Integrated Health Care Setting Research Articles

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.

Evaluation of Dipeptidyl Peptidase-4 Inhibitors versus Thiazolidinediones or Insulin in Patients with Type 2 Diabetes Uncontrolled with Metformin and a Sulfonylurea in a Real-World Setting

BACKGROUND Guidelines do not make clear recommendations for third add-on agents to metformin plus a sulfonylurea. This study compared the effectiveness and safety of dipeptidyl peptidase-4 inhibitors (DPP4is) to thiazolidinedione (TZD) or insulin as a third add-on agent to metformin plus a sulfonylurea in an integrated health care setting. METHODS This retrospective database cohort study included adults with type 2 diabetes not at goal hemoglobin A1C (HbA1C) who initiated DPP4i, TZD, or insulin as a third add-on agent to metformin plus a sulfonylurea from January 2006 to June 2016. Primary outcomes were the proportion of patients who achieved goal HbA1C after starting the third add-on agent and change in HbA1C. Subgroup analysis was performed for patients with baseline HbA1C greater than 9%. RESULTS In this study, 2080 patients started on a DPP4i were matched to 8320 patients started on TZD and to 8320 patients taking insulin. A significantly higher percentage of patients taking TZD reached goal HbA1C (31.0% versus 23.6%; p < 0.05) and had a significantly larger HbA1C reduction (-0.94% ± 1.34% versus -0.79% ± 1.23%; p < 0.01) compared to patients taking a DPP4i. No difference in the percentage of patients meeting goal HbA1C nor in change in HbA1C was demonstrated between insulin versus DPP4i regimens. For patients with baseline HbA1C greater than 9%, insulin or TZD resulted in a significantly higher proportion of patients achieving goal HbA1C compared to DPP4i (17.3% and 19.0% versus 12.4%, respectively; p < 0.01). CONCLUSION TZD was more effective than DPP4i but DPP4i was as effective as insulin as a third add-on agent in the overall study population. Insulin was more effective than DPP4i only in the subgroup analysis of patients with baseline HbA1C greater than 9%.

Long-term Risk of Colorectal Cancer and Related Death After Adenoma Removal in a Large, Community-based Population

The long-term risks of colorectal cancer (CRC) and CRC-related death following adenoma removal are uncertain. Data are needed to inform evidence-based surveillance guidelines, which vary in follow-up recommendations for some polyp types. Using data from a large, community-based integrated health care setting, we examined the risks of CRC and related death by baseline colonoscopy adenoma findings. Participants at 21 medical centers underwent baseline colonoscopies from 2004 through 2010; findings were categorized as no-adenoma, low-risk adenoma, or high-risk adenoma. Participants were followed until the earliest of CRC diagnosis, death, health plan disenrollment, or December 31, 2017. Risks of CRC and related deaths among the high- and low-risk adenoma groups were compared with the no-adenoma group using Cox regression adjusting for confounders. Among 186,046 patients, 64,422 met eligibility criteria (54.3% female; mean age, 61.6 ± 7.1 years; median follow-up time, 8.1 years from the baseline colonoscopy). Compared with the no-adenoma group (45,881 patients), the high-risk adenoma group (7563 patients) had a higher risk of CRC (hazard ratio [HR] 2.61; 95% confidence interval [CI] 1.87-3.63) and related death (HR 3.94; 95% CI 1.90-6.56), whereas the low-risk adenoma group (10,978 patients) did not have a significant increase in risk of CRC (HR 1.29; 95% CI 0.89-1.88) or related death (HR 0.65; 95% CI 0.19-2.18). With up to 14 years of follow-up, high-risk adenomas were associated with an increased risk of CRC and related death, supporting early colonoscopy surveillance. Low-risk adenomas were not associated with a significantly increased risk of CRC or related deaths. These results can inform current surveillance guidelines for high- and low-risk adenomas.

Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration.

The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.

Colorectal Cancer Screening in People With and Without HIV in an Integrated Health Care Setting.

