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1.
Epidemiology ; 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33591051

RESUMO

BACKGROUND: Duration and number of power outages have increased over time, partly fueled by climate change, putting users of electricity-dependent durable medical equipment (hereafter, "durable medical equipment") at particular risk of adverse health outcomes. Given health disparities in the United States, we assessed trends in durable medical equipment rental prevalence and individual- and area-level sociodemographic inequalities. METHODS: Using Kaiser Permanente South California (KPSC) electronic health record data, we identified durable medical equipment renters. We calculated annual prevalence of equipment rental and fit hierarchical generalized linear models with ZIP code random intercepts, stratified by rental of breast pumps or other equipment. RESULTS: 243,559 KPSC members rented durable medical equipment between 2008-2018. Rental prevalence increased over time across age, sex, racial-ethnic, and Medicaid categories, most by >100%. In adjusted analyses, Medicaid use was associated with increased prevalence and 108 (95% CI: 99, 117) additional days of equipment rental during the study period. ZIP code-level sociodemographics were associated with increased prevalence of equipment rentals, for example, a one standard-deviation increase in percent unemployed and < high school diploma (prevalence ratio [PR] = 1.1, 95% CI: 1.1, 1.1; and PR = 1.1, 95% CI: 1.1, 1.2, respectively). Increased Supplemental Nutrition Assistance Program usage was associated with decreased breast pump rentals (PR = 0.83, 95% CI: 0.78, 0.88). CONCLUSIONS: We observed some socioeconomic disparities among a growing electricity-dependent population. Our findings are consistent with the hypothesis that reliable electricity access is increasingly required to meet the health needs of medically disadvantaged groups.

2.
JAMA Netw Open ; 3(12): e2025190, 2020 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-33284336

RESUMO

Importance: Clinical trials have demonstrated the antifracture efficacy of bisphosphonate drugs for the first 3 to 5 years of therapy. However, the efficacy of continuing bisphosphonate for as long as 10 years is uncertain. Objective: To examine the association of discontinuing bisphosphonate at study entry, discontinuing at 2 years, and continuing for 5 additional years with the risk of hip fracture among women who had completed 5 years of bisphosphonate treatment at study entry. Design, Setting, and Participants: This cohort study included women who were members of Kaiser Permanente Northern and Southern California, 2 integrated health care delivery systems, and who had initiated oral bisphosphonate and completed 5 years of treatment by January 1, 2002, to September 30, 2014. Data analysis was conducted from January 2018 to August 2020. Exposure: Discontinuation of bisphosphonate at study entry (within a 6-month grace period), discontinuation at 2 years (within a 6-month grace period), and continuation for 5 additional years. Main Outcomes and Measures: The outcome was hip fracture determined by principal hospital discharge diagnoses. Demographic, clinical, and pharmacological data were ascertained from electronic health records. Results: Among 29 685 women (median [interquartile range] age, 71 [64-77] years; 17 778 [60%] non-Hispanic White individuals), 507 incident hip fractures were identified. Compared with bisphosphonate discontinuation at study entry, there were no differences in the cumulative incidence (ie, risk) of hip fracture if women remained on therapy for 2 additional years (5-year risk difference [RD], -2.2 per 1000 individuals; 95% CI, -20.3 to 15.9 per 1000 individuals) or if women continued therapy for 5 additional years (5-year RD, 3.8 per 1000 individuals; 95% CI, -7.4 to 15.0 per 1000 individuals). While 5-year differences in hip fracture risk comparing continuation for 5 additional years with discontinuation at 2 additional years were not statistically significant (5-year RD, 6.0 per 1000 individuals; 95% CI, -9.9 to 22.0 per 1000 individuals), interim hip fracture risk appeared lower if women discontinued after 2 additional years (3-year RD, 2.8 per 1000 individuals; 95% CI, 1.3 to 4.3 per 1000 individuals; 4-year RD, 9.3 per 1000 individuals; 95% CI, 6.3 to 12.3 per 1000 individuals) but not without a 6-month grace period to define discontinuation. Conclusions and Relevance: In this study of women treated with bisphosphonate for 5 years, hip fracture risk did not differ if they discontinued treatment compared with continuing treatment for 5 additional years. If women continued for 2 additional years and then discontinued, their risk appeared lower than continuing for 5 additional years. Discontinuation at other times and fracture rates during intervening years should be further studied.

