Kaiser Permanente Regions Research Articles

Successful deployment of drug-disease interaction clinical decision support across multiple Kaiser Permanente regions.

The study sought to develop a criteria-based scoring tool for assessing drug-disease knowledge base content and creation of a subset and to implement the subset across multiple Kaiser Permanente (KP) regions. In Phase I, the scoring tool was developed, used to create a drug-disease alert subset, and validated by surveying physicians and pharmacists from KP Northern California. In Phase II, KP enabled the alert subset in July 2015 in silent mode to collect alert firing rates and confirmed that alert burden was adequately reduced. The alert subset was subsequently rolled out to users in KP Northern California. Alert data was collected September 2015 to August 2016 to monitor relevancy and override rates. Drug-disease alert scoring identified 1211 of 4111 contraindicated drug-disease pairs for inclusion in the subset. The survey results showed clinician agreement with subset examples 92.3%-98.5% of the time. Postsurvey adjustments to the subset resulted in KP implementation of 1189 drug-disease alerts. The subset resulted in a decrease in monthly alerts from 32 045 to 1168. Postimplementation monthly physician alert acceptance rates ranged from 20.2% to 29.8%. Our study shows that drug-disease alert scoring resulted in an alert subset that generated acceptable interruptive alerts while decreasing overall potential alert burden. Following the initial testing and implementation in its Northern California region, KP successfully implemented the disease interaction subset in 4 regions with additional regions planned. Our approach could prevent undue alert burden when new alert categories are implemented, circumventing the need for trial live activations of full alert category knowledge bases.

Cardiovascular medication use and risks of colon cancer recurrences and additional cancer events: a cohort study

BackgroundCardiovascular medications may be associated with cancer development, but little is known about their association with cancer recurrence. Medications such as statins and antihypertensives may be commonly used among colon cancer survivors, who are, on average, diagnosed in their mid-60s. We described the associations between statins and antihypertensive medications and colon cancer recurrence in a large, population-based study.MethodsWe conducted a cohort study among adults with stage I-IIIA colon cancer diagnosed in 1995–2014 in two Kaiser Permanente regions, Colorado and Washington. Statin and antihypertensive use were obtained from electronic pharmacy dispensing data. People were classified as medication users on the date of their first dispensing after cohort entry, which started 90 days after completing cancer treatment, continuing through the earliest of death, health plan disenrollment, or chart abstraction. We collected outcome information from medical record abstraction and tumor registries on colon cancer recurrences and second primary cancers. Using Cox proportional hazards multivariable models, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for colon cancer recurrences and any cancer event (recurrences and new primaries at any anatomic site) comparing medication users to non-users.ResultsAmong 2039 people, 937 (46%) used statins and 1425 (70%) used antihypertensives at any point during a median of 4.9 years of follow-up; 460 people had any additional cancer event, including 152 with a colon cancer recurrence. Statin use was not associated with colon cancer recurrence (HR = 1.09, 95%CI = 0.65–1.85) or any cancer event (HR = 1.12, 95%CI = 0.85–1.47), nor was antihypertensive use associated with recurrence (HR = 0.73, 95%CI = 0.44–1.21) or any cancer event (HR = 0.93, 95%CI = 0.70–1.24).ConclusionsOur results suggest no association between cardiovascular medication use and the risk of recurrence or any additional cancer, and may provide reassurance to colon cancer survivors.

Factors That Influence Selectionof Urinary Diversion Among Bladder Cancer Patients in 3 Community-based Integrated Health Care Systems

ObjectiveTo assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk nonmuscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors’ outcomes across different surgical treatment options. MethodsBladder cancer patients' age ≥21 years with cystectomy/UD performed from January 2010 to June 2015 in 3 Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect. ResultsOf 991 eligible patients, 794 (80%) received IC. One hundred sixty-nine surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (intraclass correlation coefficient = 0.26). The multilevel model with only patient factors showed good fit (area under the curve = 0.93, Hosmer-Lemeshow test P = .44), and older age, female sex, estimated glomerular filtration rate <45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs neobladder/continent pouch. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (P = .29). ConclusionIn this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.

