Integrated Health Care Delivery System Research Articles

Maternal Depression and Antidepressant Use During Pregnancy and Associations with Depressive Symptoms and Suicidality in Adolescent Children.

Children of mothers with prenatal depression have elevated risk for depression later in life. Pregnant women are hesitant to use antidepressants due to fear of adverse fetal effects. To inform prevention, this study examined associations between maternal prenatal depression and antidepressant use, and adolescent depressive symptoms and suicidality. Prospective data from 74,695 mother-adolescent dyads from the Kaiser Permanente Northern California integrated healthcare delivery system were used. Three prenatal exposure groups were examined: maternal depression and antidepressants (Med); depression and no antidepressants (No-Med); neither depression nor antidepressants (NDNM). Adolescent depressive symptoms (Patient Health Questionnaire-2 score ≥3) and suicidality were assessed for 12- to 18-year-olds. Associations were analyzed using mixed effects logistic regression, adjusted for confounders. Maternal prenatal depression was associated with higher odds of adolescent depressive symptoms (Med odds ratio [OR]: 1.50, 95% confidence interval [CI]: 1.23-1.84; No-Med OR: 1.59, CI: 1.34-1.88) and suicidality (Med OR: 2.36, CI: 1.67-3.34; No-Med OR: 1.54, CI: 1.10-2.14) compared to no prenatal depression (NDNM). Adolescents exposed to prenatal depression and antidepressants were not at greater odds of depressive symptoms (Med OR: 0.95, CI: 0.74-1.21) compared to those not exposed to antidepressants (No-Med). However, they showed non-significant but greater odds of suicidality (Med OR: 1.54, CI: 0.99-2.39). Our findings suggest that maternal prenatal depression is associated with adolescent depressive symptoms and suicidality, and that exposure to antidepressants in utero does not increase risk of depressive symptoms, specifically. While not statistically significant, the increased odds of suicidality among adolescents exposed to antidepressants suggest a possible association; however, further investigation is needed. After replication, the findings of this study may inform shared clinical decision-making when considering options regarding antidepressant use for the treatment of maternal prenatal depression.

Social Risks, Social Needs, and Attitudes Toward Social Health Screening 1 Year Into the COVID-19 Pandemic: Survey of Adults in an Integrated Health Care Delivery System.

Introduction Information about demographic differences in social risks, needs, and attitudes toward social health screening in non-highly vulnerable adult populations is lacking. Methods The authors analyzed data for 2869 Kaiser Permanente Northern California non-Medicaid-covered members aged 35 to 85 who responded to a 2021 English-only mailed/online survey. The survey covered 7 social risk and 11 social needs domains and attitudes toward social health screening. The authors used data weighted to the Kaiser Permanente Northern California membership to estimate prevalence of risks, needs, and screening receptivity in the overall population, by race/ethnicity (White, Black, Latinx, Asian American/Pacific Islander) and age (35-65 years old, 66-85 years old). Multivariable regression was used to evaluate differences between groups. Results Overall, 26% of adults were financially strained, 12% food insecure, 12% housing insecure, and 5% transportation insecure. Additionally, 7%, 8%, and 17% had difficulty paying for utilities, medical expenses, and dental care, respectively. Over 40% of adults wanted help with ≥ 1 social need. Dental care, vision/hearing care, paying for medical expenses and utilities, and managing debt/credit card repayment surpassed food, housing, and transportation needs. Prevalence of social risks and needs was generally higher among middle-aged versus older and Black and Latinx versus White adults. Among the 70% of adults receptive to screening, 85% were willing to complete a questionnaire and 40% were willing to have staff ask questions; 18% did not want to be screened. Conclusion When implementing social health screening in diverse patient populations, the prevalence of social risks and needs, as well as the acceptability of social health screening and screening modalities, will vary among demographic subgroups.

Identification of recurrent atrial fibrillation using natural language processing applied to electronic health records.

This study aimed to develop and apply natural language processing (NLP) algorithms to identify recurrent atrial fibrillation (AF) episodes following rhythm control therapy initiation using electronic health records (EHRs). We included adults with new-onset AF who initiated rhythm control therapies (ablation, cardioversion, or antiarrhythmic medication) within two US integrated healthcare delivery systems. A code-based algorithm identified potential AF recurrence using diagnosis and procedure codes. An automated NLP algorithm was developed and validated to capture AF recurrence from electrocardiograms, cardiac monitor reports, and clinical notes. Compared with the reference standard cases confirmed by physicians' adjudication, the F-scores, sensitivity, and specificity were all above 0.90 for the NLP algorithms at both sites. We applied the NLP and code-based algorithms to patients with incident AF (n=22 970) during the 12 months after initiating rhythm control therapy. Applying the NLP algorithms, the percentages of patients with AF recurrence for sites 1 and 2 were 60.7% and 69.9% (ablation), 64.5% and 73.7% (cardioversion), and 49.6% and 55.5% (antiarrhythmic medication), respectively. In comparison, the percentages of patients with code-identified AF recurrence for sites 1 and 2 were 20.2% and 23.7% for ablation, 25.6% and 28.4% for cardioversion, and 20.0% and 27.5% for antiarrhythmic medication, respectively. When compared with a code-based approach alone, this study's high-performing automated NLP method identified significantly more patients with recurrent AF. The NLP algorithms could enable efficient evaluation of treatment effectiveness of AF therapies in large populations and help develop tailored interventions.

