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1.
J Urol ; 203(1): 159-163, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31441673

RESUMO

PURPOSE: Patients who undergo cystectomy due to bladder cancer can elect an ileal conduit or a neobladder for urinary diversion. Decision regret related to this choice is an important and undesirable patient reported outcome. Our objective was to compare the severity of decision regret experienced by patients with a neobladder vs an ileal conduit. MATERIALS AND METHODS: We analyzed data from a longitudinal cohort study of patients who underwent cystectomy from 2013 to 2015. We applied multivariable linear regression to examine associations of the urinary diversion method (neobladder vs ileal conduit) with decision regret measured with the DRS (Decision Regret Scale) 6 and 18 months after cystectomy. Covariates included demographic and clinical characteristics, health care utilization and complications after cystectomy, quality of life and factors related to the decision making process, including informed and shared decision making, and goal concordance. RESULTS: Of the 192 patients in our cohort 141 received an ileal conduit and 51 received a neobladder. We observed no significant difference in the DRS score in patients with a neobladder vs an ileal conduit at 6 or 18 months (b=-1.28, 95% CI -9.07-6.53, vs b=-1.55, 95% CI -12.48-9.38). However, informed decision making was negatively related to decision regret at 6 and 18 months (b=-13.08, 95% CI -17.05--9.11, and b=-8.54, 95% CI -4.26--2.63, respectively). Quality of life was negatively associated with decision regret at 18 months (b=-5.50, 95% CI -8.95--2.03). CONCLUSIONS: Patients treated with cystectomy who were more informed about bladder reconstruction options experienced less regret independent of the method selected. Efforts to inform and prepare patients for the bladder reconstruction decision may help prevent decision regret.


Assuntos
Cistectomia , Tomada de Decisões , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Qualidade de Vida , Neoplasias da Bexiga Urinária/patologia
2.
Qual Life Res ; 2019 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-31811594

RESUMO

PURPOSE: The Bladder Cancer Quality of Life Study collected detailed and sensitive patient-reported outcomes from bladder cancer survivors in the period after bladder removal surgery, when participation in survey research may present a burden. This paper describes the study recruitment methods and examines the response rates and patterns of missing data. METHODS: Detailed surveys focusing on quality of life, healthcare decision-making, and healthcare expenses were mailed to patients 5-7 months after cystectomy. We conducted up to 10 follow-up recruitment calls. We analyzed survey completion rates following each contact in relation to demographic and clinical characteristics, and patterns of missing data across survey content areas. RESULTS: The overall response rate was 71% (n = 269/379). This was consistent across patient clinical characteristics; response rates were significantly higher among patients over age 70 and significantly lower among racial and ethnic minority patients compared to non-Hispanic white patients. Each follow-up contact resulted in marginal survey completion rates of at least 10%. Rates of missing data were low across most content areas, even for potentially sensitive questions. Rates of missing data differed significantly by sex, age, and race/ethnicity. CONCLUSIONS: Despite the effort required to participate in research, this population of cancer survivors showed willingness to share detailed information about quality of life, health care decision-making, and expenses, soon after major cancer surgery. Additional contacts were effective at increasing participation. Response patterns differed by race/ethnicity and other demographic factors. Our data collection methods show that it is feasible to gather detailed patient-reported outcomes during this challenging period.

3.
Intern Med J ; 2019 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-31707754

RESUMO

BACKGROUND: Falls and hip fractures among older people are associated with high morbidity and mortality. Hyponatremia may be a risk for falls/hip fractures, but the effect of hyponatremia duration is not well understood. AIMS: We sought to evaluate individuals with periods of sub-acute and chronic hyponatremia on subsequent risk for serious falls and/or hip fractures. METHODS: Retrospective cohort study in the period 1/1/1998-6/14/2016 within an integrated health system of individuals aged ≥55 years with ≥2 outpatient serum sodium measurements. Hyponatremia was defined as sodium <135 mEq/L with sub-acute (<30 days) and chronic (>/=30 days) and analyzed as a time-dependent exposure. Multivariable Cox proportional hazards modeling was used to estimate hazard ratios (HRs) for serious falls/hip fractures based on sodium category. RESULTS: Among 1 062 647 individuals totaling 9 762 305 sodium measurements, 96 096 serious falls/hip fracture events occurred. Incidence (per-1000-person-years) of serious falls/hip fractures were 11.5, 27.9, and 19.8 for normonatremia, sub-acute, and chronic hyponatremia. Any hyponatremia duration compared to normonatremia had a serious falls/hip fractures HR (95%CI) of 1.18(1.15, 1.22), with sub-acute and chronic hyponatremia having HRs of 1.38(1.33, 1.42) and 0.91(0.87, 0.95), respectively. Examined separately, the serious falls HR was 1.37(1.32, 1.42) and 0.92(0.88, 0.96) in sub-acute and chronic hyponatremia, respectively. Hip fracture HRs were 1.52(1.42, 1.62) and 1.00(0.92, 1.08) for sub-acute and chronic hyponatremia, respectively, compared to normonatremia. CONCLUSIONS: Our findings suggest that early/sub-acute hyponatremia appears more vulnerable and associated with serious falls/hip fractures. Whether hyponatremia is a marker of frailty or a modifiable risk factor for falls remains to be determined. This article is protected by copyright. All rights reserved.