Abstract P181: Hypertension Treatment Disruption During Pregnancy Among Women With Chronic Hypertension

Objective: In the U.S., 1.3 million women of reproductive age take antihypertensive medications for chronic hypertension. However, some of these medications are considered unsafe during pregnancy. We evaluated the burden of switching and stopping medications during pregnancy among women receiving treatment for chronic hypertension. Study Design: We identified a population-based cohort of women with chronic hypertension who received antihypertensive medications within 120 days before pregnancy and gave birth to a singleton between 2005 and 2014 within three Kaiser Permanente regions. We characterized women’s antihypertensive medication use from 120 days before pregnancy through delivery. We ascertained the highest systolic and diastolic blood pressures in the 120 days before the start of pregnancy and supplemented these values with measures up through 8 weeks’ gestation when pre-pregnancy values were missing. Results: 5,782 pregnant women were included. Prior to pregnancy, the most commonly used medication classes were thiazide diuretics (2,370/5,782, 41%), beta-blockers (1,569/5,782, 27%) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) (1,391/5,782, 24%). In contrast, the predominant medications during pregnancy were labetalol (2,165/5,782, 37%) and methyldopa (1,593/5,782, 28%). During pregnancy, 18% of the cohort (1,037/5,782) had no antihypertensive medication fills. Women taking ACEI/ARBs or thiazides before pregnancy were the most likely to have no medication fills in pregnancy (23% and 20%, respectively). Many women (n=881) had at least one severe high BP (SBP ≥160 or DBP ≥110) before pregnancy, and in this group, 15% (132/881) filled no medications throughout pregnancy. Conclusion: Women with chronic hypertension frequently stop antihypertensive medications during pregnancy, even women with a severely high BP documented before pregnancy. Research is needed to understand impact of these treatment interruptions on pregnancy outcomes and women’s long-term health.

Medical Care Costs for Recurrent versus De Novo Stage IV Cancer by Age at Diagnosis.

To address the knowledge gap regarding medical care costs for advanced cancer patients, we compared costs for recurrent versus de novo stage IV breast, colorectal, and lung cancer patients. Virtual Data Warehouse (VDW) information from three Kaiser Permanente regions: Colorado, Northwest, and Washington. We identified patients aged ≥21 with de novo or recurrent breast (ndenovo =352; nrecurrent =765), colorectal (nde novo =1,072; nrecurrent =542), and lung (nde novo =4,041; nrecurrent =340) cancers diagnosed 2000-2012. We estimated average total monthly and annual costs in the 12months preceding, month of, and 12months following the index de novo/recurrence date, stratified by age at diagnosis (<65, ≥65). Generalized linear repeated-measures models controlled for demographics and comorbidity. In the pre-index period, monthly costs were higher for recurrent than for de novo breast (<65: +$2,431; ≥65: +$1,360), colorectal (<65: +$3,219; ≥65: +$2,247), and lung cancer (<65: +$3,086; ≥65: +$2,260) patients. Conversely, during the index and post-index periods, costs were higher for de novo patients. Average total annual pre-index costs were five- to ninefold higher for recurrent versus de novo patients <65. Cost differences by type of advanced cancer and by age suggest heterogeneous patterns of care that merit further investigation.

Patient and System Characteristics Associated with Performance on the HEDIS Measures of Alcohol and Other Drug Treatment Initiation and Engagement.