Outcomes of Adults with Severe Aortic Stenosis Undergoing Urgent or Emergent vs. Elective Transcatheter Aortic Valve Replacement Within an Integrated Health Care Delivery System

BackgroundTranscatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR. MethodsWe identified all adults who received TAVR for primary aortic stenosis between 2013 and 2019 within an integrated health care delivery system in Northern California. Elective or urgent/emergent procedure status was based on standard Society of Thoracic Surgeons definitions. Data were obtained from electronic health records, the Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry, and state/national reporting databases. Logistic regression and Cox proportional hazard models were performed. ResultsAmong 1564 eligible adults that underwent TAVR, 81 (5.2%) were classified as urgent/emergent. These patients were more likely to have heart failure (63.0% vs. 47.4%), reduced left ventricular ejection fraction (21.0% vs. 11.8%), or a prior aortic valve balloon valvuloplasty (13.6% vs. 5.0%) and experienced higher unadjusted rates of 30-day and 1-year morbidity and mortality. Urgent/emergent TAVR status was independently associated with non-improved quality of life at 30-days (hazard ratio, 4.87; p < 0.01) and acute kidney injury within 1-year post-TAVR (hazard ratio, 2.11; p = 0.01). There was not a significant difference in adjusted 1-year mortality with urgent/emergent TAVR. ConclusionsUrgent/emergent TAVR status was uncommon and associated with high-risk clinical features and higher unadjusted rates of short- and long-term morbidity and mortality. Procedure status may be useful to identify patients less likely to experience significant short term improvement in health-related quality of life post-TAVR.

Incident Atrial Fibrillation and Risk of Dementia in a Diverse, Community‐Based Population

Background Atrial fibrillation (AF) is the most common, clinically relevant arrhythmia in adults and associated with ischemic stroke and premature death. However, data are conflicting on whether AF is independently associated with risk of dementia, particularly in diverse populations. Methods and Results We identified all adults from 2 large integrated health care delivery systems between 2010 and 2017 and performed a 1:1 match of incident AF: no AF by age at index date, sex, estimated glomerular filtration rate category, and study site. Subsequent dementia was identified through previously validated diagnosis codes. Fine-Gray subdistribution hazard models were used to examine the association of incident AF (versus no AF) with risk of incident dementia, adjusting for sociodemographics and comorbidity and accounting for competing risk of death. Subgroup analyses by age, sex, race, ethnicity, and chronic kidney disease status were also performed. Among 196 968 matched adults, mean (SD) age was 73.6 (11.3) years, with 44.8% women, and 72.3% White. Incidence rates (per 100 person-years) for dementia over a median follow-up of 3.3 (interquartile range, 1.7-5.4) years were 2.79 (95% CI, 2.72-2.85) and 2.04 (95% CI, 1.99-2.08) per 100 person-years in persons with versus without incident AF, respectively. In adjusted models, incident AF was associated with a significantly greater risk of diagnosed dementia (subdistribution hazard ratio [sHR], 1.13 [95% CI, 1.09-1.16]). With additional adjustment for interim stroke events, the association of incident AF with dementia remained statistically significant (sHR, 1.10 [95% CI, 1.07-1.15]). Associations were stronger for age<65 (sHR, 1.65 [95% CI, 1.29-2.12]) versus ≥65 (sHR, 1.07 [95% CI, 1.03-1.10]) years (interaction P<0.001); and those without (sHR, 1.20 [95% CI, 1.14-1.26]) versus with chronic kidney disease (sHR, 1.06 [95% CI, 1.01-1.11]; interaction P<0.001). No meaningful differences were seen by sex, race, or ethnicity. Conclusions In a large, diverse community-based cohort, incident AF was associated with a modestly increased risk of dementia that was more prominent in younger patients and those without chronic kidney disease but did not substantially vary across sex, race, or ethnicity. Further studies should delineate mechanisms underpinning these findings, which may inform use of AF therapies.

Training the next generation of delivery science researchers: 10-year experience of a post-doctoral research fellowship program within an integrated care system.

