Kaiser Permanente Members Research Articles

Risks and Predictors of Gastric Adenocarcinoma in Patients with Gastric Intestinal Metaplasia and Dysplasia: A Population-Based Study.

Gastric intestinal metaplasia and dysplasia are precursor lesions for adenocarcinoma. The risks of progression to malignancy from these lesions are not well characterized, particularly in the US populations. We identified 4,331 Kaiser Permanente Northern California members who were diagnosed with gastric intestinal metaplasia or dysplasia between 1997 and 2006 and followed them through December 2013. The incident rates of gastric adenocarcinoma, relative risks in comparison with the Kaiser Permanente general population, and predictors of progression to malignancy were investigated. Among 4,146 individuals with gastric intestinal metaplasia and 141 with low-grade dysplasia with 24,440 person-years follow-up, 17 and 6 cases of gastric adenocarcinoma were diagnosed, respectively, after 1 year from the index endoscopy. The incidence rate of gastric adenocarcinoma was 0.72/1,000 person-years in patients with intestinal metaplasia, with a relative risk of 2.56 (95% confidence interval (CI) 1.49-4.10) compared with the Kaiser Permanente member population, and 7.7/1,000 person-years for low-grade dysplasia, with a relative risk of 25.6 (95% CI, 9.4-55.7). The median time for gastric intestinal metaplasia to progress to adenocarcinoma was 6.1 years, and for low-grade dysplasia, 2.6 years. Hispanic race/ethnicity and history of dysplasia were associated with significantly higher risk of progression to gastric adenocarcinoma. Gastric intestinal metaplasia and dysplasia are significant predictors for gastric adenocarcinoma. The low risk for malignancy associated with intestinal metaplasia does not support routine endoscopic surveillance. However, surveillance should be considered in patients at higher risks, including those with suspicious endoscopic features, presence of dysplasia, and Hispanic race/ethnicity.

Incidence of Norovirus and Other Viral Pathogens That Cause Acute Gastroenteritis (AGE) among Kaiser Permanente Member Populations in the United States, 2012-2013.

Noroviruses and other viral pathogens are increasingly recognized as frequent causes of acute gastroenteritis (AGE). However, few laboratory-based data are available on the incidence of AGE caused by viral pathogens in the U.S. This study examined stool specimens submitted for routine clinical diagnostics from patients enrolled in Kaiser Permanente (KP) health plans in metro Portland, OR, and the Maryland, District of Columbia, and northern Virginia geographic areas to estimate the incidence of viral enteropathogens in these populations. Over a one-year study period, participating laboratories randomly selected stools submitted for routine clinical diagnostics for inclusion in the study along with accompanying demographic and clinical data. Selected stools were tested for norovirus, rotavirus, sapovirus, and astrovirus using standardized real-time RT-PCR protocols. Each KP site provided administrative data which were used in conjunction with previously published data on healthcare utilization to extrapolate pathogen detection rates into population-based incidence rates. A total of 1,099 specimens collected during August 2012 to September 2013 were included. Mean age of patients providing stool specimens was 46 years (range: 0–98 years). Noroviruses were the most common viral pathogen identified among patients with AGE (n = 63 specimens, 6% of specimens tested). In addition, 22 (2%) of specimens were positive for rotavirus; 19 (2%) were positive for sapovirus; and 7 (1%) were positive for astrovirus. Incidence of norovirus-associated outpatient visits was 5.6 per 1,000 person-years; incidence of norovirus disease in the community was estimated to be 69.5 per 1,000 person-years. Norovirus incidence was highest among children <5 years of age (outpatient incidence = 25.6 per 1,000 person-years; community incidence = 152.2 per 1,000 person-years), followed by older adults aged >65 years (outpatient incidence = 7.8 per 1,000 person-years; community incidence = 75.8 per 1,000 person-years). Outpatient incidence rates of rotavirus, sapovirus, and astrovirus were 2.0, 1.6, 0.6 per 1,000 person-years, respectively; community incidence rates for these viruses were 23.4, 22.5, and 8.5 per 1,000 person-years, respectively. This study provides the first age-group specific laboratory-based community and outpatient incidence rates for norovirus AGE in the U.S. Norovirus was the most frequently detected viral enteropathogen across the age spectrum with the highest rates of norovirus disease observed among young children and, to a lesser extent, the elderly. These data provide a better understanding of the norovirus disease burden in the United States, including variations within different age groups, which can help inform the development, targeting, and future impacts of interventions, including vaccines.

