Tania Tang

Recent Trends in the Identification of Incidental Pulmonary Nodules

RATIONALE Pulmonary nodules are common incidental findings, but information about their incidence in the era of computed tomography (CT) is lacking. OBJECTIVES To examine recent trends in pulmonary nodule identification. METHODS We used electronic health records and natural language processing to identify members of an integrated health system who had nodules measuring 4 to 30 mm. We calculated rates of chest CT imaging, nodule identification, and receipt of a new lung cancer diagnosis within 2 years of nodule identification, and standardized rates by age and sex to estimate the frequency of nodule identification in the U.S. population in 2010. MEASUREMENTS AND MAIN RESULTS Between 2006 and 2012, more than 200,000 adult members underwent 415,581 chest CT examinations. The annual frequency of chest CT imaging increased from 1.3 to 1.9% for all adult members, whereas the frequency of nodule identification increased from 24 to 31% for all scans performed. The annual rate of chest CT increased from 15.4 to 20.7 per 1,000 person-years, and the rate of nodule identification increased from 3.9 to 6.6 per 1,000 person-years, whereas the rate of a new lung cancer diagnosis remained stable. By extrapolation, more than 4.8 million Americans underwent at least one chest CT scan and 1.57 million had a nodule identified, including 63,000 who received a new lung cancer diagnosis within 2 years. CONCLUSIONS Incidental pulmonary nodules are an increasingly common consequence of routine medical care, with an incidence that is much greater than recognized previously. More frequent nodule identification has not been accompanied by increases in the diagnosis of cancerous nodules.

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.

Integrating qualitative research methods into care improvement efforts within a learning health system: addressing antibiotic overuse

BackgroundDespite reports advocating for integration of research into healthcare delivery, scant literature exists describing how this can be accomplished. Examples highlighting application of qualitative research methods embedded into a healthcare system are particularly needed. This article describes the process and value of embedding qualitative research as the second phase of an explanatory, sequential, mixed methods study to improve antibiotic stewardship for acute sinusitis.MethodsPurposive sampling of providers for in-depth interviews improved understanding of unwarranted antibiotic prescribing and elicited stakeholder recommendations for improvement. Qualitative data collection, transcription and constant comparative analyses occurred iteratively.ResultsEmerging themes and sub-themes identified primary drivers of unwarranted antibiotic prescribing patterns and recommendations for improving practice. These findings informed the design of a health system intervention to improve antibiotic stewardship for acute sinusitis. Core components of the intervention are also described.ConclusionQualitative research can be effectively applied in learning healthcare systems to elucidate quantitative results and inform improvement efforts.

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.

A3-1: The Just Do It Playbook for Implementation Science

Background/Aims There are over 60 published implementation science frameworks, and despite the advantages of each, none were designed to help clinicians and administrators to standardize and prioritize initiatives, implement programs efficiently, and evaluate with sufficient rigor. Methods In order to address these limitations, the Care Improvement Research Team (CIRT) at Kaiser Permanente Southern California blended implementation and behavior change frameworks into a structured process to help clinicians, operations leaders and researchers to standardize their approach and accomplish collaborative goals. To develop the “Just Do It Playbook,” we performed a pragmatic literature review, compared and synthesized published frameworks, and iteratively refined a set of steps for identifying, diagnosing and correcting gaps in care. Results The Just Do It Playbook can be simplified into four distinct steps: 1) describe the topic that needs improvement, 2) identify what or who needs to change, 3) develop an implementation strategy to facilitate change, and 4) evaluate the effectiveness of the strategy. The first step helps to prioritize the topic of interest and identifies whether there is a gap between current and best practices. Second, describing what or who needs to improve will enable identification of barriers or facilitators to change. The third step identifies strategies to promote best practices by using established behavior change theories as well as clearly defined and measurable outcomes. The final step evaluates the outcomes, costs and sustainability of the strategy, as well as the need to discontinue efforts, modify and re-evaluate, or disseminate to other settings. Conclusions In a learning health care system, there are many potential targets for improvement, and many strategies for implementation and evaluation. One way to simplify the complexities that inherently exist in health system improvement is to adopt a standardized approach. As clinicians, administrators and researchers forge meaningful collaborations, a standard process can improve the understanding of competing priorities, define roles and responsibilities, and integrate established scientific frameworks in a way that is efficient and sustainable. The Just Do It Playbook will need to be tested and adapted to individual projects, but will provide a platform to build embedded research into a functional operational standard.

Use of Imaging for Staging of Localized Breast Cancer in Two Integrated Health Care Systems: Adherence to 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.

A3-5: Research-Operations Partnerships to Improve the Quality and Affordability of Care

Background/Aims A learning health care organization requires visionary leadership to achieve the triple aim of better health, better care, and improved affordability. Effective research-operations partnerships (ROPs) can facilitate improvement efforts. Although ROPs are not novel, the process of establishing sustainable collaborations and overcoming challenges to achieve shared objectives is not well described. Methods In 2012, the executive leadership of Kaiser Permanente Southern California (KPSC) made a multi-million dollar investment by creating the Care Improvement Research Team (CIRT) within the Department of Research and Evaluation. Members of this team developed and refined ideas about ROPs by reviewing published literature, conducting semi-structured interviews with key operational leaders, consulting with experts, and sponsoring an all-day retreat on this theme. Results Key elements of the initiative include: (1) recruitment of health care researchers with complementary clinical and methodological experience, supported by an expert consultant in implementation science; (2) selection of research questions that are clearly aligned with organizational priorities; (3) development of strong, sustainable relationships with key stakeholders across multiple levels of the organization, through outreach and embedding of researchers in operational work groups; (4) dedication of internal funds to cover effort of research support staff; (5) creation of a strategic plan to define roles, responsibilities, and goals that allow for measurement of the program’s success. Key challenges to overcome include: (1) limited availability of external funds to support research that addresses operational imperatives; (2) mismatched timelines and incentives; (3) legal constraints that hamper data sharing between research and operations; and (4) balancing research rigor with operational relevance. Conclusions Prioritizing competing initiatives, identifying opportunities for early success, and aligning operational priorities with research opportunities will require continued effort. Given the austere external funding environment, novel ways to support delivery system science are needed. The creation of the CIRT at KPSC represents a strategic investment from visionary leaders who embody the credo to “be the best at getting better” and who recognize that the development of strong and sustainable ROPs will be invaluable if we are to achieve the triple aim.