U.S. Filipino Adults Have Elevated Prevalence of Hypertension Across the Adult Lifespan: Findings From a Cross-Sectional Electronic Health Record Study.

Introduction: The prevalence of hypertension increases with age and differs by race and ethnicity. Among U.S. Asian adults, prevalence is higher for Filipino adults than for other major Asian subgroups, but whether this disparity exists across the adult lifespan is unknown. This study examined hypertension prevalence by age decade, comparing Filipino adults with South Asian, Chinese, Black, Hispanic, and White adults. Methods: This cross-sectional study used 2015-2016 electronic health record data from a Northern California integrated healthcare delivery system for 1,839,603 adults aged 30-79 years, including 128,124 Filipino adults. Hypertension was defined by diagnosis codes. Sex-specific prevalence was calculated by race and ethnicity overall and by 10-year age decade from ages 30-39 years to 70-79 years. The prevalence of hypertension among 5 racial and ethnic groups was compared within each decade (with Filipino as the reference), adjusting for age, English language, diabetes, smoking, and weight category. Results: Decade-specific prevalence of hypertension among Filipino men and women, respectively, was 9.7% and 8.5% for ages 30-39 years, 26.0% and 23.9% for ages 40-49 years, 45.9% and 44.4% for ages 50-59 years, 65.4% and 63.9% for ages 60-69 years, and 82.1% and 82.9% for ages 70-79 years. Across all age decades, hypertension prevalence among Filipino adults largely tracked with Black adults and was much higher than among South Asian, Chinese, White, and Hispanic adults. This pattern remained after adjusting for covariates, with the largest differences observed for adults aged <60 years. Conclusions: Similar to Black adults, Filipino adults have persistently higher hypertension prevalence than South Asian, Chinese, Hispanic, and White adults across the adult lifespan. These findings underscore the importance of surveillance and prevention efforts for this high-risk Asian group beginning in early adulthood.

Barriers to Healthcare for Latinx Autistic Children and Adolescents.

PURPOSE: To understand the ways in which autistic Latinx children experience disparities in diagnosis, healthcare, and receipt of specialty services. METHODS: 417 individuals who identified as Latinx caregivers of autistic children who were members of the same integrated healthcare system in Northern California were surveyed. Responses were analyzed using the child's insurance coverage (Government or Commercial) and caregiver's primary language (Spanish or English). RESULTS: Compared to the commercially-insured, government-insured participants accessed several services at a higher rate and were less likely to cite the high cost of co-pays as a barrier. CONCLUSION: There were no significant differences in service access by language status, but Spanish speakers were more likely to cite health literacy as a barrier to receiving care.

Social Risks, Social Needs, and Attitudes Toward Social Health Screening 1 Year Into the COVID-19 Pandemic: Survey of Adults in an Integrated Health Care Delivery System.

Introduction Information about demographic differences in social risks, needs, and attitudes toward social health screening in non-highly vulnerable adult populations is lacking. Methods The authors analyzed data for 2869 Kaiser Permanente Northern California non-Medicaid-covered members aged 35 to 85 who responded to a 2021 English-only mailed/online survey. The survey covered 7 social risk and 11 social needs domains and attitudes toward social health screening. The authors used data weighted to the Kaiser Permanente Northern California membership to estimate prevalence of risks, needs, and screening receptivity in the overall population, by race/ethnicity (White, Black, Latinx, Asian American/Pacific Islander) and age (35-65 years old, 66-85 years old). Multivariable regression was used to evaluate differences between groups. Results Overall, 26% of adults were financially strained, 12% food insecure, 12% housing insecure, and 5% transportation insecure. Additionally, 7%, 8%, and 17% had difficulty paying for utilities, medical expenses, and dental care, respectively. Over 40% of adults wanted help with ≥ 1 social need. Dental care, vision/hearing care, paying for medical expenses and utilities, and managing debt/credit card repayment surpassed food, housing, and transportation needs. Prevalence of social risks and needs was generally higher among middle-aged versus older and Black and Latinx versus White adults. Among the 70% of adults receptive to screening, 85% were willing to complete a questionnaire and 40% were willing to have staff ask questions; 18% did not want to be screened. Conclusion When implementing social health screening in diverse patient populations, the prevalence of social risks and needs, as well as the acceptability of social health screening and screening modalities, will vary among demographic subgroups.

Fostering a High-Functioning Team in Cancer Care Using the 4R Oncology Model: Assessment in a Large Health System and a Blueprint for Other Institutions.

