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1.
Clin Genitourin Cancer ; 18(2): e91-e102, 2020 Apr.
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.

2.
Urology ; 131: 102-103, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31451150
3.
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
4.
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
5.
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
6.
Perm J ; 21: 16-184, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29035180

RESUMO

CONTEXT: Few studies have assessed the longer-term quality of preventive care in prostate cancer (PCa) survivors. OBJECTIVE: To compare the rates of preventive services among PCa survivors five years before and after diagnosis, to men without PCa. DESIGN: Men enrolled in Kaiser Permanente Southern California with newly diagnosed PCa (2002-2008) were matched 1:1 to men without a PCa diagnosis on age, race, and timing of prostate-specific antigen test (N = 31,180). The use of preventive services, including colorectal cancer screening, diabetes tests, lipid panels, and influenza and pneumococcal vaccinations was assessed 5 years before and after diagnosis (or index date for controls). MAIN OUTCOME MEASURES: Relative rates (RRs) of use were calculated for cases and controls separately and compared using Poisson regression, adjusting for comorbidities and outpatient utilization in 2014. RESULTS: Overall, the rates of preventive services were lower among men with PCa vs men without PCa. However, in the 5 years after diagnosis, rates of preventive service use for all services were greater among PCa survivors vs men without PCa (colorectal cancer: RR = 1.05, 95% confidence interval [CI] = 1.01-1.10; lipids: RR = 1.10, 95% CI = 1.08-1.11; hemoglobin A1C: RR = 1.17, 95% CI = 1.14-1.19; glucose: RR = 1.24, 95% CI = 1.23-1.26; influenza vaccine: RR = 1.05, 95% CI = 1.03-1.07; pneumococcal vaccine: RR = 1.03, 95% CI = 0.97-1.09). CONCLUSION: Delivery of preventive care improved after PCa diagnosis, with survivors receiving comparable preventive care to men without PCa during the five years following diagnosis.


Assuntos
Detecção Precoce de Câncer/estatística & dados numéricos , Detecção Precoce de Câncer/tendências , Serviços Preventivos de Saúde/estatística & dados numéricos , Serviços Preventivos de Saúde/tendências , Neoplasias da Próstata/prevenção & controle , Idoso , California , Previsões , Humanos , Masculino , Pessoa de Meia-Idade
7.
BJU Int ; 120(4): 520-529, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28425193

RESUMO

OBJECTIVE: To assess the health-related quality of life (HRQoL) of patients with prostate cancer up to 24 months after treatment in a contemporary large diverse population. PATIENTS AND METHODS: Patients with newly diagnosed prostate cancer from March 2011 to January 2014 in our healthcare system were included. The Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire was administered before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment up to November 2014 for all methods of treatment. The Kruskall-Wallis test was used to compare the distribution of each EPIC-26 domain score at each time point, and mixed models were used to assess the overall scores over the period after treatment. RESULTS: In all, 5 727 patients were included. There were data for 3 422, 2 329, 2 017, 1 922, 1 772, 1 260, and 837 patients before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment, respectively. At 1 month, bowel scores were the lowest for patients that had had radiation therapy, and urinary irritative symptoms were the lowest for those who had had brachytherapy. There were sexual function declines for all the treatment methods, with surgery having the steepest decline; open radical prostatectomy (ORP) had a greater decline than robot-assisted laparoscopic prostatectomy (RALP). Patients who underwent RALP had a better return of sexual function, approaching that of brachytherapy and radiation therapy at 24 months. Urinary incontinence (UI) also declined the most in surgical patients, with RALP patients improving slightly more than ORP patients at 12-24 months. CONCLUSIONS: Patients' HRQoL after prostate cancer treatment varies by treatment method. Notably, sexual function recovers most for RALP patients. UI remains worse at 24 months after surgery, compared to other methods of prostate cancer treatment.


Assuntos
Antígeno Prostático Específico/sangue , Neoplasias da Próstata/psicologia , Neoplasias da Próstata/terapia , Qualidade de Vida , Fatores Etários , Idoso , Braquiterapia/efeitos adversos , Braquiterapia/métodos , California , Estudos de Coortes , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Prostatectomia/efeitos adversos , Prostatectomia/métodos , Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/patologia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Taxa de Sobrevida , Resultado do Tratamento , Conduta Expectante
8.
Am J Obstet Gynecol ; 216(2): 146.e1-146.e7, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27751797

