Integrated Health Delivery System Research Articles

Assessing Electronic Health Records for Describing Racial and Ethnic Health Disparities: A Research Note.

The use of data derived from electronic health records (EHRs) to describe racial and ethnic health disparities is increasingly common, but there are challenges. While the number of patients covered by EHRs can be quite large, such patients may not be representative of a source population. One way to evaluate the extent of this limitation is by linking EHRs to an external source, in this case with the American Community Survey (ACS). Relying on a stratified random sample of about 200,000 patient records from a large, public, integrated health delivery system in North Carolina (2016-2019), we assess linkages to restricted ACS microdata (2001-2017) by race and ethnicity to understand the strengths and weaknesses of EHR-derived data for describing disparities. The results in this research note suggest that Black-White comparisons will benefit from standard adjustments (e.g., weighting procedures) but that misestimation of health disparities may arise for Hispanic patients because of differential coverage rates for this group.

Comparative effectiveness of treating prenatal depression with counseling versus antidepressants in relation to preterm delivery

BackgroundMaternal depression during pregnancy is prevalent and has been associated with increased risk of preterm delivery (PTD). However, comparative effectiveness of two commonly used treatment options, mental health counseling and use of antidepressants, in mitigating the risk of PTD associated with maternal depression remains uncertain. Although antidepressant use has been associated with increased risk of PTD in many previous studies, a direct head-to-head comparison between these two treatment options has not been investigated. Thus, the comparative risk-benefit profiles of those two treatment options remain unclear. ObjectivesTo determine the comparative effectiveness of two commonly used options for treating prenatal depression in limiting the risk of PTD associated with maternal depression. Study DesignA large prospective cohort study was conducted among 82,170 pregnant women at Kaiser Permanente Northern California (KPNC), an integrated health delivery system. Clinically diagnosed depression and its treatments (use of antidepressants and mental health counseling) were identified from the KPNC electronic health record system (EHR). Gestational age was also recorded for all deliveries and captured by EHRs for determining PTD. ResultsUsing Cox proportional hazards regression incorporating propensity score methodology to ensure comparability between comparison cohorts, relative to those without depression, pregnant women with untreated depression had 41% increased risk of PTD: adjusted hazard ratio (aHR)=1.41, 95% confidence interval (CI)=1.24-1.60, confirming increased risk of PTD associated underlying maternal depression. Relative to untreated depression, any mental health counseling was associated with a 18% of reduced risk of PTD: aHR=0.82 (0.71-0.96). The inverse association showed a dose-response pattern: increased number of counseling visits was associated with greater reduction in PTD risk with 43% reduction in PTD risk associated with 4 or more visits (aHR=0.57, 95% CI=0.45-0.73). In contrast, use of antidepressants during pregnancy was associated with an additional 31% increased risk of PTD independent of underlying depression: aHR=1.31, 95% CI=1.06-1.61. This positive association also showed a dose-response relationship: a longer duration of use was associated with an even higher risk. ConclusionsThis study provides much needed evidence regarding the comparative effectiveness of two common treatment options for prenatal depression in the context of PTD risk. The results indicate that, to reduce PTD risk due to maternal depression, mental health counseling is more effective. Use of antidepressants may add additional risk of PTD, independent of the underlying depression. The findings provide data for clinicians and pregnant women to make informed and evidence-based treatment decisions that take into account the risks and benefits to both maternal and fetal health.

Hepatocellular Carcinoma in Metabolic Dysfunction-Associated Steatotic Liver Disease

