Kaiser Permanente Northern California Research Articles

Cannabis Use During Early Pregnancy Following Recreational Cannabis Legalization

It is unknown whether state recreational cannabis legalization (RCL) is related to increased rates of prenatal cannabis use or whether RCL-related changes vary with cannabis screening methods or the local policy environment. To test whether RCL in California was associated with changes in prenatal cannabis use rates, whether changes were evident in both self-report and urine toxicology testing, and whether rates varied by local policies banning vs allowing adult-use retailers post-RCL. This population-based time-series study used data from pregnancies in Kaiser Permanente Northern California universally screened for cannabis use during early pregnancy by self-report and toxicology testing from January 1, 2012, to December 31, 2019. Analyses were conducted from September 2022 to August 2024. California state RCL passage (November 9, 2016) and implementation of legal sales (January 1, 2018) were examined with a 1-month lag. Local policies allowing vs banning medical retailers pre-RCL and adult-use retailers post-RCL were also examined. Any prenatal cannabis use was based on screening at entrance to prenatal care (typically at 8-10 weeks' gestation) and defined as (1) a positive urine toxicology test result or self-report, (2) a positive urine toxicology test result, or (3) self-report. Interrupted time series models were fit using Poisson regression, adjusting for age, race and ethnicity, and neighborhood deprivation index. The sample of 300 993 pregnancies (236 327 unique individuals) comprised 25.9% Asian individuals, 6.4% Black individuals, 26.0% Hispanic individuals, 37.7% White individuals, and 4.1% individuals of other, multiple, or unknown race, with a mean (SD) age of 30.3 (5.4) years. Before RCL implementation, rates of prenatal cannabis use rose steadily from 4.5% in January 2012 to 7.1% in January 2018. There was no change in use rates at the time of RCL passage (level change rate ratio [RR], 1.03; 95% CI, 0.96-1.11) and a statistically significant increase in rates in the first month after RCL implementation, increasing to 8.6% in February 2018 (level change RR, 1.10; 95% CI, 1.04-1.16). Results were similar when defining prenatal cannabis use by (1) a toxicology test or (2) self-report. In local policy analyses, the post-RCL implementation increase in use was only found among those in jurisdictions allowing adult-use cannabis retailers (allowed RR, 1.21; 95% CI, 1.10-1.33; banned RR, 1.01; 95% CI, 0.93-1.10). In this time-series study, RCL implementation in California was associated with an increase in rates of cannabis use during early pregnancy, defined by both self-report and toxicology testing, driven by individuals living in jurisdictions that allowed adult-use retailers.

Early Maternal Prenatal Cannabis Use and Child Developmental Delays

Maternal prenatal cannabis use is associated with adverse neonatal health effects, yet little is known about its association with child developmental outcomes. To evaluate associations between maternal prenatal cannabis use in early pregnancy and child early developmental delays. This cohort study included 119 976 children born to 106 240 unique individuals between January 2015 and December 2019 and followed up to aged 5.5 years or younger (through December 31, 2021) at Kaiser Permanente Northern California. Individuals were screened for prenatal cannabis use via self-report and urine toxicology at entrance into prenatal care (approximately 8- to 10-weeks' gestation). Data were analyzed from February 2023 to March 2024. Maternal prenatal cannabis use defined as any use (self-reported or by urine toxicology testing) and use frequency. Early developmental delays (speech and language disorders, motor delays, global delays) in children up to age 5.5 years defined by International Statistical Classification of Diseases and Related Health Problems, Ninth Revision and Tenth Revision diagnoses codes ascertained from electronic health records. In this cohort of 119 976 pregnancies among 106 240 unique pregnant individuals, there were 29 543 Hispanic pregnancies (24.6%), 6567 non-Hispanic Black pregnancies (5.5%), 46 823 non-Hispanic White pregnancies (39.0%), 12 837 pregnancies (10.7%) to individuals aged 24 years or younger, and 10 365 pregnancies (8.6%) to individuals insured by Medicaid. Maternal prenatal cannabis use was documented for 6778 pregnancies (5.6%). Daily maternal prenatal cannabis use was reported for 618 pregnancies (0.5%), weekly for 722 pregnancies (0.6%), and monthly or less for 1617 pregnancies (1.3%). No association was observed between maternal prenatal cannabis use and child speech and language disorders (HR, 0.93; 95% CI, 0.84-1.03), global developmental delays (HR, 1.04; 95% CI, 0.68-1.59), or motor delays (HR, 0.86; 95% CI, 0.69-1.06). No association was detected between the frequency of maternal prenatal cannabis use and child early developmental delays. In this cohort study, maternal prenatal cannabis use was not associated with an increased risk of child early developmental delays. Future research is needed to assess different patterns of cannabis use throughout pregnancy. Given the association between maternal prenatal cannabis use and other adverse outcomes, pregnant individuals should be educated on those risks.

Prenatal Cannabis Use and Offspring Attention Deficit Hyperactivity Disorder and Disruptive Behavior Disorders: A Retrospective Cohort Study.