As people with HIV (PWH) live longer, age-appropriate colorectal cancer (CRC) screening is increasingly important. Limited data exist on CRC screening and outcomes comparing PWH and persons without HIV. Large integrated health care system. This study included PWH and demographically matched persons without HIV who were aged 50-75 years during 2005-2016 and had no previous CRC screening. We evaluated time to first CRC screening (fecal test, sigmoidoscopy, or colonoscopy). We also assessed detection of adenoma and CRC with sigmoidoscopy or colonoscopy by HIV status, accounting for CRC risk factors including sex, age, race/ethnicity, number of outpatient visits, smoking, body mass index, type-2 diabetes, and inflammatory bowel disease. Among PWH, we evaluated whether CD4 count (<200/200-499/≥500 cells/µL) was associated with adenoma and CRC. Among 3177 PWH and 29,219 persons without HIV, PWH were more likely to be screened (85.6% vs. 79.1% within 5 years, P < 0.001). Among those with sigmoidoscopy or colonoscopy, adenoma was detected in 161 (19.6%) PWH and 1498 (22.6%) persons without HIV, and CRC was detected in 4 (0.5%) PWH and 69 (1.0%) persons without HIV. In adjusted analyses, we found no difference in prevalence of either adenoma or CRC by HIV status (adjusted prevalence ratio = 0.97, 95% confidence interval: 0.83 to 1.12). Lower CD4 count did not increase likelihood of adenoma or CRC. Within an integrated health care system with an organized CRC screening program, we found no disparities in CRC screening uptake or outcomes among people with and without HIV, and CD4 count did not influence CRC risk among PWH.

Telemedicine in the Management of Exudative Age-Related Macular Degeneration within an Integrated health care System

To investigate the outcomes of patients with exudative age-related macular degeneration (AMD) treated with intravitreal antivascular endothelial growth factors (VEGF) using a telemedicine system. Interventional case series. This study examined all patients with exudative AMD who were receiving intravitreal anti-VEGF injections from September 1, 2015, through August 31, 2017, using electronic consultations at a single academic center and health system. Patients were managed initially by a retinal specialist and then allowed to receive further care with their local ophthalmologist. There were 200 electronic consultations placed during this time period for 83 eyes of 59 patients. Data collected included the retina specialist's recommendations: intravitreal agent, interval between injections, number of injections, and when the patient was to follow-up. All occurrences of recommendations that were not completed were reported. The mean age of the patients at the time of electronic consultations was 82.3 ± 7.3 years with a mean follow-up time of 2.4 ± 0.81 years. The mean distance from the home of the patient to the retina specialist was 70 ± 44 miles. There were 14 consultations (7.1%) that did not comply with the recommendations of the retina specialist. Most of these were due to other medical comorbidities leading to missed appointments or scheduling errors. In an integrated health care setting, 59 patients with exudative AMD were identified who were able to be effectively managed using a telemedicine system. In the appropriate setting, telemedicine may be able to assist in the management of patients with wet AMD.

Implementation of a Systematic Tumor Screening Program for Lynch Syndrome in an Integrated Health Care Setting.

A subset of colorectal cancer (CRC) cases are attributable to Lynch syndrome (LS), a hereditary form of CRC. Effective evaluation for LS can be done on CRC tumors to guide diagnostic testing. Increased diagnosis of LS allows for surveillance and risk reduction, which can mitigate CRC-related burden and prevent cancer-related deaths. We evaluated participation in LS screening among newly diagnosed adult CRC patients. Some cases were referred for genetics evaluation prior to study recruitment (selective screening). Those not referred directly were randomized to the intervention or control (usual care) arms. Control cases were observed for one year, then given information about LS screening. Patients who declined participation were followed through the medical record. Of 601 cases of CRC, 194 (32%) enrolled in our study and were offered LS screening, 43 (7%) were followed as a control group, 148 (25%) declined participation and 216 (36%) were ineligible [63 (10%) of which received prior selective screening]. Six and nine cases of LS were identified through the intervention and selective screening groups, respectively. Overall, a higher proportion of PMS2 variants were identified in the intervention (3/6, 50%) versus selective screening groups (2/9, 22%) (not statistically significant). Eighty-eight percent and 23% of intervention and control patients, respectively, received LS screening. No control patients were found to have LS. Systems-based approaches are needed to ensure we fully identify LS cases. The proportion of LS cases from this program was 4% of newly diagnosed cases of CRC, similar to other programs.