4.
Urology ; 131: 102-103, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31451150
5.
Am J Kidney Dis ; 74(5): 589-600, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31324445

RESUMO

BACKGROUND: Timely follow-up of abnormal laboratory results is important for high-quality care. We sought to identify risk factors, facilitators, and barriers to timely follow-up of an abnormal estimated glomerular filtration rate (eGFR) for the diagnosis of chronic kidney disease. STUDY DESIGN: Mixed-methods study: retrospective electronic health record (EHR) analyses, physician interviews. SETTING & PARTICIPANTS: Large integrated health care delivery system. Quantitative analyses included 244,540 patients 21 years or older with incident abnormal eGFRs from January 1, 2010, to December 31, 2015, ordered by 7,164 providers. Qualitative analyses included 15 physician interviews. EXPOSURES: Patient-, physician-, and system-level factors. OUTCOME: Timely follow-up of incident abnormal eGFRs, defined as repeat eGFR obtained within 60 to 150 days, follow-up testing before 60 days that indicated normal kidney function, or diagnosis before 60 days of chronic kidney disease or kidney cancer. ANALYTICAL APPROACH: Multivariable robust Poisson regression models accounting for clustering within provider were used to estimate risk ratios (RRs) and 95% CIs for lack of timely follow-up. Team coding was used to identify themes from physician interviews. RESULTS: 58% of patients lacked timely follow-up of their incident abnormal eGFRs (ie, had a care gap). An abnormal creatinine result flag in the EHR was associated with better follow-up (RR for care gap, 0.65; 95% CI, 0.64-0.66). Patient online portal use and physician panel size were weakly associated with follow-up. Patients seen by providers behind on managing their EHR message box were at higher risk for care gaps. Physician interviews identified system-level (eg, panel size and assistance in managing laboratory results) and provider-level (eg, proficiency using EHR tools) factors that influence laboratory result management. LIMITATIONS: Unable to capture intentional delays in follow-up testing. CONCLUSIONS: Timely follow-up of abnormal results remains challenging in an EHR-based integrated health care delivery system. Strategies improving provider EHR message box management and leveraging health information technology (eg, flagging abnormal eGFR results), making organizational/staffing changes (eg, increasing the role of nurses in managing laboratory results), and boosting patient engagement through better patient portals may improve test follow-up.

6.
Urology ; 131: 93-103, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31129191

RESUMO

OBJECTIVES: To examine treatment variability, disparities, and quality among newly diagnosed nonmuscle invasive bladder cancer (NMIBC) patients, and to identify factors associated with treatment use in a large, diverse integrated delivery system. METHODS: Retrospective cohort study of 5386 NMIBC patients diagnosed between January 2001 and June 2015 within Kaiser Permanente Southern California. Electronic health data were used to identify treatment outcomes and patient, provider, and tumor characteristics. Outcomes were use of (1) postoperative intravesical chemotherapy, (2) induction Bacille Calmette-Guérin (BCG) immunotherapy, and (3) any intravesical therapy. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using generalized linear mixed models with a binary outcome and urologist as a random effect. RESULTS: From 2001 to 2015, 41% of newly diagnosed NMIBC patients were treated with intravesical therapy. Postoperative chemotherapy use increased significantly over this period (OR per-year = 1.16, 95% CI: 1.07-1.25). BCG use was strongly associated with tumor characteristics: patients with high-grade or carcinoma in situ tumors were more likely to receive BCG (OR = 10.10, 95% CI: 8.39-12.16). Few treatment differences were found by sex or race/ethnicity, but were observed by age. Wide treatment variability across urologists was observed, with some urologists never using intravesical therapy as part of initial treatment while others almost always used it. Differences across urologists accounted for more variability in postoperative chemotherapy (intraclass correlation coefficient = 0.52) than BCG immunotherapy (intraclass correlation coefficient = 0.11) use. CONCLUSION: Substantial variability in initial treatment of NMIBC was observed across urologists, accounting for tumor, patient, and provider characteristics. Results suggest a considerable opportunity for quality improvement programs to reduce unwanted treatment variability and improve care for patients.


