Kaiser Permanente Southern California Members Research Articles

Wildfire exposure and health care use among people who use durable medical equipment in Southern California

Background: Climate change-induced wildfires cause trauma, stress, and injury in affected communities, while exposing 70% of the US population to smoke particulate matter (PM2.5) annually and exacerbating cardiorespiratory disease. Few studies examine wildfire smoke exposure in vulnerable populations, and none evaluate residence near a fire. Methods: We identified 236,732 Kaiser Permanente Southern California members who used electricity-dependent durable medical equipment (DME). DME use is associated with respiratory illness and disability, indicating vulnerability to smoke exposure and difficulty evacuating disaster zones. Daily counts of outpatient, inpatient, and emergency healthcare visits made by DME users from 2016-2020 were linked with daily estimates of wildfire generated PM2.5 by residential ZIP code. We used historical maps to identify ZIPs within 20 km of the the 2018 and 2019 Getty and Woolsey fires. We performed negative binomial regression analyses using direct and lagged effects of wildfire PM2.5 and difference-in-differences analyses to evaluate the association between direct wildfire exposure and health care visit frequency. We adjusted for temperature, temporal effects, non-wildfire PM2.5, and spatial confounders. Results: Residence within 20 km of the Woolsey Fire was associated with fewer outpatient and more inpatient visits (RR = 0.98, 95% CI: 0.78, 0.87, RR = 1.45, 95% CI: 1.01, 2.11), while Getty Fire evacuation exposure was not associated with visit frequency. In contrast, increases in wildfire PM2.5 were associated with small and constant increases in outpatient visits 2-6 days after a change. Wildfire PM2.5 was not associated with frequency of inpatient or emergency visits at any lag. Conclusion: DME users, presumed vulnerable to wildfire smoke exposure, may have sheltered in place during fires or took other precautions. However, the Woolsey Fire (which was 10 times larger than the Getty) may have produced health concerns in those directly affected when evacuation was necessary and sheltering in place impossible.

Effectiveness Associated With BNT162b2 Vaccine Against Emergency Department and Urgent Care Encounters for Delta and Omicron SARS-CoV-2 Infection Among Adolescents Aged 12 to 17 Years

Data about the duration of protection of 2 and 3 doses of BNT162b2 in children and adolescents are needed to help inform recommendations for boosters in this age group. To evaluate vaccine effectiveness (VE) and durability associated with 2 doses of BNT162b2 against Delta- and Omicron-related emergency department (ED) and urgent care (UC) encounters among adolescents aged 12 to 17 years and to estimate VE associated with 3 doses against these same outcomes. This test-negative case-control study was conducted at Kaiser Permanente Southern California, an integrated health care system using electronic health records in the US. Participants included Kaiser Permanente Southern California members ages 12 to 17 years with an ED or UC encounter from November 1, 2021, through March 18, 2022, for acute respiratory infection who were tested for SARS-CoV-2 via a reverse transction-polymerase chain reaction test. Analyses were conducted from March 21 to June 22, 2022. BNT162b2 vaccination status ascertained from electronic health records and state registry data. The main outcome was VE associated with BNT162b2 against ED and UC encounters related to Delta or Omicron variant SARS-CoV-2 infection. Analyses were conducted among 3168 adolescents, including 1004 with ED visits and 2164 with UC visits. Median (IQR) age was 15 (13-16) years, and 1461 (46.1%) were boys. In adjusted analyses, VE associated with 2 doses of BNT162b2 against ED or UC encounters was highest within the first 2 months for both Delta (89% [95% CI, 69% to 96%]) and Omicron (73% [95% CI, 54% to 84%]) variants but waned to 49% (95% CI, 27% to 65%) for the Delta variant and 16% (95% CI, -7% to 34%) for the Omicron variant at 6 months and beyond. A third dose of BNT162b2 was associated with improved protection against the Omicron variant (87% [95% CI, 72% to 94%]) after a median (IQR) of 19 (9-32) days after dose 3. These findings suggest that 2 doses of the BNT162b2 COVID-19 vaccine were associated with high levels of protection against ED and UC encounters related to the Delta and Omicron variants of SARS-CoV-2 in the first few months after vaccination. However, effectiveness waned over time, especially against Omicron. A third dose of BNT162b2 was associated with improved protection against Omicron beyond that seen initially after 2 doses, underscoring the importance of boosters for adolescents aged 12 to 17 years.

Opioid and Naloxone Prescribing Following Insertion of Prompts in the Electronic Health Record to Encourage Compliance With California State Opioid Law