Understand patient and system characteristics associated with performance on the Healthcare Effectiveness Data and Information Set (HEDIS) Alcohol and Other Drug (AOD) Initiation and Engagement of Treatment (IET) measures. This mixed-methods study linked patient and health system data from four Kaiser Permanente regions to HEDIS performance measure data for 44,320 commercially or Medicare-insured adults with HEDIS-eligible AOD diagnoses in 2012. Characteristics associated with IET were examined using multilevel logistic regression models. Key informant interviews (n = 18) focused on opportunities to improve initiation and engagement. Non-white race/ethnicity, alcohol abuse, or nonopioid drug abuse diagnoses were associated with lower odds of treatment initiation among commercially insured. For both insurance groups, those diagnosed in healthcare departments other than specialty AOD treatment were less likely to initiate or engage in treatment. Being diagnosed in facilities with co-located AOD/primary care clinics, and those with medications for addiction treatment available, was each associated with higher odds of initiation and engagement for both commercially and Medicare-insured. Having behavioral medicine specialists or clinical health educators in primary care increased initiation and engagement odds among commercially insured. Key informants recommended were as follows: patient-centered care; increased treatment choices; cross-departmental patient identification, engagement, and coordination; provider education; and use of informatics/technology. Tailoring treatment, enhancing treatment motivation among individuals with lower severity diagnoses, offering medication treatment of addiction, clinician education, care coordination, co-located AOD and primary care departments, and behavioral medicine specialists in primary care may improve rates of initiation and engagement in AOD treatment.

Physical activity, bowel function, and quality of life among rectal cancer survivors.

Physical activity (PA) is positively associated with numerous health benefits among cancer survivors. This study examined insufficiently investigated relationships among PA, health-related quality of life (HRQOL), and bowel function (BF) in rectal cancer survivors. RC survivors (n=1063) ≥5years from diagnosis in two Kaiser permanente regions were mailed a multidimensional survey to assess HRQOL and BF. PA was assessed by a modified Godin Leisure-Time Exercise Questionnaire. PA minutes were categorized into weighted categories based on guidelines: (1) not active (zero PA minutes); (2) insufficiently active (1-149 PA minutes); (3) meeting guidelines (150-299 PA minutes); and (4) above guidelines (≥300 PA minutes). Relationships of PA with HRQOL and BF were evaluated using multiple linear regression, stratified by sex and ostomy status for BF. Types of PA identified as helpful for BF and symptoms addressed were summarized. Response rate was 60.5%. Of 557 participants, 40% met or exceeded PA guidelines, 34% were not active, and 26% were insufficiently active. Aerobic activities, specifically walking and cycling, were most commonly reported to help BF. Higher PA was associated with better psychological wellbeing and multiple SF12 scales, worse BF scores in men with ostomies, and better BF scores in women. Meeting or exceeding PA guidelines was associated with higher HRQOL. Although the BF findings are exploratory, they suggest women may benefit from increased PA, whereas men with ostomies may face challenges that require more study. Identifying PA strategies that will lead to improved patient compliance and benefit are needed.

Predictors of urinary diversion choice in patients with bladder cancer in integrated care settings.

4543 Background: Annually over 10,000 people with bladder cancer in the US have cystectomy surgery with urinary diversion (UD). While ileal conduit (IC) is most common, neobladder (NB) and continent pouch (CP) are options to retain urinary continence. Few studies in community settings have examined patient and clinician factors associated with UD choice. Methods: Eligible patients were age ≥21 with a cystectomy and UD for bladder cancer from 1/2010 to 6/2015 in 3 West coast Kaiser Permanente regions. Data were obtained from the EHR and chart review.We useda mixed effects logistic regression model with surgeon as a random effect, and region as a fixed effect, to identify patient factors associated with UD choice (IC vs NB/CP). We also examined whether surgeon factors were associated with UD choice above and beyond patient factors. Results: Among 1063 patients, 80% had an IC. IC patients were older (mean age 72 vs. 62), more likely female (24% vs. 16%), more likely diagnosed with AJCC stage III/IV (41% vs. 28%), and had higher Charlson comorbidity score (median 4 vs. 3) than NB/CP patients. Surgeons accounted for a sizable portion of the variability in UD choice (ICC = .26). The model with patient factors showed good fit (AUC = .93, Hosmer-Lemeshow test p = .22). Including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) did not improve model fit (p = .32). Female sex, eGFR &lt; 45, 4+ comorbidities, and stage III/IV tumors were associated with higher odds of receiving an IC vs. NB/CP (Table). Conclusions: Patient factors predict much of the variability in UD choice. The high ICC indicates that surgeons also contribute to this process, but surgeon factors we examined were not uniquely associated with IC. Future studies should explore more nuanced surgeon factors, such as how UD choice is shaped by personal beliefs about UD and likely outcomes. [Table: see text]

