Ernest Shen

Use of posttreatment imaging and biomarkers in survivors of early‐stage breast cancer: Inappropriate surveillance or necessary care?

Advanced imaging and serum biomarkers are commonly used for surveillance in patients with early‐stage breast cancer, despite recommendations against this practice. Incentives to perform such low‐value testing may be less prominent in integrated health care delivery systems. The purpose of the current study was to evaluate and compare the use of these services within 2 integrated systems: Kaiser Permanente (KP) and Intermountain Healthcare (IH). The authors also sought to distinguish the indication for testing: diagnostic purposes or routine surveillance.

Use of Imaging for Staging of Early-Stage Breast Cancer in Two Integrated Health Care Systems: Adherence With a Choosing Wisely Recommendation

PURPOSE Advanced imaging is commonly used for staging of early-stage breast cancer, despite recommendations against this practice. The objective of this study was to evaluate and compare use of imaging for staging of breast cancer in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was routine or used for diagnostic purposes. METHODS We identified patients with stages 0 to IIB breast cancer diagnosed between 2010 and 2012. Using KP and IH electronic health records, we identified use of computed tomography, positron emission tomography, or bone scintigraphy 30 days before diagnosis to 30 days postsurgery. We performed chart abstraction on a random sample of patients who received a presurgical imaging test to identify indication. RESULTS For the sample of 10,010 patients, mean age at diagnosis was 60 years (range, 22 to 99 years); with 21% stage 0, 47% stage I, and 32% stage II. Overall, 15% of patients (n = 1,480) received at least one imaging test during the staging window, 15% at KP and 14% at IH (P = .5). Eight percent of patients received imaging before surgery, and 7% postsurgery. We found significant intraregional variation in imaging use. Chart abstraction (n = 129, 16% of patients who received presurgical imaging) revealed that 48% of presurgical imaging was diagnostic. CONCLUSION Use of imaging for staging of low-risk breast cancer was similar in both systems, and slightly lower than has been reported in the literature. Approximately half of imaging tests were ordered in response to a sign or symptom.

Stepping toward discharge: Level of ambulation in hospitalized patients.

Little information is available on how active adult patients are during their hospitalization. The purpose of this study is to describe the level of ambulation in hospitalized patients. This was a cohort study of ambulatory patients from 3 hospital medical-surgical units conducted March 2014 through July 2014. Patients wore an accelerometer upon admission to the unit until discharge to home. Sensor placement and data review were performed as part of routine care. Step counts were merged with administrative and clinical data for analysis. Data were available on 777 patients who had at least 24 hours of monitoring prior to discharge. The sample included 57% females, and 55% were nonwhite. The median total step count over 24 hours was 1158 (interquartile range: 636-2238). Patients who were older accrued fewer steps compared to younger patients (962 vs 1294, P < 0.0001). For patients who had at least 48 hours of monitoring (n = 378), there was an increase from 811 steps in the first 24 hours to 1188 steps in the final 24 hours prior to discharge. More frequent documentation was associated with higher step counts (P ≤ 0.001). We found that a diverse sample of hospitalized adult patients accrued over 1000 steps in the 24 hours prior to discharge home.

Association of a Dedicated Post-Hospital Discharge Follow-up Visit and 30-Day Readmission Risk in a Medicare Advantage Population.

Association of a Dedicated Post–Hospital Discharge Follow-up Visit and 30-Day Readmission Risk in a Medicare Advantage Population The effectiveness of post–hospital discharge (POSH) follow-up visits in reducing 30-day readmissions has been mixed.1-4 We aimed to advance the evidence base by examining whether a dedicated 20-minute POSH visit with a primary care clinician (PCC) completed within 7 days after discharge is associated with a lower 30-day readmission rate compared with any other or no scheduled outpatient visit.