Assuntos
Adjuvantes Imunológicos/administração & dosagem , Antineoplásicos/administração & dosagem , Vacina BCG/administração & dosagem , Qualidade da Assistência à Saúde , Neoplasias da Bexiga Urinária/tratamento farmacológico , Administração Intravesical , Idoso , Idoso de 80 Anos ou mais , California , Estudos de Coortes , Prestação Integrada de Cuidados de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Neoplasias da Bexiga Urinária/patologia
7.
J Urol ; 202(1): 83-89, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30835627

RESUMO

PURPOSE: Patient centered care aims to align treatment with patient goals, especially when treatment options have equivalent clinical outcomes. For surgeries with lasting impacts that alignment is critical. To our knowledge no psychometrically tested preference elicitation measures exist to support patients with bladder cancer treated with cystectomy, who can often choose between ileal conduit and neobladder diversions. In this study we created a scale to measure how patient goals align with each type of urinary diversion and the associated surgical outcomes. MATERIALS AND METHODS: We performed formative research through focus groups and clinician outreach to adapt a goal dissonance measure. We mailed a survey to adult Kaiser Permanente® members who underwent cystectomy for bladder cancer between January 2013 and June 2015. Eligible patients were identified through electronic health records and chart review. Surveys were mailed 5 to 7 months postoperatively. We administered our 10-item decision dissonance scale along with other decision making measures. We explored goal alignment as well as dissonance. Psychometric analysis included factor analysis, evaluation of scale scores between surgery groups and evaluation with other decision making scores. RESULTS: We identified 10 goals associated with ileal conduit or neobladder diversion. Using survey data on 215 patients our scale differentiated patient goals associated with each diversion choice. On average patients with a neobladder strongly valued neobladder aligned goals such as maintaining body integrity and volitional voiding through the urethra. Patients with an ileal conduit had neutral values on average across all goals. CONCLUSIONS: Our measure lays the foundation for a simple value elicitation approach which could facilitate shared decision making about urinary diversion choice.


Assuntos
Tomada de Decisão Clínica/métodos , Tomada de Decisões , Preferência do Paciente , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/psicologia , Idoso , Cistectomia/efeitos adversos , Feminino , Grupos Focais , Metas , Humanos , Masculino , Pessoa de Meia-Idade , Psicometria , Inquéritos e Questionários , Derivação Urinária/efeitos adversos , Derivação Urinária/métodos
9.
Cancer Causes Control ; 30(2): 187-193, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30656539

RESUMO

PURPOSE: Bladder cancer is one of the top five cancers diagnosed in the U.S. with a high recurrence rate, and also one of the most expensive cancers to treat over the life-course. However, there are few observational, prospective studies of bladder cancer survivors. METHODS: The Bladder Cancer Epidemiology, Wellness, and Lifestyle Study (Be-Well Study) is a National Cancer Institute-funded, multi-center prospective cohort study of non-muscle-invasive bladder cancer (NMIBC) patients (Stage Ta, T1, Tis) enrolled from the Kaiser Permanente Northern California (KPNC) and Southern California (KPSC) health care systems, with genotyping and biomarker assays performed at Roswell Park Comprehensive Cancer Center. The goal is to investigate diet and lifestyle factors in recurrence and progression of NMIBC, with genetic profiles considered, and to build a resource for future NMIBC studies. RESULTS: Recruitment began in February 2015. As of 30 June 2018, 1,281 patients completed the baseline interview (774 KPNC, 511 KPSC) with a recruitment rate of 54%, of whom 77% were male and 23% female, and 80% White, 6% Black, 8% Hispanic, 5% Asian, and 2% other race/ethnicity. Most patients were diagnosed with Ta (69%) or T1 (27%) tumors. Urine and blood specimens were collected from 67% and 73% of consented patients at baseline, respectively. To date, 599 and 261 patients have completed the 12- and 24-month follow-up questionnaires, respectively, with additional urine and saliva collection. CONCLUSIONS: The Be-Well Study will be able to answer novel questions related to diet, other lifestyle, and genetic factors and their relationship to recurrence and progression among early-stage bladder cancer patients.