OUTCOMES AFTER IMPLANTABLE CARDIAC DEFIBRILLATOR PLACEMENT IN PATIENTS WITH END-STAGE RENAL DISEASE

There is a paucity of data on cardiovascular outcomes in patients with end-stage renal disease (ESRD) after implantation of an implantable cardiac defibrillator (ICD) or cardiac resynchronization therapy (CRT). We enrolled 7,825 Kaiser Permanente members across 6 geographical regions of the United

A4-1: Validating Electronic Health Record Demographic Data Using Self-reported Data from the Autism Registry Survey

Background/AimsThe use of administrative patient data via the electronic health record (EHR) is very important in research. It’s critical we have a sense of the validity and relative accuracy of key data in this widely available data source. The HMORN Virtual Data Warehouse (VDW) is an example of a large repository of administrative data used in numerous studies. The recent Mental Health Research Network (MHRN) Autism Spectrum Disorder (ASD) Registry Survey was hosted by four HMORN sites inviting Kaiser Permanente members to complete a Web-based questionnaire on behalf of their child identified as having an ASD diagnosis in the EHR.MethodsIn addition to an extensive battery of questions regarding ASD, the survey collected data on a number of demographic data elements also available in the VDW. These are: age, gender, race/ethnicity (child), income (household) and education (household adult). A total of 1155 adults responded to the ASD Registry Survey. These records were matched with demographic data from the VDW for the same child.ResultsPreliminary examination of race-ethnicity and gender data shows that there‘s a good to excellent level of agreement between the two sources when data are non-missing in both data sources. A total of 992 records had non-missing race/ethnicity data from both data sources. In 81.1% (805/992) of the cases, both data sources agreed (kappa = 0.68, CI = 0.64–0.72). The categories that had the highest level of agreement are White, Black, and Asian, while the Hispanic and multi-racial groupings had a comparatively much lower level of agreement (46.9%). For gender, level of agreement was very high (99.0%, 1118/1129, kappa = 0.97, CI = 0.95–0.99).ConclusionsIn this study, race in the electronic health record was a very accurate measure for major race categories but was far less accurate when reporting the emergent and important multi-racial category and Hispanic ethnicity. Gender had an excellent level of agreement between the two sources. Age, gender, and race-ethnicity are key covariates for many studies analyzing EHR data. Income and education can serve to illuminate socioeconomic factors very relevant to health care research. Having a sense of the validity and accuracy of these data is crucial to the research process.

Leveraging Geographic Information Systems in an Integrated Health Care Delivery Organization

A handful of the many changes resulting from the Affordable Care Act underscore the need for a geographic understanding of existing and prospective member communities. Health exchanges require that health provider networks are geographically accessible to underserved populations, and nonprofit hospitals nationwide are required to conduct community health needs assessments every three years. Beyond these requirements, health care providers are using maps and spatial analysis to better address health outcomes that are related in complex ways to social and economic factors.Kaiser Permanente is applying geographic information systems, with spatial analytics and map-based visualizations, to data sourced from its electronic medical records and from publicly and commercially available datasets. The results are helping to shape an understanding of the health needs of Kaiser Permanente members in the context of their communities. This understanding is part of a strategy to inform partnerships and interventions in and beyond traditional care delivery settings.

Midlife risk score for the prediction of dementia four decades later

ObjectiveThe objective of this study was to obtain external validation of the only available midlife dementia risk score cardiovascular risk factors , aging and dementia study (CAIDE) constituting age, education, hypertension, obesity, and hyperlipidemia in a larger, more diverse population. Our second aim was to improve the CAIDE risk score by additional midlife risk factors. MethodsThis retrospective cohort study was conducted in an integrated health care delivery system. A total of 9480 Kaiser Permanente members who participated in a health survey study (age range, 40–55 years) from 1964 to 1973 were included in this study. Dementia diagnoses from primary care and medical specialist visits were collected from January 1, 1994 to January 16, 2006, using International Classification of Diseases 9 codes 290.0, 290.1 for “possible dementia,” and 331.0 and 290.4 for “specialist confirmed dementia.” Risk model prediction and validation were examined with the C statistic, net reclassification improvement, and integrated discrimination improvement. Dementia risk per sum score was calculated with Kaplan-Meier estimates. ResultsA total of 2767 participants (25%) were diagnosed with any type of dementia, of which 1011 diagnoses (10.7%) were specialist-confirmed diagnoses. Average time between midlife examination and end of follow-up was 36.1 years. The CAIDE risk score replicated well with a C statistic of 0.75, quite similar to the original CAIDE C statistic of 0.78. The CAIDE score also predicted well within different race strata. Other midlife risk factors (central obesity, depressed mood, diabetes mellitus, head trauma, lung function, and smoking) did not improve predictability. The risk score allowed stratification of participants into those with 40-year low (9%) and high (29%) dementia risk. ConclusionsA combination of modifiable vascular risk factors in midlife is highly predictive of the likelihood of dementia decades later. Possible dementia prevention strategies should point to a life course perspective on maintaining vascular health.

