Joanna Bulkley

Early Term Delivery and Health Care Utilization in the First Year of Life

OBJECTIVE To assess health care utilization during the first year of life among early term-born infants. STUDY DESIGN We assessed health care utilization of 22420 singleton term infants (37-42 weeks gestational age [GA]) without major birth defects, fetal growth restriction, or exposure to diabetes or hypertension in utero, delivered between 1998 and 2007 and continuously enrolled at Kaiser Permanente Northwest for 12 months after delivery. GA, duration of delivery hospitalization, and postdelivery rehospitalizations and sick/emergency room visits in the first year of life were obtained from electronic medical records. Logistic regression models were used to estimate associations between GA and number of hospitalizations and length of stay. Generalized linear models were used to estimate the adjusted mean number of sick/emergency visits. RESULTS Overall, 20.9% of term infants were born early. Infants delivered vaginally at 37 weeks GA had a 2.2 greater odds (95% CI, 1.6-3.1) of staying 4 or more days compared with those born at 39-40 weeks GA. Similar association was found among infants delivered by cesarean delivery at 37 or 38 weeks GA. Infants born at 37 weeks GA had increased odds of being rehospitalized within 2 weeks of delivery (OR, 2.6; 95% CI, 1.9-3.6). The adjusted mean number of sick/emergency room visits was higher for infants born at 37 and 38 weeks GA than for those born at 39-40 weeks GA (8.1, 7.7, and 7.3, respectively; P < .0001). CONCLUSIONS Early term-born infants had greater health care utilization during their entire first year of life than infants born at 39-40 weeks GA.

A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes

OBJECTIVE We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM). STUDY DESIGN In early 2009, we conducted obstetrics department staff education sessions, revised GDM patient care protocols, and developed an electronic system to trigger reminder calls to patients who had not completed diabetes mellitus screening by 3 months postpartum. We then evaluated the rates of postpartum glucose test order entry and completion for women with GDM delivering from July 2009 through June 2010 (n = 179) and July 2007 through June 2008 (n = 200). RESULTS After the programs implementation, the proportion of women receiving an order for a postpartum glucose test within 3 months of delivery increased from 77.5-88.8% (P = .004), and test completion increased from 59.5-71.5% (hazard ratio, 1.37; 95% confidence interval, 1.07-1.75). CONCLUSION Rates of postpartum diabetes testing can be improved with system changes and reminders.

Spiritual well‐being in long‐term colorectal cancer survivors with ostomies

Spiritual well‐being (SpWB) is integral to health‐related quality of life. The challenges of colorectal cancer (CRC) and subsequent bodily changes can affect SpWB. We analyzed the SpWB of CRC survivors with ostomies.

Health Care Utilisation in the First Year of Life Among Infants of Mothers With Perinatal Depression or Anxiety

BACKGROUND Limited information is available on associations between maternal depression and anxiety and infant health care utilisation. METHODS We analysed data from 24 263 infants born between 1998 and 2007 who themselves and their mothers were continuously enrolled for the infants first year in Kaiser Permanente Northwest. We used maternal depression and anxiety diagnoses during pregnancy and postpartum to categorise infants into two depression and anxiety groups and examined effect modification by timing of diagnosis (pregnancy only, postpartum only, pregnancy and postpartum). Using generalised estimating equations in multivariable log-linear regression, we estimated adjusted risk ratios (RR) between maternal depression and anxiety and well baby visits (<5 and ≥ 5), up to date immunisations (yes/no), sick/emergency visits (<6 and ≥ 6) and infant hospitalisation (any/none). RESULTS Infants of mothers with perinatal depression or anxiety were as likely to attend well baby visits and receive immunisations as their counterparts (RR = 1.0 for all). Compared with no depression or anxiety, infants of mothers with prenatal and postpartum depression or anxiety, or postpartum depression or anxiety only were 1.1 to 1.2 times more likely to have ≥ 6 sick/emergency visits. Infants of mothers with postpartum depression only had marginally increased risk of hospitalisation (RR = 1.2 [95% confidence interval 1.0, 1.4]); 70% of diagnoses occurred after the infants hospitalisation. CONCLUSIONS An understanding of the temporality of the associations between maternal depression and anxiety and infant acute care is needed and will guide strategies to decrease maternal mental illness and improve infant care for this population.

