Integrated Health Care Setting Research Articles

Abstract SY15-02: Health insurance and outcome disparities in adolescents and young adults with cancer

Abstract SY15-02: Health insurance and outcome disparities in adolescents and young adults with cancer

Randomized Trial of Patient Outreach Approaches to De-implement Outdated Colonoscopy Surveillance Intervals

Guidelines now recommend patients with low-risk adenomas receive colonoscopy surveillance in 7-10 years and those with the previously recommended 5-year interval be re-evaluated. We tested 3 outreach approaches for transitioning patients to the 10-year interval recommendation. This was a 3-arm pragmatic randomized trial comparing telephone, secure messaging, and mailed letter outreach. The setting was Kaiser Permanente Northern California, a large integrated healthcare system. Participants were patients 54-70 years of age with 1-2 small (<10 mm) tubular adenomas at baseline colonoscopy, due for 5-year surveillance in 2022, without high-risk conditions, and with access to all 3 outreach modalities. Patients were randomly assigned to the outreach arm (telephone [n= 200], secure message [n= 203], and mailed letter [n= 201]) stratified by age, sex, and race/ethnicity. Outreach in each arm was performed by trained medical assistants (unblinded) communicating in English with 1 reminder attempt at 2-4 weeks. Participants could change their assigned interval to 10 years or continue their planned 5-year interval. Sixty-day response rates were higher for telephone (64.5%) and secure messaging outreach (51.7%) vs mailed letter (31.3%). Also, more patients adopted the 10-year surveillance interval in the telephone (37.0%) and secure messaging arms (32.0%) compared with mailed letter (18.9%) and rate differences were significant for telephone (18.1%; 97.5% confidence interval: 8.3%-27.9%) and secure message outreach (13.1%; 97.5% confidence interval: 3.5%-22.7%) vs mailed letter outreach. Telephone and secure messaging were more effective than mailed letter outreach for de-implementing outdated colonoscopy surveillance recommendations among individuals with a history of low-risk adenomas in an integrated healthcare setting. (ClinicalTrials.gov, Number: NCT05389397).

763 Obstetric Care and Pregnancy Health among Autistic Individuals in an Integrated Healthcare Setting in California

763 Obstetric Care and Pregnancy Health among Autistic Individuals in an Integrated Healthcare Setting in California

Implementing Systemwide Physician Change Management in an Integrated Health Care Setting: Improving Physician Participation in an Advanced Care at Home Model.

Advanced Care at Home is a clinical model that delivers hospital-level care in a patient's home. This model of care has been studied for decades, but there have been difficulties scaling the model to a higher census because of poor physician participation. Kaiser Permanente at Home, an Advanced Care at Home model created by Kaiser Permanente Northwest, was able to quickly increase its patient census by using several different change management interventions. The aim of this study was to describe the specific physician change management interventions used and to determine their relative impacts on physician participation with Kaiser Permanente at Home. This study used a retrospective qualitative approach. Hospitalist and emergency department (ED) physicians completed an online survey in December 2021. This was followed by focused, one-on-one interviews that were held in February 2022. Content analysis was performed using a general inductive approach to identify core themes. Of 78 ED and 79 hospitalist physicians recruited, 35% submitted responses. Of these respondents, 16 (29%) were ED physicians, and 39 (61%) were hospitalist physicians. Of these respondents, 90% rated Kaiser Permanente at Home favorably over the course of a year. More than 90% of respondents rated a combination of multiple approaches as impactful, but respondents overwhelmingly noted that physician-to-physician engagement was the most important (51%). In the development of the Kaiser Permanente at Home, physicians highlighted that a multifactorial change management approach centered on peer-to-peer engagement had the most substantial effect on their participation, a process that could extend up to a year.

