Comparative Trends in Heart Disease, Stroke, and All-Cause Mortality in the United States and a Large Integrated Healthcare Delivery System.

OBJECTIVES: Heart disease and stroke remain among the leading causes of death nationally. We examined whether differences in recent trends in heart disease, stroke, and total mortality exist in the United States and Kaiser Permanente Northern California (KPNC), a large integrated healthcare delivery system. METHODS: The main outcome measures were comparisons of US and KPNC total, age-specific, and sex-specific changes from 2000 to 2015 in mortality rates from heart disease, coronary heart disease, stroke, and all causes. The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system was used to determine US mortality rates. Mortality rates for KPNC were determined from health system, Social Security vital status, and state death certificate databases. RESULTS: Declines in age-adjusted mortality rates were noted in KPNC and the United States for heart disease (36.3% in KPNC vs 34.6% in the United States), coronary heart disease (51.0% vs 47.9%), stroke (45.5% vs 38.2%), and all-cause mortality (16.8% vs 15.6%). However, steeper declines were noted in KPNC than the United States among those aged 45 to 65 years for heart disease (48.3% KPNC vs 23.6% United States), coronary heart disease (55.6% vs 35.9%), stroke (55.8% vs 26.0%), and all-cause mortality (31.5% vs 9.1%). Sex-specific changes were generally similar. CONCLUSIONS: Despite significant declines in heart disease and stroke mortality, there remains an improvement gap nationally among those aged less than 65 years when compared with a large integrated healthcare delivery system. Interventions to improve cardiovascular mortality in the vulnerable middle-aged population may play a key role in closing this gap.

25-Year Physical Activity Trajectories and Development of Subclinical Coronary Artery Disease as Measured by Coronary Artery Calcium: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.

OBJECTIVE: To evaluate 25-year physical activity (PA) trajectories from young to middle age and assess associations with the prevalence of coronary artery calcification (CAC). PATIENTS AND METHODS: This study includes 3175 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study who self-reported PA by questionnaire at 8 follow-up examinations over 25 years (from March 1985-June 1986 through June 2010-May 2011). The presence of CAC (CAC>0) at year 25 was measured using computed tomography. Group-based trajectory modeling was used to identify PA trajectories with increasing age. RESULTS: We identified 3 distinct PA trajectories: trajectory 1, below PA guidelines (n=1813; 57.1%); trajectory 2, meeting PA guidelines (n=1094; 34.5%); and trajectory 3, 3 times PA guidelines (n=268; 8.4%). Trajectory 3 participants had higher adjusted odds of CAC>0 (adjusted odds ratio [OR], 1.27; 95% CI, 0.95-1.70) vs those in trajectory 1. Stratification by race showed that white participants who engaged in PA 3 times the guidelines had higher odds of developing CAC>0 (OR, 1.80; 95% CI, 1.21-2.67). Further stratification by sex showed higher odds for white males (OR, 1.86; 95% CI, 1.16-2.98), and similar but nonsignificant trends were noted for white females (OR, 1.71; 95% CI, 0.79-3.71). However, no such higher odds of CAC>0 for trajectory 3 were observed for black participants. CONCLUSION: White individuals who participated in 3 times the recommended PA guidelines over 25 years had higher odds of developing coronary subclinical atherosclerosis by middle age. These findings warrant further exploration, especially by race, into possible biological mechanisms for CAC risk at very high levels of PA.

Bariatric surgery results: reporting clinical characteristics and adverse outcomes from an integrated healthcare delivery system.

BACKGROUND: Limited data have been reported on bariatric surgery within a large, high-volume regional multicenter integrated healthcare delivery system. OBJECTIVES: Review clinical characteristics and short- and intermediate-term outcomes and adverse events from a bariatric surgery program within an integrated healthcare delivery system. SETTING: Single high-volume, multicenter regional integrated healthcare delivery system. METHODS: Adult patients who underwent primary bariatric surgery during 2010-2011 were reviewed. Clinical characteristics, outcomes, and weight loss results were extracted from the electronic medical record. RESULTS: A total of 2399 patients were identified within the study period. The 30-day rates of clinical outcomes for Roux-en-Y gastric bypass (RYGB; n = 1313) and sleeve gastrectomy (SG; n = 1018) were 2.9% for readmission, 3.0% for major complications, .8% for reoperation, and 0% for mortality. One-year and 2-year weight loss results were as follows: percent weight loss (%WL) was 31.4 (±SD 8.5) and 34.2±12.0% for SG and 34.1±9.3 and 39.1±11.9 for RYGB; percent excess weight loss (%EBWL) was 64.2±18.0 and 69.8±23.7 for SG and 68.0±19.3 and 77.8±23.7 for RYGB; percent excess body mass index loss (%EBMIL) was 72.9±21.0 and 77.7±22.4 for SG and 76.6±22.1% and 85.6±21.6 for RYGB. Follow-up for each procedure at 1 year was 76% for SG (n = 778) and 80% for RYGB (n = 1052) and at 2 years was 65% for SG (n = 659) and 67% for RYGB (n = 875). CONCLUSIONS: A large regional high-volume multicenter bariatric program within an integrated healthcare delivery system can produce excellent short-term results with low rates of short- and intermediate-term adverse outcomes.

Effects of the September 11th attacks on urgent and emergent medical evaluations in a Northern California managed care plan.

PURPOSE: To determine whether the terrorist attacks on September 11, 2001, affected the health of persons far from the attacks, we studied rates of urgent and emergency medical evaluations among the 3 million persons enrolled in a managed care plan in Northern California. METHODS: Using a computerized database of all urgent care and emergency department evaluations, we monitored physician diagnoses made during the 6 weeks before and after September 11, 2001, at 16 hospitals in the Kaiser Permanente Medical Care Program. Actual rates of evaluations and diagnoses were compared with expected rates based on similar periods in 1998, 1999, and 2000. RESULTS: There were 4260 fewer urgent and emergent medical evaluations than expected during the 6 weeks beginning September 11, 2001 (-4%; 95% confidence interval [CI]: -3% to -5%; P <0.0001; N = 95,603). Emergency department visits occurred at the expected rate (-1%; 95% CI: -2% to 1%; P = 0.34), but urgent care visits were reduced (-9%; 95% CI: -8% to -11%; P <0.0001). Evaluations were particularly less frequent during the week beginning September 11 (-7%; 95% CI: -4% to -9%; P <0.0001), but a decrease persisted afterwards. Compared with expected rates, injuries (P <0.0001) and ill-defined/symptom-related diagnoses (P <0.0001) were less frequent, while gastrointestinal diagnoses (P = 0.01) were more frequent, during the 6 weeks after the attacks. Total urgent and emergent evaluations were mostly unchanged on September 11; only diagnoses associated with cardiac ischemia were more frequent (+70%; 95% CI: 10% to 163%; P = 0.02). CONCLUSION: Total urgent and emergent medical evaluations in a California managed care plan were reduced during the 6 weeks after the September 11th attacks. These results may help in allocation of resources during national disasters.