Kaiser Permanente Northern California Region Research Articles

Socio-Demographic and Preoperative Clinical Factors Associated With 5-Year Weight Trajectories After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

To determine whether socio-demographic and preoperative clinical factors contribute to the percent total body weight loss (%TBWL) after bariatric surgery (BS). BS is the most effective long-term treatment for medically complicated obesity. More information is needed about the factors that contribute to postoperative %TBWL in large and ethnically diverse cohorts. This retrospective study conducted in the Kaiser Permanente Northern California region included 7698 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 2009 and March 2015. Trajectory analyses were conducted from 5-year follow-up data to assign patients to "low," "average," or "high" postoperative %TBWL groups. We then evaluated whether age, sex, race/ethnicity, neighborhood deprivation index and preoperative body mass index (BMI)/weight loss, diabetes, hypertension, and sleep apnea contributed to postoperative %TBWL using logistic regression models. Of 7698 patients (83.2% women), 48.6% underwent a RYGB and 51.4% underwent a SG. Postoperative %TBWL trajectories over 5 years were obtained in 6229 (81%) of 7698 eligible patients. About 27.8% and 29.3% of patients followed the "low" postoperative %TBWL trajectory, for RYGB and SG, respectively. Men, older patients, and Asian, Black, and Hispanic/Latino patients were more likely to be classified in the low postoperative %TBWL group. Patients showing lower postoperative %TBWL had a lower preoperative BMI (but lost less weight before surgery) and were more likely to have preoperative comorbidities. This study confirms and extends prior findings of the effects of several demographic and preoperative clinical factors on postoperative weight loss. Findings could improve the support of patients to achieve desired surgical outcomes.

7A Implementation of ERAS Program Drives a Robust Multimodal Analgesia Approach While Concurrently Decreasing Opioid Usage

Effective management of post-operative pain and surgical complications represents an ongoing challenge for providers. Opioid-related surgical complications include nausea, ileus, delirium and respiratory depression. Despite the known harmful effects of opioids, opioid monotherapy is still a common approach to surgical pain management. Multimodal analgesia (MMA) offers enhanced pain control while minimizing the harmful side effects of opioid medications. MMA combines both opioid and non-opioid medications (often NSAIDs) with regional anesthesia to provide optimal opioid sparing pain relief. The Enhanced Recovery After Surgery (ERAS) is an evidence-based bundle of interventions aimed at reducing surgical complications. MMA is a key foundational component of all ERAS pathways. The primary principles of ERAS include multimodal analgesia, early mobilization, maintenance of adequate nutrition, and active patient engagement. The Kaiser Permanente Northern California Region, part of the largest not-for-profit integrated healthcare system in the United States, rapidly and successfully implemented ERAS across 21 medical centers. This evidence-based approach has integrated a standardized MMA approach to improve care for more than 20,000 surgical patients across 6 different surgical specialties. Results include the reduction of post-operative surgical complication rates by as much as 33%, an overall decrease in average hospital length of stay by 1.1 days, and an overall reduction in opioid usage by 44%. The implementation of an ERAS program has promoted a significant increase in MMA usage, while concurrently promoting improved surgical patient care. ERAS has established a new paradigm for providing the highest quality and safest surgical care at Kaiser Permanente Northern California.

Transformational quality in Kaiser Permanente Northern California.

The evolving nature of health care related to optimizing the quality of patient care while increasing efficiencies presents an opportunity to redesign roles within hospital quality departments to meet these upcoming challenges. Specifically, passage of the Patient Protection and Affordable Care Act and creation of Accountable Care Organizations will require hospitals to carefully monitor patient care outcomes as well as continually seek to improve their processes. An approach used by the Kaiser Permanente Northern California Regional Quality and Regulatory Services Department assisted the 21 hospitals of Kaiser Permanente Northern California to improve quality-of-care outcomes, establish effective assessment teams, and create infrastructure for sustainability. Leadership by a centralized internal consulting group used a model that weighs risk and opportunity against cost and outcomes to support strategic planning as projects and initiatives developed, rather than after they were initiated. This model can assist other organizations in maximizing cost-efficient and -effective performance improvement approaches to clinical and operational excellence.

Pregnancy after transvaginal sling for stress urinary incontinence: a case series.