In the US, hepatocellular carcinoma (HCC) has been the most rapidly increasing cancer since 1980, and metabolic dysfunction-associated steatotic liver disease (MASLD) is expected to soon become the leading cause of HCC. To develop a prediction model for HCC incidence in a cohort of patients with MASLD. This prognostic study was conducted among patients aged at least 18 years with MASLD, identified using diagnosis of MASLD using International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes; natural language processing of radiology imaging report text, which identified patients who had imaging evidence of MASLD but had not been formally diagnosed; or the Dallas Steatosis Index, a risk equation that identifies individuals likely to have MASLD with good precision. Patients were enrolled from Kaiser Permanente Northern California, an integrated health delivery system with more than 4.6 million members, with study entry between January 2009 and December 2018, and follow-up until HCC development, death, or study termination on September 30, 2021. Statistical analysis was performed during February 2023 and January 2024. Data were extracted from the electronic health record and included 18 routinely measured factors associated with MASLD. The cohort was split (70:30) into derivation and internal validation sets; extreme gradient boosting was used to model HCC incidence. HCC risk was divided into 3 categories, with the cumulative estimated probability of HCC 0.05% or less classified as low risk; 0.05% to 0.09%, medium risk; and 0.1% or greater, high risk. A total of 1 811 461 patients (median age [IQR] at baseline, 52 [41-63] years; 982 300 [54.2%] female) participated in the study. During a median (range) follow-up of 9.3 (5.8-12.4) years, 946 patients developed HCC, for an incidence rate of 0.065 per 1000 person-years. The model achieved an area under the curve of 0.899 (95% CI, 0.882-0.916) in the validation set. At the medium-risk threshold, the model had a sensitivity of 87.5%, specificity of 81.4%, and a number needed to screen of 406. At the high-risk threshold, the model had a sensitivity of 78.4%, a specificity of 90.1%, and a number needed to screen of 241. This prognostic study of more than 1.8 million patients with MASLD used electronic health record data to develop a prediction model to discriminate between individuals with and without incident HCC with good precision. This model could serve as a starting point to identify patients with MASLD who may need intervention and/or HCC surveillance.

Prevalence and appropriateness of in-person versus not-in-person ambulatory antibiotic prescribing in an integrated academic health system: A cohort study.

Ambulatory antibiotic stewardship generally aims to address the appropriateness of antibiotics prescribed at in-person visits. The prevalence and appropriateness of antibiotics prescribed outside of in-person visits is poorly studied. Retrospective cohort study of all ambulatory antibiotic prescribing in an integrated health delivery system in the United States. Antibiotic prescribers and patients receiving oral antibiotic prescriptions between January 2016 and December 2019. Proportion of antibiotics prescribed with in-person visits or not-in-person encounters (e.g., telephone, refills). Proportion of prescriptions in in 5 mutually exclusive appropriateness groups: 1) chronic antibiotic use; 2) antibiotic-appropriate; 3) potentially antibiotic-appropriate; 4) non-antibiotic-appropriate; and 5) not associated with a diagnosis. Over the 4-year study period, there were 714,057 antibiotic prescriptions ordered for 348,739 unique patients by 2,391 clinicians in 467 clinics. Patients had a mean age of 41 years old, were 61% female, and 78% White. Clinicians were 58% women; 78% physicians; and were 42% primary care, 39% medical specialists, and 12% surgical specialists. Overall, 81% of antibiotics were prescribed with in-person visits and 19% without in-person visits. The most common not-in-person encounter types were telephone (10%), orders only (5%), and refill encounters (3%). Of all antibiotic prescriptions, 16% were for chronic use, 15% were antibiotic-appropriate, 39% were potentially antibiotic-appropriate, 22% were non-antibiotic-appropriate, and 8% were not associated with a diagnosis. Antibiotics prescribed in not-in-person encounters were more likely to be chronic (20% versus 15%); less likely to be associated with appropriate or potentially appropriate diagnoses (30% versus 59%) or non-antibiotic-appropriate diagnoses (8% versus 25%); and more likely to be associated with no diagnosis (42% versus <1%). Ambulatory stewardship interventions that focus only on in-person visits may miss a large proportion of antibiotic prescribing, inappropriate prescribing, and antibiotics prescribed in the absence of any diagnosis.

Evaluation of potential socioeconomic and racial/ethnic disparities in all-cause mortality in adolescent and young adult patients with cancer.

