Northern California Health Care System Research Articles

Outcomes of Ophthalmology Telemedicine in a Large Health Care System Beyond Initial Pandemic Crisis

PurposeTo compare the outcome of telemedicine versus in-person visit in a large health care system. DesignRetrospective cohort study. Methods174,245 patients with a telemedicine or in-person visit from September 2020 to June 2021 in the Kaiser Permanente Northern California Health Care System were included. Main outcome measures were whether an initial telemedicine or in-person visit required a subsequent in-person visit and patient characteristics that differed between telemedicine and in-person groups. Charts of selected televisits with return in-person visits were reviewed for diagnostic accuracy of telemedicine. Results27% of patients who had telemedicine visit had a subsequent in-person visit compared to 13% of patients who had initial in-person visit. Telemedicine visit was associated with higher risk of needing a subsequent in-person visit compared to an initial in-person visit (RR 2.35, CI 2.30-2.40). Patient characteristics associated with higher risk of telemedicine visit compared to in-person visit included female gender (RR 1.07, CI 1.05-1.08), Asian/Black/Hispanic/other race (RRAsian 1.06, CI 1.04-1.08; RRBlack 1.07, CI 1.04-1.11; RRHispanic 1.03, CI 1.02-1.05; RROther 1.04, CI 1.03-1.06,), and English language preference (RR 1.08, CI 1.04-1.11). Age had bimodal distribution with patients younger than 18 and 65 and older associated with less usage of telemedicine. Diagnostic accuracy of telemedicine was 93%. ConclusionsAlthough telemedicine visit was associated with higher risk of needing return in-person visits, telemedicine was able to address ophthalmic needs in majority of patients with high diagnostic accuracy. This large health care system study supports the continued used of telemedicine in ophthalmology in post pandemic setting.

Race and ethnicity and self-reported racial/ethnic discrimination in breast cancer patient interactions with providers in the Pathways Study.

To examine the association of race and ethnicity groups with self-reported racial/ethnic discrimination in patient-provider interactions during the diagnosis and treatment for breast cancer. We analyzed data from the Pathways Study, a prospective cohort of women diagnosed with breast cancer from 2006-2013 in the Kaiser Permanente Northern California Health Care System. Racial/ethnic discrimination in patient-provider interactions was assessed with two questions from the Interpersonal Processes of Care survey at baseline and 6-months and 24-months post-diagnosis. Logistic regression was performed to compare women who self-identified as racial or ethnic minorities with Non-Hispanic White (NHW) women. Covariates included age at diagnosis, country of origin, education level, income, marital status, and medical provider's race/ethnicity. Our sample included 1836 participants: 1350 NHW women and 486 women (87 Black, 208 Asian American, 153 Hispanic, 38 American Indian/Alaskan Native/Pacific Islander [AIANPI]) from racial or ethnic minority groups. In multivariate analysis, minority women were more likely to report racial/ethnic discrimination in patient-provider interactions than NHW women (adjusted odds ratio [aOR]: 4.73; 95% confidence interval [CI] 3.45-6.50). Specifically, Black women were most likely to self-report racial/ethnic discrimination in patient-provider interactions (aOR: 9.65; 95% CI 5.92-15.70), followed by Asian (aOR: 5.39; 95% CI 3.46-8.40), Hispanic (aOR: 2.55; 95% CI 1.54-4.14), and AIANPI (aOR: 1.74; 95% CI 0.58-4.25) women, compared with NHW women. Racial/ethnic discrimination was more likely self-reported from minority women diagnosed with breast cancer. Additional studies are needed to understand the mechanisms and impact of racial/ethnic discrimination in patient-provider interactions on disparities.