PURPOSE: Delivering cancer care by high-functioning multidisciplinary teams promises to address care fragmentation, which threatens care quality, affects patient outcomes, and strains the oncology workforce. We assessed whether the 4R Oncology model for team-based interdependent care delivery and patient self-management affected team functioning in a large community-based health system. METHODS: 4R was deployed at four locations in breast and lung cancers and assessed along four characteristics of high-functioning teams: recognition as a team internally and externally; commitment to an explicit shared goal; enablement of interdependent work to achieve the goal; and engagement in regular reflection to adapt objectives and processes. RESULTS: We formed an internally and externally recognized team of 24 specialties committed to a shared goal of delivering multidisciplinary care at the optimal time and sequence from a patient-centric viewpoint. The team conducted 40 optimizations of interdependent care (22 for breast, seven for lung, and 11 for both cancers) at four points in the care continuum and established an ongoing teamwork adaptation process. Half of the optimizations entailed low effort, while 30% required high level of effort; 78% resulted in improved process efficiency. CONCLUSION: 4R facilitated development of a large high-functioning team and enabled 40 optimizations of interdependent care along the cancer care continuum in a feasible way. 4R may be an effective approach for fostering high-functioning teams, which could contribute to improving viability of the oncology workforce. Our intervention and taxonomy of results serve as a blueprint for other institutions motivated to strengthen teamwork to improve patient-centered care.

Prospective evaluation of social risks, physical function, and cognitive function in prediction of non-elective rehospitalization and post-discharge mortality.

BACKGROUND: Increasing evidence suggests that social factors and problems with physical and cognitive function may contribute to patients' rehospitalization risk. Understanding a patient's readmission risk may help healthcare providers develop tailored treatment and post-discharge care plans to reduce readmission and mortality. This study aimed to evaluate whether including patient-reported data on social factors; cognitive status; and physical function improves on a predictive model based on electronic health record (EHR) data alone. METHODS: We conducted a prospective study of 1,547 hospitalized adult patients in 3 Kaiser Permanente Northern California hospitals. The main outcomes were non-elective rehospitalization or death within 30 days post-discharge. Exposures included patient-reported social factors and cognitive and physical function (obtained in a pre-discharge interview) and EHR-derived data for comorbidity burden, acute physiology, care directives, prior utilization, and hospital length of stay. We performed bivariate comparisons using Chi-square, t-tests, and Wilcoxon rank-sum tests and assessed correlations between continuous variables using Spearman's rho statistic. For all models, the results reported were obtained after fivefold cross validation. RESULTS: The 1,547 adult patients interviewed were younger (age, p = 0.03) and sicker (COPS2, p < 0.0001) than the rest of the hospitalized population. Of the 6 patient-reported social factors measured, 3 (not living with a spouse/partner, transportation difficulties, health or disability-related limitations in daily activities) were significantly associated (p < 0.05) with the main outcomes, while 3 (living situation concerns, problems with food availability, financial problems) were not. Patient-reported cognitive (p = 0.027) and physical function (p = 0.01) were significantly lower in patients with the main outcomes. None of the patient-reported variables, singly or in combination, improved predictive performance of a model that included acute physiology and longitudinal comorbidity burden (area under the receiver operator characteristic curve was 0.716 for both the EHR model and maximal performance of a random forest model including all predictors). CONCLUSIONS: In this insured population, incorporating patient-reported social factors and measures of cognitive and physical function did not improve performance of an EHR-based model predicting 30-day non-elective rehospitalization or mortality. While incorporating patient-reported social and functional status data did not improve ability to predict these outcomes, such data may still be important for improving patient outcomes.

Understanding differences within ethnic group designation: comparing risk factors and health indicators between Iranian and Arab Americans in Northern California.

BACKGROUND: The Middle Eastern and North African (MENA) ethnic group is a diverse group composed of two primary subsets in the United States: Iranian and Arab Americans. We aimed to compare health risk factors, chronic health conditions, and mental health conditions of Iranian and Arab American adults in Northern California. METHODS: We used cross-sectional electronic health record (EHR) data from a 2016 Northern California health plan study cohort to compare adults classified as Iranian or Arab American based on ethnicity, language, or surname. We produced age-standardized prevalence estimates of obesity, smoking, hyperlipidemia, prediabetes, diabetes, hypertension, depression, and anxiety for Iranian and Arab American men and women by age group (35-44, 45-64, and 65-84) and overall (35-84). We used generalized linear models to calculate prevalence ratios (PR) to compare Iranian and Arab American adults ages 35-84 on all health indicators. RESULTS: Compared to Arab Americans, Iranian Americans had a lower prevalence of obesity (PR: 0.77, 95% confidence interval, CI: 0.73, 0.82), current smoking (PR: 0.80, 95% CI: 0.73, 0.89), and ever smoking (PR: 0.95, 95% CI: 0.91, 0.99), but a higher prevalence of hyperlipidemia (PR: 1.09, 95% CI: 1.06, 1.12), prediabetes (PR: 1.12, 95% CI: 1.09, 1.16), depression (PR; 1.41, 95% CI: 1.30, 1.52), and anxiety (PR: 1.52, 95% CI: 1.42, 1.63). Similar patterns were observed for men and women. CONCLUSION: This work supports the need to collect granular data on race and ethnicity within the MENA ethnic group to improve identification in clinical care settings and population health reporting to better address the physical and mental health needs of different MENA subgroups.