Learning health systems require a workforce of researchers trained in the methods of identifying and overcoming barriers to effective, evidence-based care. Most existing postdoctoral training programs, such as NIH-funded postdoctoral T32 awards, support basic and epidemiological science with very limited focus on rigorous delivery science methods for improving care. In this report, we present the 10-year experience of developing and implementing a Delivery Science postdoctoral fellowship embedded within an integrated health care delivery system. In 2012, the Kaiser Permanente Northern California Division of Research designed and implemented a 2-year postdoctoral Delivery Science Fellowship research training program to foster research expertise in identifying and addressing barriers to evidence-based care within health care delivery systems. Since 2014, 20 fellows have completed the program. Ten fellows had PhD-level scientific training, and 10 fellows had clinical doctorates (eg, MD, RN/PhD, PharmD). Fellowship alumni have graduated to faculty research positions at academic institutions (9), and research or clinical organizations (4). Seven alumni now hold positions in Kaiser Permanente's clinical operations or medical group (7). This delivery science fellowship program has succeeded in training graduates to address delivery science problems from both research and operational perspectives. In the next 10 years, additional goals of the program will be to expand its reach (eg, by developing joint research training models in collaboration with clinical fellowships) and strengthen mechanisms to support transition from fellowship to the workforce, especially for researchers from underrepresented groups.

Approach to Multimorbidity Burden Classification and Outcomes in Older Adults With Heart Failure.

The optimal approach to classifying multimorbidity burden in assessing treatment-associated outcomes using real-world data remains uncertain. We assessed whether 2 measurement approaches to characterize multimorbidity influenced observed associations of β-blocker use with outcomes in adults with heart failure (HF). We conducted a retrospective study on adults with HF from 4 integrated health care delivery systems. Multimorbidity burden was characterized by either (1) simple counts of chronic conditions or (2) a weighted multiple chronic conditions score using data from electronic health records. We assessed the impact of these 2 approaches to characterizing multimorbidity on associations between exposure to β-blockers and subsequent all-cause death, hospitalization for HF, and hospitalization for any cause. The study population characterized by a count of chronic conditions included 9988 adults with HF who had a mean (SD) age of 76.4 (12.5) years, with 48.7% women and 24.7% racial/ethnic minorities. The cohort characterized by weighted multiple chronic conditions included 10,082 adults with HF who had a mean (SD) age of 76.4 (12.4) years, 48.9% women, and 25.5% racial/ethnic minorities. The multivariable associations of risks of death or hospitalizations for HF or for any cause associated with incident β-blocker use were similar regardless of how multimorbidity burden was characterized. Simple counts of chronic conditions performed similarly to a weighted multimorbidity score in predicting outcomes using real-world data to examine clinical outcomes associated with β-blocker therapy in HF. Our findings challenge conventional wisdom that more complex measures of multimorbidity are always necessary to characterize patients in observational studies examining therapy-associated outcomes.

Assessment of the Risk of Venous Thromboembolism in Nonhospitalized Patients With COVID-19

Patients hospitalized with COVID-19 have higher rates of venous thromboembolism (VTE), but the risk and predictors of VTE among individuals with less severe COVID-19 managed in outpatient settings are less well understood. To assess the risk of VTE among outpatients with COVID-19 and identify independent predictors of VTE. A retrospective cohort study was conducted at 2 integrated health care delivery systems in Northern and Southern California. Data for this study were obtained from the Kaiser Permanente Virtual Data Warehouse and electronic health records. Participants included nonhospitalized adults aged 18 years or older with COVID-19 diagnosed between January 1, 2020, and January 31, 2021, with follow-up through February 28, 2021. Patient demographic and clinical characteristics identified from integrated electronic health records. The primary outcome was the rate per 100 person-years of diagnosed VTE, which was identified using an algorithm based on encounter diagnosis codes and natural language processing. Multivariable regression using a Fine-Gray subdistribution hazard model was used to identify variables independently associated with VTE risk. Multiple imputation was used to address missing data. A total of 398 530 outpatients with COVID-19 were identified. The mean (SD) age was 43.8 (15.8) years, 53.7% were women, and 54.3% were of self-reported Hispanic ethnicity. There were 292 (0.1%) VTE events identified over the follow-up period, for an overall rate of 0.26 (95% CI, 0.24-0.30) per 100 person-years. The sharpest increase in VTE risk was observed during the first 30 days after COVID-19 diagnosis (unadjusted rate, 0.58; 95% CI, 0.51-0.67 per 100 person-years vs 0.09; 95% CI, 0.08-0.11 per 100 person-years after 30 days). In multivariable models, the following variables were associated with a higher risk for VTE in the setting of nonhospitalized COVID-19: age 55 to 64 years (HR 1.85 [95% CI, 1.26-2.72]), 65 to 74 years (3.43 [95% CI, 2.18-5.39]), 75 to 84 years (5.46 [95% CI, 3.20-9.34]), greater than or equal to 85 years (6.51 [95% CI, 3.05-13.86]), male gender (1.49 [95% CI, 1.15-1.96]), prior VTE (7.49 [95% CI, 4.29-13.07]), thrombophilia (2.52 [95% CI, 1.04-6.14]), inflammatory bowel disease (2.43 [95% CI, 1.02-5.80]), body mass index 30.0-39.9 (1.57 [95% CI, 1.06-2.34]), and body mass index greater than or equal to 40.0 (3.07 [1.95-4.83]). In this cohort study of outpatients with COVID-19, the absolute risk of VTE was low. Several patient-level factors were associated with higher VTE risk; these findings may help identify subsets of patients with COVID-19 who may benefit from more intensive surveillance or VTE preventive strategies.

