Northern California Region Research Articles

Impact of pharmacist managed oral epidermal growth factor receptor inhibitors.

Pharmacists are an integral part of medication management, with the positive impact of their clinical services in patient outcomes previously studied and reported in literature. The roles and responsibilities of pharmacists continue to expand, including optimizing patient medication and health outcomes related to complex oral anticancer drugs. To evaluate the impact of a pharmacist-managed oral chemotherapy clinic in patients with non-small cell lung cancer (NSCLC) taking oral epidermal growth factor receptor inhibitor (EGFRi) regimens within an integrated healthcare delivery system. This was an observational cohort study using data from Kaiser Permanente Northern and Southern California regions on adult patients who received oncology pharmacist-managed care compared to patients with usual care. Patients were newly initiated with EGFRi therapy to treat NSCLC between 2017 and 2019. The follow-up period was defined as the time from index date (first sold date of EGFRi) to December 2020 or end of membership or death, whichever occurred first. Primary outcome measures included adherence to EGFRi, frequency of imaging during drug exposure, and presence of imaging prior to treatment change. Outcomes were analyzed with Chi-square test for categorical variables, and Student's t-test or Wilcoxon rank-sum test for continuous variables. There were 613 patients in the pharmacist-managed group and 714 patients in the usual care group. Overall, the mean age was 68.2 ± 11.3 years, and 65.1% were female. In the pharmacist-managed group, there was a significantly higher mean proportion of days covered (PDC) during the first three months of therapy (0.86 ± 0.24 vs 0.82 ± 0.36, p = 0.01) and a higher percentage of patients who were adherent to EGFRi therapy (with PDC ≥0.80) during the drug exposure period (95.8% vs 92.4%, p = 0.01). The rate of computed tomography (CT) and magnetic resonance imaging (MRI) during drug exposure was higher in the pharmacist-managed group compared to the usual care group (31.8% vs 20.7%, p < 0.01) with a higher number of mean scans completed per patient (1.15 ± 2.42 vs 0.62 ± 1.63, p < 0.01) and per patient-year (2.60 ± 7.27 vs 1.58 ± 5.95, p < 0.01). Overall, 66.2% of patients had a treatment change, with a higher percentage of patients in the pharmacist-managed group who completed a CT or MRI scan prior to treatment change (36.3% vs 26.3%, p < 0.01). Additionally, the median time between the scan and treatment change was shorter for patients with pharmacist-managed care (1.8 vs 4 months, p = 0.04). Clinical pharmacy services contributed to improved adherence, higher rates of imaging, and shorter time between imaging and treatment changes in NSCLC patients who were taking EGFRi regimens.

California wildfire smoke contributes to a positive atmospheric temperature anomaly over the western United States

Abstract. Wildfires in the southwestern United States, particularly in northern California (nCA), have grown in size and severity in the past decade. As they have grown larger, they have been associated with large emissions of absorbing aerosols and heat into the troposphere. Utilizing satellite observations from MODIS, CERES, and AIRS as well as reanalysis from MERRA-2, the meteorology associated with fires during the wildfire season (June–October) was discerned over the nCA-NV (northern California and Nevada) region during the period 2003–2022. Wildfires in the region have a higher probability of occurring on days of positive temperature (T) anomalies and negative relative humidity (RH) anomalies, making it difficult to discern the radiative effects of aerosols that are concurrent with fires. To attempt to better isolate the effects of large fire emissions on meteorological variables, such as clouds and precipitation, variable anomalies on high fire emission days (90th percentile) were compared with low fire emission days (10th percentile) and were further stratified based on whether surface relative humidity (RHs) was anomalously high (75th percentile) or low (25th percentile) compared with typical fire season conditions. Comparing the simultaneously high fire emission and high RHs data with the simultaneously low fire emission and high RHs data, positive tropospheric T anomalies were found to be concurrent with positive AOD anomalies. Further investigation found that due to shortwave absorption, the aerosols heat the atmosphere at a rate of 0.041 ± 0.016 to 0.093 ± 0.019 K d−1, depending on whether RH conditions are anomalously positive or negative. The positive T anomalies were associated with significant negative 850–300 hPa RH anomalies during both 75th percentile RHs conditions. Furthermore, high fire emission days under high RHs conditions are associated with negative CF anomalies that are concurrent with the negative RH anomalies. This negative CF anomaly is associated with a significantly negative regional precipitation anomaly and a positive net top-of-atmosphere radiative flux anomaly (a warming effect) in certain areas. The T, RH, and CF anomalies under the simultaneously high fire emission and high RHs conditions compared with the simultaneously low fire emission and high RHs conditions have a significant spatial correlation with AOD anomalies. Additionally, the vertical profile of these variables under the same stratification is consistent with positive black carbon mass mixing ratio anomalies from MERRA-2. However, causality is difficult to discern, and further study is warranted to determine to what extent the aerosols are contributing to these anomalies.