705. Burden of Medically-Attended Diarrhea and Clostridioides difficile Infection (CDI) Among Persons in the Community in an Integrated Healthcare Setting, 2016-2021

Abstract Background Population-based surveillance by the Centers for Disease Control and Prevention (CDC) indicates that the incidence of community-associated Clostridioides difficile infection (CDI) is increasing. However, CDI testing practices and incidence among patients seeking care for diarrhea in the outpatient setting have not been well described. Further, little is known about healthcare utilization and outcomes of patients with medically-attended CDI who are not subsequently hospitalized. Methods We conducted a retrospective cohort study of Kaiser Permanente Southern California (KPSC) and Northwest (KPNW) adult (≥ 18 years of age) members from January 1, 2016 to December 31, 2021. We identified medically-attended diarrhea (MAD) in the outpatient setting through ICD-10 diagnosis codes. Among those with MAD, we identified C. difficile testing and outpatient CDI (oCDI), defined as a positive CDI test without hospitalization in the following 0-7 days. We described the demographic and clinical characteristics of patients with MAD and oCDI and calculated incidence rates (IR) of oCDI. We also described the occurrence of oCDI-associated healthcare visits, CDI testing, and oCDI treatment in the 12 months following oCDI diagnosis. Results We identified 777,533 outpatient MAD episodes of which 93,964 (12.1%; 93,964/777,533) were tested for CDI. Among tested episodes, 10,110 (10.8%; 10,110/93,964)), involving 9,517 patients, had a positive CDI laboratory test. IR of outpatient oCDI decreased from 58.2 (95%CI: 55.7-60.7) per 100,000 person-years (PY) in 2016 to 45.7 (43.7-47.8) per 100,000 PY in 2021. Among 9,517 oCDI patients, 84.1% (n=8,006) CDI were ‘community-associated’ (without hospitalizations in the 84 days prior to index date) and only 44.1% (n=4,200) received an antibiotic in the previous 30 days. Only 6.7% (n=526) of oCDI patients had a CDI-associated hospitalization in the 12 months after diagnosis. Conclusion There was a high incidence of MAD and CDI in among outpatients. The majority of our outpatient CDI population had no recent hospitalization and no recent antibiotic exposure. Further studies are needed to understand the factors associated with CDI diagnosed and managed in the outpatient setting. Disclosures Sara Y. Tartof, PhD MPH, Genentech: Grant/Research Support|GSK: Grant/Research Support|Pfizer: Grant/Research Support|SPERO: Grant/Research Support Mark A. Schmidt, PhD, MPH, Intercept Pharmaceuticals: Grant/Research Support|Pfizer: Grant/Research Support|Vir Biotechnology: Grant/Research Support Fredrick J. Angulo, DVM, PhD, Pfizer Vaccines: Employee|Pfizer Vaccines: Employee|Pfizer Vaccines: Stocks/Bonds|Pfizer Vaccines: Stocks/Bonds Ana Florea, PhD MPH, Gilead: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Joann M. Zamparo, MPH, Pfizer Inc.: Full Time Employee|Pfizer Inc.: Stocks/Bonds Deborah S. Ling Grant, PhD, MPH, MBA, Pfizer: Grant/Research Support Elisa Gonzalez, MPH, Pfizer: Stocks/Bonds Jennifer L. Kuntz, MS, PhD, Pfizer: Grant/Research Support

Undiagnosed Cognitive Impairment and Impact on Instrumental Activities of Daily Living Among People With HIV Infection in Primary Care.

Little is known about the prevalence of undiagnosed cognitive impairment and its impact on instrumental activities of daily living (IADL) among people with HIV (PWH) in primary care. PWH were recruited from an integrated health care setting in the United States. PWH were eligible for recruitment if they were ≥50 years old, taking antiretroviral therapy (ie, ≥1 antiretroviral therapy [ART] prescription fill in the past year), and had no clinical diagnosis of dementia. Participants completed a cognitive screen (St. Louis University Mental Status exam) and a questionnaire on IADL (modified Lawton-Brody). Study participants (n = 47) were mostly male (85.1%), 51.1% White, 25.5% Black, 17.0% Hispanic, and the average age (SD) was 59.7 (7.0) years. Overall, 27 (57.5%) participants were categorized as cognitively normal, 17 (36.2%) as having mild cognitive impairment, and 3 (6.4%) as having possible dementia. Of the 20 participants with mild cognitive impairment or possible dementia, 85.0% were men, the average age (SD) was 60.4 (7.1) years; 45.0% were White, 40.0% were Black, 10.0% were Hispanic, and 30.0% reported difficulty with at least 1 IADL. Most (66.7%) attributed difficulty with IADL primarily (33.3%) or in part (33.3%) to cognitive problems. Undiagnosed cognitive impairment is frequent among ART-treated PWH, with possible elevated risk among Black PWH, and may be accompanied by difficulty with IADL. Efforts are needed to optimize identification of factors contributing to cognitive and IADL difficulties among ART-treated PWH in primary care.

