Integrated Health Care System Research Articles

Assessment of Screening for Adverse Childhood Experiences and Receipt of Behavioral Health Services Among Children and Adolescents

Screening for adverse childhood experiences (ACEs) in primary care settings has been increasing as a response to the overwhelming and consistent evidence of the deleterious associations between ACEs and later physical and mental health. However, there is little empirical guidance on the appropriate implementation of ACEs screening in pediatric primary care. To test the use of a pilot intervention for ACEs screening and referral on the receipt of behavioral health care for children and adolescents within a large integrated health care delivery system. A retrospective cohort study was conducted in a large integrated health care system serving Southern California. Child and adolescent members of the target health care system younger than 18 years between July 1, 2018, and November 30, 2021, who received a positive screening for ACEs at the pilot clinic were included. This pilot clinic implemented an intervention that included additional screening questions and incorporated social workers into the process of evaluation and referral for behavioral health needs following ACEs screening. ACEs screening. Visit to a behavioral health care service within 90 days of a positive ACEs screen determined as a score of 1 or higher and behavioral symptoms. The cohort consisted of 4030 children (mean [SD] age, 9.94 [4.55] years) with positive ACEs screening, 48% adolescents (11-17.99 years), approximately equal gender (51% females), 73% Hispanic, and 33% with Medicaid insurance. After the intervention, children were more likely to have a behavioral health services visit within 90 days of the screening than before the intervention (from 4.33% to 32.48%; incidence rate ratio, 7.50; 95% CI, 1.55-36.2). In this cohort study, the implementation of a new ACEs screening and referral process was associated with increased receipt of behavioral health services among children with a positive ACEs screening. This could be useful strategy for other health care systems responding to state and local mandates to screen and provide care for children with ACEs.

1097. Risk of Severe COVID-19 Disease in Individuals with Down syndrome: a Matched Cohort Study from a Large, Integrated Health Care System

Abstract Background Down syndrome (DS) is associated with an increased risk of infections attributed to immune defects. Whether individuals with DS are at an increased risk of severe COVID-19 remains unclear. Methods In a matched cohort study, we evaluated the risk of COVID-19 infection and severe COVID-19 disease in individuals with DS and their matched counterparts in a pre-COVID-19 vaccination period at Kaiser Permanente Southern California. Multivariable Cox proportion hazard regression was used to investigate associations between DS and risk of COVID-19 infection and severe COVID-19 disease. Results Our cohort included 2,541 individuals with DS and 10,164 without DS matched on age, sex, and race/ethnicity (51.6% female, 53.3% Hispanic, median age 25 years [interquartile range 14 – 38]), with pulmonary disease as the most common comorbidity (13.1%) followed by diabetes (5.4%). While the rate of COVID-19 infection in individuals with DS was 32% lower than their matched counterparts (adjusted hazard ratio [aHR] 0.68, 95% CI: 0.56-0.83), the rate of severe COVID-19 disease was 6-fold higher (aHR 6.14, 95% CI: 1.87-20.16) (Table 1). The Kaplan-Meier plot demonstrated similar cumulative incidence for those with and without DS at the beginning of the pandemic, followed by a rate increase in July 2020 (at 4 months of follow-up), and in November 2020 (at 8 months of follow-up) (Figure 1), after which the cumulative incidence for those with DS was consistently higher. Figure 2 demonstrated consistently higher cumulative incidence estimates of COVID-19 hospitalization for those with DS than those without. Table 1.Incidence rates and hazard ratios of COVID-19 infection, severe COVID-19 disease and COVID-19 hospitalization mortality among 2,541 individuals with Down Syndrome and 10,164 matched counterparts without Down Syndrome at Kaiser Permanente Southern California, 03/01/2020 - 12/31/2020 aAdjusted for covariates: body mass index, smoking, number of outpatient visits, number of emergency department visits, number of hospitalizations, frailty status based on frailty index (yes/no), all baseline comorbidities, and medical center area. Abbreviations: DS = Down Syndrome; non-DS = matched counterparts without Down Syndrome; CI = confidence interval Figure 1.Cumulative incidence estimates of COVID-19 infection by Down syndrome status, Kaiser Permanente Southern California, 03/01/2020 - 12/31/2020Figure 2.Cumulative incidence estimates of COVID-19 hospitalization by Down syndrome status, Kaiser Permanente Southern California, 03/01/2020 - 12/31/2020 Conclusion Although the risk of COVID-19 infection is lower, the risk of severe disease is higher in individuals with DS compared to their matched counterparts. Better infection monitoring, early treatment, and promotion of vaccine for COVID-19 are warranted for DS populations. Disclosures Jennifer H. Ku, PhD MPH, GSK: Grant/Research Support|Moderna: Grant/Research Support Myron J. Levin, MD, Curevo: Advisor/Consultant|Merck: Advisor/Consultant|Pfizer: Advisor/Consultant|seqirus: Advisor/Consultant|SmithKline Beecham: Grant/Research Support Yi Luo, PhD, Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support|Seqirus: Grant/Research Support Ana Florea, PhD MPH, Gilead: Grant/Research Support|GSK: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Yun Tian, MS, Glaxosmithkline: Grant/Research Support|Moderna: Grant/Research Support Hung Fu Tseng, PhD MPH, GSK: Grant/Research Support|Janssen: Advisor/Consultant|Moderna: Grant/Research Support|Pfizer: Advisor/Consultant|Seqirus: Grant/Research Support.