Opioid addiction or dependency is a serious crisis in the US that affects public health as well as social and economic welfare. The State of California passed Assembly Bill (AB) 2760 in 2018 that mandates the coprescription of naloxone and opioids for patients with a high overdose risk. To assess whether the AB 2760-based electronic prompts were associated with increased naloxone orders for opioid users and reduced opioid prescribing when integrated into the practitioner workflow. This cohort study used interrupted time series mixed models to evaluate data obtained from the regional integrated health care system Kaiser Permanente Southern California (KPSC) from January 1, 2018, to December 31, 2019. Clinician participants were continuously employed at KPSC during the study period and ordered an opioid analgesic for eligible patients in 2018. Patient participants were KPSC members aged 18 years or older who received an opioid analgesic prescription during the study period. A series of AB 2760-based electronic prompts were integrated into the KPSC electronic health record system on December 27, 2018. The prompts are triggered or activated when 1 or more opioid prescribing conditions, defined in the AB 2760, are met at outpatient visits. Data were analyzed from January 8, 2021, to September 15, 2021. Assembly Bill 2760-based electronic prompts for outpatient opioid prescriptions in the electronic health record system. Primary outcomes were changes in outpatient naloxone order rates among patients who were prescribed opioids and changes in outpatient opioid prescribing rates. Secondary outcomes were total morphine milligram equivalents (MMEs) ordered per prescriber-month, prompts-targeted objectives, and unintended consequences. Risk for opioid abuse among 3 types of patients was also assessed. The 6515 eligible clinicians (mean [SD] age, 45.9 [9.43] years; 3604 men [55.3%]) included in the study served 500 711 unique patients in 1 903 289 outpatient encounters (mean [SD] age, 60.4 [15.67] years; 1 121 004 women [58.9%]) in which an opioid analgesic was prescribed. Naloxone order rate increased from 2.0% in December 2018 to 13.2% in January 2019 and then continued to increase to 27.1% in December 2019. Outpatient opioid prescribing rates decreased by 15.1% (rate ratio [RR], 0.85; 95% CI, 0.83-0.87) per prescriber-month when the electronic prompts were implemented. The postimplementation trend increased by 0.7% per prescriber-month (RR, 1.01; 95% CI, 1.01-1.01); the overall trend was still decreasing. The total MMEs per prescriber-month decreased by 7.8% (RR, 0.92; 95% CI, 0.89-0.96) after implementation of the prompts. The postimplementation trend tapered off. Other safe opioid prescribing measures also improved after implementation (decreases in concomitant muscle relaxants orders [RR, 0.94; 95% CI, 0.89-1.00], initial [RR, 0.86; 0.83-0.89] and renewal [RR, 0.65; 95% CI, 0.62-0.69] opioid orders, and long-term high-dose orders [RR, 0.96; 95% CI, 0.94-0.98]). This study found an association between implementation of AB 2760-based prompts and increased naloxone order rate; improved opioid prescribing measures (ie, decreased concomitant muscle relaxants orders, initial and renewal opioid orders, and long-term high-dose orders), except monthly median MMEs; and reduced opioid prescribing. The findings suggest that opioid overdose risks can be mitigated by encouraging safe prescribing habits.

Factors Affecting Compliance with Diabetic Retinopathy Screening: A Qualitative Study Comparing English and Spanish Speakers.

PurposeThe purpose of this study was to understand individual-, social-, and system-level factors that affect compliance with recommended diabetic retinopathy (DR)-evaluations, and how these factors vary between English and Spanish speakers.Patients and MethodsWe conducted a qualitative study using semi-structured interviews. Study subjects included Kaiser Permanente Southern California members with type II diabetes mellitus at least aged 26 years who spoke English or Spanish. Patients were divided into groups based on their adherence with DR evaluations. Our main outcome measure was the major themes expressed by patients that explained their compliance with DR evaluation.ResultsFifty-one participants were enrolled: 30 English speakers (11 nonadherent, 19 adherent) and 21 Spanish speakers (8 nonadherent, 13 adherent). Adherent patients were more likely to have had experience with diabetes and identify as being responsible for their own care. Substantially more non-adherent patients suggested that beliefs and attitudes were the reasons people missed retinopathy appointments. More English-speaking participants tended to be self-directed in managing their healthcare, whereas more Spanish speakers relied on others for help. English speakers also noted better relationships with their physicians. Spanish speakers outlined problems with insurance coverage and costs as barriers.ConclusionThese data suggest two specific intervention strategies that eye care providers could implement to improve adherence with diabetic retinopathy screening and follow up: incorporating a person with DR-related visual loss into the team of staff delivering diabetes support programs and communication campaigns including specific messaging to address fears related to vision loss.

Abstract P2-11-02: Subsequent breast cancer among women with HER2+ disease in a large integrated healthcare system