Hypertensive Blood Pressure in Adolescent Females with Polycystic Ovary Syndrome: Adolescent PCOS and hypertensive blood pressure

INTRODUCTIONPolycystic ovary syndrome (PCOS) is associated with hypertension in women, but few population studies have examined findings among adolescents. This retrospective study examines PCOS and hypertensive blood pressure (BP) in a large adolescent population receiving routine healthcare. METHODSAmong females aged 13-17 years who had a well-child visit with systolic/diastolic BP measured in a Northern California healthcare system (2013-2019), the outcome of hypertensive BP (≥130/80 mmHg) was examined. PCOS was based on clinical diagnosis (ICD-9/10 256.4/E28.2) within one year of the visit. Overweight and obesity were defined by body mass index 85th to <95th percentile and ≥95th percentile, respectively; 1.7% with underweight (<5th percentile) were excluded. Multivariable logistic regression was used to examine the association of PCOS and hypertensive BP, adjusting for age, race/ethnicity, BMI category, and estimated neighborhood deprivation index. Analyses were conducted in 2023-2024. RESULTSThe cohort included 224,418 females (mean age 14.9±1.4 years; 34.3% non-Hispanic White, 30.1% Hispanic, 19.5% Asian/Pacific Islander, and 9.7% Black. Overall, 18.7% had overweight and 15.8% had obesity. The prevalence of hypertensive BP was 7.2%, much higher for those with PCOS (18.2%) versus no PCOS (7.1%, p<0.001). In adjusted analyses, PCOS was associated with 1.25-fold greater odds of hypertensive BP [95% confidence interval 1.10-1.42]). Similar findings were seen among the subset with obesity (odds ratio 1.23 [1.06-1.42]). CONCLUSIONSNearly 1 in 5 adolescents with PCOS had hypertensive BP. PCOS was associated with 25% increased adjusted odds of hypertensive BP, emphasizing the importance of BP surveillance in this population with higher cardiometabolic risk.

Prevalence of allergic diseases among Asian American children in a Northern California healthcare system

Prevalence of allergic diseases among Asian American children in a Northern California healthcare system

Patterns of use of advanced wound matrices in the Veterans Administration clinics.

Chronic wounds are a common and costly health issue affecting millions of individuals in the United States, particularly those with underlying conditions such as diabetes, venous insufficiency, and peripheral artery disease. When standard treatments fail, advanced wound care therapies, such as skin substitutes, are often applied. However, the clinical effectiveness, indications, and comparative benefits of these therapies have not been well established. In this study, we report on the usage of both acellular and cellular, single and bilayer, natural and synthetic, dermal, and epidermal skin substitutes in a VA hospital system. We performed a retrospective chart review to understand the ordering and usage patterns of advanced wound therapies for patients with chronic wounds at the VA Northern California Health Care System. We examined types of products being recommended, categories of users recommending the products, indications for orders, and rate of repeated orders. Neuropathic, venous, or pressure ulcers were the main indications for using advanced wound matrices. Only 15.6% of patients for whom the matrices were ordered had supporting laboratory tests. Exactly 34.3% of the ordered matrices were not applied. And the use of wound matrices resulted in increased costs per patient visit of $1018-$3450. Our study sheds light on the usage patterns of these therapies in a VA healthcare facility and highlights the need for more robust evidence-based studies to determine the true benefits, efficacy, and cost-effectiveness of these innovative treatment options.

Introducing Sialendoscopy in a Veteran Population: Effect on Benign Salivary Disease Treatment

ObjectiveTo compare rates of sialadenectomy in a veteran population before and after introduction of sialendoscopy. Materials and methodsAll Veterans Affair (VA) Northern California Healthcare System (NCHS) encounters from 2006 to 2021 for benign obstructive salivary etiologies were identified using International Classification of Disease 9/10 codes. This cohort was then cross referenced with Current Procedural Terminology codes to identify patients who underwent a procedure for their salivary pathologies. The rates of sialadenectomy and minimally invasive procedures were measured before and after sialendoscopy was introduced to the VA NCHCS in 2016.Data was obtained via chart review and demographic information, diagnosis, and procedure type were extracted. Rates of sialadenectomy, minimally invasive procedures, and other patient and procedural characteristics were compared between the Pre-Sialendoscopy Era (PSE) and Sialendoscopy Era (SE). Statistical analysis was performed using Microsoft Excel (Microsoft, version 16.66). ResultsAn increasing number of patients per year sought care for benign obstructive salivary pathology in the SE when compared to the PSE cohort and a higher rate of female patients were treated in the SE cohort. A simultaneous reduction in sialadenectomy rates and increase in minimally invasive procedure rates was observed in the SE. Sialendoscopy represented most of the increase in minimally invasive techniques, but there was a slight increase in other procedure types. Submandibular gland obstructive pathologies required the most procedures and resulted in the most gland excisions. ConclusionThis retrospective review strongly suggests introducing sialendoscopy reduced the incidence of sialadenectomy for benign non-tumor obstructive pathology in this VA NCHS population. Further prospective studies are needed to evaluate this in a more generalized setting.