To examine whether maternal cannabis use during early pregnancy is associated with offspring attention deficit hyperactivity disorder (ADHD) and disruptive behavior disorders (DBD). We conducted a population-based retrospective birth cohort study of children (N = 141,570) born between 2011 and 2018 to pregnant individuals (N = 117,130) in Kaiser Permanente Northern California universally screened for any prenatal cannabis use at the entrance to prenatal care (at ∼8-10 wk gestation). Prenatal cannabis use was defined as (1) self-reported use and/or a positive toxicology test, (2) self-reported use, (3) a positive toxicology test, and (4) self-reported use frequency. Cox proportional hazards regression models adjusting for maternal characteristics (sociodemographics, other substance use and substance use disorders, prenatal care initiation, comorbidities) examined associations between prenatal cannabis use and offspring ADHD and DBD diagnosed by age 11 years. The sample of pregnant individuals was 27.2% Asian/Pacific Islander, 5.7% Black, 24.5% Hispanic, and 38.8% non-Hispanic White, with a mean (SD) age of 30.9 (5.2) years; 4.6% screened positive for any cannabis use (0.4% daily, 0.5% weekly, 1.1% monthly or less, 2.7% unknown frequency); 3.92% had a positive toxicology test and 1.8% self-reported use; 7.7% of offspring had ADHD and 6.8% had DBD. Maternal prenatal cannabis use was not associated with ADHD (adjusted hazard ratio [aHR]: 0.84, 95% CI, 0.70-1.01), and there was an inverse association with DBD (aHR: 0.83, 95% CI, 0.71-0.97), which remained when cannabis was defined by toxicology testing but not by self-report. Frequency of use was not associated with outcomes. Maternal prenatal cannabis use was not associated with an increased risk of offspring ADHD or DBD.

Contextual factors associated with successful alcohol screening and brief intervention implementation and sustainment in adult primary care

IntroductionHazardous drinking is a public health problem affecting approximately 20 % of the U.S. primary care population. Clinical trials have documented the efficacy and effectiveness of Alcohol Screening and Brief Intervention (ASBI), yet widespread implementation remains elusive, and questions remain regarding optimal implementation and sustainment strategies. Kaiser Permanente Northern California (KPNC) implemented systematic ASBI in adult primary care in mid-2013. We used 8 years of electronic health record (EHR) data, combined with surveys which captured primary care provider perceptions organized into PRISM (Practical, Robust Implementation and Sustainability Model) implementation framework domains (Intervention, External Environment, Implementation Infrastructure, and Recipients), to characterize ASBI implementation and sustainment and test how various factors are associated with ASBI rates. MethodsUsing EHR data, we calculated yearly screening rates of adults with a primary care visit, and brief intervention (BI) rates among those with a positive hazardous drinking screen, (exceeding the age and sex-specific daily and weekly low-risk NIH guidelines (≤3 per day and ≤ 7 per week for women and older men; ≤4 per day and ≤ 14 per week for men 18–65)), across KPNC, from 2014 to 2021. We collected web-based survey data, informed by the PRISM domains, from primary care providers (n = 796; 35.5 % RR) to assess perceptions on ASBI implementation and sustainability. ResultsBetween 1/1/2014 and 12/31/21 there were 5,072,270 completed screenings and 624,167 BIs. After adjusting for patient panel characteristics, we found that facilities with higher Implementation Infrastructure domain scores, indicating more robust implementation capacity, had higher screening and BI rates; facilities with higher Intervention domain scores, indicating positive perceptions of SBIRT evidence, and facilities with higher Recipients domain scores, indicating perceived organizational robustness, clinician culture and management support; and greater perceived patient needs and their likely benefit from SBIRT, had higher BI rates. ConclusionsResults provide information on factors which may facilitate successful ASBI implementation and sustainability and could inform future ASBI implementation efforts in healthcare system settings. In particular, efforts toward bolstering an organization's implementation infrastructure capacity, prior to embarking on implementation of a systematic ASBI program, could potentially help pave the way for successful implementation.

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.

Racial Residential Segregation and Mental Health During Pregnancy

Research suggests the social, physical, and socioeconomic contexts of residing in segregated neighborhoods may negatively affect mental health. To assess the association between racial residential segregation and prenatal mental health among Asian, Black, Hispanic, and White individuals. This population-based cross-sectional study was conducted in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system. Participants included self-identified Asian, Black, Hispanic, and White pregnant individuals who attended at least 1 prenatal care visit at KPNC between January 1, 2014, and December 31, 2019. Data were analyzed from January 14, 2023, to August 15, 2024. Racial residential segregation, defined by the local Getis-Ord Gi* statistic, was calculated in each racial and ethnic group and categorized as low (<0), medium (0-1.96), or high (>1.96). A positive Gi* statistic indicates overrepresentation (greater clustering or segregation) of the racial and ethnic group in an index census tract and neighboring tracts compared with the larger surrounding geographic area. Prenatal depression and anxiety defined by diagnoses codes documented in the electronic health record between the first day of the last menstrual period and the day prior to birth. Among the 201 115 participants included in the analysis (mean [SD] age, 30.8 [5.3] years; 26.8% Asian, 6.6% Black, 28.0% Hispanic, and 38.6% White), prenatal depression and anxiety were highest in Black individuals (18.3% and 18.4%, respectively), followed by White (16.0% and 18.2%, respectively), Hispanic (13.0% and 14.4%, respectively), and Asian (5.7% and 6.4%, respectively) individuals. Asian (40.8% vs 31.1%) and Black (43.3% vs 22.6%) individuals were more likely to live in neighborhoods with high vs low segregation, while Hispanic individuals were equally likely (34.3% vs 34.7%). High compared with low segregation was associated with greater odds of prenatal depression (adjusted odds ratio [AOR], 1.25 [95% CI, 1.10-1.42]) and anxiety (AOR, 1.14 [95% CI, 1.00-1.29]) among Black individuals. High segregation was associated with lower odds of prenatal depression among Asian (AOR, 0.75 [95% CI, 0.69-0.82]), Hispanic (AOR, 0.88 [95% CI, 0.82-0.94]), and White (AOR, 0.91 [95% CI, 0.86-0.96]) individuals. Similar associations were found for anxiety among Asian (AOR, 0.80 [95% CI, 0.73-0.87]) and Hispanic (AOR, 0.88 [95% CI, 0.82-0.93]) but not White (AOR, 0.95 [95% CI, 0.90-1.00]) individuals. In this cross-sectional study, racial and ethnic residential segregation was associated with worse prenatal mental health for Black individuals but better mental health for Asian, Hispanic, and White individuals. Policies reducing segregation and its impact may improve mental health outcomes in pregnant Black individuals.