Evaluation of approaches to recruitment of racially and ethnically diverse breast cancer patients from an integrated health care setting for collection of observational social network data.

We compared approaches to recruitment of diverse women with breast cancer in a study designed to collect complex social network data. We recruited 440 women from the Kaiser Permanente Northern California population newly diagnosed with breast cancer, either in person at a clinic, by email, or by mailed letter. In clinic and mail recruitment, women completed a brief 3-page paper survey (epidemiologic data only), and women had the option to complete a separate, longer (30-40min) personal social network survey online. In email recruitment, we administered epidemiologic and personal social network measures together in a single online survey. In email and mail recruitment, we limited the sample of non-Hispanic white (NHW) women to 30% of their total. We used descriptive analysis and multinomial logistic regression to examine odds of recruitment vs. mailed letter. Women responded to the social network surveys on average 3.7months post-diagnosis. Mean age was 59.3 (median = 61.0). In-person clinic recruitment was superior with a 52.1% success rate of recruitment compared with 35.6% by mail or 17.3% by email (χ2 = 65.9, p < 0.001). Email recruitment produced the highest completion rate (82.1%) of personal network data compared with clinic (36.5%) or mail (28.7%), (χ2 = 114.6, p < 0.001). Despite intentional undersampling of NHW patients, response rates for Asian, Hispanic, and Black women by email were lower. However, we found no significant differences in recruitment rates by race and ethnicity for face-to-face clinic recruitment vs. by letter. Letter recruitment produced the highest overall response. Mailed letter was the best approach to representative recruitment of diverse women with breast cancer and collection of social network data, and further yielded the highest absolute response.

Overall and Annual Postcolonoscopy Colorectal Cancer Rates in a Large Integrated Healthcare Setting: A Cross-Sectional Study

Overall and Annual Postcolonoscopy Colorectal Cancer Rates in a Large Integrated Healthcare Setting: A Cross-Sectional Study

SAT356 - Management of chronic hepatitis B virus infection within a large integrated health care setting: treatment patterns among kaiser permanente members in southern california, 2008–2019

SAT356 - Management of chronic hepatitis B virus infection within a large integrated health care setting: treatment patterns among kaiser permanente members in southern california, 2008–2019

Primary Outcomes for Adults Receiving the Unified Protocol after Hurricane Harvey in an Integrated Healthcare Setting.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated efficacy for treating anxiety and depression. However, there are limited effectiveness data when conducted in real-world settings with diverse populations, including those with trauma. We evaluated treatment outcomes in a naturalistic, community setting among 279 adults who received UP following Hurricane Harvey. We examined change in overall clinical severity, depression and anxiety symptoms, functional impairment, and baseline outcome predictors (i.e., demographic characteristics, impact from Hurricane Harvey, co-occurrence of depression and anxiety symptoms). Global clinical severity, depression and anxiety symptoms, and functional impairment decreased by end-of-treatment. Participants experienced global symptom improvement to a lesser degree than demonstrated in efficacy trials. Participants who experienced greater storm impact reported larger reductions in anxiety symptoms than those less impacted by Harvey. Further studies evaluating the effectiveness of the UP post-disaster and with diverse samples are needed.

