Treatment of Stress Urinary Incontinence: Does Race Matter?

IMPORTANCE: The importance of this study was to examine treatment patterns and surgical complications for stress urinary incontinence (SUI). OBJECTIVES: The aim of this study was to describe the treatment of SUI and associated complications in a racially and ethnically diverse population. STUDY DESIGN: This was a retrospective cohort study of patients with a new diagnosis of SUI. We identified patients who received treatment with a pessary, pelvic floor physical therapy, or surgery. Surgical complications were abstracted. Logistic regression was used to examine the association between race/ethnicity and treatment, as well as surgical complications. RESULTS: A total of 67,187 patients with a new diagnosis of SUI were included. The population was predominately Hispanic (47.5%) followed by White, Asian, Black, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native. Comparing no treatment to any treatment, all racial/ethnic groups, except American Indian/Alaska Native, had decreased odds of receiving treatment compared with White women. Hispanic and Native Hawaiian/Pacific Islander women had increased odds of referral for pelvic floor physical therapy compared with White women. All racial/ethnic groups, except for American Indian/Alaska Native women, had decreased odds of receiving a sling procedure compared with White women. When these racial/ethnic minority groups did receive treatment, it was more likely to be conservative treatment compared with White women. There were no significant differences in individual surgical complications. CONCLUSIONS: Racial minority women were 20-50% less likely to undergo a sling procedure, commonly posited as the gold standard surgical treatment. Racial minority women were 40-100% more likely to receive conservative management and 20-50% less likely to receive any treatment compared with White women.

Clinical Outcomes of Telehealth in Patients With Coronary Artery Disease and Heart Failure During the COVID-19 Pandemic.

The COVID-19 pandemic necessitated a rapid adoption of telehealth (TH); however, its safety in subspecialty clinical practice remains uncertain. To assess the clinical outcomes associated with TH use in patients with coronary artery disease and/or heart failure during the initial phase of the COVID-19 pandemic, eligible adult patients who saw cardiologists from March 1, 2020, to August 31, 2020 (TH period) were identified. Patients were divided into two 3-month subcohorts (TH1, TH2) and compared with corresponding 2019 prepandemic subcohorts. The primary outcome was cardiovascular (CV) events within 3 months after index visits. Secondary analysis was CV events in patients aged ≥75 years within 3-month follow-up associated with TH use. Multivariable logistic regression was used to evaluate the association between TH use and CV outcomes. The study cohort included 6,485 TH and 7,557 prepandemic patients. The mean age was 70 years, with 40% of patients aged ≥75 years and 35% women. TH visits accounted for 0% of visits during the prepandemic period, compared with 68% during the TH period. Telephone visits comprised ≥92% of all TH encounters. Compared with the prepandemic period, patients seen during the TH period had fewer overall CV events (adjusted odds ratio 0.78, 95% confidence interval 0.67 to 0.90). Patients aged ≥75 years had similar findings (adjusted odds ratio 0.70, 95% confidence interval 0.55 to 0.89). Additional analysis of CV outcome events within 6 months after index visits showed similar findings. In conclusion, TH largely by way of telephone encounters can be safely incorporated into the ambulatory cardiology practice regardless of age.

Satisfaction With Telehealth Among Patients With Irritable Bowel Syndrome During COVID-19: Cross-Sectional Survey Findings.