2219. Syphilis Diagnosis and Treatment Practices in the Ambulatory Setting of a Large Vertically Integrated Healthcare Organization: An Opportunity for Infectious Diseases Physician Engagement

Abstract Background Sexually transmitted infections (STIs) continue to increase in the United States. Syphilis management may challenge busy outpatient clinicians and diagnostic delays have been described. To better understand syphilis treatment practices and identify targets for improvement in our organization, we characterized outpatient encounters associated with a positive syphilis test. Methods Intermountain Healthcare (IH) is an integrated healthcare system with 23 emergency departments (ED), 34 urgent care (UC), and >100 primary care (PC) clinics. Protocols favor treponemal testing as the initial screening test. All positive treponemal tests associated with a positive non-treponemal test in the ambulatory setting were routed to an electronic inbox within the electronic health record (EHR) and reviewed by a team of Infectious Disease (ID) clinicians from May 1st 2021 – January 31st, 2022. Positive results originating from ID or HIV-trained primary care clinicians were excluded. Each encounter was assessed for staging and treatment plans based on CDC guidelines as well as HIV pre-exposure prophylaxis (PrEP) and HIV treatment eligibility. Results 119 encounters were reviewed. Patients 30-44 years old were most likely to have a positive test (50, 42.0%). PC (63, 52.9%) and UC (24, 20.2%) accounted for the most positive tests. 102 (85.7%) positive tests were from white patients, consistent with racial demographics of Utah. Only 40 (33.6%) encounters could be clinically staged after chart review by an ID clinician. Of these, 17 (42.5%) were determined to be staged and treated inappropriately by the treating provider. 54 (45.4%) encounters could not be staged and required further testing or more clinical history to determine the significance of positive test. 18 (15.1%) patients could possibly have benefitted from PrEP evaluation and one new HIV diagnosis was referred to ID clinic. Conclusion Our exploratory analysis revealed many syphilis cases unable to be staged on chart review and opportunities to improve care. Strategies such as prospective audit and feedback or eConsults may be insufficient and clinical evaluation may be necessary to stage syphilis infection. Syphilis care improvements in our system may be a future target for ID physician engagement and novel stewardship strategies. Disclosures All Authors: No reported disclosures.

296. SARS-CoV-2 Illness Severity and Early Hospitalization Outcomes in a Multicenter Prospective Cohort Study Among Veterans

Abstract Background Over 600,000 SARS-CoV-2 infections and 20,000 deaths have occurred among users of the Veterans Health Administration, the US’s largest integrated health care system. We explored early outcomes of SARS-COV-2 infection in Veterans. Methods An ongoing, prospective longitudinal cohort study of Veterans ages ≥ 18 enrolled 1,826 participants (29.0% inpatient; 49.1% vaccinated; 68.3% SARS-CoV-2-positive; 85.0% male, mean age = 57.1 years) seeking inpatient or outpatient care after SARS-CoV-2 testing at 15 Department of Veterans Affairs medical centers in July 2020 to February 13, 2022. Using multivariable regression, we estimated relationships of baseline demographic characteristics, COVID-19 vaccination, and clinical history to illness severity and cumulative length of hospital stay within 60 days of study entry. Illness severity was defined by a Veterans Affairs adaptation of the WHO COVID-19 severity scale and included 4 levels (mild, moderate, severe, or death). We derived the Charlson co-morbidity index (CCI) and other baseline characteristics from electronic health data and study questionnaires, and reported qualitative SARS-CoV-2 IgG responses using inpatients’ study-collected blood specimens. Results High CCI scores (≥ 5) occurred in 47 (42.7%) vaccinated SARS-CoV-2-positive inpatients and 47 (21.2%) unvaccinated. Severe illness occurred in 17 (15.5%) vaccinated inpatients, 37 (16.7%) unvaccinated inpatients, 4 (0.9%) vaccinated outpatients, and 3 (0.7%) unvaccinated outpatients. Eleven (10%) of 110 vaccinated SARS-CoV-2-positive inpatients died, as did 15 (6.8%) of the 222 unvaccinated. In SARS-CoV-2-positive inpatients, a one-step higher CCI was associated with more severe illness (aOR 1.10, 95% CI 1.01-1.20) and more hospitalization days (aIRR 1.06, 95% CI 1.03-1.10), adjusting for vaccination status. Respectively, 93% of vaccinated and 63% of unvaccinated SARS-CoV-2 positive inpatients with baseline antibody results had an anti-spike IgG response. Conclusion In an ongoing longitudinal cohort study of COVID-19 in US Veterans, comorbidity burden was higher among vaccinated than unvaccinated inpatients and was associated with more severe illness and hospitalization days, independent of vaccination status. Disclosures Christine M. Hunt, MD, MPH, Adaptive Phage Therapeutics: Advisor/Consultant|Akebia: Advisor/Consultant|Galmed: Advisor/Consultant|Otsuka: Advisor/Consultant|Palladio: Advisor/Consultant.