3.
Proc Natl Acad Sci U S A ; 117(43): 27054-27058, 2020 10 27.
Artigo em Inglês | MEDLINE | ID: mdl-33046627

RESUMO

Previous research suggests that stressors may trigger the onset of acute cardiovascular disease (CVD) events within hours to days, but there has been limited research around sociopolitical events such as presidential elections. Among adults ≥18 y of age in Kaiser Permanente Southern California, hospitalization rates for acute CVD were compared in the time period immediately prior to and following the 2016 presidential election date. Hospitalization for CVD was defined as an inpatient or emergency department discharge diagnosis of acute myocardial infarction (AMI) or stroke using International Classification of Diseases, 10th revision codes. Rate ratios (RR) and 95% confidence intervals (CIs) were calculated comparing CVD rates in the 2 d following the 2016 election to rates in the same 2 d of the prior week. In a secondary analysis, AMI and stroke were analyzed separately. The rate of CVD events in the 2 d after the 2016 presidential election (573.14 per 100,000 person-years [PY]) compared to the rate in the window prior to the 2016 election (353.75 per 100,000 PY) was 1.62 times higher (95% CI 1.17, 2.25). Results were similar across sex, age, and race/ethnicity groups. The RRs were similar for AMI (RR 1.67, 95% CI 1.00, 2.76) and stroke (RR 1.59, 95% CI 1.03, 2.44) separately. Transiently heightened cardiovascular risk around the 2016 election may be attributable to sociopolitical stress. Further research is needed to understand the intersection between major sociopolitical events, perceived stress, and acute CVD events.

4.
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
5.
N Engl J Med ; 383(8): 743-753, 2020 08 20.
Artigo em Inglês | MEDLINE | ID: mdl-32813950

RESUMO

BACKGROUND: Bisphosphonates are effective in reducing hip and osteoporotic fractures. However, concerns about atypical femur fractures have contributed to substantially decreased bisphosphonate use, and the incidence of hip fractures may be increasing. Important uncertainties remain regarding the association between atypical femur fractures and bisphosphonates and other risk factors. METHODS: We studied women 50 years of age or older who were receiving bisphosphonates and who were enrolled in the Kaiser Permanente Southern California health care system; women were followed from January 1, 2007, to November 30, 2017. The primary outcome was atypical femur fracture. Data on risk factors, including bisphosphonate use, were obtained from electronic health records. Fractures were radiographically adjudicated. Multivariable Cox models were used. The risk-benefit profile was modeled for 1 to 10 years of bisphosphonate use to compare associated atypical fractures with other fractures prevented. RESULTS: Among 196,129 women, 277 atypical femur fractures occurred. After multivariable adjustment, the risk of atypical fracture increased with longer duration of bisphosphonate use: the hazard ratio as compared with less than 3 months increased from 8.86 (95% confidence interval [CI], 2.79 to 28.20) for 3 years to less than 5 years to 43.51 (95% CI, 13.70 to 138.15) for 8 years or more. Other risk factors included race (hazard ratio for Asians vs. Whites, 4.84; 95% CI, 3.57 to 6.56), height, weight, and glucocorticoid use. Bisphosphonate discontinuation was associated with a rapid decrease in the risk of atypical fracture. Decreases in the risk of osteoporotic and hip fractures during 1 to 10 years of bisphosphonate use far outweighed the increased risk of atypical fracture among Whites but less so among Asians. After 3 years, 149 hip fractures were prevented and 2 bisphosphonate-associated atypical fractures occurred in Whites, as compared with 91 and 8, respectively, in Asians. CONCLUSIONS: The risk of atypical femur fracture increased with longer duration of bisphosphonate use and rapidly decreased after bisphosphonate discontinuation. Asians had a higher risk than Whites. The absolute risk of atypical femur fracture remained very low as compared with reductions in the risk of hip and other fractures with bisphosphonate treatment. (Funded by Kaiser Permanente and others.).


Assuntos
Conservadores da Densidade Óssea/efeitos adversos , Difosfonatos/efeitos adversos , Fraturas do Fêmur/induzido quimicamente , Fraturas do Quadril/prevenção & controle , Osteoporose Pós-Menopausa/tratamento farmacológico , Fraturas por Osteoporose/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Americanos Asiáticos , Conservadores da Densidade Óssea/uso terapêutico , Difosfonatos/uso terapêutico , Grupo com Ancestrais do Continente Europeu , Feminino , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etnologia , Fraturas do Quadril/epidemiologia , Humanos , Incidência , Pessoa de Meia-Idade , Análise Multivariada , Osteoporose Pós-Menopausa/complicações , Fraturas por Osteoporose/induzido quimicamente , Fraturas por Osteoporose/epidemiologia , Modelos de Riscos Proporcionais , Medição de Risco , Fatores de Risco , Fatores de Tempo
6.
Medicine (Baltimore) ; 99(17): e19569, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32332605