A virtual, pilot randomized trial of a brief intervention to prevent suicide in an integrated healthcare setting

ObjectivePatients who die by suicide are often seen in primary care settings in the weeks leading to their death. There has been little study of brief interventions to prevent suicide in these settings. MethodWe conducted a virtual, pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients who presented to a primary care mental health walk-in clinic for a new mental health intake appointment and were at risk for suicide. Our primary aim was to assess feasibility. We measured our ability to recruit 20 patients. We measured the proportion of enrolled patients who completed all study assessments. We assessed adherence among patients assigned to VA BIC. ResultsTwenty patients were enrolled and 95% (N = 19) completed all study assessments. Among the 10 patients assigned to VA BIC, 90% (N = 9) of patients completed all required intervention visits, and 100% (N = 10) completed ≥70% of the required interventions visits. ConclusionIt is feasible to conduct a virtual trial of VA BIC in an integrated care setting. Future research should clarify the role of VA BIC as a suicide prevention strategy in integrated care settings using an adequately powered design.Clinical Trial Registration: NCT04054947.

Understanding the Experience of Service Users in an Integrated Care Programme for Obesity and Mental Health: A Qualitative Investigation of Total Wellbeing Luton.

Obesity is a complex public health issue with multiple contributing factors. The emphasis on joined care has led to the development and implementation of a number of integrated care interventions targeting obesity and mental health. The purpose of this study was to examine user experience in an integrated care programme for obesity and mental health in Luton, UK. Semi-structured interviews were conducted with a purposeful sample of service users (N = 14). Interview transcripts were analysed using thematic analysis. Analysis of the interviews identified six main themes for understanding service users’ experiences of integrated care: (1) ‘A user-centered system’, (2) ‘Supports behaviour change’, (3) ‘Valued social support’, (4) ‘Communication is key’, (5) ‘Flexible referral process’, and (6) ‘Positive impact on life’. These themes describe how the service is operated, evidence perceived value service users place on social support in behavior change intervention, and address which service areas work well and which require improvement. The findings of these interviews have offered a significant contribution to understanding what service users value the most in an integrated healthcare setting. Service users value ongoing support and being listened to by healthcare professionals, as well as the camaraderie and knowledge acquisition to support their own behaviour change and promote self-regulation following their participation in the programme.

S252 Biopsy of Non-Tumor Sites After Biopsy of a Colorectal Cancer Is Associated With Metachronous Cancers: A Case-Control Study

Introduction: A recent proof-of-concept study demonstrated the plausibility of iatrogenic tumor seeding via colonoscopy as a cause of subsequent metachronous colorectal cancer (CRC). We aimed to evaluate the association of colonoscopy-related biopsy of non-tumor sites following tumor biopsy and subsequent risk of metachronous CRC. Methods: We performed a matched case-control study of adult patients with an initial CRC diagnosed by colonoscopy between January 2006 and June 2018 who underwent curative resection in a large, community-based integrated healthcare setting. Cases were individuals with a second primary CRC diagnosed between 6 months and 4 years after the initial CRC (metachronous CRC). Each case was matched with up to five controls by age, sex, and race/ethnicity; controls were without a second CRC diagnosis. The primary exposure was biopsy at the site of metachronous CRC (or corresponding site in controls) after biopsy of the initial CRC during index colonoscopy, which was ascertained through chart review while blinded to case status. The association was evaluated using conditional logistic regression, and sensitivity analyses performed to assess for potential confounders. Results: During the study period, 14,119 patients were diagnosed with an initial CRC by biopsy during colonoscopy and 106 patients were subsequently diagnosed with a second CRC. Of these, 49 were metachronous CRC cases, of which 47 were successfully matched to 222 controls. After exclusions for inflammatory bowel disease and hereditary CRC syndrome, 30 cases and 148 controls were included in the analytic sample (Figure 1). Biopsy of non-tumor sites after biopsy of the initial CRC was associated with a >3-fold increased risk of metachronous CRC compared to no endoscopic manipulation (Table 1, odds ratio (OR) 3.53, 95% confidence interval (CI) 1.06-11.78). In sensitivity analyses, excluding patients with incomplete polyp removal at the reference site (1 case and 1 control) and then adjusting for bowel preparation adequacy or extent of examination did not substantially change the point estimates but widened CIs (OR with 95% CI 3.54 [0.93, 13.47] and 3.62 [0.96, 13.66], respectively). Conclusion: Biopsy of non-tumor sites after CRC biopsy was associated with a >3-fold increased risk of metachronous CRC. These findings suggest biopsy of non-tumor sites following tumor biopsy may be a risk factor for iatrogenic tumor seeding, though we cannot exclude alternate etiologies such as incomplete polypectomy.Figure 1.: Cohort Development DiagramTable 1.: Odds of Having Biopsy After Tumor Biopsy at the Reference Site* in Cases and Controls | Footnote: *Site of metachronous cancer in cases, and the corresponding site in matched controls

