Permanente Northern California Research Articles

Clinical impacts of an integrated electronic health record-based smoking cessation intervention during hospitalisation

ObjectiveTo assess the effects of an electronic health record (EHR) intervention that prompts the clinician to prescribe nicotine replacement therapy (NRT) at hospital admission and discharge in a large integrated...

Effectiveness of the live zoster vaccine during the 10 years following vaccination: real world cohort study using electronic health records

ObjectivesTo assess the effectiveness of live zoster vaccine during more than 10 years after vaccination; and to describe methods for ascertaining vaccine effectiveness in the context of waning.DesignReal world cohort...

Prognostic Accuracy of Presepsis and Intrasepsis Characteristics for Prediction of Cardiovascular Events After a Sepsis Hospitalization.

OBJECTIVES:Sepsis survivors face increased risk for cardiovascular complications; however, the contribution of intrasepsis events to cardiovascular risk profiles is unclear.SETTING:Kaiser Permanente Northern California (KPNC) and Intermountain Healthcare (IH) integrated healthcare delivery systems.SUBJECTS:Sepsis survivors (2011–2017 [KPNC] and 2018–2020 [IH]) greater than or equal to 40 years old without prior cardiovascular disease.DESIGN:Data across KPNC and IH were harmonized and grouped into presepsis (demographics, atherosclerotic cardiovascular disease scores, comorbidities) or intrasepsis factors (e.g., laboratory values, vital signs, organ support, infection source) with random split for training/internal validation datasets (75%/25%) within KPNC and IH. Models were bidirectionally, externally validated between healthcare systems.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Changes to predictive accuracy (C-statistic) of cause-specific proportional hazards models predicting 1-year cardiovascular outcomes (atherosclerotic cardiovascular disease, heart failure, and atrial fibrillation events) were compared between models that did and did not contain intrasepsis factors. Among 39,590 KPNC and 16,388 IH sepsis survivors, 3,503 (8.8%) at Kaiser Permanente (KP) and 600 (3.7%) at IH experienced a cardiovascular event within 1-year after hospital discharge, including 996 (2.5%) at KP and 192 (1.2%) IH with an atherosclerotic event first, 564 (1.4%) at KP and 117 (0.7%) IH with a heart failure event, 2,310 (5.8%) at KP and 371 (2.3%) with an atrial fibrillation event. Death within 1 year after sepsis occurred for 7,948 (20%) KP and 2,085 (12.7%) IH patients. Combined models with presepsis and intrasepsis factors had better discrimination for cardiovascular events (KPNC C-statistic 0.783 [95% CI, 0.766–0.799]; IH 0.763 [0.726–0.801]) as compared with presepsis cardiovascular risk alone (KPNC: 0.666 [0.648–0.683], IH 0.660 [0.619–0.702]) during internal validation. External validation of models across healthcare systems showed similar performance (KPNC model within IH data C-statistic: 0.734 [0.725–0.744]; IH model within KPNC data: 0.787 [0.768–0.805]).CONCLUSIONS:Across two large healthcare systems, intrasepsis factors improved postsepsis cardiovascular risk prediction as compared with presepsis cardiovascular risk profiles. Further exploration of sepsis factors that contribute to postsepsis cardiovascular events is warranted for improved mechanistic and predictive models.

Abstract P126: The 2020 Us Presidential Election, Sociopolitical Stress And Acute Cardiovascular Disease Hospitalizations

Background: Prior studies demonstrated a higher risk of acute cardiovascular disease (CVD) around population-wide psychosocial or environmental stressors. Less is known about the impact of sociopolitical events. The objective of the current study was to examine acute CVD hospitalizations following the 2020 presidential election. Methods: We examined hospitalizations for acute CVD around the 2020 presidential election, among adults enrolled in Kaiser Permanente Southern and Northern California, two integrated health care delivery systems that provide care for >9 million persons. CVD was defined as hospitalizations for acute myocardial infarction (AMI), heart failure (HF) or stroke. Rate ratios (RR) and 95% confidence intervals (CIs) were calculated comparing rates in the five days following the 2020 election to the same five days two weeks prior. Results: Among 6,396,830 members ≥18 years, rates of hospitalization for CVD following the election (666 hospitalizations; rate = 760.5 per 100,00 person-years [PY]) were 1.17 times higher (95% CI 1.05, 1.31) compared to the same five days two weeks prior (569 hospitalizations; rate = 648.0 per 100,000 PY). (Table) RR for AMI, stroke, and HF were 1.42 (95% CI 1.13, 1.79), 1.02 (95% CI 0.86, 1.21) and 1.18 (95% CI 0.98, 1.42), respectively. Conclusions: Higher rates of acute CVD were observed following the 2020 presidential election. Awareness of the heightened risk of CVD and strategies to mitigate risk during significant sociopolitical events are needed.

