Rong Wei

Incidence of Polymerase Chain Reaction–Diagnosed Clostridium difficile in a Large High-Risk Cohort, 2011-2012

OBJECTIVEnTo describe incidence rates (IRs) of polymerase chain reaction (PCR)-diagnosed Clostridium difficile infection (CDI) in a large high-risk cohort.nnnPATIENTS AND METHODSnMembers of Kaiser Permanente Southern California 1 year or older who were admitted to any of 14 Kaiser Permanente hospitals from January 1, 2011, through December 31, 2012, were included in the study. The CDI cases were identified by PCR in the inpatient and outpatient settings. The CDI IRs per 10,000 inpatient-days are estimated by year, surveillance category, age, sex, race/ethnicity, and Charlson comorbidity index. Recurrence rates are presented by age, sex, and race/ethnicity. Death and colectomy in the 30 days after CDI diagnosis, white blood cell count, and serum creatinine level are assessed.nnnRESULTSnAmong 268,655 patients, 4286 (1.6%) had CDI. Among these patients, 671 (15.7%) had recurrent infections. The IR was highest among community-onset, health care facility-associated infections (11.1 per 10,000 inpatient-days). The CDI IRs differed by age, sex, and race/ethnicity. Overall, 528 patients (12.3%) died within 30 days of a positive CDI test result. The CDI IRs increased 34% with implementation of PCR testing.nnnCONCLUSIONnIncreasingly, PCR is being used because of its higher diagnostic sensitivity. Reassessing the epidemic using PCR updates our understanding of CDI risk. Our capacity to identify patients presenting in the outpatient setting after discharge provides a more accurate picture of health care-associated CDI rates, particularly because the community appears to assume an increasing role in CDI onset and possibly transmission. The CDI burden differs by race, comorbidity, sex, and previous health care use. The detected increase in CDI incidence after transitioning to PCR diagnosis was modest compared with previous studies.

Unmet Patient Need in Statin Intolerance: the Clinical Characteristics and Management

PurposeA substantial percentage of patients report intolerance or side effects of statin treatment leading to treatment changes or discontinuation. The purpose of this study was to examine statin therapy changes and subsequent effects on low-density lipoprotein cholesterol (LDL-C) among patients with statin intolerance (SI).MethodsWe identified 45,037 adults from Kaiser Permanente Southern California with SI documented between 2006 and 2012. Changes in statin therapy in the year before and after the SI index date were examined. We categorized patients into those who initiated statin therapy, discontinued, up-titrated, down-titrated, or did not switch therapy. We calculated the percentage change in LDL-C from the year before to the year after SI, and the percentage of patients attaining LDL-C <u2009100 and <u200970xa0mg/dL.ResultsIn the year prior to the SI date, 77.8% of patients filled a statin prescription. Following SI, 44.6% had no treatment change, 25.5% discontinued, and 30.0% altered their statin therapy. Of those who altered statin therapy, 52.6% down-titrated and 17.2% up-titrated their dose. Rhabdomyolysis was documented in <u20091% of the cohort. The largest changes in LDL-C were experienced by patients who were on a high-intensity statin then discontinued treatment (35.6% increase) and those who initiated a high-intensity statin (25.5% decrease). The proportion of patients achieving LDL-C <u2009100xa0mg/dL and LDL-C <u200970xa0mg/dL was the lowest among those who discontinued therapy.ConclusionsAlthough adjustments to the statin dosage may be appropriate upon documentation of SI, many of these patients will have high LDL-C. Strategies for LDL-C reduction in patients with SI may be necessary.

Treatment discontinuation of oral hypoglycemic agents and healthcare utilization among patients with diabetes

AIMSnTo investigate the discontinuation of oral antihyperglycemic agents (OHA), and examine factors associated with OHA discontinuation, and the effect of OHA discontinuation on glycemic control and healthcare utilization among diabetes patients prescribed dual OHA therapy.nnnMETHODSnWe identified 23,612 adult patients aged >18years with a diagnosis of type 2 diabetes who initiated dual OHA therapy between 1/1/2005 and 6/30/2010. The date of initiation of the second OHA was defined as the index date. Discontinuation was defined as a gap >1.5 times the last days supply without subsequent reinitiation.nnnRESULTSnOver 24months, 16.9% discontinued 1 OHA and 9.2% discontinued both. Patients who discontinued were more likely to be female, younger, Black or of Hispanic ethnicity, have more comorbidities, higher medication co-pays, start both OHAs together, have higher healthcare utilization before the index date and less likely to use prescription mail order compared with patients who did not discontinue. In multivariable regression models, patients who discontinued were more likely to be hospitalized or have emergency department visits during follow-up.nnnCONCLUSIONSnDiscontinuation of OHAs is common among patients with diabetes and is associated with several patient factors and increased healthcare utilization. Future research should further examine reasons for OHA discontinuation.