Prevalence of Dementia in a Diverse Cohort of Adults with Hip Fracture

AbstractBackgroundThere is a 2.5‐fold increased risk of hip fracture for persons living with dementia compared to persons without dementia. Independently, the risk of hip fracture and Alzheimer’s Disease and Related Dementias (ADRD) increase with age and vary by sex and race and ethnicity. However, few studies have examined racial and ethnic variations in dementia prevalence among older US adults who experienced a hip fracture.MethodThis retrospective observational cohort study included adult health plan members aged ≥50y in a large Northern California healthcare system during 2000‐2019 who had a hip fracture event during follow‐up to 2021. ADRD diagnosis (ICD‐9/10) was obtained from clinical encounters within 5 years prior to and including the hip fracture hospitalization. Modified log‐Poisson regression models were performed with ADRD as the outcome and race and ethnicity as the primary predictor, adjusting for age and sex. Sensitivity analyses expanded the definition of prevalence of ADRD to include ADRD diagnoses up to 3 months after hip fracture.ResultAmong 46,622 adults with hip fracture (mean age 80.6 ± 9.9y, 69.7% female, 78.8% non‐Hispanic White (NHW) race), ADRD prevalence was 21.0% based on diagnoses prior to and during hip fracture hospitalization, increasing to 24.2% when including diagnoses within 3 months post‐hip fracture. ADRD prevalence was significantly higher in Black (29.2%), Hispanic (22.5%), and Asian (22.0%) adults compared to NHW (20.3%) adults. Expanding the definition found similar observations except no significant differences for Hispanic and Asian adults (see Figure). Adjusting for age and sex, Black (RR = 1.47, 95%CI 1.35‐1.59), Hispanic (RR = 1.15, 95%CI 1.07‐1.24) and Asian adults (RR = 1.12, 95% CI 1.04‐1.21) had greater risk of prevalent ADRD compared to NHW adults. Sensitivity analysis results were similar.ConclusionAt least 1 in 5 adults with hip fracture had diagnosed ADRD, with higher prevalence among racial and ethnic minority populations. Age‐ and sex‐adjusted risk was highest in Black adults and modestly higher in Hispanic and Asian adults. Hip fractures and ADRD are serious public health concerns leading to increased morbidity and mortality, and understanding differences among high risk groups will aid in the development of socially appropriate patient and caregiver interventions.