RESUMO

Hypothyroidism and chronic kidney disease (CKD) are highly prevalent conditions with a potential mechanistic link. We sought to determine whether hypothyroidism is associated with CKD among a large diverse community-based cohort.A cross-sectional study was performed (January 1, 1990-December 31, 2017) within a large integrated health system. Individuals age ≥55 years of age with outpatient measurements of thyroid stimulating hormone (TSH) and ≥2 serum creatinine values were included. Hypothyroidism was defined as TSH >4 mIU/L and/or receipt of thyroid hormone replacement and further categorized as hypothyroid status: TSH >4 mcIU/mL and attenuated-hypothyroid status: TSH <4 mcIU/mL with receipt of thyroid hormone replacement. Euthyroidism was defined as TSH <4 mIU/L and no thyroid hormone replacement. Our primary measure was CKD defined as an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m. Multivariable logistic regression adjusting for age, sex, race, and comorbidities was used to estimate odds ratios (OR) for CKD by thyroid status.Among 378,101 individuals, 114,872 (30.4%) had hypothyroidism among whom 31,242 and 83,630 had hypothyroid and attenuated-hypothyroid statuses, respectively. Individuals with hypothyroidism had a CKD OR (95%CI) of 1.25 (1.21-1.29) compared with those with euthyroidism. Granular examination of thyroid statuses showed that hypothyroid and attenuated-hypothyroid statuses had CKD ORs (95% CI) of 1.59 (1.52-1.66) and 1.12 (1.08-1.16), respectively. A similar relationship was observed in analyses that defined CKD as an eGFR <60 L/min/1.73 m.Among individuals 55 years and older, we observed that those with hypothyroidism were more likely to have CKD. A stronger association was found among patients of hypothyroid status compared with attenuated-hypothyroid status suggesting a dose dependent relationship.


Assuntos
Hipotireoidismo/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Idoso , California/epidemiologia , Comorbidade , Estudos Transversais , Taxa de Filtração Glomerular , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Razão de Chances , Tireotropina/sangue
7.
J Am Heart Assoc ; 9(5): e013542, 2020 03 03.
Artigo em Inglês | MEDLINE | ID: mdl-32114888

RESUMO

Background Trends in acute myocardial infarction (AMI) incidence rates for diverse races/ethnicities are largely unknown, presenting barriers to understanding the role of race/ethnicity in AMI occurrence. Methods and Results We identified AMI hospitalizations for Kaiser Permanente Southern California members, aged ≥35 years, during 2000 to 2014 using discharge diagnostic codes. We excluded hospitalizations with missing race/ethnicity information. We calculated annual incidence rates (age and sex standardized to the 2010 US census population) for AMI, ST-segment-elevation myocardial infarction, and non-ST-segment-elevation myocardial infarction by race/ethnicity (Hispanic and non-Hispanic racial groups: Asian or Pacific Islander, black, and white). Using Poisson regression, we estimated annual percentage change in AMI, non-ST-segment-elevation myocardial infarction, and ST-segment-elevation myocardial infarction incidence by race/ethnicity and AMI incidence rate ratios between race/ethnicity pairs, adjusting for age and sex. We included 18 630 776 person-years of observation and identified 44 142 AMI hospitalizations. During 2000 to 2014, declines in AMI, non-ST-segment-elevation myocardial infarction, and ST-segment-elevation myocardial infarction were 48.7%, 34.2%, and 69.8%, respectively. Age- and sex-standardized AMI hospitalization rates/100 000 person-years declined for Hispanics (from 307 to 162), Asians or Pacific Islanders (from 271 to 158), blacks (from 347 to 199), and whites (from 376 to 189). Annual percentage changes ranged from -2.99% to -4.75%, except for blacks, whose annual percentage change was -5.32% during 2000 to 2009 and -1.03% during 2010 to 2014. Conclusions During 2000 to 2014, AMI, non-ST-segment-elevation myocardial infarction, and ST-segment-elevation myocardial infarction hospitalization incidence rates declined substantially for each race/ethnic group. Despite narrowing rates among races/ethnicities, differences persist. Understanding these differences can help identify unmet needs in AMI prevention and management to guide targeted interventions.

8.
J Manag Care Spec Pharm ; 26(2): 197-202, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32011964

RESUMO

BACKGROUND: Few studies have examined factors that determine bisphosphonate (BP) continuation beyond 5 years in clinical practice. OBJECTIVE: To investigate factors associated with BP continuation among women who completed 5 years of BP therapy. METHODS: Women who received 5 consecutive years of oral BP treatment entered the cohort during 2002-2014 and were followed up to 5 additional years. Multivariable logistic regression was used to evaluate the association of demographic and clinical factors with adherent treatment continuation. RESULTS: The cohort included 19,091 women with a median age of 72 years. Baseline and time-varying factors associated with increased odds of BP continuation after 5 years were (a) most recent bone mineral density (BMD) T-score -2 to -2.4 (OR = 1.31, 95% CI = 1.25-1.38), T-score -2.5 to -2.9 (OR = 1.48, 95% CI = 1.39-1.57), and T-score ≤ -3.0 (OR = 1.57, 95% CI = 1.47-1.68) versus T-scores above -2.0; (b) index date before 2008 (OR =1.35, 95% CI = 1.29-1.41); and (c) diabetes mellitus (OR = 1.08, 95% CI = 1.01-1.16). In contrast, factors associated with decreased odds of BP continuation were (a) recent hip (OR = 0.61, 95% CI = 0.52-0.71) or humerus (OR = 0.79, 95% CI = 0.66-0.94) fracture or fracture other than hip, wrist, spine, or humerus (OR = 0.90, 95% CI = 0.84-0.97); (b) Charlson Comorbidity Index score > 2 (OR = 0.91, 95% CI = 0.84-0.98); (c) history of rheumatoid arthritis (OR = 0.89, 95% CI = 0.80-0.99); (d) Hispanic (OR = 0.89, 95% CI=0.85-0.94) or Asian (OR = 0.90, 95% CI = 0.85-0.94) race/ethnicity; and (e) use of proton pump inhibitors (OR = 0.65, 95% CI = 0.59-0.71). Patient age and fracture before BP initiation were not associated with treatment continuation. CONCLUSIONS: Clinical factors predicting continued BP treatment beyond 5 years include low BMD T-score, absence of recent fracture, and earlier era of treatment. Use of proton pump inhibitors was associated with lower likelihood of BP continuation. Other clinical and demographic factors were also noted to have variable effects on BP treatment continuation. DISCLOSURES: This study was supported by a grant from the National Institute on Aging and National Institute of Arthritis, Musculoskeletal and Skin Diseases at the National Institutes of Health (NIH; R01AG047230, S1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or Kaiser Permanente. Lo has received previous research funding from Amgen and Sanofi, unrelated to the current study. Adams has received previous research funding from Merck, Amgen, Otsuka, and Radius Health, unrelated to the current study. Ettinger has served as an expert witness for Teva Pharmaceuticals, unrelated to the current study. Ott previously attended a scientific advisory meeting for Amgen but declined the honorarium. The other authors have nothing to disclose. These data were presented at the 2018 Annual Meeting of the American Society of Bone and Mineral Research (ASBMR), September 28-October 1, 2018, Montreal, Quebec, Canada.