Socio-Demographic and Preoperative Clinical Factors Associated With 5-Year Weight Trajectories After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

To determine whether socio-demographic and preoperative clinical factors contribute to the percent total body weight loss (%TBWL) after bariatric surgery (BS). BS is the most effective long-term treatment for medically complicated obesity. More information is needed about the factors that contribute to postoperative %TBWL in large and ethnically diverse cohorts. This retrospective study conducted in the Kaiser Permanente Northern California region included 7698 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 2009 and March 2015. Trajectory analyses were conducted from 5-year follow-up data to assign patients to "low," "average," or "high" postoperative %TBWL groups. We then evaluated whether age, sex, race/ethnicity, neighborhood deprivation index and preoperative body mass index (BMI)/weight loss, diabetes, hypertension, and sleep apnea contributed to postoperative %TBWL using logistic regression models. Of 7698 patients (83.2% women), 48.6% underwent a RYGB and 51.4% underwent a SG. Postoperative %TBWL trajectories over 5 years were obtained in 6229 (81%) of 7698 eligible patients. About 27.8% and 29.3% of patients followed the "low" postoperative %TBWL trajectory, for RYGB and SG, respectively. Men, older patients, and Asian, Black, and Hispanic/Latino patients were more likely to be classified in the low postoperative %TBWL group. Patients showing lower postoperative %TBWL had a lower preoperative BMI (but lost less weight before surgery) and were more likely to have preoperative comorbidities. This study confirms and extends prior findings of the effects of several demographic and preoperative clinical factors on postoperative weight loss. Findings could improve the support of patients to achieve desired surgical outcomes.

Lead Time and Immortal Time Biases Impact the Calculation of Post-colonoscopy Colorectal Cancer Survival

The World Endoscopy Organization (WEO) standardized the reporting of post-colonoscopy colorectal cancers (PCCRCs), which account for 7% to 10% of colorectal cancers (CRCs).1 PCCRCs are diagnosed 6 to 36 months after a false negative colonoscopy. Detected CRCs (dCRCs) are diagnosed ≤6 months after an index true positive colonoscopy.2 PCCRC prognosis is unclear, with outcomes reported as comparable,3 superior,4 or inferior5,6 to those of dCRC. Because WEO terminology defines cases relative to the index colonoscopy, conventional survival analyses of PCCRC are susceptible to lead time and immortal time biases. We evaluated the influence of these biases on mortality in a population-based retrospective cohort of 10,938 dCRCs (93.8%) and 717 PCCRCs (6.2%). This study was set within Kaiser Permanente Northern California (KPNC), a large integrated health system, whose members are similar in demographic and socioeconomic characteristics to the Northern California region.7.