Abstract BACKGROUND: Women with breast cancer are living longer, including those with risk factors like HER2+ tumors or diagnosed at later stages, but a dearth of information exists on patients’ outcomes beyond clinical trials. We aimed to describe the risk of subsequent breast cancer (recurrence, second primary breast cancer, breast cancer-specific death) in women with HER2+ disease in a large community health plan. METHODS: We assembled a cohort of 3550 women (≥18 years) with HER2+ breast cancer (Stages I-III) during 2009-2017 whom were Kaiser Permanente Southern California members and followed them through December 2018. Subjects were identified from the plan’s NCI-SEER tumor registry. Data elements were captured from the tumor registry, pathology reports, and electronic health records. Hormone receptor (HR, ER and/or PR+), and HER2 status were assessed by immunohistochemistry or FISH. Subsequent breast cancer (SBC) events were identified from pathology report review (2/3 of cohort) or a validated computerized algorithm (1/3 of cohort without pathology reports). We computed SBC rates by trastuzumab use, HR status and tumor size and followed women from the index date to the date of SBC, disenrollment, death, or end of study in December 2018, whichever occurred first. Multivariable Cox proportional hazards regression was used to estimated adjusted hazard ratios (HR) and 95% confidence intervals. RESULTS: Of the 3550 women, the median age at diagnosis was 57 years. The cohort comprised 46% White; 13% Black; 16% Asian/Pacific Islander; and 24% Hispanic. 83% had stage I-II disease and 68% were HR+. Among these women, 81% received adjuvant trastuzumab; 3% other chemotherapy only and 16% neither. Less than 20 women used neoadjuvant trastuzumab. The cohort was followed a mean of 4.1 years (IQR: 1.5-6.3), with a maximum of 10 years. In the trastuzumab treated group, the cumulative 1-, 3-, 5-, and 10-year SBC risk were: 9.8%, 24.6%, 27.8%, and 30.4%, respectively. The mean time to SBC was 2.0 years (IQR: 0.9-2.5). SBC rate was lower in women who had trastuzumab (73.5/1,000 PY) therapy than those who did not (90.8/1,000 PY), corresponding to 22% reduced risk (adjusted HR=0.78, 95% CI: 0.66-0.91) (Table 1). Compared to women diagnosed at stage I, those with stage II-III disease were 1.19 times (adj HR=1.19, 95% CI: 1.01-1.40) more likely to develop SBC. Tumor size≥2cm was associated with a 23% greater risk of SBC (adj HR=1.23, 95% CI: 1.00-1.51) versus tumors<2cm. The multivariable analyses included these covariates: trastuzumab use; diagnosis age and year; stage; race/ethnicity; geocoded income; ER/PR; surgery type; other adjuvant therapy (endocrine, radiation, chemotherapy); lymph node status; histology; BMI; comorbidity; neoadjuvant trastuzumab, and other chemotherapy. CONCLUSION: This population-based study using one of the most comprehensive electronic medical records in California, we observed that the cumulative SBC risk persists, and was 30.4% at 10 years in women with HER2+ breast cancer treated with trastuzumab. Further, the SBC risk was greater in those with higher stages, large tumors (≥2 cm) and lymph node positive, even after accounting for trastuzumab use. Table. Multivariable HRs (95% CI) for subsequent breast-cancer in women with HER2+ invasive diseaseTotal Women*SBCSBC rates per 1,000 woman-yearsCrude modelMultivariable modelNNHR (95% CI)HR (95% CI)All Women 3550110176.5 TrastuzumabNo67522790.81.00 (ref)1.00 (ref)Yes287587473.50.86 (0.74-0.99)0.78 (0.66-0.91) Stage at dxI147138862.31.00 (ref)1.00 (ref)II-III207971387.31.45 (1.28-1.65)1.19 (1.01-1.40) Tumor sizeTumors<2 cm53012657.11.00 (ref)1.00 (ref)Tumors≥2 cm291094380.11.51 (1.25-1.83)1.23 (1.00-1.51) Lymph NodesPositive (ref)117043387.11.00 (ref)1.00 (ref)Negative206254363.90.69 (0.61-0.79)0.75 (0.65-0.88)*Some variables do not sum to N=3550 due to missing Citation Format: Reina Haque, Lie H Chen, Karen Kwan, Nina Oestreicher, Rowan T. Chlebowski, Deepa Lalla. Subsequent breast cancer among women with HER2+ disease in a large integrated healthcare system [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-02.

Herpes Zoster Following Recombinant Zoster Vaccine With or Without Concomitant Vaccination.

BackgroundThe 2-dose recombinant zoster vaccine (RZV) series is recommended for prevention of herpes zoster (HZ) in adults aged ≥50 years, but data are limited on the impact of concomitant administration with other vaccines on subsequent HZ risk.MethodsThis cohort study included Kaiser Permanente Southern California members aged ≥50 years who received 2 doses of RZV 4 weeks to ≤6 months apart during 1 April 2018–30 September 2019. RZV recipients with and without same-day concomitant vaccination for either RZV dose were followed up for incident HZ beginning 31 days after the second RZV dose until 30 September 2020. The hazard ratio (HR) for HZ comparing RZV recipients with and without concomitant vaccination was estimated using Cox proportional hazards regression, adjusting for confounders.ResultsRZV with and without concomitant vaccination was received by 12 898 and 28 353 individuals, respectively. HZ occurred among 41 individuals with concomitant vaccination (incidence rate, 2.2 [95% confidence interval {CI}, 1.6–3.0] per 1000 person-years) and 136 without concomitant vaccination (3.4 [95% CI, 2.9–4.0] per 1000 person-years). The adjusted HR for HZ comparing RZV recipients with and without concomitant vaccination was 0.75 (95% CI, .53–1.08).ConclusionsHZ risk was not significantly different between RZV recipients with and without concomitant vaccination, supporting recommendations allowing for concomitant administration of RZV with other vaccines.