Assuntos
Conservadores da Densidade Óssea/administração & dosagem , Difosfonatos/administração & dosagem , Osteoporose/tratamento farmacológico , Fraturas por Osteoporose/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Pessoa de Meia-Idade , Osteoporose/complicações , Fraturas por Osteoporose/epidemiologia , Inibidores da Bomba de Prótons/administração & dosagem , Fatores de Tempo
9.
Circulation ; 141(7): 509-519, 2020 02 18.
Artigo em Inglês | MEDLINE | ID: mdl-32065770

RESUMO

BACKGROUND: In recent decades, the rates of incident acute myocardial infarction (AMI) have declined in the United States, yet disparities by sex remain. In an integrated healthcare delivery system, we examined temporal trends in incident AMI among women and men. METHODS: We identified hospitalized AMI among members ≥35 years of age in Kaiser Permanente Southern California. The first hospitalization for AMI overall, and for ST-segment-elevation MI and non-ST-segment-elevation MI was identified by International Classification of Diseases, Ninth Revision, Clinical Modification primary discharge diagnosis codes in each calendar year from 2000 through 2014. Age- and sex-standardized incidence rates per 100 000 person-years were calculated by using direct adjustment to the 2010 US Census population. Average annual percent changes (AAPCs) and period percent changes were calculated, and trend tests were conducted using Poisson regression. RESULTS: We identified 45 331 AMI hospitalizations between 2000 and 2014. Age- and sex-standardized incidence rates of AMI declined from 322.4 (95% CI, 311.0-333.9) in 2000 to 174.6 (95% CI, 168.2-181.0) in 2014, representing an AAPC of -4.4% (95% CI, -4.2 to -4.6) and a period percent change of -46.6%. The AAPC for AMI in women was -4.6% (95% CI, -4.1 to -5.2) between 2000 and 2009 and declined to -2.3% (95% CI, -1.2 to -3.4) between 2010 and 2014. The AAPC for AMI in men was stable over the study period (-4.7% [95% CI, -4.4 to -4.9]). The AAPC for ST-segment-elevation MI hospitalization overall was -8.3% (95% CI, -8.0% to -8.6%).The AAPC in ST-segment-elevation MI changed among women in 2009 (2000-2009: -10.2% [95% CI, -9.3 to -11.1] and in 2010-2014: -5.2% [95% CI, -3.1 to -7.3]) while remaining stable among men (-8.0% [95% CI, -7.6 to -8.4]). The AAPC for non-ST-segment-elevation MI hospitalization was smaller than for ST-segment-elevation MI among both women and men (-1.9% [95% CI, -1.5 to -2.3] and -2.8% [95% CI, -2.5 to -3.2], respectively). CONCLUSIONS: These results suggest that the incidence of hospitalized AMI declined between 2000 and 2014; however, declines in AMI have slowed among women in comparison with men in recent years. Determining unmet care needs among women may reduce these sex-based AMI disparities.