A Chronic Hepatitis B Identification and Surveillance Program Improves Care in an Integrated Health Plan.

Optimal management of patients with chronic hepatitis B (CHB) requires surveillance for hepatocellular carcinoma (HCC) and identification of antiviral therapy candidates, but few dedicated CHB surveillance models have been described. Kaiser Permanente Northern California developed a systematic CHB surveillance and management program in 2012. We report the results of the program's performance over the initial 8-year period. We conducted a retrospective cohort study of all patients with CHB meeting guideline criteria for HCC surveillance. Eligible patients were invited into the Kaiser Permanente Northern California Liver Care Program (LCP), wherein patients receive reminders to obtain semiannual laboratory and imaging surveillance, which are reviewed by nurse practitioners. Treatment-eligible patients are provided with antiviral medications. Since its inception, 14,630 patients met study criteria, and 9,373 (64.1%) enrolled in the LCP. Adherence to imaging recommendations was higher in the LCP-managed group (41.5% of patients in the LCP received ≥80% of recommended imaging compared with 10.9% among patients not enrolled [risk ratio = 3.8; P < 0.001]). Approximately 63% of treatment-eligible patients in both groups received medication, although full-adherence rates were higher in patients managed in the LCP (72.3% vs 63.4%, respectively, P < 0.001). Among the 197 patients who developed HCC, recommended surveillance imaging was performed more frequently among LCP-managed patients (71.4% vs 53.8%, respectively, P < 0.05) who were also significantly more likely to be diagnosed at Barcelona Clinic Liver Cancer Stage 0/A (95.9% vs 74.6%; P < 0.001). In this integrated healthcare system, a systematic program for surveilling and managing patients with CHB seemed beneficial for both process and clinical endpoints.

Oral Antibiotic Use in Adulthood and Risk of Early-Onset Colorectal Cancer: A Case-Control Study

Prior antibiotic use may be a factor in the rising incidence of colorectal cancer seen in those under 50 years of age (early-onset colorectal cancer [EOCRC]); however, the few studies to examine this link have reported conflicting results. Therefore, we evaluated the association between oral antibiotic use in adulthood and EOCRC in a large integrated healthcare system in the United States. A population-based nested case-control study was conducted among Kaiser Permanente Northern California patients 18-49 years of age diagnosed with EOCRC (adenocarcinoma of the colon or rectum) in 1998-2020 who had ≥2 years of continuous pharmacy benefit prior to diagnosis. Cases were matched 4:1 to healthy controls on birth year, sex, race and ethnicity, medical facility, and duration of pharmacy benefit. Antibiotic exposure >1 year before the diagnosis/index date was assessed using prescribing records. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). A sensitivity analysis was performed among those with ≥10 years of continuous prescribing records. 1359 EOCRC cases were matched to 4711 healthy controls. Antibiotic use in adulthood was not significantly associated with EOCRC in unadjusted or adjusted analyses (adjusted OR: 1.04; 95% CI: 0.94-1.26). No associations were seen for cumulative number of oral antibiotic dispensations or for any prior period of antibiotic exposure. In a large United States healthcare setting, there was no conclusive evidence of an association between oral antibiotic use in adulthood and risk of EOCRC.

Incidence and Risk of Coronavirus Disease 2019 Hospitalization Among Unvaccinated Children.

The aim of this study is to determine the incidence and risk factors associated with COVID-19 hospitalization among unvaccinated children. Children aged 0- < 18 years, members of Kaiser Permanente Northern California (KPNC), were followed from March 1, 2020, until the earliest occurrence of: chart-confirmed COVID-19 hospitalization, disenrollment from KPNC, age 18 years, receipt of COVID-19 vaccine, death, or study end (December 31, 2022). We calculated the incidence rate of hospitalization by SARS-CoV-2 variant period and by age group. We determined risk factors for hospitalization using Poisson regression. We also conducted descriptive analyses of hospitalized cases. Among 1,107,799 children, 423 were hospitalized for COVID-19 during follow-up. The incidence of hospitalization increased with each new SARS-CoV-2 variant and was highest among children aged < 6 months. Among the < 6-month-olds, the incidence rate per 100,000 person-months was 7 during predelta, 13.3 during delta, and 22.4 during omicron. Black (RR = 2.05, 95% CI: 1.33-3.16) and Hispanic children (RR = 1.82, 95% CI: 1.34-2.46) and children with any comorbidities were at high risk of hospitalization (RR = 3.81, 95% CI: 2.94-4.95). Overall, 20.3% of hospitalized children were admitted to an intensive care unit (ICU), but ICU admission was 36.1% among 12- < 18-year-olds. The majority of ICU admits (91.8%) had no comorbidities. Children too young to be vaccinated had the highest incidence of COVID-19 hospitalization, while adolescents had the highest proportion of ICU admissions. To prevent severe disease in children and adolescents, everyone eligible should be vaccinated.