Health Risks and Chronic Health Conditions among Arab American and White Adults in Northern California.

Objectives: To characterize the prevalence of chronic cardiovascular conditions and risk factors among Arab American adults stratified by sex and compare these with non-Hispanic Whites. Design: Cross-sectional study using electronic health record data from visits between January 2015 and December 2016. Age-adjusted prevalence estimates were calculated for men and women and compared using generalized linear models. Setting: Kaiser Permanente health plan in Northern California. Participants: Non-Hispanic White (N=969,566) and Arab American (N=18,072) adult members. Main Outcome Measures: Sex-stratified prevalence and prevalence ratios of diabetes, pre-diabetes, hypertension, and hyperlipidemia diagnosed by December 2016 and of obesity, ever smoking, and current smoking status. Results: Arab American men had a significantly higher prevalence of ever smoking (41.8 vs 40.8%), diabetes (17.3 vs 12.5%), and hyperlipidemia (40.8 vs 34.7%) than White men, but a significantly lower prevalence of obesity (34.4 vs 37.8%) and hypertension (30.5 vs 33.3%). Arab American women had a significantly higher prevalence of diabetes (11.1 vs 8.7%) and hyperlipidemia (31.5 vs 28.3%) than White women but significantly lower prevalence of obesity (31.0 vs 34.2%), ever smoking (24.8 vs 34.5%), and hypertension (25.8 vs 28.4%). Conclusions: Hospital and health systems should intentionally collect data on Middle Eastern and North African ethnicity in electronic health records to identify and reduce the disparities this minority group faces.

Oral Health Care: A Missing Pillar of Total Health Care?

INTRODUCTION: Oral health is an important component of overall health, and preventive dental care is essential for maintaining good oral health. However, many patients face significant barriers to preventive dental care. We examined prevalence of and factors associated with no recent preventive dental care in an adult health plan population. METHODS: For this cross-sectional study, we used data for 19,672 Kaiser Permanente members aged 25-85 who participated in the 2014/2015 or 2017 Member Health Survey (MHS) and 20,329 Medicaid members who completed an intake questionnaire. We estimated percentages of adults with no preventive dental care (teeth cleaning and examination by a dental professional) in the prior 12 months, overall and among four racial groups, by age, sex, education, income, and dental care cost factors. We used logistic regression to model associations of sociodemographic and cost factors with no preventive dental care. We also examined lack of preventive dental care in subgroups at elevated risk for periodontal disease. RESULTS: Overall prevalence of no preventive dental care was 21%, with significant differences by race (non-Hispanic White, 19.6%; African-American/Black, 29.3%; Latinx, 24.9%, Asian American/Pacific Islander, 19.6%). Adults with lower educational attainment and household income and dental care cost barriers were more likely to lack preventive dental care. Racial and socioeconomic factors remained significant in the multivariable models. Lack of preventive dental care was fairly common among adults with diabetes, prediabetes, hypertension, smokers, frequent consumption of sugary beverages, and Medicaid coverage. CONCLUSION: Oral health care should be better integrated with primary medical care to promote adult total health.

Racial-ethnic differences in prevalence of social determinants of health and social risks among middle-aged and older adults in a Northern California health plan.

