Integrated Health Care Delivery System Research Articles

Comparison of Short-Term Health Care Utilization Between Telemedicine-Delivered vs In-Person Care Visits for Heart Failure

BackgroundPatients with heart failure (HF) are a medically complex population with frequent hospitalizations. Downstream health care utilization following primary care delivered by telemedicine compared to in-person is unknown. ObjectivesThe purpose of this study was to understand differences in return in-person visits, emergency department (ED) encounters, and hospitalizations following a telemedicine vs an in-person primary care visit for patients with HF seen for a HF-related complaint. MethodsThis was an observational study of all primary care visits for HF from January 1, 2022, to December 31, 2022, in an integrated health care delivery system. We compared 7-day in-person follow-up visits, ED visits, and hospitalizations (all-cause and HF-specific) by index visit type. ResultsWe included 3,902 primary care visits with a primary diagnosis of HF. Most visits utilized telephone or video visits (58.4% total; 44.9% telephone, 13.5% video). After adjustment, telephone visits were associated with more in-person follow-up visits (6.14% vs 4.20%; adjusted OR: 1.08-2.21; P < 0.05) but fewer ED visits (6.12% vs 8.07%; adjusted OR: 0.55-0.97; P < 0.05) compared to in-person visits. Most hospitalized patients (74%) had an admitting diagnosis of HF. There was no difference between 7-day all-cause hospitalization following telephone or video visits compared to in-person visits. ConclusionsMost patients used telemedicine to address HF-specific primary care concerns. Telephone visits were associated with slightly higher short-term in-person primary care follow-up but lower ED utilization. Overall, downstream ED visits and hospitalizations were low. Telephone and video visits appear to offer safe alternatives to in-person care for HF-related primary care and are a promising health care delivery strategy

Retropubic Versus Transobturator Midurethral Slings at Time of Colpocleisis.

This study aimed to evaluate if there is a difference between outcomes when retropubic or transobturator midurethral sling surgery is performed at the time of colpocleisis. The purpose of this study was to compare the surgical outcomes of the retropubic midurethral sling (RP-MUS) versus the transobturator midurethral sling (TO-MUS) in women who underwent concomitant colpocleisis, specifically 2-year MUS failure and 1-year lower urinary tract symptoms (LUTSs). A secondary aim was to identify factors associated with these surgical outcomes. All cases of concomitant MUS and colpocleisis within a closed, integrated health care delivery system were reviewed between April 1, 2010, and March 31, 2020. Postoperative MUS failure was defined as (1) postoperative stress urinary incontinence symptoms and/or (2) additional anti-incontinence surgery. Postoperative LUTSs were defined as (1) MUS lysis and/or (2) overactive bladder requiring management with a new treatment. Of the 558 women included, 454 (81%) received RP-MUS and 104 (19%) received TO-MUS. Cohort demographics were similar. Neither MUS failure (7% RP-MUS and 9% TO-MUS, P = 0.450) nor LUTSs (7% RP-MUS and 12% TO-MUS, P = 0.171) were significantly different between RP-MUS and TO-MUS. In multivariable analysis, age was found to be significantly associated with LUTSs (odds ratio 0.29, 95% confidence interval 0.09-0.93, P = 0.038 among 70-74-year-olds; odds ratio 0.28, 95% confidence interval 0.09-0.83, P = 0.022 among 75-79-year-olds). At the time of colpocleisis, both RP-MUS and TO-MUS were highly successful and associated with a low incidence of LUTSs, including MUS lysis. The findings of this large study support RP-MUS and TO-MUS as similarly effective anti-incontinence options at time of colpocleisis.

Pubertal Timing Across Asian American, Native Hawaiian, and Pacific Islander Subgroups