Assuntos
Prestação Integrada de Cuidados de Saúde , Disparidades em Assistência à Saúde , Hospitalização , Infarto do Miocárdio , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia
10.
Intern Med J ; 50(9): 1100-1108, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-31707754

RESUMO

BACKGROUND: Falls and hip fractures among older people are associated with high morbidity and mortality. Hyponatraemia may be a risk for falls/hip fractures, but the effect of hyponatraemia duration is not well understood. AIMS: To evaluate individuals with periods of sub-acute and chronic hyponatraemia on subsequent risk for serious falls and/or hip fractures. METHODS: Retrospective cohort study in the period 1 January 1998 to 14 June 2016 within an integrated health system of individuals aged ≥55 years with ≥2 outpatient serum sodium measurements. Hyponatraemia was defined as sodium <135 mEq/L with sub-acute (<30 days) and chronic (≥30 days) analysed as a time-dependent exposure. Multivariable Cox proportional-hazards modelling was used to estimate hazard ratios (HR) for serious falls/hip fractures based on sodium category. RESULTS: Among 1 062 647 individuals totalling 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 normonatraemia, sub-acute and chronic hyponatraemia. Any hyponatraemia duration compared to normonatraemia had a serious falls/hip fractures HR (95%CI) of 1.18 (1.15, 1.22), with sub-acute and chronic hyponatraemia having HR 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 hyponatraemia, respectively. Hip fracture HR were 1.52 (1.42, 1.62) and 1.00 (0.92, 1.08) for sub-acute and chronic hyponatraemia, respectively, compared to normonatraemia. CONCLUSIONS: Our findings suggest that early/sub-acute hyponatraemia appears more vulnerable and associated with serious falls/hip fractures. Whether hyponatraemia is a marker of frailty or a modifiable risk factor for falls remains to be determined.

11.
Am J Kidney Dis ; 74(5): 589-600, 2019 11.
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.


Assuntos
Assistência à Saúde/métodos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Taxa de Filtração Glomerular/fisiologia , Insuficiência Renal Crônica/fisiopatologia , Progressão da Doença , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Estados Unidos/epidemiologia
12.
Urology ; 119: 70-78, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29906480

RESUMO

OBJECTIVE: To compare the risk of mortality among men treated for benign prostatic hyperplasia (BPH) with 5 alpha-reductase inhibitors (5ARI) to those treated with alpha-blockers (AB) in community practice settings. METHODS: We employed a retrospective matched cohort study in 4 regions of an integrated healthcare system. Men aged 50 years and older who initiated pharmaceutical treatment for BPH and/or lower urinary tract symptoms between 1992 and 2008 and had at least 3 consecutive prescriptions that were eligible and followed through 2010 (N = 174,895). Adjusted hazard ratios were used to estimate the risk of mortality due to all-causes associated with 5ARI use (with or without concomitant ABs) as compared to AB use. RESULTS: In this large and diverse sample with 543,523 person-years of follow-up, 35,266 men died during the study period, 18.9% of the 5ARI users and 20.4% of the AB users. After adjustment for age, medication initiation year, race, region, prior AB history, Charlson score, and comorbidities, 5ARI use was not associated with an increased risk of mortality when compared to AB use (Adjusted hazard ratios: 0.64, 95% confidence interval: 0.62, 0.66). CONCLUSION: Among men receiving medications for BPH in community practice settings, 5ARI use was not associated with an increased risk of mortality when compared to AB use. These data provide reassurance about the safety of using 5ARIs in general practice to manage BPH and/or lower urinary tract symptoms.


Assuntos
Inibidores de 5-alfa Redutase/uso terapêutico , Antagonistas Adrenérgicos alfa/uso terapêutico , Hiperplasia Prostática/tratamento farmacológico , Hiperplasia Prostática/mortalidade , Idoso , Causas de Morte , Estudos de Coortes , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco
13.
Am J Manag Care ; 23(12): e421-e422, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-29261250

RESUMO

In the setting of changing temporal trends in the management of osteoporosis, we examined how select characteristics of new oral bisphosphonate (BP) initiators changed over time among 94,073 women within a large, integrated healthcare organization during the period 2004 to 2012. In the earlier era (2004-2007), approximately half of women younger than 65 years initiating BP therapy (47%-54%) had osteoporosis by bone mineral density (BMD) criteria, but this proportion increased sharply in the later era (2008-2012), with 55% to 81% having osteoporosis. This trend was not evident in older women (≥65 years). The proportion of younger women with prior fracture increased from 15% in 2008 to 32% in 2012, after remaining relatively stable (10%-15%) during the earlier era. Again, this trend was not observed among older women. Thus, among women younger than 65 years, we observed a marked temporal shift in initiation of BP treatment toward women at high risk (including those with prior fracture and those with osteoporosis by BMD testing) and away from those at lower risk (such as those with osteopenia and/or no prior fracture).


Assuntos
Conservadores da Densidade Óssea/administração & dosagem , Doenças Ósseas Metabólicas/complicações , Doenças Ósseas Metabólicas/tratamento farmacológico , Prestação Integrada de Cuidados de Saúde , Difosfonatos/administração & dosagem , Fraturas Ósseas/etiologia , Fatores Etários , Idoso , Densidade Óssea , Doenças Ósseas Metabólicas/prevenção & controle , Feminino , Humanos , Adesão à Medicação , Pessoa de Meia-Idade , Osteoporose Pós-Menopausa/tratamento farmacológico , Estados Unidos
14.
Mayo Clin Proc ; 91(12): 1717-1726, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28126151