Predictors of early and sustained cessation of heavy drinking over 5years among adult primary care patients.

To identify factors asociated with early and sustained cessation of heavy drinking. Retrospective cohort study over 5years. Kaiser Permanente Northern California, United States. Adults reporting heavy drinking during primary care-based alcohol screening between 1 June 2013 and 31May 2014. The sample (n=85 434) was 40.7% female and 33.8% non-white; mean age was 50.3years (standard deviation=18.1). Following US guidelines, early and sustained cessation of heavy drinking was defined as reporting lower-risk drinking or abstinence at 1year and to 5years after achieving early cessation, respectively. Associations between patient characteristics and service use and cessation outcomes were examined using logistic regression with inverse probability weights addressing attrition. Nearly two-thirds of participants achieved early cessation of heavy drinking. Women [odds ratio (OR)=1.39, 95% confidence interval (CI)=1.35, 1.44], middle-age (35-64years: ORs=1.16-1.19), non-white race/ethnicity (ORs=1.03-1.57), medical conditions (OR=1.05, 95% CI=1.04, 1.06), psychiatric (OR=1.10, 95% CI=1.06, 1.15) and drug use disorders (OR=1.35, 95% CI=1.17, 1.56) and addiction treatment (OR=1.19, 95% CI=1.09, 1.30) were associated with higher odds of early cessation, while older age (≥65years: OR=0.91, 95% CI=0.86, 0.96), smoking (OR=0.81, 95% CI=0.77, 0.84), higher index drinking levels (exceeding both daily and weekly limits: OR=0.30, 95% CI=0.29, 0.32) and psychiatric treatment (OR=0.91, 95% CI=0.84, 0.99) were associated with lower odds. Among those who achieved early cessation (n=19 200), 60.0% sustained cessation. Associations between patient factors and sustained cessation paralleled those observed in analyses of early cessation. Additionally, routine primary care (OR=1.57, 95% CI=1.44, 1.71) and addiction treatment post-1year (OR=1.41, 95% CI=1.19, 1.66) were associated with higher odds of sustained cessation. Lower-risk drinking versus abstinence at 1year was associated with lower odds of sustained cessation (OR=0.62, 95% CI=0.57, 0.66). Nearly two-thirds of a large, diverse sample of patients who reported heavy drinking in a Californian health-care system achieved early and sustained cessation of heavy drinking. Vulnerable subgroups (i.e. non-white patients and those with psychiatric disorders), patients who received routine primary care and those who received addiction treatment were more likely to sustain cessation of heavy drinking than other participants.

Visual outcomes after cataract surgery: topical nonsteroidal anti-inflammatory drug prophylaxis compared with prednisolone.

To compare visual outcomes in patients without a history of macular edema after phacoemulsification using combination topical nonsteroidal anti-inflammatory drug plus prednisolone with prednisolone alone. Kaiser Permanente Northern California, USA. Retrospective cohort study. Information was obtained from the electronic health record. The first measure of corrected distance visual acuity (CDVA) recorded during the period 3 weeks to 1 year after phacoemulsification was obtained. Confounding factors and clustering of eyes within patients were adjusted using linear mixed effects regression models for the continuous outcome of CDVA improvement and general estimating equations for the dichotomous outcome of 20/20 or better vs 20/25 or worse. The study included 62 700 health plan members of whom 26,309 (42%) used topical prednisolone alone, whereas 36,391 (58%) used combination treatment. The mean within-person change in CDVA from the preoperative measurement to the postoperative measurement was the same (-0.43 logMAR) for patients in the 2 groups. However, the group that received combination treatment was somewhat more likely to achieve CDVA of 20/20 or better (odds ratio 1.24 with 95% CI, 1.20-1.28). In this large study of cataract surgery patients, a small statistically significant association of combination treatment compared with prednisolone alone was observed.

Participant education, spousal education and dementia risk in a diverse cohort of members of an integrated health care delivery system in Northern California

ObjectiveThe role of spousal education on dementia risk and how it may differ by gender or race/ethnicity is unknown. This study examines the association between one’s own education separate from...

