Arona Ragins

Differences in Prevalence of Urinary Incontinence by Race/Ethnicity

PURPOSE We compared the prevalence of urinary incontinence by type among white, black, Hispanic and Asian-American women. MATERIALS AND METHODS The RRISK is a population based cohort study of 2,109 randomly selected middle-aged and older women. Incontinence and other variables were assessed by self-report questionnaires and in person interviews. Labor and delivery and surgical data were abstracted from medical records archived since 1946. Logistic regression was used to estimate the OR with 95% CIs for incontinence while adjusting for covariates. RESULTS The age adjusted prevalence of weekly incontinence was highest among Hispanic women, followed by white, black and Asian-American women (36%, 30%, 25% and 19%, respectively, p <0.001). Type of incontinence also differed among groups, with weekly stress incontinence prevalence being 18%, 15%, 8% and 8% (p <0.001), and weekly urge incontinence prevalence being 10%, 9%, 14% and 7% (p <0.001). After adjustment for age, parity, hysterectomy, estrogen use, body mass, menopausal status and diabetes, the risk of stress incontinence remained significantly lower in black (adjusted OR 0.36, 95% CI 0.23-0.57) and Asian-American (adjusted OR 0.54, 95% CI 0.34-0.86) women compared to white women. In contrast, the risk of urge incontinence was similar in black (adjusted OR 1.19, 95% CI 0.79-1.81) and Asian-American (adjusted OR 0.86, 95% CI 0.52-1.43) women compared to white women. CONCLUSIONS Significant differences in the adjusted risk of stress incontinence among Hispanic, white, black and Asian-American women suggest the presence of additional, as yet unrecognized, risk or protective factors for stress incontinence.

Mixed Urinary Incontinence: Greater Impact on Quality of Life

PURPOSE We compared the impact of mixed, stress and urge urinary incontinence on quality of life in middle-aged or older women. MATERIALS AND METHODS We analyzed cross-sectional data from a population based cohort of 2,109 ethnically diverse middle-aged or older women. Among participants reporting weekly incontinence, clinical type of incontinence was assessed by self-reported questionnaires and disease specific quality of life impact was evaluated using the Incontinence Impact Questionnaire. Multivariable logistic regression was used to compare the odds of greater quality of life impact from incontinence, defined as an Incontinence Impact Questionnaire score in the 75th percentile or greater in women with stress, urge and mixed incontinence. RESULTS More than 28% (598) of women reported weekly incontinence, including 37% with stress, 31% with urge and 21% with mixed incontinence. Unadjusted Incontinence Impact Questionnaire scores were higher for women with mixed vs urge or stress incontinence (median score 29 vs 17 and 13, respectively, p <0.01). Adjusting for age, race/ethnicity, health status and clinical incontinence severity, women with mixed incontinence were more likely to report a greater overall quality of life impact compared to those with stress incontinence (OR 2.5, 95% CI 1.4-4.3), as well as a greater specific impact on travel (OR 2.2, 95% CI 1.3-3.7) and emotional (OR 1.8, 95% CI 1.0-3.4) Incontinence Impact Questionnaire domains. The overall impact of urge incontinence did not differ significantly from that of stress (urge vs stress OR 1.6, 95% CI 0.9-2.7) or mixed incontinence (mixed vs urge OR 1.6, 95% CI 0.9-2.8) in adjusted models. CONCLUSIONS In middle-aged or older women mixed incontinence is associated with a greater quality of life impact than stress incontinence independent of age, race, health or incontinence severity. Identification of women with mixed incontinence symptoms may be helpful in discovering which women are most likely to experience functional limitations and decreased well-being from incontinence.

Sexual function and aging in racially and ethnically diverse women.

OBJECTIVES: To examine factors influencing sexual activity and functioning in racially and ethnically diverse middle‐aged and older women.

Incidence of and Risk Factors for Change in Urinary Incontinence Status in a Prospective Cohort of Middle-Aged and Older Women: The Reproductive Risk of Incontinence Study in Kaiser

PURPOSE Urinary incontinence is a dynamic condition that can progress and regress but few groups have examined risk factors for change in incontinence status. MATERIAL AND METHODS We used stratified random sampling to construct a racially and ethnically diverse, population based cohort of 2,109 women 40 to 69 years old. Data were collected by questionnaires and medical record review. A second survey approximately 5 years later was completed by 1,413 women (67%) from the original cohort. The frequency of urinary incontinence was categorized as less than weekly, weekly and daily. Change in incontinence status was defined as new onset incontinence, incontinence progression or regression between frequency categories and resolution of incontinence. Predictor variables were demographics, body mass index and other medical conditions. We used logistic regression to estimate the adjusted OR and 95% CI. RESULTS Compared to white nonHispanic women, black women were less likely to have incontinence progression (OR 0.46, 95% CI 0.24-0.88). New onset incontinence was more common in women with a higher body mass index at baseline (p = 0.006) and those who experienced increased body mass index (p = 0.03) or decreased general health (p = 0.007) during the study. Participants with chronic obstructive pulmonary disorder at baseline were more likely to report incontinence progression (OR 2.64, 95% CI 1.22-5.70). Baseline incontinence type was not significantly associated with the risk of change in continence status independent of frequency. CONCLUSIONS Identifying risk factors for change in incontinence status may be important to develop interventions to decrease the burden of incontinence in the general population.

