive mode of inheritance). For SNPs previously linked to hippocampal sclerosis, meta-analyses of Stage I results show OR=1.16 for rs5848 (GRN) and OR=1.22 rs1990622 (TMEM106B), with the risk alleles as previously described. Sulfonylureas, a widely prescribed drug class used to treat diabetes, also modify human ABCC9 protein function. A subsample of patients from the NACC database (n=624) were identified who were older than age 85 at death with known drug history. Controlling for important confounders such as diabetes itself, exposure to a sulfonylurea drug was associated with risk for HS-Aging pathology (p=0.03). Thus, we describe a novel and targetable dementia risk factor.

NIMH Fosters ‘Practice-Ready’ Solutions to Integrating Primary, MH Care

Research at the interface of mental health and primary care should focus on generating knowledge that decision makers need and incorporating practice-based evidence.

Population Health Management and the Journey to Medical Home Certification in a Rural Community

WHY ADOPT POPULATION HEALTH MANAGEMENT?Population health management has been the focus of many studies and articles as a critical strategy for success as the healthcare delivery system changes in response to government regulations and insurance industry shifts. It also is frequently cited as a tool to manage costs. Zenty and Bieber's feature article discusses how University Hospitals Health System's (UH) population health management initiative evolved through the experience of its various accountable care organizations (ACOs), which were formed to address the rising costs of their self-insured plans.In the other feature article for this issue, Kindig and Isham discuss the need to improve the health of our communities and close the lag in health outcomes across the United States compared to most developed countries. I believe their message that the challenge of population health improvement cannot be the sole responsibility of the healthcare industry is critical to understanding how we move forward.A recent article in the Journal of the American Medical Association, by Friedberg and colleagues (2014), complicates this discussion, however. Those authors suggest that the care offered in a patient-centered medical home (PCMH) environment, which is designed to coordinate resources to improve patient care, offers little benefit to the outcomes experienced by the patient or in reducing the cost of care. One might conclude from Friedberg and colleagues' findings that if a PCMH or another population health management tool produces no cost management or patient outcome benefits, why invest in the effort?These authors directly or indirecuy link population health management to the Triple Aim as articulated by the Institute for Healthcare Improvement (IHI): improvement of individuals' experience of care, improvement of the health of populations, and reduction of per capita cost of care for populations. Of these, in my opinion, that improvement of the individual experience of care could be the most significant factor influencing the achievement of health improvement and, eventually, cost management.The Perspective of a Critical Access Hospital/Rural Health ClinicYuma District Hospital and Clinics (YDHC) consists of a 12-bed critical access hospital and two rural health clinics offering family medicine, a specialty clinic that brings a variety of medical and surgical specialists to the community throughout the month, and a PhD-degreed psychologist and licensed professional counselor. We offer post-acute care through our swing-bed program and a home health agency. Our ten primary care providers are employees of the organization. Consider us a micro-integrated healthcare delivery system serving a population of approximately 14,000 people spread across a wide geographic area.In 2008, YDHC was invited to participate in an initiative led by the Commonwealth Fund, Qualis Health, and the MacCoil Center for Health Care Innovation at the Group Health Research Institute. The objective of the initiative was to develop and demonstrate a sustainable model to transform primary care safety net practices into PCMHs, thereby achieving the IHI Triple Aim goals. (For more detail about the initiative, refer to www.safetynet medicalhome.org.) We eagerly agreed to participate, with the simple thought that this would be a tool to improve patient care in our rural health clinic. The timing seemed right: We had recently moved into a newly constructed replacement facility to house our hospital and our main clinic, and we were midway through the rebuilding of our medical staff. It was our feeling that this would not be a long journey and that the care provided in our facilities was already close to that of a medical home environment. It did not take long for us to realize that we were just beginning.At the same time as we were moving forward with this initiative, we were faced with a population of patients who believed that their experience of care was not satisfactory. …

Health Care for Chronic Pain

Group Health Research Institute, Seattle, WA Supported by National Institute on Aging Grant: R01 AG034181. Dr Von Korff has a research grant from Pfizer Inc. Reprints: Michael R. Von Korff, ScD, Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle WA, 98101. E-mail: [email protected].

The Placebo Effect: A Conversation With Dr Irving Kirsch.

The Placebo Effect: A Conversation With Dr Irving Kirsch.

CA8-04: Health Plan Implementation of a Major Risk Mitigation Initiative for Chronic Opioid Therapy

Background/Aims Increased opioid prescribing for chronic non-cancer pain has been accompanied by large increases in prescription opioid abuse and overdose. In April 2011, when the US government initially outlined a plan of action to stem a national epidemic of prescription drug abuse, Group Health (GH) had already implemented a major initiative to increase opioid prescribing safety. Group Health Research Institute had been conducting NIH-funded research on Chronic Opioid Therapy (COT). This research had shown rapid growth in COT prescribing and significant dose-related risks.

PS1-59: Collecting Biomedical Specimens in Health Research

Survey research organizations are increasingly being tasked with obtaining consent and, in some cases, collecting biological specimens from potential respondents. In order to obtain high response rates in these types of studies, it is crucial that survey methodologists investigate best practices to improve response in the collection of these types of data. Under what circumstances are participants willing to consent to these procedures? What methods can be utilized to best facilitate the collection of these types of data? This poster reviews outcomes from multiple studies conducted by the Survey Research Program at Group Health Research Institute, which required the collection of various biological specimens. Recruitment procedures, methodologies for obtaining consent, response rates, characteristics of participants and non-participants, and recommendations for best practices are discussed.