Effectiveness of a Gender Affirming Surgery Class for Transgender and non-binary Patients and their Caregivers in an Integrated Healthcare Setting

Background: Gender affirming surgeries are increasingly accessible to transgender and non-binary individuals due to changes in health care coverage policies and rising numbers of trained providers. Improved access to care has led to an increase in the number of individuals pursuing gender affirming surgeries. Little is known about how to optimally prepare patients for these surgeries.Aims: This evaluation examined attendees’ assessment of a four-hour single-session class developed to prepare transgender and non-binary patients and their caregivers for gender affirming surgeries in a multi-disciplinary transgender clinic within an integrated health care system.Methods: A multi-disciplinary group of providers within a health maintenance organization in Northern California designed and facilitated two separate curricula, one for patients preparing for metoidioplasty/phalloplasty and the other preparing for vaginoplasty. Between November 2015 and June 2017, 214 patients and caregivers took one of the two versions of the class and completed the post-class survey evaluating perceived favorability of the class and preparedness regarding surgery options, complications and postoperative care. Descriptive statistics were used to summarize the Likert scale questions, with 1 showing the least improvement and 5 showing the most.Results: Of the 214 patients and caregivers that completed the survey, the majority reported that they were better informed about their surgical options (mean: 4.4, SD: 0.7), more prepared for surgery (mean: 4.5, SD: 0.6), better informed about possible complications (mean: 4.5, SD: 0.7), and better understood their postoperative care needs (mean: 4.6, SD: 0.6). Of the respondents, 204 (95%) reported they would recommend the course to a friend preparing for gender affirming surgery.Discussion: Our findings demonstrate that a single-session class is a favorable method for preparing transgender and non-binary patients to make informed decisions regarding the perioperative gender affirming surgical process, from preoperative preparedness, to surgical complications, and postoperative care.

Integrative Care Models in Neuropsychology: A National Academy of Neuropsychology Education Paper

Although collaborative, and more specifically, integrated models of care have existed for years, the 2010 Patient Protection and Affordable Care Act expanded their use, and Medicare has adopted a value-based payment system that further emphasizes service provision within the collaborative health care setting. Neuropsychology as a field is well-situated to work within the integrated health care setting, which presents both opportunities and challenges for clinical neuropsychologists. This education paper details how different neuropsychology clinical practice settings fit into an integrated care framework; discusses challenges to service delivery and fiscal viability in such settings and other health care related settings; and examines future directions for the role of neuropsychology within a dynamic health care system.

Patient Experiences Navigating Chronic Pain Management in an Integrated Health Care System: A Qualitative Investigation of Women and Men

Rates of pain among veterans are as high as 60%; rates approach 80% in women seeking Department of Veterans Affairs (VA) care. Prior studies examined experiences managing pain in community samples, with gender disparities observed. As the largest national integrated health care system in the country, the VA offers a unique environment to a) study perceptions of pain care among men and women and b) contrast experiences using an integrated health care setting with prior observations in the private sector. A purposive sample of chronic pain patients was recruited to qualitatively describe perceptions of managing pain in an integrated health care system (VA) and to explore gender differences. A constant comparative approach with sequential analysis was used to reach thematic consensus. Ten focus groups (N = 48; six groups of women [N = 22]; four groups of men [N = 26]) revealed an overarching theme, "just keep plugging," which reflected pain as a constant struggle. Three subthemes emerged: "always a reacquaintance process" described frustration with the use of trainees in the medical center. The need to navigate "so many hoops" referred to frustrations with logistical barriers. "To medicate or not" reflected tensions around medication use. A distinct theme, "the challenges of being female," reflected women's perceptions of stigma and bias. Most of the identified challenges were not unique to the integrated setting. Findings revealed advantages to receiving pain care in this setting. Tensions between patient expectations and guidelines governing provider behavior emerged. Improved patient education, provider communication and sensitivity to the unique needs of women may optimize care.