BACKGROUND: Social determinants of health (SDoHs) and social risks (SRs) have been associated with adverse health and healthcare utilization and racial/ethnic disparities. However, there is limited information about the prevalence of SRs in non-"safety net" adult populations and how SRs differ by race/ethnicity, age, education, and income. METHODS: We analyzed weighted survey data for 16,247 White, 1861 Black, 2895 Latino, 1554 Filipino, and 1289 Chinese adults aged 35 to 79 who responded to the 2011 or 2014/2015 Kaiser Permanente Northern California Member Health Survey. We compared age-standardized prevalence estimates of SDoHs (education, household income, marital status) and SRs (financial worry, cost-related reduced medication use and fruit/vegetable consumption, chronic stress, harassment/discrimination, health-related beliefs) across racial/ethnic groups for ages 35 to 64 and 65 to 79. RESULTS: SDoHs and SRs differed by race/ethnicity and age group, and SRs differed by levels of education and income. In both age groups, Blacks, Latinos, and Filipinos were more likely than Whites to be in the lower income category and be worried about their financial situation. Compared to Whites, cost-related reduced medication use was higher among Blacks, and cost-related reduced fruit/vegetable consumption was higher among Blacks and Latinos. Younger adults were more likely than older adults to experience chronic stress and financial worry. Racial/ethnic disparities in income were observed within similar levels of education. Differences in prevalence of SRs by levels of education and income were wider within than across racial/ethnic groups. CONCLUSIONS: In this non-"safety net" adult health plan population, Blacks, Latinos, and Filipinos had a higher prevalence of social risks than Whites and Chinese, and prevalence of social risks differed by age group. Our results support the assessment and EHR documentation of SDoHs and social risks and use of this information to understand and address drivers of racial/ethnic disparities in health and healthcare use.

Association of Social and Behavioral Risk Factors With Earlier Onset of Adult Hypertension and Diabetes.

Importance: The National Academy of Medicine has recommended incorporating information on social and behavioral factors associated with health, such as educational level and exercise, into electronic health records, but questions remain about the clinical value of doing so. Objective: To examine whether National Academy of Medicine-recommended social and behavioral risk factor domains are associated with earlier onset of hypertension and/or diabetes in a clinical population. Design, Setting, and Participants: This prospective cohort study used data collected from April 1, 2005, to December 31, 2016, from a population-based sample of 41 745 patients from 4 cycles of Kaiser Permanente Northern California's Adult Member Health Survey, administered to members at 19 Kaiser Permanente Northern California medical center service populations. The study used Kaplan-Meier survival tables and Cox proportional hazards regression analysis to estimate the onset of hypertension and diabetes among patients with no indication of disease at baseline. Data analysis was performed from June 2, 2017, to March 26, 2019. Exposures: Race/ethnicity, educational level, financial worry, partnership status, stress, intimate partner violence, concentrated neighborhood poverty, depressive symptoms, infrequent exercise, smoking, heavy alcohol consumption, and cumulative social and behavioral risk. Main Outcomes and Measures: Onset of hypertension and diabetes during the 3.5 years after survey administration. Results: The study included 18 133 people without baseline hypertension (mean [SD] age, 48.1 [15.3] years; 10 997 [60.7%] female; and 11 503 [63.4%] white) and 35 788 people without baseline diabetes (mean [SD] age, 56.2 [16.9] years; 20 191 [56.4%] female; and 24 351 [68.0%] white). There was a dose-response association between the number of social and behavioral risk factors and likelihood of onset of each condition. Controlling for age, sex, race/ethnicity, body mass index, and survey year, hazard ratios (HRs) comparing those with 3 or more risk factors with those with 0 risk factor were 1.41 (95% CI, 1.17-1.71) for developing hypertension and 1.53 (95% CI, 1.29-1.82) for developing diabetes. When the same covariates were adjusted for, having less than a high school educational level (hazard ratio [HR], 1.84; 95% CI, 1.40-2.43), being widowed (HR, 1.38; 95% CI, 1.11-1.71), concentrated neighborhood poverty (HR, 1.26; 95% CI, 1.00-1.59), infrequent exercise (HR, 1.22; 95% CI, 1.08-1.38), and smoking (HR, 1.35; 95% CI, 1.10-1.67) were significantly associated with hypertension onset. Having less than a high school educational level (HR, 1.58; 95% CI, 1.26-1.97), financial worry (HR, 1.29; 95% CI, 1.13-1.46), being single or separated (HR, 1.24; 95% CI, 1.08-1.42), high stress (HR, 1.28; 95% CI, 1.09-1.51), intimate partner violence (HR, 1.68; 95% CI, 1.14-2.48), concentrated neighborhood poverty (HR, 1.31; 95% CI, 1.07-1.60), depressive symptoms (HR, 1.28; 95% CI, 1.10-1.50), and smoking (HR, 1.53; 95% CI, 1.27-1.86) were significantly associated with diabetes onset, although heavy alcohol consumption was associated with protection (HR, 0.75; 95% CI, 0.66-0.85) rather than risk. Conclusions and Relevance: Independent of traditional risk factors, individual and cumulative social and behavioral risk factor exposures were associated with onset of hypertension and diabetes within 3.5 years in a clinical setting. The findings support the value of assessing social and behavioral risk factors to help identify high-risk patients and of providing targets for intervention.

Sociodemographic Determinants of Health and Well-Being Among Adults Residing in the Combined Kaiser Permanente Regions.