Provider and facility factors in relation to receipt of dose-reduced chemotherapy among patients with breast cancer.

310 Background: Little is known about how provider and facility factors relate to patients’ receipt of dose-reduced adjuvant chemotherapy. Methods: In a cohort of 8,581 stage I-IIIA women with breast cancer treated with chemotherapy at Kaiser Permanente Northern California between 2006 and 2019, we evaluated the associations between provider- and facility-level factors related to chemotherapy dosing with a primary interest in the first cycle dose reduction (FCDR). Here, FCDR is defined as a first cycle dose proportion &lt;90% of that expected based on the intended regimen, reflecting clinician intent at the outset of chemotherapy. Provider-level factors examined included provider gender, age, race, Hispanic ethnicity, years since completion of medical school, volume of breast cancer patients treated per year, and patient-provider racial concordance; we also examined practice size and rurality. Prevalence ratios (PR) were calculated using generalized linear models of the Poisson family with a log-link function and robust standard errors, accounting for significant patient factors and clustering at the provider level. Results were further mutually-adjusted for significant provider- and facility-level factors to ensure independence of associations. Results: Patients treated by providers practicing for longer (30+ years since medical school vs &lt;10 years) were more likely to be dose-reduced at the outset of chemotherapy (PR: 1.94; 95% CI: 1.15-3.25; p-trend: 0.02). Patients treated by providers in a larger practice (10+ vs ≤5 oncologists) were less likely to be dose reduced (PR: 0.53; 95% CI: 0.34-0.84; p-trend: 0.03) as were patients treated by providers treating a higher volume of breast cancer patients (30+ vs ≤15 patients/year: PR 0.64 (95% CI: 0.41-0.99; p-trend: 0.03). Other factors examined were not significantly associated with use of FCDR. Conclusions: These results indicate provider years of experience, as well as practice size and the volume of breast cancer patients treated per year are significantly associated with first cycle dose reductions in chemotherapy. This is a complex, multi-factorial issue, and these results indicate that provider- and provider- and facility-level factors should be considered when evaluating sources of heterogeneity in chemotherapy delivery.

Associations between age at diagnosis and chemotherapy dose reductions in women treated for stage I-IIIA breast cancer.

99 Background: Several studies have shown that older women diagnosed with breast cancer and eligible for chemotherapy treatment are more likely to be dose-reduced than younger women; however, most prior studies were limited by small sample sizes and examined relative dose intensity of a single drug. We assessed the association between age at diagnosis with first cycle dose proportion (FCDP) and average relative dose intensity (ARDI) across multiple regimens in the Optimal Breast Cancer Chemotherapy Dosing (OBCD) study. Methods: This retrospective cohort study included 10,386 women ages 18+ years treated with adjuvant chemotherapy for stage I-IIIA breast cancer at Kaiser Permanente Northern California (KPNC) and Washington (KPWA) between 2004-2019. We examined associations between age at diagnosis with first cycle dose proportion (FCDP, defined as &lt;90% of the guideline-recommended dose, reflecting clinician intent at treatment outset) and average relative dose intensity (ARDI, defined as dose proportion &lt;90% across the course of chemotherapy). We used multivariable-adjusted generalized linear models of the Poisson family with a log link-function and robust standard errors to calculate prevalence ratios (PR) and corresponding 95% confidence intervals (CI). We adjusted for patient and tumor characteristics, with and without adjusting for pre-existing comorbidities. Results: The proportion of women with a FCDP &lt;90% ranged from 3% among women ages 18-39 years to 19% among women ages 75+ years. Women ages 75+ years were statistically significantly more likely to have a FCDP &lt;90% and ARDI &lt;90% vs women ages 40-49 years regardless of adjustment for comorbidities (Table). Conclusions: Older age at diagnosis is strongly associated with chemotherapy dose reductions relative to guideline recommendations, both at the outset of chemotherapy initiation and across the course of treatment. Understanding implications of dose reductions on chemotoxicities and survival will be particularly important for improving the quality of care and long-term outcomes for older women. Age at Diagnosis (years) FCDP &lt;90% Multivariable Adjusted*PR (95% CI) FCDP &lt;90% Additionally Adjusted* for ComorbiditiesPR (95% CI) ARDI &lt;90% Multivariable Adjusted*PR (95% CI) ARDI &lt;90% Additionally Adjusted* for ComorbiditiesPR (95% CI) 18-39 0.81 (0.53-1.23) 0.84 (0.55-1.29) 0.84 (0.68-1.03) 0.85 (0.69-1.04) 40-49 REF REF REF REF 50-64 1.32 (1.08-1.61) 1.29 (1.06-1.59) 1.16 (1.04-1.29) 1.14 (1.02-1.26) 65-74 1.72 (1.36-2.17) 1.65 (1.29-2.10) 1.34 (1.18-1.52) 1.26 (1.11-1.43) 75+ 4.90 (3.61-6.65) 4.39 (3.16-6.09) 1.94 (1.61-2.35) 1.75 (1.44-2.13) p-trend &lt;0.001 &lt;0.001 &lt;0.001 &lt;0.001 *Adjusted for BMI, stage at diagnosis, year of diagnosis, study site, race/ethnicity, income, body mass index, human epidermal growth factor receptor status, grade, nodal number, estrogen and progesterone receptor status.