Earlier puberty is associated with adverse health outcomes, such as mental health issues in adolescence and cardiometabolic diseases in adulthood. Despite rapid growth of the Asian American, Native Hawaiian, and Pacific Islander populations in the US, limited research exists on their pubertal timing, potentially masking health disparities. To examine pubertal timing among Asian American, Native Hawaiian, and Pacific Islander children and adolescents by disaggregating ethnic subgroups. This retrospective cohort study included Asian American, Native Hawaiian, and Pacific Islander youths aged 5 to 18 years assessed for pubertal development at Kaiser Permanente Northern California, a large, integrated health care delivery system. Follow-up occurred from March 2005, through December 31, 2019. Data were analyzed in October 2023. Race and ethnicity, categorized into 11 ethnic subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Native Hawaiian and Pacific Islander, Other South Asian, Other Southeast Asian, Vietnamese, multiethnic, and multiracial. Pubertal timing was determined using physician-assessed sexual maturity ratings (SMRs). Outcomes included the median age at transition from SMR 1 (prepubertal) to SMR 2 or higher (pubertal) for onset of genital development (gonadarche) in boys, breast development (thelarche) in girls, and pubic hair development (pubarche) in both boys and girls. In this cohort of 107 325 Asian American, Native Hawaiian, and Pacific Islander children and adolescents (54.61% boys; 12.96% Asian Indian, 22.24% Chinese, 26.46% Filipino, 1.80% Japanese, 1.66% Korean, 1.96% Native Hawaiian and Pacific Islander, 0.86% Other South Asian, 3.26% Other Southeast Asian, 5.99% Vietnamese, 0.74% multiethnic, and 22.05% multiracial), the overall median ages for girls' pubarche and thelarche were 10.98 years (95% CI, 10.96-11.01 years) and 10.13 years (95% CI, 10.11-10.15 years), respectively. For boys' pubarche and gonadarche, median ages were 12.08 years (95% CI, 12.06-12.10 years) and 11.54 years (95% CI, 11.52-11.56 years), respectively. Differences between subgroups with earliest and latest median age at onset were 14 months for girls' pubarche, 8 months for thelarche, 8 months for boys' pubarche, and 4 months for gonadarche. In general, Asian Indian, Native Hawaiian and Pacific Islander, and Other South Asian subgroups had the earliest ages at onset across pubertal markers, while East Asian youths exhibited the latest onset. Restricting to those with healthy body mass index did not substantially change the findings. In this cohort study of Asian American, Native Hawaiian, and Pacific Islander children and adolescents, pubertal timing varied considerably across ethnic subgroups. Further investigation is warranted to assess whether these differences contribute to observed health disparities in adulthood, such as type 2 diabetes and cardiovascular diseases.

Group Multimodal Prenatal Care and Postpartum Outcomes.

An increasing body of evidence suggests equivalent if not improved postpartum outcomes of in-person group prenatal care compared with individual prenatal care. However, research is needed to evaluate outcomes of group multimodal prenatal care (GMPC), with groups delivered virtually in combination with individual in-person office appointments to collect vital signs and conduct other tests compared with individual multimodal prenatal care (IMPC) delivered through a combination of remotely delivered and in-person visits. To compare postpartum outcomes between GMPC and IMPC. A frequency-matched longitudinal cohort study was conducted at Kaiser Permanente Northern California, an integrated health care delivery system. Participants included 424 individuals who were pregnant (212 GMPC and 212 frequency-matched IMPC controls (matched on gestational age, race and ethnicity, insurance status, and maternal age) receiving prenatal care between August 17, 2020, and April 1, 2021. Participants completed a baseline survey before 14 weeks' gestation and a follow-up survey between 4 and 8 weeks post partum. Data analysis was performed from January 3, 2022, to March 4, 2024. GMPC vs IMPC. Validated instruments were used to ascertain postpartum psychosocial outcomes (stress, depression, anxiety) and perceived quality of prenatal care. Self-reported outcomes included behavioral outcomes (breastfeeding initiation, use of long-acting reversible contraception), satisfaction with prenatal care, and preparation for self and baby care after delivery. Primary analyses included all study participants in the final cohort. Three secondary dose-stratified analyses included individuals who attended at least 1 visit, 5 visits, and 70% of visits. Log-binomial regression and linear regression analyses were conducted. The final analytic cohort of 390 participants (95.6% follow-up rate of 408 singleton live births) was racially and ethnically diverse: 98 (25.1%) Asian/Pacific Islander, 88 (22.6%) Hispanic, 17 (4.4%) non-Hispanic Black, 161 (41.3%) non-Hispanic White, and 26 (6.7%) multiracial participants; median age was 32 (IQR, 30-35) years. In the primary analysis, after adjustment, GMPC was associated with a 21% decreased risk of perceived stress (adjusted risk ratio [ARR], 0.79; 95% CI, 0.67-0.94) compared with IMPC. Findings were consistent in the dose-stratified analyses. There were no significant differences between GMPC and IMPC for other psychosocial outcomes. While in the primary analyses there was no significant group differences in perceived quality of prenatal care (mean difference [MD], 0.01; 95% CI, -0.12 to 0.15) and feeling prepared to take care of baby at home (ARR, 1.09; 95% CI, 0.96-1.23), the dose-stratified analyses documented higher perceived quality of prenatal care (MD, 0.16; 95% CI, 0.01-0.31) and preparation for taking care of baby at home (ARR, 1.27; 95% CI, 1.13-1.43) for GMPC among those attending 70% of visits. No significant differences were noted in patient overall satisfaction with prenatal care and feeling prepared for taking care of themselves after delivery. In this cohort study, equivalent and, in some cases, better outcomes were observed for GMPC compared with IMPC. Health care systems implementing multimodal models of care may consider incorporating virtual group prenatal care as a prenatal care option for patients.