The aim of this study is to assess the incidence, medical course, and outcomes of women who carried a pregnancy to delivery after the placement of a transvaginal mesh sling for treatment of stress urinary incontinence (SUI) in a closed health care system. We conducted a retrospective case series of 15 women identified within the Kaiser Permanente Northern California region based on coding for placement of a sling for SUI. Records were cross-matched against the records of live births. The electronic medical records of subjects were extensively reviewed. Fifteen patients were identified and included in the analysis. Twelve patients had retropubic midurethral slings, 2 patients had transobturator slings, and one had a single-incision sling procedure. Ten of 15 were delivered via cesarean delivery. Five of the 15 patients had concomitant prolapse surgery at the time of sling placement; all of these patients had cesarean deliveries. There were no reports of voiding dysfunction or sling-related complications during pregnancy. Eleven of 15 patients were dry after the sling procedure, and 9 of the 15 were dry after delivery. No patients have had additional procedures or interventions for SUI after pregnancy. Our case series may suggest that vaginal delivery is not contraindicated and sling-related complications during pregnancy are not prevalent.

Smoking and Risk of Multiple Sclerosis

Tobacco smoke is an established risk factor for multiple sclerosis (MS). We hypothesized that variation in genes involved in metabolism of tobacco smoke constituents may modify MS risk in smokers. A three-stage gene-environment investigation was conducted for NAT1, NAT2, and GSTP1 variants. The discovery analysis was conducted among 1588 white MS cases and controls from the Kaiser Permanente Northern California Region HealthPlan (Kaiser). The replication analysis was carried out in 988 white MS cases and controls from Sweden. Tobacco smoke exposure at the age of 20 years was associated with greater MS risk in both data sets (in Kaiser, odds ratio [OR] = 1.51 [95% confidence interval (CI) = 1.17-1.93]; in Sweden, OR = 1.35 [1.04-1.74]). A total of 42 NAT1 variants showed evidence for interaction with tobacco smoke exposure (P(corrected) < 0.05). Genotypes for 41 NAT1 single nucleotide polymorphisms (SNPs) were studied in the replication data set. A variant (rs7388368C>A) within a dense transcription factor-binding region showed evidence for interaction (Kaiser, OR for interaction = 1.75 [95% CI = 1.19-2.56]; Sweden, OR = 1.62 [1.05-2.49]). Tobacco smoke exposure was associated with MS risk among rs7388368A carriers only; homozygote individuals had the highest risk (A/A, OR = 5.17 [95% CI = 2.17-12.33]). We conducted a three-stage analysis using two population-based case-control datasets that consisted of a discovery population, a replication population, and a pooled analysis. NAT1 emerged as a genetic effect modifier of tobacco smoke exposure in MS susceptibility.

Topiramate use in pregnancy and the birth prevalence of oral clefts

First marketed in the USA in 1996, topiramate (TPM) is an antiepileptic drug later approved for migraine prophylaxis, and in 2012 for weight loss in combination with phentermine. Some studies indicate an elevated prevalence of oral cleft (OC) in infants exposed to TPM in utero. We evaluated the association between TPM use in early pregnancy and the risk of OC. This retrospective cohort study used 1997-2011 automated data from four sources: HealthCore and OptumInsight (commercial insurance claims), Truven Health (Medicaid claims), and Kaiser Permanente Northern California Region (electronic medical records). We compared the prevalence of OCs in infants of women exposed to TPM in the first trimester (TPM cohort) with the prevalence in infants of women formerly exposed to TPM or other antiepileptic drugs (formerly exposed [FE] cohort) and infants of women with similar medical profiles (SMPs) to the TPM cohort that were not exposed to TPM (SMP cohort). To control for confounding, we used stratification and standardization for individual variables and propensity score deciles. The birth prevalence of OCs was 0.36% (7/1945) in the TPM cohort, 0.14% (20/13 512) in the FE cohort, and 0.07% (9/13 614) in the SMP cohort. Standardized by site, the prevalence ratio (PR) for TPM versus FE was 2.5 (95% CI: 1.0-6.0) and for TPM versus SMP was 5.4 (95% CI: 2.0-14.6). Adjustment for covariates one at a time or by propensity score yielded similar results. Consistent with other recent epidemiologic research, first-trimester TPM exposure was associated with an elevated birth prevalence of OC.