Fostering Socio-Ecological Resilience to Wildfire by Interconnecting Knowledge Systems at Cal Poly Humboldt

The wildfire-related challenges of Northern California and many other regions in the western United States are daunting in scope and magnitude. Ecologically and culturally salient solutions that limit the negative impacts of wildfire and promote resilience of human and ecological systems will require newer approaches. Through Cal Poly Humboldt and the Fire Resilience Institute, there is greater emphasis on the interconnection of knowledge systems across education, training, research, and management. Here we highlight several on-going efforts that seek to enhance the fire resilience workforce, promote socio-ecological resilience through interdisciplinary projects, and inform management through monitoring and research projects that intentionally incorporate multiple knowledge systems. Shifting to a more inclusive process has many potential benefits but will also pose challenges and require modification of approaches. Here we emphasize some on-going efforts at Cal Poly Humboldt to intentionally bridge knowledge systems to make advances on wildfire-related challenges. Socio-ecological resilience and coexistence with fire can be fostered but the long-term effectiveness will greatly benefit from approaches that are inclusive, equitable, and interconnected across the many stakeholders affected and disciplines involved.

Meaning Well Is Not the Same as Doing Good: The Fraught Circumstances of Allyship With Indigenous Groups

Meaning Well Is Not the Same as Doing Good: The Fraught Circumstances of Allyship With Indigenous Groups

Community Experience with Pediatric Inspired Treatment of Acute Lymphoblastic Leukemia in the Adolescent and Young Adult Population in Kaiser Permanente Northern and Southern California Regions

Background:Pediatric inspired treatment for Acute Lymphoblastic Leukemia has been increasingly used for treatment of adolescents and young adults in the United States and Europe. In 2019 Dr. Stock published results of CALGB 10403 which showed that a pediatric inspired regimen was tolerable and efficacious in a population of ALL patients up to the age 40. Prior to that publication the use of pediatric inspired treatment was quite variable and mostly used in academic hospital systems. There was concern about tolerability, utilization and efficacy of pediatric inspired protocols. Kaiser Permanente is a vertically integrated care delivery system. The Northern and Southern California regions are the two largest regions each caring for approximately 4.5 million members and cared for in a network of medical offices and hospitals.Methods:We reviewed the Cancer Registries of the Kaiser Permanente Northern and Southern California regions for patients aged 15-39 diagnosed with acute lymphoblastic leukemia between 2010 - 2018. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. We examined the initial induction plan selected and determined if the induction used steroids, vincristine, an anthracycline and asparaginase and if so was classified as pediatric inspired. If not induction was classified as an adult protocol. Patients were characterized as pediatric inspired or adult then followed based on the initial induction plan selected. Neither the sub type of ALL, the molecular characteristics or the MRD status at the end of induction was reviewed. The selection of chemotherapy agents after the initial induction plan was not reviewed. The use of pediatric inspired induction over the time of the study was reviewed. The patients clinical course was reviewed for the next 6 months and utilization including hospital days, ICU days was reviewed. Patients were followed for toxicities of treatments including sepsis, lab abnormalities, and documented side effects of chemotherapy. The pattern of BMT referral was reviewed. The vital status known at the end of the evaluation was also reviewed.ResultsA total of 222 patients were evaluated. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. Over the study period 66.7 % of the patients received a pediatric inspired induction. The use of pediatric inspired treatments increased over the study period with 38% use in 2010 to 90% in 2018. For patients over age 21 in 2010 the use was 10% in 2018 84%. There was a significantly greater number of inpt days for patients initiated on adult protocols at months, 1, 3 and 6. There was no difference in ICU days. For outpatient utilization there was a significantly higher use of the ED at months 1,3,6 for patients initiated on adult treatments. For patients over 21 there was a significantly increased number of BMT consults during the first 6 months after diagnosis. There was no statistical difference in documented bacteremia, mucositis, pancreatitis, neuropathy or sepsis between the 2 groups. For patients over 26 there was a significant increase in peripheral neuropathy in the adult treated group. There was a significantly elevated risk of mortality at 2 years after diagnosis for the adult treated group. For patients over the age 26 the risk of mortality was similar at 2 years.ConclusionWe saw a rapid increase of utilization of pediatric inspired inductions over the study period within the Kaiser Permanente California regions. Patients who initiated treatment on adult protocols had over the first 6 months more inpatient days, were more likely to utilize the ED, were more likely to have a BMT consult. Patients who received adult protocol treatments had higher mortality at 2 years after diagnosis. We conclude that adult oncologists now favor pediatric inspired treatment approaches and there do not seem to be any safety concerns with this approach and in fact pediatric inspired treatments may lead to lower utilization and decreased mortality. DisclosuresNo relevant conflicts of interest to declare.

