Clinical Outcomes Following Regionalization of Gastric Cancer Care in a US Integrated Health Care System.

PURPOSE: In 2016, Kaiser Permanente Northern California regionalized gastric cancer care, introducing a regional comprehensive multidisciplinary care team, standardizing staging and chemotherapy, and implementing laparoscopic gastrectomy and D2 lymphadenectomy for patients eligible for curative-intent surgery. This study evaluated the effect of regionalization on outcomes. METHODS: The retrospective cohort study included gastric cancer cases diagnosed from January 2010 to May 2018. Information was obtained from the electronic medical record, cancer registry, state vital statistics, and chart review. Overall survival was compared in patients with all stages of disease, stage I-III disease, and curative-intent gastrectomy patients using annual inception cohorts. For the latter, the surgical approach and surgical outcomes were also compared. RESULTS: Among 1,429 eligible patients with gastric cancer with all stages of disease, one third were treated after regionalization, 650 had stage I-III disease, and 394 underwent curative-intent surgery. Among surgical patients, neoadjuvant chemotherapy utilization increased from 35% to 66% (P < .0001), laparoscopic gastrectomy increased from 18% to 92% (P < .0001), and D2 lymphadenectomy increased from 2% to 80% (P < .0001). Dissection of ≥ 15 lymph nodes increased from 61% to 95% (P < .0001). Surgical complication rates did not appear to increase after regionalization. Length of hospitalization decreased from 7 to 3 days (P < .001). Overall survival at 2 years was as follows: all stages, 32.8% pre and 37.3% post (P = .20); stage I-III cases with or without surgery, 55.6% and 61.1%, respectively (P = .25); and among surgery patients, 72.7% and 85.5%, respectively (P < .03). CONCLUSION: Regionalization of gastric cancer care within an integrated system allowed comprehensive multidisciplinary care, conversion to laparoscopic gastrectomy and D2 lymphadenectomy, increased overall survival among surgery patients, and no increase in surgical complications.

Use of complementary and alternative medicine by the adult membership of a large northern California health maintenance organization, 1999.

Data from general health surveys completed by random samples of adult members of a large Northern California health maintenance organization in 1996 and 1999 were used to investigate (a) the prevalence of use of 15 complementary and alternative medicine (CAM) modalities by adult members in 1999, (b) how prevalence varied by age group and gender, and (c) which modalities were increasing in popularity. While Northern California is not representative of the nation as a whole, it tends to be a harbinger of trends to come. The most widely used modalities in 1999 were herbal and other nonvitamin/nonmineral nutritional supplements, prayer/spiritual healing done by oneself, chiropractic, massage therapy, and mind-body medicine modalities. However, use of the different modalities varied significantly by age and gender, and rates of use of nutritional supplements and the manipulatives were approximately doubled, when restricted to subpopulations at high risk, for use because of relevant health conditions. There appeared to be a statistically significant, but modest increase in CAM use, mostly due to a large increase in use of nutritional supplements. Implications for how CAM use should be tracked for ambulatory care populations and the importance of addressing nutritional supplement use in ambulatory clinical care are discussed.