169-LB: A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence

Medication non-adherence is a major contributor to poor diabetes outcomes. Observational studies show positive associations between mail order pharmacy (MOP) use and adherence, and suggest that mail order is cost-saving to patients. However, no prospective trials have examined the effect of encouraging MOP use on medication adherence. We conducted a randomized encouragement trial in 2017 in three health plans: Kaiser Permanente (KP) Northern California, KP Hawaii, and Harvard Pilgrim Health Care (HPHC). Patients were eligible if they had diabetes, poor adherence (Proportion of Days Covered <80%) to at least one class of cardiometabolic medications, and had not used MOP in the prior 12 months. Patients were randomized to receive either no intervention (controls) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use for diabetes patients; HPHC intervention patients received the letter only. We compared the percentages of patients in both arms that began using mail order and that became adherent to cardiometabolic medication classes during the 12-month follow-up. A total of 63,012 patients were included: mean age was 60; 45% were female; 41% were non-Hispanic white; 12% were black; 25% were Hispanic/Latino, and 22% were Asian/Native Hawaiian/Pacific Islander. During follow-up, 12% of intervention patients used the mail order pharmacy vs. 10% of controls (p<.001); the percent of cardiometabolic medications delivered via mail was 42% vs. 39% (p<.01). Metformin adherence improved in the intervention group relative to controls at the two KP sites (52% vs. 49%, p<.01). This randomized trial shows that simple outreach to encourage MOP use modestly improved its use, and improved adherence to a key class of diabetes medications in some settings. Clinicians and health systems should consider such low-cost interventions to actively promote MOP among diabetes patients. Disclosure J. Schmittdiel: None. C.M. Trinacty: None. J. Wharam: None. O. Duru: Advisory Panel; Self; Healthwise. R. Neugebauer: None. S.D. Brown: None. D. Ross-Degnan: None. A.J. Karter: None. W.T. Dyer: None. B. Ramachandran: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

Risk factors for medication non-adherence among atrial fibrillation patients

BackgroundAtrial fibrillation (AF) patients are routinely prescribed medications to prevent and treat complications, including those from common co-occurring comorbidities. However, adherence to such medications may be suboptimal. Therefore, we sought to identify risk factors for general medication non-adherence in a population of patients with atrial fibrillation.MethodsData were collected from a large, ethnically-diverse cohort of Kaiser Permanente Northern and Southern California adult members with incident diagnosed AF between January 1, 2006 and June 30, 2009. Self-reported questionnaires were completed between May 1, 2010 and September 30, 2010, assessing patient socio-demographics, health behaviors, health status, medical history and medication adherence. Medication adherence was assessed using a previously validated 3-item questionnaire. Medication non-adherence was defined as either taking medication(s) as the doctor prescribed 75% of the time or less, or forgetting or choosing to skip one or more medication(s) once per week or more. Electronic health records were used to obtain additional data on medical history. Multivariable logistic regression analyses examined the associations between patient characteristics and self-reported general medication adherence among patients with complete questionnaire data.ResultsAmong 12,159 patients with complete questionnaire data, 6.3% (n = 771) reported medication non-adherence. Minority race/ethnicity versus non-Hispanic white, not married/with partner versus married/with partner, physical inactivity versus physically active, alcohol use versus no alcohol use, any days of self-reported poor physical health, mental health and/or sleep quality in the past 30 days versus 0 days, memory decline versus no memory decline, inadequate versus adequate health literacy, low-dose aspirin use versus no low-dose aspirin use, and diabetes mellitus were associated with higher adjusted odds of non-adherence, whereas, ages 65–84 years versus < 65 years of age, a Charlson Comorbidity Index score ≥ 3 versus 0, and hypertension were associated with lower adjusted odds of non-adherence.ConclusionsSeveral potentially preventable and/or modifiable risk factors related to medication non-adherence and a few non-modifiable risk factors were identified. These risk factors should be considered when assessing medication adherence among patients diagnosed with AF.

Abstract 4: Variation in Published Stroke Rates Results in Wide Variation in the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation

Background: The risk of ischemic stroke without anticoagulation for a given CHA 2 DS 2 -VASc score varies significantly across published cohorts. The resulting impact on the net clinical benefit of anticoagulation in atrial fibrillation (AF) is not known. We aimed to determine the effect of variation in published stroke rates on the net clinical benefit of anticoagulation. Methods: A decision analysis study. We used ischemic strokes rates corresponding to CHA 2 DS 2 -VASc scores from four studies - ATRIA study, SPORTIF, Swedish AF study, and the Danish National Patient Registry - in a 28-state Markov state transition model that compared the benefit of oral anticoagulation vs. no anticoagulation. During each monthly cycle, patients face a chance of stroke and hemorrhage, either of which may lead to death, neurologic sequelae, or symptom resolution. The simulation ran for the entire life expectancy of the patient. We applied this decision analytic model to a cohort of 33434 patients with incident AF (Jan 06 to Jun 09) in the Kaiser Permanente Northern and Southern California integrated health care delivery systems. Results: Of the 33434 patients, 27122 had a CHA 2 DS 2 -VASc score ≥2. Among those with CHA 2 DS 2 -VASc score ≥2, use of ATRIA Study stroke rates yielded the lowest population benefit (2576 QALYs, 0.06 expected median per person, IQR -0.02 to 0.18), while the Danish National Patient Registry stroke rates yielded the greatest population benefit (28934 QALYs, 0.70 expected median per person, IQR 0.38 to 1.47). The CHA 2 DS 2 -VASc threshold at or above which the population derives the greatest net clinical benefit from anticoagulation varies based on the stroke rates used: CHA 2 DS 2 -VASc ≥3 using ATRIA Study stroke rates, ≥2 using Swedish AF study stroke rates, ≥1 using SPORTIF and ≥0 using the Danish National Patient Registry stroke rates. Conclusion: Using current guidelines, variation in published off-anticoagulation stroke rates results in tenfold variation in the estimated net clinical benefit of anticoagulation. Guidelines should better reflect the uncertainty of the current approach that uses a CHA 2 DS 2 -VASc threshold to recommend anticoagulation.

