Kaiser Permanente Southern California Members Research Articles

Application of Performance Improvement Methods to Improve Timeliness of Lung Cancer Care

Background/Aims: Timeliness, an essential element of high-quality care as defined by the Institute of Medicine, is critical in cancer care delivery. Timeliness of diagnosis and treatment is associated with improved outcomes for some cancers. A Kaiser Permanente Southern California (KPSC) organizational goal is to achieve optimal timeliness of cancer care to ensure best possible outcomes for KPSC members.

Vaccines and the risk of multiple sclerosis and other central nervous system demyelinating diseases.

Because vaccinations are common, even a small increased risk of multiple sclerosis (MS) or other acquired central nervous system demyelinating syndromes (CNS ADS) could have a significant effect on public health. To determine whether vaccines, particularly those for hepatitis B (HepB) and human papillomavirus (HPV), increase the risk of MS or other CNS ADS. A nested case-control study was conducted using data obtained from the complete electronic health records of Kaiser Permanente Southern California (KPSC) members. Cases were identified through the KPSC CNS ADS cohort between 2008 and 2011, which included extensive review of medical records by an MS specialist. Five controls per case were matched on age, sex, and zip code. Vaccination of any type (particularly HepB and HPV) identified through the electronic vaccination records system. All forms of CNS ADS were analyzed using conditional logistic regression adjusted for race/ethnicity, health care utilization, comorbid diseases, and infectious illnesses before symptom onset. We identified 780 incident cases of CNS ADS and 3885 controls; 92 cases and 459 controls were females aged 9 to 26 years, which is the indicated age range for HPV vaccination. There were no associations between HepB vaccination (odds ratio [OR], 1.12; 95% CI, 0.72-1.73), HPV vaccination (OR, 1.05; 95% CI, 0.62-1.78), or any vaccination (OR, 1.03; 95% CI, 0.86-1.22) and the risk of CNS ADS up to 3 years later. Vaccination of any type was associated with an increased risk of CNS ADS onset within the first 30 days after vaccination only in younger (<50 years) individuals (OR, 2.32; 95% CI, 1.18-4.57). We found no longer-term association of vaccines with MS or any other CNS ADS, which argues against a causal association. The short-term increase in risk suggests that vaccines may accelerate the transition from subclinical to overt autoimmunity in patients with existing disease. Our findings support clinical anecdotes of CNS ADS symptom onset shortly after vaccination but do not suggest a need for a change in vaccine policy.

Melanoma in patients with chronic lymphocytic leukemia and non-Hodgkin lymphoma

The relationship between melanoma and chronic lymphocytic leukemia (CLL) or non-Hodgkin lymphoma (NHL) has been minimally investigated. The objective of this study was to examine the incidence of melanoma in patients with a history of CLL or NHL, and their associated mortality. Cohorts of Kaiser Permanente Southern California members with a history of CLL and NHL were identified. Age-adjusted incidence density rates of melanoma among patients with CLL or NHL were compared with rates of melanoma among the general population of Kaiser Permanente Southern California patients. The mortality of patients with melanoma was examined using Cox proportional hazards modeling. The age-adjusted incidence rate per 100,000 person-years for melanoma among patients witheither CLL or NHL was 107 (95% confidence interval 84.4-129.6) versus 25.9 among the general population (95% confidence interval 84.4-129.6, P < .001). Patients with melanoma and a history of CLL or NHL had 2.46 greater odds of death compared with those without CLL or NHL (95% confidence interval 1.77-3.41). This study was retrospective in nature; the International Classification of Diseases, Ninth Revision codes used may contain diagnostic errors; and only overall survival was used in our analysis. Patients with a history of CLL or NHL have a higher incidence of melanoma. Patients with CLL or NHL who are subsequently given the diagnosis of melanoma have a higher mortality than patients with melanoma without a preceding diagnosis of CLL.

E-Autopsy: Using Structured Hybrid Manual/Electronic Mortality Reviews to Identify Quality Improvement Opportunities

Mortality reviews are a foundation of inpatient quality improvement (QI), but low levels of harm among a random or sequential sample may not yield actionable improvement opportunities. To increase the efficiency of mortality reviews at identifying QI opportunities, Kaiser Permanente Southern California (KPSC) developed a condition-specific hybrid electronic/manual chart review called the "e-autopsy." KPSC hospital deaths are filtered electronically by predetermined criteria. Teams consisting of a registered nurse and physician trained in QI at each hospital then manually review selected charts using a structured data-extraction tool to identify gaps in provision of evidence-based care. Results are aggregated and studied to identify improvement opportunities. E-autopsy has identified opportunities amenable to system improvements. The first e-autopsy of all KPSC members who died with a ruptured abdominal aortic aneurysm (AAA) in a KPSC hospital indicated that many patients meeting criteria had not been screened for AAA. This study showed KPSC leaders the value of point-of-care electronic decision support to increase evidence-based AAA screening and of a tracking system for patients with positive results. Screening among high-risk patients in 2012 increased by more than 8,000 individuals, compared with the annual average during the previous four years. E-autopsies have also been conducted of patients who died with aspiration pneumonia; after unplanned transfers to the ICU; and after diagnosis of colon cancer. E-autopsy reveals actionable opportunities to improve care systems, complementing other QI activities. This hybrid electronic/manual process can be applied to a wide variety of patient conditions and settings.