RESUMO

OBJECTIVE: To compare the risk of prostate cancer mortality among men treated with 5- alpha reductase inhibitors (5-ARIs) with those treated with alpha-adrenergic blockers (ABs) in community practice settings. PATIENTS AND METHODS: A retrospective matched cohort (N=174,895) and nested case-control study (N=18,311) were conducted in 4 regions of an integrated health care system. Men 50 years and older who initiated pharmaceutical treatment for benign prostatic hyperplasia between January 1, 1992, and December 31, 2007, and had at least 3 consecutive prescriptions were followed through December 31, 2010. Adjusted subdistribution hazard ratios, accounting for competing risks of death, and matched odds ratios were used to estimate prostate cancer mortality associated with 5-ARI use (with or without concomitant ABs) as compared with AB use. RESULTS: In the cohort study, 1,053 men died of prostate cancer (mean follow-up, 3 years), 15% among 5-ARI users (N= 25,388) and 85% among AB users (N=149,507) (unadjusted mortality rate ratio, 0.80). After accounting for competing risks, it was found that 5-ARI use was not associated with prostate cancer mortality when compared with AB use (adjusted subdistribution hazard ratio, 0.85; 95% CI, 0.72-1.01). Similar results were observed in the case-control study (adjusted matched odds ratio, 0.95; 95% CI, 0.78-1.17). CONCLUSION: Among men being pharmaceutically treated for benign prostatic hyperplasia, 5-ARI use was not associated with an increased risk of prostate cancer-specific mortality when compared with AB use. The increased prevalence of high-grade lesions at the time of diagnosis noted in our study and the chemoprevention trials may not result in increased prostate cancer mortality.


Assuntos
Inibidores de 5-alfa Redutase/efeitos adversos , Hiperplasia Prostática/tratamento farmacológico , Neoplasias da Próstata/induzido quimicamente , Neoplasias da Próstata/mortalidade , Antagonistas Adrenérgicos alfa/efeitos adversos , Idoso , Estudos de Coortes , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
15.
Langenbecks Arch Surg ; 400(4): 505-12, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25876737

RESUMO

PURPOSE: The aim of this study is to assess the incidence of incisional ventral hernia and small bowel obstruction following laparoscopic and open colorectal resection. METHODS: A retrospective review was performed of a large database comprising 13 hospitals, serving 3.6 million patients in Southern California. Patients 18 years and older undergoing elective colorectal resection over a 3-year period were included. The crude incidence rates were calculated, and relative risks of ventral hernia and small bowel obstruction were determined using multivariable proportional hazard modeling. RESULTS: Four thousand six hundred and thirteen patients underwent 4765 colorectal resections between August 2008 and August 2011. Fifty-nine percent of the cases were performed laparoscopically; the median age was 63 years, and 49% were males. Colorectal carcinoma (45%) and diverticulitis (18%) were the most common indications for surgery. The median follow-up was 2.4 years. Kaplan-Meier estimates of ventral hernia at 1, 2, and 3 years among the open cohort were significantly higher at 10.1, 17.0, and 20.5%, compared to 5.7, 8.7, and 10.8% in the laparoscopic cohort (p < 0.001). Similarly, small bowel obstruction was higher in the open compared to the laparoscopic group (open 10.4, 15.0, and 18.3% vs. laparoscopic 2.7, 4.4, and 5.5%, p < 0.001). Patients undergoing laparoscopic colorectal resection were less likely to develop ventral hernia [adjusted hazard ratio (AHR) 0.64 (95% CI 0.52, 0.80); p < 0.0001] and small bowel obstruction [AHR 0.41 (95% CI 0.31, 0.54); p < 0.0001]. CONCLUSIONS: The incidence of incisional ventral hernia and small bowel obstruction is significantly reduced in patients who undergo laparoscopic compared to open colorectal resection.


Assuntos
Colectomia/efeitos adversos , Colectomia/métodos , Hérnia Ventral/epidemiologia , Obstrução Intestinal/epidemiologia , Laparoscopia , Adulto , Idoso , Neoplasias Colorretais/cirurgia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos
16.
Diabetologia ; 58(2): 272-81, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25341460

RESUMO

AIMS/HYPOTHESIS: The aim of this study was to assess and compare risks of having large- or small-for gestational age (LGA and SGA, respectively) infants born to women with gestational diabetes mellitus (GDM) from ten racial/ethnic groups. METHODS: LGA and SGA were defined as birthweight >90th and <10th percentile, respectively, specific to each racial/ethnic population and infant sex. Risks of LGA and SGA were compared among a retrospective cohort of 29,544 GDM deliveries from Hispanic, non-Hispanic white (NHW), non-Hispanic black (NHB), Filipino, Chinese, Asian Indian, Vietnamese, Korean, Japanese and Pacific Islander (PI) groups of women. RESULTS: Unadjusted LGA and SGA risks varied among the ten groups. For LGA, the highest risk was in infants born to NHB women (17.2%), followed by those born to PI (16.2%), Hispanic (14.5%), NHW (13.1%), Asian Indian (12.8%), Filipino (11.6%) and other Asian (9.6-11.1%) women (p < 0.0001). Compared with NHW, the LGA risk was significantly greater for NHB women with GDM (RR 1.25 [95% CI 1.11-1.40]; p = 0.0001 after adjustment for maternal characteristics). Further adjustment for maternal pre-pregnancy BMI and gestational weight gain in the sub-cohort with available data (n = 8,553) greatly attenuated the elevated LGA risk for NHB women. For SGA, the risks ranged from 5.6% to 11.3% (p = 0.003) where most groups (8/10) had risks that were lower than the population-expected 10% and risks were not significantly different from those in NHW women. CONCLUSIONS/INTERPRETATION: These data suggest that variation in extremes of fetal growth associated with GDM deliveries across race/ethnicity can be explained by maternal characteristics, maternal obesity and gestational weight gain. Women should be advised to target a normal weight and appropriate weight gain for pregnancies; this is particularly important for NHB women.