Frequency of CKD Patient Referrals to Nephrology Clinics Using the Kidney Failure Risk Equation at Kaiser Permanente Northern California

Frequency of CKD Patient Referrals to Nephrology Clinics Using the Kidney Failure Risk Equation at Kaiser Permanente Northern California

Was receipt of any specialty alcohol treatment during the pandemic effective at reducing drinking for patients with or at risk of AUD?

IntroductionThe COVID-19 pandemic changed the way healthcare providers delivered most health services, including treatment for alcohol use disorder (AUD). Specialty alcohol treatment remained available through the pandemic, and within some systems treatment use increased likely due to telehealth availability. However, the field knows little about the relationship between the pandemic's expanded access to specialty alcohol treatment and alcohol use outcomes. MethodsThe sample included 14,712 patients from Kaiser Permanente Northern California who screened positive for unhealthy alcohol use in primary care and had an AUD diagnosis or risked developing an AUD by reporting 5 or more heavy drinking days in a 3-month period between 1/1/2019 and 2/29/2020 (pre-pandemic). The study examined the receipt of any specialty alcohol treatment (including at least one outpatient, inpatient, or telehealth specialty treatment encounter, or pharmacotherapy prescription) from 3/1/2020 (pandemic start) to either the first completed follow-up alcohol screening or 6/20/2022 (study period end). The outcomes of alcohol use included changes in heavy drinking days, drinks per week, drinking days per week, and drinks per drinking day between the pre- and post-pandemic periods. ResultsOn average patients significantly decreased alcohol use across all four alcohol use measures examined, regardless of whether they received treatment. However, those who received any treatment compared to those who did not have greater reductions in alcohol use, with an additional decrease of −3.55 heavy drinking days (95 % CI = −5.93, −1.17), −3.80 drinks per week (95 % CI = −5.18, −2.42), −0.72 drinks per drinking day (95 % CI = −1.14, −0.30), and − 1.01 drinking days per week (95 % CI = −1.30, −0.72). Treatment effects were greatest among patients who exceeded both daily and weekly limits pre-pandemic, with an additional decrease of −10.75 heavy drinking days (95 % CI = −15.28, −6.21), −12.83 drinks per week (95 % CI = −16.31, −9.35), −1.67 drinks per drinking day (95 % CI = −2.19, −1.14), and −2.02 drinking days per week (95 % CI = −2.41, −1.63). ConclusionsOn average, patients decreased alcohol use during the onset of the pandemic, however, those who had any specialty alcohol treatment had significantly greater decreases, suggesting that the hybrid in-person and telehealth treatment approach was effective during the pandemic.

The impact of COVID-19 on time toxicity in patients with advanced cancer.

267 Background: The COVID-19 pandemic necessitated the rapid adoption of telemedicine but little is known about whether the changes in care delivery has led to differences in time toxicity for patients with advanced cancer. This study examines the impact of the pandemic on time toxicity, defined as the time burden of interacting with the healthcare system, by comparing healthcare contact days between pre-COVID and post-COVID periods. Methods: A retrospective cohort study was performed on patients with advanced (stage 4) cancer who died within one year of diagnosis at Kaiser Permanente Northern California between January 1, 2015 and June 30, 2023. Time toxicity was defined as the percentage of healthcare contact days over the course of survival period between cancer diagnosis and death (contact days/survival days). We included outpatient days (imaging, labs, treatment, provider visits), inpatient stays (emergency department, acute inpatient, non-acute institutional stays), and in-home days (in-home care, virtual care, home hospice). Differences between pre-COVID (diagnosed and died before March 1, 2020) and post-COVID (diagnosed after March 1, 2020) periods were analyzed using Wilcoxon tests. Results: The cohort included 9643 patients, with 6558 pre-COVID and 3085 post-COVID. Median age at diagnosis was 74 years, and the cohort was 46.9% female, largely white (64.5%), with a high comorbidity score (median Elixhauser score: 4). Post-COVID, there was an increase in institutional stay (8.7% vs. 9.3%) and outpatient service (imaging and labs) (4.4% vs. 3.1%), while in-person outpatient visits decreased (5.9% vs. 8.7%, p&lt;0.0001). Additionally, in-home days increased (25.0% vs. 20.8%), with a significant rise in in-home virtual care (3.9% vs. 1.8%, all p&lt;0.01). Conclusions: The COVID-19 pandemic led to notable shifts in healthcare utilization for patients with advanced cancer in the last year of life. The increase in telehealth and in-home services in the post-COVID era was accompanied by a slight increase in emergency and ancillary services. Further understanding patient experiences around these shifts is crucial for optimizing care and managing time toxicity in the evolving healthcare landscape. Description of outcomes pre and post-COVID-19 pandemic. Total Pre-COVID Post-COVID P-value Survival Days, median 86.0 84.0 89.0 0.02 Percentage of Contact, median (interquartile range) Comprehensive Contact 63.3 (41.0-92.0) 62.5 (40.7-91.0) 65.2 (41.7-94.1) 0.01 Institutional stay 9.0 (2.7-26.2) 8.7 (2.7-25.9) 9.3 (2.9-26.8) 0.11 Outpatient 12.4 (5.3-19.8) 12.9 (5.6-20.6) 11.2 (4.8-18.1) &lt;.001 Outpatient visit 7.7 (2.8-13.4) 8.7 (3.5-14.6) 5.9 (1.6-10.7) &lt;.0001 Outpatient service 3.5 (0.8-6.3) 3.1 (0.4-5.8) 4.4 (1.5-7.1) &lt;.0001 In-home 22.2 (7.4-50.0) 20.8 (6.0-48.4) 25.0 (10.4-51.7) &lt;.001 In-home care 18.1 (1.7-46.6) 17.4 (1.2-46.2) 19.2 (2.4-47.2) 0.03 In-home virtual care 2.2 (0.0-4.8) 1.8 (0.0-3.8) 3.9 (0.7-7.0) &lt;.0001