550. Effectiveness of Remdesivir for Treatment of COVID-19 in the Outpatient Setting

Abstract Background Remdesivir (REM) was the first FDA-approved treatment for COVID-19. A clinical trial evaluated the effectiveness of REM for the outpatient treatment of COVID-19, showing an 87% lower risk of hospitalization and death when given within the first 7 days of infectious symptoms in confirmed infection. "Real-world" studies evaluating the outpatient use of REM when Omicron was the predominant variant have not been published. We aim to evaluate the use of REM in the outpatient setting (REM-OP) at our institution. Methods VA Northern California Health Care System developed an outpatient clinic for the treatment of COVID-19 after FDA approval of REM-OP in January 2022. Patients had to meet institutional criteria for outpatient management of COVID-19 with REM, including a confirmed positive PCR test, lack of supplemental oxygen, risk for severe disease, and reliable transportation. We retrospectively evaluated patients given REM-OP from 1/21/2022 - 413/2022 when Omicron was the predominant variant in our region. Data were obtained using a data query of outpatient REM prescriptions. Subsequently, the administrations of REM were verified and patient variables, including risk factors for progression to severe disease, COVID vaccination, history of previous infection, and subsequent hospitalization or death within 30 days, were collected via manual chart review. Results 88 patients received REM-OP with a mean age of 70.0 (SD +/- 11.4) with a predominantly male (92%) and white (67%) population. Most patients had received a least one dose of COVID-19 vaccination but 17% were unvaccinated. The most common risk factors for progression to severe disease included age (75% were over age 65), diabetes (45%), hypertension (64.8%), and cardiovascular disease (31.8%). 98% of patients met at least one risk factor for progression to severe disease and 95% completed REM-OP. 93% of patients received REM within 7 days of symptom onset. Of the 88 patients who were treated, 5 patients were admitted within 30 days (2/5 were due to COVID-19 infection), and 2 patients died (1 of which was attributed to COVID-19). Patient Characteristics Comparison to PINETREE Clinical Trial Conclusion REM-OP during the Omicron surge in our single-center retrospective study had comparable effectiveness to its use in a clinical trial during the Delta surge. Disclosures All Authors: No reported disclosures

Risk of Incident Asthma Among Young Asian American, Native Hawaiian, and Pacific Islander Children from Age 3 to 7 Years in a Northern California Healthcare System

Incident childhood asthma risk has not been examined among diverse Asian American, Native Hawaiian, and Pacific Islander subgroups. In a large California healthcare system, incident asthma was higher among young Filipino/a, Native Hawaiian/Pacific Islander, and South Asian children compared with non-Hispanic White children, whereas Chinese and Japanese children were similar.

Evaluation of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage

Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI). To derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage. This retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022. Assigned ESI level. Rate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage. A total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]). In this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.

Genomic, clinical characteristics, and treatment outcomes of patients with metastatic castration-sensitive prostate cancer with SPOP mutations: Analysis from the Kaiser Permanente Northern California Healthcare System.

261 Background: Androgen deprivation therapy (ADT) plus either Abiraterone, Docetaxel or Enzalutamide (ADE) improves overall survival (OS) of men with metastatic M1 castrate-sensitive prostate cancer (mCSPC), compared to ADT alone and is currently standard of care. Men with mCSPC with a point mutation of the speckle-type pox virus and zinc finger mutation (mutSPOP) derive superior response to ADT compared to wild type SPOP. The additive benefit of ADE to ADT in this subclass of CSPC is unclear. We sought to evaluate the benefit of therapy in patients with mutSPOP in a real-world setting. Methods: Between November 2017 and July 2022, 1002, patients in the Kaiser Permanente Northern California (KPNC) health system with advanced prostate cancer had tumor specimens examined by next generation sequencing (NGS). Of these patients, we retrospectively identified 70 mCSPC patients with mutSPOP. Patient records were reviewed to determine baseline characteristics, therapy for CSPC, subsequent therapy for Castrate Resistant Prostate Cancer (CRPC), and clinical outcome. The primary outcome was progression-free survival (PFS) for patients who received ADT alone or ADT plus ADE. PFS was defined as time to either PSA progression by PCWG2 criteria, clinical progression, or time to next line of therapy. Results: Median age for the 70 patients with mutSPOP was 75 years (range 50-91). Thirty-six (51%) were non-Hispanic white; 11 (16%) were African American; and 13 (19%) were Asian. F133 was the most frequently mutated allele (64%), TP53 was the most common co-mutated gene (27%), and mutations in MSH2, MSH6 and BRCA1 were identified in one patient each. Two patients had concurrent ERG fusion. Thirty-six patients (51%) had a Gleason score 8-10 and 48 (69%) were diagnosed with de-novo metastatic disease. Twenty-seven patients (39%) received ADT alone, 41 (59%) received ADT + ADE, 2 patients elected observation only. PFS was 28.1 months (mos) for ADT alone vs 35 for ADT+ADE (p=0.08). Twenty-nine patients (41%) received 2nd line therapy at CRPC; among them 24 received ADT plus Abiraterone or Enzalutamide. Median PFS for all the CRPC patients who received 2nd line treatment was 15mos. Median PFS for CRPC patients who received 2nd line treatment with Abiraterone, or Enzalutamide was 15.3 mos. Median overall survival for the entire group was 173 mos (95% CI 135-NR). Conclusions: In this real-world study within KPNC, we confirmed the durable benefit of ADT based therapy in patients with mutSPOP. Patients with mutSPOP derived similar benefit regardless of 1st line therapy (ADT vs ADT + ADE). We also noted durable responses to abiraterone or enzalutamide for CRPC after initial treatment with ADE for CSPC. Confirmation of these findings from an another large NGS database is ongoing and will be reported later.