1389. A Comparison of a Telephone versus In-Person HIV Linkage to Care Intervention in a Large Health Care System

Abstract Background Evidence suggests linkage to care (LTC) should occur immediately after HIV diagnosis improves retention in care and viral suppression. Established protocol for newly diagnosed or out of care people living with HIV (PLwH) with hospital admission in our healthcare system is for an in person LTC encounter for outpatient care including clinic follow up. We compared whether an in-person versus phone encounter intervention, were equally effective LTC methods. Methods PLwH admitted to any of three hospitals in our vertically integrated healthcare system were identified through the electronic health record (EHR) daily by the LTC coordinator for further screening. Inclusion criteria included: inpatient status with ICD9/10 code in EHR for HIV, no self-reported combination anti-retroviral therapy (cART) in the 30 days prior to admission, and not engaged in HIV care in greater than 12 months. Patients were randomized to either an in-person visit or a phone-call LTC encounter. Primary outcomes included follow up with an HIV provider within 30 days of discharge, and cART prescription 90 days of being discharged. Viral load suppression, CD4 count and readmission rates were secondary outcomes. Results were analyzed using an intent to treat model. All tests were two-sided at the significance level of 0.05 Results 2750 patients were screened for eligibility, 260 randomized during an 18-month period to an in-person visit (n=131) or telephone visit (n=129). The median age was 45 years, 67% were male, and 78% Black/African American. 15% of patients were newly diagnosed during admission. (Table 1) No differences were observed between the two LTC groups in follow up within 30 days (41% total), cART prescription within 90 days (76%), viral load suppression at 6 months (45%), CD4 count (57%), and readmission within 30 days of discharge (34%). (Table 2). Conclusion Telephone and in-person encounters for LTC had similar outcomes regarding HIV follow up, ART prescribing, viral suppression, and hospital readmission at our institution. Improvements in the linkage process do need to be made in all outcome categories to further improve care with and ultimately viral suppression. Telephone visits provide opportunity to make LTC more efficient and with less human resource needs. Disclosures Christopher Polk, MD, Gilead: Advisor/Consultant.

1739. An Exploratory Analysis to Examine Urgent Care Antibiotic Prescribing Inequities in a Vertically Integrated Healthcare System

Abstract Background Previous studies have shown antibiotic prescribing differences based on patient demographics which may represent inequitable care. Our objective was to perform an exploratory analysis of antibiotic prescribing rates for respiratory conditions to better understand possible inequities and identify disparities in our health system. Methods This was a retrospective cohort study of urgent care encounters for respiratory conditions in the Intermountain Healthcare (IH) network from July 1st 2018 – June 30th 2019. Individual respiratory encounters were identified using a validated methodology based on ICD10 codes. Overall antibiotic prescribing rates and rates for Tier 1 (antibiotics indicated), 2 (sometimes indicated), and 3 (not indicated, eg bronchitis) conditions were assessed. Prescribing rates for categories in which inequities might exist, including age, weight, patient race/ethnicity, preferred language, provider type, and provider/patient gender combinations, were examined. We considered an absolute percentage difference between groups within a category of ≥5.0% to represent a potential disparity. Results 93,588 (48.5%) of 193,107 respiratory urgent care encounters were associated with an antibiotic prescription. Overall antibiotic prescribing rates (Results Image 1) were higher in white compared to non-white patients (49.0% vs 38.2%) and in those reporting non-Hispanic ethnicity compared to Hispanics (49.1% vs 43.2%). Patients over 18 years-old were prescribed antibiotics more frequently than younger patients. Among Tier 3 encounters male providers prescribed antibiotics more frequently for male patients than female providers did for female patients (20.8% vs 15.6). Overweight and obese patients with Tier 3 diagnoses received antibiotic prescriptions more frequently than non-obese patients (22.8% vs 15.3%). Minimal differences between patients who preferred English and those who preferred non-English languages were observed. Results Image 1 - Table 1 Overall antibiotic prescribing rates and antibiotic prescribing rates for Tier 3 conditions for urgent care respiratory condition encounters July 1st, 2018 – June 30th, 2019*¥. *Tier 3 codes are those where antibiotics are not indicated (eg bronchitis). ¥Absolute differences of ≥5.0% between groups within each category are indicated in bold. Conclusion Antibiotic prescribing rates for respiratory conditions in urgent care encounters in our system differed based on race, ethnicity, age, obesity, and gender. These differences may represent biases contributing to inequities in care and may serve as potential targets for improved stewardship efforts. Disclosures All Authors: No reported disclosures.