Trends in Lipid Screening Among Adults in an Integrated Health Care Delivery System, 2009-2015

BACKGROUNDnLipid screening determines eligibility for statins and other cardiovascular risk reduction interventions.nnnOBJECTIVEnTo examine trends in lipid screening among adults aged ≥20 years in a large, multiethnic, integrated health care delivery system in southern California.nnnMETHODSnTemporal trends in lipid screening were examined from 2009 to 2015 with an index date of September 30 of each year. Lipid screening was defined as the proportion of eligible members each year who (a) had ever been screened among those aged 20-39 years and (b) had been screened in the previous 6 years for those aged ≥ 40 years. Trends were analyzed by age, gender, and the presence of atherosclerotic cardiovascular disease (ASCVD) or diabetes without ASCVD status.nnnRESULTSnMore than 2 million individuals were included each year: 5%-6% had ASCVD (includes those with diabetes), 7%-8% had diabetes without ASCVD, and 87% had neither condition. Among the entire population, lipid screening increased from 79.8% in 2009 to 82.6% in 2015 (P < 0.0001). Among those with ASCVD or diabetes, lipid screening was 99% across all years. Among those without ASCVD or DM, screening increased from 76.9% in 2009 to 80.0% in 2015 (P < 0.0001), with higher screening among women compared with men and lower screening among individuals younger than 55 years.nnnCONCLUSIONSnConsistently high rates of lipid screening were observed among individuals with ASCVD or diabetes. In individuals without these conditions, screening increased over time. However, there is room to further increase screening rates in adults younger than 55 years.nnnDISCLOSURESnThis manuscript and research work was supported by a contractual agreement between the Southern California Permanente Medical Group and Regeneron Pharmaceuticals and Sanofi U.S. Researchers from Regeneron and Sanofi collaborated on the study design, interpretation of data, and writing of the manuscript. Ling Grant, Harrison, Chang, Hsu, Cheetham, Wei, and Reynolds are employed by Kaiser Permanente Southern California. Scott is employed by Southern California Permanente Medical Group. Boklage is employed by Regeneron, and Romo-LeTourneau is employed by Sanofi. Preliminary results from this study were presented at the American Heart Association Scientific Sessions; November 12-16, 2016; New Orleans, LA.

Trends in Statin Use 2009–2015 in a Large Integrated Health System: Pre- and Post-2013 ACC/AHA Guideline on Treatment of Blood Cholesterol

PurposeImplementation of the 2013 ACC/AHA cholesterol treatment guideline is likely to vary by statin benefit group. The aim of this study was to document trends in statin use before and after introduction of the ACC/AHA guideline.MethodsWe conducted a retrospective study with annual cohorts from 2009 to 2015 among members of Kaiser Permanente Southern California aged ≥u200921xa0years. Members were categorized into four mutually exclusive statin benefit groups: atherosclerotic cardiovascular disease (ASCVD), LDL-C ≥u2009190xa0mg/dL in the last year, diabetes (aged 40–75xa0years), and 10-year ASCVD risk ≥u20097.5% (aged 40–75xa0years).ResultsThe cohorts ranged from 1,993,755 members in 2009 to 2,440,429 in 2015. Approximately 5% of patients had ASCVD, 1% had LDL-C ≥u2009190xa0mg/dL, 6% had diabetes, and 10% had a 10-year ASCVD risk ≥u20097.5% each year. Trends in statin use were stable for adults with ASCVD (2009 78%; 2015 80%), recent LDL-C ≥u2009190xa0mg/dL (2009 45%; 2015 44%), and diabetes (2009 74%; 2015 73%), but increased for patients with 10-year ASCVD risk ≥u20097.5% (2009 36%; 2015 47%). High-intensity statin use also increased 142% and 54% among patients with LDL-C ≥u2009190xa0mg/dL and those with ASCVD ≤u200975xa0years of age, respectively. Moderate-to-high intensity statin utilization increased over 50% among those with a 10-year ASCVD risk ≥u20097.5%.ConclusionsStatin use increased substantially among patients with 10-year ASCVD risk ≥u20097.5% and use of appropriate statin dosage increased in each of the four statin benefit groups between 2009 and 2015; however, there is room for improvement.

Low Systolic Blood Pressure From Treatment and Association With Serious Falls/Syncope

INTRODUCTIONnWith the growing emphasis on intensive blood pressure control, the potential for overtreatment and treatment-related adverse outcomes has become an area of interest. A large representative population within a real-world clinical environment with successful hypertension control rates was used to evaluate serious falls and syncope in people with low-treated systolic blood pressure (SBP).nnnMETHODSnA cross-sectional study among medically treated hypertensive individuals within the Kaiser Permanente Southern California health system (2014-2015) was performed. Serious fall injuries and syncope were identified using ICD codes based on emergency department and hospitalization diagnoses. SBPs in a 1-year window were used to compare serious falls and syncope among individuals with SBP <110 mmHg vs ≥110 mmHg. Logistic regression was used to evaluate the association between low minimum and mean SBP and serious falls/syncope after adjustment for demographics, comorbidities, and medications.nnnRESULTSnIn 477,516 treated hypertensive individuals, the mean age was 65 (SD=13) years and the mean SBP was 129 (SD=10) mmHg, with 27% having a minimum SBP <110 mmHg and 3% having mean SBP <110 mmHg. A total of 15,419 (3.2%) individuals experienced a serious fall or syncope or both during the observation window (5.7% among minimum SBP <110 mmHg and 5.4% among mean SBP <110 mmHg). The multivariable ORs for serious falls/syncope were 2.18 (95% CI=2.11, 2.25) for minimum SBP <110 mmHg and 1.54 (95%CI=1.43, 1.66) for mean SBP <110 mmHg compared with SBP ≥110 mmHg.nnnCONCLUSIONSnAmong treated hypertensive patients, both minimum and mean SBP less than 110 mmHg were associated with serious falls and syncope. Low treatment-related blood pressures deserve consideration given the emphasis on intensive blood pressure control.