Assuntos
Recidiva Local de Neoplasia/epidemiologia , Neoplasias da Bexiga Urinária/epidemiologia , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Sobreviventes de Câncer , Dieta , Progressão da Doença , Feminino , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/genética , Recidiva Local de Neoplasia/prevenção & controle , Estudos Prospectivos , Neoplasias da Bexiga Urinária/genética
10.
Urology ; 125: 222-229, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30471370

RESUMO

OBJECTIVE: To assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk nonmuscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors' outcomes across different surgical treatment options. METHODS: Bladder cancer patients' age ≥21 years with cystectomy/UD performed from January 2010 to June 2015 in 3 Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect. RESULTS: Of 991 eligible patients, 794 (80%) received IC. One hundred sixty-nine surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (intraclass correlation coefficient = 0.26). The multilevel model with only patient factors showed good fit (area under the curve = 0.93, Hosmer-Lemeshow test P = .44), and older age, female sex, estimated glomerular filtration rate <45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs neobladder/continent pouch. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (P = .29). CONCLUSION: In this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.


Assuntos
Cistectomia , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária , Idoso , Serviços de Saúde Comunitária , Prestação Integrada de Cuidados de Saúde , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia , Neoplasias da Bexiga Urinária/patologia , Derivação Urinária/métodos , Derivação Urinária/estatística & dados numéricos
11.
Artigo em Inglês | MEDLINE | ID: mdl-31917174

RESUMO

BACKGROUND: Disparities in bladder cancer survival by race/ethnicity and gender are likely related to differences in diagnosis. We assessed disparities in stage at diagnosis and potential contributing factors within a large, integrated delivery system. PATIENTS AND METHODS: We conducted a retrospective cohort study of 7244 patients with bladder cancer age ≥ 21 years diagnosed from January 2001 to June 2015 within Kaiser Permanente Southern California. Bivariate analyses compared stage at diagnosis - as well as comorbidities, health plan membership length, and health care utilization prior to diagnosis - by race/ethnicity, gender, and age. Multivariable generalized linear mixed models with urologist as a random effect were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for diagnosis of muscle-invasive bladder cancer (MIBC) versus non-muscle-invasive bladder cancer. RESULTS: In multivariable analyses, stage at diagnosis varied significantly by race/ethnicity (P < .001). Non-Hispanic black patients had significantly higher odds of being diagnosed with MIBC than non-Hispanic white patients (OR, 1.33; 95% CI, 1.05-1.67), whereas Asian patients had significantly lower odds (OR, 0.67; 95% CI, 0.49-0.91). Women were significantly more likely to be diagnosed with MIBC than men (OR, 1.40; 95% CI, 1.22-1.61). Non-Hispanic black women had the highest proportion (39%) of MIBC diagnoses. Among Hispanic and Asian patients, a greater proportion of diagnoses occurred at younger ages. CONCLUSIONS: Health care coverage within an equal-access system did not eliminate disparities in stage at diagnosis by race/ethnicity or gender. Studies are needed to identify etiologic factors and aspects of care delivery (eg, patient-physician interactions) that may affect the diagnostic process to inform efforts to improve health equity.

12.
Perm J ; 21: 16-143, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28241912

RESUMO

OBJECTIVES: The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. METHODS: Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. RESULTS: Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). CONCLUSION: Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening.


Assuntos
Creatinina/urina , Programas de Rastreamento , Avaliação de Programas e Projetos de Saúde , Insuficiência Renal Crônica/diagnóstico , Segurança , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , California , Estudos de Coortes , Feminino , Taxa de Filtração Glomerular , Humanos , Falência Renal Crônica/prevenção & controle , Falência Renal Crônica/urina , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/urina , Fatores de Risco , Adulto Jovem
13.
Am J Respir Crit Care Med ; 192(10): 1208-14, 2015 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-26214244

RESUMO

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.


