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1.
Artigo em Inglês | MEDLINE | ID: mdl-33823116

RESUMO

RATIONALE: Most lung cancers are diagnosed at an advanced stage. Pre-symptomatic identification of high-risk individuals can prompt earlier intervention and improve long-term outcomes. OBJECTIVE: To develop a model to predict a future diagnosis of lung cancer based on routine clinical and laboratory data, using machine-learning. METHODS: We assembled 6,505 non-small cell lung cancer (NSCLC) cases and 189,597 contemporaneous controls and compared the accuracy of a novel machine-learning model to a modified version of the well-validated PLCOm2012 risk model, using the area under the receiver operating characteristic curve (AUC), sensitivity and diagnostic odds ratio (OR) as measures of model performance. RESULTS: Among ever-smokers in the test set, the a machine-learning model was more accurate than the modified PLCOm2012 for identifying NSCLC 9-12 months before clinical diagnosis (P<0.00001), with an AUC of 0.86, a diagnostic OR of 12.8 3 and a sensitivity of 40.31% at a pre-defined specificity of 95%. In comparison, the modified PLCOm2012 had an AUC of 0.79, an OR of 7.4 and a sensitivity of 27.9% at the same specificity. The machine-learning model was more accurate than standard eligibility criteria for lung cancer screening and more accurate than the modified PLCOm2012 model when applied to a screening-eligible population. Influential model variables included known risk factors and novel predictors such as white blood cell and platelet counts. CONCLUSIONS: A machine-learning model was more accurate for early diagnosis of NSCLC than either standard eligibility criteria for screening or the modified PLCOm2012, demonstrating the potential to help prevent lung cancer deaths through early detection.

2.
Chest ; 2021 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-33482176

RESUMO

BACKGROUND: Multiple morbidity is the norm in advanced COPD and contributes to high symptom burden and worse outcomes. RESEARCH QUESTION: Can distinct comorbidity profiles be identified and validated in a community-based sample of patients with COPD from a large integrated health-care system using a standard, commonly used diagnostic code-based comorbidity index and downstream 2-year health-care use data? STUDY DESIGN AND METHODS: In this retrospective cohort study, we used latent class analysis (LCA) to identify comorbidity profiles in a population-based sample of 91,453 patients with a COPD diagnosis between 2011 and 2015. We included specific comorbid conditions from the Charlson Comorbidity Index (CCI) and accounted for variation in underlying prevalence of different comorbidities across the three study sites. Sociodemographic, clinical, and health-care use data were obtained from electronic health records (EHRs). Multivariate logistic regression analysis was used to compare rates of acute and postacute care use by class. RESULTS: The mean age was 71 ± 11 years, 55% of patients were women, 23% of patients were people of color, and 80% of patients were former or current smokers. LCA identified four distinct comorbidity profiles with progressively higher CCI scores: low morbidity (61%; 1.9 ± 1.4), metabolic renal (21%; 4.7 ± 1.8), cardiovascular (12%; 4.6 ± 1.9), and multimorbidity (7%; 7.5 ± 1.7). In multivariate models, during 2 years of follow-up, a significant, nonoverlapping increase was found in the odds of having any all-cause acute (hospitalizations, observation stays, and ED visits) and postacute care use across the comorbidity profiles. INTERPRETATION: Distinct comorbidity profiles can be identified in patients with COPD using standard EHR-based diagnostic codes, and these profiles are associated with subsequent acute and postacute care use. Population-based risk stratification schemes for end-to-end, comprehensive COPD management should consider integrating comorbidity profiles such as those found in this study.