A prospective study of lifestyle factors and bone health in breast cancer patients who received aromatase inhibitors in an integrated healthcare setting.

Fracture and osteoporosis are known side effects of aromatase inhibitors (AIs) for postmenopausal hormone receptor positive (HR+) breast cancer (BC) patients. How modifiable lifestyle factors impact fracture risk in these patients is relatively unknown. We conducted a prospective cohort study to examine the association of lifestyle factors, focusing on physical activity, with risk of incident major osteoporotic fracture and osteoporosis in 2152 HR+ BC patients diagnosed from 2006 to 2013 at Kaiser Permanente Northern California and who received AIs. Patients self-reported lifestyle factors at study entry and at 6-month follow-up. Fracture and osteoporosis outcomes were prospectively ascertained by physician-adjudication and bone mineral density (BMD) values, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated from multivariable proportional hazards regression. Models were adjusted for age, menopausal status, race/ethnicity, body mass index (BMI), AJCC stage, breast cancer treatment, prior osteoporosis, and prior major fracture. Over a median 6.1 years of follow-up after AI initiation, 165 women experienced an incident osteoporotic fracture and 243 women had osteoporosis. No associations were found between overall moderate-vigorous physical activity and fracture risk, although < 150 min/week of aerobic exercise in the 6 months after BC diagnosis was associated with increased fracture risk (HR=2.42; 95% CI: 1.34, 4.37) compared with ≥ 150 min/week (meeting physical activity guidelines). Risk was also higher for never or infrequently engaging in aerobic exercise (HR=1.90; 95% CI: 1.05, 3.44). None or infrequent overall moderate-vigorous physical activity in the 6 months before BC diagnosis was associated with increased risk of osteoporosis (HR=1.94; 95% CI: 1.11; 3.37). Moderate-vigorous physical activity during the immediate period after BC diagnosis, particularly aerobic exercise, was associated with lower risk of major osteoporotic fractures in women on AI therapy. Findings may inform fracture prevention in women on AI therapy through non-pharmacologic lifestyle-based strategies.