Assuntos
Achados Incidentais , Nódulos Pulmonares Múltiplos/diagnóstico por imagem , Nódulo Pulmonar Solitário/diagnóstico por imagem , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Progressão da Doença , Registros Eletrônicos de Saúde , Feminino , Humanos , Incidência , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/epidemiologia , Masculino , Programas de Assistência Gerenciada/estatística & dados numéricos , Pessoa de Meia-Idade , Nódulos Pulmonares Múltiplos/epidemiologia , Radiografia Torácica , Estudos Retrospectivos , Distribuição por Sexo , Nódulo Pulmonar Solitário/epidemiologia , Tomografia Computadorizada por Raios X , Adulto Jovem
14.
EGEMS (Wash DC) ; 2(1): 1056, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25848588

RESUMO

Efforts to improve patient safety have largely focused on inpatient or emergency settings, but the importance of patient safety in ambulatory care is increasingly being recognized as a key component of overall health care quality. Care gaps in outpatient settings may include missed diagnoses, medication errors, or insufficient monitoring of patients with chronic conditions or on certain medications. Further, care gaps may occur across a wide range of clinical conditions. We report here an innovative approach to improve patient safety in ambulatory settings - the Kaiser Permanente Southern California (KPSC) Outpatient Safety Net Program - which leverages electronic health information to efficiently identify and address a variety of potential care gaps across different clinical conditions. Between 2006 and 2012, the KPSC Outpatient Safety Net Program implemented 24 distinct electronic clinical surveillance programs, which routinely scan the electronic health record to identify patients with a particular condition or event. For example, electronic clinical surveillance may be used to scan for harmful medication interactions or potentially missed diagnoses (e.g., abnormal test results without evidence of subsequent care). Keys to the success of the program include strong leadership support, a proactive clinical culture, the blame-free nature of the program, and the availability of electronic health information. The Outpatient Safety Net Program framework may be adopted by other organizations, including those who have electronic health information but not an electronic health record. In the future, the creation of a forum to share electronic clinical surveillance programs across organizations may facilitate more rapid improvements in outpatient safety.

15.
Perm J ; 17(4): 4-13, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24361013

RESUMO

OBJECTIVE: To identify high-priority comparative effectiveness questions directly relevant to care delivery in a large, US integrated health care system. METHODS: In 2010, a total of 792 clinical and operational leaders in Kaiser Permanente were sent an electronic survey requesting nominations of comparative effectiveness research questions; most recipients (83%) had direct clinical roles. Nominated questions were divided into 18 surveys of related topics that included 9 to 23 questions for prioritization. The next year, 648 recipients were electronically sent 1 of the 18 surveys to prioritize nominated questions. Surveys were assigned to recipients on the basis of their nominations or specialty. High-priority questions were identified by comparing the frequency a question was selected to an "expected" frequency, calculated to account for the varying number of questions and respondents across prioritization surveys. High-priority questions were those selected more frequently than expected. RESULTS: More than 320 research questions were nominated from 181 individuals. Questions most frequently addressed cardiovascular and peripheral vascular disease; obesity, diabetes, endocrinology, and metabolic disorders; or service delivery and systems-level questions. Ninety-five high-priority research questions were identified, encompassing a wide range of health questions that ranged from prevention and screening to treatment and quality of life. Many were complex questions from a systems perspective regarding how to deliver the best care. CONCLUSIONS: The 95 questions identified and prioritized by leaders on the front lines of health care delivery may inform the national discussion regarding comparative effectiveness research. Additionally, our experience provides insight in engaging real-world stakeholders in setting a health care research agenda.


Assuntos
Pesquisa Comparativa da Efetividade , Prestação Integrada de Cuidados de Saúde , Inquéritos e Questionários , Coleta de Dados , Humanos , Pesquisa , Estados Unidos
16.
Diabetes Care ; 36(12): 3953-60, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24170756

RESUMO

OBJECTIVE: To examine whether use of insulin glargine, compared with another long-acting insulin, is associated with risk of breast, prostate, colorectal cancer, or all cancers combined. RESEARCH DESIGN AND METHODS: Computerized health records from Kaiser Permanente Northern and Southern California regions starting in 2001 and ending in 2009 were used to conduct a population-based cohort study among patients with diabetes aged ≥18 years. With use of Cox regression modeling, cancer risk in users of insulin glargine (n = 27,418) was compared with cancer risk in users of NPH (n = 100,757). RESULTS: The cohort had a median follow-up of 3.3 years during which there was a median of 1.2 years of glargine use and 1.4 years of NPH use. Among users of NPH at baseline, there was no clear increase in risk of breast, prostate, colorectal, or all cancers combined associated with switching to glargine. Among those initiating insulin, ever use or ≥2 years of glargine was not associated with increased risk of prostate or colorectal cancer or all cancers combined. Among initiators, the hazard ratio (HR) for breast cancer associated with ever use of glargine was 1.3 (95% CI 1.0-1.8); the HR for breast cancer associated with use of glargine for ≥2 years was 1.6 or 1.7 depending on whether glargine users had also used NPH. CONCLUSIONS: Results of this study should be viewed cautiously, given the relatively short duration of glargine use to date and the large number of potential associations examined.


