Debbie Postlethwaite

Neisseria gonorrhea and Chlamydia trachomatis Screening at Intrauterine Device Insertion and Pelvic Inflammatory Disease

OBJECTIVE: To evaluate the relationship between Neisseria gonorrhea and Chlamydia trachomatis screening strategies and risk of pelvic inflammatory disease (PID) after intrauterine device (IUD) insertion. METHODS: We conducted a retrospective cohort study of all IUD insertions at Kaiser Permanente Northern California from January 2005 to August 2009. The PID incidence within 90 days after insertion was compared among women who were and were not screened for N gonorrhea and C trachomatis. The study was powered for equivalence with a PID risk difference of −0.006 to 0.006 between two groups considered to be clinically insignificant. Risk difference was calculated by subtracting the proportion of females with PID in one screening group from the proportion of females with PID in the comparison screening group. RESULTS: Of 57,728 IUD insertions, 47% were unscreened within 1 year of insertion; of screened women, 19% were screened on the same day. The overall risk of PID was 0.54% (95% confidence interval [CI] 0.48–0.60%). Nonscreening had an equivalent risk of PID as any screening (risk difference −0.0034, 95% CI −0.0045 to −0.0022), and same-day screening was equivalent to prescreening (risk difference −0.0031, 95% CI −0.0049 to −0.0008). The equivalence persisted when adjusted for age and race and when stratified by age younger than 26 years and older than 26 years. CONCLUSION: The risk of PID in women receiving IUDs was low. These results support IUD insertion protocols in which clinicians test women for N gonorrhea and C trachomatis based on risk factors and perform the test on the day of insertion. These findings have potential to reduce barriers to IUD use for women seeking highly effective, long-term, reversible contraception. LEVEL OF EVIDENCE: II

Counseling and provision of long-acting reversible contraception in the US: National survey of nurse practitioners

OBJECTIVE Nurse practitioners (NPs) provide frontline care in womens health, including contraception, an essential preventive service. Their importance for contraceptive care will grow, with healthcare reforms focused on affordable primary care. This study assessed practice and training needs to prepare NPs to offer high-efficacy contraceptives - intrauterine devices (IUDs) and implants. METHOD A US nationally representative sample of nurse practitioners in primary care and womens health was surveyed in 2009 (response rate 69%, n=586) to assess clinician knowledge and practices, guided by the CDC US Medical Eligibility Criteria for Contraceptive Use. RESULTS Two-thirds of womens health NPs (66%) were trained in IUD insertions, compared to 12% of primary care NPs. Contraceptive counseling that routinely included IUDs was low overall (43%). Nurse practitioners used overly restrictive patient eligibility criteria, inconsistent with CDC guidelines. Insertion training (aOR=2.4, 95%CI: 1.10 5.33) and knowledge of patient eligibility (aOR=2.9, 95%CI: 1.91 4.32) were associated with IUD provision. Contraceptive implant provision was low: 42% of NPs in womens health and 10% in primary care. Half of NPs desired training in these methods. CONCLUSION Nurse practitioners have an increasingly important position in addressing high unintended pregnancy in the US, but require specific training in long-acting reversible contraceptives.

Provision of contraceptive services to women with diabetes mellitus.

ABSTRACTBACKGROUNDWomen with diabetes mellitus who delay pregnancy until glycemic control is achieved experience lower rates of adverse pregnancy outcomes.OBJECTIVETo compare rates of provision of contraceptive services among women with diabetes mellitus and women without chronic medical conditions.DESIGNA retrospective cohort study of 459,181 women aged 15–44 who had continuous membership and pharmacy benefits in a managed care organization in Northern California between January 2006 and June 2007. Rates of documented provision of contraceptive counseling, prescriptions, and services were compared between women with diabetes and women without chronic medical conditions.RESULTSAmong 8,182 women with diabetes and 122,921 women without any chronic conditions, women with diabetes were less likely than women without a chronic condition to have documented receipt of any contraceptive counseling, prescriptions, or services (47.8% vs 62.0%, p < 0.001). After controlling for age and race, women with diabetes were more likely to have undergone tubal sterilization compared to women without a chronic condition (OR = 1.41, 95% CI 1.30–1.54), but less likely to have received highly effective, reversible methods of contraception such as intrauterine contraception (OR = 0.68, 95% CI 0.61–0.75). In addition, more women with diabetes had undergone hysterectomy, which is rarely performed solely for contraceptive purposes.CONCLUSIONSWomen with diabetes were less likely to receive highly effective reversible contraception and more likely to undergo sterilization procedures. Increasing the use of highly effective reversible contraceptives may help diabetic women who want to retain their fertility to delay pregnancy until glycemic control is achieved.

