Janet S. Lee

Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease.

RATIONALEnEfforts to reduce 30-day readmission have mostly concentrated on addressing deficiencies in care transitions and outpatient management after discharge. There is growing evidence to suggest that physical inactivity is associated with increased hospitalizations.nnnOBJECTIVESnWe examined whether or not a potentially modifiable factor such as regular physical activity at baseline was associated with lower risk of 30-day readmission in patients with chronic obstructive pulmonary disease (COPD).nnnMETHODSnPatients from a large integrated health system were included in this retrospective cohort study if they were hospitalized for COPD (following the Centers for Medicare and Medicaid Services and National Quality Forum proposed criteria) and discharged between January 1, 2011 and December 31, 2012, aged 40 years or older, on a bronchodilator or steroid inhaler, alive at discharge, and continuously enrolled in the health plan 12 months before the index admission and at least 30 days post discharge. Our main outcome was 30-day all-cause readmission. Regular physical activity was routinely assessed at the time of all outpatient visits and expressed as the total minutes of moderate or vigorous physical activity (MVPA) per week.nnnMEASUREMENTS AND MAIN RESULTSnThe sample included a total of 4,596 patients (5,862 index admissions) with a mean age of 72.3 ± 11 years. The 30-day readmission rate was 18%, with 59% of readmissions occurring in the first 15 days. Multivariate adjusted analyses showed that patients reporting any level of MPVA had a significantly lower risk of 30-day readmission compared with inactive patients (1-149 min/wk of MVPA: relative risk, 0.67; 95% confidence interval, 0.55-0.81; ≥150 min/wk of MVPA: relative risk, 0.66; 95% confidence interval, 0.51-0.87). Other significant independent predictors of increased readmission included anemia, prior hospitalizations, longer lengths of stay, more comorbidities, receipt of a new oxygen prescription at discharge, use of the emergency department or observational stay before the readmission (all, P < 0.05), and being unpartnered (P = 0.08).nnnCONCLUSIONSnOur findings further support the importance of physical activity in the management of COPD across the care continuum. Although it is possible that lower physical activity is a reflection of worse disease, promoting and supporting physical activity is a promising strategy to reduce the risk of readmission.

Patterns of familial leukemia. Ten cases of leukemia in two interrelated families

Ten members of 2 interrelated families developed leukemia between 1948 and 1967. In one family, 6 cases of chronic lymphocytic leukemia occurred in 2 first‐cousin sibships. In the other family, 4 cases of acute leukemia occurred in mother, daughter, and two distant cousins. One case of chronic lymphocytic leukemia was diagnosed prospectnvly during a hematologic survey of close relatives of leukemic patients. Cytogenetic studies of peripheral blood lymphocytes from 19 unaffected relatives showed no abnormalities. These findings suggest that the genetic factors which predispose to leukemia in some families may also determine the leukemic cell types.

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

PURPOSEnAdvanced 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.nnnMETHODSnWe 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.nnnRESULTSnFor 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.nnnCONCLUSIONnUse 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.

Physical activity assessed in routine care predicts mortality after a COPD hospitalisation

The independent relationship between physical inactivity and risk of death after an index chronic obstructive pulmonary disease (COPD) hospitalisation is unknown. We conducted a retrospective cohort study in a large integrated healthcare system. Patients were included if they were hospitalised for COPD between January 1, 2011 and December 31, 2011. All-cause mortality in the 12u2005months after discharge was the primary outcome. Physical activity, expressed as self-reported minutes of moderate to vigorous physical activity (MVPA), was routinely assessed at outpatient visits prior to hospitalisation. 1727 (73%) patients were inactive (0u2005min of MVPA per week), 412 (17%) were insufficiently active (1–149u2005min of MVPA per week) and 231 (10%) were active (≥150u2005min of MVPA per week). Adjusted Cox regression models assessed risk of death across the MVPA categories. Among 2370 patients (55% females and mean age 73±11u2005years), there were 464 (20%) deaths. Patients who were insufficiently active or active had a 28% (adjusted HR 0.72 (95% CI 0.54–0.97), p=0.03) and 47% (adjusted HR 0.53 (95% CI 0.34–0.84), p<0.01) lower risk of death, respectively, in the 12u2005months following an index COPD hospitalisation compared to inactive patients. Any level of MVPA is associated with lower risk of all-cause mortality after a COPD hospitalisation. Routine assessment of physical activity in clinical care would identify persons at high risk for dying after COPD hospitalisation. Any level of moderate to vigorous physical activity decreases risk of dying over 12 months after COPD hospitalisation http://ow.ly/XZqj0

Impact of pulmonary rehabilitation on hospitalizations for chronic obstructive pulmonary disease among members of an integrated health care system.