Data-driven classification of health status of older adults with diabetes: The diabetes and aging study.

We set out to identify empirically-derived health status classes of older adults with diabetes based on clusters of comorbid conditions which are associated with future complications. We conducted a cohort study among 105,786 older (≥65 years of age) adults with type 2 diabetes enrolled in an integrated healthcare delivery system. We used latent class analysis of 19 baseline comorbidities to derive health status classes and then compared incident complication rates (events per 100 person-years) by health status class during 5 years of follow-up. Complications included infections, hyperglycemic events, hypoglycemic events, microvascular events, cardiovascular events, and all-cause mortality. Three health status classes were identified: Class 1 (58% of the cohort) had the lowest prevalence of most baseline comorbidities, Class 2 (22%) had the highest prevalence of obesity, arthritis, and depression, and Class 3 (20%) had the highest prevalence of cardiovascular conditions. The risk for incident complications was highest for Class 3, intermediate for Class 2 and lowest for Class 1. For example, the age, sex and race-adjusted rates for cardiovascular events (per 100 person-years) for Class 3, Class 2 and Class 1 were 6.5, 2.3, and 1.6, respectively; 2.1, 1.2, 0.7 for hypoglycemia; and 8.0, 3.8, and 2.3 for mortality. Three health status classes of older adults with diabetes were identified based on prevalent comorbidities and were associated with marked differences in risk of complications. These health status classes can inform population health management and guide the individualization of diabetes care.

Association of Education With Dementia Incidence Stratified by Ethnicity and Nativity in a Cohort of Older Asian American Individuals

High education protects against dementia, but returns on educational attainment may be different across sociodemographic groups owing to various social factors. Asian American individuals are a growing and diverse group, but little research has assessed dementia determinants in this population. To examine the association of education with dementia in a large cohort of Asian American individuals, stratifying by ethnicity and nativity. This cohort study used electronic health record (EHR) and survey data from the Research Program on Genes, Environment, and Health and the California Men's Health Study surveys (2002-2020). Data are from Kaiser Permanente Northern California, an integrated health care delivery system. This study used a volunteer sample who completed the surveys. Participants included Chinese, Filipino, and Japanese individuals who were aged 60 to less than 90 years without a dementia diagnosis in the EHR at the time of the survey (baseline) and who had 2 years of health plan coverage before baseline. Data analysis was performed from December 2021 to December 2022. The main exposure was educational attainment (college degree or higher vs less than a college degree), and the main stratification variables were Asian ethnicity and nativity (born in the US or born outside the US). The primary outcome was incident dementia diagnosis in the EHR. Dementia incidence rates were estimated by ethnicity and nativity, and Cox proportional hazards and Aalen additive hazards models were fitted for the association of college degree or higher vs less than a college degree with time to dementia, adjusting for age (timescale), sex, nativity, and an interaction between nativity and college degree. Among 14 749 individuals, the mean (SD) age at baseline was 70.6 (7.3) years, 8174 (55.4%) were female, and 6931 (47.0%) had attained a college degree. Overall, among individuals born in the US, those with a college degree had 12% lower dementia incidence (HR, 0.88; 95% CI, 0.75-1.03) compared with those without at least a college degree, although the confidence interval included the null. The HR for individuals born outside the US was 0.82 (95% CI, 0.72-0.92; P = .46 for the college degree by nativity interaction). The findings were similar across ethnicity and nativity groups except for Japanese individuals born outside the US. These findings suggest that college degree attainment was associated with lower dementia incidence, with similar associations across nativity. More work is needed to understand determinants of dementia in Asian American individuals and to elucidate mechanisms linking educational attainment and dementia.