2212. Improving Sexually Transmitted Infection Co-testing in a Large Urgent Care Network

Abstract Background Sexually transmitted infections (STIs) remain a serious public health concern. The state of Utah has the lowest percentage of adults 18-64 years-old ever tested for HIV (26.5%) and the lowest percentage tested for HIV in the previous 12 months (6.5%). Increasing HIV testing in Utah is of the utmost importance. Delayed diagnoses and missed testing opportunities for HIV and other STIs exist. Encounters for evaluation of possible gonorrhea (GC) or chlamydia (CT) infection is a critical opportunity to co-test for HIV and syphilis. With continued growth, urgent care (UC) sites are well-positioned to increase STI diagnosis and treatment. We aimed to develop a multi-faceted quality improvement (QI) bundle to increase STI testing in our UC centers. Methods Intermountain Healthcare (IH) is a vertically integrated healthcare network predominantly in Utah and operates a network of 35 UC clinics across the state. In 2020, qualitative interviews to evaluate barriers to STI testing were performed with UC clinicians. Based on these interviews a QI initiative was designed and implemented throughout 2021. The bundle included clinician education, electronic health record (EHR) improvements, and automatic referral for patients with a new diagnosis of HIV to an Infectious Diseases (ID) physician (Methods Image 1). We compared co-testing rates before (July 2018 – December 2020) and after the intervention began (March 2021 – April 2022). Methods Table 1 The quality improvement (QI) initiative began in 2021 and consisted of multiple components as detailed below. Results 13,715 and 5,628 UC encounters were associated with GC/CT testing during the pre-intervention and intervention periods, respectively. HIV co-testing was performed in 2,784 (20.3%) GC/CT testing encounters in the pre-intervention period and in 1,674 (29.7%) encounters during the intervention, a relative increase of 37.6%. HIV/syphilis co-testing was performed in 2,304 (16.8%) GC/CT testing encounters and 1,225 (21.8%) encounters during the pre-intervention and intervention phases, respectively. From January 1 2022 – April 1 2022 3 new outpatient HIV diagnoses were identified. The average time from diagnosis to contact with an ID provider was 30.0 hours. Results Image 1 Co-testing rates for GC/CT UC encounters are presented for HIV (blue), syphilis (green), and HIV/syphilis (orange). Testing reagent quality issues in early 2022 lead to an abrupt decline in syphilis co-testing and once these issues were resolved co-testing trends returned to similar rates prior to the reagent quality issue and testing limitation. Conclusion Multi-modal QI initiatives may increase STI testing rates within UC centers of integrated healthcare systems. Further study is needed to optimize STI screening, diagnosis, and care in UC centers. Disclosures Kimberly D. Brunisholz, PhD, MST, Johnson and Johnson: Advisor/Consultant.

Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors.

To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy. The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates. A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges. Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.

Perception of Healthcare Providers during the COVID-19 Pandemic: A Mixed Method Survey in an Integrated Healthcare Delivery System in Saudi Arabia.

During the COVID-19 pandemic, telemedicine was broadly adopted for patient care. Considering this experience, it is crucial to understand the perceptions of teleclinic healthcare professionals. In Saudi Arabia, telemedicine literature was restricted to physicians working in government and private hospitals. This study examined perceptions in relation to telemedicine among physicians and other healthcare professionals practicing in Saudi Arabian military hospitals in the Taif region. During COVID-19, telemedicine was implemented in military hospitals; consequently, this study assists in evaluating introduced practices and the perceptions of health professionals regarding these new practices. A quantitative, descriptive, correlational, and cross-sectional study was undertaken on healthcare professionals (N = 153). Twenty (20) items based on standardized measures were used to collect data using an online questionnaire. The measures contained three subscales: perceived usefulness, perceived ease, and behavioral intention. It was hypothesized that the perception of teleclinic usefulness and ease score by healthcare providers would be significantly correlated with behavioral intention. Descriptive statistics for mean, frequency, and standard deviation, as well as a Pearson correlation coefficient and regression analysis, were conducted to assess the relationship and predictive association between variables. In addition, a focus group discussion was organized to collect information directly from healthcare professionals. Most of the participants were approximately 40 years of age, Saudi Nationals (63%), medical specialists (62%), and were involved in teleclinic practices before the COVID-19 pandemic (60%). The reliability of all three scales was determined to be acceptable (α = 0.75-0.91). Perceived usefulness and perceived ease were shown to be significantly correlated with behavioral intention (r = 0.877, p = 0.05). In addition, the regression analysis indicated that perceived usefulness and perceived ease are predictors of the behavioral intention (R2 = 0.777, F (2,152) = 261.76, p = 0.001) of teleclinic practices among healthcare professionals. The positive perception of telemedicine integration in healthcare systems revealed by this study is a major catalyst for continuous adoption. On the other hand, certified telemedicine platforms, on-the-job training, Internet of things, and a flexible approach are required to find opportunities and enhancements in telemedicine interactions.

Prepregnancy body mass index and risk of childhood asthma.