Economic Burden of Acute Gastroenteritis among Members of Integrated Healthcare Delivery System, United States, 2014-2016.

We conducted a large surveillance study among members of an integrated healthcare delivery system in Pacific Northwest of the United States to estimate medical costs attributable to medically attended acute gastroenteritis (MAAGE) on the day care was sought and during 30-day follow-up. We used multivariable regression to compare costs of MAAGE and non-MAAGE cases matched on age, gender, and index time. Differences accounted for confounders, including race, ethnicity, and history of chronic underlying conditions. Analyses included 73,140 MAAGE episodes from adults and 18,617 from children who were Kaiser Permanente Northwest members during 2014-2016. Total costs were higher for MAAGE cases relative to non-MAAGE comparators as were costs on the day care was sought and costs during follow-up. Costs of MAAGE are substantial relative to the cost of usual-care medical services, and much of the burden accrues during short-term follow-up.

Sex-Based Differences in the Epidemiology, Clinical Characteristics, and Outcomes Associated with Worsening Heart Failure Events in a Learning Health System

BackgroundDifferences in demographics, risk factors, and clinical characteristics may contribute to variations in men and women in terms of the prevalence, clinical setting, and outcomes associated with worsening heart failure (WHF) events. We sought to describe sex-based differences in the epidemiology, clinical characteristics, and outcomes associated with WHF events across clinical settings. Methods and ResultsWe examined adults diagnosed with HF from 2010 to 2019 within a large, integrated health care delivery system. Electronic health record data were accessed for hospitalizations, emergency department (ED) visits and observation stays, and outpatient encounters. WHF was identified using validated natural language processing algorithms and defined as ≥1 symptom, ≥2 objective findings (including ≥1 sign), and ≥1 change in HF-related therapy. Incidence rates and associated outcomes for WHF were compared across care setting by sex. We identified 1,122,368 unique clinical encounters with a diagnosis code for HF, with 124,479 meeting WHF criteria. These WHF encounters existed among 102,116 patients, of whom 48,543 (47.5%) were women and 53,573 (52.5%) were men. Women experiencing WHF were older and more likely to have HF with preserved ejection fraction compared with men. The clinical settings of WHF were similar among women and men: hospitalizations (36.8% vs 37.7%), ED visits or observation stays (11.8% vs 13.4%), and outpatient encounters (4.4% vs 4.9%). Women had lower odds of 30-day mortality after an index hospitalization (adjusted odds ratio 0.88, 95% confidence interval 0.83–0.93) or ED visit or observation stay (adjusted odds ratio 0.86, 95% confidence interval 0.75–0.98) for WHF. ConclusionsWomen and men contribute similarly to WHF events across diverse clinical settings despite marked differences in age and left ventricular ejection fraction.

Long-Term Risk of Reintervention After Surgical Leiomyoma Treatment in an Integrated Health Care System.

To compare long-term risk of reintervention across four uterus-preserving surgical treatments for leiomyomas and to assess effect modification by sociodemographic factors in a prospective cohort study in an integrated health care delivery system. We studied a cohort of 10,324 patients aged 18-50 (19.9% Asian, 21.2% Black, 21.3% Hispanic, 32.5% White, 5.2% additional races and ethnicities) who had a first uterus-preserving procedure (abdominal, laparoscopic, or vaginal myomectomy [referred to as myomectomy]; hysteroscopic myomectomy; endometrial ablation; uterine artery embolization) after leiomyoma diagnosis in the 2009-2021 electronic health records of Kaiser Permanente Northern California. We followed up patients until reintervention (second uterus-preserving procedure or hysterectomy) or censoring. We used a Kaplan-Meier estimator to calculate the cumulative incidence of reintervention and Cox regression models to estimate hazard ratios and 95% CIs comparing rates of reintervention across procedures, adjusting for age, parity, race and ethnicity, body mass index (BMI), Neighborhood Deprivation Index, and year. We also assessed effect modification by demographic characteristics. Median follow-up was 3.8 years (interquartile range 1.8-7.4 years). Index procedures were 18.0% (1,857) hysteroscopic myomectomies, 16.2% (1,669) uterine artery embolizations, 21.4% (2,211) endometrial ablations, and 44.4% (4,587) myomectomies. Accounting for censoring, the 7-year reintervention risk was 20.6% for myomectomy, 26.0% for uterine artery embolization, 35.5% for endometrial ablation, and 37.0% for hysteroscopic myomectomy; 63.2% of reinterventions were hysterectomies. Within each procedure type, reintervention rates did not vary by BMI, race and ethnicity, or Neighborhood Deprivation Index. However, rates of reintervention after uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy decreased with age, and reintervention rates for hysteroscopic myomectomy were higher for parous than nulliparous patients. Long-term reintervention risks for uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy are greater than for myomectomy, with potential variation by patient age and parity but not BMI, race and ethnicity, or Neighborhood Deprivation Index.