Crowdsourcing Electronic Health Record Improvements at Scale across an Integrated Health Care Delivery System

Despite widespread adoption of electronic health records (EHRs), these systems have significant room for improved efficiency and efficacy. While the idea of crowdsourcing EHR improvement ideas has been reported, little is known about how this might work across an integrated health care delivery system in practice. Our program solicited EHR improvement submissions during two timeframes across 10 hospitals and 60 clinics in an upper-Midwest integrated health care delivery system. Submissions were primarily collected via an EHR help feature. A total of 262 and 294 submissions were received in 2019 and 2022, with a majority initiated from physicians (73.5 and 46.9%, 2019 and 2022) specializing in family medicine (52.0 and 59.3%). In 2022, the program reached a larger variety of personnel than 2019, with 53.0% of submissions from advanced practice providers, nurses, administrative staff, and other roles (p < 0.0001). Many ideas (36.4 and 50.0% in 2019 and 2022) reflected a lack of user understanding of EHR features and were addressed through training/education. Significant (27.1 and 25.9%) or simple (24.0 and 14.7%) EHR optimizations were required to address most remaining suggestions, with a number part of planned EHR improvement projects already (16.3 and 17.6%). Our experience using a crowdsourcing approach for EHR improvement ideas provided clinicians and staff the opportunity to address frustrations with the EHR and offered concrete feedback and solutions. While previous studies have suggested EHR technology improvements as paramount, we observed large numbers of users having a misunderstanding of EHR features, highlighting the need for improved EHR user competency and training.

Abstract P3-03-09: Assessment of Breast Cancer Chemotherapy Dose Reduction in an Integrated Healthcare Delivery System

Abstract Background: Most cytotoxic drugs are dosed according to body surface area (BSA), yet not all patients receive the full BSA-determined dose. Prior work suggests that dose reduction may occur more frequently in obese patients, likely due to concern about inducing toxicity at high doses. Other factors, such as race/ethnicity, have been suggested to be associated with dosing, yet the factors associated with dose reduction remain poorly understood, with little known about dosing patterns in integrated healthcare delivery systems and how such patterns have changed over time. Methods: We examined chemotherapy dosing in 452 women diagnosed with stage I-IIIA primary breast cancer at Kaiser Permanente Northern California. All study participants were a part of the Pathways Study, diagnosed between 2006-2013, and treated with the common breast cancer regimen, ACT (cyclophosphamide and doxorubicin, followed by paclitaxel). We explored the association between obesity and dose reduction, and further explored other factors in relation to dose reduction, including various sociodemographic characteristics, tumor characteristics, and comorbidities. We assessed dosing using first cycle dose proportion (&amp;lt; 90% expected dose) and average relative dose intensity (ARDI, a metric of dose intensity over the entire course of chemotherapy). Results: Overall, 8% of women received a dose reduction &amp;gt;10% in the first cycle of chemotherapy and 21.2% of patients had an ARDI &amp;lt; 90%. Obesity was a strong predictor of dose reduction, both in the first cycle and across all cycles. In the first cycle, 21.9% of severely obese patients (body mass index, BMI: 35+ kg/m2) were dose reduced, whereas no normal weight patients (BMI: 18.5-&amp;lt; 25 kg/m2) experienced a first cycle dose reduction. Across all cycles, 38.4% of severely obese women had an ARDI &amp;lt; 90%, as compared 12.8% of normal weight women. In logistic regression models adjusted for age, race/ethnicity, and white blood cell count, obese women had 4.1-fold higher odds of receiving a dose reduction of 10% or more over the course of chemotherapy than their normal weight counterparts (95% CI: 1.9, 8.9; p-trend: 0.006). Increasing age was positively associated with dose reduction across the course of chemotherapy, as was the presence of comorbidity. Importantly, dose reduction was less common in later calendar years. Sensitivity analyses revealed that the positive association between obesity and dosing was robust to further adjustment for these other significantly associated factors. Impact: These results offer insight on factors associated with variation in chemotherapy dosing for a common breast cancer treatment regimen. Larger studies are required to evaluate relevance of these findings to other treatment regimens. Further work will be needed to determine whether dose reductions impact breast cancer outcomes. Citation Format: Elizabeth D. Kantor, Kelli O’Connell, Isaac J. Ergas, Emily Valice, Janise M. Roh, Jenna Bhimani, Narre Heon, Jennifer J. Griggs, Jean Lee, Erin J. Bowles, Donna R. Rivera, Tatjana Kolevska, Elisa Bandera, Lawrence H. Kushi. Assessment of Breast Cancer Chemotherapy Dose Reduction in an Integrated Healthcare Delivery System [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-03-09.