Cervical Cancer Rates After the Transition From Annual Pap to 3-Year HPV and Pap

Kaiser Permanente Northern California (KPNC) introduced 3-year Pap and human papillomavirus DNA cotesting for cervical cancer screening in women 30 years or older in 2003 to 2004. Patient and provider willingness to extend screening intervals and the impact on annual cervical cancer incidence after interval extension are evaluated. Age-adjusted cervical cancer rates and screening intervals were calculated from KPNC Regional Laboratory databases and Northern California Cancer Registry from 2000 to 2009. The median screening interval between negative cotests was 36 months compared to the 16 months after a negative Pap test alone before the implementation of cotesting. The age-adjusted invasive cancer rate was 6.5 per 100,000 women in 2000 and 6.3 in 2009; there was no difference in the rates of cervical cancer in women 30 years or older from 2000 to 2009 (p(trend) = .7). Patients and providers were compliant with the extension of screening intervals with cotesting. Cervical cancer rates remained constant during the 10-year study period despite extending screening intervals after a negative cotest.

Hypogonadism in Men With Chronic Pain Linked to the Use of Long-acting Rather Than Short-acting Opioids

There is a need to elucidate the variables associated with testosterone suppression among men on daily opioid therapy for chronic pain. The objective of this study was to examine several variables related to opioid use including daily dose, duration of action (long acting vs. short acting), and specific opioid to ascertain specific influences on total serum testosterone levels in men with chronic pain who use opioids daily. This is a retrospective cohort study of men within the Kaiser Permanente, Northern California (KPNC) health care system on some form of daily opioid use for chronic pain. Eighty-one men between the age of 26 and 79 years were seen in a chronic pain clinic between January 2009 and June 2010. All men were on stable dose of an opioid for at least 3 months, none with a previous diagnosis of hypogonadism. Total serum AM testosterone levels were measured at KPNC Regional Laboratory. Average total serum AM testosterone levels for this population showed 53% of all men receiving daily opioids were hypogonadal (AM total serum testosterone <250 ng/dL). In men receiving long-acting opioids, 74% (34/46) were hypogonadal compared with 34% (12/35) in men using short-acting opioids (hydrocodone or oxycodone) exclusively [AM total testosterone: median, 126 ng/dL; mean, 169 ng/dL (SD, 128 ng/dL) vs. median, 283 ng/dL; mean, 315 ng/dL (SD, 142 ng/dL); P<0.001]. After controlling for daily dosage and body mass index, men on long-acting opioids had 4.78 times greater odds of becoming hypogonadal than did men on short-acting opioids [95% confidence interval (CI), 1.51-15.07; P=0.008]. Body mass index was also significantly associated with hypogonadism (odds ratio, 1.13; 95% CI, 1.03-1.24; P=0.006), whereas daily dose was not (odds ratio, 1.02; 95% CI, 0.99-1.05; P=0.29). Among a contemporary sample of men receiving chronic daily opioids, we found a high prevalence of hypogonadism associated with duration of action, but not with total daily dose of the opioid.

Maternal Exposure to Angiotensin-converting Enzyme Inhibitors in the First Trimester and Risk of Malformations in Offspring

Objective To examine a reported association between use of angiotensin converting enzyme (ACE) inhibitors during the first trimester and risk of malformations in offspring. Design A population based, retrospective cohort study linking automated clinical and pharmacy databases including comprehensive electronic medical records. Participants Pregnant women and their live born offspring (465 754 mother-infant pairs) in the Kaiser Permanente Northern California region from 1995 to 2008. Main outcome measure Congenital malformation in live births. Results The prevalence of ACE inhibitor use in the first trimester only was 0.9/1000, and the use of other antihypertensive medications was 2.4/1000. After adjustment for maternal age, ethnicity, parity, and obesity, use of ACE inhibitors during the first trimester only seemed to be associated with increased risk of congenital heart defects in offspring compared with normal controls (those with neither hypertension nor use of any antihypertensives during pregnancy) (15/381 (3.9%) v 6232/400 021 (1.6%) cases, odds ratio 1.54 (95% confidence interval 0.90 to 2.62)). A similar association was observed for use of other antihypertensives (28/1090 (2.6%) cases of congenital heart defects, odds ratio 1.52 (1.04 to 2.21)). However, compared with hypertension controls (those with a diagnosis of hypertension but without use of antihypertensives) (708/29 735 (2.4%) cases of congenital heart defects), neither use of ACE inhibitors or of other antihypertensives in the first trimester was associated with increased congenital heart defects risk (odds ratios 1.14 (0.65 to 1.98) and1.12 (0.76 to 1.64) respectively). Conclusions Maternal use of ACE inhibitors in the first trimester has a risk profile similar to the use of other antihypertensives regarding malformations in live born offspring. The apparent increased risk of malformations associated with use of ACE inhibitors (and other antihypertensives) in the first trimester is likely due to the underlying hypertension rather than the medications.