6501 Background: Adolescent Young Adult (AYA) cancer patients, aged 15-39, have historically been understudied. For older adults, socioeconomic (SES) and racial/ethnic disparities in mortality have been demonstrated, but less is known about survival disparities for AYA patients. Most existing studies do not account for the influence of insurance status and access to care. To address this gap, we evaluated the association of SES and race/ethnicity with overall mortality for AYA cancer patients who were members of an integrated health delivery system with relatively equal access to care. Methods: Patients diagnosed with cancer at age 15-39 years old in Kaiser Permanente Southern California between 2010-2018 were included. The fourteen most common AYA cancer types within our cohort were included (excluding thyroid cancer due to low mortality rate). The Neighborhood Deprivation Index (NDI) was used as a marker of SES. Patients were placed into NDI quartiles (Q1: least deprived-Q4: most deprived). Mortality rate per 1,000 patient years was calculated for each racial/ethnic group and NDI quartile. Multivariable cox model was used to estimate hazard ratios (HRs) for all-cause mortality. Models included race/ethnicity and NDI subgroup simultaneously, adjusting for sex, age and stage at diagnosis, and cancer type. Results: A total of 6,380 patients (59% female, median age: 33) were followed for a maximum of ten years. Racial/ethnic distribution was 45% Hispanic, 36% non-Hispanic White, 10% non-Hispanic Asian/Pacific Islander, 7% non-Hispanic Black, 2% Other/Unknown. Overall mortality was 21.8 deaths per 1,000 person years. Crude mortality rates were higher among Non-White racial/ethnic groups (Asian/Pacific Islander: 26.7, Black: 26.2, Hispanic: 25.6, Other/Unknown: 30.3) compared to White patients (16.4). In the adjusted model, Hispanic (HR=1.32, 95% confidence interval [CI] 1.03-1.50, p=0.004) and Black (HR=1.35, 95% CI 1.00-1.83, p=0.05) patients experienced significantly higher risk of all-cause mortality compared to White patients. No mortality differences were observed between Asian/Pacific Islander and White patients. Patients from more deprived neighborhoods had higher mortality risk (Q1: 19.9, Q2: 19.8, Q3: 24.1, Q4: 27.4). In the adjusted model, there was no significant difference in all-cause mortality between Q1 and Q2-Q4 [Q2 (HR=0.88, 95% CI 0.71-1.10), Q3 (HR=0.94, 95% CI 0.75-1.17), Q4 (HR=0.96, 95% CI 0.76-1.22)]. Conclusions: Our study suggests that for insured AYA cancer patients with similar access to care, Hispanic and Black patients have increased risk of all-cause mortality as compared to White patients, while no significant SES survival disparities were observed. These findings warrant further investigation, awareness, and intervention to address inequities in cancer care among vulnerable populations.

Creating a Safety Net Process to Improve Colon Cancer Diagnosis in Patients With Rectal Bleeding.

Background Failure to follow up on patients with rectal bleeding is common and may result in a delay in diagnosis of colorectal cancer or in missing high-risk adenomas. The authors' purpose was to create an electronic patient safety net for those diagnosed with rectal bleeding but who did not have colonoscopy to ensure proper detection of colonic abnormalities, including colon cancer. Methods In an integrated health delivery system serving < 4.6 million patients in Southern California, from 2014 to 2019, the authors electronically identified patients with rectal bleeding aged 45 to 80 years but with no recently documented colonoscopy. These cases were reviewed by a gastroenterologist to determine if colonoscopy was appropriate. The physician looked for known documentation as to the cause of rectal bleeding and verified no contraindications to the procedure; if indicated, testing was offered. Results Using the authors' safety net program, 1430 patients with rectal bleeding who needed and completed a colonoscopy were identified. Of those patients, 7.5% had an advanced adenoma or cancer, with a total of 20 cancers, and 34% had findings that warranted more frequent colonoscopy. Conclusions The authors designed a safety net system that was able to capture information on patients with rectal bleeding who had not had a colonoscopy and detected in 34% colonic pathology that would have otherwise gone undetected. The program did not require many resources to implement and had the ability to potentially prevent harm from reaching patients whose rectal bleeding did not get prompt workup. Other health systems and practices should consider implementing a similar system.