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

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

Behavioral adjustments, supplements, and medications to manage bowel dysfunction in rectal cancer survivors.

150 Background: Bowel dysfunction is a common long-term treatment effect that adversely impacts the quality of life (QOL) of rectal cancer (RC) survivors. Research suggests that self-care strategies such as behavioral adjustments and supplements/medications are used to achieve bowel control. Evidence describing the specific types of self-care strategies is lacking. The purpose of this study is to describe behavioral adjustments and supplement/medications use in long-term ( ≥ 5 years) RC survivors for managing bowel dysfunction. Methods: Long-term RC survivors with or without permanent ostomies who were enrolled in two Kaiser Permanente Regions completed a survey that included questions eliciting behavioral adjustments and supplements/medications used for bowel control. Written comments from the questions were coded for content and themes. The themes were reviewed and agreed upon by the research team. Responses mentioned &lt; 9 times were combined into broader categories; those mentioned ≥ 9 times were coded separately. Results: A total of 577 RC survivors responded to the survey. 118 survivors (20.4%) responded to the behavioral adjustment question, while 248 (43%) responded to the helpful supplements/medications question. Behavioral adjustments included controlling meal portions (38.9%), eating meals at regular times (19.4%), not eating late or before bedtime (10.1%), and grazing (8.4%); they mitigated constipation, obstruction, bloating, frequency, urgency, and improved bowel predictability. Other behavioral adjustments include not eating before or after activities (5.9%), not eating (5.1%), snacking at regular times (2.5%), and eating less when traveling (1.6%). Helpful supplements/medications include anti-diarrheals (23.6%), dietary fiber supplements (16.6%), stool softeners (15.0%), laxatives (12.6%), antacid (5.6%), probiotics (5.0%), and opioids (3.6%). Conclusions: RC survivors used multiple behavioral adjustments and supplements/medications to achieve bowel control. The specific adjustments and strategies varied greatly. Findings will aid in developing personalized strategies to manage bowel symptoms during survivorship.

Effect of Angiotensin System Inhibitors on Survival in Patients Receiving Chemotherapy for Advanced Non–Small-Cell Lung Cancer

IntroductionPreclinical studies suggest that angiotensin system inhibitors (ASI) and bevacizumab improve tumor perfusion and chemotherapy efficacy. We performed a retrospective study to examine whether concomitant ASI use during carboplatin and paclitaxel (CP) without or with bevacizumab (CPB) was associated with improved overall survival (OS) in patients with advanced nonsquamous, non–small-cell lung cancer (NS-NSCLC). Patients and MethodsIn a retrospective cohort study, adult patients diagnosed with stage IIIB or IV NS-NSCLC between 2005 and 2011 were identified from tumor registries at 1 of 4 Kaiser Permanente regions. Survival differences between those who did and did not receive ASIs concomitant with chemotherapy (CP or CPB) were assessed using propensity score–matched proportional hazard models. OS was measured from the initiation of chemotherapy until death, disenrollment, or December 31, 2012. ResultsOf the 1465 CP and 348 CPB patients included, 273 (19%) and 78 (22%), respectively, received concomitant ASI. For CP patients with and without concomitant ASI exposure, median OS was 12.0 and 8.4 months, respectively (crude hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.63-0.84). For CPB patients, the comparable median OS was 14.9 and 11.9 months, respectively (crude HR, 0.77; 95% CI, 0.57-1.02). Using propensity score–matched cohorts, the HR for concomitant ASI use was 0.73 (95% CI, 0.61-0.88) for CP patients and 0.79 (95% CI, 0.51-1.21) for CPB patients. ConclusionConcomitant ASI receipt during CP or CPB therapy for NS-NSCLC was associated with improved survival, although the association was only statistically significant in the CP group.