CONTEXT: Kaiser Permanente commissioned a health and well-being (HWB) survey of adult members and nonmembers in its 8 Regions. OBJECTIVE: To estimate the prevalence of HWB indicators and evaluate differences in prevalence of excellent/very good (E/VG) health and thriving overall in life (thriving) by race/ethnicity, age group, sex, education, and financial situation. DESIGN: Cross-sectional survey conducted by email and phone during Winter 2016-2017 with a racial/ethnic group-stratified quota sample. Participants (N = 26,304) provided sociodemographic characteristics and ratings for 6 HWB indicators. Using population-weighted data, we estimated the prevalence of HWB indicators and used logistic regression models to test for differences in E/VG health and thriving by sociodemographic factors. MAIN OUTCOME MEASURES: Overall health and overall life evaluation. RESULTS: Of adults, 52% were in E/VG health and 63% were thriving. Blacks were less likely to be in E/VG health than whites, Hispanics, and Asian/Pacific Islanders, but there was little racial/ethnic variation in those who were thriving. E/VG health and thriving varied significantly by level of education and financial situation. Across all racial/ethnic groups, large differences in percentages were observed in E/VG health and thriving between the lowest and highest levels of education and financial situation but little racial/ethnic variation within education and financial situation strata. CONCLUSION: Differences in health status and life evaluation are associated very strongly with financial situation and educational attainment, and these social determinants partially explain racial/ethnic disparities in HWB. The lack of strong correlation of health status and life evaluation suggests these are different domains of well-being.

Sexual Orientation Disparities in Physical Activity: Results From Insured Adults in California.

BACKGROUND: The majority of adults in the United States fail to meet the Centers for Disease Control and Prevention (CDC) physical activity (PA) guideline recommendations for health promotion. Despite evidence of disparities by sexual orientation in adverse health outcomes related to PA, little is known about whether PA patterns and the likelihood of meeting these guidelines differ between heterosexual and sexual minority (SM) men and women. METHODS: In 2018, we pooled unweighted respondent data from Kaiser Permanente Northern California Member Health Surveys conducted in 2008, 2011, and 2014/15 (N=42,534) to compare PA patterns among heterosexual and SM men and women. RESULTS: In total, 38.8% of heterosexual men, 43.4% of SM men, 32.9% of heterosexual women, and 40.0% of SM women meet the CDC PA guidelines, yet there was no statistically significant difference in the adjusted odds of meeting these guidelines. Compared with heterosexual women, SM women engage in PA more frequently [odds ratio=0.81; 95% confidence interval (CI), 0.74-0.89], for more minutes per week on average (12.71; 95% CI, 4.85-20.57), and at higher levels of intensity (relative risk ratio=1.26; 95% CI, 1.02-1.56). Compared with heterosexual men, SM men engage in PA more frequently (OR=0.85; 95% CI, 0.74-0.98), for fewer minutes per week on average (-12.89; 95% CI, -25.84 to 0.06), and at lower levels of intensity (relative risk ratio=0.83; 95% CI, 0.67-0.99). CONCLUSIONS: We find that SMs get more frequent PA than their heterosexual peers, which suggests that the higher prevalence of obesity and other PA-related adverse health outcomes among SMs may be due to factors other than PA patterns.

Understanding functional and social risk characteristics of frail older adults: a cross-sectional survey study.

BACKGROUND: Frailty is a condition of increasing importance, given the aging adult population. With an anticipated shortage of geriatricians, primary care physicians will increasingly need to manage care for frail adults with complex functional risks and social-economic circumstances. METHODS: We used cross-sectional data from 4551 adults ages 65-90 who responded to the 2014/2015 cycle of the Kaiser Permanente Northern California Member Health Survey (MHS), a self-administered survey that covers multiple health and social characteristics, to create a deficits accumulation model frailty index, classify respondents as frail or non-frail, and then compare prevalence of functional health issues including Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL) and social determinants of health (SDOHs) by frailty status. RESULTS: The overall prevalence of frailty was 14.3%, higher for women than men, increased with age, and more common among those with low levels of education and income. Frail older adults were more likely than non-frail to have ≥ 3 chronic diseases (55.9% vs. 10.1%), obesity (32.7% vs. 22.8%), insomnia (36.4% vs. 8.8%), oral health problems (25.1% vs. 4.7%), balance or walking problems (54.2% vs. 4.9%), ≥ 1 fall (56.1% vs. 19.7%), to use ≥ 1 medication known to increase fall risk (56.7% vs. 26.0%), and to need help with ≥2 ADLs (15.8% vs. 0.8%) and ≥ 2 IADLs (38.4% vs. 0.8%). They were more likely to feel financial strain (26.9% vs. 12.6%) and to use less medication than prescribed (7.4% vs. 3.6%), less medical care than needed (8.3% vs 3.7%), and eat less produce (9.5% vs. 3.2%) due to cost. Nearly 20% of frail adults were unpaid caregivers for an adult with frailty, serious illness or disability. CONCLUSIONS: This study examined the prevalence of frailty and identified modifiable and non-modifiable risk factors of health. The frail older adult population is heterogeneous and requires a patient-centered assessment of their circumstances by healthcare providers and caregivers to improve their quality of life, avoid adverse health events, and slow physical and mental decline. The characteristics identified in this study can be proactively used for the assessment of patient health, quality of life, and frailty prevention.