Abstract 11847: Acute Myocarditis Following COVID-19 mRNA Vaccination

Introduction: Acute myocarditis after coronavirus disease 2019 (COVID-19) mRNA vaccination is not well described. Recent public reports have signaled that this is an entity that requires ongoing surveillance. The goal of this study is to investigate myocarditis incidence following COVID-19 mRNA vaccination, and to report the clinical course and outcomes. Methods: This is a retrospective population-based cohort study performed at Kaiser Permanente Southern California (KPSC), an integrated health care system in California. Patients who received at least one dose of BNT162b2 (Pfizer) or mRNA-1273 (Moderna) mRNA vaccine were included. Clinically significant cases of acute myocarditis within 10 days of COVID-19 mRNA vaccination were identified between 12/14/2020 and 5/31/2021. Key demographic, clinical, laboratory, diagnostic data, and clinical course were obtained from medical record review. Results: Of 1,776,608 KPSC members who received at least one dose of COVID-19 mRNA vaccines, 12 developed acute myocarditis within 10 days following vaccination, for an estimated incidence of 6.6 cases per 1 million patients. All patients were relatively healthy White or Hispanic men between the ages of 18 and 40 years. Patients reported chest pain two to eight days after vaccine administration (Moderna N=5; Pfizer N=7). Eleven patients developed myocarditis after the second dose, and one after the first dose. Troponin I elevations ranged from 1.53-32.30 ng/mL. All cases were self-limited, with troponin peaking within 24-48 hours of admission and symptom resolution prior to discharge. None of the patients had evidence of decompensated heart failure. Length of stay was 1-4 days, with all patients discharged home and no recurrence, readmission, or major adverse cardiac events. Conclusions: Acute myocarditis after COVID-19 mRNA vaccination is a rare and self-limited event that warrants further description and investigation.

Abstract P117: Comparison Between Routine Clinical And Research Blood Pressure Measurements

Background: Prior studies have found a large difference between blood pressure (BP) when measured routinely in the clinic compared with research studies. We aimed to compare routine clinic BP to research-grade BP in a large, integrated health care system that has initiatives to standardize clinic BP measurements. Methods: We identified Kaiser Permanente Southern California members ≥ 65 years old diagnosed with hypertension and taking antihypertensive medication from the Ambulatory Blood Pressure in Older Adults (AMBROSIA) study. Research-grade BPs were obtained under standardized conditions by certified research staff using a semi-automatic oscillometric device, pre-programmed to take 3 measurements at 1-minute intervals. The average of the 3 BPs was used. The most recent (prior to study enrollment) routine clinic BP from an outpatient, non-urgent clinical care encounter, measured using a semi-automatic oscillometric device, was obtained via electronic health records. If there were multiple BP readings on the same day, the first reading was used. The mean difference between clinic BP and research-grade BP was tested using paired t-tests, while the Pearson correlation and a Bland-Altman analysis were used to assess level of agreement. Results: We included 309 participants (mean age 75 ± 6 years; 54% female; 49% non-Hispanic white, 17% non-Hispanic Black, 17% Hispanic, 15% Asian/Pacific Islander). When measured in routine clinic practice and in the research study, the mean (SD) systolic BP (SBP) was 135 (16) mm Hg and 132 (15) mm Hg, respectively, (mean difference = - 2.7 mm Hg; 95% CI -4.6 to -0.9; limits of agreement = -36 to 30 mm Hg) and the mean diastolic BP (DBP) was 70 (10) mm Hg and 69 (10) mm Hg, respectively (mean difference = - 0.9 mm Hg; 95% CI -2.1 to 0.3; limits of agreement = -22 to 20 mm Hg). Pearson correlation analysis showed modest correlations between the two types of BP measurements (SBP r=0.40, p<0.01; DBP r=0.45, p<0.01). Conclusion: The difference between clinic and research-grade BP was, on average, small, but differences at the individual level were often substantial.

Disparities in Outpatient and Telehealth Visits During the COVID-19 Pandemic in a Large Integrated Health Care Organization: Retrospective Cohort Study.

BackgroundDramatic decreases in outpatient visits and sudden increases in telehealth visits were observed during the COVID-19 pandemic, but it was unclear whether these changes differed by patient demographics and socioeconomic status.ObjectiveThis study aimed to assess the impact of the pandemic on in-person outpatient and telehealth visits (telephone and video) by demographic characteristics and household income in a diverse population.MethodsWe calculated weekly rates of outpatient and telehealth visits by age, sex, race/ethnicity, and neighborhood-level median household income among members of Kaiser Permanente Southern California (KPSC) from January 5, 2020, to October 31, 2020, and the corresponding period in 2019. We estimated the percentage change in visit rates during the early pandemic period (March 22 to April 25, 2020) and the late pandemic period (October 4 to October 31, 2020) from the prepandemic period (January 5 to March 7, 2020) in Poisson regression models for each subgroup while adjusting for seasonality using 2019 data. We examined if the changes in visit rates differed by subgroups statistically by comparing their 95% CIs.ResultsAmong 4.56 million KPSC members enrolled in January 2020, 15.0% (n=682,947) were ≥65 years old, 51.5% (n=2,345,020) were female, 39.4% (n=1,795,994) were Hispanic, and 7.7% (n=350,721) lived in an area of median household income <US $40,000. Increases in telehealth visits during the pandemic varied across subgroups, while decreases in outpatient visits were similar, except by age. Among age groups, the ≥65 years population had the least increase in telehealth visits (236.6%, 95% CI 228.8%-244.5%), with 4.9 per one person-year during the early pandemic period versus 1.5 per one person-year during the prepandemic period. During the same periods, across racial/ethnic groups, Hispanic individuals had the largest increase in telehealth visits (295.5%, 95% CI 275.5%-316.5%). Across income levels, telehealth visits in the low-income group increased the most (313.5%, 95% CI 294.8%-333.1%). The rate of combined outpatient and telehealth visits in the Hispanic, non-Hispanic Black, and low-income groups returned to prepandemic levels by October 2020.ConclusionsThe Hispanic group and low-income group had the largest percentage increase in telehealth utilization in response to the COVID-19 pandemic. The use of virtual care potentially mitigated the impact of the pandemic on health care utilization in these vulnerable populations.