Colorectal Cancer Screening Participation Among Asian Americans Overall and Subgroups in an Integrated Health Care Setting with Organized Screening.

BackgroundScreening reduces colorectal cancer deaths, but <50% of Asian Americans are screening up-to-date according to surveys, with variability across Asian subgroups. We examined colorectal cancer screening participation among Asian Americans overall and Asian subgroups in a large integrated health care system with organized screening.MethodsData were electronically accessed to characterize screening in 2016 for Asians overall and subgroups relative to the National Colorectal Cancer Roundtable target of ≥80% screening and compared with non-Hispanic whites. Screening up-to-date was defined as a colonoscopy with 10 years, a sigmoidoscopy within 5 years, or a fecal immunochemical test (FIT) completed in 2016.ResultsAmong 436,398 patients, 69,826 (16.0%) were Asian, of whom 79.8% were screening up-to-date vs. 77.6% of non-Hispanic whites (p < 0.001). Almost all subgroups met the 80% target: Chinese (83.3%), Vietnamese (82.4%), Korean (82.1%), other Asian (80.3%), Filipino (78.7%), Asian Indian (79.6%), and Japanese (79.0%). Among Asians overall and non-Hispanic whites, 50.6% and 48.4% of members were up-to-date with screening by colonoscopy, and 28.0% and 28.2% were up-to-date by FIT, respectively. Across Asian subgroups, colonoscopy most frequently accounting for being screening up-to-date (range: 47.4–59.7%), followed by FIT (range: 21.6–31.5%).ConclusionsIn an organized screening setting, there were minimal differences in screening participation among Asian subgroups and almost all met the 80% screening target, despite differences in language preference. Screening test type differences across subgroups suggest possible preferences in screening modality, which can inform future research into tailored education or outreach.

Abstract IA27: Disparities in breast cancer survivorship and outcomes

Abstract In the U.S., women of European ancestry have historically had the highest incidence of breast cancer compared to other major race/ethnicity groups. In recent years, the incidence rate for black women has approached that of white women, while rates for Asian and Hispanic women are about 25% lower than for white or black women. However, once diagnosed with breast cancer, black women have poorer survival rates than white women. The most recent “Annual Report to the Nation on the Status of Cancer” using nationwide cancer-registry data from 2006-2013 (Jemal et al., JNCI, 2017) reported a higher age- and stage-adjusted relative mortality risk after breast cancer of 1.71 (95% confidence interval (CI), 1.66-1.76) for non-Hispanic blacks compared to non-Hispanic whites. Hispanic women also experienced a slightly increased relative mortality risk of 1.14 (95% CI, 1.10-1.18) compared to white women, while Asians experienced a lower relative mortality risk of 0.84 (95% CI, 0.80-0.88). The reasons for such disparities in outcomes after breast cancer are complex. One suggested contributing factor is differences in access to care, as blacks and Hispanics tend to be of lower socioeconomic status than whites or Asians. It is possible to minimize the effects of access to health care by examining outcomes after breast cancer diagnosis in an integrated health care setting such as Kaiser Permanente Northern California (KPNC), in which all patients have health insurance coverage with access to the same health care providers. We are currently conducting the Pathways Study, a prospective cohort study of 4,505 women diagnosed with breast cancer with enrollment from 2006-2013. This diverse cohort includes 557 Hispanics, 578 Asians, and 358 blacks. Preliminary analyses in the larger population of 11,176 women who were diagnosed with invasive breast cancer in KPNC and eligible for the Pathways Study found that, despite the uniform health care access, racial disparities in mortality after breast cancer were qualitatively similar to those observed nationally. With 1,738 total deaths as of September 20, 2016, and adjusted for age and stage at diagnosis, compared to white women, black women had an increased relative mortality risk of 1.59 (95% CI, 1.24-2.03). For Hispanic women, the relative risk was 0.92 (95% CI, 0.72-1.19), and for Asians it was 0.70 (95% CI, 0.51-0.97). Among the subset of women enrolled in the Pathways Study (n=538 total deaths), comparable relative risks were 1.74 (95% CI, 1.35-2.24) for black women, 0.99 (95% CI, 0.75-1.29) for Hispanic women, and 0.73 (95% CI, 0.52-1.02) for Asians. Similar black-white differences were also seen for breast cancer-specific mortality and recurrence in the Pathways Study cohort in which recurrences are being documented. These observations indicate that health care access is unlikely to explain racial/ethnic disparities in breast cancer outcomes. As the Pathways Study, we will be able to explore aspects of health care utilization, such as treatment-related factors such as treatment delay, adherence, and early discontinuation. We will also be able to explore presence of comorbid conditions or use of non-cancer medications that may influence mortality and breast cancer outcomes. In the Pathways Study, we are collecting data on lifestyle and psychosocial factors (e.g., food intake, physical activity, social support, doctor-patient communications, and quality of life); linking to geospatial databases to characterize the social and built environment of cohort members; and conducting genome-wide assays. For example, in preliminary analyses that adjusted additionally for estrogen receptor status, body mass index, educational attainment, and physical activity, black-white differences in mortality persisted even though they were somewhat attenuated (relative risk of 1.43; 95% CI, 1.09-1.86). Along with other studies that are examining breast cancer outcomes in different populations, the Pathways Study is poised to contribute to better understanding of the persistent black-white differences in mortality after breast cancer, and thus identify avenues to improve outcomes for all women with breast cancer. Citation Format: Lawrence H. Kushi, Isaac J. Ergas, Janise M. Roh, Scarlett Lin Gomez, Marilyn L. Kwan, Catherine Thomsen, Song Yao, Christine B. Ambrosone. Disparities in breast cancer survivorship and outcomes [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr IA27.