Early Detection of Septic Shock Onset Using Interpretable Machine Learners

Background: Developing a decision support system based on advances in machine learning is one area for strategic innovation in healthcare. Predicting a patient’s progression to septic shock is an active field of translational research. The goal of this study was to develop a working model of a clinical decision support system for predicting septic shock in an acute care setting for up to 6 h from the time of admission in an integrated healthcare setting. Method: Clinical data from Electronic Health Record (EHR), at encounter level, were used to build a predictive model for progression from sepsis to septic shock up to 6 h from the time of admission; that is, T = 1, 3, and 6 h from admission. Eight different machine learning algorithms (Random Forest, XGBoost, C5.0, Decision Trees, Boosted Logistic Regression, Support Vector Machine, Logistic Regression, Regularized Logistic, and Bayes Generalized Linear Model) were used for model development. Two adaptive sampling strategies were used to address the class imbalance. Data from two sources (clinical and billing codes) were used to define the case definition (septic shock) using the Centers for Medicare & Medicaid Services (CMS) Sepsis criteria. The model assessment was performed using Area under Receiving Operator Characteristics (AUROC), sensitivity, and specificity. Model predictions for each feature window (1, 3 and 6 h from admission) were consolidated. Results: Retrospective data from April 2005 to September 2018 were extracted from the EHR, Insurance Claims, Billing, and Laboratory Systems to create a dataset for septic shock detection. The clinical criteria and billing information were used to label patients into two classes-septic shock patients and sepsis patients at three different time points from admission, creating two different case-control cohorts. Data from 45,425 unique in-patient visits were used to build 96 prediction models comparing clinical-based definition versus billing-based information as the gold standard. Of the 24 consolidated models (based on eight machine learning algorithms and three feature windows), four models reached an AUROC greater than 0.9. Overall, all the consolidated models reached an AUROC of at least 0.8820 or higher. Based on the AUROC of 0.9483, the best model was based on Random Forest, with a sensitivity of 83.9% and specificity of 88.1%. The sepsis detection window at 6 h outperformed the 1 and 3-h windows. The sepsis definition based on clinical variables had improved performance when compared to the sepsis definition based on only billing information. Conclusion: This study corroborated that machine learning models can be developed to predict septic shock using clinical and administrative data. However, the use of clinical information to define septic shock outperformed models developed based on only administrative data. Intelligent decision support tools can be developed and integrated into the EHR and improve clinical outcomes and facilitate the optimization of resources in real-time.

Barriers to Human Papillomavirus Vaccine Series Completion among Insured Individuals in an Integrated Healthcare Setting.

Introduction:Infection with certain types of human papillomavirus (HPV) can lead to cervical cancer as well as other cancers in both men and women. However, the requirement for multiple doses may limit the vaccine’s effectiveness for cancer prevention. We conducted a pilot study to investigate barriers to HPV vaccine series completion among members of an integrated healthcare system with clinical documentation of only 1 dose.Methods:We surveyed parents or legal guardians of 11-17-year-old girls (n = 10) and boys (n = 18), as well as 18-31-year-old women (n = 20) and men (n = 9), about their reasons for not completing the HPV vaccine series.Results:Most participants (70.2%) were non-Hispanic white. Among parents of children, commonly reported barriers to HPV vaccine series completion included not being aware or informed of the need for additional doses (28.6%), as well as the inconvenience of returning for additional doses (17.9%). Concerns about the HPV vaccine or vaccines in general were more common among parents of girls (30.0%) compared with parents of boys (16.7%). Among adults, barriers to HPV vaccine series completion included the inconvenience of returning for additional doses (31.0%), not being aware or informed of the need for additional doses (10.3%), and forgetting (10.3%).Conclusion:Our findings suggest that clinicians and healthcare systems can play a greater role in promoting awareness of the multiple-dose requirement, addressing vaccine concerns, and increasing opportunistic vaccination in a variety of settings. Increasing these efforts may facilitate HPV vaccine completion and increase its effectiveness in cancer prevention.

Efficacy of paired tumor and germline testing in evaluation of patients with Lynch-like syndrome in a large integrated healthcare setting.

Patients with mismatch repair (MMR) deficient colorectal cancer (CRC) without detectable germline pathogenic variants (PVs) or likely pathogenic variants (LPVs) in MMR genes are often labeled as Lynch-like syndrome (LLS). We sought to evaluate the efficacy of paired tumor and germline testing in risk stratification of patients with LLS in a large, community-based, integrated healthcare setting. Through the universal screening program for Lynch syndrome at Kaiser Permanente Northern California, we identified all patients with MMR deficient colorectal tumors without detectable germline PVs or LPVs between April 2011 and October 2018. These patients were categorized as LLS and were offered paired tumor and germline testing. Risk stratification and patient management were assessed upon completion of all testing. Of the 50 patients with LLS who underwent paired tumor and germline testing, 62% (n = 31) were categorized as sporadic, 6% (n = 3) had Lynch syndrome, and 32% (n = 16) remained inconclusive. Among the sporadic cases, 65% (n = 20) had a PV (n = 18) or LPV (n = 2) in combination with loss of heterozygosity while 35% (n = 11) had two somatic PVs/LPVs involving the same MMR gene. Our findings showed paired tumor and germline testing resolved the etiology in the majority of patients and is a valuable strategy in risk stratification and management of patients with LLS. Further studies are needed to assess the optimal application of paired testing in different practice settings, particularly with evolving technology and decreasing cost of molecular sequencing.