3.
Chest ; 159(3): 1273-1282, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33393476

RESUMO

BACKGROUND: The Pan-Canadian Early Detection of Lung Cancer (PanCan) risk model and the Lung CT Screening Reporting & Data System (Lung-RADS) estimate cancer probability for screening-detected nodules. The accuracy and agreement of these models require further study. RESEARCH QUESTION: What is the performance of the PanCan model and Lung-RADS to estimate the probability of cancer in screening-detected solid nodules? STUDY DESIGN AND METHODS: We analyzed data for newly identified, solid nodules detected on any screening round in the low-dose CT arm of the National Lung Screening Trial to assign a PanCan risk and Lung-RADS score. We compared PanCan risk with the corresponding Lung-RADS category according to the expected prevalence of cancer and examined accuracy using logistic regression and between-test agreement. We also analyzed baseline screen-detected nodules only, high (defined as ≥ 5% probability of cancer) vs low-risk nodules, "risk-gap" nodules with a 3% to 5% PanCan probability and no equivalent Lung-RADS category, and procedure use by model. RESULTS: Participants with solid nodules (6,956) had a calculable PanCan risk and Lung-RADS score. PanCan accuracy by cancer probabilities < 1%, 1% to 2%, 5% to 15%, and > 15% was similar to corresponding Lung-RADS categories 2, 3, 4A, and 4B for any solid nodule (area under the curve, 0.84 vs 0.84; P = .95) and for nodules identified at baseline (area under the curve, 0.85 vs 0.84; P = .17). When dichotomized by high/low risk, PanCan and Lung-RADS were discordant (P < .001). Participants with risk-gap nodules (n = 543) were distributed across Lung-RADS categories 2 through 4; 41 (8%) had invasive procedures with 23 (4%) having unnecessary invasive procedure use for solid, benign nodules. INTERPRETATION: PanCan and Lung-RADS had similar overall accuracy for assessing cancer in screening-detected, solid lung nodules with evidence of discordance by subgroup. The existence of Lung-RADS category 4 nodules with a ≥ 3% to 5% PanCan risk may result in unnecessary procedures.

4.
J Gen Intern Med ; 2021 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-33474640

RESUMO

BACKGROUND: Despite significant investment in colorectal cancer (CRC) screening, 40% of US adults are not up-to-date. Commitment devices, which are psychologically tailored approaches to enforce health goals, may be an effective method to increase CRC screening. OBJECTIVE: Compare the effectiveness of a commitment device (patient self-ordering fecal immunochemical test (FIT) kits) to standard CRC screening outreach. DESIGN: A retrospective observational study. PARTICIPANTS: Participants were > 49 years and < 75 years, had no history of CRC, and were eligible for CRC screening. INTERVENTION: An electronic screening reminder with an embedded order button allowed participants to order FIT kits directly from a patient portal. Those who used the order button were promptly sent a kit; those who did not were later mailed kits. MAIN MEASURES: Primary outcome was completion of FIT kits. Secondary outcomes included number of days to completion, completion of follow-up for positive results, and CRC diagnosis; we also examined prior use of FIT kit. We used inverse probability of treatment weights to control for pretreatment imbalances. KEY RESULTS: The cohort comprised 176,231 participants: 53% female; median age was 59; 11% were Asian, 21% Hispanic/Latino, 7% black, 51% White, 3% other/mixed race. Approximately 10% (N = 16,918) used the button. Using inverse probability of treatment weights, we found that those who used the button had 3.8 times the odds of completing a kit compared to participants who did not (odds ratio, 3.77; 95% confidence interval, 3.57-3.98). Within the button group, 63% of those eligible completed a FIT kit in the year prior to the button compared to 87% in the year after the button became available (p < 0.0001). CONCLUSION: The ability to self-order screening kits may act as a commitment device that increases CRC screening. Scalable tools leveraging existing patient portals such as this can complement existing CRC outreach strategies.

5.
Clin Lung Cancer ; 22(2): 83-91, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33436279

RESUMO

BACKGROUND: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality in high-risk patients, but most of those eligible are not referred for screening, and most eligible smokers are not aware of LCS. Smoking cessation counseling may be an opportune time to educate smokers about LCS. Here we investigate the effect of LCS educational information on LDCT utilization and smoking cessation in LCS-eligible patients receiving smoking cessation counseling. PATIENTS AND METHODS: We randomized 1281 smokers aged 55-80 who underwent smoking cessation services to view a web-based educational video about LCS (n = 1026) or to receive usual care (n = 255). Outcomes included the utilization of chest computed tomographic (CT) scan during 6 months of follow-up, responses to survey questions, and patient-reported abstinence from smoking at 6 months. RESULTS: One hundred forty-six participants (14%) watched the video. Overall, 87 participants (8.5%) in the intervention group underwent any chest CT and 37 (3.6%) underwent LDCT compared to 22 (8.6%) and 11 (4.3%) in the control group during the 6-month follow-up period (P = .94 and .59, respectively). Among participants who completed watching the video, 27 (18.5%) underwent any chest CT and 13 (8.9%) underwent LDCT, compared to 22 (8.6%) and 11 (4.3%) in controls during follow-up (P = .0037 and .062, respectively). There was no difference in abstinence from smoking between groups. CONCLUSION: An LCS educational intervention may be effective in improving utilization of LDCT in eligible individuals who currently smoke at the time of smoking cessation counseling. Further research on the effect of LCS education in the context of smoking cessation counseling is needed.