Time toxicity faced by patients with advanced cancer across primary cancer sites.

268 Background: Time toxicity, defined as the burden of time for patients interacting with the health care systems, is particularly important for patients with limited life expectancy. Little is known about the relative impact of time toxicity among different cancer types at the end of life. This study examines median contact days for inpatient, outpatient, and home health services among different primary cancer types for patients with advanced cancer with limited prognosis. Methods: A retrospective cohort analysis was performed on patients with advanced (stage 4) cancer who died within one year of diagnosis at Kaiser Permanente Northern California between January 1, 2015, and June 30, 2023. Time toxicity was defined as comprehensive contact days with healthcare system over the course of patients’ survival period between cancer diagnosis and death (i.e., contact days divided by survival or contact %). Types of contact included institutional stay (emergency department visit, hospitalization, skilled nursing facility, rehabilitation); outpatient visits (ambulatory care, labs, imaging); and in-home care (home-health, home hospice, telephone and virtual visit). The study quantified overall median contact % and contact % by specific care settings, stratified by cancer primary site. Results: The study included 10102 patients. The median age at diagnosis was 74 years with 47% female. Patients were predominantly white (65%), followed by Asian (12%), Hispanic (12%), and black (8%). The median Elixhauser comorbidity score was 4. With the exception of head and neck cancers, most cancers had higher contact % near diagnosis and at end of life (U-shaped curve). Head and neck cancers had the highest percent of patients undergoing surgery (36%) and radiation (52%), which may explain its sinuosity-like curve with a rapid increase of weekly contact % after diagnosis (a small peak), followed by rapid decrease and another increase by the end of their life. Survival days were comparatively long for head and neck cancers (158 days, IQR: 84-265) and short for thoracic (80 days, IQR: 35-166) and upper gastrointestinal cancers (80 days, IQR: 38-173). Malignant hematology patients had notably higher comprehensive contact % (74%, IQR: 47-100) which was driven primarily by emergency room department visits and hospital stays (p&lt;0.001 for all contact types). Conclusions: The study highlights the high burden of time toxicity in patients with advanced cancer with limited prognosis. The significant variations in time toxicity among different cancer types, especially in malignant hematology and head and neck patients, emphasize the need to tailor goals of care discussions for patients with cancer at the end of life. By focusing on reducing unwanted time toxicity, healthcare providers can enhance the quality of life for patients with cancer, ensuring more efficient and patient-centered care delivery.

Beyond the pain: Decoding opioid use in advanced cancer ED visits.

298 Background: Patients with advanced cancer often turn to the emergency department (ED) for pain treatment, impacting their quality of life and escalating healthcare costs. A crucial step in reducing avoidable ED visits and maintaining patient safety is to identify the characteristics of this patient group and explore potential intervention points. This study aims to characterize the use of narcotics in the ED among patients with advanced cancer. Methods: This retrospective cross-sectional study at Kaiser Permanente Northern California involved adults aged 18 and older diagnosed with Stage IV solid cancers between 2018 to 2020, who had at least one ED visit and passed away within one year (excluding those who died within 30 days). Demographics, clinical variables, frequencies, and trends in ED visits were collected and compared based on opioid utilization. Results: The study encompassed 2,554 patients with 6,406 ED visits in their final year of life. Sixty-one percent of these patients received opioids during their ED visits, with a median of three visits per patient. Pain scores taken at triage of these visits showed 23% reported severe pain, 23% moderate pain, and 7% mild pain. In 56% of visits, patients had filled an opioid prescription within the last 30 days. Morphine (39%) and hydromorphone (29%) were the most commonly administered opioids, primarily intravenously (66%). The prevalent cancer subtypes receiving opioids during ED visits were breast, head and neck, and upper GI. Among patients who received chemo or radiation, 65% received opioids during ED visits, compared to the 55% of patients not in treatment. For treated patients, chemotherapy was associated with increased ED visits requiring opioid pain management. Median survival did not differ significantly between those who received opioids during ED visits (130 days) and those who did not (123 days). Conclusions: This study emphasizes the dynamic pain needs of patients with cancer at the end of life driving utilization of emergency care. Factors influencing these needs include cancer subtype and current treatment status, particularly chemotherapy. Further studies are essential to enable providers to better recognize cancer pain and to improve patient safety by addressing changes in patients' pain requirements outside the emergency setting.