Specialty pharmaceuticals care management in an integrated health care delivery system with electronic health records.

The specialty pharmaceuticals market is expanding more rapidly than the traditional pharmaceuticals market. Specialty pharmacy operations have evolved to deliver selected medications and associated clinical services. The growing role of specialty drugs requires new approaches to managing the use of these drugs. The focus, expectations, and emphasis in specialty drug management in an integrated health care delivery system such as Kaiser Permanente (KP) can vary as compared with more conventional health care systems. The KP Specialty Pharmacy (KP-SP) serves KP members across the United States. This descriptive account addresses the impetus for specialty drug management within KP, the use of tools such as an electronic health record (EHR) system and process management software, the KP-SP approach for specialty pharmacy services, and the emphasis on quality measurement of services provided. Kaiser Permanente's integrated system enables KP-SP pharmacists to coordinate the provision of specialty drugs while monitoring laboratory values, physician visits, and most other relevant elements of the patient's therapy. Process management software facilitates the counseling of patients, promotion of adherence, and interventions to resolve clinical, logistic, or pharmacy benefit issues. The integrated EHR affords KP-SP pharmacists advantages for care management that should become available to more health care systems with broadened adoption of EHRs. The KP-SP experience may help to establish models for clinical pharmacy services as health care systems and information systems become more integrated.

Exposure to antiretroviral therapy and risk of cancer in HIV-infected persons

The incidence of certain non-AIDS-defining cancers (NADCs) in HIV patients has been reported to have increased in the combination antiretroviral therapy (ART) era. Studies are needed to directly evaluate the effect of ART use on cancer risk. We followed 12 872 HIV-infected Kaiser Permanente members whose complete ART history was known for incident cancers between 1996 and 2008. Cancers, identified from Surveillance, Epidemiology, and End Results (SEER)-based cancer registries, were grouped as ADCs, infection-related NADCs, or infection-unrelated NADCs. We also evaluated the most common individual cancer types. Rate ratios for ART use (yes/no) and cumulative duration of any ART, protease inhibitor, and nonnucleotide reverse transcriptase inhibitor (NNRTI) therapy were obtained from Poisson models adjusting for demographics, pretreatment or recent CD4 cell count and HIV RNA levels, years known HIV-infected, prior antiretroviral use, HIV risk, smoking, alcohol/drug abuse, overweight/obesity, and calendar year. The cohort experienced 32 368 person-years of ART, 21 249 person-years of protease inhibitor therapy, and 15 643 person-years of NNRTI therapy. The mean follow-up duration was 4.5 years. ADC rates decrease with increased duration of ART use [rate ratio per year = 0.61 (95% confidence interval 0.56-0.66)]; the effect was similar by therapy class. ART, protease inhibitor, or NNRTI therapy duration was not associated with infection-related or infection-unrelated NADC [rate ratio per year ART = 1.00 (0.91-1.11) and 0.96 (0.90-1.01), respectively], except a higher anal cancer risk with longer protease inhibitor therapy [rate ratio per year = 1.16 (1.02-1.31)]. No therapy class-specific effect was found for ADC. ART exposure was generally not associated with NADC risk, except for long-term use of protease inhibitor, which might be associated with increased anal cancer risk.