Validation of a Multivariable Model to Predict Suicide Attempt in a Mental Health Intake Sample

Given that suicide rates have been increasing over the past decade and the demand for mental health care is at an all-time high, targeted prevention efforts are needed to identify individuals seeking to initiate mental health outpatient services who are at high risk for suicide. Suicide prediction models have been developed using outpatient mental health encounters, but their performance among intake appointments has not been directly examined. To assess the performance of a predictive model of suicide attempts among individuals seeking to initiate an episode of outpatient mental health care. This prognostic study tested the performance of a previously developed machine learning model designed to predict suicide attempts within 90 days of any mental health outpatient visit. All mental health intake appointments scheduled between January 1, 2012, and April 1, 2022, at Kaiser Permanente Northern California, a large integrated health care delivery system serving over 4.5 million patients, were included. Data were extracted and analyzed from August 9, 2022, to July 31, 2023. Suicide attempts (including completed suicides) within 90 days of the appointment, determined by diagnostic codes and government databases. All predictors were extracted from electronic health records. The study included 1 623 232 scheduled appointments from 835 616 unique patients. There were 2800 scheduled appointments (0.17%) followed by a suicide attempt within 90 days. The mean (SD) age across appointments was 39.7 (15.8) years, and most appointments were for women (1 103 184 [68.0%]). The model had an area under the receiver operating characteristic curve of 0.77 (95% CI, 0.76-0.78), an area under the precision-recall curve of 0.02 (95% CI, 0.02-0.02), an expected calibration error of 0.0012 (95% CI, 0.0011-0.0013), and sensitivities of 37.2% (95% CI, 35.5%-38.9%) and 18.8% (95% CI, 17.3%-20.2%) at specificities of 95% and 99%, respectively. The 10% of appointments at the highest risk level accounted for 48.8% (95% CI, 47.0%-50.6%) of the appointments followed by a suicide attempt. In this prognostic study involving mental health intakes, a previously developed machine learning model of suicide attempts showed good overall classification performance. Implementation research is needed to determine appropriate thresholds and interventions for applying the model in an intake setting to target high-risk cases in a manner that is acceptable to patients and clinicians.

Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management.

Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation. The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status. This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI. Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% (P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures (P = 0.01). When controlling for age, no clinically significant difference was demonstrated. Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.

Rising Trends of Childhood Attention-Deficit/Hyperactivity Disorder in a Large Integrated Healthcare Delivery System in Southern California, 2010-2021

ObjectiveTo evaluate trends of attention-deficit/hyperactivity disorder (ADHD) diagnosis rates among children aged 5-17 years over the past decade (2010-2021) and to investigate whether there have been differences in temporal changes based on race and ethnicity, sex, or income Study designChildhood ADHD diagnosis was ascertained from electronic health records using ICD-9 (314.xx) and ICD-10 (F90.x) codes. Data were stratified by child’s sex, race and ethnicity, and household income, and rates of ADHD were estimated before and after adjustment for potential confounders. ResultsThe overall ADHD diagnosis rates increased from 3.5% in 2010 to 4.0% in 2021. ADHD diagnosis was most prevalent among White children (6.1%), then Black (4.6%), Other/multiple (3.7%), Hispanic (3.1%), and Asian/Pacific Islander (PI) (1.7%). ADHD was also highly prevalent among boys (73.3%) or family income≥$70,000 (50.0%). ADHD diagnosis increased among Black (4.2% to 5.1%), Hispanic (2.8% to 3.6%) ,and Asian/PI children (1.5% to 2.0%) but remained stable for White (6.2% to 6.1%) and Other/multiple race/ethnic children (3.7% to 3.7%). Increases in the prevalence among girls were also observed. ConclusionThe prevalence of ADHD in children has risen with the largest increases observed for Black, Hispanic, and Asian/PI children. Rates among less affluent families and girls have also been increasing, narrowing the gaps in diagnosis rates previously observed. These increases may reflect improvements in screening and provision of care among demographics where ADHD has been historically underdiagnosed.