A Standardized Approach To Clinical Engineering

A Standardized Approach To Clinical Engineering

Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study

Objective To examine a reported association between use of angiotensin converting enzyme (ACE) inhibitors during the first trimester and risk of malformations in offspring.Design A population based, retrospective cohort study...

Intermethod comparison of breast receptor studies by immunohistochemistry and quantitative RT-PCR (21 gene assay).

48 Background: The ASCO/CAP Guidelines mandate that laboratories performing HER2 and hormone receptor analyses monitor and correlate their results with results obtained from outside testing. Herein, we evaluate the concordance between results obtained by the 21 gene assay (ODx) with those performed by immunohistochemistry (IHC) at the Kaiser Permanente Northern California Regional IHC Laboratory (KP-NCAL). Methods: Sequential specimens from KP-NCAL were evaluated by IHC for ER (SP1), PR (PgR636) using 5% staining for positivity and HER2 (4B5) using &gt;30% with 3+ positivity. Standardized quantitative RT-PCR analysis for ER, PR and HER2 was performed using pre-defined cutoffs of 6.5, 5.5, 11.5 units. Reference normalized expression measurements ranged from 0 to 15, where each 1-unit increase reflects about a 2-fold increase in RNA. The percent positive agreement (PPA) and percent negative agreement (PNA) was calculated for each of the three markers. For the purposes of this inter-method comparison we define ODx as the reference test; in this comparison, a “true positive” is IHC+ and ODx+. A “false positive” would be IHC+ and ODx-. Results: Evaluable data was obtained from 216 sequential patients from 11/2009 to 5/2010 with both IHC (KP-NCAL) and the 21 gene assay (ODx) results. The HER2 PPA was 100%, PNA 99.4%. The ER PPA was 99.1%, PNA 100%. The PR PPA was 92%, PNA 52%. Conclusions: There is a high degree of agreement between KP-NCAL IHC and ODx results for ER and HER2. This level of agreement is particularly striking given that in &gt;90% of cases, IHC was performed on an initial biopsy, while the RT-PCR assay was performed on a subsequent excision specimen. The negative agreement for PR was moderate and suggests a possible lack of sensitivity in the IHC assay that needs to be studied further. [Table: see text]

Burkitt’s Lymphoma of the Abdomen: The Northern California Kaiser Permanente Experience

We retrospectively reviewed the experience of the Kaiser Permanente Northern California Region (KPNCR) with Burkitt’s lymphoma and studied patients with abdominal Burkitt’s lymphoma. During a 16-year period from 1987-2002, 7868 patients with lymphoma were entered into the California Cancer Registry (CCR) of KPNCR. Of these patients, 121 patients (1.5%) were found to be Burkitt’s type of lymphoma. Of the 121 patients, 36 were associated with HIV infection and an additional 35 patients hadBurkitt’s lymphoma presenting at a site outside of the abdomen The charts and computerized medical records of 50 cases of abdominal Burkitt’s lymphoma form the basis of this study. Of these 50 patients with intra-abdominal Burkitt’s lymphoma, involvement of mesenteric, retroperitoneal or pelvic structures was so extensive that the diagnosis was made by fine-needle aspiration, core biopsy or biopsy of a regional lymph node in 24 patients. Investigation of vague upper gastrointestinal symptoms led to CT scan and endoscopic stomach biopsy which demonstrated involvement with Burkitt’s lymphoma in three patients. Seven additional patients had open biopsies of large intraabdominal masses showing Burkitt’s lymphoma. The primary treatment of these patients was chemotherapy. Sixteen patients from the CCR had surgical exploration and resection of their tumor. One patient had disease of the jejunum. Two patients had isolated disease of ileum. Seven had disease of the ileum and cecum and six were felt to have disease primarily of cecum. When possible, abdominal Burkitt’s lymphoma was resected. All patients were also treated with chemotherapy.