Assuntos
Grupo com Ancestrais do Continente Africano , Grupo com Ancestrais do Continente Asiático , Diabetes Gestacional/epidemiologia , Grupo com Ancestrais do Continente Europeu , Grupo com Ancestrais Oceânicos , Ganho de Peso , Adulto , Peso ao Nascer , Grupos Étnicos , Feminino , Disparidades nos Níveis de Saúde , Humanos , Lactente , Recém-Nascido , Gravidez , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
17.
J Diabetes Complications ; 28(3): 279-85, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24581944

RESUMO

AIMS: To assess associations between race/ethnicity, glycated hemoglobin (HbA1c), and glycemic control among youth with type 1 (T1D) or type 2 diabetes (T2D). METHODS: The study sample was youth<20years old from the SEARCH California Center diagnosed from 2002 to 2009 who remained insured for at least one year. HbA1c at one year was from clinical data; HbA1c at diagnosis was from clinical data (81%) or imputed (19%). Multivariable logistic and linear regression models were used to examine associations between race/ethnicity and poor glycemic control (≥9.5%), HbA1c at one-year, and change in HbA1c. RESULTS: The study included 1162 Hispanic (52.3%), non-Hispanic White (NHW, 28.4%), African American (15.1%) and Asian/Pacific Islander (4.1%) youth. Among T1D youth (n=789), Hispanics were 1.60 times as likely (95% CI 1.01-2.53) to have poor control at one year compared to NHWs, after adjustments. Among T2D youth (n=373), only African American youth were significantly more likely (OR=4.85; 95% CI 1.49-15.77) to have poor control at one year, after adjustments. HbA1c at one year and change in HbA1c did not differ by race/ethnicity. CONCLUSION: Poor glycemic control was evident one year after diagnosis in some minority youth with T1D or T2D in an integrated managed health care setting.


Assuntos
Grupos de Populações Continentais/etnologia , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/etnologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/etnologia , Hemoglobina A Glicada/metabolismo , Hiperglicemia/sangue , Adolescente , Afro-Americanos , Americanos Asiáticos , Criança , Pré-Escolar , Estudos de Coortes , Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Gerenciamento Clínico , Grupo com Ancestrais do Continente Europeu , Feminino , Seguimentos , Hispano-Americanos , Humanos , Hipoglicemiantes/uso terapêutico , Lactente , Recém-Nascido , Modelos Lineares , Modelos Logísticos , Estudos Longitudinais , Masculino , Fatores Socioeconômicos , Resultado do Tratamento
18.
Vaccine ; 32(16): 1863-8, 2014 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-24508041

RESUMO

BACKGROUND: In an effort to maximize vaccine acceptance by minimizing adverse events following immunization associated with fever, including seizures, the Advisory Committee on Immunization Practices (ACIP) recommended in 2009 the use of measles, mumps and rubella vaccine (MMR) and varicella vaccines (V) given separately (MMR+V) rather than combination MMRV as the first dose of MMR-containing vaccine to infants. We evaluated factors associated with continued administration of MMRV as the first dose in many infants despite the ACIP recommendation. METHODS: Children 12 to 23 months of age who received MMRV or MMR+V between May 1, 2010 and April 30, 2011 were identified. Patient, provider and facility characteristics associated with MMRV or MMR+V administration were analyzed by bivariate and by multilevel multivariable logistic regression analysis. RESULTS: Altogether, 30,017 children received the first dose of MMRV or MMR+V at 12 to 23 months of age between May 1, 2010 and April 30, 2011. Of these, 10.2% received MMRV while 89.8% received MMR+V. MMRV was more likely to be administered to children who were non-compliant with vaccine recommendations at age one (adjusted odds ratio=1.48, 95%CI=1.28, 1.71). In addition, administration of MMRV by a Pediatric Infectious Disease specialist affiliated with a clinic was significantly associated with an increased likelihood of administration of MMRV by other providers at that clinic (interval odds ratio 80=2.18, 675.94, P(OR>1)=95%). CONCLUSIONS: These data suggest that while most providers followed the ACIP recommendation to administer MMR and V separately, Pediatric Infectious Disease specialists' vaccination practices may impact compliance with ACIP recommendations by other providers. Further study of the drivers behind the use of MMRV rather than MMR+V as the first dose of measles-containing vaccine is needed to determine if reinforcement or if clarification of ACIP recommendations is needed to elucidate when MMRV might be preferred over MMR+V.