Abstract 3415: Identifying lifestyle and genetic factors to prevent recurrence of non-muscle invasive bladder cancer in a prospective cohort study at Kaiser Permanente (The Be-Well Study)

Abstract Background: Bladder cancer is one of the top 10 incident cancers. Most cases (75%) are diagnosed as non-muscle invasive disease (NMID), yet NMID typically recurs (70%) and a subset (25%) progresses to muscle-invasive disease. The Be-Well Study is an NCI-funded collaborative, multi-center prospective cohort study, with NMID bladder cancer patients enrolled at Kaiser Permanente Northern (KPNC) and Southern California (KPSC) and bioassays performed at Roswell Park Cancer Institute (RPCI). The goal is to examine diet and lifestyle factors and prognosis, with an emphasis on cruciferous vegetable (CV) intake and their unique isothiocyanate (ITC) content, the modifying effect of polymorphisms of ITC-metabolizing genes, and interactions with treatment. Our prior work suggests that dietary ITCs may prevent disease recurrence and progression in NMID patients. Methods: Newly-diagnosed patients with NMID (Ta, Tis, T1), who are English-speaking, KP members, and ≥21 years of age, are ascertained rapidly from electronic pathology reports and enrolled on average 2.6 months post-diagnosis. Baseline participation consists of a telephone interview including a food frequency questionnaire focused on CV intake, and providing blood and urine samples. Patients will be contacted for follow-up interviews and urine samples at 12 and 24 months. Smoking, medication use, occupational exposures, physical activity, quality of life, and urinary function are also queried. Biospecimens are processed and assayed at RPCI. Strong support for Be-Well by KP urologists will promote dissemination of study results in patient care and recommendations. Results: Recruitment began in February 2015. To date, 222 patients have completed the baseline interview, representing 78% male and 22% female, and 81% White, 7% Black, 5% Hispanic, 3% Asian, and 4% Other. Urine specimens have been collected from 82% of consented patients. Blood specimens have been collected from 85% of KPNC patients, and collection at KPSC began in November 2015. The 12-month follow-up interview and outcome ascertainment for disease recurrence and progression are scheduled to begin in February 2016. Conclusions: The Be-Well Study is poised to be the largest and most comprehensive study to answer critical questions related to prognosis, quality of life, and care in patients diagnosed with early-stage bladder cancer. Citation Format: Marilyn L. Kwan, Lawrence H. Kushi, Virginia P. Quinn, Nirupa R. Ghai, Janise M. Roh, Tracy Becerra, Adriana Martinez, Kimberly L. Cannavale, Alexander S. Carruth, Valerie S. Lee, Isaac J. Ergas, Ronald K. Loo, David S. Aaronson, Yuesheng Zhang, Christine B. Ambrosone, Li Tang. Identifying lifestyle and genetic factors to prevent recurrence of non-muscle invasive bladder cancer in a prospective cohort study at Kaiser Permanente (The Be-Well Study). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3415.

Identifying lifestyle and genetic factors to prevent recurrence of non-muscle invasive bladder cancer in a prospective cohort study at Kaiser Permanente (the Be-Well study).