Comorbidity Profiles and Their Effect on Treatment Selection and Survival among Patients with Lung Cancer

Rationale: Prior work has shown that the comorbidity burden is high among patients with lung cancer, but patterns of comorbid conditions have not been systematically identified. Objectives: We aimed to identify distinct comorbidity profiles in a large sample of patients with lung cancer and to examine the effect of comorbidity profiles on treatment and survival. Methods: In this retrospective cohort study, we used latent class analysis to identify comorbidity profiles (or classes) in a population‐based sample of 6,662 patients with bronchogenic carcinoma diagnosed between 2008 and 2013. We included specific comorbid conditions from the Charlson comorbidity index. We used Cox proportional hazards analysis to examine the effect of comorbidity class on survival. Results: The mean age of the patients was 70 years, and 50% were female, 34% were nonwhite, and 17% were never‐smokers. Most patients had stage III (21%) or IV (53%) disease. Over half (51%) had at least one comorbid condition, whereas 18% had at least four comorbidities. Latent class analysis identified five distinct comorbidity classes. Classes were defined by progressively greater Charlson comorbidity index scores and were further distinguished by the presence or absence of specific types of vascular disease and diabetes. Comorbidity class was independently associated with treatment selection (P < 0.001) and survival (P < 0.0001), especially among patients with stages 0‐II disease (P < 0.0001). Conclusions: Patients with lung cancer can be described by distinct comorbidity profiles that are independent predictors of treatment and survival. These profiles provide a more nuanced understanding of how comorbidities cluster within patients with lung cancer and how they can be applied for descriptive purposes or in research.

The Online Personal Action Plan: A Tool to Transform Patient-Enabled Preventive and Chronic Care.

INTRODUCTION Patient-facing online tools for managing preventive and chronic care can be a resource-effective way to increase patient agency in health promotion. Recently, Kaiser Permanente Southern California added the Online Personal Action Plan (oPAP) to the member web portal to better enable members to access information about prevention, health promotion, and care gaps. This study described Kaiser Permanente Southern California members who use oPAP, as well as how members use oPAP to close five different care gaps: hemoglobin A1c testing, pneumonia vaccination, and three cancer screenings. METHODS Care gap closure rates between oPAP users and members not registered on the online patient portal between December 2014 and March 2015 were compared. Data were analyzed in 2015. A total of 838,638 cases (48.9% women; mean age, 49.5 years; 40.4% oPAP users) were examined. RESULTS Adjusting for demographics, BMI, smoking status, health and insurance status, and number of open care gaps, oPAP access was associated with a somewhat greater likelihood of care gap closure within 90 days for select care gap types, particularly hemoglobin A1c testing and breast, cervical, and colorectal cancer screening among eligible members. The effect of oPAP access on care gap closure differed by certain ethnic minority groups. CONCLUSIONS Although healthcare organizations have developed approaches to managing and closing preventive care gaps, these efforts are resource intensive. Users of oPAP are more likely than non-registered members to close gaps, especially cancer screening tests. The oPAP appears to be an effective tool at improving patient engagement in preventive health care.

Understanding Comorbidity Profiles and Their Effect on Treatment and Survival in Patients With Colorectal Cancer

Background: Patients with colorectal cancer (CRC) commonly present at an older age with multiple comorbid conditions and complex care needs at the time of diagnosis. Clusters of comorbid conditions, or profiles, have not been systematically identified in this patient population. This study aimed to identify clinically distinct comorbidity profiles in a large sample of patients with CRC from an integrated healthcare system, and to examine the effect of comorbidity profiles on treatment and survival. Methods: In this retrospective cohort study, we used latent class analysis (LCA) to identify comorbidity profiles in a sample of 7,803 patients with CRC diagnosed between 2008 and 2013. We identified treatment received from electronic health records and used Cox proportional hazards analysis to examine the effect of comorbidity class on survival. We also examined the effect of comorbidity profile on receipt of guideline-recommended treatment. Results: Median age at diagnosis was 66 years, 52% of patients were male, and 48% were nonwhite. A plurality had stage 0-I disease (42%), with 22% stage II, 22% stage III, and 14% stage IV. More than half (59%) had ≤1 comorbid condition, whereas 19% had ≥4 comorbidities. LCA identified 4 distinct comorbidity classes. Classes were distinguished by the presence or absence of vascular and/or respiratory disease and diabetes with complications, as well as progressively greater Charlson comorbidity index scores. Comorbidity class was independently associated with treatment selection (P<.001) and survival (P<.001). Conclusions: Patients with CRC can be described by 4 distinct comorbidity profiles that are independent predictors of treatment and survival. These results provide insight into how comorbidities cluster within patients with CRC. This work represents a shift away from simple counting of comorbid conditions and toward a more nuanced understanding of how comorbidities cluster within groups of patients with CRC.