The mediating sex-specific effect of psychological distress on the relationship between adverse childhood experiences and current smoking among adults

BackgroundResearch suggests that ACEs have a long-term impact on the behavioral, emotional, and cognitive development of children. These disruptions can lead to adoption of unhealthy coping behaviors throughout the lifespan. The present study sought to examine psychological distress as a potential mediator of sex-specific associations between adverse childhood experiences (ACEs) and adult smoking.MethodData from 7,210 Kaiser-Permanente members in San Diego California collected between April and October 1997 were used.ResultsAmong women, psychological distress mediated a significant portion of the association between ACEs and smoking (21% for emotional abuse, 16% for physical abuse, 15% for physical neglect, 10% for parental separation or divorce). Among men, the associations between ACEs and smoking were not significant.ConclusionsThese findings suggest that for women, current smoking cessation strategies may benefit from understanding the potential role of childhood trauma.

Kaiser Permanente’s Farmers’ Market Program: Description, Impact, and Lessons Learned

Farmers' markets are an innovative strategy to potentially increase healthy nutrition environments. Kaiser Permanente (KP), the largest private, nonprofit healthcare system in the country, has been hosting farmers' markets on its medical campuses since 2003 and now has markets in nearly 40 KP locations in four states: California, Hawaii, Oregon, and Maryland. This paper describes the KP farmers' market program and summarizes the results of a patron survey conducted in 2010 among 2,435 market patrons. The majority of patrons are KP physicians and staff, and a quarter of patrons are KP members and community residents. The markets appear to have an impact on what people are eating: 74% of all patrons reported eating more fruits and vegetables as a result of coming to the market. The KP experience may be generalizable to other healthcare organizations and to other large employers.

Abstract 060: Contribution of Immunodeficiency to Coronary Heart Disease: Cohort Study of HIV-infected and HIV-uninfected Kaiser Permanente Members

Background: We compared CHD rates among HIV+ and HIV- patients in a large integrated care system, to explore the role of immunodeficiency in CHD. Methods: Kaiser Permanente (KP) California serves &gt;6 million members. Using previously described databases, we matched adult HIV+ members to HIV- members (1:10 ratio) on age, sex, medical center and year of start of follow-up. We searched hospitalization records to identify members with discharge diagnoses codes [MH1] ICD-9: 410x-411x, 413x-414x. The cohort was followed from first KP enrollment after 1996 until earliest recorded CHD event, death, KP disenrollment, or 12/31/2009. We stratified HIV+ members by antiretroviral therapy (ART) use, recent and lowest KP-recorded CD4, and compared rates with HIV- KP members. We obtained rate ratios (RRs) for any CHD diagnosis and MIs from Poisson regression models adjusting for age, sex, race, tobacco use, alcohol/drug abuse, obesity, diabetes, use of lipid lowering, and hypertension therapy. An additional analysis of only HIV+ individuals examined the effects of antiretroviral therapy use, recent HIV RNA, and recent and nadir CD4 on CHD.[MH2] Results: 22,081 HIV+ and 215,158 HIV- members contributed 101,044 pys and 1,265,819 pys respectively. HIV+ had 446 CHD events (including 280 MIs), corresponding to a rate of 451/100,000 py. HIV- had 3,926 CHD events (including 2,064 MIs), corresponding to a rate of 316 cases/100,000 py. The adjusted CHD RR for HIV status was 1.4 (95% CI: 1.3-1.6; p&lt;0.001), and the adjusted MI RR was 1.7 (95% CI: 1.5-1.9; p&lt;0.001). CHD RRs for HIV+ as stratified by ART use and CD4 level are shown in Table (with HIV- as reference). Table. Adjusted rate ratios * for CHD among HIV+ individuals by recent and lowest CD4 Recent CD4 Lowest KP CD4 RR (95% CI) p value RR (95% CI) p value ART+, CD4 ≥500 0.9 (0.7, 1.1) 0.218 0.8 (0.5, 1.2) 0.231 ART+, CD4 201-499 1.4 (1.2, 1.6) &lt;0.001 1.1 (0.9, 1.3) 0.300 ART+, CD4 ≤200 1.8 (1.4, 2.2) &lt;0.001 1.4 (1.3, 1.6) &lt;0.001 ART-, CD4 ≥500 1.3 (0.9, 1.9) 0.213 1.3 (0.8, 2.1) 0.363 ART-, CD4 201-499 1.1 (0.7, 1.7) 0.671 1.3 (0.9, 1.8) 0.182 ART-, CD4 ≤200 1.8 (0.9, 3.8) 0.113 1.1 (0.6, 2.2) 0.778 * HIV- as reference for all RRs Conclusions: Adjusting for traditional risk factors, HIV+ individuals have a statistically significant increased risk for cardiovascular complications. Aggressive attention to modifiable risk factors is particularly important. As increased CHD risk was not seen for patients with relatively preserved CD4, earlier initiation of ART may further reduce CHD [. l