Association between Residential Green Space and Healthcare Utilization

BACKGROUND AND AIMS Prior studies have shown greenness to be associated with beneficial health outcomes. We sought to determine if residential greenness correlated with healthcare utilization within an integrated health delivery system. METHODS We linked 5,189,303 members of Kaiser Permanente Northern California (KPNC) to Normalized Differentiated Vegetation Index (NDVI) values from Landsat satellite data (30m x 30m resolution) in 250, 500, and 1000 m radial buffers around each member&amp;#x27;s home. Healthcare utilization data for inpatient, outpatient, and emergency room visits were obtained by accessing data from the KPNC electronic health record. Using generalized estimating equations that adjusted for demographic, socioeconomic and other environmental factors, we regressed green space (in deciles) on healthcare utilization across the 2013 and 2017 study period. Adjustments were made for area sociodemographic and socioeconomic factors, and population and housing density. RESULTS We observed a significant trend across the decile range between higher levels of residential greenness and lower utilization of inpatient services (p&amp;#x3c;0.01) and emergency room visits (p&amp;#x3c;0.01). For outpatient visits, we observed a U-shaped curve where residing in middle of the NDVI range for this population was associated with greater outpatient visits than either the highest or lowest green space areas. Sensitivity analyses, including using various buffer sizes and tree canopy cover, an alternative measure of green space, yielded consistent findings. CONCLUSION Residing in an area with greater greenspace relative to low levels of greenspace was associated with greater in-patient and emergency room utilization. Residential greening can have a significant healthcare impact as measured by healthcare utilization. Keywords: green space, green cover, healthcare utilization, healthcare services

Mobile Team Vaccine - Standing up an Integrated Health Delivery System in 48 hours

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Adherence to lipid monitoring and its impact on treatment intensification of LDL-C lowering therapies at an urban academic medical center

Lipid monitoring is recommended by treatment guidelines to assess efficacy and adherence to lipid lowering therapy, but the available data is mostly limited to integrated health delivery systems with less diverse populations. To determine the proportion of patients that completed appropriate lipid monitoring at an urban academic medical center and whether lipid monitoring is associated with treatment intensification. Adults prescribed ≥1 LDL-C lowering therapy and with ≥1 outpatient encounter during 2018 and 2019 were included. Appropriate lipid monitoring was defined as ≥1 lipid panel obtained during the 12 month follow up period. Treatment intensification was defined as a dose increase, change to a higher intensity statin, or addition of a new LDL-C lowering therapy. The association between lipid monitoring and treatment intensification were assessed using regression models. Of the 12,332 patients on LDL-C lowering therapy, 88% had ≥1 lipid panel. The average patient was 60 years of age, 50% were female, and 50% identified as black or African American. On regression analysis (odds ratio [OR], 95% confidence interval [CI]), lipid monitoring occurred less frequently in adults >75 years of age (0.63, 0.44 to 0.90), black or African American individuals (0.78, 0.69 to 0.89), and those insured by Medicaid (0.72, 0.61 to 0.86). The odds of treatment intensification steadily increased with the number of lipid panels compared to those without lipid monitoring. Lipid monitoring is associated with treatment intensification but occurs less frequently in adults >75 years of age, black or African American individuals, and those insured by Medicaid.

Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia: CARE-FH Protocol.

The Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia (CARE-FH) study aims to improve diagnostic evaluation rates for FH at Geisinger, an integrated health delivery system. This clinical trial relies upon implementation science to transition the initial evaluation for FH into primary care, attempting to identify individuals prior to the onset of atherosclerotic cardiovascular disease events. The protocol for the CARE-FH study of this paper is available online. The first phase of the project focuses on trial design, including the development of implementation strategies to deploy evidence-based guidelines. The second phase will study the intervention, rolled out regionally to internal medicine, community medicine, and pediatric care clinicians using a stepped-wedge design, and analyzing data on diagnostic evaluation rates, and implementation, service, and health outcomes.

‘Trying to fly the plane while we were building it’. Applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study

ObjectiveA learning health system (LHS) uses data to generate evidence and answer questions required to continually improve system performance and patient care. Given the complexities of practice transformation, an area...