Glycemic Control Trajectories and Risk of Perinatal Complications Among Individuals With Gestational Diabetes

ABSTRACT Approximately 8% of pregnancies in the United States are affected by gestational diabetes mellitus (GDM) per year. The condition is associated with higher risk of adverse perinatal outcomes, including hypertensive disorders of pregnancy, cesarean delivery (CD), macrosomia, shoulder dystocia, neonatal hypoglycemia, and adverse long-term outcomes, including diabetes and cardiovascular disease. Randomized clinical trials have suggested that glycemic control of GDM with medical nutritional and insulin therapies may improve perinatal outcomes. The American Diabetes Association recommends using self-monitoring of blood glucose (BG) to manage glycemic control during pregnancy. However, large-scale, population-based studies evaluating self-monitoring of BG are limited. In addition, the conventional model for glycemic control status using optimal versus suboptimal is insufficient to capture progressive changes during pregnancy. The aim of this study was to review whether glycemic control trajectories (GCTs) from GDM diagnosis to delivery are associated with the risk of perinatal complications. This was a population-based, cohort study of individuals with GDM who received prenatal care in an integrated health care delivery system between 2007 and 2017. Included were those diagnosed with GDM at 24 to 28 weeks of gestation. Excluded were those who had diabetes before pregnancy. Individuals were asked to self-monitor BG measurements to assess glycemic control 4 times per day at mealtimes. The measurements were collected by nurses or dietitians during weekly counseling calls. Optimal glycemic control was defined as &lt;95 mg/dL for fasting and &lt;140 mg/dL for 1 hour after lunch or dinner. Perinatal complications were the outcomes measured, including CD, preterm birth, shoulder dystocia, neonatal intensive care unit (NICU) admission, NICU stays ≥7 days, stillbirth, large-for-gestational age (LGA), and small-for-gestational age (SGA). To estimate associations between GCTs with the perinatal complications, multivariate Poisson regression models were used. A total of 26,774 individuals were included in the analysis. Four distinct GCTs were identified: trajectory 1 (T1) for stably optimal GCTs (39.3% of individuals), trajectory 2 (T2) for rapidly improving GCTs (34.9%), trajectory 3 (T3) for slowly improving to near-optimal GCTs (15.4%), and trajectory 4 (T4) for slowly improving to suboptimal GCTs (11%). For the T1 group, there were lower risks of CD (adjusted relative risk [aRR], 0.93; 95% confidence internal [CI], 0.89–0.96), shoulder dystocia (aRR, 0.75; 95% CI, 0.61–0.92), and NICU admission (aRR, 0.90; 95% CI, 0.83–0.97) compared with the T2 or reference group (P for trend &lt;0.001), whereas for the T4 group there were higher risks of CD (aRR, 1.18; 95% CI, 1.12–1.24; P for trend &lt;0.001), shoulder dystocia (aRR, 1.41; 95% CI, 1.12–1.78; P for trend &lt;0.001), and NICU admission (aRR, 1.33; 95% CI, 1.20–1.47; P for trend &lt;0.001). There was an increased risk of LGA across GCTs (from T1 [aRR, 0.74; 95% CI, 0.69–0.80] to T4 [aRR, 1.42; 95% CI, 1.31–1.53]; P for trend &lt;0.001; vs T2), but there was a decreased trend of SGA (from T1 [aRR, 1.10; 95% CI, 1.02–1.20] to T4 [aRR, 0.63; 95% CI, 0.53–0.75]; P for trend &lt;0.001). There was not a significant trend across GCTs for the risk of preterm birth and NICU stays ≥7 days. Overall, there was increasing risk of perinatal complications from T1 to T4 GCT, except for SGA. This study highlights the need for early GDM management to prevent perinatal complications.

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals.

Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services. Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services. SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT). HbA1c, blood pressure, and LDL over time for each study group. Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05). The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

State-Level Indicators of Childhood Educational Quality and Incident Dementia in Older Black and White Adults