Persistent Steroid Exposure Before Coronavirus Disease 2019 Diagnosis and Risk of Hospitalization in Patients With Chronic Obstructive Pulmonary Disease.

It is unclear whether persistent inhaled steroid exposure in chronic obstructive pulmonary disease (COPD) patients before coronavirus disease 2019 (COVID-19) is associated with hospitalization risk. Our objective was to examine the association between persistent steroid exposure and COVID-19-related hospitalization risk in COPD patients. This retrospective cohort study used electronic health records from the Kaiser Permanente Northern California health care system (February 2, 2020, to September 30, 2020) for patients aged ≥40 years with COPD and a positive polymerase chain reaction test result for COVID-19. Primary exposure was persistent oral and/or inhaled steroid exposure defined as ≥6 months of prescriptions filled in the year before the COVID-19 diagnosis. Multivariable logistic regression was performed for the primary outcome of COVID-19-related hospitalization or death/hospice referral. Steroid exposure in the month before a COVID-19 diagnosis was a covariate. Of >4.3 million adults, 697 had COVID-19 and COPD, of whom 270 (38.7%) had COVID-19-related hospitalizations. Overall, 538 (77.2%) were neither exposed to steroids in the month before COVID-19 diagnosis nor persistently exposed; 53 (7.6%) were exposed in the month before but not persistently; 23 (3.3%) were exposed persistently but not in the month before; and 83 (11.9%) were exposed both persistently and in the month before. Adjusting for all confounders including steroid use in the month before, the odds ratio for hospitalization was 0.77 (95% confidence interval 0.41-1.46) for patients persistently exposed to steroids before a COVID-19 diagnosis. No association was observed between persistent steroid exposure and the risk of COVID-19-related hospitalization in COPD patients.

Trends in Self-reported and Biochemically Verified Cocaine and Methamphetamine Use Among Pregnant Individuals in Northern California, 2011-2019

This cross-sectional study uses data from the Kaiser Permanente Northern California health care system with universal screening via self-report and urine toxicology at prenatal care entrance to examine trends in cocaine and methamphetamine use among pregnant individuals from 2011 to 2019.

Quantification of risk factors for diabetic retinopathy progression.

To determine the importance of blood sugar control, blood pressure, and other key systemic factors on the risk of progression from no retinopathy to various stages of diabetic retinopathy. Restrospective cohort analysis of patients (N = 99, 280) in the Kaiser Permanente Northern California healthcare system with a baseline retina photographic screening showing no evidence of retinopathy and a minimum follow-up surveillance period of 3 years from 2008 to 2019. We gathered longitudinal data on diabetic retinopathy progression provided by subsequent screening fundus photographs and data captured in the electronic medical record over a mean surveillance of 7.3 ± 2.2 (mean ± SD) years. Progression from an initial state of no diabetic retinopathy to any of four outcomes was determined: (1) any incident retinopathy, (2) referable (moderate or worse) retinopathy, (3) diabetic macular edema, and (4) proliferative diabetic retinopathy.Multiple predictors, including age, race, gender, glycosylated hemoglobin (HbA1c), systolic blood pressure (SBP), cholesterol, chronic renal disease, and type of diabetes were investigated. Among modifiable risk factors, the average HbA1c had the strongest impact on the progression of diabetic retinopathy, followed by average SBP control and total cholesterol. Patients with an average HbA1c of 10.0% or greater (≥ 97mmol/mol) had a risk ratio of 5.72 (95% CI 5.44-6.02) for progression to any retinopathy, 18.84 (95% CI 17.25-20.57) for referable retinopathy, 22.85 (95% CI 18.87-27.68) for diabetic macular edema, and 25.96 (95% CI 18.75-36.93) for proliferative diabetic retinopathy compared to those with an average HbA1c of 7.0% (53mmol/mol) or less. Non-white patients generally had a higher risk of progression to all forms of diabetic retinopathy, while Asian patients were less likely to develop diabetic macular edema (HR 0.76, 95% CI 0.66-0.87). We confirm the critical importance of glucose control as measured by HbA1c on the risk of development of diabetic retinopathy.