Association Between Cardiovascular Health Status and Healthcare Utilization in a Large Integrated Healthcare System

IntroductionThe American Heart Association (AHA) “Life's Simple 7” schema can be used to categorize patients’ cardiovascular health (CVH) status as Poor, Intermediate or Ideal based on smoking, body mass index (BMI), physical activity, dietary patterns, blood pressure, cholesterol, and fasting blood sugar. This study examined the association between CVH status and subsequent healthcare utilization. MethodsThis was an observational cohort study of adults from an integrated health care delivery system – Kaiser Permanente Northern California – that had outpatient care between 2013-2014. Patients were categorized by AHA CVH status: Poor, Intermediate or Ideal. Individual-level health care utilization and costs in 2015 were accumulated for each patient and compared across the 3 CVH categories and stratified by age groups. Results991,698 patients were included in the study. 194,003 (19.6%) were age 18-39, 554,129 (55.9%) age 40-64, and 243,566 (24.6%) age ≥65 years. 259,931 (26.2%) had Ideal CVH, 521,580 (52.6%) had Intermediate CVH, and 210,187 (21.2%) had Poor CVH. Healthcare utilization measured by average relative cost per patient increased monotonically across age categories (p<0.001). In addition, CVH category was inversely associated with lower cost in each age group (p<0.001). ConclusionAdults who were younger and had more ideal CVH had relatively lower health care costs across age groups. Interventions to promote better CVH may improve patient outcomes and reduce overall healthcare expenditures.

Care Partner Engagement in Secure Messaging Between Patients With Diabetes and Their Clinicians: Cohort Study.

Patient engagement with secure messaging (SM) via digital patient portals has been associated with improved diabetes outcomes, including increased patient satisfaction and better glycemic control. Yet, disparities in SM uptake exist among older patients and racial and ethnic underserved groups. Care partners (family members or friends) may provide a means for mitigating these disparities; however, it remains unclear whether and to what extent care partners might enhance SM use. We aim to examine whether SM use differs among older patients with diabetes based on the involvement of care partner proxies. This is a substudy of the ECLIPPSE (Employing Computational Linguistics to Improve Patient-Provider Secure Emails) project, a cohort study taking place in a large, fully integrated health care delivery system with an established digital patient portal serving over 4 million patients. Participants included patients with type 2 diabetes aged ≥50 years, newly registered on the patient portal, who sent ≥1 English-language message to their clinician between July 1, 2006, and December 31, 2015. Proxy SM was identified by having a registered proxy. To identify nonregistered proxies, a computational linguistics algorithm was applied to detect words and phrases more likely to appear in proxy messages compared to patient-authored messages. The primary outcome was the annual volume of secure messages (sent or received); secondary outcomes were the length of time to the first SM sent by patient or proxy and the number of annual SM exchanges (unique message topics generating ≥1 reply). The mean age of the cohort (N=7659) at this study's start was 61 (SD 7.16) years; 75% (n=5573) were married, 15% (n=1089) identified as Black, 10% (n=747) Chinese, 12% (n=905) Filipino, 13% (n=999) Latino, and 30% (n=2225) White. Further, 49% (n=3782) of patients used a proxy to some extent. Compared to nonproxy users, proxy users were older (P<.001), had lower educational attainment (P<.001), and had more comorbidities (P<.001). Adjusting for patient sociodemographic and clinical characteristics, proxy users had greater annual SM volume (20.7, 95% CI 20.2-21.2 vs 10.9, 95% CI 10.7-11.2; P<.001), shorter time to SM initiation (hazard ratio vs nonusers: 1.30, 95% CI 1.24-1.37; P<.001), and more annual SM exchanges (6.0, 95% CI 5.8-6.1 vs 2.9, 95% CI 2.9-3.0, P<.001). Differences in SM engagement by proxy status were similar across patient levels of education, and racial and ethnic groups. Among a cohort of older patients with diabetes, proxy SM involvement was independently associated with earlier initiation and increased intensity of messaging, although it did not appear to mitigate existing disparities in SM. These findings suggest care partners can enhance patient-clinician telecommunication in diabetes care. Future studies should examine the effect of care partners' SM involvement on diabetes-related quality of care and clinical outcomes.