Influenza vaccination and mortality among adults with heart failure in an integrated healthcare delivery system, 2009-2018.

Influenza infection can result in decompensation or exacerbation of heart failure (HF) symptoms, hospitalization, and death. To examine the association of influenza vaccination with mortality and hospitalization during influenza and non-influenza seasons between 2009 and 2018. In this prospective, observational cohort study, we included Kaiser Permanente Southern California members with a HF diagnosis prior to September 1 each year from 2009 to 2017. The first influenza vaccination in each season (September 1 to May 31) was recorded. Vaccinated/unvaccinated patients were matched 1:1 on age, sex, and ejection fraction at the vaccination date (n-total = 74,870). Patients were followed through the end of each influenza season for all-cause mortality. Secondary outcomes included cardiovascular mortality and all-cause hospitalization. In a sensitivity analysis, we examined mortality in the non-influenza season. Influenza vaccinated vs unvaccinated patients had more comorbidities and higher healthcare utilization. After multivariable adjustment for utilization, sociodemographics, comorbidities, and medications, influenza vaccinated vs unvaccinated patients had a lower risk of all-cause mortality and cardiovascular mortality during the influenza season (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.63, 0.70 and HR 0.68, 95% CI 0.63, 0.74, respectively) but a higher risk of all-cause hospitalization (HR 1.27, 95% CI 1.21, 1.31). There was no association between influenza vaccination and all-cause or cardiovascular mortality during the non-influenza season (HR 0.99, 95% CI 0.89, 1.09 and HR 1.00, 95% CI 0.84, 1.21, respectively). Influenza vaccination in HF patients was associated with a lower risk of mortality during the influenza season. Our findings provide support for recommendations of universal influenza vaccination in patients with HF.

Adverse Events of Sodium-Glucose Cotransporter-2 Inhibitors in Chronic Kidney Disease: A Retrospective Chart Review.

The renal benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2) are now well established, and these agents are recommended by the American Diabetes Association and Kidney Disease: Improving Global Outcomes guidelines for patients with type 2 diabetes and chronic kidney disease. However, the safety profile of SGLT2 inhibitors in chronic kidney disease is not as clear. We describe the adverse event rates of SGLT2 inhibitors, primarily empagliflozin, in Kaiser Permanente Southern California members with diabetic kidney disease. This study was a multicenter retrospective descriptive analysis evaluating Kaiser Permanente Southern California members with type 2 diabetes and chronic kidney disease 1, 2, or 3 who first filled an SGLT2 inhibitor prescription in 2018, with follow-up through 2019. Primary outcomes were event rates of diabetic ketoacidosis, bone fracture, amputation, urinary tract infection, genital mycotic infection, hyperkalemia, and acute kidney injury. Secondary outcomes were mean changes in estimated glomerular filtration rates, serum creatine levels, urine albumin-to-creatinine ratios, and hemoglobin A1c percentages during the follow-up period. Of 213 patients, 39 experienced at least 1 adverse event, for a total of 50 adverse events. Urinary tract infection had the highest incidence (62.1 events/1000 person-years), followed by genital mycotic infection (58.0 events/1000 person-years). Favorable changes were observed during the follow-up period for urine albumin-to-creatinine ratios and hemoglobin A1c percentages, with mean decreases of 81.8 mg/g and 0.7%, respectively. SGLT2 inhibitors were discontinued in 47.4% of patients, with the top reasons including increase in serum creatinine (8%) and urinary or genital side effects (5.6%). Although most patients did not experience adverse events, urinary tract infections and genital mycotic infections were more common. Our detection of rates and types of adverse effects replicated most results reported in clinical trials. Discontinuations were largely attributed to reasons other than adverse events.

Trends in Influenza Vaccine Uptake and Severe Influenza-Related Outcomes at Kaiser Permanente Southern California, 2007-2017.

Major efforts to increase influenza vaccine uptake among Kaiser Permanente Southern California (KPSC) members have been undertaken in recent years. However, whether these improvements translate to a decline in severe influenza-related outcomes has not been examined. We aimed to understand the impact of the influenza vaccination program at KPSC by examining influenza vaccine uptake and 3 severe influenza-related outcomes. We conducted an ecologic trend analysis to understand influenza vaccine uptake and influenza-related hospitalization, intensive care unit (ICU) admission, and mortality for each influenza season (2007-2017). The same cohort was followed from the influenza season to the noninfluenza season immediately afterward while using the noninfluenza season as the comparison group. We also assessed the within-season correlation between influenza vaccine uptake and influenza-related outcomes. Influenza vaccine uptake rose from 23.9% to 45.5%, and all 3 influenza-related outcome rates declined (hospitalization: 35.4-26.8/10,000 patients; ICU: 5.9-5.2/10,000 patients; and mortality: 3.4-2.3/10,000 patients). Influenza vaccine uptake was negatively correlated with hospitalization (-0.32, p < 0.001) and mortality (-0.29, p = 0.001). However, once we adjusted for the noninfluenza season, the results of the correlation analysis were no longer statistically significant. Although we could not establish a statistically significant inverse relationship between influenza vaccination and severe influenza-related outcomes over the study period, our findings indicate an overall decline in influenza-related outcomes over the study period, suggesting improvements in both preventive and acute care quality at KPSC.