Maternal Prenatal Cannabis Use and Child Autism Spectrum Disorder

Despite an increase in maternal prenatal cannabis use and associations with adverse neonatal outcomes, research on child neurodevelopmental outcomes is limited. To evaluate the association between maternal cannabis use in early pregnancy and child autism spectrum disorder (ASD). This population-based retrospective birth cohort study included children born between 2011 and 2019 to pregnant Kaiser Permanente Northern California members screened for prenatal cannabis use during pregnancy. Statistical analysis was conducted February 2023 to March 2024. Maternal prenatal cannabis use was assessed at entrance to prenatal care (approximately 8- to 10-weeks' gestation) via self-report and/or positive urine toxicology test. Use frequency was assessed. Child ASD was defined by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes ascertained from the electronic health record. Associations between maternal prenatal cannabis use and child ASD were modeled using Cox proportional hazards regression adjusted for maternal sociodemographic, other substance use and disorders, prenatal care initiation, comorbidities, and clustering among maternal siblings. The study cohort included 178 948 singleton pregnancies among 146 296 unique pregnant individuals, including 48 880 (27.3%) Asian or Pacific Islander, 42 799 (23.9%) Hispanic, 9742 (5.4%) non-Hispanic Black, and 70 733 (39.5%) non-Hispanic White pregnancies. The median (IQR) maternal age at pregnancy onset was 31 (6) years; 8486 (4.7%) screened positive for cannabis use, 7054 (3.9%) via urine toxicology testing and 3662 (2.0%) by self-report. In the total study population, the frequency of self-reported use was monthly or less for 2003 pregnancies (1.1%), weekly for 918 pregnancies (0.5%), daily for 741 pregnancies (0.4%), and unknown for 4824 pregnancies (2.7%). ASD was diagnosed in 3.6% of children. After adjustment for maternal characteristics, maternal prenatal cannabis use was not associated with child ASD (hazard ratio [HR], 1.05; 95% CI, 0.84-1.32). When self-reported frequency of use was assessed, no statistically significant associations were observed after confounder adjustment. No sex-specific associations were documented (males: HR, 1.01; 95% CI, 0.77-1.32; and females: HR, 1.19; 95% CI, 0.77-1.85). In this cohort study, maternal cannabis use assessed in early pregnancy was not associated with child ASD. Additional studies are needed to evaluate different patterns of use throughout pregnancy. Given the known adverse neonatal health effects of maternal prenatal cannabis use, clinicians should follow national guidelines and advise against use.

Improving flu vaccination rates among adult patients with cancer at Kaiser Permanente.

326 Background: Vaccines protect cancer patients from developing severe illness, hospitalization, and death. At Kaiser Permanente (KP) South Sacramento Medical Center (KPSSC), oncology patients on active chemotherapy had an overall flu vaccination rate of 13% between September 1, 2022, and December 1, 2022. Our aim was to increase this rate to 33% during the 2023 flu season. Methods: In conjunction with the ASCO Quality Training Program, we applied quality improvement initiatives to improve flu vaccination. Our population of interest included adult cancer patients on active chemotherapy at KPSCC. We evaluated the barriers to vaccination assessment by distributing surveys to infusion nurses. We performed three Plan-Do-Study-Act (PDSA) cycles for quality improvement and monitored flu vaccination rates. Cycle 1 (9/11/2023 to 11/5/2023): We distributed the ASCO flu vaccine handout at oncology clinic. We had medical assistants and infusion nurses administer flu vaccines during clinic visits and chemotherapy sessions. Cycle 2 (11/6/2023 to 11/21/2023): We added the vaccine handout in Chinese and Spanish and updated our receptionists’ script to strongly encourage patients to receive flu vaccine. Cycle 3 (11/22/2023 to 12/6/2023): KP flu clinic set up an onsite flu vaccine cart one half day per week in the oncology clinic. Results: Barriers to vaccination assessment in the clinic included lack of time (60%), difficulty remembering to ask (10%), and non-influenza season (10%). Our interventions resulted in an increased flu vaccination rate from 13% in 2022 to 36% in 2023. During cycle 1, 298 out of 615 patients received their vaccine (48.5%). During cycle 2, 16 out of 118 patients received their vaccine (13.6%). PDSA cycle 3 resulted in 14 out of 178 patients receiving their vaccine (7.9%). Conclusions: Promoting vaccine awareness via active engagement with nurses and medical assistants early on and having onsite vaccine availability in the oncology clinic were keys to improve the overall flu vaccination rate. While most vaccines were administered at the beginning of flu season, the addition of language-tailored vaccine handouts and having an onsite vaccine cart towards the end of the season did result in late season vaccinations. Our findings do support the importance of providing timely vaccine information in the oncology clinic. Our future goal is to expand these efforts to other KP Northern California oncology centers to establish stable onsite vaccine availability in clinics and include additional vaccine types.