Prescription Long-term Opioid Use in HIV-infected Patients

To examine changes the in use of prescription opioids for the management of chronic noncancer pain in human immunodeficiency virus (HIV)-infected patients and to identify patient characteristics associated with long-term use. Long-term prescription opioid use (ie, 120+ days supply or 10+ prescriptions during a year) was assessed between 1997 and 2005 among 6939 HIV-infected Kaiser Permanente members and HIV-uninfected persons in the general health plan memberships. In 2005, 8% of HIV individuals had prevalent long-term opioid use, more than double the prevalence among HIV-uninfected individuals. However, the large increases in use from 1997 to 2005 in the general population were not observed for HIV-infected individuals. The strongest associations with prevalent use among HIV-infected individuals were female sex with a prevalence ratio (PR) of 1.8 (95% CI=1.3, 2.5); Charlson comorbidity score of 2 or more (compared with a score of 0) with a PR of 1.9 (95% CI=1.4, 2.8); injection drug use history with a PR of 1.8 (95% CI=1.3, 2.6); and substance use disorders with a PR of 1.8 (95% CI=1.3, 2.5). CD4, HIV viral load, and acquired immunodeficiency syndrome diagnoses were associated with prevalent opioid use early in the antiretroviral therapy era (1997), but not in 2005. Long-term opioid use for chronic pain has remained stable over time for HIV patients, whereas its use increased in the general population. The prevalence of prescribed opioids in HIV patients was highest for certain subgroups, including women, and those with a comorbidity and substance abuse history.

Associations Between Adverse Childhood Experiences, Psychological Distress, and Adult Alcohol Problems

To examine the mediating role of psychological distress on the relationship between adverse childhood experiences and adult alcohol problems by gender. Linear and logistic regression analyses were conducted on 7279 Kaiser-Permanente members, aged >18 years. Psychological distress mediated significant proportions of alcohol problems associated with childhood emotional abuse and neglect, physical abuse and neglect, mental illness in the household, parental separation or divorce, sexual abuse, and household drug use among women and mental illness in the household, emotional neglect, physical abuse, household drug use, and sexual abuse among men. It may be important to identify early childhood trauma and adult psychological distress in programs that focus on reducing alcohol abuse.

New Technology Review Process: The Laparoscopic Adjustable Gastric Band

The Interregional New Technologies Committee (INTC) is one evaluation route for new medical technologies or technologies with expanded indications within Kaiser Permanente (KP). The primary focus of the INTC is to consider all available published evidence on a particular technology, surgical technique, or implantable device for a specific clinical indication and provide a recommendation on the sufficiency of the evidence for determining net medical benefit to Permanente Medical Group leaders and Kaiser Foundation Health Plan management throughout KP Regions. This iterative process provides an objective, evidence-based assessment to inform decision making by physicians and support the most appropriate care for KP members. This overview illustrates the INTC process and how it supports clinical decision making using implantation of laparoscopic adjustable gastric bands (LAGBs) as an example. In February 2011, the US Food and Drug Administration (FDA) approved lowering the acceptable body mass index for the Lap-Band from 35 to 30 kg/m(2) for patients with at least one comorbid condition. It is difficult to find published studies on medical technologies that have been recently approved by the FDA. The manufacturer often submits clinical data to the FDA, but details are frequently not publicly available at the time of approval. The LAGB example demonstrates the complex issues addressed by the INTC, particularly when there is some evidence of short-term improvement in outcomes with a medical device but little if any confirmation of long-term safety or effectiveness.