Temporal trends in heart failure mortality in an integrated healthcare delivery system, California, and the US, 2001\u20132017

BackgroundIn recent years, decreases in mortality rates attributable to cardiovascular diseases have slowed but mortality attributable to heart failure (HF) has increased.MethodsBetween 2001–2017, trends in age-adjusted mortality with HF as an underlying cause for Kaiser Permanente Southern California (KPSC) members were derived through linkage with state death files and compared with trends among California residents and the US. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated using Joinpoint regression. Analyses were repeated examining HF as a contributing cause of death.ResultsIn KPSC, the age-adjusted HF mortality rates were comparable to California but lower than the US, increasing from 23.9 per 100,000 person-years (PY) in 2001 to 44.7 per 100,000 PY in 2017, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). HF mortality also increased in California from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI − 0.5%, 0.5%). Trends among KPSC members ≥ 65 years old were similar to the overall population, while trends among members 45–64 years old were flat between 2001–2017. Small changes in mortality with HF as a contributing cause were observed in KPSC members between 2001 and 2017, which differed from California and the US.ConclusionLower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and care-related factors driving susceptibility to HF mortality.

Abstract MP41: Rates Of Acute Myocardial Infarction Around The Covid-19 Pandemic And Comparable Time Periods In 2019 In An Integrated Healthcare Delivery System

Background: Stay at home orders and fear of acquiring COVID-19 may have led to an avoidance of care for medical emergencies including acute myocardial infarction (AMI). We sought to examine rates of confirmed AMI cases between January 1-June 30, 2019 and 2020. Methods: We identified Kaiser Permanente Southern California members ≥ 18 years old with a hospitalization or emergency department visit for AMI, defined by ICD-10 primary diagnosis codes. Rates of AMI per 100,000 member-weeks were calculated for pre-pandemic and pandemic periods of January 1-March 3, 2020 and March 20-June 30, 2020, respectively, and in the same periods of 2019 overall and for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), separately. March 4-19, 2020 was considered a washout period given the gradual rollout of stay-at-home orders. Rate ratios (RR) and 95% confidence intervals (CI) were calculated comparing pre-pandemic and pandemic periods of 2020 to 2019 using Poisson regression. Results: The mean age of patients presenting with AMI during the 2020 (n=3,029) and 2019 (n=3,518) periods was 69 years, and a majority of events occurred among men (62%) and whites (47%). Rates of AMI in the pre-pandemic period of 2020 and same period in 2019 were 4.23 and 4.45 per 100,000 member weeks, respectively. During the pandemic period of 2020 and the same period in 2019, rates were 3.04 and 3.85 per 100,000 member-weeks, respectively. (Figure) There was no evidence rates of AMI were different during the pre-pandemic period of 2020 compared to the same period in 2019 (RR 0.95, 95% CI 0.88, 1.03). In contrast, rates of AMI were lower during the pandemic period of 2020 compared to the same period of 2019 (RR 0.79, 95% CI 0.74, 0.85), and among NSTEMI (RR 0.80, 95% CI 0.74, 0.86) and STEMI (0.74, 95% CI 0.66, 0.84) cases. Conclusion: AMI rates were lower during the COVID-19 pandemic compared to the year prior. Public health messaging is important to ensure people seek care for medical emergencies.

COVID-19 Inequities Across Multiple Racial and Ethnic Groups: Results From an Integrated Health Care Organization.

COVID-19 Inequities Across Multiple Racial and Ethnic Groups: Results From an Integrated Health Care Organization.

Belatacept Conversion Protocols and Outcomes in Kidney Transplant Recipients

BackgroundConversion from calcineurin inhibitor (CNI)-based to belatacept-based immunosuppression has become common; however, numerous protocols have emerged in lieu of a standardized protocol. The purpose of this study was to characterize belatacept conversion protocols from multiple centers and observe outcomes. MethodsThis was a retrospective study that included Kaiser Permanente Southern California members. The primary outcome was rejection 6 months after conversion and secondary outcomes included change in serum creatinine and graft loss. ResultsSeventy-eight patients were included. Thirteen distinct protocols were identified from 8 different transplant centers. Protocols varied by initial dose, induction schedule, and CNI taper. The observed rate of rejection was 6%. There was a trend toward an association of rejection with lower tacrolimus exposure at the time of conversion and lower mycophenolic acid dosing postconversion. Graft survival was 88% and patient survival was 94%. There was a significant improvement in creatinine after conversion. Those with early conversions and creatinine >2.0 mg/dL at the time of conversion had the best response. ConclusionsA large variety of belatacept conversion protocols were identified. Protocols were defined by the initial dose, induction regimen, and CNI taper. Rejection rates were low and may be influenced by exposure to maintenance immunosuppression during and after conversion. Most patients showed stabilization and improvement in creatinine postconversion, with the largest effect in those with an early conversion and serum creatinine >2.0 mg/dL.