Older adults' readiness to engage with eHealth patient education and self-care resources: a cross-sectional survey.

BACKGROUND: This study examined access to digital technologies, skills and experience, and preferences for using web-based and other digital technologies to obtain health information and advice among older adults in a large health plan. A primary aim was to assess the extent to which digital divides by race/ethnicity and age group might affect the ability of a large percentage of seniors, and especially those in vulnerable groups, to engage with online health information and advice modalities (eHIA) and mobile health (mHealth) monitoring tools. METHODS: A mailed survey was conducted with age-sex stratified random samples of English-speaking non-Hispanic white, African-American/black (black), Hispanic/Latino (Latino), Filipino-American (Filipino), and Chinese-American (Chinese) Kaiser Permanente Northern California members who were aged 65-79 years. Respondent data were weighted to the study population for the cross-sectional analyses. RESULTS: Older seniors and black, Latino, and Filipino seniors have less access to digital tools, less experience performing a variety of online tasks, and are less likely to believe that they would be capable of going online for health information and advice compared to younger and white Non-Hispanic seniors. Consequently, they are also less likely to be interested in using eHIA modalities. CONCLUSIONS: The same subgroups of seniors that have previously been shown to have higher prevalence of chronic conditions and greater difficulties with healthcare access are also less likely to adopt use of eHIA and mHealth monitoring technologies. At the patient population level, this digital divide is important to take into account when planning health information and chronic disease management programs. At the individual patient level, to provide good patient-centered care, it is important for providers to assess rather than assume digital access, eHealth skills, and preferences prior to recommending use of web-based resources and mHealth tools.

Racial-Ethnic Differences in Fall Prevalence among Older Women: A Cross-Sectional Survey Study.

BACKGROUND: Falls are the leading cause of hip fracture in older women, with important public health implications. Fall risk increases with age and other clinical factors, and varies by race/ethnicity. International studies suggest that fall risk is lower in Asians, although data are limited in U.S. POPULATIONS: This study examines racial/ethnic differences in fall prevalence among older U.S. women within a large integrated healthcare delivery system. METHODS: This cross-sectional study used data from 6277 women ages 65-90 who responded to the 2008 or 2011 Kaiser Permanente Northern California Member Health Survey (KPNC-MHS). The KPNC-MHS is a mailed questionnaire sent to a random sample of adult members stratified by age, gender, and geographic location, representing a population estimate of >200,000 women age ≥65 years. Age, race/ethnicity, self-reported health status, presence of diabetes, arthritis or prior stroke, mobility limitations and number of falls in the past year were obtained from the KPNC-MHS. The independent association of race/ethnicity and recent falls was examined, adjusting for known risk factors. RESULTS: The weighted sample was 76.7% non-Hispanic white, 6.2% Hispanic, 6.8% black and 10.3% Asian. Over 20% reported having fallen during the past year (28.5% non-Hispanic white, 27.8% Hispanic, 23.4% black and 20.1% Asian). Older age was associated with greater fall risk, as was having diabetes (OR 1.24, CI 1.03-1.48), prior stroke (OR 1.51, CI 1.09-2.07), arthritis (OR 1.61, CI 1.39-1.85) and mobility limitations (OR 2.82, CI 2.34-3.39), adjusted for age. Compared to whites, Asian (OR 0.64, CI 0.50-0.81) and black (OR 0.73, CI 0.55-0.95) women were much less likely to have ≥1 fall in the past year, adjusting for age, comorbidities, mobility limitation and poor health status. Asians were also less likely to have ≥2 falls (OR 0.62, CI 0.43-0.88). CONCLUSIONS: Among older women, the risk of having a recent fall was substantially lower for black and Asian women when compared to white women. This may contribute to their lower rates of hip fracture. Future studies should examine cultural and behavioral factors that contribute to these observed racial/ethnic differences in fall risk among U.S. women.

The Kaiser Permanente Northern California Adult Member Health Survey.