Evaluation of an outreach programme for patients with COVID-19 in an integrated healthcare delivery system: a retrospective cohort study

ObjectivesIn the first year of the COVID-19 pandemic, health systems implemented programmes to manage outpatients with COVID-19. The goal was to expedite patients’ referral to acute care and prevent overcrowding...

Advanced care at home at scale in an integrated health care system.

To assess the feasibility of scaling advanced care at home (ACAH) (otherwise known as hospital at home) within an integrated health care delivery system. Retrospective cohort study of patients qualified for hospital-level care who were admitted to either ACAH or a traditional hospital. From April 29, 2020, to November 14, 2021, patients requiring hospital-level care received Kaiser Permanente at Home or traditional hospital care. In a subgroup of patients, we compared outcomes for Kaiser Permanente at Home vs traditional hospital care using regression models. A total of 1005 patients were admitted to Kaiser Permanente at Home. Average daily census (ADC) was intentionally increased over time in stages, from 7.2 to 8.8, then to 12.7. The maximum daily census was 22, with a peak ADC of 16, representing 9% of the total hospital inpatient medicine service census. During this time, there were numeric decreases in Kaiser Permanente at Home escalation rates (17.5% to 10.8%), median length of stay (7.43 days to 5.46 days), and readmission rates (9.79% to 9.24%). A subgroup of Kaiser Permanente at Home patients contributed to the comparative analyses, which showed that patients admitted to Kaiser Permanente at Home were 64% less likely to experience delirium than patients admitted for traditional hospital care (OR, 0.36; 95% CI, 0.15-0.88; P = .026). Comparisons of quality metrics across stages of implementation (readmissions, escalations, length of stay) were inconclusive. In an integrated delivery system, ACAH care can be scaled and can create hospital capacity. However, our data were inconclusive regarding quality throughout scaling due to the small effective sample size, necessitating replication in a larger prospective study with adequate power/precision.

Eligibility and Potential Benefit of Transcatheter Edge-to-Edge Repair in a Contemporary Cohort With Heart Failure: Evidence From a Large Integrated Health Care Delivery System

BackgroundThe eligibility and potential benefit of transcatheter edge-to-edge repair (TEER) in addition to guideline-directed medical therapy to treat moderate-severe or severe secondary mitral regurgitation (MR) has not been reported in a contemporary heart failure (HF) population. MethodsEligibility for TEER based on Food and Drug Administration (FDA) labeling: (1) HF symptoms, (2) moderate-severe or severe MR, (3) left ventricular ejection fraction (LVEF) 20% to 50%, (4) left ventricular end-systolic dimension 7.0 cm, and (5) receiving GDMT (blocker + angiotensin-converting enzyme inhibitor/angiotensin receptor blocker). The proportion (%) of patients eligible for TEER. The hypothetical number needed to treat to prevent or postpone adverse outcomes was estimated using relative risk reductions from published hazard ratios in the registration trial and the observed event rates. ResultsWe identified 50,841 adults with HF and known LVEF. After applying FDA criteria, 2461 patients (4.8%) were considered eligible for transcatheter mitral valve replacement (FDA+), with the vast majority of patients excluded (FDA-) based on a lack of clinically significant MR (N = 47,279). FDA+ patients had higher natriuretic peptide levels and were more likely to have a prior HF hospitalization compared to FDA- patients. Although FDA+ patients had a more dilated left ventricle and lower LVEF, median (25th-75th) left ventricular end-systolic dimension (cm) was low at 4.4 (3.7-5.1) and only 30.8% had severely reduced LVEF. FDA+ patients were at higher risk of HF-related morbidity and mortality. The estimated number needed to treat to potentially prevent or postpone all-cause hospitalization was 4.4, 8.8 for HF hospitalization, and 5.3 for all-cause death at 24 months in FDA+ patients. ConclusionsThere is a low prevalence of TEER eligibility based on FDA criteria primarily due to absence of moderate-severe or severe MR. FDA+ patients are a high acuity population and may potentially derive a robust clinical benefit from TEER based on pivotal studies. Additional research is necessary to validate the scope of eligibility and comparative effectiveness of TEER in real-world populations.

Household Transmission of Viral Acute Gastroenteritis Among Participants Within an Integrated Health Care Delivery System, 2014-2016.