Switch from Infliximab to Infliximab-dyyb for Rheumatology Indications

Introduction Multiple expert panels at Kaiser Permanente approved infliximab-dyyb (Inflectra®), a biosimilar to the reference product infliximab (Remicade®), to be the preferred infliximab agent for therapeutic substitution from infliximab for adult patients with dermatologic, rheumatologic, and/or gastroenterologic diagnoses. The objective of this study was to assess the safety and effectiveness of infliximab-dyyb for Kaiser Permanente Northern California patients with psoriatic and rheumatoid arthritis who switched from infliximab to infliximab-dyyb. Methods This was an observational, data-only, non-inferiority study assessing adult patients with a rheumatologic condition of psoriatic arthritis (PsA) or rheumatoid arthritis (RA) who were switched from infliximab to infliximab-dyyb or used infliximab continuously in the Northern California region of Kaiser Permanente from May 2017 through May 2018. Both groups were followed for 12 months. The primary effectiveness outcome was disease worsening requiring acute care defined as emergency room visit or hospitalization related to the rheumatologic condition or orthopedic surgery intervention. Non-inferiority was set at an upper limit of 4%. Results A total of 70 individuals were identified as continuing infliximab and 727 individuals were switched to infliximab-dyyb. There were 2 patients (2.9%) in the infliximab group and 22 patients (3.0%) in the infliximab-dyyb group who experienced disease worsening requiring acute care (P = 0.03 for non-inferiority). Conclusion There was no increased risk of disease worsening requiring acute care in patients with RA or PsA who switched from infliximab to infliximab-dyyb when compared to patients who remained on infliximab in this population.

Using a report card to increase HIV screening in a large primary care group practice

BackgroundDespite increased efforts to promote HIV screening, a large proportion of the US population have never been tested for HIV.ObjectiveTo determine whether provider education and personalised HIV screening report cards...

Insights for New Physician Leaders.

As a senior health care administrator in both the Northern and Southern California Regions of Kaiser Permanente, I was intrigued by ways to enhance the skills of a new physician leader. The role of a leader is to help others succeed. Although emotional intelligence is a key characteristic of an effective leader, skills and behaviors can be learned and leaders can be developed. Emerging leaders can learn to listen to various points of view, develop a "let's go see" attitude, gather all the facts before making a decision, train others to be leaders, embrace a spirit of adventure, and develop a knowledge of statistics and finance. Additionally, recognizing and avoiding common pitfalls in leadership will augment effective leadership skills and behaviors.

Gregory A. Adams, MHA

Gregory A. Adams is executive vice president and group president for Kaiser Permanente, reporting to the chairman and CEO. He has direct responsibility for all 8 Kaiser Permanente Regions, serving more than 12.3 million members and operating 39 hospitals and 701 medical office facilities. In addition to his group president responsibilities, he serves on the organization's national executive team and executive committee. Adams started his career with Kaiser Permanente in 1999 and has held a number of executive leadership positions within the organization, including president of the Northern California Region. Prior to joining Kaiser Permanente, Adams held several executive roles in the health care industry, providing strategic and operational leadership for hospitals, health systems, and medical groups throughout the country.

Opportunities to encourage mail order pharmacy delivery service use for diabetes prescriptions: a qualitative study

BackgroundMedication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional “brick and mortar” pharmacies to refill prescriptions.MethodsWe conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software.ResultsA total of 28 diabetes patients participated. Participants’ average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of ‘Opportunity.’ Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions.ConclusionsThis study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.