Risk of myocardial infarction in psoriasis patients: a retrospective cohort study

Background: Psoriasis may or may not be associated with a higher risk for myocardial infarction (MI). We sought to assess differences in MI incidence between control, mild psoriasis and severe psoriasis patients.Methods: We performed a retrospective cohort study of Kaiser Permanente Southern California members with psoriasis between 1 January 2004 and 30 June 2012, assessing the risk and incidence rates of MI.Results: There were 50 865 control patients matched to 10 173 patients with mild psoriasis and 19 205 control patients matched to 3841 patients with severe psoriasis. The MI incidence per 1000 person-years for mild psoriasis controls, mild psoriasis, severe psoriasis controls and severe psoriasis were 4.9, 6.7, 3.7 and 5.1, respectively. Upon multivariable analysis, mild psoriasis patients had a significantly higher risk of MI compared to matched control patients {hazard ratio (HR) = 1.31 [95% confidence interval (CI): 1.14, 1.51]} and severe psoriasis patients had a significantly higher risk of MI compared to matched control patients [HR = 1.28 (95% CI: 1.02, 1.60)].Conclusion: Patients with psoriasis are at higher risk for MI compared to control patients.

HIV infection and incidence of ischemic stroke

To determine the association of HIV infection and immunodeficiency with incidence of ischemic stroke. Cohort study of HIV-positive and matched HIV-negative adult Kaiser Permanente Northern and Southern California (KPNC and KPSC, respectively) members during 1996-2011 (KPNC) or 2000-2011 (KPSC). We used Poisson models to obtain rate ratios for incident ischemic stroke associated with HIV infection, both overall and stratified by CD4 cell counts (cells/μl) and HIV RNA copies (copies/ml), with HIV-negative individuals as the reference group. We also obtained rate ratios for risk factors in the HIV-positive subset. Among 24,768 HIV-positive and 257,600 HIV-negative individuals, the ischemic stroke rate per 100,000 person-years was 125 (n = 151 events) for HIV-positive and 74 (n = 1128 events) for HIV-negative individuals, with an adjusted rate ratio of 1.4 [95% confidence interval (CI) 1.2-1.7). Compared with HIV-negative individuals, HIV-positive individuals with recent CD4 cell counts of 500 cells/μl at least (rate ratio 1.0, 95% CI 0.8-1.4) or recent HIV RNA less than 500 copies/ml (rate ratio 1.1, 95% CI 0.9-1.4) had no excess risk of ischemic stroke, with similar results for HIV-positive individuals with nadir CD4 cell counts of 500 cells/μl at least (rate ratio 1.4, 95% CI 0.8-2.2) or 200-499 cells/μl (rate ratio 1.2, 95% CI 0.9-1.5). Among HIV-positive individuals only, recent CD4 cell count less than 200 cells/μl (rate ratio 2.5, 95% CI 1.3-4.6) was associated with an increased risk of ischemic stroke after adjustment for recent HIV RNA and nadir CD4 cell count, whereas recent HIV RNA and nadir CD4 were not independent risk factors. Ischemic stroke incidence in HIV-positive individuals with high CD4 cell count or low HIV RNA is similar to that of HIV-negative individuals.

Vaccination against zoster remains effective in older adults who later undergo chemotherapy.

Approximately 40% of adults develop invasive cancer during their lifetimes, many of whom require chemotherapy. Herpes zoster (HZ) is common and often severe in patients undergoing chemotherapy, yet there are no data regarding whether these patients retain specific protection against HZ if they had previously received zoster vaccine. We conducted a study to determine whether zoster vaccine was effective in patients who subsequently underwent chemotherapy. The cohort study consisted of Kaiser Permanente Southern California members aged ≥60 years treated with chemotherapy. The exposure variable was receipt of zoster vaccine prior to initiation of chemotherapy. Incident HZ cases were identified using International Classification of Diseases, Ninth Revision diagnostic codes. HZ incidence rates were calculated; hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards regression models. There were 91 and 583 HZ cases in the vaccinated and unvaccinated cohorts, respectively, yielding an incidence rate of 12.87 (95% CI, 10.48-15.80) vs 22.05 (95% CI, 20.33-23.92) per 1000 person-years. Thirty-month cumulative incidence was 3.28% in the vaccinated group and 5.34% in the unvaccinated group (P < .05). The adjusted HR for HZ was 0.58 (95% CI, .46-.73) and showed no significant variation by age, sex, or race. HZ incidence rates remained increased in the small subgroup of persons receiving zoster vaccine within 60 days before chemotherapy, but this was the only group affected by indication bias. No vaccinated patients underwent hospitalization for HZ, compared with 6 unvaccinated patients. Zoster vaccine continues to protect against HZ if recipients later undergo chemotherapy. Our findings provide an additional rationale for offering zoster vaccine to indicated adults while they are immunocompetent.