While enteric viruses are highly transmissible, household factors associated with transmission are less well documented. We identified individual- and household-level factors associated with viral acute gastroenteritis (AGE) transmission in a large health care network in the United States. Patients presenting with AGE were enrolled from April 2014 to September 2016. Patients and symptomatic household members were interviewed, and stool specimens were collected and tested for viral pathogens. Within a household, primary cases were those with the earliest symptom onset and a positive viral test result; secondary cases were household contacts (HHCs) with symptom onset 1-7 days from the primary case onset. Transmission households had at least 1 secondary case. Our analysis included 570 primary cases with 1479 HHCs. The overall secondary attack rate was 23%. HHCs were likely to become secondary cases (n = 338) if they were <5 years old (adjusted odds ratio [aOR], 1.8; 95% CI, 1.2-2.6). Secondary transmission was likely to occur if the primary case was aged <5 years (aOR, 2.2; 95% CI, 1.4-3.6) or 5 to 17 years (aOR, 3.3; 95% CI, 1.9-5.7), was norovirus positive (aOR, 2.7; 95% CI, 1.9-3.7), had a diapered contact (aOR: 2.2, 95% CI: 1.6-3.2), or reported symptoms for >4 days (aOR, 1.5; 95% CI, 1.1-2.1). Households with ≥3 members (aOR, 2.1; 95% CI, 1.1-4.5) were more likely to experience transmission. Risk of AGE transmission within households increased if the primary case was younger, was norovirus positive, had a longer symptom duration, or had a diapered contact. Targeted prevention messaging around appropriate cleaning, disinfection, and isolation of persons with AGE should be encouraged.

Glycemic variability and dementia risk in a diverse cohort of older adults with type 2 diabetes

AbstractBackgroundType 2 diabetes is associated with a two‐fold increase in dementia risk. Although glycemic variability is becoming increasingly recognised as contributing to end‐organ damage, less is known about its contribution to dementia risk. We aimed to study the association between HbA1c variability and dementia risk in a large, diverse sample of people in Northern California.MethodOver 209,000 members of a fully integrated health care delivery system with type 2 diabetes aged ≥ 50 years were followed from 1996 to 2018 to obtain repeated measures of HbA1c, dementia diagnoses, and comorbidities. Variability was measured using standard deviation (SD), coefficient of variation, and average real variability. Cox proportional hazards models estimated the association between HbA1c variability in the first 3 years of cohort entry and incident dementia at least 2 years after the end of the exposure period adjusting for age (as timescale) and baseline health conditions.ResultThere were a total of 209,703 people in the cohort (mean baseline age 61.0 years (SD = 9.2), 47.5% women) (Table1). Approximately 49.6% of the sample were non‐Latino White. The mean number of HbA1c values available for each participant was 5.8 (SD = 2.3). The mean HbA1c for each participant in the first 3 years was 7.4% (SD = 1.33). Greater HbA1c variability was associated with greater hazard of dementia when measured using SD (aHR = 1.12 [95%CI: 1.10, 1.14]), coefficient of variation (aHR = 2.17 [95%CI: 1.85, 2.55]) (Figure1), or average real variability (aHR = 1.06 [95%CI: 1.06, 1.07]). When stratified by mean HbA1c, we found that ‐ relative to the lowest quintile of variation ‐ increasing variability of SD of HbA1c was associated with greater hazard of dementia in HbA1c categories of &lt;6% (p = 0.0004) and 6 ‐8% (p&lt;0.0001) but not in those with a mean HbA1c ≥8% (p = 0.42).ConclusionGreater HbA1c variability is associated with greater dementia hazard in those with good glycemic control. The absence of association in less well controlled (HbA1c ≥8%) patients may stem from greater variability including lower risk periods of optimal glycemic control. These results support current clinical recommendations to minimize glycemic variability and extend known benefits to include lowering of dementia risk.

Strategies to Increase Cervical Cancer Screening With Mailed Human Papillomavirus Self-Sampling Kits

