Large Integrated Healthcare Delivery System Research Articles

Qualitative evaluation to Understand barriers and facilitators to prescribing angiotensin receptor-neprilysin inhibitors (ARNi) and sodium-glucose cotransporter inhibitors (SGLT2i) in patients with heart failure with reduced ejection fraction (HFrEF)

BackgroundDespite sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor/neprilysin inhibitors (ARNi) being cost-effective evidenced-based therapies for the management of Heart Failure with Reduced Ejection Fraction (HFrEF), research shows that less than 30% of patients with HFrEF are prescribed these agents. ObjectiveThis study aimed to understand clinician-perceived barriers and facilitators to prescribing ARNi and SGLT2i in patients with HFrEF. MethodsWe conducted virtual and in-person semi-structured interviews in a large integrated healthcare delivery system in the United States. Twenty cardiology clinicians managing patients with HFrEF were recruited using purposeful sampling to target providers across professions and practice sites. The interview guide was developed based on a literature review and insights from a practicing cardiologist. It inquired about perceived prescribing behaviors, focusing on factors affecting the use of ARNi and SGLT2i. We identified key themes using rapid qualitative analysis. ResultsTwenty clinicians were interviewed: 13 physicians, 5 advanced practitioners, and 2 clinic-based pharmacists. Eighteen interviews were analyzed; we excluded 2 as the clinicians interviewed did not meet the inclusion criteria. Three major themes were identified: 1) clinician-reported prescribing patterns don't always align with the American College of Cardiology/American Heart Association guidelines for the use of SGLT2i and ARNi due to clinical inertia, lack of familiarity, knowledge, and comfort with use, and concerns over polypharmacy or adverse events, 2) clinician-perceived and actual out-of-pocket cost reduced prescribing of ARNi or SGLT2i to patients, exacerbated by a lack of visibility into patients' prescription coverage, denials of coverage by insurance, and navigating prior authorization related workflows, and 3) incorporation of a clinic-based pharmacist increased the prescribing of these medications. ConclusionIncreasing cost transparency, implementing interventions to overcome clinical inertia and cost hurdles, and increasing clinic-based pharmacist support may improve evidenced-based prescribing in patients with HFrEF, especially for comparatively novel classes such as ARNi and SGLT2i.

Charlson’s comorbidity and remission outcomes in women diagnosed with epithelial ovarian cancer.

e17562 Background: Several prior studies have examined the role of comorbidity on overall survival in ovarian cancer (OC) patients and reported an association between comorbidity and inferior overall survival. However, it is unclear if the inferior survival was solely due to the excess mortality from the comorbidities, or that the comorbidities can impact OC treatment outcomes. Our objective was to determine whether pre-existing Charlson comorbidity index (CCI) was associated with lower likelihood of achieving complete remission. Methods: This retrospective cohort study included patients diagnosed with OC of epithelial subtype between 01/01/2017-06/30/2021 at a large integrated healthcare delivery system in the United States. OC patients were identified from the healthcare system’s cancer registry or via chart review of those with the ICD-10 diagnosis code. Patient’s CCI was determined based on data from the 12-month window prior to OC diagnosis. Patients’ remission outcomes, including complete remission and clinical remission (complete + partial remission) were ascertained via chart review, considering physician’s assessment, CA125 value and imaging evidence. Data on potential confounders (pandemic period, age, race/ethnicity, FIGO stage, prior length of membership, and time to treatment) were obtained from the healthcare system’s electronic medical records. Bivariate and multivariable modified Poisson regressions adjusting for potential confounders were used to evaluate the associations between CCI and achieving complete remission or clinical remission by end of therapy. Results: A total of 799 patients diagnosed with OC were included in our study. Overall, the cohort was racially/ethnically diverse with 46.2% White, 33.8% Hispanic, 12.4% Asian, and 7.6% Black patients. In the crude analysis, those with CCI score=1 and CCI≥2 had lower likelihood of achieving complete remission, compared with those with CCI=0 (no Charlson comorbidity) [RR= 0.84 (0.76-0.93) and RR=0.72 (0.64-0.81), respectively]. In the multivariable analysis, those with CCI=1 and CCI≥2 continued to have lower likelihood of achieving complete remission, compared with those with CCI= 0 [RR= 0.84 (0.77-0.92) and RR=0.81 (0.72-0.91), respectively]. Similar findings were observed for clinical remission, although the associations were attenuated: RR= 0.95 (0.89-1.01) for CCI=1 and RR=0.92 (0.86-1.00) for CCI≥2 vs. CCI=0. Conclusions: Having Charlson comorbidity was associated with lower likelihood of achieving complete remission in OC patients. This finding suggest that pre-existing comorbidities may contribute to inferior survival via, at least in part, adversely affecting the likelihood of achieving complete remission. The potential mechanisms underlying this association should be further studied to inform patient management.