Dental provider practices and perceptions regarding adolescent vaccination.

To assess dental providers' clinical practices and perceptions regarding adolescent vaccinations. We surveyed 234 dental providers in an integrated health care setting in Portland, Oregon, in March-April 2015. We assessed participants' knowledge of adolescent vaccines, barriers to recommending vaccines, and their perceived role in the promotion of vaccination and preventive medical care. Over 80 percent of respondents correctly identified influenza, tetanus-diphtheria-acellular pertussis, and human papillomavirus as vaccinations recommended for adolescents; 60 percent correctly identified meningococcal conjugate. Forty-four percent of providers reported previously discussing vaccination with their adolescent patients. Lack of knowledge (66 percent), uncertainty about whether patients would accept recommendations (62 percent), and lack of time (61 percent) were commonly reported barriers. While few providers expressed personal concerns about the safety (13 percent) and effectiveness (10 percent) of adolescent vaccines, most believed parents had concerns about safety (70 percent) and effectiveness (60 percent). Although 80 percent endorsed the premise that providers should discuss preventive medical care with their patients, only 54 percent said they should discuss vaccinations specifically. Dental providers reported several barriers to recommending vaccines. While comfortable with discussing preventive medical care in general, providers are less comfortable making vaccine recommendations to their patients. Vaccine recommendations are not a traditional practice among dental providers and may require additional education and communication tools.

Breast Cancer Chemoprevention in an Integrated Health Care Setting.

National guidelines encourage counseling high-risk women about pharmacologic breast cancer risk reduction. We evaluated the use of integrated health care data to identify and characterize breast cancer chemoprevention use. Chemoprevention included US Food and Drug Administration-approved use of tamoxifen and raloxifene and off-label use of aromatase inhibitors (AIs). Using electronic medical and pharmacy records (EMRs) in the Kaiser Permanente Northern California health care system, we sampled cancer-free women age 35 to 69 years who used tamoxifen, raloxifene, exemestane, anastrozole, or letrozole from 2005 to 2013. Risk-benefit profiles were calculated for tamoxifen and raloxifene using published indices. The proportion of days covered was calculated from pharmacy records to assess adherence. Among 90 chemoprevention users (confirmed with EMR review from a sample of 371 women), 74% used tamoxifen, 11% used raloxifene, and 13% used an AI. For tamoxifen and raloxifene users, the risk-benefit index indicated 23% of women had insufficient evidence that benefits would outweigh risks. For all agents, adherence decreased from an average proportion of days covered of 75% at 1 year to 67% at 5 years. Automated EMR searches identified breast cancer chemoprevention users with 60% positive predictive value overall and 75% for tamoxifen after post hoc modifications. Our study contributes to an emerging picture of breast cancer chemoprevention use in real-world settings, where evidence of net benefit is not uniform and nonadherence is common. Among breast cancer chemoprevention agents, our automated selection best performed for tamoxifen use. We also identified off-label use of AIs for chemoprevention, suggesting that expansion of risk-benefit indices to include AIs is warranted.