Geographic Accessibility of Retail Cannabis in Northern California and Prenatal Cannabis Use During the COVID-19 Pandemic

Prenatal cannabis use is associated with health risks for mothers and their children. Prior research suggests that rates of prenatal cannabis use in Northern California increased during the COVID-19 pandemic, but it is unknown whether increases varied with the local cannabis retail and policy environment. To test whether pandemic-related increases in prenatal cannabis use were greater among pregnant individuals with greater retail availability of cannabis around their homes or among those living in jurisdictions that allowed storefront retailers. A cross-sectional, population-based time series study used data from pregnancies in the Kaiser Permanente Northern California health care system screened for cannabis use before (January 1, 2019, to March 31, 2020) and during (April 1 to December 31, 2020) the early COVID-19 pandemic. Proximity to the nearest retailer and number of retailers within a 15-minute drive from one's home and local cannabis storefront retailer policy (banned vs permitted) were calculated. Interrupted time series models were fit using multiplicative and additive Poisson regression, adjusting for age and race and ethnicity. The COVID-19 pandemic. Prenatal cannabis use based on universal urine toxicology tests conducted during early pregnancy at entrance to prenatal care. The sample (n = 99 127 pregnancies) included 26.2% Asian or Pacific Islander, 6.8% Black, 27.6% Hispanic, 34.4% non-Hispanic White, and 4.9% other, unknown, or multiracial individuals, with a mean (SD) age of 30.8 (5.3) years. Prenatal cannabis use before (6.8%) and during (8.2%) the pandemic was associated with closer proximity to a retailer, greater retailer density, and residing in a jurisdiction that permitted vs banned retailers. There was a greater absolute increase in cannabis use from before to during the pandemic among those within a 10-minute drive (<10 minutes: adjusted rate difference [aRD], 0.93 cases/100 patients; 95% CI, 0.56-1.29 cases/100 patients; ≥10 minutes: aRD, 0.40 cases/100 patients; 95% CI, 0.12-0.68 cases/100 patients; interaction P = .02). Otherwise, relative and absolute rates increased similarly across categories of cannabis retailer proximity/density and local policy (interaction P > .05). Prenatal cannabis use was more common among individuals living in areas with greater retail availability of cannabis. Although relative rates increased similarly during the pandemic regardless of local cannabis retail and policy environment, there was a larger absolute increase associated with living closer to a storefront cannabis retailer. Continued monitoring of local cannabis policy, the retail environment, and prenatal cannabis use is needed.

Rates of cardiovascular events among patients with moderate-to-severe atopic dermatitis in an integrated health care system: A retrospective cohort study.