Dementia diagnosis patterns in a racially diverse population within an integrated health delivery system

AbstractBackgroundAlthough nearly 40% of older adults receive care in Medicare Advantage (MA) plans, there are limited information on whether the patterns of dementia diagnosis and health care utilization differ from traditional Medicare fee‐for‐service. We examined first ADRD diagnoses by provider type and clinical setting and compared patient socio‐demographic and clinical characteristics across a large integrated health care system in southern California.MethodsPatients 65 years and older who were continuously enrolled in the health plan for at least one year prior to January 1, 2015 and had a first dementia diagnosis code during the study period (January 1, 2015‐ December 31, 2018) were included in the analysis. Providers classified as dementia specialists included neurologists, psychiatrists, and geriatricians; all other providers were considered nondementia specialists and mostly represented primary care. Data were derived from electronic health records.ResultsThere were a total of 25,278 incident ADRD codes over the entire study period, slightly more than half assigned in ambulatory care and the remainder during a hospital‐based encounter. For the clinic‐diagnosed cohort (n=13,962), other than a slightly younger age for those diagnosed in neurology/psychiatry compared to geriatrics or primary care (79 vs. 82 years old), there were no other differences, including race/ethnicity or spoken language. Compared to the clinic cohort, the hospital‐diagnosed cohort (n=11,316) was slightly older (83 vs. 81 years old), more likely to be white (59% vs. 53%) and English speaking (90% vs. 85%); had more missed appointments (13% vs. 10%) and were more likely to have a non‐dementia cognitive impairment code in the two years prior (36% vs. 31%). They also had a higher burden of co‐morbidity (8.7 ± 3.8 vs. 7.0 ± 3.4) and higher rate of documented advance directive or POLST (49% vs. 41%) (all, p&lt;.01).ConclusionsNearly half of the incident ADRD codes were associated with a hospital‐based encounter. Patients first diagnosed with ADRD in the hospital setting were generally older and sicker compared to patients diagnosed in the clinic. Given such differing socio‐demographic and clinical characteristics at diagnosis, claims based studies should distinguish patients first diagnosed in hospital vs. clinic‐based settings.

The effect of a public transportation expansion on no-show appointments.

To test whether there were fewer missed medical appointments ("no-shows") for patients and clinics affected by a significant public transportation expansion. A new light rail line was opened in a major metropolitan area in June 2014. We obtained electronic health records data from an integrated health delivery system in the area with over three million appointments at 97 clinics between 2013 and 2016. We used a difference-in-differences research design to compare whether no-show appointment rates differentially changed among patients and clinics located near versus far from the new light rail line after it opened. Models included fixed effects to account for underlying differences across clinics, patient zip codes, and time. We obtained data from an electronic health records system representing all appointments scheduled at 97 outpatient clinics in this system. We excluded same-day, urgent care, and canceled appointments. The probability of no-show visits differentially declined by 0.5 percentage points (95% confidence interval [CI]: -0.9 to -0.1), or 4.5% relative to baseline, for patients living near the new light rail compared to those living far from it, after the light rail opened. The effects were stronger among patients covered by Medicaid (-1.6 percentage points [95% CI: -2.4 to -0.8] or 9.5% relative to baseline). Improvements to public transit may improve access to health care, especially for people with low incomes.

Implementation and evaluation of a centralized pharmacy telehealth center within an integrated health delivery system

AbstractIntroductionAccess to healthcare is a problem in the United States, exacerbated by inefficient system processes that warrant innovative reengineering solutions like centralized telehealth services.ObjectiveThe aim of this study is to describe the genesis and evolution of a centralized pharmacy telehealth center (“TelePharmacy”) at Geisinger, an integrated health delivery system.MethodsDescriptive statistics on the operations and impact of the TelePharmacy program were performed from inception in August 2017 to November 2020 using electronic health record data. In addition, a survey of clinic staff prior to and after initial TelePharmacy roll‐out was conducted to assess the impact on time spent on medication‐related activities and satisfaction with the service.ResultsTelePharmacy completed over two million refills, resulting in a decreased workload for 40% of clinic staff. TelePharmacy pharmacists identified and rectified 3372 medication therapy problems over a 12‐month period. Over the first 3.5 years, TelePharmacy expanded into other clinical areas such as anticoagulation, transitions of care, and urinary tract infection management.ConclusionGeisinger was able to initiate and expand services offered by a centralized pharmacy telehealth center and positively impact care team burden. TelePharmacy is expected to continue to expand its efforts to improve the patient care experience at Geisinger.