INTRODUCTION: The Kaiser Permanente Northern California (KPNC) Member Health Survey (MHS) is used to describe sociodemographic and health-related characteristics of the adult membership of this large, integrated health care delivery system to monitor trends over time, identify health disparities, and conduct research. OBJECTIVE: To provide an overview of the KPNC MHS and share findings that illustrate how survey statistics and data have been and can be used for research and programmatic purposes. METHODS: The MHS is a large-scale, institutional review board-approved survey of English-speaking KPNC adult members. The confidential survey has been conducted by mail triennially starting in 1993 with independent age-sex and geographically stratified random samples, with an option for online completion starting in 2005. The full survey sample and survey data are linkable at the individual level to Health Plan and geocoded data. Respondents are assigned weighting factors for their survey year and additional weighting factors for analysis of pooled survey data. RESULTS: Statistics from the 1999, 2002, 2005, 2008, and 2011 surveys show trends in sociodemographic and health-related characteristics and access to the Internet and e-mail for the adult membership aged 25 to 79 years and for 6 age-sex subgroups. Pooled data from the 2008 and 2011 surveys show many significant differences in these characteristics across the 5 largest race/ethnic groups in KPNC (non-Hispanic whites, blacks, Latinos, Filipinos, and Chinese). CONCLUSION: The KPNC MHS has yielded unique insights and provides an opportunity for researchers and public health organizations outside of KPNC to leverage our survey-generated statistics and collaborate on epidemiologic and health services research studies.

The Digital Divide and Patient Portals: Internet Access Explained Differences in Patient Portal Use for Secure Messaging by Age, Race, and Income.

BACKGROUND: Online access to health records and the ability to exchange secure messages with physicians can improve patient engagement and outcomes; however, the digital divide could limit access to web-based portals among disadvantaged groups. OBJECTIVES: To understand whether sociodemographic differences in patient portal use for secure messaging can be explained by differences in internet access and care preferences. RESEARCH DESIGN: Cross-sectional survey to examine the association between patient sociodemographic characteristics and internet access and care preferences; then, the association between sociodemographic characteristics and secure message use with and without adjusting for internet access and care preference. SUBJECTS: One thousand forty-one patients with chronic conditions in a large integrated health care delivery system (76% response rate). MEASURES: Internet access, portal use for secure messaging, preference for in-person or online care, and sociodemographic and health characteristics. RESULTS: Internet access and preference mediated some of the differences in secure message use by age, race, and income. For example, using own computer to access the internet explained 52% of the association between race and secure message use and 60% of the association between income and use (Sobel-Goodman mediation test, P<0.001 for both). Education and sex-related differences in portal use remained statistically significant when controlling for internet access and preference. CONCLUSIONS: As the availability and use of patient portals increase, it is important to understand which patients have limited access and the barriers they may face. Improving internet access and making portals available across multiple platforms, including mobile, may reduce some disparities in secure message use.

Differences in Access to and Preferences for Using Patient Portals and Other eHealth Technologies Based on Race, Ethnicity, and Age: A Database and Survey Study of Seniors in a Large Health Plan.

BACKGROUND: Patients are being encouraged to go online to obtain health information and interact with their health care systems. However, a 2014 survey found that less than 60% of American adults aged 65 and older use the Internet, with much lower usage among black and Latino seniors compared with non-Hispanic white seniors, and among older versus younger seniors. OBJECTIVE: Our aims were to (1) identify race/ethnic and age cohort disparities among seniors in use of the health plan's patient portal, (2) determine whether race/ethnic and age cohort disparities exist in access to digital devices and preferences for using email- and Web-based modalities to interact with the health care system, (3) assess whether observed disparities in preferences and patient portal use are due simply to barriers to access and inability to use the Internet, and (4) learn whether older adults not currently using the health plan's patient portal or website have a potential interest in doing so in the future and what kind of support might be best suited to help them. METHODS: We conducted two studies of seniors aged 65-79 years. First, we used administrative data about patient portal account status and utilization in 2013 for a large cohort of English-speaking non-Hispanic white (n=183,565), black (n=16,898), Latino (n=12,409), Filipino (n=11,896), and Chinese (n=6314) members of the Kaiser Permanente Northern California health plan. Second, we used data from a mailed survey conducted in 2013-2014 with a stratified random sample of this population (final sample: 849 non-Hispanic white, 567 black, 653 Latino, 219 Filipino, and 314 Chinese). These data were used to examine race/ethnic and age disparities in patient portal use and readiness and preferences for using digital communication for health-related purposes. RESULTS: Adults aged 70-74 and 75-79 were significantly less likely than 65-69 year olds to be registered to use the patient portal, and among those registered, to have used the portal to send messages, view lab test results, or order prescription refills. Across all age groups, non-Hispanic whites and Chinese seniors were significantly more likely than black, Latino, and Filipino seniors to be registered and to have performed these actions. The survey found that black, Latino, and Filipino seniors and those 75 years old and older were significantly less likely to own digital devices (e.g., computers, smartphones), use the Internet and email, and be able and willing to use digital technology to perform health care-related tasks, including obtaining health information, than non-Hispanic whites, Chinese, and younger seniors (aged 65-69), respectively. The preference for using non-digital modalities persisted even among Internet users. CONCLUSIONS: Health plans, government agencies, and other organizations that serve diverse groups of seniors should include social determinants such as race/ethnicity and age when monitoring trends in eHealth to ensure that eHealth disparities do not induce greater health status and health care disparities between more privileged and less privileged groups.