Risks and Predictors of Gastric Adenocarcinoma in Patients with Gastric Intestinal Metaplasia and Dysplasia: A Population-Based Study.

OBJECTIVES:Gastric intestinal metaplasia and dysplasia are precursor lesions for adenocarcinoma. The risks of progression to malignancy from these lesions are not well characterized, particularly in the US populations.METHODS:We identified 4,331 Kaiser Permanente Northern California members who were diagnosed with gastric intestinal metaplasia or dysplasia between 1997 and 2006 and followed them through December 2013. The incident rates of gastric adenocarcinoma, relative risks in comparison with the Kaiser Permanente general population, and predictors of progression to malignancy were investigated.RESULTS:Among 4,146 individuals with gastric intestinal metaplasia and 141 with low-grade dysplasia with 24,440 person-years follow-up, 17 and 6 cases of gastric adenocarcinoma were diagnosed, respectively, after 1 year from the index endoscopy. The incidence rate of gastric adenocarcinoma was 0.72/1,000 person-years in patients with intestinal metaplasia, with a relative risk of 2.56 (95% confidence interval (CI) 1.49–4.10) compared with the Kaiser Permanente member population, and 7.7/1,000 person-years for low-grade dysplasia, with a relative risk of 25.6 (95% CI, 9.4–55.7). The median time for gastric intestinal metaplasia to progress to adenocarcinoma was 6.1 years, and for low-grade dysplasia, 2.6 years. Hispanic race/ethnicity and history of dysplasia were associated with significantly higher risk of progression to gastric adenocarcinoma.CONCLUSIONS:Gastric intestinal metaplasia and dysplasia are significant predictors for gastric adenocarcinoma. The low risk for malignancy associated with intestinal metaplasia does not support routine endoscopic surveillance. However, surveillance should be considered in patients at higher risks, including those with suspicious endoscopic features, presence of dysplasia, and Hispanic race/ethnicity.

Does increased experience with laparoscopic cholecystectomy yield more complex bile duct injuries

BACKGROUND Two decades since the advent of laparoscopic cholecystectomy, the rate of bile duct injuries still remains higher than in the open cholecystectomy era. METHODS The rate and complexity of bile duct injuries was evaluated in 83,449 patients who underwent laparoscopic cholecystectomy between 1995 and 2008 in the Kaiser Permanente Northern California system. Fifty-six surgeons who performed a laparoscopic cholecystectomy in the past were surveyed to determine factors that predispose to bile duct injuries. RESULTS The overall incidence of bile duct injuries was .10%; 59.5% of the 84 injuries were cystic duct leaks. Incidence varied slightly from .10% (1995-1998) to .08% (1999-2003) and .12% (2004-2008). There was a trend toward more proximal injuries (injury <2 cm from the bifurcation: 14.3% to 44.4% to 50.0% of major injuries). The misinterpretation of anatomy was cited by 92.9% of surgeons as the primary cause of bile duct injuries; 70.9% cited a lack of experience as a contributing factor. CONCLUSIONS Laparoscopic cholecystectomy has an overall low risk of bile duct injuries; the rate remains constant, but injury complexity may have increased over time.

Pregnancy Outcomes by Pregnancy Intention in a Managed Care Setting

Objectives Published studies show poor pregnancy outcomes associated with unintended pregnancies are disproportionately higher than in planned pregnancies and place a burden on the health care system. This study was designed to compare pregnancy intention rates, compare sociodemographic characteristics of women by pregnancy intention and compare pregnancy outcomes in a managed care setting. Methods A large managed health care organization in California conducted a retrospective medical record review of 1,784 women seeking prenatal care in 2002 to learn how women self-reported their pregnancy intention, compare pregnancy intention rates between this health plan to the national data, and to compare antecedents and pregnancy outcomes based on pregnancy intention. Results Overall, 62.1% of pregnancies were self-reported as intended with 26.4% mistimed and 11.4% unwanted. Being young, single, having lower educational attainment, having other living children, consuming alcohol and being a woman of color were the greatest predictors of having an unintended pregnancy. Despite these predictors, birth outcomes for unintended pregnancies in this setting showed no statistical difference from planned pregnancies. Conclusion Awareness of pregnancy intention of the women who are at greatest risk may be an important contributor to improving birth outcomes and health plan decisions about reproductive care services. Early entry to prenatal care and integrated services that decrease substance abuse and support high-risk pregnancy management are important contributors to reducing poor pregnancy outcomes.