Investing in Obesity Treatment: Kaiser Permanente's Approach to Chronic Disease Management.

Kaiser Permanente, an integrated health care delivery system in the USA, takes a "whole systems" approach to the chronic disease of obesity that begins with efforts to prevent it by modifying the environment in communities and schools. Aggressive case-finding and substantial investment in intensive lifestyle modification programs target individuals at high risk of diabetes and other weight-related conditions. Kaiser Permanente regions are increasingly standardizing their approach when patients with obesity require treatment intensification using medically supervised diets, prescription medication to treat obesity, or weight loss surgery.

Improving screening and prophylaxis of Hepatitis B in immunosuppressed patients.

139 Background: Kaiser Permanente (KP) is an integrated health care delivery system that provides clinical services to over 10 million members in nine states and the District of Columbia. Since 2007, KP oncology community collaborates at the national level to systematically improve safety and quality of care. Our improvements are accelerated by rapid adoption of evidence based protocols, leveraging of EMR and integration of quality improvement methods into clinical operations. Methods: KP created a team that included oncologists, hepatologists, rheumatologist, pharmacy, and quality improvement experts to evaluate safety of existing practice. Based on internal findings, we decided to focus on screening and prophylaxis of Hepatitis B in immunosuppressed patients. Hepatitis B primary infection can be self-limited with viral elimination and lasting immunity or can result in a state of chronic infection with persistent viremia. Hepatitis B can be reactivated with, or after withdrawal of, immune suppressive cancer therapy. Reactivation can result in clinical hepatitis, treatment interruptions, and not infrequently death from fulminant hepatitis. The goal of this initiative is to save lives (i.e. track % patients on chemotherapy who were not tested for Hepatitis B surface Antigen and Hepatitis B core Antibody and for those with a positive test, to determine if they received appropriate prophylaxis). Results: The multidisciplinary group initiated interventions: 1) Defined the patient safety measure of a rate of patients on anti-CD 20 therapies who had a Hepatitis B test prior to therapy; 2) Completed a baseline analyses and shared results with KP regions for appropriate actions; 3) Created an alert and incorporated into KP oncology/ rheumatology Beacon module; 4) Developed KP National screening and prophylaxis resource for hepatitis B in immunosuppressed patients; 5) Developed capacity for ongoing monitoring. Conclusions: We determined a need to educate clinicians and to standardize recommendations for screening and prophylaxis of Hepatitis B in patients receiving Anti-CD20 therapy. Changes were instituted in the Beacon protocols to check baseline labs. Ongoing surveillance using a safety net will be developed.

Recovery challenges faced by bladder cancer survivors after recent cystectomy and urinary diversion.

90 Background: Bladder cancer patients who are treated with cystectomy (bladder removal) and urinary diversion (bladder replacement) experience high rates of complications and hospital readmissions, and have substantial supportive care needs. Patient-reported priorities for improving early-phase survivorship care are lacking. Methods: On the basis of focus groups and in-depth interviews with 32 bladder cancer survivors about post-operative challenges, we developed a structured question listing 16 early survivorship challenges. We asked respondents to indicate which challenges had been difficult to manage at home. The item was part of a survey mailed to members of three Kaiser Permanente regions who had undergone cystectomy and urinary diversion for bladder cancer approximately 6 months previously (N = 197). Eligible patients were identified through health plan databases and chart review. Results: The response rate to the survey was 65%. Respondents reported an average of 3 challenges. The most commonly reported challenges pertained to coordination of medical care (69%), such as confusion about follow-up care, problems obtaining medical and ostomy supplies, knowing what complications to look for and who to notify if they occur, receiving home health care, or obtaining prompt medical advice. Other problems were caring for the urinary diversion (53%); dealing with urine leaks and incontinence (49%); problems with balance, vision, and dexterity (32%); difficulty managing emotions (23%); and management of lymphedema (11%) or incisional or parastomal hernias (7%). Conclusions: More than two thirds of bladder cancer survivors who had recently undergone cystectomy and urinary diversion struggled with medical care coordination. Managing self-care, complications, and emotional well-being after this major surgery can be difficult for patients, who must also navigate a variety of supportive services, such as medical follow-up with multiple departments and providers, home health services, and wound or ostomy care. A more formal approach to discharge and better communication among patients and providers will help improve early survivorship care for this group.