Optimal strategies for increasing cervical cancer screening may differ by patient screening history and health care setting. Mailing human papillomavirus (HPV) self-sampling kits to individuals who are overdue for screening increases adherence; however, offering self-sampling kits to screening-adherent individuals has not been evaluated in the US. To evaluate the effectiveness of direct-mail and opt-in approaches for offering HPV self-sampling kits to individuals by cervical cancer screening history (screening-adherent and currently due, overdue, or unknown). Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Individuals aged 30 to 64 years with female sex, a primary care clinician, and no hysterectomy were identified through electronic health records (EHRs) and enrolled between November 20, 2020, and January 28, 2022, with follow-up through July 29, 2022. Individuals stratified as due (eg, at the time of randomization, these individuals have been previously screened and are due for their next screening in ≤3 months) were randomized to receive usual care (patient reminders and clinician EHR alerts [n = 3671]), education (usual care plus educational materials about screening [n = 3960]), direct mail (usual care plus educational materials and a mailed self-sampling kit [n = 1482]), or to opt in (usual care plus educational materials and the option to request a kit [n = 3956]). Individuals who were overdue for screening were randomized to receive usual care (n = 5488), education (n = 1408), or direct mail (n = 1415). Individuals with unknown history for screening were randomized to receive usual care (n = 2983), education (n = 3486), or to opt in (n = 3506). The primary outcome was screening completion within 6 months. Primary analyses compared direct-mail or opt-in participants with individuals randomized to the education group. The intention-to-treat analyses included 31 355 randomized individuals (mean [SD] age, 45.9 [10.4] years). Among those who were due for screening, compared with receiving education alone (1885 [47.6%]), screening completion was 14.1% (95% CI, 11.2%-16.9%) higher in the direct-mail group (914 [61.7%]) and 3.5% (95% CI, 1.2%-5.7%) higher in the opt-in group (2020 [51.1%]). Among individuals who were overdue, screening completion was 16.9% (95% CI, 13.8%-20.0%) higher in the direct-mail group (505 [35.7%]) compared with education alone (264 [18.8%]). Among those with unknown history, screening was 2.2% (95% CI, 0.5%-3.9%) higher in the opt-in group (634 [18.1%]) compared with education alone (555 [15.9%]). Within a US health care system, direct-mail self-sampling increased cervical cancer screening by more than 14% in individuals who were due or overdue for cervical cancer screening. The opt-in approach minimally increased screening. To increase screening adherence, systems implementing HPV self-sampling should prioritize direct-mail outreach for individuals who are due or overdue for screening. For individuals with unknown screening history, testing alternative outreach approaches and additional efforts to document screening history are warranted. ClinicalTrials.gov Identifier: NCT04679675.

Gaps in guideline-recommended anticoagulation in patients with atrial fibrillation and elevated thromboembolic risk within an integrated healthcare delivery system

BackgroundAtrial Fibrillation (AF) is the leading cause of stroke, which can be reduced by 70% with appropriate oral anticoagulation (OAC) therapy. Nationally, appropriate anticoagulation rates for patients with AF with elevated thromboembolic risk are as low as 50% even across the highest stroke risk cohorts. This study aims to evaluate the variability of appropriate anticoagulation rates among patients by sex, ethnicity, and socioeconomic status within the Kaiser Permanente Mid-Atlantic States (KPMAS).MethodsThis retrospective study investigated 9513 patients in KPMAS’s AF registry with CHADS2 score ≥ 2 over a 6-month period in 2021.ResultsAppropriately anticoagulated patients had higher rates of diabetes, prior stroke, and congestive heart failure than patients who were not appropriately anticoagulated. There were no significant differences in anticoagulation rates between males and females (71.8% vs. 71.6%%, [OR] 1.01; 95% CI, 0.93-1.11; P = .76) nor by SES-SVI quartiles. There was a statistically significant difference between Black and White patients (70.8% vs. 73.1%, P = .03) and Asian and White patients (68.3% vs. 71.6%, P = .005). After adjusting for CHADS2, this difference persisted for Black and White participants with CHADS2 scores of ≤3 (62.6% vs. 70.6%, P < .001) and for Asian and White participants with CHADS2 scores > 5 (68.0% vs. 79.3%, P < .001).ConclusionsBlack and Asian patients may have differing rates of appropriate anticoagulation when compared with White patients. Characterizing such disparities is the first step towards addressing treatment gaps in AF.

Travel Burden to Cancer Screening and Treatment Facilities Among Washington Women: Data From an Integrated Healthcare Delivery System

Purpose To characterize distance traveled for breast cancer screening and to sites of service for breast cancer treatment, among rural and urban women served by a Washington State healthcare network. Methods Data for this study came from one of the largest not-for-profit integrated healthcare delivery systems in Washington State. Generalized linear mixed models with gamma log link function were used to examine the associations between travel distance and sociodemographic and contextual characteristics of patients. Results Median travel distance for breast cancer screening facilities, hematologist/oncologists, radiation oncologists, or surgeons was 11, 19, 23, or 11 miles, respectively. Travel distance to breast cancer screening or referral facilities was longer in non-core metropolitan ZIP codes compared to metropolitan ZIP codes. AI/AN and Hispanic women travelled longer distances to reach referral facilities compared to other racial and ethnic groups. Conclusion Disparities exist in travel distance to breast cancer screening and treatment. Further research is needed to describe sociodemographic and system level characteristics that contribute to such disparities and to discover novel approaches to alleviate this burden.