Abstract C040: Racial and ethnic differences in breast cancer prognosis and survival in a multiethnic cohort of Asian American breast cancer patients compared with non-Latina White patients at Kaiser Permanente Northern California

Abstract Background: In the U.S., breast cancer (BC) survival differs significantly by race and ethnicity, with Asian American (AA) patients consistently showing more favorable survival relative to other racial and ethnic groups. Factors contributing to the survival advantage of AA females, a heterogeneous population, are unknown. Methods: We included 5,294 AA female patients diagnosed with incident AJCC stage I-IV BC from 2000-2015 at Kaiser Permanente Northern California, and a random sample of 5,294 non-Latina White (NLW) patients. Follow-up was through 12/31/2020 for recurrence, second primary cancer, BC death, and all-cause death. Survival analysis was conducted using multivariable, cause-specific Cox proportional hazards models. Results: The AA cohort consisted of 41% Filipina, 27% Chinese, 9% Japanese, 9% South Asian, 7% Other Asian, 3% Korean, and 5% Southeast Asian females. AA and NLW females had similar stage (12% III/IV) and ER/PR status (15-18% ER-/PR-), yet more AA females were diagnosed with HER2+ or borderline disease (19% vs. 14%). More AA females had chemotherapy (48% vs. 39%) and mastectomy (47% vs. 36%) with less radiation therapy (38% vs. 46%) than NLW females. Receipt of endocrine therapy was similar between AA and NLW females (72-73%). Compared with NLW females, AA females were younger (mean=56.9 vs. 63.2 years), lived in higher SES neighborhoods (census tract-level education and income), had no comorbidities (45% vs. 36%), lower BMI (mean=25.5 vs. 28.6 kg/m2), and were never smokers (77% vs. 50%) at diagnosis. Fewer AA vs. NLW females met national guidelines of 150 minutes/week of moderate-vigorous exercise (27% vs. 33%). In multivariable Cox models adjusted for diagnosis year, diagnosis age, stage, ER/PR and HER2 status, chemotherapy, radiation therapy, endocrine therapy, and surgery type, AA females had 20% lower risk of BC death and all-cause death compared with NLW females. Similar lower risks were seen across AA ethnicities. Specifically, Japanese and Chinese females had lower risks of BC death (hazard ratio, HR=0.66; 95% confidence interval, CI: 0.47-0.93 and HR=0.78; 95% CI: 0.63-0.97) and all-cause death (HR=0.67; 95% CI: 0.53-0.84 and HR=0.78; 95% CI: 0.67-0.92). South Asian females also had lower risk of all-cause death (HR=0.71; 95% CI: 0.53-0.96). AA females had 17% lower risk of second primary cancer compared with NLW females, specifically for Japanese, South Asian, and Other Asian females (HR range: 0.60-0.66). No difference in risk of recurrence was observed for AA vs. NLW females (HR=1.08; 95% CI: 0.90-1.29), including by Asian ethnicities. Conclusions: In this large, multiethnic cohort in an integrated health care system, clear differences in sociodemographic, clinical, and lifestyle factors exist between AA and NLW BC patients. After accounting for these factors, AA females had a survival advantage over NLW females, mostly in Japanese, South Asian, and Chinese females. These findings identify contributors to outcomes that may be specific to Asian ethnicities and can inform improving survival in all BC patients. Citation Format: Marilyn , Lia D'Addario, Janise Roh, Isaac Ergas, Catherine Lee, Salma Shariff-Marco, Iona Cheng, Valerie McGuire, Julie Von Behren, Katherine Lin, Esperanza Castillo, Mi-Ok Kim, Esther John, Anna Wu, Lenora Woo, Allison Kurian, Angela Omilian, Christine Ambrosone, Song Yao, Scarlett Gomez, Lawrence Kushi. Racial and ethnic differences in breast cancer prognosis and survival in a multiethnic cohort of Asian American breast cancer patients compared with non-Latina White patients at Kaiser Permanente Northern California [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C040.

Prospective changes in drinking during the COVID-19 pandemic among adults with unhealthy alcohol use.

This study examined differential changes in alcohol use during the COVID-19 pandemic among adults with unhealthy alcohol use. Among 62924 adults identified with unhealthy alcohol use in primary care prepandemic (1 January 2019 to 29 February 2020), changes in alcohol use during the pandemic (1 March 2020 to 30 June 2022) were examined using electronic health record data from Kaiser Permanente Northern California. Outcomes were changes in heavy drinking days in the past threemonths (HDDs) and overall consumption (drinks/week), including continuous and categorical measures. Differences in outcomes by sex, age, race/ethnicity, and alcohol use disorder (AUD) were examined. On average, drinking was reduced by 3.0 HDDs (in the past threemonths) (SD = 18.4) and 4.1 drinks/week (SD = 12.2), but women, certain age groups, White patients, and patients without AUD had smaller decreases than their counterparts. Overall, 9.1% increased, 34.4% maintained, and 56.5% decreased HDDs, and 20.2% increased, 19.8% maintained, and 60.1% decreased drinks/week. Women, patients aged ≥35years, White patients, and patients with AUD had higher odds of increasing versus decreasing HDDs, and maintaining versus decreasing, compared to their counterparts. Patients aged 18-20years, White patients, and patients without AUD had higher odds than their counterparts of increasing versus decreasing drinks/week. Women, patients aged 18-20years, Asian/Pacific Islander, and Latino/Hispanic patients had higher odds of maintaining versus decreasing drinks/week. While alcohol use decreased overall among this sample of primary care patients with unhealthy drinking prepandemic, certain subgroups were more likely to increase drinking, suggesting a greater risk of alcohol-related problems.