Relation of Acute Heart Failure Hospital Length of Stay to Subsequent Readmission and All-Cause Mortality

Heart failure (HF) hospitalization length of stay (LOS) has been associated with the risk of subsequent readmission and mortality. We identified 19,927 hospitalized patients with HFwho were discharged alive from 2008 to 2011 from 3 Kaiser Permanente regions. In adjusted Cox models using LOS 3 to 4days as the reference category, shorter LOS was not significantly associated with hospital readmissions. LOS of 5 to 10days was associated with 17% greater risk of readmission within 30days (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.07 to 1.28) and 9% greater risk within 1year (HR 1.09, 95% CI 1.03 to 1.15). LOS of 11 to 29days was associated with increased readmission risk of 52% at 30days (HR 1.52, 95% CI 1.30 to 1.76) and 25% at 1year (HR 1.25, 95% CI 1.16 to 1.35). Mortality risk within 30days among those with LOS of 1day was 47% lower (HR 0.53, 95% CI 0.43 to 0.65) and 32% lower at 1year (HR 0.68, 95% CI 0.62 to 0.74). LOS of 2days was associated with lower mortality risk of 17% (HR 0.83, 95% CI 0.76 to 0.90) at 1year. At LOS 5 to 10days, 30-day and 1-year risk of mortality was increased by 52% (HR 1.52, 95% CI 1.30 to 1.76) and 25% (HR 1.25, 95% CI 1.16 to 1.35), respectively. LOS of 11 to 29days was associated with 171% higher mortality risk at 30days (HR 2.71, 95% CI 2.19 to 3.35) and 73% at 1year (HR 1.73, 95% CI 1.53 to 1.97). Longer LOS during the index HF hospitalization was associated with readmission and mortality within 30days and 1year independent of co-morbidities and cardiovascular risk factors. These results suggest that LOS may be a proxy for the severity of HF during the index hospitalization.

Delivery System Partnerships Empower Large Pragmatic Trials: The Case of Diabetes Prevention in Kaiser Permanente

Background/Aims: Successful pragmatic trials require close partnership between researchers and health care organizations. We describe the process by which we engaged clinical and operational leaders from three Kaiser Permanente (KP) regions to design a trial to test alternative population-based models for diabetes prevention.

Comparing Implementation Models Across Two Kaiser Permanente Regions to Improve Outcomes for Patients With Comorbid Depression and Diabetes

Comparing Implementation Models Across Two Kaiser Permanente Regions to Improve Outcomes for Patients With Comorbid Depression and Diabetes

Treatment patterns for ductal carcinoma in situ from 2000-2010 across six integrated health plans.