HER2 Evaluation and Its Impact on Breast Cancer Treatment Decisions

Background: Eighteen to twenty percent of breast cancer tumors show abnormal amplification of the Human Epidermal growth factor Receptor 2 (HER2) gene and increased expression of the associated protein. HER2 amplification is associated with rapid tumor proliferation and shorter disease-free and overall survival. Because women with HER2 amplification are more likely to benefit from treatment with the drug trastuzumab, testing for HER2 is recommended to guide therapy. However, little is known about use of HER2 testing in real-world settings. This study examined uptake, use, appropriateness of HER2 testing, and the relationship between HER2 test results and treatment decisions. Methods: We assessed electronic data from 3,634 patients with invasive breast cancer diagnosed from 1998 to 2007 in a large integrated health system. We collected data on patient and tumor characteristics, HER2 testing status, test results, and trastuzumab treatment. Results:From 1998 to 2000, the percent of patients who underwent HER2 evaluation increased from 12 to 94%; <3% of women with ductal carcinoma in situ, for whom HER2 testing is not recommended, were tested. Trastuzumab use increased 5-fold after 2004, when guidelines expanded to include recommending adjuvant treatment for early-stage breast cancer in addition to metastatic treatment. Ninety-five percent of women receiving trastuzumab had a positive HER2 result. After 2004, 55% of women with invasive breast cancer and overexpression of HER2 received trastuzumab treatment; this ranged from 44% of women with localized breast cancer to 80% of women with distant metastatic disease. Conclusions:These findings illustrate appropriate and effective implementation of a HER2 testing strategy in a managed care setting.

Self-reported depression and perceived financial burden among long-term rectal cancer survivors

Types of surgery for rectal cancer (RC), including permanent ostomy (PO) or temporary ostomy followed by anastomosis (TO) or initial anastomosis (AN), can affect psychological and financial well‐being during active treatment. However, these relationships have not been well studied among long‐term survivors (≥5 years post‐diagnosis).

Greatest Challenges of Rectal Cancer Survivors: Results of a Population-based Survey

BACKGROUND:Eliciting the priorities of cancer survivors is essential to address the specific needs of cancer survivor subgroups. OBJECTIVE:The purpose of this study was to describe the greatest challenges related to treatment for long-term rectal cancer survivors. DESIGN:This was an observational study with a cross-sectional survey. SETTINGS:The study included members of Kaiser Permanente Northern California and Northwest health plans. PATIENTS:A survey was mailed to long-term (≥5 years postdiagnosis) survivors of rectal cancer who had an anastomosis, temporary ostomy, or permanent ostomy. MAIN OUTCOME MEASURES:The main outcome was measured with an open-ended question about the greatest challenge related to cancer surgery. We categorized responses using a grounded theory approach with double coding for reliability. Bonferroni-adjusted &khgr;2 values were used to assess differences in the proportions of subgroups who mentioned challenges within each response category. RESULTS:The survey completion rate was 61% (577/953); 76% (440/577) of participants responded to the greatest challenge question. The greatest challenges for respondents were bowel/ostomy management (reported by 44%), negative psychosocial effects (37%), late effects of treatment (21%), comorbidities and aging (13%), postoperative recovery (5%), and negative healthcare experiences (5%). Survivors with temporary ostomy or anastomosis were more likely than survivors with permanent ostomy to report late effects (p < 0.0001 and p = 0.01). Survivors with anastomosis were less likely than survivors with permanent ostomy to report negative psychosocial impacts (p = 0.0001). LIMITATIONS:Generalizability is restricted by the lack of ethnically and racially diverse, uninsured (non-Medicare–eligible population), and non-English–speaking participants. Because the survey was cross-sectional and included respondents at different times since diagnosis, we could not adequately address changes in the greatest challenges over time. CONCLUSIONS:Our results reveal the need for bowel/ostomy management, psychosocial services, and surveillance for late effects in survivorship and supportive care services for all survivors of rectal cancer, regardless of ostomy status. The perspective of long-term survivors with anastomosis reveals challenges that may not be anticipated during decision making for treatment (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A254).