Multiple Determinants of the Abortion Care Experience From the Patient’s Perspective

Because of the highly stigmatized nature of abortion care delivery and the restriction of abortion provision in most states, little is known about abortion care quality beyond procedural safety. This study examined which aspects of abortion care contributed to patient experiences. Data from a prospective, observational study of 9087 women aged 16 to 44 years, from 22 clinics across California, who responded to a postprocedure survey, were analyzed using mixed-effects logistic regression. Patient experience scores were very high (mean overall satisfaction = 9.4 [0-10 scale]) for all clinicians trained in abortion provision (physicians, nurse practitioners, nurse-midwives, and physician assistants). Multiple patient factors (pain rating, expectations of care, sociodemographics) and clinic-level factors (timely care, treatment by clinicians and staff) were significantly associated with patient experience. Study findings demonstrated that clinic environment, treatment by clinical staff, and managed pain levels contributed to a patient’s experience of abortion care, whereas clinician type was not significantly associated.

Impact of Age on Clinicopathological Features and Survival of Patients with Noncardia Gastric Adenocarcinoma

Purpose Gastric cancer often occurs in the elderly but is uncommon in young individuals. Whether young patients have different clinical behaviors and outcomes from those of older patients remain unclear. Materials and Methods We identified 1,366 cases of newly diagnosed noncardia gastric adenocarcinoma from the Kaiser Permanente Northern California Cancer Registry between 2000 and 2010. We then compared the clinicopathological features and survival among the different age groups. Results The male : female ratio differed significantly between the younger and older patient groups (0.84 in age <50 years vs. 1.52>60 years, P<0.01). More younger patients were Hispanic (54% patients <40 years vs. 19% patients ≥70 years, P<0.0001), while more older patients were Caucasian (49% patients ≥70 years vs. 15% patients <40 years; P<0.0001). The diffuse/mixed histological type was more prevalent in younger patients (70% patients <40 years vs. 27% patients ≥70 years; P<0.0001), whereas the intestinal type was more frequent in older patients (71% in patients ≥70 years vs. 30% in patients <40 years; P<0.0001). Poorly differentiated adenocarcinoma was more common in the younger patients (80% in patients <40 years vs. 60% in patients ≥70 years; P=0.016). Survival rates at 1, 2, and 5 years gradually declined with increasing age (overall P=0.0002). Conclusions Young patients with gastric cancer had more aggressive disease but higher overall survival rates than older patients. Younger Hispanic patients and older Caucasian patients were more likely to be diagnosed with gastric cancer. These differences may be due to biological predisposition and/or environmental exposure.

Maternal race/ethnicity as a risk factor for cervical insufficiency

BACKGROUND Preterm birth (PTB) affects 1 in 9 pregnancies in the United States. There are well known but poorly understood racial/ethnic disparities in PTB rates. The role that racial/ethnic disparities in cervical insufficiency (CI) may play in the overall disparities in preterm birth rates is unknown. OBJECTIVE The primary objective of this study was to examine racial/ethnic differences in risk of CI. STUDY DESIGN We conducted a retrospective cohort study of singleton pregnant women in 2012 who were members of Kaiser Permanente Northern California (KPNC), excluding elective termination, delivery outside KPNC, and loss to follow-up. The primary outcome was CI; the secondary outcomes included stillbirth, PTB, and neonatal intensive care unit (NICU) admission. We compared rates of these outcomes among women of different racial/ethnic background. Multivariable logistic regression modeling was used to assess other potential risk factors for CI, including maternal age, parity, medical co-morbidities, prior cervical procedures, prior pregnancy terminations, and history of PTB. RESULTS A total of 34,173 women who were pregnant in 2012 were included in the study. The racial/ethnic makeup of the cohort was 38.6% White, 25.8% Asian, 25.1% Hispanic, 7% Black, and 3.5% other. Approximately 1% (401) of women were diagnosed with CI. Black women had a significantly higher rate of CI (3.2%) compared to White women (0.9%, P < 0.001) as well as higher rates of PTB (9.2%). Infants born to black women had higher rates of NICU care (8.7%) compared to other racial/ethnic groups. Regression analysis showed that Black race/ethnicity was significantly associated with CI compared to Whites (OR 2.89, 95% CI 2.13-3.92) after controlling for other variables associated with CI. CONCLUSION Black women had higher odds of CI compared to White women. This disparity may contribute to the significantly higher rate of PTB among Black women nationally. Further investigation of this association may provide important contributions to our understanding of both CI and PTB.

Effect of availability of at-home phototherapy on the use of systemic medications for psoriasis

Phototherapy is safe, effective, and economical for treatment of psoriasis and selected dermatoses, but in-office phototherapy is often inconvenient1. Kaiser Permanente, Northern California (KPNC) extended durable medical equipment coverage of home-based phototherapy to most insured members in 2015. After this enhancement in coverage, most dermatologists in the Permanente Medical Group, exclusively serving KPNC members, prescribed home phototherapy units to willing patients. This article is protected by copyright. All rights reserved.