PNS75 The Evolution of Payer Perceptions of Icer

The influence of the Institute for Clinical and Economic Review (ICER) value assessment framework (VAF) on payer decisions has been increasing in recent years. There is limited evidence assessing how ICER’s VAF updates have influenced payer perceptions of ICER reports over time. To assess trends in payer perceptions of ICER’s evaluations over the last 4 years. Double-blinded web-based surveys were fielded in November 2016, November 2018, and October 2020 to individuals from integrated health delivery systems, pharmacy benefits managers, managed care organizations, and specialty pharmacies. There were 55, 54, and 47 payers who completed the surveys in 2016, 2018, and 2020, respectively. Respondents identified clinical outcomes relevant to decision making (62%), validity of the framework (57%), and clear and transparent methodology (53%) as the top strengths of ICER reports in 2020. In prior years, a transparent methodology (53% in 2016 and 56% in 2018) was considered a top strength. Limitations were somewhat consistent with prior years, including not having results at the time of decision making (30% in 2020 vs 28% in 2018 and 45% in 2016). Respondents identified comparative clinical effectiveness (79%) and health-benefit price benchmarks (57%) as the most influential components of ICER reports in 2020, which was consistent with prior years, especially for comparative clinical effectiveness (100% in 2016 and 89% in 2018). The most unclear component of ICER reports has steadily been the other benefits and contextual considerations section (30% in 2020 vs 37% in 2018 and 27% in 2016). While payer perceptions of ICER’s evaluations have evolved, methodology transparency has consistently been reported as a top strength over time, and timeliness of ICER reports continues to be a primary limitation.

Examining racial disparities in male breast cancer.

6555 Background: Male breast cancer (MBC) accounts for approximately 1% of all breast cancers. Racial disparities have not been examined in MBC. Methods: Within a large, integrated health delivery system, all adult female and male patients who were diagnosed with breast cancer from 01-01-2010 to 12-31-2018 were examined. Bivariate analysis was performed to examine clinical and demographic factors associated with breast cancer-related mortality. We conducted more detailed chart review in the MBC-only group (data period 01-01-2010 to 12-31-2019) to assess the mean time to treatment (from diagnosis to surgery, surgery to chemotherapy, and surgery to radiation) stratified by race using bivariate (t-test, one way ANOVA) analyses. Results: 32,848 female breast cancer and 226 MBC patients were evaluated; MBC patients represented 0.63% of all breast cancer patients. Between males and females, there was no statistically significant difference in race, with an overall distribution of 62% White, 19% Asian, 8% Black, and 11% Hispanic. To our knowledge, this is the largest and most racially diverse sample of MBC patients to date. MBC patients at diagnosis were significantly older (p &lt;.0001), more obese (p &lt; 0.0018), and sicker according to the Charlson Comorbidity Index (CCI) (p &lt; 0.0001) compared to female breast cancer patients. Males were more likely to be diagnosed at an advanced stage (19.2%) compared to females (12.5%) (p = 0.0037). With a mean follow up of 5 years, overall mortality was statistically significantly worse in MBC (23.0%) compared to female breast cancer patients (12.0%) (p &lt; 0.0001). Furthermore, breast cancer-related mortality was significantly higher in males (8.1%) than in females (4.5%) (p = 0.0124). In the MBC-only analysis, stage at diagnosis was not influenced by patient race. Asian and White MBC patients had the shortest mean time from diagnosis to surgery (27 and 29 days, respectively), with Hispanic MBC patients experiencing the longest time to surgery (46 days). Black MBC patients experienced the shortest mean time to chemotherapy after surgery (39 days), whereas Asian MBC patients experienced the longest time to chemotherapy (50 days). In survivorship, Black and Asian patients were least likely to undergo screening mammography (33.3%, and 43.3%, respectively), compared to 52% of White and 50% of Hispanic MBC patients. Ultimately, 13% of Asian and 11% of Hispanic MBC patients died of breast cancer, compared to 6.7% of Black and 6.2% of White MBC patients. Conclusions: While we found no statistically significant differences in mortality by race among MBC patients, our findings indicate that non-white patients had longer time to treatments, less survivorship screening, and worse disease related mortality than their white counterparts. Future study can elucidate these racial inequalities, enabling more equitable breast cancer treatment among patient subgroups.

Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care

BackgroundAfter implementation of the Surgical Home Recovery (SHR) initiative for mastectomy within a large, integrated health delivery system, most patients are discharged on the day of the procedure. We sought to identify predictors of SHR and unplanned return to care (RTC).Study DesignMastectomy cases with and without reconstruction from October 2017 to August 2019 were analyzed. Patient characteristics, operative variables, and multimodal pain management were compared between admitted patients and SHR patients using logistic regression. We identified predictors of RTC in SHR patients, defined as 7-day readmission, reoperation, or emergency department visit.ResultsOf 2,648 mastectomies, 1,689 (64%) were outpatient procedures and the mean age of patients was 58.5 years. Predictors of SHR included perioperative IV acetaminophen (odds ratio [OR] 1.59; 95% CI, 1.28 to 1.97), perioperative opiates (OR 1.47; 95% CI, 1.06 to 2.02), and operation performed by a high-volume breast surgeon (OR 2.12; 95% CI, 1.42 to 3.18). Bilateral mastectomies (OR 0.70; 95% CI, 0.54 to 0.91), immediate reconstruction (OR 0.52; 95% CI, 0.39 to 0.70), and American Society of Anesthesiologists class 3 to 4 (OR 0.69; 95% CI, 0.54 to 0.87) decreased the odds of SHR. Of SHR patients, 111 of 1,689 patients (7%) experienced RTC. Patients with American Society of Anesthesiologists class 3 to 4 (OR 2.01; 95% CI, 1.29 to 3.14) and African American race (OR 2.30; 95% CI, 1.38 to 4.91) were more likely to RTC; receiving IV acetaminophen (OR 0.56; 95% CI, 0.35 to 0.88) and filling an opiate prescription (OR 0.51; 95% CI, 0.34 to 0.77) decreased the odds of RTC.ConclusionsSurgeon volume and multimodal pain medication increased the odds of SHR. Within the SHR group, American Society of Anesthesiologists Class 3 to 4 and African American patients increased the likelihood of RTC. This study helps optimize patient selection and perioperative practice for successful SHR.

Overactive bladder in an integrated delivery system: a longitudinal cohort study

BackgroundOveractive bladder (OAB) is common and morbid. Medication and diagnosis claims may be specific, but lack sensitivity to identify patients with overactive bladder. We used an “electronic health record (EHR) phenotype” to identify cases and describe treatment choices and anticholinergic burden for OAB.MethodsWe conducted a retrospective cohort study in a large, integrated health delivery system between July 2011 and June 2012 (2-year follow-up). We examined care from primary care and specialty clinics, medication and procedure use, and anticholinergic burden for each patient.ResultsThere were 7362 patients with an EHR OAB phenotype; 50% of patients were > 65 years old, 74% were female, and 83% were white. The distribution of care included primary care physician (PCP)/specialty co-management (25% of patients); PCP care only (18%); urology only (13%); or some other combination of specialty care (33%). Only 40% of patients were prescribed at least 1 OAB medication during the study. The mean duration of prescribed medication was 1.5 months (95% confidence interval [CI], 1.4 to 1.6 months; range, < 1 month to 24 months). Independent predictors of receipt of an OAB medication included increasing age (odds ratio [OR], 1.4 for every 10 years; 95% CI, 1.4 to 1.5), women (OR, 1.6 compared with men; 95% CI, 1.4 to 1.8), diabetes (OR, 1.3; 95% CI, 1.1 to 1.5), and certain sources of care compared with PCP-only care: PCP/specialty co-management (OR, 1.8; 95% CI, 1.5 to 2.0), urology (OR, 2.2; 95% CI, 1.8 to 2.6), and multiple specialists (OR, 1.4; 95% CI, 1.2 to 1.8). Very few patients received other treatments: biofeedback (< 1%), onabotulinumtoxinA (2%), or sacral nerve stimulation (1%). Patients who received OAB medications had significantly higher anticholinergic burden than patients who did not (anticholinergic total standardized daily dose, 125 versus 46; P < .001).ConclusionsAlthough OAB is common and morbid, in a longitudinal study using an EHR OAB phenotype 40% of patients were treated with OAB medication and only briefly.