Successful deployment of drug-disease interaction clinical decision support across multiple Kaiser Permanente regions.

The study sought to develop a criteria-based scoring tool for assessing drug-disease knowledge base content and creation of a subset and to implement the subset across multiple Kaiser Permanente (KP) regions. In Phase I, the scoring tool was developed, used to create a drug-disease alert subset, and validated by surveying physicians and pharmacists from KP Northern California. In Phase II, KP enabled the alert subset in July 2015 in silent mode to collect alert firing rates and confirmed that alert burden was adequately reduced. The alert subset was subsequently rolled out to users in KP Northern California. Alert data was collected September 2015 to August 2016 to monitor relevancy and override rates. Drug-disease alert scoring identified 1211 of 4111 contraindicated drug-disease pairs for inclusion in the subset. The survey results showed clinician agreement with subset examples 92.3%-98.5% of the time. Postsurvey adjustments to the subset resulted in KP implementation of 1189 drug-disease alerts. The subset resulted in a decrease in monthly alerts from 32 045 to 1168. Postimplementation monthly physician alert acceptance rates ranged from 20.2% to 29.8%. Our study shows that drug-disease alert scoring resulted in an alert subset that generated acceptable interruptive alerts while decreasing overall potential alert burden. Following the initial testing and implementation in its Northern California region, KP successfully implemented the disease interaction subset in 4 regions with additional regions planned. Our approach could prevent undue alert burden when new alert categories are implemented, circumventing the need for trial live activations of full alert category knowledge bases.

Abstract 139: Adherence and Persistence to Direct Oral Anticoagulants for the Treatment of Cancer-Associated Venous Thromboembolism

Background: Direct oral anticoagulant (DOAC) therapy may be a safe and effective oral alternative to low-molecular-weight heparin (LMWH) or warfarin therapy for treatment for cancer-associated venous thromboembolism. Whether differences exist in adherence and persistence to these medications in this clinical setting is unknown. Methods: We identified all Kaiser Permanente members in the Colorado and Northern California regions who experienced a hospitalization for a cancer-associated thromboembolism between 2014-2017 (index event). The primary exposure was the initial anticoagulant regimen used which we defined using outpatient pharmacy dispense records in the 30-days after hospital discharge: 1) DOAC ± an injectable, 2) low-molecular weight heparin monotherapy, or 3) warfarin ± an injectable (index regimen). The primary outcome was medication adherence (i.e., the proportion of days covered) and medication persistence and reasons for non-persistence (i.e., the time to medication discontinuation, regimen change, or death) over the next 6-months. We used Kaiser Permanente’s comprehensive electronic health records to define patient’s demographic and cancer characteristics, comorbidities (inpatient and outpatient ICD-9-CM diagnoses), and other medication use. Multivariable log-binomial models were used to calculate adjusted risk ratios and 95% confidence intervals for adherence &gt;80% and persistence &gt;6 months associated with DOAC use. Results: Of the 2,843 patients included, the mean age was 66±13 and 1,523 (54%) were female. Patients receiving DOAC therapy were more likely to be older and have less advanced stages of cancer. In the 6-months post-index, DOAC therapy was associated with higher adherence than LMWH monotherapy and higher persistence than warfarin therapy (Table 1). When non-persistence was observed during the 6 months, the distribution of reasons for non-persistence varied significantly by index regimen with patients receiving DOAC therapy significantly more likely to stop filling the medication as opposed to death or switching regimens. Conclusion: In this large community-treated population, initial anticoagulation therapy with a DOAC was associated with improved adherence and persistence rates compared to traditional therapies.