RESUMO

BACKGROUND: Urologic cancer has a lower prevalence in women compared with men; however, there are no differences in the recommended evaluation for women and men with microscopic hematuria. OBJECTIVES: The purpose of this study was to identify risk factors that are associated with urologic cancer in women with microscopic hematuria and to determine the applicability of a hematuria risk score for women. STUDY DESIGN: We conducted a retrospective cohort study within an integrated healthcare system in Southern California. All urinalyses with microscopic hematuria (>3 red blood cells per high-power field) that were performed from 2009-2015 were identified. Women who were referred for urologic evaluation were entered into a prospective database. Clinical and demographic variables that included the presence of gross hematuria in the preceding 6 months were recorded. The cause of the hematuria, benign or malignant, was entered into the database. Cancer rates were compared with the use of chi-square and logistic regression models. Adjusted risk ratios of urologic cancer were estimated with the use of multivariate regression analysis. We also explored the applicability of a previously developed, gender nonspecific, hematuria risk score in this female cohort. RESULTS: A total of 2,705,696 urinalyses were performed in women during the study period, of which 552,119 revealed microscopic hematuria. Of these, 14,539 women were referred for urologic evaluation; clinical data for 3573 women were entered into the database. The overall rate of urologic cancer was 1.3% (47/3573). In women <60 years old, the rate of urologic cancer was 0.6% (13/2053) compared with 2.2% (34/1520) in women ≥60 years old (P<.01). In women who reported a history of gross hematuria, the rate of urologic cancer was 5.8% (20/346) compared with a 0.8% (27/3227) in women with no history of gross hematuria (P<.01). In multivariate analysis, > 60 years old (odds ratio, 3.1; 95% confidence interval, 1.6-5.9), a history of smoking (odds ratio, 3.2; 95% confidence interval, 1.8-5.9), and a history of gross hematuria in the previous 6 months (odds ratio, 6.2; 95% confidence interval, 3.4-11.5) were associated with urologic cancers. A higher microscopic hematuria risk score was associated with an increased risk of cancer in this test cohort (P<.01). Women in the highest risk group had a urologic cancer rate of 10.8% compared with a rate of 0.5% in the lowest risk group. CONCLUSIONS: In this female population, >60 years old and a history of smoking and/or gross hematuria were the strongest predictors of urologic cancer. Absent these risk factors, the rate of urologic cancer did not exceed 0.6%. A higher hematuria risk score correlated significantly with the risk of urologic cancer in this female test cohort.


Assuntos
Hematúria/epidemiologia , Fumar/epidemiologia , Neoplasias Urológicas/epidemiologia , Adulto , Fatores Etários , California/epidemiologia , Estudos de Coortes , Bases de Dados Factuais , Feminino , Hematúria/urina , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Neoplasias Urológicas/urina
9.
Urology ; 96: 121-127, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27316374

RESUMO

OBJECTIVE: To examine the racial and ethnic variation in time to prostate biopsy after an elevated screening level of serum prostate-specific antigen (PSA). METHODS: Male members of the Kaiser Permanente of Southern California health plan, 45 years of age or older, with no history of prostate cancer or a prostate biopsy, and at least 1 elevated screening level of serum PSA between January 1, 1998 and December 31, 2007 were retrospectively identified (n = 59,506). All participants were passively followed via electronic health records until their time of prostate biopsy, death, membership disenrollment, or study conclusion (December 31, 2014), whichever was the initial event. Proportional hazard regression analyses were used to estimate the association between time from an elevated screening level of serum PSA to prostate biopsy, adjusting for age, benign prostatic hyperplasia, prostatitis, type 2 diabetes mellitus, hypertension, and Charlson Comorbidity Index score. RESULTS: Median time until biopsy was 0.6 years (214 days), with approximately 41% of participants receiving a prostate biopsy within the study period. Results from the fully adjusted analysis indicated that the non-Hispanic Asian or Pacific Islanders (hazard ratio: 1.10, 95% confidence interval: [1.04, 1.15]) and the non-Hispanic blacks (hazard ratio: 1.04, 95% confidence interval: [1.00, 1.08]) had a slightly shorter time to prostate biopsy after an elevated screening level of serum PSA compared to the non-Hispanic whites. CONCLUSION: These data suggest that, within an integrated healthcare organization, minimal differences exist between racial and ethnic subgroups in their time to prostate biopsy after an elevated screening level of serum PSA.