Minilaparotomy: A Minimally Invasive Alternative for Major Gynecologic Abdominal Surgery

In the 1960s or 1970s, gynecology residency training emphasized vaginal hysterectomy as the preferred technique for treating many conditions now managed by less invasive alternatives. This led gynecologists to become very skilled at operating through very small incisions. More recently, as these less invasive procedures are rapidly becoming the standard of care, and women are having fewer babies, vaginal surgery is performed less often. Because our young colleagues are acquiring less experience with this technique, the skill of operating through a very small incision is becoming a lost art. Of the 600,000 hysterectomies done in the United States each year—a number which has remained stable for the past 20 years—65% to 75% are done through large abdominal incisions.1 Rates in the Kaiser Permanente Northern California (KPNC) Region are somewhat better: The rate of abdominal hysterectomy is 68%, the rate of vaginal hysterectomy is 21%, and 11% of these procedures are done laparoscopically. Although laparoscopic hysterectomy offers a minimally invasive alternative when vaginal hysterectomy is contraindicated or considered too difficult by the surgeon, laparoscopic hysterectomy has many drawbacks. The procedure is very costly because of its requirements for equipment and time in the operating suite and because the procedure has a very steep learning curve. However, when length of hospital stay and postoperative utilization of medical services are taken into account, laparoscopic hysterectomy in the KPNC Region is less expensive than abdominal hysterectomy but substantially more expensive than vaginal hysterectomy. In addition, compared with patients who have the more invasive (ie, abdominal) procedure, our patients who undergo vaginal or laparoscopic hysterectomy have better postoperative quality of life.2 Minilaparotomy is technically less difficult to perform than laparoscopic myomectomy … Development of Minilaparotomy Techniques Use of minilaparotomy in surgery for benign gynecologic disease has been well established.3 Laparoscopically assisted myomectomy was first reported by Nezhat et al in 1994.4 In their review of 57 cases, these authors concluded that the use of the minilaparotomy incision is a safe alternative to myomectomy done by laparotomy. Minilaparotomy is technically less difficult to perform than laparoscopic myomectomy, allows better closure of the uterine defect, and may require less time to perform. Most women in the series reported by Nezhat et al4 returned to normal activity within three weeks. In 2002, we adopted the Pelosi minilaparotomy hysterectomy technique as an effective alternative to laparoscopic hysterectomy and standard open laparotomy hysterectomy. First presented at the Global Congress of Gynecologic Endoscopy in 2002 and described in OBG Management in April 2003,5 the procedure relies on traditional open techniques learned by all Ob/Gyn residents and relies also on use of an inexpensive, soft, sleeve-type self-retaining abdominal retractor. Minilaparotomy is a minimally invasive procedure ideal for gynecologists who are less skilled in vaginal or laparoscopic surgery and who are more comfortable with the (standard) abdominal approach. In addition to combining the surgical principles and techniques of vaginal and laparoscopic surgery, minilaparotomy requires the same postoperative care as less invasive procedures. Detailed description of the surgical technique would be more appropriate for an obstetrics/gynecology journal; here I describe some of the most important technical principles of minilaparotomy.

Kaiser Permanente Women's Health Center of Excellence in Culturally Competent Care