Rising Trends of Childhood Attention-Deficit/Hyperactivity Disorder in a Large Integrated Healthcare Delivery System in Southern California, 2010-2021

ObjectiveTo evaluate trends of attention-deficit/hyperactivity disorder (ADHD) diagnosis rates among children aged 5-17 years over the past decade (2010-2021) and to investigate whether there have been differences in temporal changes based on race and ethnicity, sex, or income Study designChildhood ADHD diagnosis was ascertained from electronic health records using ICD-9 (314.xx) and ICD-10 (F90.x) codes. Data were stratified by child’s sex, race and ethnicity, and household income, and rates of ADHD were estimated before and after adjustment for potential confounders. ResultsThe overall ADHD diagnosis rates increased from 3.5% in 2010 to 4.0% in 2021. ADHD diagnosis was most prevalent among White children (6.1%), then Black (4.6%), Other/multiple (3.7%), Hispanic (3.1%), and Asian/Pacific Islander (PI) (1.7%). ADHD was also highly prevalent among boys (73.3%) or family income≥$70,000 (50.0%). ADHD diagnosis increased among Black (4.2% to 5.1%), Hispanic (2.8% to 3.6%) ,and Asian/PI children (1.5% to 2.0%) but remained stable for White (6.2% to 6.1%) and Other/multiple race/ethnic children (3.7% to 3.7%). Increases in the prevalence among girls were also observed. ConclusionThe prevalence of ADHD in children has risen with the largest increases observed for Black, Hispanic, and Asian/PI children. Rates among less affluent families and girls have also been increasing, narrowing the gaps in diagnosis rates previously observed. These increases may reflect improvements in screening and provision of care among demographics where ADHD has been historically underdiagnosed.

P‐IG‐46 | Weak and Partial D Genotype Frequencies in a Large Integrated Healthcare Delivery System in the USA

P‐IG‐46 | Weak and Partial D Genotype Frequencies in a Large Integrated Healthcare Delivery System in the USA

Impacts of COVID-19 on Appropriate Use of Screening Colonoscopy in a Large Integrated Healthcare Delivery System.

Decreasing low-value colonoscopy is critical to optimizing access for high-need patients, particularly in resource-constrained environments such as those created by the COVID-19 pandemic. We hypothesized that rates of screening colonoscopy overuse would decline during COVID compared to pre-COVID due to enhanced procedural scrutiny and prioritization in the setting of constrained access. To characterize impacts of COVID-19 on screening colonoscopy overuse DESIGN: Retrospective national cohort study using Veterans Health Administration administrative data PARTICIPANTS: Veterans undergoing screening colonoscopy in Q4 2019 (pre-COVID) and Q4 2020 (COVID) at 109 endoscopy facilities MAIN MEASURES: Rates of screening colonoscopy overuse KEY RESULTS: 18,376 screening colonoscopies were performed pre-COVID, 19% (3,641) of which met overuse criteria. While only 9,360 screening colonoscopies were performed in Q4 2020, 25% met overuse criteria. Overall change in median facility-level overuse during COVID compared to pre-COVID was 6% (95%CI 5%-7%), with significant variability across facilities (IQR: 2%-11%). Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed <9 years after previous screening procedure (55% pre-COVID, 49% during COVID). The largest shifts in overuse category were in screening procedures performed <9 years after prior screening colonoscopy (-6% decline COVID vs. pre-COVID) and screening procedures performed in patients below average-risk screening age (i.e., age <40 (5% increase COVID compared to pre-COVID), age 40-44 (4% increase COVID vs. pre-COVID)). Within facility performance was stable over time; 83/109 facilities changed their performance by <=1 quartile during COVID compared to pre-COVID. Despite pandemic-related resource constraints and enhanced procedural scrutiny and prioritization in the setting of COVID-related backlogs, screening colonoscopy overuse rates remained roughly stable during COVID compared to pre-COVID, with continued variability across facilities. These data highlight the need for systematic and concerted efforts to address overuse, even in the face of strong external motivating factors.