Assuntos
Neoplasias da Mama/epidemiologia , Neoplasias Colorretais/epidemiologia , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Insulina de Ação Prolongada/efeitos adversos , Neoplasias da Próstata/epidemiologia , Medição de Risco , Adolescente , Adulto , Idoso , Neoplasias da Mama/induzido quimicamente , California/epidemiologia , Neoplasias Colorretais/induzido quimicamente , Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Seguimentos , Humanos , Hipoglicemiantes/efeitos adversos , Hipoglicemiantes/uso terapêutico , Incidência , Insulina Glargina , Insulina de Ação Prolongada/uso terapêutico , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Neoplasias da Próstata/induzido quimicamente , Estudos Retrospectivos , Risco , Fatores de Tempo , Adulto Jovem
17.
J Thorac Oncol ; 7(8): 1257-62, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22627647

RESUMO

INTRODUCTION: Lung nodules are commonly encountered in clinical practice, yet little is known about their management in community settings. An automated method for identifying patients with lung nodules would greatly facilitate research in this area. METHODS: Using members of a large, community-based health plan from 2006 to 2010, we developed a method to identify patients with lung nodules, by combining five diagnostic codes, four procedural codes, and a natural language processing algorithm that performed free text searches of radiology transcripts. An experienced pulmonologist reviewed a random sample of 116 radiology transcripts, providing a reference standard for the natural language processing algorithm. RESULTS: With the use of an automated method, we identified 7112 unique members as having one or more incident lung nodules. The mean age of the patients was 65 years (standard deviation 14 years). There were slightly more women (54%) than men, and Hispanics and non-whites comprised 45% of the lung nodule cohort. Thirty-six percent were never smokers whereas 11% were current smokers. Fourteen percent of the patients were subsequently diagnosed with lung cancer. The sensitivity and specificity of the natural language processing algorithm for identifying the presence of lung nodules were 96% and 86%, respectively, compared with clinician review. Among the true positive transcripts in the validation sample, only 35% were solitary and unaccompanied by one or more associated findings, and 56% measured 8 to 30 mm in diameter. CONCLUSIONS: A combination of diagnostic codes, procedural codes, and a natural language processing algorithm for free text searching of radiology reports can accurately and efficiently identify patients with incident lung nodules, many of whom are subsequently diagnosed with lung cancer.


Assuntos
Algoritmos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/patologia , Processamento de Linguagem Natural , Reconhecimento Automatizado de Padrão , Interpretação de Imagem Radiográfica Assistida por Computador , Nódulo Pulmonar Solitário/diagnóstico por imagem , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Relatório de Pesquisa , Tomografia Computadorizada por Raios X
18.
Int J Cancer ; 128(12): 2953-61, 2011 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-20725997

RESUMO

Previous investigations have provided conflicting results regarding whether alcohol consumption affects endometrial cancer risk, although in many of these studies the highest category of alcohol intake examined was limited. Further, most were unable to resolve how alcohol associations are affected by beverage type, the presence of other endometrial cancer risk factors, or tumor characteristics. To address these issues, we prospectively evaluated the association between alcohol intake and incident endometrial cancer (n = 1,491) in a cohort of 114,414 US women enrolled in the NIH-AARP Diet and Health Study. We calculated relative risks (RR) and 95% confidence intervals (CI) using Cox proportional hazards regression. After adjustment for age, body mass index (BMI), smoking and other potential confounders, the multivariable RRs (and 95% CIs) compared with nondrinkers were 0.97 (0.87-1.09) for >0-<12 g of alcohol/day, 1.06 (0.87-1.31) for 12-<24 g/day and 0.93 (0.71-1.20) for ≥ 24 g/day (p trend = 0.90). There was, however, some suggestion of higher risks associated with alcohol consumption among lean women (BMI, <25) and users of menopausal hormone therapy, with significant interactions with both parameters (respective interaction p-values of 0.002 and 0.005). The relationship was also enhanced, albeit nonsignificantly so, for low grade cancers. Our results do not support that alcohol is a strong contributor to endometrial cancer risk, but slight risk increases may prevail among some users or for selected tumor characteristics.