Seasonal Influenza Vaccination Status Among Children With Laboratory Evidence of Pandemic H1N1 Infection

The 2009 pandemic H1N1 influenza virus emerged in March 2009 and spread rapidly, causing many thousands of deaths worldwide. A case-control study of 60 Mexican adults with H1N1 suggested that the seasonal influenza vaccine protected against H1N1 infection (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.11-0.66), but subsequent studies have had varied results and few have addressed this question in children. The objective of this study was to evaluate the effect of 2008-2009 seasonal influenza vaccination on pandemic H1N1 infection in children. Cases (n = 165) were Kaiser Permanente Colorado inpatients and outpatients aged between 18 months and 18 years, with laboratory-confirmed pandemic H1N1 infection from May to November 2009. Controls (n = 660) were pediatric Kaiser Permanente members without documented H1N1 infection who were matched by age and gender. Seasonal influenza vaccination status was recorded for all cases and controls; conditional logistic regression analyses were used to calculate matched odds ratios. Cases were more likely than controls to have underlying chronic health conditions (45% vs. 21%, P < 0.0001). Pandemic H1N1 cases were neither more nor less likely to have received the 2008-2009 seasonal influenza vaccine (OR, 1.31; 95% CI, 0.92-1.88). After adjustment for chronic medical conditions and health-seeking behavior, H1N1 cases were as likely as controls to have received the 2008-2009 seasonal influenza vaccine (OR, 1.08; 95% CI, 0.75-1.57). There was no overall association--either protection or risk--between seasonal influenza vaccination and medically attended pandemic H1N1 infection in children. These results have important implications for understanding influenza immunity and future public health efforts to prevent pandemic influenza.

Kaiser Permanente's Total Health Environment

Iremember when Kaiser Permanente launched its Thrive campaign on television in 2004. As a long time California resident but somewhat shorterterm Kaiser Permanente member, it struck me that this behemoth of an organization, established by Henry Kaiser in 1945 to care for the workers in his shipyards and steel mills, was now touting in its advertisements that they stood for Pilates, broccoli, dental floss, and treadmills. Long known for its low-cost, dependable care for millions of Californians and others; its nonprofit status; and its commitment to community health, they took a bold stand in saying that health was not an industry but a cause. So what did all this mean to us, the members of Kaiser Permanente? I called my local Kaiser Permanente hospital and asked if I could come to a Pilates class or if there was a treadmill I could use. Unfortunately there wasn’t. So what was Thrive and why was it launched? I posed that question to Patricia Gin, senior brand strategist at Kaiser Permanente, who has worked on the campaign since its inception. She says that Thrive was an external expression of Kaiser Permanente’s commitment to “total health,” the result of several years of in-depth consumer market research into the public’s perceptions of health and healthcare. They found that perceptions of healthcare delivery were often negative, expressed by words such as red tape and paperwork, but personal health was viewed as more than not being sick, and included lifestyle, life balance, and optimism. Soon Thrive helped galvanize many Kaiser Permanente initiatives, including the following: (1) food policy—promoting healthy food choices in inpatient food services, cafeterias, and vending machines; (2) farmer’s markets—25 facilities in the country have established on-campus farmer’s markets offering healthy produce to employees and members; (3) health and wellness initiatives—classes provide instruction in exercise, yoga, tai chi, smoking cessation, mindfulness, and stress reduction; (4) Healthy Eating Active Living Community Benefit Programs—these devoteseveralhundredmilliondollarsinservicesandfundingtocommunityorganizations to promote the overall health of communities in which Kaiser Permanente is located; and (5) online health tools— tools for weight loss, nutrition, stress reduction, and smoking cessation are now available. 1 In an effort to further deliver on the promise of the expectations created by their advertising campaign, they set out to understand the needs, emotions, and outlook on health of their members. In 2007 they launched a methodical research initiative that covered all eight regions of the country where Kaiser Permanente operated—at their hospitals, medical office buildings, and even competitor facilities. It included walk-throughs, interviews, observational studies, and workshops with various constituents. The research revealed some key themes regarding needs expressed by members with regard to information, clinical care delivery, service, and facilities. They found that information, whetherthroughtechnologyorcommuni

From Tragedy, Opportunity—A New Beginning for Haiti and the Dominican Republic

John Freedman, MD Fall 2010 - Volume 14 Number 3 I went to Haiti in late January as a member of an Operation Rainbow (www.operationrainbow.org) surgical team which comprised both Kaiser Permanente (KP) and non-KP team members. As background, my own

Statin Use and Risk of Colorectal Cancer in a Cohort of Middle-Aged Men in the US