Diet and Behavior Modifications by Long-term Rectal Cancer Survivors to Manage Bowel Dysfunction-Associated Symptoms*

Background: Rectal cancer (RC) survivors experience significant bowel function issues after treatment. We aimed to describe self-reported dietary and behavioral modifications among long-term (≥5 yr) RC survivors to manage bowel dysfunction.Methods: RC survivors from Kaiser Permanente Northern California and Northwest regions completed surveys either via postage-paid return mail or telephone. Summary statistics on diet/behavioral modifications data were tabulated by proportion of responses. Modifications and frequency of bowel symptoms cited and were compared by ostomy status.Results: A total of 575 respondents were included (overall response rate = 60.5%). Fruits and vegetables were troublesome for symptoms, but was also helpful in mitigating constipation, obstruction, and frequency, as well as improving predictability. Many respondents attributed red meat (17.7%), fried foods (13.9%), spicy foods (13.1%), carbonated beverages (8.0%), and sweets (7.6%) to increased diarrhea, gas, and urgency. Common behavioral modifications included controlling meal portions (50.6%), timing regularity (25.3%), and refraining from late night eating (13.8%). Permanent ostomy survivors were more likely to report symptoms of obstruction, while anastomosis survivors were more likely to report urgency.Conclusion: Multiple modifications were attempted by RC survivors to manage bowel symptoms. Identifying diet changes among RC survivors can improve symptom management and survivorship care.

Perceptions and Experience of Patients, Staff, and Clinicians with Social Needs Assessment.

Assessment of social needs is expanding at Kaiser Permanente (KP), but little is known about how members and clinicians experience the incorporation of social needs into health care. To assess how KP members and clinicians experience social needs assessments incorporated into care. Qualitative and descriptive analysis of data from member and clinician focus groups, interviews, and surveys among 68 members and family caregivers who had participated in social needs assessment programs and 90 clinicians and staff in the KP Colorado, Georgia, Northern California, Northwest, and Southern California Regions. Members' and clinicians' perceptions and experiences of social needs assessment. Members and clinicians understood the impact of social needs on health and why a health care system representative would ask about food, housing, transportation, and other social needs. Members and clinicians supported social needs assessment at KP and agreed that KP should help address identified social needs. However, both groups emphasized the importance of assessments yielding actionable information. Members were also concerned about how the information would be used and by whom. Our findings support the continuing assessment of social needs at KP and identify issues that require attention as it expands. Assessment should not outpace organizational capacity to connect members with resources. Careful attention to communications is required because members may be uncertain or concerned about the purpose of the assessment and the dissemination of sensitive information. Messaging should assure members about data use and dissemination and what they can expect after screening.

Hospital staffing technology: Hazard and opportunity risks.

Lisa J. Massarweh is the executive director of financial performance and workforce strategy for patient care services at Kaiser Foundation Hospitals, Northern California region, in Oakland, Calif. The author has disclosed no financial relationships related to this article.

The Effect of Age and Comorbidities on the Association Between the Medicare STAR Oral Antihyperglycemic Adherence Metric and Glycemic Control.

The Medicare STAR program for Medicare Advantage Plans that include drug benefits provides monetary incentives for health plans to achieve good adherence to oral antihyperglycemic (OAH) agents but does not account for differential case mix that could affect the ability of health plans to achieve the required quality metrics. To determine whether OAH adherence varies by age and comorbidities among patients aged 65 years or older and the extent to which adherence affects glycemic control across age and comorbidity strata. We studied 54,480 patients with diabetes aged > 65 years from the Colorado, Northwest, and Northern California regions of Kaiser Permanente who received OAH agents but not insulin in 2010. We calculated adherence using the proportion of days covered (PDC) method. Per the STAR program, hemoglobin A1c < 8% defined good glycemic control. We also defined poor control as A1c > 9%. We used modified Poisson regression to identify predictors of adherence and to determine its effects on A1c across age and comorbidity strata, adjusting for sociodemographics and medication-related variables. The risk of being adherent to OAH declined moderately with an increasing number of comorbidities (risk ratio [RR] = 0.99, 95% CI = 0.98-1.00 for 1 comorbidity and RR = 0.90, 95% CI = 0.88-0.91 for 4 or more comorbidities). Adherence to OAH agents was associated with a 0%-3% increased risk of A1c < 8% across age and comorbidity categories, as well as a large decreased risk (RR = 0.55-0.73) of A1c > 9% for patients aged < 80 years or with < 3 comorbidities. Among patients with diabetes aged > 65 years, having multiple comorbidities affects adherence. Adherence reduces the risk of poor A1c control among patients aged 65-79 years or with 2 or fewer comorbidities. Our results suggest that health plan case mix minimally influenced the Medicare STAR OAH adherence metric, but it may affect glycemic control quality measures, especially if a HEDIS-like measure of poor control were adopted. This study was supported by grant number 1R21DK103146-01A1 from the National Institute of Diabetes and Digestive and Kidney Disorders. Nichols currently receives grant funding from Boehringer-Ingelheim, Sanofi, Amarin Pharma, and Janssen Pharmaceuticals for other unrelated research projects. The other authors declare no conflicts of interest. This study was presented at the American Diabetes Association's 77th Scientific Sessions; June 9-13, 2017; San Diego, CA.