e296 Background: Bladder cancer is one of the top 10 incident cancers. Most cases (75%) are diagnosed as non-muscle invasive disease (NMID), yet NMID typically recurs (70%) and a subset (25%) progresses to muscle-invasive disease. Be-Well is a 5-year, NCI-funded prospective cohort study of NMID bladder cancer patients at Kaiser Permanente Northern (KPNC) and Southern California (KPSC). The goal is to examine diet and lifestyle factors and prognosis, with an emphasis on cruciferous vegetable (CV) intake and their unique isothiocyanate (ITC) content, the modifying effect of polymorphisms of ITC-metabolizing genes, and interactions with treatment. Our prior work suggests that dietary ITCs may prevent disease recurrence and progression in NMID patients. Methods: Newly-diagnosed patients with NMID (Ta, Tis, T1), who are English-speaking, KP members, and ≥ 21 years of age, are rapidly ascertained from electronic pathology reports and enrolled on average 2.6 months post-diagnosis. Baseline participation consists of a telephone interview including a food frequency questionnaire focused on CV intake, and providing blood and urine samples. Patients will be contacted for follow-up interviews and urine samples at 12 and 24 months. Smoking, medication use, occupational exposures, physical activity, quality of life, and urinary function are also queried. Biospecimens are processed and assayed at Roswell Park Cancer Institute. Strong support for Be-Well by KP urologists will promote dissemination of study results in patient care and recommendations. Results: Recruitment began in February 2015. To date, 159 patients have completed the baseline interview, representing 76% male and 24% female, and 80% White, 8% Black, 6% Hispanic, 3% Asian, and 3% Other. Urine specimens have been collected from 87% of consented patients. Blood specimens have been collected from 87% of KPNC patients, with collection at KPSC to begin in Fall 2015. Conclusions: The Be-Well Study is poised to be the largest and most comprehensive study to answer critical questions related to prognosis, quality of life, and care in patients diagnosed with early-stage bladder cancer.

Abstract 3431: What are the greatest challenges of rectal cancer survivors? Results of a population-based survey

Abstract Purpose: Rectal cancer (RC) survivors with and without permanent ostomy have similar health-related quality of life outcomes, though these may be driven by different factors. Identifying patient-centered concerns among survivors with different surgical reconstructions can guide treatment decision-making and optimize survivorship care. Methods: We mailed a survey to long-term (≥5 years post-diagnosis) RC survivors enrolled in Kaiser Permanente (Northern California and Oregon/Southwest Washington). Participants with anastomosis, temporary ostomy, and permanent ostomy were asked an open-ended question about the “greatest challenge” they experienced related to their cancer surgery. Using a grounded theory approach, we identified all topics in the responses of 440 participants who wrote an answer (76% of 577 respondents). These topics were collapsed into codes and organized into domains. Responses were assigned as many codes as were applicable and double-coded by pairs of researchers who met to resolve any discrepancies. We used Bonferroni-adjusted chi-squares to test differences in the proportion of respondents within each surgical group who mentioned challenges in each domain. Results: Greatest challenge responses were provided by 241 participants with anastomosis, 54 with temporary ostomy, and 145 with permanent ostomy. Respondents were more educated but otherwise they resembled non-respondents demographically and clinically. Respondents described seven challenge domains: 1) bowel dysfunction; 2) bowel self-care; 3) post-operative recovery; 4) complications and late-effects; 5) negative psychosocial impacts; 6) comorbidities and aging (unrelated to RC); and 7) negative health care experiences. The most commonly reported problems in each group were bowel dysfunction, negative psychosocial impacts, complications and late effects, and bowel self-care. Anastomosis and temporary ostomy groups provided similar response profiles, but there were some significant differences in the proportion of respondents in each group who mentioned challenges for each domain. Respondents with permanent ostomy were less likely to mention challenges with bowel management than either respondents with temporary ostomy (p = .0024) or anastomosis (p = .0003). Respondents with temporary ostomy reported more complications and late effects than those with permanent ostomy (p = .0009). Respondents with anastomosis were less likely to report negative psychosocial impacts than those with permanent ostomy (p = .0003). Conclusions: We identified enduring concerns for long-term RC survivors that should be prioritized in survivorship care. Patients choosing among surgical options should know that long-term bowel dysfunction, complications, and late effects are more common concerns for patients without permanent ostomy. In contrast, patients with permanent ostomy report the most negative psychosocial impacts. Citation Format: Robert S. Krouse, Joanna E. Bulkley, Andrea Altschuler, Christopher S. Wendel, Marcia Grant, Mark C. Hornbrook, Virginia Sun, Carmit K. McMullen. What are the greatest challenges of rectal cancer survivors? Results of a population-based survey. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3431. doi:10.1158/1538-7445.AM2015-3431

Abstract 3432: Dietary modifications of rectal cancer survivors to improve bowel function symptoms