Performance of the pooled cohort equation in South Asians: insights from a large integrated healthcare delivery system

South Asian ethnicity is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk and has been identified as a “risk enhancer” in the 2018 American College of Cardiology/American Heart Association Guidelines. Risk estimation and statin eligibility in South Asians is not well understood; we studied the accuracy of 10-years ASCVD risk prediction by the pooled cohort equation (PCE), based on statin use, in a South Asian cohort. This is a retrospective cohort study of Kaiser Permanente Northern California South Asian members without existing ASCVD, age range 30–70, and 10-years follow up. ASCVD events were defined as myocardial infarction, ischemic stroke, and cardiovascular death. The cohort was stratified by statin use during the study period: never; at baseline and during follow-up; and only during follow-up. Predicted probability of ASCVD, using the PCE was calculated and compared to observed ASCVD events for low < 5.0%, borderline 5.0 to < 7.5%, intermediate 7.5 to < 20.0%, and high ≥ 20.0% risk groups. A total of 1835 South Asian members were included: 773 never on statin, 374 on statins at baseline and follow-up, and 688 on statins during follow-up only. ASCVD risk was underestimated by the PCE in low-risk groups: entire cohort: 1.8 versus 4.9%, p < 0.0001; on statin at baseline and follow-up: 2.58 versus 8.43%, p < 0.0001; on statin during follow-up only: 2.18 versus 7.77%, p < 0.0001; and never on statin: 1.37 versus 2.09%, p = 0.12. In this South Asian cohort, the PCE underestimated risk in South Asians, regardless of statin use, in the low risk ASCVD risk category.

COVID-19 outcomes in patients taking cardioprotective medications.

The coronavirus disease 2019 (COVID-19) caused a worldwide pandemic and has led to over five million deaths. Many cardiovascular risk factors (e.g. obesity or diabetes) are associated with an increased risk of adverse outcomes in COVID-19. On the other hand, it has been suggested that medications used to treat cardiometabolic conditions may have protective effects for patients with COVID-19. To determine whether patients taking four classes of cardioprotective medications-aspirin, metformin, renin angiotensin aldosterone system inhibitors (RAASi) and statins-have a lower risk of adverse outcomes of COVID-19. We conducted a retrospective cohort study of primary care patients at a large integrated healthcare delivery system who had a positive COVID-19 test between March 2020 and March 2021. We compared outcomes of patients who were taking one of the study medications at the time of the COVID-19 test to patients who took a medication from the same class in the past (to minimize bias by indication). The following outcomes were compared: a) hospitalization; b) ICU admission; c) intubation; and d) death. Multivariable analysis was used to adjust for patient demographics and comorbidities. Among 13,585 study patients, 1,970 (14.5%) were hospitalized; 763 (5.6%) were admitted to an ICU; 373 (2.8%) were intubated and 720 (5.3%) died. In bivariate analyses, patients taking metformin, RAASi and statins had lower risk of hospitalization, ICU admission and death. However, in multivariable analysis, only the lower risk of death remained statistically significant. Patients taking aspirin had a significantly higher risk of hospitalization in both bivariate and multivariable analyses. Cardioprotective medications were not associated with a consistent benefit in COVID-19. As vaccination and effective treatments are not yet universally accessible worldwide, research should continue to determine whether affordable and widely available medications could be utilized to decrease the risks of this disease.

Implementation of a Multidisciplinary Expert Testicular Cancer Tumor Board Across a Large Integrated Healthcare Delivery System Via Early Case Ascertainment

In 2016, Kaiser Permanente Northern California began regionalizing testicular cancer care using population-based tumor board review. This mixed methods evaluation describes implementation outcomes and learnings. We conducted in-depth interviews with key stakeholders, administered surveys to local oncologists and urologists, and used clinical data to evaluate changes in care delivery during 2015-2018. An average of 135 patients with testicular cancer were diagnosed each year. Interviews with 16 key stakeholders provided several insights. Implementation resulted in high levels of satisfaction, was dependent on leadership and staff at various levels, and required technology and consulting solutions aligned to user agreements and clinical workflows. Of 123 local oncologists and urologists who completed surveys, 97% understood why care was regionalized and 89% agreed that tumor board review improved treatment decisions. Among 177 patients with stage I seminoma, the percentage appropriately observed rather than treated with adjuvant chemotherapy or radiation therapy increased from 48% (95% CI, 35 to 62) in 2015 to 87% (75 to 99) in 2018. Review altered care based on pathology and radiology re-review in 14.5 % of cases. Regionalization was feasible and effective.

Epidemiology Unknown: Developing an Approach to Identify Potential Smoldering Multiple Myeloma Cases