Changes in body mass index and stoma related problems in the elderly

OBJECTIVES Weight gain can cause retraction of an intestinal stoma, possibly resulting in difficulty with wafer and pouch fit, daily care challenges, and discomfort. This cross-sectional study examined the association between body mass index (BMI) and ostomy-related problems among long-term (>5years post-diagnosis) colorectal cancer (CRC) survivors. MATERIALS AND METHODS CRC survivors from three Kaiser Permanente Regions completed a mailed survey. The response rate for those with an ostomy was 53% (283/529). Questions included stoma-related problems, and time to conduct daily ostomy care. Poisson regression evaluated associations between report of problems and change in BMI. Our analysis sample included 235 survivors. RESULTS Sample was 76% ≥65years of age. Since their surgeries, BMI remained stable (ST) in 44% (103), decreased (DE) in 20% (48), and increased (IN) in 36% (84). Compared to ST, male IN (RR 2.15 [1.09-4.25]) and female DE (RR 5.06 [1.26-25.0]) were more likely to spend more than 30min per day on stoma care. IN (vs. ST) were more likely to report interference with clothing (RR 1.51 [1.06-2.17]) and other stoma-related problems (RR 2.32 [1.30-4.14]). Survivors who were obese at time of survey were more likely to report interference with clothing (RR 1.88 [1.38-2.56]) and other stoma-related problems (RR 1.68 [1.07-2.65]). CONCLUSION A change in BMI is associated with ostomy-related problems among long-term CRC survivors. Equipment and care practices may need to be adapted for changes in abdominal shape. Health care providers should caution that a significant increase or decrease in BMI may cause ostomy-related problems.

Extent of maternal morbidity in a managed care population in georgia.

BACKGROUND Although maternal deaths are among the most tragic events related to pregnancy, they are uncommon in the US and, therefore, inadequate indicators of a womans pregnancy-related health. Maternal morbidity has become a more useful measure for surveillance and research. Traditional attempts to monitor maternal morbidity have used hospital discharge data, which include data only on complications that resulted in hospitalisation, underestimating the frequency and scope of complications. METHODS To obtain a more accurate assessment of morbidity, we applied a validated computerised algorithm to identify pregnancies and pregnancy-related complications in a defined population enrolled in a health maintenance organisation in the south-eastern US. We examined the most common morbidities by pregnancy outcome and maternal characteristics. RESULTS We identified 37 741 pregnancies; in half (50.7%), at least one complication occurred. The five most common were urinary tract infections, anaemia, mental health conditions, pelvic and perineal complications, and obstetrical infections. Complications were more likely in women with low socio-economic status (SES), and among non-Hispanic Black women compared with non-Hispanic White women. Multivariable models stratified by race/ethnicity indicated that in pregnancies among non-Hispanic White women, low SES had a modest effect on the odds of having preexisting medical conditions [adjusted odd ratio (AOR) 1.3 [95% confidence interval (CI) 1.2, 1.5]] or having any morbidity (AOR 1.3 [95% CI 1.2, 1.4]). Low SES had little effect on complications among non-Hispanic Black women. CONCLUSION Our findings suggest that comprehensive health insurance coverage may lessen the unfavourable impact of socio-economic disadvantage on the risk of maternal morbidity.

C-B5-04: An Algorithm for Classifying Potential Cases of Amyotrophic Lateral Sclerosis from Electronic Health Records Using Decision Tree Analysis

Background/Aims: The CDC is developing a national amyotrophic lateral sclerosis (ALS) registry that would be based on electronically available medical records and claims. The HMORN contracted with the CDC to help examine the feasibility of doing this in locations (e.g., HMOs) where complete longitudinal records are more likely to be available. Any final system used by the CDC will require an algorithm to classify putative cases. Our aim was to develop an automated algorithm to classify putative cases of ALS and other motor neuron diseases using electronic health records. Methods: We identified potential cases of ALS by review of inpatient, outpatient, other provider services, mortality and pharmacy data for any evidence of ALS or, more generally, motor neuron disease (MND) from 2001 to 2005 at Kaiser Permanente, Northern California. The records of each individual were reviewed to classify into five categories: probable ALS, not ALS, other MND (not ALS), insufficient information, or unclear. Classification And Regression Tree (CART) analyses were used to create an algorithm based on a comprehensive set of variables that may predict the likelihood of having true ALS (or, conversely, ruling them out). Results: Multiple algorithms were developed with key variables being number times an ALS code appeared in the record, physician-type making diagnosis, alternative diagnoses, mortality records, and length of follow-up. In our best model, we were able to correctly classify 99.6% of those originally determined to be probable ALS. However, there remain a substantial number of individuals classified by review or algorithm in the unclear, insufficient, or other MND categories. In addition, with this analytic approach, the “costs” of misclassification can be modified, and we will present alternative algorithms with a discussion of the benefits and disadvantages of each. Validation analysis results conducted in a second HMO will be presented. Conclusions: An algorithm was developed that appropriately classifies the vast majority of probable ALS cases. However, given the lack of detail in some records and the difficulty in diagnosing some clinical cases, there will be some misclassification when based solely on electronic medical records.