Growing evidence suggests that maternal obesity may affect the intrauterine environment and increase a child's risk of developing asthma. We aim to investigate the relationship between prepregnancy obesity and childhood asthma risk. Cohorts of children enrolled in Kaiser Permanente Northern California integrated healthcare system were followed from birth (2005-2014) to age 4 (n=104,467), 6 (n=63,084), or 8 (n=31,006) using electronic medical records. Child's asthma was defined using ICD codes and asthma-related prescription medication dispensing. Risk ratios (RR) and 95% confidence intervals (95% CIs) for child's asthma were estimated using Poisson regression with robust error variance for (1) prepregnancy BMI categories (underweight [<18.5], normal [18.5-24.9], overweight [25-29.9], obese 1 [30-34.9], and obese 2/3 [≥35]) and (2) continuous prepregnancy BMI modeled using cubic splines with knots at BMI category boundaries. Models were adjusted for maternal age, education, race, asthma, allergies, smoking, gestational weight gain, child's birth year, parity, infant sex, gestational age, and child's BMI. Relative to normal BMI, RRs (95%CIs) for asthma at ages 4, 6, and 8 were 0.91 (0.75, 1.11), 0.95 (0.78, 1.16), and 0.97 (0.75, 1.27) for underweight, 1.06 (0.99, 1.14), 1.08 (1.01, 1.16), and 1.03 (0.94, 1.14) for overweight, 1.09 (1.00, 1.19), 1.12 (1.03, 1.23), 1.03 (0.91, 1.17) for obese 1, and 1.10 (0.99, 1.21), 1.13 (1.02, 1.25), 1.14 (0.99, 1.31) for obese 2/3. When continuous prepregnancy BMI was modeled with splines, child's asthma risk generally increased linearly with increasing prepregnancy BMI. Higher prepregnancy BMI is associated with modestly increased childhood asthma risk.

Electroconvulsive Therapy Anesthetic Choice and Clinical Outcomes.

Etomidate and methohexital are the 2 commonly used anesthetics for electroconvulsive therapy (ECT) in the United States. The objective of this study was to examine how anesthetic choice between etomidate and methohexital is associated with real-world clinical outcomes. This naturalistic retrospective cohort study examined longitudinal electronic health records for 495 adult patients who received 2 or more ECT treatments from 2010 to 2019 in Kaiser Permanente North California, a large integrated health care system. Study outcomes included 12-month posttreatment depression remission as measured by the 9-item Patient Health Questionnaire, psychiatric and all-cause emergency department visits, and psychiatric and all-cause hospitalizations. Anesthetic choice was not significantly related to depression severity, emergency department visits, or psychiatric hospitalizations at 12 months after completing ECT. In exploratory analyses, we found that etomidate compared with methohexital was associated with higher rates of patient discomfort adverse effects-postictal agitation, phlebitis, and myoclonus (2.4% vs 0.4%; P < 0.001). We present the first large comparison of etomidate and methohexital as anesthetics for ECT and their associations with real-world outcomes. Our study showed no significant difference on depression remission, emergency department visits, or hospitalizations 12-months posttreatment. Thus, clinicians should focus on other patient or treatment characteristics when deciding on anesthetics for ECT. Further investigation is needed to confirm our exploratory findings that etomidate use was correlated with a higher rate of patient discomfort adverse effects relative to methohexital.

Health Disparities in Kidney Failure Among Patients With Autosomal Dominant Polycystic Kidney Disease: A Cross-Sectional Study

Understanding potential differences in patterns of kidney failure among patients with autosomal dominant polycystic kidney disease (ADPKD) may provide insights into improving disease management. We sought to characterize patients with ADPKD and kidney failure across different race/ethnicities. Cross-sectional study. Kaiser Permanente Southern California members diagnosed with ADPKD between January1, 2002, and December 31,2018. ADPKD. Kidney failure, dialysis, or receipt of kidney transplant. Differences in characteristics by race/ethnicity were assessed using analysis of variance F test and χ2 test. To compare the range and distribution of the average age at onset of kidney failure by race/ethnicity and sex, we used box plots and confidence intervals. Multivariable logistic regression was used to estimate OR for kidney transplant. Among 3,677 ADPKD patients, 1,027 (27.3%) had kidney failure. The kidney failure cohort was comprised of Black (n=138; 30.7%), White (n=496; 30.6%), Hispanic (n=306; 24.7%), and Asian (n=87; 23.6%) patients. Hispanic patients had the youngest mean age of kidney failure onset (50 years) compared to Black (56 years) and White (57 years) patients. Black (44.2%; OR, 0.72) and Hispanic (49.7%; OR, 0.65) patients had lower rates of kidney transplantation compared to White (53.8%) patients. Preemptive kidney transplantations occurred in 15.0% of patients. Retrospective study design and possible misclassification of ADPKD cases. Kidney function calculations were based on equations incorporating race, potentially overestimating kidney function in African Americans. The study was conducted within a single, integrated health care system in 1 geographic region and may not be generalizable to all ADPKD patients. Among a large diverse ADPKD population, we observed racial/ethnic differences in rates of kidney failure, age of kidney failure onset, and rates of kidney transplantation. Our real-world ADPKD cohort provides insight into racial/ethnic variation in clinical features of disease and potential disparities in care, which may affect ADPKD outcomes.

Identifying monoclonal gammopathy of undetermined significance from electronic health records.