BackgroundSmoldering Multiple Myeloma (SMM) is an asymptomatic clonal plasma cell disorder that identifies patients at risk for progression to Multiple Myeloma (MM). The standard of care for SMM has traditionally been observation, but some cancer centers are now treating high-risk SMM before progression to MM. The diagnostic criteria for SMM have also changed in recent years, and current estimates of SMM are derived from large MM databases and observations from tertiary centers. The goal of this study was to develop an approach for identifying SMM cases in a large integrated healthcare delivery system to better characterize the epidemiology of SMM in community-based populations.MethodsThis retrospective, observational study was conducted in Kaiser Permanente Northern California (KPNC) using KPNC SEER-based Cancer Registry data and information from the electronic health record (EHR). Potential SMM cases from 1/1/2010 to 12/31/2018 were identified using three approaches: Group 1 - identified via the KPNC Cancer Registry based on indicators of ‘asymptomatic myeloma’, ‘evolving myeloma’, and ‘smoldering myeloma’; Group 2 - identified via the KPNC Cancer Registry as MM cases who had a physician visit note containing the word ‘smoldering’ but did not begin treatment within 1 year of diagnosis; Group 3 - identified via the KPNC Cancer Registry as MM cases who had a physician visit note containing the word ‘smoldering’ but did begin treatment within 1 year of diagnosis. Chart review was performed for these potential SMM cases (Groups 1-3) to document initial bone marrow biopsy results (bone marrow plasma cell percentage, BMPC) and skeletal findings (presence or absence of lytic bone lesions) around the time of biopsy. When BMPC was reported as a range, the highest value was captured. Patient demographics (age, sex and race/ethnicity) were obtained from the EHR. Bivariate analyses were performed using the chi-squared test and the Wilcoxon-Mann-Whitney nonparametric test. For binomial comparisons by mode of potential SMM case identification, Groups 1 and 2 were combined and compared to Group 3.ResultsA total of 471 potential SMM cases were identified, including 178 (37.8%) via Group 1, 35 (7.4%) via Group 2, and 258 (54.8%) via Group 3 (Figure). The median age was 71 years (interquartile range, IQR 62-78) and 40.0% were female. The racial/ethnic distribution included 57.1% White, 17.6% Black, 10.8% Hispanic, 13.6% Asian, and 0.9% other/unknown race. There were no significant differences across groups (Group 1+2 vs Group 3) with respect to age (p=0.07), sex (p=0.85), or race/ethnicity (p=0.81).There were 442 (93.8%) who underwent bone marrow biopsy. Among those with BMPC data, the median BMPC for Group 1 was 20.0% (IQR 10.0%-28.0%); for Group 2 was 25.0% (IQR 12.5%-50.0%), for Group 3 was 28.0% (IQR 15.0%-50.0%) (p<0.001 comparing Groups 1+2, combined median 20.0%, IQR 10.0%-30.0%, vs Group 3, 28.0%, IQR 15.0%-50.0%). The proportion with BMPC ≥60% was 4%, 13%, and 22% for Groups 1, 2, and 3, respectively (Figure).There were 413 (87.7%) who had skeletal imaging (n=405, 86.0% with available results) within 6 months of diagnosis. Of those with imaging results available to view, n=68 were found to have lytic lesions; 7.6% among Group 1, 6.9% among Group 2, 24.9% among Group 3 (p<0.001 comparing Groups 1+2, 7.5%, vs Group 3, 24.9%).DiscussionThis study used a multifaceted approach to identify potential SMM cases from a large real-world clinical population in an integrated health system. We used an approach similar to prior SMM epidemiological studies and also included those with physician visit notes specifically containing the word ‘smoldering’ within the text. The vast majority of our cohort had BMPC between 10 and 60%, but those who received treatment within 1 year had greater BMPC and a higher proportion of lytic lesions. This suggests those who received treatment, Group 3, may have actually had a MM diagnosis, and physician visit notes containing the word ‘smoldering’ may have been intended to communicate something other than a SMM diagnosis. Further analyses will determine the effectiveness of each approach by confirming SMM cases according to the International Myeloma Working Group diagnostic criteria with incorporation of laboratory data and additional clinical findings. Among confirmed cases of SMM, the rate of progression to MM and the severity of end-organ damage at time of progression will be assessed. [Display omitted] DisclosuresLo: Novartis: Research Funding; Bristol-Myers-Squibb: Research Funding; CSL-Bering: Research Funding.

Differential Cardiometabolic Risk Factor Clustering Across U.S. Asian Ethnic Groups

Ethnic differences in the prevalence of diabetes, obesity, and hypertension are well described,1 but the differential clustering of these risk conditions, which have multiplicative effects on cardiovascular disease risk,2 is less well characterized for Asian Americans. Such information may inform intervention strategies that target multiple cardiovascular risk factors simultaneously. To better understand their contemporary risk profile in clinical settings, this study examines clustered cardiometabolic risks (CCRs) among Filipino, Chinese, and South Asian adults compared with those among other races/ethnicities in a large integrated healthcare delivery system.