Factors associated with use and non-use of the Fecal Immunochemical Test (FIT) kit for Colorectal Cancer Screening in Response to a 2012 outreach screening program: a survey study.

BACKGROUND: The one-sample fecal immunochemical test (FIT) is gaining popularity for colorectal cancer (CRC) screening of average-risk people. However, uptake and annual use remain suboptimal. METHODS: In 2013, we mailed questionnaires to three groups of nonHispanic White, Black, and Latino Kaiser Permanente Northern California (KPNC) members ages 52-76 who received FIT kits in 2010-2012: Continuers did the FIT all 3 years; Converts in 2012, but not 2010 or 2011; and Nonusers in none of the 3 years. The questionnaires covered social influences, perceived CRC risk, reasons for using (Continuers, Converts) or avoiding using (Nonusers) the FIT, and recommendations for improving the kit. RESULTS: Continuers (n = 607, response rate 67.5%), Converts (n = 317, response rate 35.6%), and Nonusers (n = 215, response rate 21.1%) did not differ in perceived risk or family history of CRC, but Nonusers were less likely than Continuers and Converts to know someone who had polyps or CRC. Continuers, Converts, and Nonusers did not differ in social network encouragement of CRC screening, but did differ in believing that it was very important that they be screened (88.3%, 68.4%, 47.7%) and that their medical team thought it very important that they be screened (88.6%, 79.9%, 53.9%). Approximately half of Continuers and Converts completed the FIT to please their doctor. Converts were less likely than Continuers to use the FIT to "make sure they were OK" (53.7% vs. 72.6%) or "protect their health" (46.1% vs. 76.4%). Nearly half of Converts completed the FIT out of guilt. Approximately half of FIT kit users suggested adding a disposable glove, extra paper, and wider-mouth tube to the kit. Nonusers' reasons for not using the FIT included discomfort, disgust, or embarrassment (59.6%); thinking it unnecessary (32.9%); fatalism/fear (15.5%); and thinking it too difficult to use (14.5%), but <10% did not want CRC screening at all. CONCLUSIONS: Nonusers and irregular users of the FIT are less intrinsically motivated to get CRC screening than long-term users and more averse to preparing their stool sample. Changes to the FIT kit to address discomfort and difficulty factors might improve uptake and continued use.

Patient-initiated e-mails to providers: associations with out-of-pocket visit costs, and impact on care-seeking and health.

OBJECTIVES: To understand when patients use secure e-mail messaging with healthcare providers across several types of questions or concerns, associations between out-of-pocket costs for in-person visits and use of secure messaging, and to examine patient-reported impacts on care-seeking behavior and overall health. STUDY DESIGN: Cross-sectional survey of patients in an integrated healthcare delivery system, with access to a patient portal to send secure e-mail messages to providers at no out-of-pocket cost. METHODS: The study included patients with a chronic condition (N = 1041). We described patient-reported preferences for contacting providers and patient-reported impact of e-mail use on phone calls, in-person visits, and overall health. We used multivariate analyses to examine patient characteristics associated with using e-mail as a first contact method, and effects on care-seeking and health. RESULTS: Overall, 56% of patients sent their provider an e-mail within 1 year, and 46% reported e-mail as their first method of contact for 1 or more types of medical concerns. After adjustment, higher out-of-pocket costs for in-person visits were significantly associated with choosing e-mail as a first method of contact (P < .05). Among patients who had e-mailed their provider, 42% reported that it reduced their phone contacts, 36% reduced in-person office visits and 32% reported e-mailing improved their overall health. CONCLUSIONS: Patients reported using e-mail broadly to initiate conversations with their providers, and patients with higher out-of-pocket costs for in-person visits were more likely to choose e-mail as a first contact method. Use of secure e-mails reduced patients' use of other types of healthcare and resulted in improved overall health.