6.
JAMA Intern Med ; 181(4): 480-489, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-33464296

RESUMO

Importance: Whether guideline-concordant lung nodule evaluations lead to better outcomes remains unknown. Objective: To examine the association between the intensity of lung nodule diagnostic evaluations and outcomes, safety, and health expenditures. Design, Setting, and Participants: This comparative effectiveness research study analyzed health plan enrollees at Kaiser Permanente Washington in Seattle, Washington, and Marshfield Clinic in Marshfield, Wisconsin, with an incidental lung nodule detected between January 1, 2005, and December 31, 2015. Included patients were 35 years or older, had no high suspicion of infection, had no history of malignant neoplasm, and had no evidence of advanced lung cancer on nodule detection. Data analysis was conducted from January 7 to August 19, 2020. Exposures: With the 2005 Fleischner Society guidelines (selected for their applicability to the time frame under investigation) as the comparator, 2 other intensities of lung nodule evaluation were defined. Guideline-concordant evaluation followed the guidelines. Less intensive evaluation was the absence of recommended testing, longer-than-recommended surveillance intervals, or less invasive testing than recommended. More intensive evaluation consisted of testing when the guidelines recommended no further testing, shorter-than-recommended surveillance intervals, or more invasive testing than recommended. Main Outcomes and Measures: The main outcome was the proportion of patients with lung cancer who had stage III or IV disease, radiation exposure, procedure-related adverse events, and health expenditures 2 years after nodule detection. Results: Among the 5057 individuals included in this comparative effectiveness research study, 1925 (38%) received guideline-concordant, 1863 (37%) less intensive, and 1269 (25%) more intensive diagnostic evaluations. The entire cohort comprised 2786 female patients (55%), and the mean (SD) age was 67 (13) years. Adjusted analyses showed that compared with guideline-concordant evaluations, less intensive evaluations were associated with fewer procedure-related adverse events (risk difference [RD], -5.9%; 95% CI, -7.2% to -4.6%), lower mean radiation exposure (-9.5 milliSieverts [mSv]; 95% CI, -10.3 mSv to -8.7 mSv), and lower mean health expenditures (-$10 916; 95% CI, -$16 112 to -$5719); no difference in stage III or IV disease was found among patients diagnosed with lung cancer (RD, 4.6%; 95% CI, -22% to +31%). More intensive evaluations were associated with more procedure-related adverse events (RD, +8.1%; 95% CI, +5.6% to +11%), higher mean radiation exposure (+6.8 mSv; 95% CI, +5.8 mSv to +7.8 mSv), and higher mean health expenditures ($20 132; 95% CI, +$14 398 to +$25 868); no difference in stage III or IV disease was observed (RD, -0.5%; 95% CI, -28% to +27%). Conclusions and Relevance: This study found inconclusive evidence of an association between less intensive diagnostic evaluations and more advanced stage at lung cancer diagnosis compared with guideline-concordant care; higher intensities of diagnostic evaluations were associated with greater procedural complications, radiation exposure, and expenditures. These findings underscore the need for more evidence on better ways to evaluate lung nodules and to avoid unnecessarily intensive diagnostic evaluations of lung nodules.