Abstract Purpose: Rectal cancer (RC) survivors with and without permanent ostomy have similar bowel function challenges, and seek improvement of symptoms through dietary modifications. Identifying patient-reported dietary modifications among survivors with different surgical reconstructions can guide postoperative supportive care and improve health-related quality of life (HRQOL). Methods: We mailed a survey to long-term (≥5 years post-diagnosis) RC survivors enrolled in Kaiser Permanente (Northern California and Northwest). It included a question eliciting foods that were helpful with bowel function and the bowel symptoms that were impacted. Food types were recoded into broader categories based on food families developed around nutrition and common usage patterns and frequencies of food types and symptoms addressed were compared by sex and surgery type (ostomy vs. anastomosis). Results: Of the 577 RC survivors who responded to the survey, 201 (35%) responded to the question related to foods that helped bowel function. Food groups that most commonly were used were fruits other than prunes (16.3%) and vegetables (15.5%). Water was often used (9.2%). The only specific food that was commonly used was prunes (7.6%). Most foods cited were credited with helping prevent the constellation of symptoms and signs of constipation or bloating, followed by predictability. A few foods (e.g., bananas, bread, rice) were more likely to help with diarrhea. Helpful foods addressing constipation/bloating were more likely cited by women than men (55% vs. 44%, p = .007). Vegetables were more likely cited by anastomosis than ostomy subjects (18% vs. 11%, p = .03). Conclusions: Multiple dietary alterations are attempted by RC survivors. It appears very individualized, although multiple strategies can be suggested to improve bowel function. Through this exploratory analysis, strategies can be developed and tested for RC survivors. Citation Format: Robert S. Krouse, Christopher S. Wendel, Wendy Demark-Wahnefried, Joanna E. Bulkley, Carmit K. McMullen, Marcia Grant, Mark C. Hornbrook, Andrea Altschuler, Virginia Sun, Lisa J. Herrinton. Dietary modifications of rectal cancer survivors to improve bowel function symptoms. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3432. doi:10.1158/1538-7445.AM2015-3432

Abstract 156: Body Mass Index and Outcomes among Patients with Atrial Fibrillation from the ATRIA2-CVRN Study

Atrial fibrillation (AF) is a strong, independent risk factor for stroke, CVD-related mortality, and other cardiovascular complications. While studies have reported associations between higher BMI and AF incidence, few have examined the risk of thromboembolic and bleeding outcomes attributable to overweight or obesity in AF patients. We examined the longitudinal effect of BMI on all-cause mortality, as well as thromboembolic and major bleeding events, in a large cohort of incident AF patients from Kaiser Permanente Northern and Southern California. Outcomes include stroke (STR), STR and/or any other thromboembolic event (OTE), STR and/or intracranial hemorrhage (ICH), ICH and/or any other bleed (OBL). BMI (kg/m 2 ) measured nearest AF diagnosis, and demographic and clinical covariates were extracted from electronic health records and administrative databases. BMI was categorized as underweight (BMI &lt; 18.5), normal weight (18.5 &lt; BMI &lt; 25), overweight (25 &lt; BMI &lt; 30), moderately obese (30 &lt; BMI &lt; 40) or extremely obese (BMI &gt; 40). Multivariable Cox proportional hazard models were used to estimate the effect of BMI on time to event, during off-warfarin periods, adjusted for age, sex, race/ethnicity, and history of hypertension, diabetes and coronary artery disease. Among 22,487 AF patients (46% female; 6% Black, 12% Hispanic, 7% API) with off-warfarin time during follow-up, 34% were overweight, 29% obese and 6% extremely obese. Mean age ± SD was 72 ± 13 years. Median (IQR) length of off-warfarin follow-up was 1.38 (1.57) years. Crude all-cause mortality and incident thromboembolic and bleeding rates were highest among underweight or normal weight patients and gradually declined with increasing BMI (Table; all P-trend &lt; 0.002). The unadjusted relative risks for all outcomes were substantially and significantly lower with increasing BMI (Table). However, after adjustment for demographic and clinical confounders, only risk of all-cause mortality was significantly lower for overweight and moderately obese compared to normal weight patients (Table). In conclusion, overweight and moderate obesity appear protective for all-cause mortality in at-risk AF patients during off-warfarin periods, but these effects do not appear to be mediated by reduced risk of thromboembolism or major bleeding.

Abstract P3-07-05: Bisphosphonate use after primary breast cancer and risk of contralateral breast cancer using pharmacy data