Completion of the two-dose recombinant zoster vaccine series in adults 50 years and older

BackgroundIn 2017, a new adjuvanted recombinant zoster vaccine (RZV) was recommended for adults ≥50 years as two-dose series 2–6 months apart. We evaluated two-dose RZV completion and factors associated with completion. MethodsThe study included Kaiser Permanente Southern California members ≥50 years who received an RZV dose during April-November 2018 and had continuous membership 12 months before to 9 months after the first RZV dose. Completion was defined as receipt of the second dose ≥4 weeks to 9 months after the first dose (allowing 3-month grace period). Characteristics including age, sex, race/ethnicity, Medicaid status, neighborhood level income and education, comorbidities, history of zoster, health care utilization before and after the first dose, receipt of influenza vaccine, vaccination month (supply shortage proxy), concomitant vaccine, medical center, and medically attended reactions, pain, or gout after the first dose were compared between completers and non-completers. Adjusted odds ratios and 95% confidence intervals for factors associated with completion were estimated by multivariable logistic regression. ResultsAmong 31,120 first dose recipients, 67.2% completed the series within 9 months. In adjusted analyses, higher completion was associated with White compared with Black or Hispanic race/ethnicity, higher neighborhood income and education, no chronic pulmonary disease, diabetes, or dementia, more outpatient visits and fewer emergency department visits before or after the first dose, no hospitalizations after the first dose, receipt of influenza vaccine, receipt of the first dose in June-November rather than April-May 2018, and no concomitant vaccine with the first dose. Systemic reactions or pain after the first dose was not associated with completion. ConclusionCompletion of RZV series appears suboptimal in the early phase of implementation. Despite similar accessibility in a health care system, completion varied by race/ethnicity, socioeconomic status, health status, and care seeking behavior, suggesting areas to target for improvement.

19. Completion of Two-Dose Recombinant Zoster Vaccine Series in Adults 50 Years and Older

BackgroundIn 2017, the Advisory Committee on Immunization Practices preferentially recommended adjuvanted recombinant zoster vaccine (RZV) for adults ≥ 50 years as a two-dose series 2–6 months apart.1 We evaluated two-dose RZV completion and factors associated with completion.MethodsThe study included Kaiser Permanente Southern California members ≥ 50 years who received an RZV dose during April-November 2018 and had continuous membership 12 months before to 9 months after the 1st RZV dose (RZV1). Completion was defined as receipt of the 2nd dose ≥4 weeks to 9 months after RZV1 (allowing a 3-month grace period). Characteristics including age at RZV1, sex, race/ethnicity, Medicaid status, neighborhood level income and education, distance from home to medical office, comorbidities, history of herpes zoster, health care utilization before and after RZV1, receipt of influenza vaccine, vaccination month (supply shortage proxy), concomitant vaccine, department administering RZV1, medical center, and medically attended local or systemic reaction, pain, or gout after RZV1 were compared between completers and non-completers. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) for factors associated with completion were estimated by multivariable logistic regression.ResultsAmong 31,120 RZV1 recipients, 67.2% completed the series within 9 months. In adjusted analyses, higher completion was associated with White compared with Black or Hispanic race/ethnicity, higher neighborhood income and education, no chronic pulmonary disease, diabetes, or dementia, more outpatient visits and fewer emergency department visits before or after RZV1, no hospitalizations after RZV1, receipt of influenza vaccine, receipt of RZV1 in June-November rather than April-May 2018, no concomitant vaccine with RZV1, and receipt of RZV1 in Family Practice rather than Internal Medicine. Systemic reactions or pain after RZV1 was not associated with completion.Table 2. RZV Series Completion by Selected Characteristics During Follow-up of Members Aged ≥50 Years Who Received at Least One Dose of RZV at Kaiser Permanente Southern California in April-November 2018 Table 2. RZV Series Completion by Selected Characteristics During Follow-up of Members Aged ≥ 50 Years Who Received at Least One Dose of RZV at KPSC in April-November 2018 Figure 1. Factors Associated with RZV Series Completion of Members Aged ≥ 50 Years Who Received at Least One Dose of RZV at KPSC in April-November 2018 ConclusionCompletion of RZV series appears moderate in the early phase of implementation. Despite similar accessibility in a health care system, completion varied by race/ethnicity, socioeconomic status, health status, and care seeking behavior, suggesting areas to target for improvement.DisclosuresHung-Fu Tseng, MPH, PhD, GlaxoSmithKlein (Research Grant or Support) Lei Qian, PhD, GlaxoSmithKlein (Research Grant or Support) Jun Wu, MD, MS, GlaxoSmithKlein (Research Grant or Support) Yi Luo, PhD, GlaxoSmithKlein (Research Grant or Support) Lina S. Sy, MPH, GlaxoSmithKlein (Research Grant or Support) Katia Bruxvoort, PhD, MPH, GlaxoSmithKlein (Research Grant or Support) Bradley Ackerson, MD, GlasoSmithKlein (Research Grant or Support)

1623. Outcomes of Critically Ill Adults, Hospitalized Patients (Pts) with Pseudomonas aeruginosa (PSA) Hospital- and Ventilator-Associated Pneumonia (HAP/VAP) Who Received an Active Anti-Pseudomonal β-Lactam (ASPB): Does “S” Equal Success in the Presence of Resistance to other ASPB?