Opportunities to Encourage Mail Order Pharmacy Use in Diabetes—A Qualitative Study

Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between mail order pharmacy (MOP) and better medication adherence, but little is known about the barriers and facilitators to MOP use in diabetes patients. This qualitative study examined factors related to use of MOP vs. traditional pharmacies to obtain prescription medications. We conducted four 90-minute focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred pharmacy use and perceptions of barriers and facilitators of MOP use. One researcher independently coded each focus group transcript, with two transcripts double-coded by an additional researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. The average age of participants was 64.1; 57% were female; 21% were Asian; 21% were black/African-American; 7% were Hispanic/Latino, and 14% were Native Hawaiian/Pacific Islander. Analysis uncovered 26 themes related to the decision to use MOP for dispensing medications. Most themes (18 out of 26) fell into the COM-B category of ’Opportunity.’ Barriers to MOP use included unpredictability of medication delivery date, concerns about mail security, and difficulty of coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Receiving a MOP incentive of free one-month supply of prescriptions was a motivational facilitator to using MOP for delivering medications. These findings can be used to design interventions and quality improvement initiatives to increase MOP usage and improve medication adherence in diabetes patients across health care systems. Disclosure J. Schmittdiel: None. C. Marshall: None. D. Wiley: None. C.V. Chau: None. C.M. Trinacty: None. J.F. Wharam: None. O. Duru: None. A.J. Karter: None. K. Estacio: None. S. Brown: None.

A Community-Level Initiative to Prevent Obesity: Results From Kaiser Permanente’s Healthy Eating Active Living Zones Initiative in California

A growing number of health systems are leading health promotion efforts in their wider communities. What impact are these efforts having on health behaviors and ultimately health status? This paper presents evaluation results from the place-based Kaiser Permanente Healthy Eating Active Living Zones obesity prevention initiative, implemented in 2011-2015 in 12 low-income communities in Kaiser Permanente's Northern and Southern California Regions. The Healthy Eating Active Living Zones design targeted places and people through policy, environmental, and programmatic strategies. Each Healthy Eating Active Living Zone is a small, low-income community of 10,000 to 20,000 residents with high obesity rates and other health disparities. Community coalitions planned and implemented strategies in each community. A population-dose approach and pre and post surveys were used to assess impact of policy, program, and environmental change strategies; the analysis was conducted in 2016. Population dose is the product of reach (number of people affected by a strategy divided by target population size) and strength (the effect size or relative change in behavior for each person exposed to the strategy). More than 230 community change strategies were implemented over 3 years, encompassing policy, environmental, and programmatic changes as well as efforts to build community capacity to sustain strategies and make changes in the future. Positive population-level results were seen for higher-dose strategies, particularly those targeting youth physical activity. Higher-dose strategies were more likely to be found in communities with the longest duration of investment. These results demonstrate that strong (high-dose), community-based obesity prevention strategies can lead to improved health behaviors, particularly among youth in school settings. This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.