7.
J Am Heart Assoc ; 10(3): e019669, 2021 02 02.
Artigo em Inglês | MEDLINE | ID: mdl-33307964

RESUMO

Background Previous reports suggest that the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may upregulate angiotensin-converting enzyme 2 receptors and increase severe acute respiratory syndrome coronavirus 2 infectivity. We evaluated the association between ACEI or ARB use and coronavirus disease 2019 (COVID-19) infection among patients with hypertension. Methods and Results We identified patients with hypertension as of March 1, 2020 (index date) from Kaiser Permanente Southern California. Patients who received ACEIs, ARBs, calcium channel blockers, beta blockers, thiazide diuretics (TD), or no therapy were identified using outpatient pharmacy data covering the index date. Outcome of interest was a positive reverse transcription polymerase chain reaction test for COVID-19 between March 1 and May 6, 2020. Patient sociodemographic and clinical characteristics were identified within 1 year preindex date. Among 824 650 patients with hypertension, 16 898 (2.0%) were tested for COVID-19. Of those tested, 1794 (10.6%) had a positive result. Overall, exposure to ACEIs or ARBs was not statistically significantly associated with COVID-19 infection after propensity score adjustment (odds ratio [OR], 1.06; 95% CI, 0.90-1.25) for ACEIs versus calcium channel blockers/beta blockers/TD; OR, 1.10; 95% CI, 0.91-1.31 for ARBs versus calcium channel blockers/beta blockers/TD). The associations between ACEI use and COVID-19 infection varied in different age groups (P-interaction=0.03). ACEI use was associated with lower odds of COVID-19 among those aged ≥85 years (OR, 0.30; 95% CI, 0.12-0.77). Use of no antihypertensive medication was significantly associated with increased odds of COVID-19 infection compared with calcium channel blockers/beta blockers/TD (OR, 1.32; 95% CI, 1.11-1.56). Conclusions Neither ACEI nor ARB use was associated with increased likelihood of COVID-19 infection. Decreased odds of COVID-19 infection among adults ≥85 years using ACEIs warrants further investigation.


Assuntos
Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Prestação Integrada de Cuidados de Saúde/métodos , Hipertensão/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
8.
Am J Emerg Med ; 2020 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-33189516

RESUMO

OBJECTIVE: Develop and validate a risk score using variables available during an Emergency Department (ED) encounter to predict adverse events among patients with suspected COVID-19. METHODS: A retrospective cohort study of adult visits for suspected COVID-19 between March 1 - April 30, 2020 at 15 EDs in Southern California. The primary outcomes were death or respiratory decompensation within 7-days. We used least absolute shrinkage and selection operator (LASSO) models and logistic regression to derive a risk score. We report metrics for derivation and validation cohorts, and subgroups with pneumonia or COVID-19 diagnoses. RESULTS: 26,600 ED encounters were included and 1079 experienced an adverse event. Five categories (comorbidities, obesity/BMI ≥ 40, vital signs, age and sex) were included in the final score. The area under the curve (AUC) in the derivation cohort was 0.891 (95% CI, 0.880-0.901); similar performance was observed in the validation cohort (AUC = 0.895, 95% CI, 0.874-0.916). Sensitivity ranging from 100% (Score 0) to 41.7% (Score of ≥15) and specificity from 13.9% (score 0) to 96.8% (score ≥ 15). In the subgroups with pneumonia (n = 3252) the AUCs were 0.780 (derivation, 95% CI 0.759-0.801) and 0.832 (validation, 95% CI 0.794-0.870), while for COVID-19 diagnoses (n = 2059) the AUCs were 0.867 (95% CI 0.843-0.892) and 0.837 (95% CI 0.774-0.899) respectively. CONCLUSION: Physicians evaluating ED patients with pneumonia, COVID-19, or symptoms suspicious for COVID-19 can apply the COVAS score to assist with decisions to hospitalize or discharge patients during the SARS CoV-2 pandemic.

9.
Acad Emerg Med ; 2020 Nov 18.
Artigo em Inglês | MEDLINE | ID: mdl-33206443

RESUMO

BACKGROUND: Evaluate the effect of changing the laboratory reported D-dimer thresholds to age-adjusted standards on the use of advanced chest imaging and 30-day adverse events among emergency department (ED) encounters. METHODS: A retrospective interrupted time series analysis of ED encounters for patients > 50 years evaluated for suspected PE from April 2014-April 2016. The primary outcome was use of advanced diagnostic imaging. and the secondary outcome was 30-day mortality or PE diagnosis. Secondary analyses also quantified delayed PE diagnoses pre- and post- intervention. A generalized estimating equation segmented logistic regression model, adjusting for patient and facility characteristics, was used to determine changes in odds of diagnostic imaging, and 30-day mortality or PE diagnoses. RESULTS: 10,534 (5,153 pre- and 5,381 post-implementation) ED encounters were included. Advanced imaging was obtained in 35.9% of pre- vs 33% of post-implementation encounters. Age-adjusted D-dimer (AADD) showed a small and non-significant decrease in month-to-month trends of advanced chest imaging post-implementation (OR 0.98; 95% CI 0.96 to 1.00). Use of advanced imaging in patients with D-dimer values lower than 500 ng/mL FEU was similar in the pre-intervention (5.8%) and post-intervention (6.8%) periods. However, imaging was obtained in 30% of patients post-intervention with a D-dimer result than the historical 500 ng/mL FEU reference. Implementing an AADD threshold demonstrated no change in the rate of 30-day adverse events (missed PE or mortality). CONCLUSION: Changing the laboratory reported D-dimer thresholds for evaluation of PE was not associated with reduction in advanced chest imaging and did not increase 30-day adverse events. However, there was substantial non-compliance with the age-adjusted standards in the post-intervention period likely blunting the impact of this intervention.