Implementation of the Canadian CT Head Rule and Its Association With Use of Computed Tomography Among Patients With Head Injury

Study objective Approximately 1 in 3 computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the association of implementation of the Canadian CT Head Rule on head CT imaging in community emergency departments (EDs). Methods We conducted an interrupted time‐series analysis of encounters from January 2014 to December 2015 in 13 Southern California EDs. Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score at ED triage were included. A multicomponent intervention included clinical leadership endorsement, physician education, and integrated clinical decision support. The primary outcome was the proportion of patients receiving a head CT. The unit of analysis was ED encounter, and we compared CT use pre‐ and postintervention with generalized estimating equations segmented logistic regression, with physician as a clustering variable. Secondary analysis described the yield of identified head injuries pre‐ and postintervention. Results Included were 44,947 encounters (28,751 preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3% (95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use postintervention. Adjusted pre‐post comparison showed a trend in decreasing odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction between the intervention and study site over time existed (P=.34). After the intervention, diagnostic yield of CT‐identified intracranial injuries increased by 2.3% (95% CI 1.5% to 3.1%). Conclusion A multicomponent implementation of the Canadian CT Head Rule was associated with a modest reduction in CT use and an increased diagnostic yield of head CTs for adult trauma encounters in community EDs.

The HEART Score for Suspected Acute Coronary Syndrome in U.S. Emergency Departments

Acute coronary syndrome (ACS) is a leading cause of morbidity and mortality worldwide, resulting in millions of emergency department (ED) visits and billions in hospital costs each year [(1)][1]. However, no evidence suggests that the current paradigm of acute care, which includes serial evaluation

Emergency Care of Patients with Acute Ischemic Stroke in the Kaiser Permanente Southern California Integrated Health System.

CONTEXT Tissue plasminogen activator (tPA) is underutilized for treatment of acute ischemic stroke. OBJECTIVE To determine whether the probability of tPA administration for patients with ischemic stroke in an integrated health care system improved from 2009 to 2013, and to identify predictors of tPA administration. DESIGN Retrospective analysis of all ischemic stroke presentations to 14 Emergency Departments between 2009 and 2013. A generalized linear mixed-effects model identified patient and hospital predictors of tPA. MAIN OUTCOME MEASURES Primary outcome was tPA administration; secondary outcomes were door-to-imaging and door-to-needle times and tPA-related bleeding complications. RESULTS Of the 11,630 patients, 3.9% received tPA. The likelihood of tPA administration increased with presentation in 2012 and 2013 (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.26-2.43; and OR = 2.58; 95% CI = 1.90-3.51), female sex (OR = 1.27; 95% CI = 1.04-1.54), and ambulance arrival (OR = 2.17; 95% CI = 1.76-2.67), and decreased with prior stroke (OR = 0.47; 95% CI = 0.25-0.89) and increased age (OR = 0.98; 95% CI = 0.97-0.99). Likelihood varied by Medical Center (pseudo-intraclass correlation coefficient 13.5%). Among tPA-treated patients, median door-to-imaging time was 15 minutes (interquartile range, 9-23 minutes), and door-to-needle time was 73 minutes (interquartile range, 55-103 minutes). The rate of intracranial hemorrhage was 4.2% and 0.9% among tPA- and non-tPA treated patients (p < 0.001). CONCLUSION Acute ischemic stroke care improved over time in this integrated health system. Better understanding of differences in hospital performance will have important quality-improvement and policy implications.