Timing of AKI after urgent percutaneous coronary intervention and clinical outcomes: a high-dimensional propensity score analysis

IntroductionAcute kidney injury is a common complication of percutaneous coronary intervention and has been associated with an increased risk of death and progressive chronic kidney disease. However, whether the timing of acute kidney injury after urgent percutaneous coronary intervention could be used to improve patient risk stratification is not known.MethodsWe conducted a retrospective cohort study in adults surviving an urgent percutaneous coronary intervention between 2008 and 2013 within Kaiser Permanente Northern California, a large integrated healthcare delivery system, to evaluate the impact of acute kidney injury during hospitalization at 12 (±6), 24 (±6) and 48 (±6) hours after urgent percutaneous coronary intervention and subsequent risks of adverse outcomes within the first year after discharge. We used multivariable Cox proportional hazards models with adjustment for a high-dimensional propensity score for developing acute kidney injury after percutaneous coronary intervention to examine the associations between acute kidney injury timing and all-cause death and worsening chronic kidney disease.ResultsAmong 7250 eligible adults undergoing urgent percutaneous coronary intervention, 306 (4.2%) had acute kidney injury at one or more of the examined time periods after percutaneous coronary intervention. After adjustment, acute kidney injury at 12 (±6) hours was independently associated with higher risks of death (adjusted hazard ratio [aHR] 3.55, 95% confidence interval [CI] 2.19–5.75) and worsening kidney function (aHR 2.40, 95% CI:1.24–4.63). Similar results were observed for acute kidney injury at 24 (±6) hours and death (aHR 3.90, 95% CI:2.29–6.66) and worsening chronic kidney disease (aHR 4.77, 95% CI:2.46–9.23). Acute kidney injury at 48 (±6) hours was associated with excess mortality (aHR 1.97, 95% CI:1.19–3.26) but was not significantly associated with worsening kidney function (aHR 0.91, 95% CI:0.42–1.98).ConclusionsTiming of acute kidney injury after urgent percutaneous coronary intervention may be differentially associated with subsequent risk of worsening kidney function but not death.

Characteristics of patients with lymphoma presenting initially as a neck mass referral to otolaryngology.

e18054 Background: Lymphomas that present initially as a neck mass can be challenging to diagnose as their onset is often insidious, frequently without classic symptoms, and fine-needle aspiration has limited utility for diagnosis. Understanding their clinical presentation may facilitate recognition and diagnosis, essential for timely treatment of aggressive lymphoma subtypes. Methods: Using data from a large integrated healthcare delivery system, adults aged 18-89 years without known previous cancer who were referred to Head and Neck Surgery for evaluation of a “neck mass” in 2017 were identified. Among the subset of 205 patients found to have malignancy, 76 had lymphoma (N = 69) or leukemia (N = 7) and 129 had a non-lymphoma/leukemia malignancy. The demographic characteristics of patients with and without lymphoma/leukemia were compared. Among the 69 with lymphoma, tumor histology and stage were examined. Differences between subgroups were compared using Chi-squared, Fisher’s exact, Student’s t-test, F-tests, and Tukey’s range tests for pairwise comparison. Results: Among 205 patients identified with a malignant neck mass, 76 (37%) were diagnosed with lymphoma/leukemia. Patients with lymphoma/leukemia were more likely to be female (47% vs. 27%, p = 0.003) and under age 50 years (36% vs. 13%, p = 0.001). There were no statistically significant differences in race, smoking status, or BMI between the two groups. Among the lymphoma/leukemia subset, 18 (24%) had Diffuse Large B-Cell Lymphoma (DLBCL), 13 (17%) had Follicular Lymphoma (FL), and 25 (33%) had Hodgkin’s Lymphoma (HL). The HL subset was significantly younger than both the FL and DLBCL subsets (mean age 41.6 years vs. 62.2 and 66.6, p &lt; 0.001). A range of findings was seen when examining sex (72%, 44% and 46% male), race/ethnicity (60%, 72% and 69% non-Hispanic White), smoking status (36%, 33% and 62% current/former) and tumor stage at presentation (52%, 50% and 69% late stage (III-IV)) for HL, DLBCL and FL subtypes, respectively, but the differences were not statistically significant in these smaller subsets. Conclusions: Significant differences in baseline characteristics exist between lymphoma and non-lymphoma patients presenting with a malignant neck mass. Notably, the lymphoma subset was younger and, except for those with HL, did not demonstrate a male predominance. Within the lymphoma subset, HL patients were significantly younger than patients with other lymphoma subtypes. Further studies in a larger population identifying demographic differences by cancer subtype may inform efforts to prevent diagnostic delays in head and neck lymphoma. Characterizing the diagnostic pathway is also needed to quantify room for improvement in the treatment approach of patients with neck mass considered at higher risk for lymphoma.

Lifestyle-related education and counseling resource utilization and cardiovascular biomarkers in midlife women with low physical activity.