10.
J Am Coll Radiol ; 2020 Nov 16.
Artigo em Inglês | MEDLINE | ID: mdl-33212069

RESUMO

PURPOSE: The aim of this study was to examine radiologists' beliefs about existing guidelines for pulmonary nodule evaluation. METHODS: A self-administered survey was developed to ascertain awareness of, agreement with, and adherence to published guidelines, including those from the Fleischner Society and the Lung CT Screening Reporting and Data System (Lung-RADS™). Surveys were distributed to 514 radiologists at 13 health care systems that are participating in a large, pragmatic trial of pulmonary nodule evaluation. Prespecified comparisons were made among groups defined by type of health system, years of experience, reader volume, and study arm. RESULTS: The response rate was 26.3%. Respondents were most familiar with guidelines from Fleischner (94%) and Lung-RADS (71%). For both incidental and screening-detected nodules, self-reported adherence to preferred guidelines was very high (97% and 94%, respectively), and most respondents believed that the benefits of adherence outweigh the harms (81% and 74%, respectively). Underlying evidence was thought to be high in quality by 68% of respondents for screening-detected nodules and 41% for incidental nodules. Approximately 70% of respondents believed that the frequency of recommended follow-up was "just right" for both guidelines. Radiologists who practice in nonintegrated health care systems were more likely to believe that the evidence was high in quality (79.5% vs 57.1%) and that the benefits of adherence outweigh the harms (85.1% vs 67.5%). Low-volume readers had lower awareness and self-reported adherence than higher volume readers. CONCLUSIONS: Radiologists reported high levels of familiarity and agreement with and adherence to guidelines for pulmonary nodule evaluation, but many overestimated the quality of evidence in support of the recommendations.

11.
Healthc (Amst) ; 8(4): 100476, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33007650

RESUMO

BACKGROUND: The Embedded Healthcare Research Conference aimed to promote and enhance research-operations partnerships in diverse health care settings. Within this conference, the Priorities and Methods Workgroup set out to define a vision of embedded research that leverages diverse methods to address clearly articulated research questions of importance to health systems. METHODS: The Workgroup session involved a combination of small and large group discussions around three broadly focused topics: the integration of embedded research within the existing quality improvement (QI) ecosystem; the identification, prioritization and formulation of embedded research questions; the creation of an embedded research "tool kit." RESULTS: Workgroup participants envisioned a future for embedded research that is characterized by authentic engagement between researchers and health system leaders; seamless integration between research, QI and clinical operations; clear and explicit articulation of research questions; an appropriate balance between rigor and relevance in applied methodology; alignment between study design, available resources and the importance of the knowledge to be gained; efficient processes; and bi-directional communication. Important barriers to achieving this vision include limited access to executive leaders, silos that discourage integration of research and QI, generally low tolerance for disruption in high-risk clinical settings, limited access to data, and limited availability of researchers with requisite skills and training. CONCLUSIONS: Embedded research holds potential to enhance the relevance, value and use of research, while also creating generalizable knowledge. Key recommendations include building authentic relationships, discouraging silos, encouraging innovation and experimentation, and expanding opportunities for funding research in delivery systems.

12.
JAMA Intern Med ; 2020 Oct 05.
Artigo em Inglês | MEDLINE | ID: mdl-33031502

RESUMO

Importance: Professional guidelines recommend noninvasive cardiac testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI). Objective: To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days. Design, Setting, and Participants: This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive cardiac testing vs no testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge. Exposures: Noninvasive cardiac testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome. Main Outcomes and Measures: The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge. Results: A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin. Conclusions and Relevance: Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.