PURPOSE: The evidence regarding the effects of pulmonary rehabilitation (PR) on health care resource use remains limited. This retrospective study evaluated the effects of PR on the primary outcome of all-cause hospitalizations and secondary outcomes of other health care use, exercise capacity, health-related quality of life (HRQOL), and body weight in patients with chronic obstructive pulmonary disease (COPD) in a large integrated health care system. METHODS: The PR cohort included 558 patients with a COPD diagnosis, age ≥ 40 years, who were treated with a bronchodilator or steroid inhaler, participated in 1 of 13 PR programs between January 1, 2008, and August 1, 2013, and were continuously enrolled in the health plan ≥ 12 months prior to and after PR. Two non-PR control cohorts were assembled for comparison. Data were extracted from electronic health records. The 6-minute walk test and St. Georges Respiratory Questionnaire results were available for a subset. RESULTS: The proportion of patients who were hospitalized 12 months post-PR was lower compared with the 12 months prior (37% vs 45%, P = .001) while emergency department use was not different (52% vs 54%). Patients who declined PR for logistical reasons had a 40% higher risk of hospitalization than PR participants (relative risk = 1.40, 95% CI: 0.96-2.06, P = .08). There were significant improvements in the 6-minute walk test distance (+43 m) and the St. Georges Respiratory Questionnaire total score (−9.6 points) but minimal changes in weight. CONCLUSIONS: Our finding that participation in PR is associated with reductions in hospitalizations corroborates previous studies. A notable strength of this study is the capture of complete utilization data.

Functional status at discharge and 30-day readmission risk in COPD

BACKGROUNDnEfforts to reduce 30-day readmissions are resource intensive. Healthcare systems need to target interventions at patients with the highest risk. Information on physical functioning has been found to increase the performance of previously published risk prediction models. We examined whether functional status documented during routine nursing care in the 24xa0hxa0prior to discharge was an independent predictor of 30-day readmission risk in patients with COPD.nnnMETHODSnPatients from a large integrated healthcare system were included in this retrospective cohort study if they were hospitalized for COPD and discharged between January 1, 2011, and December 31, 2012, age 40+, on a bronchodilator or steroid inhaler, alive at discharge, and continuously enrolled in the health plan 12 months prior to the index admission and at least 30-days post discharge. Our main outcome was 30-day all-cause readmission. Functional status was documented as part of routine nursing care within 24xa0hxa0prior to discharge as follows: bed bound (Level I), able to sit (Level II), stand next to bed (Level III), walk <50xa0feet (Level IV), and walk >50xa0feet (Level V).nnnRESULTSnThe sample included 2910 patients (nxa0=xa03631 index admissions) with a mean age of 72xa0±xa011. The 30-day readmission rate was 19%. Multivariate analyses showed that patients who were non-ambulatory at discharge (Levels I-III) were more than twice as likely to be re-admitted within 30-days compared to patients who were able to walk more than 50xa0feet (RR: 2.14, 95% CI 1.62-2.84, pxa0<xa0.001). There was no significant difference in readmission risk between patients classified as Level IV or V (pxa0>xa0.05).nnnCONCLUSIONnPatients with COPD who were non-ambulatory within 24xa0hxa0prior to discharge were at significantly greater risk of readmission compared to ambulatory patients. Functional status should be used to risk stratify patients for more intensive supportive interventions post discharge.

Characterizing Kaiser Permanente Southern California’s Experience With the California End of Life Option Act in the First Year of Implementation

Characterizing Kaiser Permanente Southern California’s Experience With the California End of Life Option Act in the First Year of Implementation The California End of Life Option Act (EOLOA),1 which took effect on June 9, 2016, allows qualified adults diagnosed with a terminal disease to request aid-in-dying drugs from their physician. The California Department of Public Health recently published data on 191 individuals who received aid-in-dying prescriptions during the act’s first 6 months.2 In response to recommendations for more comprehensive documentation of EOLOA implementation to improve end-of-life care,3 this study describes the experience of a large integrated health system and provides in-depth descriptions of individuals who initiated the EOLOA process.

Application of text information extraction system for real-time cancer case identification in an integrated healthcare organization

Background: Surgical pathology reports (SPR) contain rich clinical diagnosis information. The text information extraction system (TIES) is an end-to-end application leveraging natural language processing technologies and focused on the processing of pathology and/or radiology reports. Methods: We deployed the TIES system and integrated SPRs into the TIES system on a daily basis at Kaiser Permanente Southern California. The breast cancer cases diagnosed in December 2013 from the Cancer Registry (CANREG) were used to validate the performance of the TIES system. The National Cancer Institute Metathesaurus (NCIM) concept terms and codes to describe breast cancer were identified through the Unified Medical Language System Terminology Service (UTS) application. The identified NCIM codes were used to search for the coded SPRs in the back-end datastore directly. The identified cases were then compared with the breast cancer patients pulled from CANREG. Results: A total of 437 breast cancer concept terms and 14 combinations of “breast” and “cancer” terms were identified from the UTS application. A total of 249 breast cancer cases diagnosed in December 2013 was pulled from CANREG. Out of these 249 cases, 241 were successfully identified by the TIES system from a total of 457 reports. The TIES system also identified an additional 277 cases that were not part of the validation sample. Out of the 277 cases, 11% were determined as highly likely to be cases after manual examinations, and 86% were in CANREG but were diagnosed in months other than December of 2013. Conclusions: The study demonstrated that the TIES system can effectively identify potential breast cancer cases in our care setting. Identified potential cases can be easily confirmed by reviewing the corresponding annotated reports through the front-end visualization interface. The TIES system is a great tool for identifying potential various cancer cases in a timely manner and on a regular basis in support of clinical research studies.