Health plan-based resources are promising avenues for decreasing cardiovascular disease risk. This study examined associations of lifestyle-related resource utilization within a healthcare delivery system and cardiovascular biomarkers among midlife women with low physical activity. Midlife women (45-55 years old) with <10min/week of reported physical activity at a primary care visit within a large integrated healthcare delivery system in Northern California in 2015 (n=55,393) were identified. Within this cohort, subsequent lifestyle-related health education and individual coaching resource utilization, and the next recorded physical activity, weight, systolic blood pressure, plasma glucose, HDL and LDL cholesterol measures up to 2years after the index primary care visit were identified from electronic health records. We used a multilevel linear model to estimate associations. About 3% (n=1587) of our cohort had ≥1 lifestyle-related resource encounter; 0.3% (n=178) had≥4 encounters. Participation in ≥4 lifestyle-related resource encounters (compared to none) was associated with 51 more minutes/week of physical activity (95% CI: 33,69) at the next clinical measurement in all women, 6.2kg lower weight (95% CI: -7.0,-5.5) at the next measurement in women with obesity, and 8-10mg/dL lower plasma glucose (95% CI: -30,14 and -23,2, respectively) at the next measurement in women with diabetes or prediabetes. Our results support the sustained utilization of health plan-based lifestyle-related resources for improving physical activity, weight, and plasma glucose in high-risk midlife women. Given the observed low utilization, health system-wide efforts may be warranted to increase utilization of lifestyle-related resources in this population.

Project SLIP: Implementation of a PrEP Screening and Linkage Intervention in Primary Care.

Nearly a decade after becoming formally available in the U.S., HIV pre-exposure prophylaxis (PrEP) remains underutilized by populations at risk for HIV acquisition. The next generation of PrEP research is pivoting toward implementation research in order to identify the most impactful avenues for scaling up PrEP uptake. Rapid identification of patients who may be at risk for HIV in primary care settings and the ability to provide brief consultation and prescription or referral for PrEP could help to increase PrEP uptake. The current study aimed to develop and pilot-test a PrEP screening instrument that could be integrated into the workflow of busy primary care clinics to help facilitate PrEP uptake among at-risk men. During the study, PrEP screening occurred for 12months in two primary care clinics nested within a large integrated healthcare delivery system in Southern California. An interrupted time series analysis found a significant increase in PrEP referrals overall during the screening intervention period as compared to the preceding 12months. Findings suggest that brief HIV risk screening in primary care is acceptable, feasible, and shows preliminary effects in increasing PrEP referral rates for Black and Hispanic/Latinx men.

Abstract SS2-06: Characterization of breast cancer management during the COVID 19 pandemic in a large integrated healthcare delivery system: Stage at diagnosis and timing/modality of first treatment

Abstract Background: The COVID 19 pandemic has disrupted all aspects of healthcare, including the diagnosis and treatment of breast cancer. In March 2020, the Society of Surgical Oncology, the American College of Surgeons, and the American Society of Breast Surgeons issued guidelines regarding the timing of surgery for cancer patients to preserve hospital resources and minimize exposure of patients and staff to COVID 19. Recommendations included delaying breast cancer surgery if possible, and using neoadjuvant chemotherapy or neoadjuvant endocrine therapy to treat selected patients while waiting for definitive surgery. In California, the “shelter in place” (SiP) order began March 17, 2020, and both screening mammography and elective surgeries were stopped in a large, integrated health care system. We evaluated the impact of these operational changes on the presentation and treatment of breast cancer patients in our system.Methods:We performed a retrospective review of patients newly diagnosed between 3/17/20, the starting date of SiP, and 5/18/20, when elective operations resumed in our system. We compared this cohort to patients who were diagnosed between 3/17/19 and 5/18/19. Age, histology, anatomic staging features, grade, receptor status, and initial treatment were compared between the cohorts. For the patients who underwent surgery, we compared the time from biopsy to time to surgery (TTS) and the type of operation. Comparisons involving categorical variables were performed using the chi-square test. Normally-distributed continuous variables were compared using two sample-t-tests. P-values of &amp;lt;0.05 were considered statistically significant.Results:There were 790 patients in the 2019 cohort and 279 in the 2020 cohort. There were no significant differences in age at presentation, histologic subtypes, nodal status, or operation type between the two groups. The T-stages at presentation of the 2020 group were higher than those of the 2019 group; 29% presented with T1c tumors in 2020 vs 26% in 2019, and 37% with T2 tumors in 2020 vs 30% in 2019 (p=0.03). A higher percentage of patients presented with distant metastatic disease at the time of diagnosis in 2020 (7% in 2020 vs 2% in 2019, p&amp;lt;0.001), although the absolute numbers of patients were similar (19 patients in 2020 vs 17 patients in 2019). Of patients with invasive breast cancer, a higher percentage of patients presented with grade 3 tumors in 2020 (35% in 2020 vs 24% in 2019, p=0.002), and triple negative tumors (15% vs 10%, p=0.02). Fewer patients underwent surgery first in 2020 (73% in 2020 vs 85% in 2019, p&amp;lt;0.001) and more underwent neoadjuvant chemotherapy (13% in 2020 vs 9% in 2019, p=0.03). Only 4% of the 2020 surgery group had been placed on neoadjuvant endocrine therapy while awaiting definitive surgery. The TTS for patients with surgery as the initial treatment was significantly shorter for the 2020 group (mean 22 days in 2020 vs 31 days in 2019, p&amp;lt;0.001).Conclusions: Without screening mammography, newly-diagnosed patients in a large, integrated health care system during the COVID 19 pandemic presented with more advanced and aggressive breast cancers as compared to the equivalent time period in 2019. Fewer patients underwent surgery first, and more underwent neoadjuvant chemotherapy. The TTS for breast cancer patients in 2020 was significantly shorter than in 2019, which we hypothesize was due to the availability of operating rooms since elective operations had been stopped. This study demonstrates the ability of a large, integrated health care system to deliver timely breast cancer care to patients presenting with symptomatic disease during the constraints of the COVID 19 pandemic, and highlights the importance of screening in the early detection of breast cancer. Citation Format: Sharon B. Chang, Alison C. Savitz, Brooke Vuong, Annie Tang, Margaret Mentakis, Amy M. Miller, Veronica C. Shim, Gillian E. Kuehner. Characterization of breast cancer management during the COVID 19 pandemic in a large integrated healthcare delivery system: Stage at diagnosis and timing/modality of first treatment [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS2-06.