Monoclonal gammopathy of undetermined significance (MGUS) precedes multiple myeloma (MM). Use of electronic health records may facilitate large-scale epidemiologic research to elucidate risk factors for the progression of MGUS to MM or other lymphoid malignancies. We evaluated the accuracy of an electronic health records-based approach for identifying clinically diagnosed MGUS cases for inclusion in studies of patient outcomes/ progression risk. Data were retrieved from Kaiser Permanente Southern California's comprehensive electronic health records, which contain documentation of all outpatient and inpatient visits, laboratory tests, diagnosis codes and a cancer registry. We ascertained potential MGUS cases diagnosed between 2008 and 2014 using the presence of an MGUS ICD-9 diagnosis code (273.1). We initially excluded those diagnosed with MM within 6months after MGUS diagnosis, then subsequently those with any lymphoid malignancy diagnosis from 2007 to 2014. We reviewed medical charts for 100 randomly selected potential cases for evidence of a physician diagnosis of MGUS, which served as our gold standard for case confirmation. To assess sensitivity, we also investigated the presence of the ICD-9 code in the records of 40 randomly selected and chart review-confirmed MGUS cases among patients with a laboratory report of elevated circulating monoclonal (M-) protein (a key test for MGUS diagnosis) and no subsequent lymphoid malignancy (as described above). The positive predictive value (PPV) for the ICD-9 code was 98%. All MGUS cases confirmed by chart review also had confirmatory laboratory test results. Of the confirmed cases first identified via M-protein test results, 88% also had the ICD-9 diagnosis code. The diagnosis code-based approach has excellent PPV and likely high sensitivity for detecting clinically diagnosed MGUS. The generalizability of this approach outside an integrated healthcare system warrants further evaluation.

Harnessing the Electronic Medical Record to Improve the Utilization of Ultrasound Screening for Abdominal Aortic Aneurysms

The US Preventive Services Task Force recommends one-time ultrasound screening to detect abdominal aortic aneurysms (AAAs) in male smokers. Despite this recommendation, AAA screening is still underutilized. The aim of this study was to determine the effectiveness of an electronic medical record (EMR) automated ordering program in increasing AAA screening at an integrated health care system. This study was a retrospective chart review of patients who underwent ultrasound screening for AAA from January 1, 2016, to December 31, 2021, at a geographically isolated integrated health care system. An automated ordering system was implemented in a stepwise fashion within our EMR beginning in March 2019. The number of ultrasound studies and the incidence of AAA were compared between manual referral and EMR automated ordering periods. A total of 4,176 patients met the inclusion criteria for this study, among whom 148 aneurysms were identified. There was an increase in the average number of monthly screening ultrasound studies performed during the automated ordering period compared with the manual referral period (105 vs 16.3 studies, P < .001). The incidence of AAA was lower in the automated ordering period compared with the manual referral period (3.2% vs 5.3%, P= .013). An EMR automated ordering program can increase the number of screening ultrasound studies performed for AAA, which may help clinicians identify more high-risk aneurysms requiring urgent repair.

Veterans’ Experiences Using a Complementary and Integrated Healthcare System: Identifying Themes Across Multiple Dimensions of Wellness

<h3>Research Objectives</h3> The Department of Veterans' Affairs (VA) has implemented the Whole Health System (WH), an approach to care focusing on what matters to individual veterans to support health and well-being.1 The approach includes a personalized values-based health plan and complementary and integrative (CIH) health activities.2-4 The purpose of this locally initiated quality improvement effort is to explore veterans' WH experiences, and the programs perceived effect on participants' dimensions of wellness. <h3>Design</h3> A qualitative study design was used to conduct semi-structured telephone interviews; questions aligned with wellness constructs. Data were analyzed using rapid data matrix.5 Data were collected June 2020 through January 2021. <h3>Setting</h3> A WH flagship VA hospital located in the southeast United States. <h3>Participants</h3> This project used purposive recruitment of WH program participants, with emphasis on cohorts of particular interest to the VA including females (n=22) and Veterans with mental health conditions (n=21), chronic pain (n=27), and spinal cord injury (n=4). Participants met inclusionary criteria if they participated in at least two WH program activities. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> The perceived effects of WH program participation on veterans' well-being related to mental, emotional, social, physical, financial, spiritual, and environmental dimensions. <h3>Results</h3> Participants (N=50) were predominantly married, non-Hispanic white males with an average age of 61 years, with a college degree and an annual income of $50,000 or more. Data indicates veterans experienced improvements relevant to mental health, including mindfulness and coping strategies; physical ailments, including mobility, pain management, and sleep quality; and social engagement in group sessions and daily life. With respect to financial and spiritual wellness, veterans indicated minimal effect. Notably, approximately 5% of the sample indicated, without prompt, reduced suicidal ideation and improvements relevant to medication use. <h3>Conclusions</h3> WH program participation improved veterans' mental, physical, and social well-being in an integrative, non-pharmacological manner. Further research is warranted to assess the impact of CIH approach to care on veterans' health, specifically relevant to suicidal ideation and medication use. <h3>Author(s) Disclosures</h3> Non-disclosed.

Decreasing trends in reintervention and readmission after endovascular aneurysm repair in a multiregional implant registry.