In 2002, Kaiser Permanente (KP) launched its Women's Health Center of Excellence in Culturally Competent Care in the KP Northern California Region's Greater Southern Alameda Area (GSAA) Service Area, which includes the KP Fremont and Hayward Medical Centers. The KP National Diversity Program Offices' Institute for Culturally Competent Care made this designation of excellence possible. The Institute has awarded designation of Center of Excellence in Culturally Competent Care to KP facilities that are hallmark models of health care delivery to KP's diverse membership. The designation is an internal KP award. Centers develop innovative approaches to delivering clinical care customized to respond to the unique cultural beliefs and health practices of diverse member populations. The KP Women's Health Center of Excellence establishes the GSAA Service Area as a leader in delivering personalized health care, education, and services for women. The Center will integrate three necessary principles for delivering health care in the 21st century: Awareness and knowledge of diversity; Respect for individual beliefs, customs, and practices; and Culturally competent care. The GSAA Service Area continues to reflect a growing multicultural and multilingual population that is highly diverse and has substantial language requirements: At least 56 languages have been identified among KP members in the East Bay. According to the 2003 Meteor Survey, the GSAA KP membership is 49% white, 20% Hispanic, 20% Asian, and 6% black. Current data indicate that marketing efforts are not penetrating a substantial Asian population—in particular, the Chinese and Latino populations, which will continue to grow. Women with limited English proficiency are known to go to extra lengths to access and receive health care services for themselves and for their family members. Recent data from the KP Fremont and Hayward Medical Centers show that women are the major users of health care services. Women are the largest group of patients in all departments except urology and pediatrics, where male children surpass females by a small percentage. Despite these statistics, KP continues to provide medical care in a mostly traditional manner. The Women's Health Center of Excellence has four primary goals: To assemble and analyze background data used for implementing program interventions and to expand culturally competent care and services for women; To compile key learnings and tools; To share our experiences and expertise with others internal and external to KP; and To develop best practices and approaches for women's health care. The center offers learnings derived from women's health and multilingual communication programs and services initiated by such programs and services as the Multilingual Women's Health Program, the Baby-Friendly Hospital Initiative, and the Latina Breast Cancer Project. These programs and services continue to evolve along with the rapid growth of our diverse communities and member population segments. The center's current focus includes a Women's Health Educational Series, the Breastfeeding and Cultural Norms Research Project, and domestic violence. Key learnings as well as identified gaps and opportunities will enrich these programs and services to more effectively meet the health care needs of all women.

Managing High-Risk Obstetric Cases and Analyzing Neonatal Outcome: The KP Northern California Regional Perinatal Service Center

Yvonne Crites, MD; Jenny Ching, RN, BSN; Connie Lessner, RN; Deborah Ray, MD Winter 2005 - Volume 9 Number 1 Located in Santa Clara, California, the Kaiser Permanente (KP) Northern California Regional Perinatal Service Center provides obstetric care to h

The perinatal patient safety project: new can be great!

Although in 2000, the frequency of birth injury claims filed in the Kaiser Permanente Northern California Region (KPNC) had remained stable for years, their cost had risen dramatically. In response to this trend, the KP Board of Directors assigned Bruce Merl, MD, Director of The Permanente Medical Group (TPMG) Medical-Legal Affairs, and Julie Nunes, KPNC Regional Risk Management Director, the task of reducing the cost of these claims. Also assembled to address this problem was an expert group consisting of Susan Smarr, MD (obstetrician and Assistant Physician-in-Chief for Risk at the KP Santa Clara Medical Center), Robin Field, MD (perinatologist at the KP San Francisco Medical Center), Sonia SooHoo, MD (obstetrician and Chief of Medical-Legal Affairs at the KP South San Francisco Medical Center), and Mary Parks (KPNC Senior Counsel for Professional Liability). They performed an in-depth analysis of both the literature and the KPNC experience regarding perinatal events. Risk strategies developed from these efforts were highlighted at a Medicine Today broadcast in 2001. A theme that emerged from this analysis was the integral role of communication and teamwork in successfully managing obstetric emergencies. Sidebar 1. PPSP Innovations are Big Steps Forward PPSP is being adopted Programwide. Teams are being identified in all KP Regions. A Critical Events Team Training (CETT) Train-the-Trainer program was offered in 2004 in the KP Southern California Region. Several KP Regions are purchasing mannequins in preparation for the training. A Fetal Heart Rate training video has been developed for Programwide dissemination to standardize language and interpretation of fetal heart rate tracings.

Fragile Fracture Care Management Program

Previous osteoporotic fracture is a strong risk factor for recurrent fracture, both in men and in women,1–7 yet only one in five patients receive osteoporosis intervention after sustaining a fracture.8 In 2003, implementation of a new HEDIS measure assessing health plan performance on postfracture care reflected national recognition of the importance and magnitude of this issue. The HEDIS measure assesses the percentage of women 67 years of age and older who receive either a bone mineral density (BMD) test or a prescription for an osteoporosis drug within six months after sustaining a fracture. Data available from the Kaiser Permanente Northern California Region (KPNC) in 1999 showed a need to improve our postfracture care. Only 6% of women and <1% of men had received bone densitometry testing after an osteoporotic fracture of the hip, spine, wrist, or humerus. Similarly low percentages were found for initiation of osteoporosis medication for women (7%) and men (2%) (BE, unpublished data, 1999). The Fragile Fracture Care Management (FFCM) Program was a year-long pilot project implemented in July 2003 at the KP Vacaville Medical Center. The goal of the project was to evaluate efficacy of a care management program in increasing the rate of BMD testing and initiation of osteoporosis medication among women and men who have had a fragility fracture of the wrist, hip, spine, or humerus.