Identifying hypertension in pregnancy using electronic medical records: The importance of blood pressure values.

To incorporate blood pressure (BP), diagnoses codes, and medication fills from electronic medical records (EMR) to identify pregnant women with hypertension. A retrospective cohort study of singleton pregnancies at three US integrated health delivery systems during 2005-2014. Women were considered hypertensive if they had any of the following: (1) ≥2 high BPs (≥140/90mmHg) within 30days during pregnancy (High BP); (2) an antihypertensive medication fill in the 120days before pregnancy and a hypertension diagnosis from 1year prior to pregnancy through 20weeks gestation (Treated Chronic Hypertension); or (3) a high BP, a hypertension diagnosis, and a prescription fill within 7days during pregnancy (Rapid Treatment). We described characteristics of these pregnancies and conducted medical record review to understand hypertension presence and severity. Of 566,624 pregnancies, 27,049 (4.8%) met our hypertension case definition: 24,140 (89.2%) with High BP, 5,409 (20.0%) with Treated Chronic Hypertension, and 5,363 (19.8%) with Rapid Treatment (not mutually exclusive). Of hypertensive pregnancies, 19,298 (71.3%) received a diagnosis, 9,762 (36.1%) received treatment and 11,226 (41.5%) had a BP≥160/110. In a random sample (n=55) of the 7,559 pregnancies meeting the High BP criterion with no hypertension diagnosis, clinical statements about hypertension were found in medical records for 58% of them. Incorporating EMR BP identified many pregnant women with hypertension who would have been missed by using diagnosis codes alone. Future studies should seek to incorporate BP to study treatment and outcomes of hypertension in pregnancy.

Clinical Effectiveness of Decision Support for Prescribing Opioids for Chronic Noncancer Pain: A Prospective Cohort Study

ObjectivesThis prospective cohort study examines the clinical effectiveness of electronic medical record clinical decision support (EMR CDS) for opioid prescribing. MethodsData analysis included primary care patients with chronic opioid therapy for noncancer pain seen within an integrated health delivery system in Louisiana between January 2017 and October 2018. EMR CDS incorporated an opioid health maintenance tool to display the status of risk mitigation, and the medication order embedded the morphine equivalent daily dose (MEDD) calculator and a hyperlink to the Louisiana pharmacy drug monitoring program. Outcome measures included change in the average MEDD and rates of opioid risk mitigation, hospitalization, and emergency department use. ResultsAmong 14 221 patients, 9% had prescriptions with an average MEDD ≥90 mg. There were no significant changes in MEDD after EMR CDS implementation. Increasing age, Charlson Comorbidity Index score, female sex, black non-Hispanic race, non-opioid pain medication co-prescriptions, and specialty referrals were associated with a lower odds of MEDD ≥90 (high-dose threshold). Medicare or self-pay, substance abuse history, and pain agreements were associated with increased odds of prescribing above this high-dose threshold. After incorporation of EMR CDS, patients had higher rates of urine drug screens (17% vs 7%) and naloxone prescriptions (3% vs 1%, all P < .001). In addition, specialty referrals to physical or occupational therapy, orthopedics, neurology, and psychiatry or psychology increased in the postintervention period. Although emergency department use decreased (rate ratio 0.92; 95% confidence interval 0.89-0.95), hospitalization rates did not change. ConclusionsEMR CDS improved adherence to opioid risk mitigation strategies. Further research examining which practice redesign interventions effectively reduce high-dose opioid prescribing is needed.