Patients with versus without atopic dermatitis may have a greater risk of cardiovascular events, and the risk increases with severity of atopic dermatitis. The incidence of cardiovascular events in the population of patients with moderate-to-severe atopic dermatitis is largely unknown. This retrospective study evaluates incidence rates of cardiovascular events in patients aged ≥12 years with moderate-to-severe atopic dermatitis in a cohort of Kaiser Permanente Northern California health care system members without recognized risk factors for adverse events. Patients with moderate-to-severe atopic dermatitis, as defined by dermatologist-rendered code and prescription history between 2007 and 2018, were included. Major adverse cardiovascular events, venous thrombotic events, deep vein thrombosis, and pulmonary embolisms were identified via International Classification of Diseases codes. Stratification variables included age, sex, race, smoking history, and diabetes. Incidence rates per 1000 person-years were calculated by the number of patients with an incident event divided by the total person-years of observation. Among 8197 patients with moderate-to-severe atopic dermatitis, incidence rates per 1000 person-years (95% confidence interval) for major adverse cardiovascular events, venous thrombotic events, deep vein thrombosis, and pulmonary embolism were: 2.6 (2.1-3.2), 2.0 (1.5-2.5), 1.6 (1.2-2.1), and 0.7 (0.5-1.0), respectively. Incidence rates for all events were higher for older versus younger patients, patients with versus without diabetes, former smokers versus patients who had never smoked, and men versus women, except for pulmonary embolisms, which were higher in women. This study estimated the incidence of cardiovascular events in patients with moderate-to-severe atopic dermatitis and provides valuable information for clinicians.

Cellular and humoral immune response to SARS-CoV-2 vaccination and booster dose in immunosuppressed patients: An observational cohort study.

Background: Humoral and cellular immune responses to SARS-CoV-2 vaccination among immunosuppressed patients remain poorly defined, as well as variables associated with poor response.Methods: We performed a retrospective observational cohort study at a large Northern California healthcare system of infection-naïve individuals fully vaccinated against SARS-CoV-2 (mRNA-1273, BNT162b2, or Ad26.COV2.S) with clinical SARS-CoV-2 interferon gamma release assay (IGRA) ordered between January through November 2021. Humoral and cellular immune responses were measured by anti-SARS-CoV-2 S1 IgG ELISA (anti-S1 IgG) and IGRA, respectively, following primary and/or booster vaccination.Results: 496 immunosuppressed patients (54% female; median age 50 years) were included. 62% (261/419) of patients had positive anti-S1 IgG and 71% (277/389) had positive IGRA after primary vaccination, with 20% of patients having a positive IGRA only. Following booster, 69% (81/118) had positive anti-S1 IgG and 73% (91/124) had positive IGRA. Factors associated with low humoral response rates after primary vaccination included anti-CD20 monoclonal antibodies (P < 0.001), sphingosine 1-phsophate (S1P) receptor modulators (P < 0.001), mycophenolate (P = 0.002), and B cell lymphoma (P = 0.004); those associated with low cellular response rates included S1P receptor modulators (P < 0.001) and mycophenolate (P < 0.001). Of patients who had poor humoral response to primary vaccination, 35% (18/52) developed a significantly higher response after the booster. Only 5% (2/42) of patients developed a significantly higher cellular response to the booster dose compared to primary vaccination.Conclusions: Humoral and cellular response rates to primary and booster SARS-CoV-2 vaccination differ among immunosuppressed patient groups. Clinical testing of cellular immunity is important in monitoring vaccine response in vulnerable populations.

Ethnic diversity and burden of polycystic ovary syndrome among US adolescent females.

Polycystic Ovary Syndrome (PCOS) is a common female endocrine disorder presenting as early as adolescence. Recent data suggest that Asians may be at increased risk. This study examines PCOS prevalence by race/ethnicity in a large, diverse population of adolescent females. This retrospective study included 244,642 females (ages 13-17) with well-child visits during 2012-2018 in a Northern California healthcare system. Race/ethnicity and Asian ethnicity were classified using self-reported data. Body mass index was classified as healthy, overweight, and moderate/severe obesity. PCOS was determined by clinical diagnosis within one year of the visit. The overall prevalence of PCOS was 0.7% and increased substantially with weight. Among those with obesity, PCOS prevalence was 4.2, 2.9, 2.4, 2.1% in Asian/Pacific Islander (PI), Hispanic/Latina, Non-Hispanic White, Black adolescents and 7.8, 6.7, 5.7, 3.4% in South Asian, Chinese, Filipina, Native Hawaiian/PI adolescents, respectively. Compared to White adolescents, Asian/PIs had two-fold higher risk of PCOS, and Hispanic/Latinas had 1.3-fold higher risk. Compared to Chinese adolescents, South Asians had 1.7-fold higher risk, while Native Hawaiian/PIs had half the risk. The increased burden of diagnosed PCOS in Asian/PI and Hispanic/Latina adolescents, especially those with obesity, calls for further examination and clinical surveillance of at-risk populations.