Learning Health Care Systems: Leading Through Research: The 18th Annual HMO Research Network Conference, April 29-May 2, 2012, Seattle, Washington

The Health Maintenance Organization Research Network (HMORN), a consortium of 19 health care delivery systems with integrated research centers, held their 18th annual conference in Seattle, Washington from April 29 to May 2, 2012. Group Health Research Institute hosted the conference, "Learning health care systems: Leading through research". The 2012 theme was chosen to reflect the critical role of collaboration among researchers, clinicians and health systems to improve health care nationally. Over 500 researchers and health care professionals participated in this conference. Representatives from the NCI, NHLBI, NIMH, and PCORI met with researchers to advance the quality and breadth of public domain research in HMOs. In this article we summarize information about the HMORN and its 18th annual conference.

Evaluating the Kaiser Permanente Community Fund's Social Determinants of Health Portfolio

Keywords: Social determinants of health, logic models, equity, Pacific NorthwestIntroductionHealth begins where we live, work, learn and play - long before any clinical intervention is required to treat disease or injury.- Northwest Health FoundationThe concept of the social determinants of health (SDOH) has been widely embraced within the public health community. Research over the past two decades repeatedly demonstrates the relationship between poor health outcomes and socioeconomic factors such as poor housing, unsafe work environments, poor education, social exclusion, poverty, racism, and structural inequity (Krieger, 1994; Marmot & Wilkinson, 1999; Williams, Costa, Odunlami, & Mohammed, 2008; Commission on the Social Determinants of Health, 2008; Centers for Disease Control and Prevention, 2011). Despite this evidence, few community-based health foundations have taken the opportunity to invest in the social determinants of health.Addressing the social determinants of health is a challenge for two reasons. One is that societal conditions have evolved over generations; as a result, problems such as poverty, racism, and social exclusion cannot be mitigated, much less solved, through short-term investments. The second challenge is the long lag time between changes in social determinants and corresponding health outcomes. This delay means that scalable best practices are still largely theoretical (Bramba et al., 2010).BackgroundIn late 2004, Kaiser Permanente Northwest established the Kaiser Permanente Community Fund within the Northwest Health Foundation (NWHF) with a $28 million gift. In 2006, the fund advisors took the bold and strategic step of investing in improvements to the social determinants of health. In order to improve the impact of the fund, key leaders at the NWHF and Kaiser Permanente Northwest made a commitment to continuous learning based on their own experiences and those of community partners. As part of this commitment, NWHF commissioned the Center for Community Health and Evaluation (CCHE), part of Group Health Research Institute in Seattle, Wash., to retrospectively evaluate the first five years of the fund's grantmaking (2005-2009).In this article we present an overview of the Kaiser Permanente Community Fund's SDOH initiative and its theory of change. We then introduce the frameworks and methods we used to conduct our evaluation. In the findings section we summarize the accomplishments of the initiative and grantee success factors. We conclude the article by imparting the lessons learned during and from the evaluation. We believe these lessons will be helpful to other foundations and funders interested in interventions and initiatives focused on social determinants of health.Development of the InitiativeThe fund is based at the Northwest Health Foundation in Portland, Ore. In 2005, the fund invited and funded proposals to advance health equity and promote cultural competency in health care. Although some of the fund's 2005 grantees were already addressing social determinants, the following year, the fund's advisory board and NWHF staffmade a commitment to focus grantmaking on social determinants of health. They believed this refined strategy offered the greatest opportunity to improve community health. A survey of the local philanthropic landscape revealed a significant gap in upstream community health initiatives. The fund focused on determinants as diverse as economic opportunity, public safety, civic engagement, and early education as avenues for long-term health improvements.The fund is governed by an advisory board comprised of six representatives of different constituencies within the Kaiser Permanente system and five representatives from the broader community. Community representatives have worked in a variety of areas, including housing, economic development, public health, and advocacy for social equity. Advisors and NWHF staffjointly develop requests for proposals, outreach strategies, and criteria for selecting proposals that are most likely to achieve sustained community impact. …

Comparative Effectiveness of Digital Versus Film-Screen Mammography

Letters7 February 2012Comparative Effectiveness of Digital Versus Film-Screen MammographyKarla Kerlikowske, MD and Rebecca Hubbard, PhDKarla Kerlikowske, MDFrom San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, and Group Health Research Institute, Seattle, WA 98101-1448.Search for more papers by this author and Rebecca Hubbard, PhDFrom San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, and Group Health Research Institute, Seattle, WA 98101-1448.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-156-3-201202070-00024 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We compared the interpretative performance of digital versus film-screen mammography in community practice and were reassured to find that no subgroups of women have substantially worse performance with either modality. In fact, digital mammography tended to perform as well or slightly better in most subgroups. Dr. Keen suggests that if we had taken use of computer-aided detection into account, we would have found less favorable performance results for digital compared with film-screen mammography because computer-aided detection is widely used to interpret digital mammograms. Computer-aided detection was more commonly used for digital than for film-screen mammography (56% vs. 23%) ...