BackgroundThe most commonly prescribed antibiotics for PSA HAP/VAP are ASPBs: meropenem (MER), piperacillin/tazobactam (TZP),cefepime (FEP) and ceftazidime (CAZ). Similar resistance mechanisms in PSA affect these agents, and it is unclear if you can use a susceptible ASPB when the PSA is resistant to other ASPBs. This study evaluates the impact of ASPB resistance among pts with PSA HAP/VAP who initially received therapy with an ASPB to which PSA was susceptible.MethodsA cohort study of Kaiser Permanente Southern California (KPSC) members (1/1/11-12/31/17) was performed. Inclusion criteria: (1) age ≥ 18 years; (2) HAP/VAP diagnosis; (3) monomicrobial PSA on a clinical respiratory culture (index PSA); (4) ICU at index PSA; (5) received MER, TZP, FEP or CAZ within ≤ 2 days of index PSA; (6) index PSA was susceptible to ASPB received; (7) no cystic fibrosis; (8) survived > 2 days post index PSA, and (9) ≥ 6 months of KPSC membership prior to index PSA. Pts were stratified by presence of resistance to MER, TZP, and FEP on index PSA (0 vs. ≥1 resistant ASPB). Outcomes: 30-day mortality and discharge to home.Results560 patients were included. Mean (SD) age was 70.5 (14.2) years, 60% were male, and most had many comorbidities. Thirty-day mortality was 28%, and 32% were discharged home. Ninety-five (17%) received an active ASPB for PSA HAP/VAP that was resistance to ≥ 1 ASPB. Relative to pts with no ASPB resistance, pts with resistance ≥ 1 ASPB had higher 30-day mortality (32% vs. 27%) and were less likely to be discharged home (17% vs. 35%). In multivariate analyses, pts with resistance ≥ 1 ASPB had higher 30-day mortality (aOR=1.61 [CI: 1.01-2.56]) and were less likely to be discharged home (aHR [95%]: 0.5 [0.3-0.9]).Crude and Adjusted Associations Between Presence of Anti-Pseudomonal β-Lactam -Resistance (Reference= no ASPB resistance) and Outcomes among Adult, ICU patients with HAP/VAP due to PSA who received a Microbiologic Active Anti-Pseudomonal β-Lactam ConclusionDespite receiving a microbiologic active agent within ≤ 2 days of their PSA HAP/VAP, pts with PSA that were resistant to ≥ 1 ASPB had worse outcomes relative to those that had no ASPB resistance. Further study is needed, but these findings suggest that the full ASPB susceptibility profile needs to be considered when selecting therapy for pts with PSA HAP/VAP. More studies are also needed to determine if alternative or combination therapies may be needed to maximize outcomes in PSA infection when there is resistance ≥ 1 ASPB.DisclosuresThomas Lodise, PharmD, PhD, Paratek Pharmaceuticals, Inc. (Consultant) Laura A. Puzniak, PhD, Merck (Employee) Rong Wei, MA, Kaiser Permenante (Research Grant or Support) Yun Tian, MS, Merck (Research Grant or Support) Theresa M. Im, MPH, Merck (Research Grant or Support) Lie Hong Chen, DrPH, Merk (Research Grant or Support) Sara Tartof, PhD, Merck (Grant/Research Support)

Recurrent Atherosclerotic Cardiovascular Event Rates Differ Among Patients Meeting the Very High Risk Definition According to Age, Sex, Race/Ethnicity, and Socioeconomic Status.

BackgroundThe risk for atherosclerotic cardiovascular disease (ASCVD) events may differ by sociodemographic factors among patients meeting the definition of very high risk according to the 2018 American Heart Association/American College of Cardiology cholesterol guideline, leading to treatment disparities. We estimated the risk for recurrent ASCVD events among adults meeting the definition of very high risk by age, sex, race/ethnicity, and socioeconomic status in a US integrated healthcare system.Methods and ResultsThe study cohort included Kaiser Permanente Southern California members aged ≥21 years with a history of clinical ASCVD on September 30, 2009. Very high risk for recurrent ASCVD was defined by a history of ≥2 major ASCVD events or a history of 1 major event along with ≥2 high‐risk conditions. Patients were followed through 2015 for a first recurrent ASCVD event. Of 77 101 patients with ASCVD, 50.8% met the definition for very high risk. Among patients meeting the definition of very high risk, recurrent ASCVD rates were higher in older (>75 years) versus younger patients (21–40 years) (sex‐adjusted hazard ratio [HR] [95% CI] 1.85; 1.23–2.79), non‐Hispanic Black patients versus non‐Hispanic White patients (age‐, sex‐adjusted HR, 1.32; 1.23–1.41), those who lived in neighborhoods with lower (<$35k) versus higher annual household income (≥$80k) (HR, 1.20; 1.11–1.30), or with lower (≥31.2%) versus higher education levels (<8.8% high school or lower) (HR, 1.26; 1.19–1.34).ConclusionsDisparities in the risk for recurrent ASCVD events were present across sociodemographic factors among very high risk patients. The addition of sociodemographic factors to current definitions of very high risk could reduce health disparities.