Abstract Background: It is not clear if bisphosphonates (BP) are associated with improved breast cancer prognosis in women with early breast cancer. Clinical trials have reported mixed results, yet BPs may be most beneficial in patients with low estrogen levels. However, BPs and risk of second (contralateral) breast cancer has been minimally studied. We examined the association of oral BP use (ever/never and duration) on risk of contralateral breast cancer (CBC) in 17,224 women with early stage breast cancer treated with tamoxifen. Materials and Methods: A cohort was assembled of women diagnosed with their first primary breast cancer (Stage 0, I, II) from 1996 to 2007 on tamoxifen and followed through 31 December 2009 at Kaiser Permanente Northern and Southern California. Demographic, tumor, pharmacy, and cancer treatment information was extracted from electronic medical records and SEER-affiliated cancer registries at each site. Second (contralateral) tumors were identified from the cancer registries. Detailed information on oral BP use (before and after initial breast cancer diagnosis) was obtained from pharmacy databases. A record of &amp;gt;90 days supply was considered the minimum exposure. Initiation and duration of post-diagnosis use was categorized as 1) non-use (≤90 days supply) and use (&amp;gt;90 days supply) and 2) non-use (≤90 days supply), 91 days–&amp;lt;1 year supply, 1-&amp;lt;2 years supply, and ≥2 years supply. Delayed entry Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) with BP use modeled as a time-varying covariate. Women were followed through CBC, health plan disenrollment, death, or end of study, whichever occurred first. We adjusted for age, stage and year of diagnosis; race/ethnicity; income; comorbidity; tumor factors; primary and adjuvant cancer treatments; previous BP use, and study site. Results: Over a mean (SD) follow-up of 6.4 (6.3) years, 586 women (3.4%) were diagnosed with CBC after their initial breast cancer diagnosis. Around 19.2% (n = 3303) of the cohort used a BP post-initial breast cancer diagnosis (&amp;gt;93% alendronate). To minimize confounding by indication, all models were adjusted for prior use of BPs before breast cancer diagnosis (n = 1047, 6.1%) and excluded women with prior 5-year history of osteopenia, osteoporosis, and fractures (n = 1808, 10.5%). Compared to non-users, ever use (&amp;gt;90 days supply) was associated with a modestly lower CBC risk (HR = 0.80; 95% CI: 0.61, 1.16). However, stratified analyses by age at breast cancer diagnosis (&amp;lt;50 years vs. ≥50 years) suggested lower risk among older women (HR = 0.80; 95% CI: 0.57, 1.12) compared with younger women (HR = 1.00; 95% CI: 0.39, 2.52). Increasing duration of use was not associated with CBC risk compared to non-use and possibly reflective of some residual confounding by indication: &amp;lt;1 year (HR = 0.56; 95% CI: 0.30, 1.02), 1-&amp;lt;2 years (HR = 0.99; 95% CI: 0.56, 1.72), ≥2 years (HR = 0.91; 95% CI: 0.58, 1.42). Discussion: While we found modestly lower CBC risk with BP use after diagnosis of primary breast cancer, the protective effects were perhaps confined to older women compared with younger women. Next steps include adding BMD to further explore confounding by indication and examining BP use and breast cancer recurrence and mortality. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-07-05.

A Standardized Approach To Clinical Engineering

A Standardized Approach To Clinical Engineering

Abstract P185: Self-Reported Medication Adherence in 14,246 Patients with Atrial Fibrillation from the ATRIA2-CVRN Study

Background: Although anticoagulation therapy has been shown to significantly reduce risk of stroke in patients with atrial fibrillation (AF), adherence to prescribed therapy is challenging. Few studies have investigated the demographic, behavioral and clinical factors associated with medication adherence in this population. Methods: We examined associations between these characteristics and self-reported medication adherence in a large, ethnically diverse cohort of patients with incident diagnosed AF from Kaiser Permanente Northern and Southern California. Medication non-adherence was defined as self-report of any one of the following during the past month: taking medications as prescribed &lt; 75% of the time, forgetting to take one or more prescribed medications &gt; once per week, or deciding to skip one or more prescribed medications &gt; once per week. Results: Among 14,246 survey respondents (43% female; 6% Black, 8% Hispanic, 7% API), 956 (7%) were non-adherent by self-report. Mean age ± SD was 72 ± 12 yrs; 26% were &lt;65 yrs old. In a multivariable model (Table), participants &lt;65 yrs old were 74% more likely (OR 95% CI: 1.50-2.00) to be non-adherent that those &gt;65. Ethnic minorities and patients having low household income were also more likely to be non-adherent. Patients who reported having poorer general health and greater memory decline over the past 2-3 yrs had higher odds of reporting non-adherence to their medications, particularly among those who forgot to take prescribed medications &gt; once per week. Patients who were prescribed warfarin during the 1 yr prior to survey completion were 44% less likely to be non-adherent by self-report (OR 95% CI: 0.49-0.64). Conclusions: In this large AF population, younger age, race/ethnicity, lower income, and perception of poor general health and declining memory were associated with increased odds of self-reported non-adherence to medications, while warfarin use was associated with decreased likelihood of non-adherence. Adjusted Odds Ratios (OR) and Confidence Intervals (95% CI) from Multivariable Logistic Regression Model of Self-Reported Medication Adherence Non-adherent (n=956) vs. Adherent (n=13,290) p-value Age [yrs] &lt; 65 1.60 (1.38, 1.85) &lt; 0.0001 &gt; 65 Referent Sex Female Referent Male 1.12 (0.97, 1.29) 0.12 Race/Ethnicity non-Hispanic White (NHW) Referent Asian/Pacific Islander (API) 1.47 (1.15, 1.88) 0.002 Black 2.06 (1.63, 2.60) &lt; 0.0001 Hispanic 1.39 (1.10, 1.74) 0.005 Other/Missing 1.32 (1.00, 1.75) 0.053 Income &lt; 25,000 1.32 (1.10, 1.58) 0.004 &gt; 25,000 Referent Missing/Unknown 0.96 (0.81, 1.14) 0.676 Marital Status Married Referent Not Married 1.28 (1.11, 1.48) 0.0009 Missing/Unknown 1.03 (0.54, 1.97) 0.933 General Health Poor 1.30 (1.02, 1.66) 0.032 &gt; Fair Referent Missing/Unknown 1.16 (0.60, 2.23) 0.664 Memory Decline Yes 1.66 (1.44, 1.92) &lt; 0.0001 No Referent Don't Know 1.30 (1.01, 1.68) 0.038 Missing/Unknown 1.55 (1.01, 2.38) 0.044 Warfarin Use Yes 0.56 (0.49, 0.64) &lt; 0.0001 No Referent