Assuntos
Consumo de Bebidas Alcoólicas , Dieta , Neoplasias do Endométrio/epidemiologia , Idoso , Estudos de Coortes , Feminino , Humanos , Pessoa de Meia-Idade
19.
Am J Epidemiol ; 172(1): 70-80, 2010 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-20562186

RESUMO

A role for vitamin D in ovarian cancer etiology is supported by ecologic studies of sunlight exposure, experimental mechanism studies, and some studies of dietary vitamin D intake and genetic polymorphisms in the vitamin D receptor. However, few studies have examined the association of circulating 25-hydroxyvitamin D (25(OH)D), an integrated measure of vitamin D status, with ovarian cancer risk. A nested case-control study was conducted among 7 prospective studies to evaluate the circulating 25(OH)D concentration in relation to epithelial ovarian cancer risk. Logistic regression models were used to estimate odds ratios and 95% confidence intervals among 516 cases and 770 matched controls. Compared with 25(OH)D concentrations of 50-<75 nmol/L, no statistically significant associations were observed for <37.5 (odds ratio (OR) = 1.21, 95% confidence interval (CI): 0.87, 1.70), 37.5-<50 (OR = 1.03, 95% CI: 0.75, 1.41), or > or =75 (OR = 1.11, 95% CI: 0.79, 1.55) nmol/L. Analyses stratified by tumor subtype, age, body mass index, and other variables were generally null but suggested an inverse association between 25(OH)D and ovarian cancer risk among women with a body mass index of > or =25 kg/m(2) (P(interaction) < 0.01). In conclusion, this large pooled analysis did not support an overall association between circulating 25(OH)D and ovarian cancer risk, except possibly among overweight women.


Assuntos
Neoplasias Ovarianas/epidemiologia , Neoplasias Ovarianas/prevenção & controle , Deficiência de Vitamina D/complicações , Vitamina D/sangue , Vitamina D/uso terapêutico , Adulto , Estudos de Casos e Controles , China/epidemiologia , Estudos de Coortes , Feminino , Finlândia/epidemiologia , Humanos , Modelos Logísticos , Sobrepeso/epidemiologia , Estudos Prospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Deficiência de Vitamina D/epidemiologia , Deficiência de Vitamina D/prevenção & controle
20.
Int J Cancer ; 126(1): 199-207, 2010 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-19569181

RESUMO

Although androgens may play an etiologic role in breast, ovarian and endometrial cancers, little is known about factors that influence circulating androgen levels. We conducted a cross-sectional analysis among 646 postmenopausal women in the Nurses' Health Study to examine associations between adult risk factors for cancer, including the Rosner/Colditz breast cancer risk score, and plasma levels of testosterone, free testosterone, androstenedione, dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS). All analyses were adjusted for age, laboratory batch and other cancer risk factors. Free testosterone levels were 79% higher among women with a body mass index of > or =30 vs. <22 kg/m(2) (p-trend <0.01) and 25% higher among women with a waist circumference of >89 vs. < or =74 cm (p-trend = 0.02). Consuming >30 g of alcohol a day vs. none was associated with a 31% increase in DHEA and 59% increase in DHEAS levels (p-trend = 0.01 and <0.01, respectively). Smokers of > or =25 cigarettes per day had 35% higher androstenedione and 44% higher testosterone levels than never smokers (p-value, F-test = 0.03 and 0.01, respectively). No significant associations were observed for height or time since menopause with any androgen. Testosterone and free testosterone levels were approximately 30% lower among women with a hysterectomy vs. without (both p-values < 0.01). Overall breast cancer risk was not associated with any of the androgens. Thus, several risk factors, including body size, alcohol intake, smoking and hysterectomy, were related to androgen levels among postmenopausal women, while others, including height and time since menopause, were not. Future studies are needed to clarify further which lifestyle factors modulate androgen levels.


Assuntos
Androgênios/sangue , Neoplasias da Mama/sangue , Neoplasias do Endométrio/sangue , Neoplasias Ovarianas/sangue , Pós-Menopausa , Adulto , Índice de Massa Corporal , Estudos Transversais , Feminino , Humanos , Estilo de Vida , Pessoa de Meia-Idade , Fatores de Risco
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