As endovascular aortic aneurysm repair (EVAR) matures into its third decade, measures such as long-term reintervention and readmission have become a focus of quality improvement efforts. Within a large United States integrated health care system, we describe time trends in the rates of long-term reinterventions utilization measures. Data from a United States multiregional EVAR registry was used to perform a descriptive study of 3891 adults who underwent conventional infrarenal EVAR for infrarenal abdominal aortic aneurysm between 2010 and 2019. Three-year follow-up was 96.7%. Outcomes included 1-, 3-, and 5-year graft revision (defined as a procedure involving placement of a new endograft component), secondary interventions (defined as a procedure necessary for maintenance of EVAR integrity [eg, coil embolization and balloon angioplasty/stenting]), conversion to open, interventions for type II endoleaks alone, and 90-day readmission. Crude cause-specific reintervention probabilities were calculated by operative year using the Aalen-Johansen estimator, with death as a competing risk and December 31, 2020 as the study end date. Excluding interventions for type II endoleak alone, 1-year secondary intervention incidence decreased from 5.9% for EVARs in 2010 to 2.0% in 2019 (P< .001) and 3-year incidence decreased from 7.2% to 3.6% from 2010 to 2017 (P= .03). The 3-year incidences of graft revision (mean incidence, 3.4%) and conversion to open remained fairly stable (mean incidence, 0.6%) over time. The 3-year incidence of interventions for type II endoleak alone also decreased from 3.4% in 2010 to 0.7% in 2017 (P= .01). Ninety-day readmission rates decreased from 19.3% for index EVAR in 2010 to 9.2% in 2019 (P= .03). Comprehensive data from a multiregional health care system demonstrates decreasing long-term secondary intervention and readmission rates over time in patients undergoing EVAR. These trends are not explained by evolving management of type II endoleaks and suggest improving graft durability, patient selection, or surgical technique. Further study is needed to define implant and anatomic predictors of different types of long-term reintervention.

Increased Dementia Incidence among Black and Hispanic Veterans across Regions of the United States

AbstractBackgroundAlthough the US military is increasingly diverse, the association of race/ethnicity and geographical region with incidence of dementia diagnosis among older Veterans is unknown.MethodWe identified a random sample of 1,869,090 patients age ≥ 55 years [mean age: 69.4 (standard deviation 7.9), 2% female] who received care at the Veterans Health Administration (VHA), the largest integrated health care system in the United States, between October 1, 1999 and September 30, 2019. Participants self‐reported race/ethnicity: White: 88.6% (n = 1,655,376); Black, 9.5% (n = 176,795); Hispanic (1.0%, n = 20,663), Asian (0.5%, n = 9,391), or American Indian/Alaska Native [AIAN (0.4%, n = 6,895). US region was derived using residential ZIP codes and categorized based on 10 Center for Disease Control and Prevention Health Promotion regions. Incident dementia was defined using International Classification of Diseases, 9th (ICD‐9) and 10th (ICD‐10) edition codes; age‐adjusted dementia incidence was estimated using direct standardization to compare rates by race/ethnicity overall and by US region.ResultOver a mean follow‐up of 10.1 years, 243,272 (13%) participants received a diagnosis of dementia. Age‐adjusted incidence per 1,000 person‐years was 14.2 [95% confidence interval (CI), 13.3‐15.1] for AIAN participants, 12.4 (95% CI, 11.7‐13.1) for Asian participants, 19.4 (95% CI, 19.2‐19.6) for Black participants, 20.7 (95% CI, 20.1‐21.3) for Hispanic participants, and 11.5 (95% CI, 11.4‐11.6) for White participants. Across US regions, a similar pattern was observed; compared to White participants, rates were significantly higher for Black participants across all regions (15.5 to 20.7, p values &lt;0.001), and for Hispanic participants in all regions except the Southeast (14.0 to 21.7, p values ≤ 0.03). Across most regions, AIAN (8.6 to 16.2,) and Asian participants (8.4 to 15.6,) showed a pattern of rates that was similar to or slightly higher than for White participants (9.8 to 12.0, p values &gt;0.05).ConclusionAmong older Veterans receiving care at VHA, where access to care for enrollees is held relatively equal, differences in dementia incidence were observed based on race/ethnicity. Across US regions, rates varied, but incidence was consistently higher for Black and Hispanic Veterans. Further research is needed to elucidate drivers of these differences.

Integrated Healthcare System Using Machine Learning

Abstract: In this digital world, data is an asset, and enormous data was generated in all fields. Data in the healthcare industry consists of all the information related to patients. Here a general architecture has been proposed for predicting disease in the healthcare industry. Many of the existing models are concentrating on one disease per analysis. There is no common system present that can analyze more than one disease at a time. Thus, we are concentrating on providing immediate and accurate disease predictions to the users about the symptoms they enter along with the disease predicted. So, we are proposing an integrated system which used to predict multiple diseases by using Deep learning and machine learning. In this system, we are going to analyze Diabetes, Heart, and covid-19, and brain tumor disease analysis. Later many more diseases can be included. To implement integrated healthcare systems, we are going to use machine learning algorithms, and deep learning such as CNN. The importance of this system analysis is that while analyzing the diseases all the parameters which cause the disease is included so it is possible to detect the disease efficiently and more accurately. In this prediction system, a user can analyze more than one disease on a single web application and if it is found that the result is positive then proper care guidance, diagnosis, and prescription will also give to the patient. Also, the list of specialist doctors in that disease will also be given. In an integrated healthcare system, the user needs to select the name of the particular disease, enter its parameters and just click on predict. The corresponding machine learning model will be invoked and it would predict the output and display it on the screen. Also, all the information will be stored securely in the database for generating reports and information for future use in understanding previous disease patterns.