An Exploration of Pediatricians’ Personal Value on Mental Health: Experience with Integrated Healthcare and its Impact on Physicians’ Lives

An integrated healthcare model incorporates behavioral health services into a medical setting to address patients’ physical, emotional, and behavioral healthcare concerns. The integrated healthcare model has been associated with positive patient satisfaction and health outcomes, yet limited studies have examined, using qualitative methods, physicians’ experiences of working alongside behavioral health consultants (BHCs) in integrated healthcare settings. Data was gathered through semi-structured interviews with pediatricians (N=4) working in an integrated healthcare model. Participants shared that as pediatricians they received personal, educational, and organizational benefits from an integrated healthcare model. Pediatricians also reported increased knowledge in effectively addressing mental health concerns for their patients and decreased physician stress-levels. Results of pediatricians’ experiences working in an integrated healthcare setting are discussed with regard to their implications for clinical practice and research.

A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients.

Increasingly more nonbinary patients are obtaining better access for gender-affirming chest surgery (top surgery), representing an important subset of patients who undergo such surgery. We review our experience at gender-affirming chest surgery in nonbinary versus transmasculine patients in an integrated health care setting. We performed a retrospective study of nonbinary and transmasculine patients who underwent gender-affirming chest surgery from May 1, 2012, to December 27, 2017. There were 111 nonbinary patients and 665 transmasculine patients included in the final analyses. Nonbinary patients were more likely to seek more than 1 surgical consultations than transmasculine patients (24.3% vs 1.7%, respectively, P < 0.0001). More nonbinary patients (17.3%) indicated nipple sensation to be important relative to their transmasculine counterparts (0.4%, P < 0.0001). Fewer nonbinary patients were on testosterone before surgery (33.64%) in comparison to transmasculine patients (86.14%, P < 0.0001). When only prior reduction mammaplasty or top surgery were considered, nonbinary patients (8.1%) were more likely than transmasculine patients (3.5%) to have had a prior chest surgery. When evaluating patients who did not have prior chest surgery before undergoing top surgery at our institution (n = 721), rates of major complications, minor complications, as well as revisions, were comparable between nonbinary and transmasculine patients. This study demonstrated that more nonbinary patients requested nonflat chests relative to their transmasculine counterparts. Both groups in our sample displayed comparable rates of complications after top surgery.

Validation of the Enriching New-Onset Diabetes for Pancreatic Cancer Model in a Diverse and Integrated Healthcare Setting.

The risk of pancreatic cancer is elevated among people with new-onset diabetes (NOD). Based on Rochester Epidemiology Project Data, the Enriching New-Onset Diabetes for Pancreatic Cancer (END-PAC) model was developed and validated. We validated the END-PAC model in a cohort of patients with NOD using retrospectively collected data from a large integrated health maintenance organization. A retrospective cohort of patients between 50 and 84years of age meeting the criteria for NOD in 2010-2014 was identified. Each patient was assigned a risk score (< 1: low risk; 1-2: intermediate risk; ≥ 3: high risk) based on the values of the predictors specified in the END-PAC model. Patients who developed pancreatic ductal adenocarcinoma (PDAC) within 3years were identified using the Cancer Registry and California State Death files. Area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were estimated. Out of the 13,947 NOD patients who were assigned a risk score, 99 developed PDAC in 3years (0.7%). Of the 3038 patients who had a high risk, 62 (2.0%) developed PDAC in 3years. The risk increased to 3.0% in white patients with a high risk. The AUC was 0.75. At the 3+ threshold, the sensitivity, specificity, PPV, and NPV were 62.6%, 78.5%, 2.0%, and 99.7%, respectively. It is critical that prediction models are validated before they are implemented in various populations and clinical settings. More efforts are needed to develop screening strategies most appropriate for patients with NOD in real-world settings.