Urinary incontinence self-report questions: reproducibility and agreement with bladder diary

Introduction and hypothesisThis study aims to measure self-report urinary incontinence questions’ reproducibility and agreement with bladder diary.MethodsData were analyzed from the Reproductive Risk of Incontinence Study at Kaiser. Participating women reporting at least weekly incontinence completed self-report incontinence questions and a 7-day bladder diary. Self-report question reproducibility was assessed and agreement between self-reported and diary-recorded voiding and incontinence frequency was measured. Test characteristics and area under the curve were calculated for self-reported incontinence types using diary as the gold standard.ResultsFive hundred ninety-one women were included and 425 completed a diary. The self-report questions had moderate reproducibility and self-reported and diary-recorded incontinence and voiding frequencies had moderate to good agreement. Self-reported incontinence types identified stress and urgency incontinence more accurately than mixed incontinence.ConclusionsSelf-report incontinence questions have moderate reproducibility and agreement with diary, and considering their minimal burden, are acceptable research tools in epidemiologic studies.

An electronic Simplified Acute Physiology Score-based risk adjustment score for critical illness in an integrated healthcare system.

Objective:Risk adjustment is essential in evaluating the performance of an ICU; however, assigning scores is time-consuming. We sought to create an automated ICU risk adjustment score, based on the Simplified Acute Physiology Score 3, using only data available within the electronic medical record (Kaiser Permanente HealthConnect). Design, Setting, and Patients:The eSimplified Acute Physiology Score 3 was developed by adapting Kaiser Permanente HealthConnect structured data to Simplified Acute Physiology Score 3 criteria. The model was tested among 67,889 first-time ICU admissions at 21 hospitals between 2007 and 2011 to predict hospital mortality. Model performance was evaluated using published Simplified Acute Physiology Score 3 global and North American coefficients; a first-level customized version of the eSimplified Acute Physiology Score 3 was also developed in a 40% derivation cohort and tested in a 60% validation cohort. Measurements:Electronic variables were considered “directly” available if they could be mapped exactly within Kaiser Permanente HealthConnect; they were considered “adapted” if no exact electronic corollary was identified. Model discrimination was evaluated with area under receiver operating characteristic curves; calibration was assessed using Hosmer–Lemeshow goodness-of-fit tests. Main Results:Mean age at ICU admission was 65 ± 17 yrs. Mortality in the ICU was 6.2%; total in-hospital mortality was 11.2%. The majority of Simplified Acute Physiology Score 3 variables were considered “directly” available; others required adaptation based on diagnosis coding, medication records, or procedure tables. Mean eSimplified Acute Physiology Score 3 scores were 45 ± 13. Using published Simplified Acute Physiology Score 3 global and North American coefficients, the eSimplified Acute Physiology Score 3 demonstrated good discrimination (area under the receiver operating characteristic curve, 0.80–0.81); however, it overpredicted mortality. The customized eSimplified Acute Physiology Score 3 score demonstrated good discrimination (area under the receiver operating characteristic curve, 0.82) and calibration (Hosmer–Lemeshow goodness-of-fit chi-square p = 0.57) in the validation cohort. The eSimplified Acute Physiology Score 3 demonstrated stable performance when cohorts were limited to specific hospitals and years. Conclusions:The customized eSimplified Acute Physiology Score 3 shows good potential for providing automated risk adjustment in the intensive care unit.

Nonelective Rehospitalizations and Postdischarge Mortality: Predictive Models Suitable for Use in Real Time.

Background:Hospital discharge planning has been hampered by the lack of predictive models. Objective:To develop predictive models for nonelective rehospitalization and postdischarge mortality suitable for use in commercially available electronic medical records (EMRs). Design:Retrospective cohort study using split validation. Setting:Integrated health care delivery system serving 3.9 million members. Participants:A total of 360,036 surviving adults who experienced 609,393 overnight hospitalizations at 21 hospitals between June 1, 2010 and December 31, 2013. Main Outcome Measure:A composite outcome (nonelective rehospitalization and/or death within 7 or 30 days of discharge). Results:Nonelective rehospitalization rates at 7 and 30 days were 5.8% and 12.4%; mortality rates were 1.3% and 3.7%; and composite outcome rates were 6.3% and 14.9%, respectively. Using data from a comprehensive EMR, we developed 4 models that can generate risk estimates for risk of the combined outcome within 7 or 30 days, either at the time of admission or at 8 AM on the day of discharge. The best was the 30-day discharge day model, which had a c-statistic of 0.756 (95% confidence interval, 0.754–0.756) and a Nagelkerke pseudo-R2 of 0.174 (0.171–0.178) in the validation dataset. The most important predictors—a composite acute physiology score and end of life care directives—accounted for 54% of the predictive ability of the 30-day model. Incorporation of diagnoses (not reliably available for real-time use) did not improve model performance. Conclusions:It is possible to develop robust predictive models, suitable for use in real time with commercially available EMRs, for nonelective rehospitalization and postdischarge mortality.