INTRODUCTION: Coronavirus disease 2019 rapidly shifted health care toward telehealth. We assessed satisfaction with and preferences for telehealth among patients with irritable bowel syndrome (IBS). METHODS: We conducted a cross-sectional survey in an integrated healthcare system in Southern California with members aged 18-90 years with an International Classification of Diseases 9 and 10 codes for IBS from office-based encounters between June 1, 2018, and June 1, 2020. Eligible patients were emailed a survey assessing telehealth satisfaction overall and by patient-related factors, IBS characteristics, health and technologic literacy, utilization, and coronavirus disease 2019 perceptions. We identified perceived telehealth benefits and challenges. Multivariable logistic regression identified predictors of telehealth dissatisfaction. RESULTS: Of 44,789 surveys sent, 5,832 (13.0%) patients responded and 1,632 (3.6%) had Rome IV IBS. Among 1,314 (22.5%) patients with IBS and prior telehealth use (mean age 52.6 years [17.4]; 84.9% female; and 59.4% non-Hispanic White, 29.0% Hispanic, and 5.6% non-Hispanic Black), 898 (68.3%) were satisfied, 130 (9.9%) were dissatisfied, and 286 (21.8%) felt neutral. In addition, 78.6% would use telehealth again. Independent predictors of telehealth dissatisfaction include social media use of once a week or less (adjusted odds ratio [OR] = 2.1; 1.3-3.5), duration of IBS for <1 year (adjusted OR = 8.2; 1.9-35.8), and willingness to travel 60 plus minutes for face-to-face visits (adjusted OR = 2.6; 1.4-3.7). Patients' main concern with telehealth was a lack of physical examination. DISCUSSION: Most of the patients with IBS are satisfied with telehealth. Shorter duration of IBS diagnosis, comfort with technology, and increased willingness to travel were associated with telehealth dissatisfaction. These predictors may help identify a target population for a focused IBS-telehealth program.

Determining whether ethnic minorities with severe obesity face a disproportionate risk of serious disease and death from COVID-19: outcomes from a Southern California-based retrospective cohort study.

OBJECTIVE: Obesity has been recognised as a risk factor for poor outcomes associated with COVID-19. Ethnic minorities with COVID-19 have been independently found to fare poorly. We aim to determine if ethnic minorities with severe obesity-defined as a body mass index (BMI) above 40 kg/m²-experience higher rates of hospitalisation, invasive ventilation and death. DESIGN AND SETTING: Retrospective cohort study from 1 March 2020 to 28 February 2021 within an integrated healthcare organisation in Southern California. PARTICIPANTS: We identified 373 831 patients by COVID-19 diagnosis code or positive laboratory test. METHODS: Multivariable Poisson regression with robust error variance estimated adjusted risks of hospitalisation, invasive ventilator use and death within 30 days. Risks were stratified by ethnicity and BMI. RESULTS: We identified multiple differences in risk of poor outcomes across BMI categories within individual ethnic groups. Hospitalisation risk with a BMI over 45 kg/m² was greater in Asian (RR 2.31, 95% CI 1.53 to 3.49; p<0.001), Hispanic (RR 3.22, 95% CI 2.99 to 3.48; p<0.001) and Pacific Islander (RR 3.79, 95% CI 2.49 to 5.75; p<0.001) patients compared with White (RR 2.04, 95% CI 1.79 to 2.33; p<0.001) and Black (RR 2.00, 95% CI 1.70 to 2.34; p<0.001) patients. A similar trend was observed with invasive ventilation risk. The risk of death was greater in Asian (RR 3.96, 95% CI 1.88 to 8.33; p<0.001), Hispanic (RR 3.03, 95% CI 2.53 to 3.61; p<0.001) and Pacific Islander (RR 4.60, 95% CI 1.42 to 14.92; p=0.011) patients compared with White (RR 1.47, 95% CI 1.13 to 1.91; p=0.005) and Black (RR 2.83, 95% CI 1.99 to 4.02; p<0.001) patients with a BMI over 45 kg/m². CONCLUSIONS: Ethnic minorities with severe obesity, particularly Asian, Hispanic and Pacific Islander patients, had a statistically significant higher risk of hospitalisation, invasive ventilator use and death due to COVID-19. Potential explanations include differences in adipose tissue deposition, overall inflammation and ACE-2 receptor expression.

The Shieh Score as a Risk Assessment Tool for Hospital-Acquired Pressure Injuries: A Retrospective Cohort Study.