COVID-19 and Advance Care Planning: A Unique Opportunity (QI429)

Outcomes1. Apply process for completing advance care planning2. Evaluate process for efficacy of document completionBackgroundAdvance care planning (ACP) is a process to document patient preferences for future healthcare. Conversations between healthcare providers, patients, and loved ones are needed to reflect a patient's values, goals, and choices for life-sustaining treatments (LSTs). The COVID-19 pandemic highlighted the critical importance of these discussions and the need for improved patient engagement.Aim StatementTo improve ACP documentation for patients at high risk for COVID-19 complications and death.MethodsAs COVID-19 surged, the VA Northern California Health Care System Hospice and Palliative Care Section (HPCS)partnered with patient aligned care teams to expand outreach to high-risk patients needing LST documentation. High risk was defined as age >80, COPD or asthma, or Care Assessment Need Score >80 (which models risk of hospitalization or death within 1 year). An experienced HPCS nurse practitioner contacted these identified patients to provide COVID-19 education, conduct a high-quality goals-of-care conversation, and complete LST documentation and other ACP needs. A representative cohort was followed up to evaluate concordance of treatment with documented preferences.ResultsBetween March and September 2020, 910 patients were identified as high risk, of which 294 agreed to participate in the telehealth visit and complete LST documentation. Importantly, 108 (37%) patients chose DNR and other LST limitations. Additionally, 142 (48%) patients created POLST documentation and 128 (43%) completed advance directives. Over 70% of patients hospitalized received care concordant with the documented LST preferences. A follow-up survey found the outreach impactful, with LST preferences documented correctly.Conclusions and ImplicationsPrior studies have demonstrated success at training primary providers to conduct ACP discussions, but given the limitations imposed by COVID-19 restrictions, this novel and highly cost-effective process of coupling a highly trained HPCS NP with multiple primary care teams to perform ACP was piloted with success.

The Safety Profile of FDA-Approved Epithelium-Off Corneal Cross-Linking in a US Community-Based Healthcare System.

PurposeTo determine the occurrence of early post-operative complications following FDA-approved epithelium-off corneal cross-linking in the United States.Materials and MethodsThis multicenter, retrospective cohort study identified patients who underwent epithelium-off (epi-off) corneal cross-linking (CXL) for keratoconus and post-refractive keratectasia within the Kaiser Permanente Northern California healthcare system between 2016 and 2018. Post-operative complications including delayed epithelial healing, infection, and loss of visual acuity were recorded.ResultsThe study included 878 eyes of 654 patients. The mean age was 27±9.4 years (range 7–71). Five hundred ninety-nine patients (91.6%) had keratoconus while 55 had post-refractive corneal ectasia (8.4%). Forty-seven eyes had prolonged follow-up because of the occurrence of complications in the early post-operative period. The respective rates of delayed epithelial healing, and keratitis were 3.9% (95% CI 2.7–5.3%), and 1.5% (95% CI 0.8–2.5%). Four approaches for management of delayed epithelial healing were compared; epithelium healing duration was the longest in the repeat bandage contact lens (BCL) group (23.8 days) and the shortest in the antibiotic ointment group (14.3 days), with statistically significant differences (p < 0.05) in the healing time between these 2 groups.ConclusionThe concern for early clinical complications after epi-off CXL often leads to delayed CXL intervention and further keratoconus progression with increased economic burdens. A large retrospective review of 878 eyes found that FDA-approved epi-off CXL protocol appears to be safe with low occurrence rates of early post-operative complications. The recommended management for delayed epithelial healing is using antibiotic ophthalmic ointment.