Combined hysterectomy and mastectomy surgery for transgender patients in an integrated health care setting

ABSTRACT Background: Hysterectomy and mastectomy surgery for gender affirmation have traditionally been performed as separate surgeries. Our institution offers these surgeries as a single combined procedure, typically with same-day discharge. Decreasing the number of times patients need to have surgery may reduce barriers to care by limiting surgical and hospital stay events. Our primary objective was to describe the perioperative experience of transgender patients who underwent combined hysterectomy and mastectomy surgery.Methods: This retrospective case series assessed patients who underwent combined hysterectomy and mastectomy surgery between 2013 and 2015 in an integrated health care setting in the United States. Chart reviews were performed for outcomes of interest, which included operative and postoperative complications.Results: We identified 25 patients who underwent a combined hysterectomy and mastectomy for the indication of gender transition. Preoperative patient characteristics included a median age of 31, with a median BMI of 25. Ninety-two percent of the patients were on testosterone therapy at the time of surgery. A total of 76% and 24% of patients had laparoscopic and vaginal hysterectomies, respectively. Intraoperatively, the average blood loss was 104 mL, and there were no complications. Eighty percent of patients were discharged on the same day. Postoperatively, 92% of patients experienced no major complications. One patient received a uterine artery embolization and blood transfusion for postoperative intraabdominal bleeding, and one patient presented 9 weeks after surgery with partial vaginal cuff dehiscence requiring a cuff revision. There were no re-admissions within six months of surgery. There were no major mastectomy-related complications.Conclusions: Combined surgeries are feasible and reduce the number of surgical events and hospital stays. There were no complications that could be attributed to undergoing two procedures as a single incident.

Diagnosis and predictors of sessile serrated adenoma after educational training in a large, community-based, integrated healthcare setting

Sessile serrated adenomas (SSAs) are precursors of 15% to 30% of colorectal cancers but are frequently underdiagnosed. We sought to measure the SSA detection rate (SDR) and predictors of SSA detection after educational training for community gastroenterologists and pathologists. Colonoscopy and pathology data (2010-2014) from 3 medical centers at Kaiser Permanente Northern California were accessed electronically. Gastroenterologists and pathologists attended a training session on SSA diagnosis in 2012. Mean SDRs and patient-level predictors of SSA detection post-training (2013-2014) were investigated. Mean SDRs increased from .6% in 2010-2012 to 3.7% in 2013-2014. The increase in the detection of proximal SSAs was accompanied by a decrease in the detection of proximal hyperplastic polyps (HPs). Among 34,161 colonoscopies performed in 2013 to 2014, SDRs for screening, fecal immunochemical test positivity, surveillance, and diagnostic indication were 4.2%, 4.5%, 4.9%, and 3.0%, respectively. SSA detection was lower among Asians (adjusted odds ratio [aOR], .46; 95% confidence interval [CI], .31-.69) and Hispanics (aOR, .59; 95% CI, .36-.95) compared with non-Hispanic whites and higher among patients with synchronous conventional adenoma (aOR, 1.46; 95% CI, 1.15-1.86), HP (aOR, 1.74; 95% CI, 1.30-2.34), and current smokers (aOR, 1.78; 95% CI, 1.17-2.72). SDRs varied widely among experienced gastroenterologists, even after training (1.1%-8.1%). There was a moderately strong correlation between adenoma detection rate (ADR) and SDR for any SSA (r= .64, P= .0003) and for right-sided SSAs (r= .71, P< .0001). Educational training significantly increased the detection of SSA, but a wide variation in SDR remained across gastroenterologists. SSA detection was inversely associated with Asian and Hispanic race/ethnicity and positively associated with the presence of conventional adenoma, HP, and current smoking. There was a moderately strong correlation between ADR and SDR.