Numerous modifiable factors have been associated with a reduced risk of colorectal cancer, including the chronic use of NSAIDs. Thus, it is biologically plausible that HMG-CoA reductase inhibitors (statins), therapeutic agents that also possess anti-inflammatory effects, are also associated with a lowered risk of colorectal cancer. To examine the association between statin use and the risk of colorectal cancer in a large cohort of middle-aged men enrolled in a prepaid, integrated health maintenance organization. We conducted a prospective cohort study of 69 115 Northern and Southern California Kaiser Permanente (KP) members aged 45-69 years who enrolled in the California Men's Health Study in 2002-3. Colorectal cancer cases were identified by linkage to the KP California Cancer Registries. Statin exposure, estimated from automated KP outpatient pharmacy records (available since 1991 in Southern California and 1994 in Northern California), was treated as time-varying. Cox proportional hazards regression analyses were used to estimate hazard ratios and 95% confidence intervals (CIs), while controlling for potential confounders. During a maximum of 3.5 years of follow-up, 171 colorectal cancer cases were identified. Compared with nonuse, the adjusted hazard ratio for ever use of statins was 0.89 (95% CI 0.61, 1.30). The hazard ratio for statin use of >or=5 years was 0.83 (95% CI 0.43, 1.63). The results did not differ markedly by type or severity of disease. There was also no evidence of effect modification by regular NSAID use. However, the stratified analyses were limited by small numbers. These findings provide little support for an association between the use of statins and the risk of colorectal cancer in men. There was some suggestion of a modest inverse association between statin use for >or=5 years and risk of colorectal cancer; however, the possibility that this observation may be related to regular NSAID use cannot be ruled out.

Natural History of Severe Ulcerative Colitis in a Community-Based Health Plan

We sought to evaluate long-term outcomes of patients with severe ulcerative colitis (UC) after their first hospitalization for the disease. A cohort of 656 patients hospitalized for UC during 1996 to 2004 was followed up for 9 years through 2004. Time-to-event was estimated using actuarial methods, and the proportions of those under follow-up evaluation who experienced outcomes at month 3, year 1, and year 5 were determined. Outcome measures studied were time to subsequent colectomy, rehospitalization for inflammatory bowel disease, and restarting steroid medication. We also used survival analysis to evaluate whether patient characteristics predicted the risk of rehospitalization and colectomy. Among 656 patients initially hospitalized for severe UC, 20% (N = 129) underwent colectomy during their initial hospitalization. Of the remaining 527, a total of 95% (N = 498) were discharged on a steroid taper. At 1 year after discharge, 29% of those remaining under observation were rehospitalized for UC, and an additional 10% required colectomy. At 1 and 5 years after discharge, 34% and 26% received at least a 90-day supply of steroid in the preceding 9 months. Risk of rehospitalization and colectomy were unrelated to the patient's age, sex, or race/ethnicity. The risk for colectomy in patients hospitalized for the first time with severe UC is 20%. In the 3 months after hospitalization the risk for colectomy is 6%. After that, risks appear to decrease proportionate to the time since initial hospitalization.

Statin Use and Risk of Prostate Cancer in the California Men's Health Study Cohort

Statins have known anticarcinogenic effects, however, evidence for long-term statin use as effective chemoprevention for prostate cancer is inconsistent. We examined the association between statin use and risk of prostate cancer among 69,047 eligible participants in the California Men's Health Study, a prospective cohort of Northern and Southern California Kaiser Permanente (KP) members, ages 45 to 69 years, initiated in 2002. Prostate cancer cases were identified by linkage to the KP California Cancer Registries. Statin exposure, estimated from automated KP outpatient pharmacy records (available since 1991 in Southern California and since 1994 in Northern California), was treated as time-varying and defined as the cumulative days dispensed of any statin from the first dispensing until a prostate cancer diagnosis, radical prostatectomy, termination of membership, or end of study (December 31, 2004). Cox proportional hazards models with age as the time scale were used to estimate rate ratios, while controlling for confounding variables. During follow-up, 888 prostate cancer cases, including 131 advanced cases, were identified. There was no association between ever statin use or <5 years use and prostate cancer. Conversely, >or=5 years use was associated with a 28% lower risk for prostate cancer compared with nonuse (adjusted rate ratio, 0.72; 95% confidence interval, 0.53-0.99). This association did not differ markedly for advanced disease. However, the association did seem to be restricted to those who regularly take nonsteroidal anti-inflammatory drugs. Our findings suggest that long-term statin use might be associated with a reduced risk of prostate cancer but perhaps only among regular nonsteroidal anti-inflammatory drug users.