Higher educational attainment is associated with reduced dementia risk, but the role of educational quality is understudied, presenting a major evidence gap, especially as it may contribute to racial inequities. To evaluate the association between state-level educational quality during childhood and dementia risk. This cohort study analyzed longitudinal data collected from January 1, 1997, through December 31, 2019 (23-year follow-up period). The sample comprised members of Kaiser Permanente Northern California (KPNC), a large integrated health care delivery system, who completed an optional survey during 1964-1972. Eligible individuals were US born; non-Hispanic Black or non-Hispanic White; aged 65 years or older as of January 1, 1996; were still alive; and did not have a dementia diagnosis or lapse in KPNC membership greater than 90 days between January 1 and December 31, 1996. Historical state-level administrative indicators of school quality (school term length, student-teacher ratio, and attendance rates) linked to participants using birth state and birth year (with a 6-year lag) and divided into tertiles using the pooled sample. Dementia diagnoses from electronic health records between 1997 and 2019 were analyzed between March 1 and August 31, 2022. The associations of educational quality with incident dementia were estimated using Cox proportional hazards regression models. Among 21 450 KPNC members who participated in the optional survey, individuals born before availability of educational quality records (n = 87) and missing educational attainment (n = 585) were excluded. The final analytic sample was 20 778 individuals (56.5% women, 43.5% men; mean [SD] age, 74.7 [6.5] years; 18.8% Black; 81.2% White; 41.0% with less than high school education). Among Black individuals, 76.2% to 86.1% (vs 20.8%-23.3% of White individuals) attended schools in states in the lowest educational quality tertiles. Highest (vs lowest) educational quality tertiles were associated with lower dementia risk (student-teacher ratio: hazard ratio [HR], 0.88 [95% CI, 0.83-0.94]; attendance rates: HR, 0.80 [95% CI, 0.73-0.88]; term length: HR, 0.79 [95% CI, 0.73-0.86]). Effect estimates did not differ by race and were not attenuated by adjustment for educational attainment. In this cohort study, lower state-average educational quality was more common among Black individuals and associated with higher dementia risk. Differential investment in high-quality education due to structural racism may contribute to dementia disparities.

Abstract WMP72: Acute Ischemic Stroke In Asians In A Large Integrated Health Care Delivery System

Background: Stroke is a major problem in Asia where more than half of the world population resides. Asian Americans are among the fastest growing racial-ethnic groups in the US, yet the incidence of stroke subtypes, stroke risk factors and outcomes have been largely unstudied in Asian Americans. We assessed acute stroke alert presentations in Asians compared to whites in a large integrated health care delivery system. Methods: In 2016, Kaiser Permanente Northern California launched a standardized telestroke program for 21 certified stroke centers to include immediate video evaluation by a teleneurologist. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. We evaluated all non-cancelled stroke alerts evaluated by Telestroke in 2019. Assessment included demographics, mode of arrival, initial NIHSS, neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, and discharge disposition. Results: We identified 427 Asian and 1262 White patients with potential acute ischemic stroke. Compared with whites, Asians were younger, just as likely to arrive via EMS and arrived quicker from their last known well time, but presented with more severe NIHSS, were more likely to have bleeding on the initial head CT, and less likely to receive IV thrombolytic within 30 minutes from ED arrival (Table). Asians had less detected LVO, but those with LVO were transferred out for thrombectomy faster compared with whites. There were less stroke mimics in Asians presenting with stroke alerts, and no difference in inpatient mortality compared with whites. Conclusions: Several differences existed between Asian and white patients evaluated by Telestroke as non-cancelled stroke alerts. Further research is needed to understand these differences and assess outcomes for Asians as well as major Asian subgroups presenting with acute ischemic stroke.

Real-world impact of empagliflozin on total cost of care in adults with type 2 diabetes: Results from an outcomes-based agreement.

BACKGROUND: Value-based health care is expanding through payment models such as outcomes-based agreements between manufacturers and payers. OBJECTIVE: To describe the total-cost-of-care outcomes of an outcomes-based agreement evaluating the real-world impact of empagliflozin vs other type 2 diabetes mellitus (T2DM) drugs among all patients with T2DM, with and without cardiovascular disease (within and beyond the requirement of the agreement). METHODS: In this prospective real-world analysis, members from the health plan of an integrated health care delivery system from the commercial and Medicare Advantage lines of business, who qualify under the confines of the contract, were included for analysis. Thus, members aged 18 years and older who were continuously enrolled in the identification (January 1, 2018, to December 31, 2018) and measurement periods (≤1 year post-index) with a T2DM diagnosis were retained. Patients using empagliflozin and empagliflozin-combination drugs constituted the empagliflozin group; those using all other antihyperglycemics, the nonempagliflozin group. Patients with type 1 diabetes, or those using metformin or insulin monotherapy, at index were excluded. Eligible members were followed for up to the earliest occurrence of disenrollment date, discontinuation (60-day medication fill gap allowed) of empagliflozin (or nonempagliflozin containing) medication, or the end of the measurement period. We compared, using Student's t-test and summary statistics (for reporting the outcomes agreement) and a propensity-matched difference-in-difference model (for the followup evaluation beyond the requirement of the agreement), the mean all-cause total cost of care (pharmacy plus medical) per patient per month (PPPM) between the 2 groups, including a subgroup of members with a baseline cardiovascular disease diagnosis. RESULTS: There were 4,577 (3,069 and 1,508 in the commercial and Medicare) and 33,712 (15,571 and 18,141 in the commercial and Medicare) in the empagliflozin and nonempagliflozin groups, respectively. The difference in mean total cost PPPM was $75 lower for empagliflozin vs nonempagliflozin groups, driven mainly by lower medical costs in the empagliflozin group (-$465 PPPM). However, the difference was not statistically significant in the propensity score-matched model. CONCLUSIONS: Although empagliflozin had higher pharmacy costs, the total cost of care for patients with T2DM and with established cardiovascular disease were comparable to the group of patients with all other T2DM, driven mainly by lower medical costs. DISCLOSURES: The authors report no conflicts of interest beyond being employees of the 2 organizations involved in this outcomes-based agreement. Ms. Palli is a former employee of Boehringer Ingelheim Pharmaceuticals, Inc., who was affiliated at the time of study conduct.