OBJECTIVE: To design a new risk assessment tool to identify patients at high risk for hospital-acquired pressure injuries. METHODS: The researchers developed the Shieh Score using retrospective data of 406,032 hospital admissions from January 2014 to December 2016 with 1,299 pressure injury cases from the pressure injury registry. A decision tree and best subset logistic regression were used to select predictors from demographic and clinical candidate variables, which were then used to construct the Shieh Score. RESULTS: The final Shieh Score included the following measures: sex, age, diabetes, glomerular filtration rate, albumin level, level of function, use of IV norepinephrine, mechanical ventilation, and level of consciousness. The Shieh Score had a higher Youden Index, specificity, and positive predictive value than the Braden Scale. However, the Braden Scale had a higher sensitivity compared with the Shieh Score. CONCLUSIONS: The Shieh Score is an alternative risk assessment tool that may effectively identify a smaller number of patients at high risk for hospital-acquired pressure injuries with a higher specificity and positive predictive value than the Braden Scale.

Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with No change in first 5 Years of diagnosis.

BACKGROUND: Discontinuation of branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) surveillance after 5 years of no change remains controversial. Long-term outcomes of BD-IPMN without significant changes in the first 5 years were evaluated. METHODS: We performed a multi-center retrospective analysis of patients with BD-IPMN diagnosis from 2005 to 2011 (follow-up until 2017). Significant changes were defined as pancreatic cancer (PC), pancreatectomy, high-risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). RESULTS: Of 982 patients who had no significant changes, 5 (0.5%), 7 (0.7%), 99 (10.1%), 4 (0.4%) patients developed PC, HRS, WF, WEUS, respectively, post-5 years. PC and HRS/WF/WEUS incidences at 12 years were 1.0% and 29.0%, respectively. Patients that developed HRS/WF/WEUS had larger cyst size in first 5 years compared to those that did not [16 (12-23) vs. 12 (9-17) mm, p = 0.0001], cyst size of >15 mm having higher cumulative incidence of HRS/WF/WEUS. PC mortality was 0.8%; all-cause mortality was 32%. Incidence of mortality due to PC was higher in HRS/WF/WEUS group, p < 0.0001. The mortality rate at 12 years for ACCI (age-adjusted Charlson Comorbidity Index) of ≤3, 4-6, and ≥7 were 3.5%, 19.9%, and 57.6% (p < 0.0001), respectively. CONCLUSIONS: Incidence of PC in patients with BD-IPMN without significant changes in first 5 years of diagnosis remains low at 1.0%. Incidence of HRS/WF/WEUS was higher at 29.0%. PC-related mortality was higher in HRS/WF/WEUS group. These risks should be weighed against patients' overall mortality (utilizing scoring systems such as ACCI) when making surveillance decision of BD-IPMN beyond 5 years.

Retrospective analysis of a dedicated care pathway for nonalcoholic fatty liver disease in an integrated US healthcare system demonstrates support of weight management and improved ALT.

BACKGROUND: A care pathway for nonalcoholic fatty liver disease (NAFLD) in Kaiser Permanente San Diego, California was instituted in August 2017 to improve efficiency of disease staging and promote lifestyle modification. METHODS: The NAFLD Care Pathway includes: (1) patient education (2) vibration controlled transient elastography (VCTE) examination (3) hepatology consultation for VCTE ≥ 8 kPa and (4) referral to weight management (WM). Patients referred to the pathway during the first 6 months of its implementation were studied for adherence to its components and impact on weight change and ALT values in the 12 months following referral. Retrospective assessment of WM participation, change in weight, and change in ALT were evaluated in the 12-months following referral and compared to changes 12-months prior. Student's t-test or Wilcoxon signed rank test were used as appropriate (p < 0.05). RESULTS: 632 patients were included. 575 (91.0%) completed VCTE examination with mean liver stiffness 8.5 kPa (SD 9.2). 52 patients had mean liver stiffness ≥ 15 kPa. 180/632 (28.5%) attended NAFLD education. 153/632 (24.2%) were offered hepatology clinic and 136/153 (88.9%) completed at least 1 appointment. Participation in WM was 24/632 (3.8%) prior to referral and 67/632 (10.6%) after referral and increased among patients who attended NAFLD education. Mean weight change following referral was - 0.69 kg (SD 6.58 kg) among patients without WM and - 7.78 kg (SD 13.43 kg) with WM. Overall, 44.2% of participants experienced weight gain after referral, 40.8% had weight loss < 5% and 15% had weight loss ≥ 5%. Variables associated with weight loss included WM (p < 0.0001) and higher liver stiffness (p = 0.0066). Mean ALT change was - 15.2 (SD 38.5) U/L without WM and - 28.8 (SD 29.6) U/L with WM. CONCLUSIONS: A care pathway for NAFLD within a large, integrated healthcare system provides non-invasive disease staging and minimizes hepatology clinic utilization to those with more advanced disease. Referral was associated with increased enrollment in WM, weight loss, and decreased ALT. Given its impact on healthcare resources, strategies to improve NAFLD identification, staging, and promotion of lifestyle modification are imperative.