Assuntos
Grupos de Populações Continentais , Grupos Étnicos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Antígeno Prostático Específico/sangue , Próstata/patologia , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Idoso , Biópsia/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo
10.
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
11.
J Mens Health ; 11(5): 14-21, 2015 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-26430473

RESUMO

OBJECTIVE: To examine if the use of general preventive services were diminished in a cohort of men following their diagnosis of prostate cancer. PATIENTS AND METHODS: 16,604 men enrolled in Kaiser Permanente Southern California who were newly diagnosed with prostate cancer from January 1, 2002 through December 31, 2009 were passively followed through electronic medical records to determine the use of preventive services, including screening for colorectal cancer (colonoscopy and/or fecal occult blood tests (FOBT)), tests for diabetes (glucose and hemoglobin A1c) and heart disease (serum cholesterol, high density lipoprotein (HDL) and triglycerides) and vaccinations (influenza and pneumococcal). Preventive service use was compared in the two years prior to and following prostate cancer diagnosis using matched odds ratios (MOR) and 95% confidence intervals (CI) in 2013. RESULTS: Men were more likely to receive a flu vaccine (MOR: 2.70, 95% CI: 2.52-2.90), lipid tests (MOR: 1.51, 95% CI: 1.42-1.61), diabetes tests (MOR: 2.13, 95% CI: 2.00-2.26) and screening for colorectal cancer (MOR: 1.80, 95% CI: 1.71-1.89) in the two years after prostate cancer diagnosis compared to before. Men with advanced disease at diagnosis were more likely to receive all types of preventive services after diagnosis when compared to men with localized disease. CONCLUSIONS: Once diagnosed with prostate cancer in this setting, no less attention was paid to general preventive care, although there remains room for improvement in pneumococcal vaccination and colon cancer screening rates. The delivery of high-quality continuing care after diagnosis is critical for aging cancer patients.

13.
Urology ; 86(3): 498-505, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26123517

RESUMO

OBJECTIVE: To determine whether the rates of prostate-specific antigen (PSA) screening, related biopsies and subsequent prostate cancer utilization decreased between 2000 and 2012 in a large, managed care organization. METHODS: Male members of Kaiser Permanente Southern California who were aged ≥40 years and had no history of prostate cancer (N = 15,326) were passively followed through electronic health plan files from January 1, 2000, through December 31, 2012 (N = 1,539,469). The rates of PSA testing, elevated PSA tests, prostate biopsies, prostate cancer treatment (surgery and radiation), and urology visits were calculated per year among eligible men and stratified by age group. RESULTS: A 59% decrease in PSA screening occurred among men aged ≥75 years beginning in 2008, followed by 49% in ages 65-74, 20% in ages 50-64, and 33% in ages 40-49 years in 2009. However, the number of elevated PSA tests remained largely unchanged in all groups except in men aged ≥75 years (45% decrease). Prostate biopsy rates and urology visits remained consistent among elderly men. CONCLUSION: Among men in this managed care setting, although there was a sharp decline in PSA testing among men aged ≥75 years after 2008, prostate biopsy rates remained constant, and subsequent prostate cancer treatment remained highest among men in this age group. These results suggest that the guidelines recommending against PSA and the subsequent provider-targeted interventions implemented in this system resulted in decreased screening across age groups and potentially led to more discriminant screening among those aged ≥75 years.


Assuntos
Biópsia/estatística & dados numéricos , Programas de Assistência Gerenciada/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , California , Humanos , Masculino , Pessoa de Meia-Idade , Antígeno Prostático Específico/sangue
14.
BJU Int ; 115(1): 127-33, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24840926

RESUMO

OBJECTIVES: To characterise the progression and treatment of lower urinary tract symptoms (LUTS) among men aged 45-69 years in the California Men's Health Study. PATIENTS AND METHODS: A total of 39,222 men, aged 45-69 years, enrolled in the Southern California Kaiser Permanente Health Plan were surveyed in 2002-2003 and again in 2006-2007. Those men who completed both surveys who did not have a diagnosis of benign prostatic hyperplasia (BPH) and were not on medication for LUTS at baseline were included in the study (N = 19,505). Among the men with no or mild symptoms at baseline, the incidence of moderate/severe LUTS (American Urological Association Symptom Index [AUASI] score ≥8) and odds of progression to severe LUTS (AUASI score ≥20) was estimated during 4 years of follow-up. RESULTS: Of the 9640 men who reported no/mild LUTS at baseline, 3993 (41%) reported moderate/severe symptoms at follow-up and experienced a 4-point change in AUASI score on average. Of these men, 351 (8.8%) had received a pharmacological treatment, eight (0.2%) had undergone a minimally invasive or surgical procedure and 3634 (91.0%) had no treatment recorded. Men who progressed to severe symptoms (AUASI score ≥20; n = 165) were more likely to be on medication for BPH (odds ratio [OR] 8.09, 95% confidence interval [CI] 5.77-11.35), have a BPH diagnosis (OR 4.74, 95% CI 3.40-6.61) or have seen a urologist (OR 2.49, 95% CI 1.81-3.43) when compared with men who did not progress to severe symptoms (AUASI score <20). CONCLUSION: These data show that the majority of men who experienced progression did not have pharmacological or surgical therapy for their symptoms and, therefore, may prove to be good candidates for a self-management plan.