Abstract TP60: Intravenous Thrombolytic Administration For Acute Ischemic Stroke Is Associated With Decreased 30-day Readmission As Well As 1-year Mortality And Recurrent Stroke

Background: Reducing 30-day readmission can potentially improve quality of stroke care. We investigated factors associated with 30-day readmission,1-year mortality and stroke recurrence post-ischemic stroke. Methods: Cohort included primary ischemic stroke discharges 1/1/2015 to 3/31/2021 from a large racial-ethnically diverse integrated healthcare delivery system. Assessment included demographics, comorbidity, NIHSS, IV thrombolytic, thrombectomy, hospital complications, and mRS score at discharge. Multivariate analysis was done to determine predictors for 30-day readmission, 1-year mortality and stroke recurrence. Results: Of 13,053 ischemic stroke patients,1,790 (13.7%) were readmitted within 30 days. The median time to readmission was 10 days (IQR 4-19). Readmission was most-commonly stroke-related (21.6%). Being older, having higher initial NIHSS or co-morbidity score or more hospital complications, not receiving IV thrombolysis, and being more disabled at discharged were seen more often among those who were readmitted (Table). In multivariate analysis, being older, having higher initial NIHSS and co-morbidity score were associated with higher odds of being readmitted by 30-day and having higher mortality and stroke recurrence at 1-year. Adjusted odds for stroke recurrence were elevated for black patients. Being readmitted by 30-day also predicted greater odds of 1-year stroke recurrence and 1-year mortality. On the other hand, receiving IV thrombolysis was associated with significantly less odds of being readmitted at 30-day (OR=0.74; 95% CI = 0.59 - 0.93) and less stroke recurrence (OR=0.75; 95% CI =0.64 - 0.87) and less mortality at 1-year (OR=0.57; 95% CI = 0.42 - 0.76). Conclusions: A number of factors predicted 30-day readmission as well as 1-year stroke recurrence and mortality. Receiving IV thrombolytic for acute stroke was strongly associated with lower odds of developing bad outcomes.

Learn, Earn, Return

Recently, I attended the 25th anniversary celebration for the Power of Nursing Leadership event hosted by the University of Illinois at Chicago’s College of Nursing (CON). Twenty-five years ago, Dr. Joan Shaver, dean of the CON, observed that across the greater metro Chicago-land area, there were many integrated health care delivery systems, community and public health agencies, and large academic teaching hospitals with affiliated colleges of nursing (in addition to other nursing colleges and schools); however, there was little formal acknowledgment in the area about the contributions nurse scientists, leaders, faculty, and staff were making.

Characteristics of Ocular Inflammatory Side Effects Associated with Immune Checkpoint Inhibitors in a Northern California Population

ABSTRACT Purpose To characterize the ocular inflammatory side effects associated with immune checkpoint inhibitor (CPI) treatment in a Northern California population. Design Retrospective case series. Participants Patients receiving CPI within an integrated healthcare delivery system. Methods All patients within Kaiser Permanente Northern California receiving CPI between January 1, 2012 and November 1, 2018 were identified. Medical records of those seen in the ophthalmology clinic at least once were retrospectively reviewed. Main Outcome Measures Type and duration of ocular inflammation, indication for and exposure to CPI, time from exposure to diagnosis of ocular inflammation. Results 31 cases of ocular inflammation were identified in 5061 patients (0.61%) receiving CPI. Mean ± SD age was 67 ± 11.9 (range 38–89). Mean time from exposure to diagnosis was 6.8 ± 5.5 months (range 0.5–17). 87% of cases were bilateral, and 43% of cases were chronic. Average ophthalmology follow-up was 16 ± 18 months (range 0–71). 16/31 (52%) had anterior uveitis, 7/31 (23%) had serous retinal detachment or panuveitis resembling Vogt-Koyanagi-Harada syndrome, 4/31 (13%) had papillitis, and 6/31 (19%) had diplopia or ocular motility defect. There was one case each (3.2%) of melanoma associated retinopathy, corneal edema, granulomatous lacrimal gland enlargement, and choroidal neovascularization. Conclusions Ocular inflammation is a rare immune associated side effect of CPI treatment, the most common manifestation of which is anterior uveitis.