Assuntos
Vacina contra Varicela/administração & dosagem , Fidelidade a Diretrizes , Vacina contra Sarampo-Caxumba-Rubéola/administração & dosagem , Pediatria/normas , California , Vacina contra Varicela/efeitos adversos , Estudos de Coortes , Feminino , Humanos , Esquemas de Imunização , Lactente , Modelos Logísticos , Masculino , Vacina contra Sarampo-Caxumba-Rubéola/efeitos adversos , Análise Multivariada , Cooperação do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Especialização , Vacinas Combinadas/administração & dosagem , Vacinas Combinadas/efeitos adversos
19.
JAMA Surg ; 148(9): 867-72, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23884515

RESUMO

IMPORTANCE: Current guidelines recommend that patients with an initial episode of gallstone pancreatitis receive cholecystectomy. However, for various reasons, many patients do not. OBJECTIVE: To determine the risk of developing recurrent gallstone pancreatitis in patients who never receive a cholecystectomy. DESIGN: Retrospective cohort study using electronic medical records. SETTING: Inpatient and outpatient. PATIENTS: All patients in Kaiser Permanente Southern California with a primary diagnosis of acute gallstone pancreatitis hospitalized from January 1, 1995, through December 31, 2010, with no previous diagnosis of gallstone pancreatitis documented in the medical record. INTERVENTIONS: Endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy and/or stent placement, or no intervention. MAIN OUTCOMES AND MEASURES: Recurrent acute pancreatitis. RESULTS: A total of 1119 patients were identified. The median age at diagnosis was 63 years. Among the patients, 802 received no intervention and 317 received ERCP. After a median follow-up of 2.3 years, the overall risk of recurrent pancreatitis was 14.6%; it was 8.2% and 17.1% in patients who had ERCP and no intervention, respectively (P < .001). The median time to recurrence was 11.3 and 10.1 months in the patients who had ERCP and no intervention, respectively. Kaplan-Meier estimates of recurrence for 1, 2, and 5 years in the ERCP group were 5.2%, 7.4%, and 11.1%, compared with 11.3%, 16.1%, and 22.7% in the no-intervention group (hazard ratio = 0.45; 95% CI, 0.30-0.69; P < .001). Charlson Comorbidity Index and intensive care unit stay were independently associated with recurrence, whereas age, sex, and admission Ranson score were not associated. CONCLUSIONS AND RELEVANCE: In patients who did not undergo cholecystectomy, the risk of recurrent pancreatitis is significant. Endoscopic retrograde cholangiopancreatography mitigates this risk and should be considered during initial hospitalization if cholecystectomy is not done.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Pancreatite/complicações , Pancreatite/cirurgia , Doença Aguda , Humanos , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Esfinterotomia Endoscópica , Stents
20.
J Bone Joint Surg Am ; 95(7): 653-9, 2013 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-23553301

RESUMO

BACKGROUND: Displaced patellar fractures are commonly stabilized with a modified anterior tension-band construct. The goal of the current study was to compare the incidence of complications after tension-band fixation of the patella with Kirschner wires as compared with cannulated screws. METHODS: We performed a retrospective cohort study of consecutive, surgically treated patellar fractures. Patients were divided into two cohorts: fractures fixed with use of Kirschner wires and fractures fixed with use of cannulated screws. The primary outcome measure was early loss of fixation that necessitated revision surgery. Secondary outcomes included early postoperative infection and the need for implant removal. RESULTS: Four hundred and forty-eight patellar fractures were studied. Kirschner wires were used for fixation in 315 (70%), and cannulated screws were used for fixation in 133 (30%). The incidence of fixation failure was 3.5% in the Kirschner-wire group and 7.5% in the screw group (p = 0.065). A postoperative infection occurred in 4.4% of patients in the Kirschner-wire group and 1.5% of patients in the screw group (p = 0.17). One hundred sixteen (37%) patients in the Kirschner-wire group and 30 (23%) in the screw group underwent elective implant removal (p = 0.003). After adjusting for confounding variables, a trend toward increased incidence of fixation failure with screws as compared with Kirschner wires was present (p = 0.083). Patients treated with Kirschner wires were twice as likely to undergo implant removal compared with those treated with screws (p = 0.002). CONCLUSIONS: Serious complications are uncommon following treatment of patellar fractures with a modified tension-band technique, with use of either Kirschner wires or cannulated screws. In both groups the rate of fixation failure was low, as was the rate of postoperative infection. Symptomatic implants, the most common complication observed, were twice as frequent in patients treated with Kirschner wires.


Assuntos
Parafusos Ósseos , Fios Ortopédicos , Fixação Interna de Fraturas/instrumentação , Fraturas Ósseas/cirurgia , Patela/lesões , Patela/cirurgia , Complicações Pós-Operatórias , Adulto , Idoso , Feminino , Consolidação da Fratura , Humanos , Modelos Logísticos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Método de Monte Carlo , Reoperação , Estudos Retrospectivos , Fatores de Risco
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