Primary care visit use after positive fecal immunochemical test for colorectal cancer screening.

For some patients, positive cancer screening test results can be a stressful experience that can affect future screening compliance and increase the use of health care services unrelated to medically indicated follow-up. Among 483,216 individuals aged 50 to 75 years who completed a fecal immunochemical test to screen for colorectal cancer at a large integrated health care setting between 2007 and 2011, the authors evaluated whether a positive test was associated with a net change in outpatient primary care visit use within the year after screening. Multivariable regression models were used to evaluate the relationship between test result group and net changes in primary care visits after fecal immunochemical testing. In the year after the fecal immunochemical test, use increased by 0.60 clinic visits for patients with true-positive results. The absolute change in visits was largest (3.00) among individuals with positive test results who were diagnosed with colorectal cancer, but significant small increases also were found for patients treated with polypectomy and who had no neoplasia (0.36) and those with a normal examination and no polypectomy performed (0.17). Groups of patients who demonstrated an increase in net visit use compared with the true-negative group included patients with true-positive results (odds ratio [OR], 1.60; 95% confidence interval [95% CI], 1.54-1.66), and positive groups with a colorectal cancer diagnosis (OR, 7.19; 95% CI, 6.12-8.44), polypectomy/no neoplasia (OR, 1.37; 95% CI, 1.27-1.48), and normal examination/no polypectomy (OR, 1.24; 95% CI, 1.18-1.30). Given the large size of outreach programs, these small changes can cumulatively generate thousands of excess visits and have a substantial impact on total health care use. Therefore, these changes should be included in colorectal cancer screening cost models and their causes investigated further. Cancer 2017;123:3744-3753. © 2017 American Cancer Society.

Su1725 - Repeat Annual Fecal Immunochemical Testing Patterns in a Large Community-Based Integrated Healthcare Setting

Su1725 - Repeat Annual Fecal Immunochemical Testing Patterns in a Large Community-Based Integrated Healthcare Setting

946 - Long-Term Impact of Colorectal Cancer Screening Using a Combination of Fecal Immunochemical Testing and Lower Bowel Endoscopy in a Large, Community-Based Integrated Healthcare Setting

946 - Long-Term Impact of Colorectal Cancer Screening Using a Combination of Fecal Immunochemical Testing and Lower Bowel Endoscopy in a Large, Community-Based Integrated Healthcare Setting

Predictors of Breastfeeding Initiation and Maintenance in an Integrated Healthcare Setting.

The American Academy of Pediatrics recommends exclusive breastfeeding to age 6 months. Although breastfeeding rates in the United States have been increasing over time, further improvements are needed to meet Healthy People 2020 targets. Research aim: This study examined predictors of breastfeeding initiation and maintenance among a population of insured pregnant women. Participants were 1,149 pregnant women enrolled in the Pregnancy and Influenza Project in two Kaiser Permanente regions in 2010-2011. Data were collected through interviews at enrollment and 1 month and 6 months postpartum and through participants' electronic medical records. Nearly all (99%) women reported initiating breastfeeding. Rates of exclusive breastfeeding were 70% and 54% at 1 month and 6 months, respectively; an additional 22% and 23% of women reported supplementing breastfeeding with formula. Of the women who supplemented, the mean ( SD) infant age at formula introduction was 53 (62) days. Of those who had stopped breastfeeding, the mean ( SD) infant age at cessation was 85 (59) days. Higher maternal education level, better maternal self-rated health, prenatal folic acid use, absence of chronic medical conditions, and infant full-term birth were significantly associated with breastfeeding maintenance. Although rates of breastfeeding in this population were higher than national rates, a significant number of women stopped breastfeeding or introduced formula earlier than recommended. Two to 3 months postpartum may be a critical period warranting additional encouragement or intervention by healthcare providers. Mothers' education attainment, maternal health factors, and gestational age at delivery may predict likelihood of breastfeeding maintenance.