13.
Popul Health Manag ; 2020 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-32941105

RESUMO

Interventions to support patients with complex needs are proliferating. However, little attention has been paid to methods for identifying complex patients. This study aims to summarize approaches used to define populations with complex needs in practice, by cataloging specific population criteria and organizing them into a taxonomy. The authors conducted a pragmatic review of literature published January 2000-December 2018 using PubMed. Search results were limited to English-language studies of adults that specified a set of objective criteria to identify a population with complex needs. The authors abstracted data from each article on population parameters, and conducted thematic analysis guided by deductive coding. The review identified 70 studies reflecting 90 unique complex population definitions. Complex populations criteria reflected 3 approaches: stratification, segmentation, and targeting. Six domains of population criteria were found within, including age-based criteria (59 populations); income (12); health care costs (45); health care utilization (39); health conditions (35); and subjective criteria (15). Criteria from multiple domains were frequently used in combination, and exact specifications were highly variable within each domain. Overall, 83% of the 90 population definitions included at least 1 cost- or utilization-based criterion. Nearly every study in the review presented a unique approach to identifying patients with complex needs but a limited number of "schools of thought" were found. Variability in definitions and inconsistent terminology are potential sources of ambiguity between stakeholders. Greater specificity and transparency in complex population definition would be a substantial contribution to the emerging field of complex care.

14.
Int J Infect Dis ; 99: 291-297, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32768693

RESUMO

OBJECTIVE: To examine outcomes among patients who were treated with the targeted anti-cytokine agents, anakinra or tocilizumab, for COVID-19 -related cytokine storm (COVID19-CS). METHODS: We conducted a retrospective cohort study of all SARS-coV2-RNA-positive patients treated with tocilizumab or anakinra in Kaiser Permanente Southern California. Local experts developed and implemented criteria to define COVID19-CS. All variables were extracted from electronic health records. RESULTS: At tocilizumab initiation (n = 52), 50 (96.2%) were intubated, and only seven (13.5%) received concomitant corticosteroids. At anakinra initiation (n = 41), 23 (56.1%) were intubated, and all received concomitant corticosteroids. Fewer anakinra-treated patients died (n = 9, 22%) and more were extubated/never intubated (n = 26, 63.4%) compared to tocilizumab-treated patients (n = 24, 46.2% dead, n = 22, 42.3% extubated/never intubated). Patients who died had more severe sepsis and respiratory failure and met COVID-CS laboratory criteria longer (median = 3 days) compared to those extubated/never intubated (median = 1 day). After accounting for differences in disease severity at treatment initiation, this apparent superiority of anakinra over tocilizumab was no longer statistically significant (propensity score-adjusted hazards ratio 0.46, 95% confidence interval 0.18-1.20). CONCLUSIONS: Prompt identification and treatment of COVID19-CS before intubation may be more important than the specific type of anti-inflammatory treatment. Randomized controlled trials of targeted anti-cytokine treatments and corticosteroids should report the duration of cytokine storm in addition to clinical severity at randomization.


Assuntos
Corticosteroides/uso terapêutico , Anti-Inflamatórios/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Betacoronavirus/imunologia , Infecções por Coronavirus/tratamento farmacológico , Citocinas/imunologia , Proteína Antagonista do Receptor de Interleucina 1/uso terapêutico , Pneumonia Viral/tratamento farmacológico , Idoso , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/virologia , Intervenção Médica Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/imunologia , Pneumonia Viral/virologia , Estudos Retrospectivos , Resultado do Tratamento
15.
Tob Prev Cessat ; 6: 12, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32548349

RESUMO

INTRODUCTION: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet few people who are eligible for LCS get screened. In the present study, we studied the feasibility of tobacco cessation counselors to inform about LCS during tobacco cessation group counseling. METHODS: Four tobacco cessation counselors at two different facilities offering group tobacco cessation counseling were trained to administer an educational intervention about LCS. The intervention was administered to 25 participants during May 2019 who completed surveys that assessed how much the information provided helped with understanding various aspects of lung cancer screening including benefits, risks, eligibility criteria, and insurance coverage. The intervention also provided information on how to learn more about LCS and assessed the acceptability of the information. RESULTS: The median score for understanding of all components of the intervention was 5 ('completely understand'). Most participants (92%) felt that the information provided about LCS was the right amount. Most participants (72%) were aged 55-80 years, the age range for LCS eligibility. Four participants (16%) reported undergoing LCS in the past. When we reanalyzed the subset of participants who reported no prior LCS, the results of surveys were similar. CONCLUSIONS: Our findings suggest that it is feasible to train tobacco cessation counselors to educate smokers, attending group tobacco cessation counseling classes, also about LCS. The education provided in this study was both understood and well received by the large majority of smokers surveyed. Further study is needed to understand the effect of LCS education on utilization of LDCT among smokers enrolled in tobacco cessation counseling.