Contemporary Reevaluation of Race and Ethnicity With Outcomes in Heart Failure.

BackgroundVariation in outcomes by race/ethnicity in adults with heart failure (HF) has been previously observed. Identifying factors contributing to these variations could help target interventions. We evaluated the association of race/ethnicity with HF outcomes and potentially contributing factors within a contemporary HF cohort.Methods and ResultsWe identified members of Kaiser Permanente Northern California, a large integrated healthcare delivery system, who were diagnosed with HF between 2012 and 2016 and had at least 1 year of prior continuous membership and left ventricular ejection fraction data. We used Cox regression with time‐dependent covariates to evaluate the association of self‐identified race/ethnicity with HF or all‐cause hospitalization and all‐cause death, with backward selection for potential explanatory variables. Among 34 621 patients with HF, compared with White patients, Black patients had a higher rate of HF hospitalization (adjusted hazard ratio [HR], 1.28; 95% CI, 1.18–1.38) but a lower rate of death (adjusted HR, 0.78; 95% CI, 0.72–0.85). In contrast, Asian/Pacific Islander patients had similar rates of HF hospitalization, but lower rates of all‐cause hospitalization (adjusted HR, 0.89; 95% CI, 0.85–0.93) and death (adjusted HR, 0.75; 95% CI, 0.69–0.80). Hispanic patients also had a lower rate of death (adjusted HR, 0.85; 95% CI, 0.80–0.91). Sensitivity analyses showed that effect sizes for Black patients were larger among patients with reduced ejection fraction.ConclusionsIn a contemporary and diverse population with HF, Black patients experienced a higher rate of HF hospitalization and a lower rate of death compared with White patients. In contrast, selected outcomes for Asian/Pacific Islander and Hispanic patients were more favorable compared with White patients. The observed differences were not explained by measured potentially modifiable factors, including pharmacological treatment. Future research is needed to identify explanatory mechanisms underlying ongoing racial/ethnic variation to target potential interventions.

Abstract 17062: Atherosclerotic Cardiovascular Disease Risk in South Asians by Statin Use: Insights From a Large Integrated Healthcare Delivery System

Introduction: South Asian ethnicity is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk and has been identified as a “risk enhancer” in the 2018 ACC/AHA Guideline on the Management of Blood Cholesterol. Hypothesis: An increased use of statins has been recommended since implementation of the 2013 ACC/ AHA Pooled Cohort Equation (PCE); however, the impact of statins on ASCVD outcomes in South Asians is not well understood. We aim to identify the accuracy of 10-year ASCVD risk prediction by the PCE, based on statin use, in a South Asian cohort. Methods: This is a retrospective cohort study of members within Kaiser Permanente Northern California without existing ASCVD, age range 30-70, for whom lipid panel, ethnic data, and 10-year follow up were available. ASCVD events were defined as acute myocardial infarction, ischemic stroke, and cardiovascular death. The cohort was stratified by statin use: never, at baseline and follow-up and only during follow-up. Predicted probability of ASCVD, using the PCE were calculated and compared to the observed for each ASCVD risk category: low &lt;5.0%, borderline 5.0-7.5%, intermediate 7.5-&lt;20.0%, and high &gt;=20.0%. Results: A total of 1,835 South Asian patients were included. ASCVD risk was underestimated by the PCE across all risk categories and statin groups. The greatest disparity was seen in the low-risk ASCVD risk group; entire cohort: 1.8 vs 4.9%, p&lt;0.0001; on statin at baseline and follow-up: 2.58 vs 8.43%, p&lt;0.0001; on statin during follow-up only: 2.18 vs 7.77%, p&lt;0.0001; and never on statin: 1.37 vs 2.09%, p=0.1175 (Figure 1). The absolute risk difference in ASCVD outcomes between the cohort never on statins to those on statins during follow up was 0.73%, 3.31%, and 6.67% in the borderline, intermediate, and high-risk groups, respectively. Conclusions: In a large, community-based South Asian cohort, the PCE underestimated risk in South Asians, who were taking statins, in the low ASCVD risk category.