Frequency, duration and predictors of bronchiolitis episodes of care among infants ≥32 weeks gestation in a large integrated healthcare system: a retrospective cohort study.

BackgroundBronchiolitis is common in the first two years of life and is the most frequent cause of hospitalization in this age group. No previous studies have used an episode-of-care analysis to describe the frequency, duration, and predictors of bronchiolitis episodes of care during the first two years.MethodsWe conducted a retrospective cohort study of 123,264 infants ≥32 weeks gestation born at 6 Northern California Kaiser Permanente hospitals between 1996 and 2002. We used electronic medical records to concatenate hospital, emergency department and outpatient health care encounters for bronchiolitis into discrete episodes of care. We used descriptive statistics to report frequency and duration of bronchiolitis episodes and used logistic regression to assess the effect of gestational age and other clinical and demographic predictors on the outcome of bronchiolitis episodes.ResultsAmong all infants, the rate of bronchiolitis episodes was 162 per 1000 children during the first 2 years of life; approximately 40% required >1 day of medical attention with a mean duration of 7.0 ± 5.9 days. Prematurity was associated with increased risk of bronchiolitis episodes and longer duration. Bronchiolitis episodes rates per 1000 infants were 246 for 32–33 weeks gestational age, 204 for 34–36 weeks, and 148–178 for >36 weeks. Male gender, African-American and Hispanic race/ethnicity, and parental history of asthma were associated with an increased risk of having a bronchiolitis episode and/or longer duration.ConclusionsBronchiolitis episodes of care are frequent during the first two years of life and the duration ranges from 1 to 27 days. Prematurity was associated with more frequent and longer duration of bronchiolitis episodes of care, which may reflect illness severity and/or perceived vulnerability.

Piloting electronic medical record–based early detection of inpatient deterioration in community hospitals

Patients who deteriorate in the hospital outside the intensive care unit (ICU) have higher mortality and morbidity than those admitted directly to the ICU. As more hospitals deploy comprehensive inpatient electronic medical records (EMRs), attempts to support rapid response teams with automated early detection systems are becoming more frequent. We aimed to describe some of the technical and operational challenges involved in the deployment of an early detection system. This 2-hospital pilot, set within an integrated healthcare delivery system with 21 hospitals, had 2 objectives. First, it aimed to demonstrate that severity scores and probability estimates could be provided to hospitalists in real time. Second, it aimed to surface issues that would need to be addressed so that deployment of the early warning system could occur in all remaining hospitals. To achieve these objectives, we first established a rationale for the development of an early detection system through the analysis of risk-adjusted outcomes. We then demonstrated that EMR data could be employed to predict deteriorations. After addressing specific organizational mandates (eg, defining the clinical response to a probability estimate), we instantiated a set of equations into a Java application that transmits scores and probability estimates so that they are visible in a commercially available EMR every 6 hours. The pilot has been successful and deployment to the remaining hospitals has begun. Journal of Hospital Medicine 2016;11:S18-S24.

Evaluation Following Staggered Implementation of the "Rethinking Critical Care" ICU Care Bundle in a Multicenter Community Setting.

Objectives:To evaluate process metrics and outcomes after implementation of the “Rethinking Critical Care” ICU care bundle in a community setting. Design:Retrospective interrupted time-series analysis. Setting:Three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system. Patients:ICU patients admitted between January 1, 2009, and August 30, 2013. Interventions:Implementation of the Rethinking Critical Care ICU care bundle which is designed to reduce potentially preventable complications by focusing on the management of delirium, sedation, mechanical ventilation, mobility, ambulation, and coordinated care. Rethinking Critical Care implementation occurred in a staggered fashion between October 2011 and November 2012. Measurements and Main Results:We measured implementation metrics based on electronic medical record data and evaluated the impact of implementation on mortality with multivariable regression models for 24,886 first ICU episodes in 19,872 patients. After implementation, some process metrics (e.g., ventilation start and stop times) were achieved at high rates, whereas others (e.g., ambulation distance), available late in the study period, showed steep increases in compliance. Unadjusted mortality decreased from 12.3% to 10.9% (p < 0.01) before and after implementation, respectively. The adjusted odds ratio for hospital mortality after implementation was 0.85 (95% CI, 0.73–0.99) and for 30-day mortality was 0.88 (95% CI, 0.80–0.97) compared with before implementation. However, the mortality rate trends were not significantly different before and after Rethinking Critical Care implementation. The mean duration of mechanical ventilation and hospital stay also did not demonstrate incrementally greater declines after implementation. Conclusions:Rethinking Critical Care implementation was associated with changes in practice and a 12–15% reduction in the odds of short-term mortality. However, these findings may represent an evaluation of changes in practices and outcomes still in the midimplementation phase and cannot be directly attributed to the elements of bundle implementation.