16.
Blood Adv ; 4(12): 2557-2566, 2020 06 23.
Artigo em Inglês | MEDLINE | ID: mdl-32542391

RESUMO

Risk assessment models (RAMs) for venous thromboembolism (VTE) and bleeding in hospitalized medical patients inform appropriate use of thromboprophylaxis. Our aim was to use a novel approach for selecting risk factors for VTE and bleeding to be included in RAMs. First, we used the results of a systematic review of all candidate factors. Second, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of the evidence for the identified factors. Third, we using a structured approach to select factors to develop the RAMs, by building on clinical and methodological expertise. The expert panel made judgments on whether to include, potentially include, or exclude risk factors, according to domains of the GRADE approach and the Delphi method. The VTE RAM included age >60 years, previous VTE, acute infections, immobility, acute paresis, active malignancy, critical illness, and known thrombophilia. The bleeding RAM included age ≥65 years, renal failure, thrombocytopenia, active gastroduodenal ulcers, hepatic disease, recent bleeding, and critical illness. We identified acute infection as a factor that was not considered in widely used RAMs. Also, we identified factors that require further research to confirm or refute their importance in a VTE RAM (eg, D-dimer). We excluded autoimmune disease which is included in the IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding RAM. Our results also suggest that sex, malignancy, and use of central venous catheters (factors in the IMPROVE bleeding RAM) require further research. In conclusion, our study presents a novel approach to systematically identifying and assessing risk factors to be included or further explored during RAM development.

17.
J Am Coll Radiol ; 17(7): 845-854, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32485147

RESUMO

BACKGROUND: The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. METHODS: An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. RESULTS: Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non-small-cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non-small-cell lung cancer. CONCLUSIONS: There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.


Assuntos
Infecções por Coronavirus/prevenção & controle , Diagnóstico por Imagem/normas , Neoplasias Pulmonares/diagnóstico por imagem , Nódulos Pulmonares Múltiplos/diagnóstico por imagem , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Nódulo Pulmonar Solitário/diagnóstico por imagem , Betacoronavirus , Consenso , Infecções por Coronavirus/transmissão , Detecção Precoce de Câncer , Humanos , Pneumonia Viral/transmissão
18.
J Gen Intern Med ; 35(12): 3675-3680, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32472492

RESUMO

Embedded research is an innovative means to improve performance in the learning healthcare system (LHS). However, few descriptions of successful embedded research programs have been published. In this perspective, we describe the Care Improvement Research Team, a mature partnership between researchers and clinicians at Kaiser Permanente Southern California. The program supports a core team of researchers and staff with dedicated resources to partner with health system leaders and practicing clinicians, using diverse methods to identify and rectify gaps in clinical practice. For example, recent projects helped clinicians to provide better care by reducing prescribing of unnecessary antibiotics for acute sinusitis and by preventing readmissions among the elderly. Embedded in operational workgroups, the team helps formulate research questions and enhances the rigor and relevance of data collection and analysis. A recent business-case analysis cited savings to the organization of over $10 million. We conclude that embedded research programs can play a key role in fulfilling the promise of the LHS. Program success depends on dedicated funding, robust data systems, and strong relationships between researchers and clinical stakeholders. Embedded researchers must be responsive to health system priorities and timelines, while clinicians should embrace researchers as partners in problem solving.

19.
Chest ; 158(1): 406-415, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32335067

RESUMO

BACKGROUND: The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. METHODS: An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. RESULTS: Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non-small cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non-small cell lung cancer. CONCLUSIONS: There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Infecções por Coronavirus , Neoplasias Pulmonares , Nódulos Pulmonares Múltiplos/diagnóstico , Pandemias , Pneumonia Viral , Radiografia Torácica/métodos , Betacoronavirus/isolamento & purificação , Consenso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/normas , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/patologia , Estadiamento de Neoplasias , Pandemias/prevenção & controle , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Alocação de Recursos , Medição de Risco/métodos
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