Assuntos
Sintomas do Trato Urinário Inferior/terapia , Adulto , Idoso , California/epidemiologia , Progressão da Doença , Inquéritos Epidemiológicos , Humanos , Incidência , Sintomas do Trato Urinário Inferior/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Hiperplasia Prostática
15.
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.

16.
Urology ; 81(5): 1010-5, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23490521

RESUMO

OBJECTIVE: To evaluate the incidence of hip fracture in men with prostate cancer receiving androgen deprivation therapy (ADT). MATERIALS AND METHODS: One of the detrimental side effects of ADT for prostate cancer is osteoporosis. Through an osteoporosis prevention program implemented in our healthcare system, the patients at risk undergo dual x-ray absorptiometry scans and receive treatment if the T-score indicates bone loss. We evaluated the incidence of hip fracture in men with prostate cancer who were receiving ADT through a retrospective, cohort study conducted within a managed care organization. The participants were all men newly diagnosed with prostate cancer from January 2003 to December 2007 receiving leuprolide injections. Patients who had had a dual x-ray absorptiometry scan beginning 3 months before the index date through the end of study were included in the intervention group; all others were included in the comparison group. The main outcome of interest was a hip fracture occurring after the index date, excluding cancer pathologic fractures, traumatic fractures, and fractures associated with epilepsy. RESULTS: A total of 1071 patients were in the intervention group, and 411 were in the comparison group. In the intervention group, 18 hip fractures occurred compared with 17 in the comparison group. The incidence rate of hip fractures per 1000 person-years was 5.1 (95% confidence interval 3.0-8.0) in the intervention group and 18.1 (95% confidence interval 10.5-29.0) in the comparison group. CONCLUSION: The incidence rate of hip fracture in this population was reduced >70% with enrollment in an osteoporosis management system, avoiding this morbid complication of ADT.


Assuntos
Antagonistas de Androgênios/uso terapêutico , Antineoplásicos Hormonais/uso terapêutico , Fraturas do Quadril/prevenção & controle , Osteoporose/prevenção & controle , Neoplasias da Próstata/tratamento farmacológico , Idoso , Densidade Óssea , California/epidemiologia , Seguimentos , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/etiologia , Humanos , Incidência , Masculino , Osteoporose/complicações , Osteoporose/epidemiologia , Neoplasias da Próstata/complicações , Estudos Retrospectivos
17.
BJU Int ; 111(8): 1245-52, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23320750

RESUMO

OBJECTIVE: To determine whether the rate of change in total serum prostate-specific antigen (PSA) levels accurately detects prostate cancer and to evaluate whether it adds any predictive value to a single measurement of serum PSA alone, in general practice settings. MATERIALS AND METHODS: A retrospective cohort of 219,388 community-dwelling men, aged ≥45 years, enrolled in the Kaiser Permanente Southern California health plan, with no history of prostate cancer and at least three PSA measurements, were followed from 1 January 1998 to 31 December 2007, for the development of biopsy-confirmed prostate cancer. Annual percent changes in total serum PSA levels were estimated using linear mixed models. The accuracy of prostate cancer prediction was assessed for prostate cancer overall and for aggressive disease (Gleason score ≥7) and compared with that of a single measure of PSA level using area under the receiver-operating characteristic curves (AUCs). RESULTS: The men in this cohort experienced a mean change of 2.9% in PSA levels per year and the rate of change in PSA increased modestly with age (P ≤ 0.001). Annual percent changes in PSA accurately predicted the presence of prostate cancer (AUC = 0.963) and aggressive disease (AUC = 0.955) and had more predictive accuracy for aggressive disease than did a single measurement of PSA alone (AUC = 0.727). CONCLUSIONS: Longitudinal measures of PSA improve the accuracy of aggressive prostate cancer detection when compared with a single measurement of PSA alone. Findings from this study provide insight into the usefulness of PSA velocity as a detection marker for aggressive prostate cancer.