The Predictors of Patient–Physician Race and Ethnic Concordance: A Medical Facility Fixed‐Effects Approach

To examine the predictors of patient-physician race/ethnicity concordance among diabetes patients in an integrated delivery system. Kaiser Permanente's Northern California Diabetes Registry of 2005. Logistic regression predicted concordance for each racial/ethnic group. Availability of a concordant physician, whether a patient chose their physician, and patient language were main explanatory variables. The study population consisted of 109,745 patients and 1,750 physicians. Patients who chose their physicians were more likely to have a same race/ethnicity physician with OR of 2.2 (95 percent CI 1.74-2.82) for African American patients, 1.71 (95 percent CI 1.44-2.04) for Hispanic patients, 1.11 (95 percent CI 1.04-1.18) for white patients, and 1.38 (95 percent CI 1.23, 1.55) for Asian patients. Availability of a same race/ethnicity physician was also a predictor of concordance for African American patients (OR 2.7; 95 percent CI 2.45-2.98) and marginally significant for Hispanic patients (OR 1.02; 95 percent CI 1.01-1.02), white patients (OR 1.02; 95 percent CI 1.00-1.04), and Asian patients (OR 1.05; 95 percent CI 1.03, 1.07). Limited English language was a strong predictor of concordance for Hispanic patients (OR 4.81; 95 percent CI 4.2-5.51) and Asian patients (OR 9.8; 95 percent CI 7.7, 12.6). Patient language, preferences, and the racial composition of the physician workforce predict race/ethnicity concordance.

Association Between Nonsteroidal Anti-inflammatory Drug Use and Cutaneous Squamous Cell Carcinoma

To examine the association between nonsteroidal anti-inflammatory drug (NSAID) use and cutaneous squamous cell carcinoma (SCC). Retrospective case-control study. Kaiser Permanente Northern California (KPNC), a large population based-health maintenance organization. Random sample of 415 KPNC members diagnosed as having a pathologically verified SCC in 2004 and 415 age-, sex-, and race-matched controls with no history of skin cancer. Self-reported NSAID use in the 10 years prior to baseline. Use of NSAIDs was categorized based on type (any NSAIDs, aspirin, ibuprofen, and nonaspirin NSAIDs). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression to estimate the association of SCC with regular use, dose, and duration of exposure to the different NSAID types. Information on pharmacy-dispensed NSAIDs was also examined to assess its association with SCC risk. Models were adjusted for all ascertained SCC risk factors (fully adjusted model) and only those variables associated with both SCC risk and NSAID use (parsimonious model). Fully adjusted analyses showed no statistically significant reduction in SCC risk with self-reported regular use of any NSAID (OR, 1.32; 95% CI, 0.92-1.89), aspirin (OR, 1.38; 95% CI, 0.96-1.97), ibuprofen (OR, 0.74; 95% CI, 0.46-1.19), or nonaspirin NSAIDs (OR, 0.84; 95% CI, 0.56-1.26). Analyses examining duration, dose, and variables combining duration and dose of NSAID exposure did not appreciably change results. An analysis using the parsimonious model showed similar results. The data on pharmacy-dispensed NSAIDs also showed no association with SCC risk. Neither self-reported nor pharmacy-dispensed NSAID exposure was associated with cutaneous SCC risk.