Smoking Behaviors and Prognosis in Patients With Non–Muscle-Invasive Bladder Cancer in the Be-Well Study

Tobacco smoking is an established risk factor associated with bladder cancer, yet its impact on bladder cancer prognosis is unclear. To examine associations of use of tobacco (cigarettes, pipes, and cigars), e-cigarettes, and marijuana with risk of recurrence and progression of non-muscle-invasive bladder cancer (NMIBC) and to explore use of smoking cessation interventions. The Be-Well Study is a prospective cohort study of patients with NMIBC diagnosed from 2015 to 2019 and followed-up for 26.4 months in the Kaiser Permanente Northern and Southern California integrated health care system. Eligibility criteria were age at least 21 years, first NMIBC diagnosis (stages Ta, Tis, or T1), alive, and not in hospice care. Exclusion criteria were previous diagnosis of bladder cancer or other cancer diagnoses within 1 year prior to or concurrent with NMIBC diagnosis. Data were analyzed from April 1 to October 4, 2022. Use of cigarettes, pipes, cigars, e-cigarettes, and marijuana was reported in the baseline interview. Use of smoking cessation interventions (counseling and medications) was derived from electronic health records. Hazard ratios (HRs) and 95% CIs of recurrence and progression of bladder cancer were estimated by multivariable Cox proportional hazards regression. A total of 1472 patients (mean [SD] age at diagnosis, 70.2 [10.8%] years; 1129 [76.7%] male patients) with NMIBC were enrolled at a mean (SD) of 2.3 (1.3) months after diagnosis, including 874 patients (59.4%) who were former smokers and 111 patients (7.5%) who were current cigarette smokers; 67 patients (13.7%) smoked pipes and/or cigars only, 65 patients (4.4%) used e-cigarettes, 363 patients (24.7%) used marijuana. Longer cigarette smoking duration and more pack-years were associated with higher risk of recurrence in a dose-dependent manner, with the highest risks for patients who had smoked for 40 or more years (HR, 2.36; 95% CI, 1.43-3.91) or 40 or more pack-years (HR, 1.97; 95% CI, 1.32-2.95). There was no association of having ever smoked, being a former or current cigarette smoker, and years since quit smoking with recurrence risk. No associations with pipes, cigars, e-cigarettes, or marijuana were found. Of 102 patients offered a smoking cessation intervention, 57 (53.8%) received an interventions after diagnosis, with female patients more likely than male patients to engage in such interventions (23 of 30 female patients [76.7%] vs 34 of 76 male patients [44.7%]; P = .003). These findings suggest that longer duration and more pack-years of cigarette smoking were associated with higher risk of NMIBC recurrence. Cigarette smoking remains a critical exposure before and after diagnosis in survivors of NMIBC.

Relationships between job satisfaction, organizational commitment, burnout and job performance of healthcare professionals in a district-level health care system of Shenzhen, China.

Existing research indicates that job satisfaction has effects on job performance, but little evidence exists about the mechanism through which the satisfaction-performance association operates. This study aims to examine the effect of job satisfaction on job performance in a district-level health care system of China and to explore the effect mechanism mediated by organizational commitment and burnout. Cluster sampling was used in this study. All healthcare professionals in the Nanshan Medical Group, who were at work in the last 3 months and able to complete online questionnaire independently were invited to participate the anonymous online survey. Job satisfaction, organizational commitment, burnout and job performance were measured by tools, which have been validated in China. Descriptive statistics were used for the socio-demographic variables and the four job psychological variables. Pearson correlation coefficients was used to determine associations among each of the psychological variables. Linear regression was used to examine association between job performance and other three psychological variables. PROCESS macro was used to examine the mediation effects of organizational commitment and burnout on the association between job satisfaction and performance. In total, 1,200 healthcare professionals completed the anonymous online survey. Job satisfaction, organizational commitment, and job performance were positively correlated with one another, with burnout negatively correlated with them. Linear regression revealed that demographic characteristics, job satisfaction, organizational commitment, and burnout explained 5, 6, 2, and 9% of the variance in job performance. Path analysis showed that the coefficient of the direct effect of job satisfaction on job performance was 0.18, the coefficients of the indirect effects of job satisfaction on job performance through organizational commitment and burnout were 0.17 and 0.37, respectively. The coefficients of the indirect effects of organizational commitment on job performance through burnout was -0.04, but it was not significant. It is promising to improve job performance of providers in Chinese healthcare systems by improving job satisfaction and reducing burnout. Tailored support policies for female healthcare professionals, appropriate incentive mechanisms and improving multidisciplinary healthcare delivery are potential to improve job performance of healthcare professionals in integrated healthcare systems.