Assuntos
Programas de Assistência Gerenciada/estatística & dados numéricos , Antígeno Prostático Específico/sangue , Próstata/patologia , Neoplasias da Próstata/sangue , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Biomarcadores Tumorais/sangue , Biópsia , California/epidemiologia , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Prognóstico , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/epidemiologia , Curva ROC , Estudos Retrospectivos
18.
Mayo Clin Proc ; 88(2): 129-38, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23312369

RESUMO

OBJECTIVE: To identify patients who could safely avoid unnecessary radiation and instrumentation after the detection of microscopic hematuria. PATIENTS AND METHODS: We conducted a prospective cohort study of patients who were referred to urologists and underwent a full evaluation for asymptomatic microscopic hematuria during a 2-year period in an integrated care organization in 3 regions along the West Coast of the United States. A test cohort and validation cohort of patients with hematuria evaluations between January 9, 2009, and August 15, 2011, were identified. Patients were followed passively through their electronic health records for a diagnosis of urothelial or renal cancer. The degree of microscopic hematuria, history of gross hematuria, smoking history, age, race, imaging findings, and cystoscopy findings were evaluated as risk factors for malignant tumors. RESULTS: The test cohort consisted of 2630 patients, of whom 55 (2.1%) had a neoplasm detected and 50 (1.9%) had a pathologically confirmed urinary tract cancer. Age of 50 years or older and a recent diagnosis of gross hematuria were the strongest predictors of cancer. Male sex was also predictive of cancer, whereas smoking history and 25 or more red blood cells per high-power field on a recent urinalysis were not statistically significant. A Hematuria Risk Index developed from these factors had an area under the receiver operating characteristic curve of 0.809. In the validation cohort of 1784 patients, the Hematuria Risk Index performed comparably (area under the curve = 0.829). Overall, 32% of the population was identified as low risk and 0.2% had a cancer detected; 14% of the population was identified as high risk, of whom 11.1% had a cancer found. CONCLUSION: These results suggest that a considerable proportion of patients could avoid extensive evaluations with the use of the Hematuria Risk Index.


Assuntos
Hematúria/diagnóstico , Hematúria/epidemiologia , Neoplasias Urológicas/diagnóstico , Neoplasias Urológicas/epidemiologia , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas/epidemiologia , California/epidemiologia , Causalidade , Estudos de Coortes , Comorbidade , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Noroeste dos Estados Unidos/epidemiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Fatores de Risco , Distribuição por Sexo , Fatores Sexuais , Estados Unidos , Procedimentos Desnecessários , Estudos de Validação como Assunto
19.
BJU Int ; 110(2): 254-9, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22085284

RESUMO

UNLABELLED: Study Type - Symptom prevalence (population cohort). Level of Evidence 1b. What's known on the subject? and What does the study add? It is known that medical conditions such as diabetes, high blood pressure, high cholesterol, smoking and prescribed medications cause erectile dysfunction (ED). This has been studied at the molecular level and reported in population studies. The present study shows that, after accounting for known medical problems, there is a dose-response relationship, in which worsening degrees of ED are seen when a greater number of medications are taken, regardless if they are prescribed or over the counter. The study can help primary care doctors and urologists to make a differential diagnosis of ED and it can also help improve patient's erectile function by tailoring and curtailing current medication use to maximize therapeutic benefit but minimize ED side effects in men, thus improving health-related quality of life. OBJECTIVE: • To study the association between erectile dysfunction (ED) and polypharmacy use in a large, ethnically and racially diverse cohort of men enrolled in the California Men's Health Study (CMHS). PATIENTS AND METHODS: • Men from the Kaiser Permanente Southern California (KPSC) health plan, enrolled in the CMHS in 2002, had an age range of 45-69 years. ED and comorbidities of these subjects were identified by questionnaire responses. • The number of drugs taken was determined from the year before enrollment through electronic pharmacy records and questionnaire responses. RESULTS: • Among the 37 712 (KPSC) subjects, 10 717 (29%) reported moderate or severe ED. • Across all age groups, ED was more prevalent as the number of medications increased. • In men taking 0-2, 3-5,6-9 and ≥ 10 medications, the percentage of men reporting moderate ED was 15.9, 19.7, 25.5 and 30.9%, respectively (P < 0.001). • With adjustment for age, race, smoking, diabetes, hypertension, hyperlipidaemia, peripheral vascular disease, coronary artery disease and body mass index, men taking >10 drugs were more likely to have ED (odds ratio = 2.32, 95% confidence interval 2.14-2.52) with evidence of a dose-response relationship. CONCLUSION: • These data suggest that the number of medications a man takes is associated with worse ED, even after comorbidities have been taken into account.


Assuntos
Disfunção Erétil/induzido quimicamente , Polimedicação , Idoso , Índice de Massa Corporal , California/epidemiologia , Transtorno Depressivo/epidemiologia , Complicações do Diabetes/epidemiologia , Disfunção Erétil/epidemiologia , Humanos , Hiperlipidemias/epidemiologia , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Fumar/epidemiologia
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