Prolonged Opioid Use After Primary Total Knee and Total Hip Arthroplasty: Prospective Evaluation of Risk Factors and Psychological Profile for Depression, Pain Catastrophizing, and Aberrant Drug-Related Behavior.

BACKGROUND: Forty percent of patients continue to use opioids at 3 months after joint arthroplasty. We sought to identify clinical and psychological risk factors associated with prolonged opioid use. METHODS: In this prospective study, psychological profile data were collected preoperatively. Prolonged use was defined as dispensation of an opioid after 90 days. Logistic regressions were used for univariate and multivariate modeling and to create receiver operating characteristic curves. A backward stepwise regression analysis was used to select significant factors in the multivariable model. RESULTS: The study included 258 patients (163 total knee arthroplasty, 95 total hip arthroplasty). 29.84% of patients were on preoperative opioids and 14% (37 of 258) of patients had prolonged use of opioids. In the univariate analysis, age <65, associated back pain, chronic pain syndrome or fibromyalgia, prior opioid use, drug potency of more than 10 morphine equivalent, and total score on Opioid Risk Tool of more than 7 were associated with prolong use. In the multivariate analysis, age <65, associated back pain, chronic pain, and preoperative use of opioids were significant risk factors for prolonged use (combined area under the curve = 0.83). Preoperative opioid use had the highest area under the curve = 0.72 (P = .0005). Psychological profile tests did not predict prolonged opioid use. CONCLUSION: Preoperative opioid use was the strongest predictor of postoperative prolonged opioid use. Younger age, associated backpain, and chronic pain syndrome were the other identified risk factors. Screening tools to detect aberrant drug-related behavior may be more helpful than those for depression or pain catastrophizing.

Effectiveness at 24 Months of Single-Source Generic Carbamazepine, Lamotrigine, or Levetiracetam in Newly Diagnosed Focal Epilepsy.

BACKGROUND: Kaiser Permanente advocates using single-source generics for brand-name drugs. We compared the effectiveness of 3 different-generation generic antiepileptic drugs (AEDs) in patients with focal epilepsies. OBJECTIVE: To compare the effectiveness of the 3 most commonly used AEDs (carbamazepine [CBZ], lamotrigine [LTG], and levetiracetam [LEV]) after 24-month monotherapy. METHODS: This is a retrospective data analysis of 646 consecutive AED-naive patients aged 1-88 years treated with CBZ, LTG, or LEV between 2006 and 2012 with dosing adjustments permitted during the first 6 months. Chi-squared test with p < 0.05 was used to calculate seizure-freedom and tolerability rates. RESULTS: At the end of the 24-month study period, 65.69% patients in the CBZ group continued to remain seizure free, 25.98% were drug failures, and 8.33% dropped out due to adverse events, with the corresponding numbers being 66.49%, 23.94%, and 9.57% in the LTG group and 72.44%, 12.99%, and 14.57% in the LEV group. Rash was the most common adverse event for CBZ (3.43%) and LTG (6.38%), and mood changes were the most commen adverse event for LEV (7.87%). Among the 3 groups (n = 646), AED tolerance rates and AED retention rates showed no significant difference (p = 0.08 and p = 0.23, respectively). Seizure-freedom rate difference among the 3 groups (n = 574) was significant (p = 0.003), and seizure-freedom rate for LEV was superior to CBZ (p = 0.001) and to LTG (p = 0.006). CONCLUSION: At the end of the 24-month study period, in a head-to-head comparison of single-source bioequivalent generic formulations, superior seizure-freedom rate and comparable tolerability and retention rates for LEV were observed when compared with CBZ and LTG.