Considerable debate exists about the optimal treatment of ductal carcinoma in situ (DCIS). Using electronic data sources, we examined first course treatment patterns among women aged 18 years and older diagnosed with DCIS between 2000–2010 from six Kaiser Permanente (KP) regions. We calculated the proportion of patients receiving breast conserving surgery (BCS), BCS plus radiation therapy, unilateral mastectomy, bilateral mastectomy, and hormone therapy. Multinomial logistic regression was used to assess the association between patient characteristics and treatment. We included 9,437 women: 1,086 (11.5%) African-American; 1,455 (15.4%) Asian; 918 (9.7%) Hispanic; and 5,978 (63.3%) non-Hispanic white. Most cases (42.2%) received BCS plus radiation as their initial treatment. Nearly equal numbers of women received BCS without radiation (28.5%) or unilateral mastectomy (24.6%). Use of bilateral mastectomy was uncommon (4.7%), and most women (72.2%) did not receive hormone therapy has part of their first course treatment. We observed statistically significant differences in treatment patterns for DCIS by KP region and patient age. Predictably, nuclear grade and the presence of comorbidities were associated with first course treatment for DCIS. We observed statistically significant increases in BCS plus radiation therapy and bilateral mastectomy over time. Although still uncommon, the frequency of bilateral mastectomy increased from 2.7% in 2000 to 7.0% in 2010. We also observed differences in treatment by race/ethnicity. Our findings help illustrate the complex nature of DCIS treatment in the United States, and highlight the need for evidence based guidelines for DCIS care.

Genital herpes and its treatment in relation to preterm delivery.

To examine the risks of genital herpes and antiherpes treatment during pregnancy in relation to preterm delivery (PTD), we conducted a multicenter, member-based cohort study within 4 Kaiser Permanente regions: northern and southern California, Colorado, and Georgia. The study included 662,913 mother-newborn pairs from 1997 to 2010. Pregnant women were classified into 3 groups based on genital herpes diagnosis and treatment: genital herpes without treatment, genital herpes with antiherpes treatment, and no herpes diagnosis or treatment (unexposed controls). After controlling for potential confounders, we found that compared with being unexposed, having untreated genital herpes during first or second trimester was associated with more than double the risk of PTD (odds ratio (OR) = 2.23, 95% confidence interval (CI): 1.80, 2.76). The association was stronger for PTD due to premature rupture of membrane (OR = 3.57, 95% CI: 2.53, 5.06) and for early PTD (≤35 weeks gestation) (OR = 2.87, 95% CI: 2.22, 3.71). In contrast, undergoing antiherpes treatment during pregnancy was associated with a lower risk of PTD compared with not being treated, and the PTD risk was similar to that observed in the unexposed controls (OR = 1.11, 95% CI: 0.89, 1.38). The present study revealed increased risk of PTD associated with genital herpes infection if left untreated and a potential benefit of antiherpes medications in mitigating the effect of genital herpes infection on the risk of PTD.

Use of imaging for staging of early breast cancer in two integrated health care systems.

184 Background: The initial ASCO “Top 5” list, created as part of the Choosing Wisely campaign, recommends against use of imaging for staging of early stage breast cancer in asymptomatic women at low risk for metastasis. The objective of this study was to measure and compare use of imaging for staging in two large integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was used for routine staging or for diagnostic purposes. Methods: We identified stage 0-IIB breast cancer patients diagnosed between January 1, 2010 and December 31, 2012 with first primary malignancy from tumor registries in three KP regions (Southern California, Northwest, and Mid-Atlantic) and IH. Using the KP and IH electronic health records, we identified use of imaging tests (PET, CT, bone scan) during the staging window (30 days prior to diagnosis up to initial surgery). We performed chart abstraction on a random sample of patients who received an imaging test to identify indication. Results: For the total sample of 10,014, mean age at diagnosis was 60 (range 22-99); with 21% stage 0, 47% stage I, 32% stage II. Overall, 8% of patients (792 patients) received at least one imaging test during the staging window, including 8% at KP and 6% at IH (p=0.0005). Chart abstraction (N=129) revealed that overall, almost half of all imaging tests (48%) were performed to evaluate a symptom, sign or prior imaging finding, including 55% at KP and 32% at IH. Conclusions: Use of imaging for staging of low-risk breast cancer was very low in both health care systems, with clinically trivial differences between them. Approximately half of imaging services were in response to a sign or symptom. Strategies to reduce use of imaging at staging for early stage breast cancer patients within these health care systems are unlikely to yield meaningful improvement. [Table: see text]