Association of Anticoagulant Use with COVID-19 Diagnosis

BackgroundThe Coronavirus Disease 2019 (COVID-19) pandemic has challenged anticoagulation providers with providing optimal care while minimizing exposure risk, specifically in the management of patients on chronic warfarin. Here we provide data regarding our experience with managing patients on chronic anticoagulants, including warfarin, within Kaiser Permanente Northern California (KPNC), a large integrated healthcare delivery system serving more than 4 million patients.AimTo identify whether being on anticoagulation or antiplatelet agents correlates with an increased risk of contracting COVID-19.MethodsWe identified patients within KPNC electronic medical records on either warfarin, direct oral anticoagulation (DOAC) and/or antiplatelet agents between February 25 and July 3, 2020, as well as a randomly identified control group of patients not taking anticoagulation or antiplatelet. We looked for a correlation between taking anticoagulation and antiplatelets with the risk of testing positive for COVID-19.Results/ConclusionsAmong 188,438 patients on chronic anticoagulants or antiplatelets and 188,438 controls, 1,029 patients tested positive for COVID-19 during the study period. Being on chronic anticoagulants or antiplatelets was not associated with increased risk for a positive test. Patients on warfarin (N=30,242) also had no increased risk of developing COVID-19 compared to patients not on anticoagulation or antiplatelet therapy (odds ratio 0.87, 95% confidence interval 0.64-1.17). The time in the therapeutic range (TTR) of patients on warfarin during the COVID-19 pandemic remained near 72%, consistent with prior TTR, demonstrating persistent efficacy of anticoagulation despite measures to reduce COVID-19 transmission. Our data demonstrates the safety of continuing chronic warfarin in patients during the COVID-19 pandemic.DisclosuresNo relevant conflicts of interest to declare.

Research-based versus clinical serum creatinine measurements and the association of acute kidney injury with subsequent kidney function: findings from the Chronic Renal Insufficiency Cohort study.

BackgroundObservational studies relying on clinically obtained data have shown that acute kidney injury (AKI) is linked to accelerated chronic kidney disease (CKD) progression. However, prior reports lacked uniform collection of important confounders such as proteinuria and pre-AKI kidney function trajectory, and may be susceptible to ascertainment bias, as patients may be more likely to undergo kidney function testing after AKI.MethodsWe studied 444 adults with CKD who participated in the prospective Chronic Renal Insufficiency Cohort (CRIC) Study and were concurrent members of a large integrated healthcare delivery system. We estimated glomerular filtration rate (eGFR) trajectories using serum creatinine measurements from (i) the CRIC research protocol (yearly) and (ii) routine clinical care. We used linear mixed effects models to evaluate the associations of AKI with acute absolute change in eGFR and post-AKI eGFR slope, and explored whether these varied by source of creatinine results. Models were adjusted for demographic characteristics, diabetes status and albuminuria.ResultsDuring median follow-up of 8.5 years, mean rate of eGFR loss was −0.31 mL/min/1.73 m2/year overall, and 73 individuals experienced AKI (55% Stage 1). A significant interaction existed between AKI and source of serum creatinine for acute absolute change in eGFR level after discharge; in contrast, AKI was independently associated with a faster rate of eGFR decline (mean additional loss of −0.67 mL/min/1.73 m2/year), which was not impacted by source of serum creatinine.ConclusionsAKI is independently associated with subsequent steeper eGFR decline regardless of the serum creatinine source used, but the strength of association is smaller than observed in prior studies after taking into account key confounders such as pre-AKI eGFR slope and albuminuria.

Su1495 – Healthcare Resource Utilization, Demographics, and Comorbidities by Diagnosis Codes and Histological Stage in Nonalcoholic Fatty Liver Disease (NAFLD)/Nonalcoholic Steatohepatitis (NASH) in a Large Integrated Healthcare Delivery System in the U.S

Su1495 – Healthcare Resource Utilization, Demographics, and Comorbidities by Diagnosis Codes and Histological Stage in Nonalcoholic Fatty Liver Disease (NAFLD)/Nonalcoholic Steatohepatitis (NASH) in a Large Integrated Healthcare Delivery System in the U.S