Validation of Pediatric Diabetes Case Identification Approaches for Diagnosed Cases by Using Information in the Electronic Health Records of a Large Integrated Managed Health Care Organization

We explored the utility of different algorithms for diabetes case identification by using electronic health records. Inpatient and outpatient diagnosis codes, as well as data on laboratory results and dispensing of antidiabetic medications were extracted from electronic health records of Kaiser Permanente Southern California members who were less than 20 years of age in 2009. Diabetes cases were ascertained by using the SEARCH for Diabetes in Youth Study protocol and comprised the "gold standard." Sensitivity, specificity, positive and negative predictive values, accuracy, and the area under the receiver operating characteristic curve (AUC) were compared in 1,000 bootstrapped samples. Based on data from 792,992 youth, of whom 1,568 had diabetes (77.2%, type 1 diabetes; 22.2%, type 2 diabetes; 0.6%, other), case identification accuracy was highest in 75% of bootstrapped samples for those who had 1 or more outpatient diabetes diagnoses or 1 or more insulin prescriptions (sensitivity, 95.9%; positive predictive value, 95.5%; AUC, 97.9%) and in 25% of samples for those who had 2 or more outpatient diabetes diagnoses and 1 or more antidiabetic medications (sensitivity, 92.4%; positive predictive value, 98.4%; AUC, 96.2%). Having 1 or more outpatient type 1 diabetes diagnoses (International Classification of Diseases, Ninth Revision, Clinical Modification, code 250.x1 or 250.x3) had the highest accuracy (94.4%) and AUC (94.1%) for type 1 diabetes; the absence of type 1 diabetes diagnosis had the highest accuracy (93.8%) and AUC (93.6%) for identifying type 2 diabetes. Information in the electronic health records from managed health care organizations provides an efficient and cost-effective source of data for childhood diabetes surveillance.

C-A4-01: Primary Non-Adherence to Statin Therapy in an Integrated Delivery System: Patients' Perceptions

Abstract Background/Aims Statin medications are commonly prescribed to lower cholesterol and the risk for cardiovascular events. Few published studies have, however, explored factors that may contribute to primary non-adherence with statins. We aimed to determine patients’ reasons for non-adherence with newly prescribed statin medication. Methods We identified Kaiser Permanente (KP) Southern California members aged =24 years with a new order for a statin prescription between May 10 and June 5, 2010 not redeemed within five weeks of the order date and with 12 months of continuous membership prior to the statin order. New orders were defined as the patient having no statin prescriptions in the previous 12 months. Among 1,157 eligible patients indicating English as their preferred language, we randomly selected patients and conducted 98 semi-structured telephone interviews about factors and perceptions that contribute to non-adherence. Results At six weeks post-index prescription date, 73% of respondents (74/98) reported not filling their new statin prescription while 23% (21/98) picked it up from a non-KP pharmacy. The three most commonly cited reasons for primary non-adherence were general concerns about taking the medication (63%; 46/73), a decision to try lifestyle modifications instead of taking the medication (63%; 46/73), and fear of side effects (53%; 39/73). One-third of respondents (33%; 24/72) reported taking over-the-counter products to lower their cholesterol. The majority of respondents agreed with the importance of the medication (63%; 45/73) but worried that the prescription would cause more harm than good (62%; 46/73). Fewer respondents (22%; 16/74) were burdened by the out-of-pocket expenses for the medication. Conclusions Although most respondents were convinced of the importance of their newly prescribed statin medication, they expressed concerns about adverse effects. In addition, respondents expressed a desire to modify their diet and exercise, and/or take non-prescription products to lower their cholesterol. These findings are consistent with other studies that have assessed patient factors related to adherence with statin therapy. These data warrant the need for interventions that address patients’ negative perceptions of statins while emphasizing the benefits of statins for reducing cardiovascular morbidity and mortality.

P1-335 Long-term cumulative risk of Herpes zoster among immunocompetent adults 60 years and older

IntroductionHerpes zoster (HZ) is a painful disease affecting mostly seniors. The goal of this study is to estimate the long-term cumulative risk of HZ in a general population 60 years...