Family Violence Prevention Program: Another Way to Save a Life

Domestic violence, now often referred to as intimate partner violence, is a common, costly, complex health problem. An estimated 5% to 14% of US women are currently living in abusive situations, and 22% report assault by a domestic partner during their lifetime.1 But addressing domestic violence in the health care setting is very complex—disclosure, seeking services, and recovery are all challenging.2 Despite recommendations from most professional organizations3 and clinical practice guidelines, screening for domestic violence in the health care setting remains infrequent.4 To address the complexities of domestic violence for patients as well as for health care providers, an innovative systems-model approach was developed and tested at a Kaiser Permanente Northern California (KPNC) facility in Richmond, California5 and is currently being implemented at all facilities in the KPNC Region. … screening for domestic violence in the health care setting remains infrequent.4

The Emergency Contraception Online Learning Module

Kaiser Permanente (KP) has been on the forefront of educating providers and members about emergency contraception (EC) since 1996, even before a dedicated product was available. EC is up to 89% effective and is exceedingly safe for all women at risk for an unintended pregnancy. Despite awareness efforts, EC has remained underutilized. Recognizing this fact, recommendations were made by a California-wide EC Task Force to increase prophylactic prescribing by all providers who care for women of childbearing age, especially those who are exposed to teratogenic medications and chronic conditions that negatively impact pregnancy. KP Northern California Regional Women's Health—in cooperation with Multimedia, Pharmacy and Analytical Services (PAS)—and Physician Education—developed the Emergency Contraception [Online] Learning Module. The module is approved for one CME and consists of an 18-minute video: Emergency Contraception, Not Just an Ob/Gyn Issue and a 19-slide PowerPoint presentation entitled: Emergency Contraception, You Can Make a Difference, a pretest, a posttest, and a brief evaluation of the teaching tool. The EC Learning module can be accessed by going through the Northern California Women's Health KP Intranet site: http://insidekp.kp.org/california/womenshealth. The EC Learning Module can be accessed by going through the Northern California Women's Health KP Intranet site: http://insidekp.kp.org/california/womenshealth. On the front page is a link to the hosting site: PAS (Figure 1). The focus of the module is on the evidence that supports prophylactic prescribing of EC by all primary and specialty care providers who care for women and also discusses safety, efficacy, and prescribing issues. Several case studies are included. Figure 1 Emergency Contraception link on KP Northern California Women's Health Intranet site. Women's Health has received mostly positive feedback about the EC Learning Module through online evaluations and e-mail communications. As of August 2004, more than 250 providers have participated in this online CME program. Out of the 250 responding to the evaluation, 63% were “very satisfied,” and an additional 32% reported “satisfied.” When asked if they would be likely to view another online Women's Health video module, 93% reported they would and 90% reported they would be likely to use the materials presented this way as a reference. Providers from all KP Regions have accessed the EC Learning Module, the greatest percentage have come from both Northern and Southern California. So many providers and pharmacists from Southern California have accessed the site too that SCPMG Physician Education chose to accredit the program. Two hundred pharmacists from KP Orange County plan to use the module to satisfy state requirements for direct prescribing via collaborative treatment agreements with the Ob/Gyn physicians. This strategy will result in faster screening and dispensing of EC for Orange County KP members. PAS streamlined the CME certification system to allow for providers and pharmacists to download their own CME certificate. CME records are also maintained with respective regional physician education departments. We invite you to take a look at the module for important information about EC and how it pertains to your practice. The EC Learning Module has been accredited by Northern California Physician Education until October 29, 2006. Women's Health believes the success of the EC [Online] Learning Module stems from effective marketing and cooperation from all departments that participated in its development. Look for more Women's Health online CME education projects in the future.