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Nau C, Butler RK, Huang CW, Khang VK, Chen A, Creekmur B, Broder B, Subject C, Sharp AL, Moreta-Sainz LM, Park JS, Manek AJ, Cooper RM, Mendoza SM, Luo G, Gould MK. Development and validation of the COVID-19 Hospitalized Patient Deterioration Index. Am J Manag Care 2023; 29:e365-e371. [PMID: 38170527 PMCID: PMC10843847 DOI: 10.37765/ajmc.2023.89470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To develop a COVID-19-specific deterioration index for hospitalized patients: the COVID Hospitalized Patient Deterioration Index (COVID-HDI). This index builds on the proprietary Epic Deterioration Index, which was not developed for predicting respiratory deterioration events among patients with COVID-19. STUDY DESIGN A retrospective observational cohort was used to develop and validate the COVID-HDI model to predict respiratory deterioration or death among hospitalized patients with COVID-19. Deterioration events were defined as death or requiring high-flow oxygen, bilevel positive airway pressure, mechanical ventilation, or intensive-level care within 72 hours of run time. The sample included hospitalized patients with COVID-19 diagnoses or positive tests at Kaiser Permanente Southern California between May 3, 2020, and October 17, 2020. METHODS Machine learning models and 118 candidate predictors were used to generate benchmark performance. Logit regression with least absolute shrinkage and selection operator and physician input were used to finalize the model. Split-sample cross-validation was used to train and test the model. RESULTS The area under the receiver operating curve was 0.83. COVID-HDI identifies patients at low risk (negative predictive value [NPV] > 98.5%) and borderline low risk (NPV > 95%) of an event. Of all patients, 74% were identified as being at low or borderline low risk at some point during their hospitalization and could be considered for discharge with or without home monitoring. A high-risk group with a positive predictive value of 51% included 12% of patients. Model performance remained high in a recent cohort of patients. CONCLUSIONS COVID-HDI is a parsimonious, well-calibrated, and accurate model that may support clinical decision-making around discharge and escalation of care.
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Affiliation(s)
- Claudia Nau
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101.
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Gould MK, Creekmur B, Qi L, Golden SE, Kaplan CP, Walter E, Mularski RA, Vaszar LT, Fennig K, Steiner J, de Bie E, Musigdilok VV, Altman DA, Dyer DS, Kelly K, Miglioretti DL, Wiener RS, Slatore CG, Smith-Bindman R. Emotional Distress, Anxiety, and General Health Status in Patients With Newly Identified Small Pulmonary Nodules: Results From the Watch the Spot Trial. Chest 2023; 164:1560-1571. [PMID: 37356710 DOI: 10.1016/j.chest.2023.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Anxiety and emotional distress have not been studied in large, diverse samples of patients with pulmonary nodules. RESEARCH QUESTION How common are anxiety and distress in patients with newly identified pulmonary nodules, and what factors are associated with these outcomes? STUDY DESIGN AND METHODS This study surveyed participants in the Watch the Spot Trial, a large, pragmatic clinical trial of more vs less intensive strategies for radiographic surveillance of patients with small pulmonary nodules. The survey included validated instruments to measure patient-centered outcomes such as nodule-related emotional distress (Impact of Event Scale-Revised) and anxiety (Six-Item State Anxiety Inventory) 6 to 8 weeks following nodule identification. Mixed-effects models were used to compare outcomes between study arms following adjustment for potential confounders and clustering within enrollment site, while also examining a limited number of prespecified explanatory factors, including nodule size, mode of detection, type of ordering clinician, and lack of timely notification prior to contact by the study team. RESULTS The trial enrolled 34,699 patients; 2,049 individuals completed the baseline survey (5.9%). Respondents and nonrespondents had similar demographic and nodule characteristics, although more respondents were non-Hispanic and White. Impact of Event Scale-Revised scores indicated mild, moderate, or severe distress in 32.2%, 9.4%, and 7.2% of respondents, respectively, with no difference in scores between study arms. Following adjustment, greater emotional distress was associated with larger nodule size and lack of timely notification by a clinician; distress was also associated with younger age, female sex, ever smoking, Black race, and Hispanic ethnicity. Anxiety was associated with lack of timely notification, ever smoking, and female sex. INTERPRETATION Almost one-half of respondents experienced emotional distress 6 to 8 weeks following pulmonary nodule identification. Strategies are needed to mitigate the burden of distress, especially in younger, female, ever smoking, and minoritized patients, and those with larger nodules. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT02623712; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Michael K Gould
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Lihong Qi
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA
| | | | - Celia P Kaplan
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Eric Walter
- Northwest Permanente Medical Group, Portland, OR; Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Richard A Mularski
- Northwest Permanente Medical Group, Portland, OR; Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Kathleen Fennig
- Department of Research Affairs, Wright State University School of Medicine, Dayton, OH
| | - Julie Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Evan de Bie
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA
| | - Visanee V Musigdilok
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Debra S Dyer
- Department of Radiology, National Jewish Health, Denver, CO
| | - Karen Kelly
- Department of Medicine, School of Medicine, University of California, Davis, Davis, CA
| | - Diana L Miglioretti
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA; Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Boston University School of Medicine, Boston, MA; National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
| | - Christopher G Slatore
- VA Portland Healthcare System, Portland, OR; National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC
| | - Rebecca Smith-Bindman
- Department of Epidemiology and Biostatistics, and the Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA
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Myers LC, Kipnis P, Greene JD, Chen A, Creekmur B, Xu S, Sankar V, Roubinian NH, Langer-Gould A, Gould MK, Liu VX. The impact of timing of initiating invasive mechanical ventilation in COVID-19-related respiratory failure. J Crit Care 2023; 77:154322. [PMID: 37163851 PMCID: PMC10165890 DOI: 10.1016/j.jcrc.2023.154322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 03/17/2023] [Accepted: 04/06/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Optimal timing of initiating invasive mechanical ventilation (IMV) in coronavirus disease 2019 (COVID-19)-related respiratory failure is unclear. We hypothesized that a strategy of IMV as opposed to continuing high flow oxygen or non-invasive mechanical ventilation each day after reaching a high FiO2 threshold would be associated with worse in-hospital mortality. METHODS Using data from Kaiser Permanente Northern/Southern California's 36 medical centers, we identified patients with COVID-19-related acute respiratory failure who reached ≥80% FiO2 on high flow nasal cannula or non-invasive ventilation. Exposure was IMV initiation each day after reaching high FiO2 threshold (T0). We developed propensity scores with overlap weighting for receipt of IMV each day adjusting for confounders. We reported relative risk of inpatient death with 95% Confidence Interval. RESULTS Of 28,035 hospitalizations representing 21,175 patient-days, 5758 patients were included (2793 received and 2965 did not receive IMV). Patients receiving IMV had higher unadjusted mortality (63.6% versus 18.2%, P < 0.0001). On each day after reaching T0 through day >10, the adjusted relative risk was higher for those receiving IMV compared to those not receiving IMV (Relative Risk>1). CONCLUSIONS Initiation of IMV on each day after patients reach high FiO2 threshold was associated with higher inpatient mortality after adjusting for time-varying confounders. Remaining on high flow nasal cannula or non-invasive ventilation does not appear to be harmful compared to IMV. Prospective evaluation is needed.
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Affiliation(s)
- Laura C Myers
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America.
| | - Patricia Kipnis
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - John D Greene
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Stan Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Viji Sankar
- Southern California Permanente Medical Group, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | - Nareg H Roubinian
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Annette Langer-Gould
- Southern California Permanente Medical Group, Kaiser Permanente Southern California, Pasadena, CA, United States of America; Clinical & Translational Neuroscience, Kaiser Permanente and Southern California Permanente Medical Group, Los Angeles, CA, United States of America
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America; Southern California Permanente Medical Group, Kaiser Permanente Southern California, Pasadena, CA, United States of America; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America
| | - Vincent X Liu
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, United States of America
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Myers LC, Xu S, Chen A, Greene JD, Creekmur B, Bruxvoort K, Escobar GJ, Adams JL, Langer‐Gould A, Liu VX, Gould MK. The intensity of anticoagulant dosing in hospitalized patients with COVID-19: An observational, comparative effectiveness study. J Hosp Med 2023; 18:43-54. [PMID: 36345824 PMCID: PMC9877905 DOI: 10.1002/jhm.13007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/14/2022] [Accepted: 11/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The question of anticoagulant dosing in hospitalized patients with coronavirus disease-2019 (COVID-19) is unresolved, with randomized trials showing mixed results and heterogeneity of treatment effects for in-hospital death. OBJECTIVE To examine the association between the intensity of anticoagulation and clinical outcomes in hospitalized patients with COVID-19. DESIGN, SETTING AND PARTICIPANTS Retrospective cohort study of patients with COVID-19 and respiratory impairment who were hospitalized between 3/1/2020-12/31/2020 in two Kaiser Permanente regions. EXPOSURE AND MAIN OUTCOME We fit propensity score models using categorical regression to estimate the probability of receiving standard prophylactic, intermediate, or full-dose anticoagulation beginning on the day of admission or on the day of first respiratory deterioration. Exposure was defined by the highest dose on the day of admission or within 24 hours after deterioration. The primary outcome was in-hospital death. RESULTS We included 17,130 patients in the day of admission analysis and 4,924 patients who experienced respiratory deterioration. There were no differences in propensity score-adjusted odds of in-hospital death for patients who received either intermediate (odds ratio [OR]: 1.00, 95% confidence intervals [CI] 0.89-1.12) or full anticoagulation (OR: 1.00, 95% CI: 0.85-1.17) compared with standard prophylaxis beginning on the day of admission. Similarly, there were no differences in in-hospital death for either intermediate (OR: 1.22, 95% CI: 0.82-1.82) or full anticoagulation (OR: 1.50, 95% CI: 0.90-2.51) compared with standard prophylaxis on the day of deterioration. CONCLUSION Results of this real-world, comparative effectiveness study showed no differences in in-hospital death among newly admitted or deteriorating patients with COVID-19 who received intermediate-dose or full anticoagulation compared with standard prophylaxis.
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Affiliation(s)
- Laura C. Myers
- Division of Research and The Permanente Medical GroupKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Stanley Xu
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - Aiyu Chen
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - John D. Greene
- Division of Research and The Permanente Medical GroupKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Beth Creekmur
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - Katia Bruxvoort
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
- Department of Epidemiology, School of Public HealthUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Gabriel J. Escobar
- Division of Research and The Permanente Medical GroupKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - John L. Adams
- Kaiser Permanente Center for Effectiveness and Safety ResearchPasadenaCaliforniaUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCaliforniaUSA
| | - Annette Langer‐Gould
- Neurology Department, Southern California Permanente Medical GroupKaiser Permanente Southern CaliforniaLos AngelesCaliforniaUSA
| | - Vincent X. Liu
- Division of Research and The Permanente Medical GroupKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Michael K. Gould
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCaliforniaUSA
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Langer-Gould A, Xu S, Myers LC, Chen A, Greene JD, Creekmur B, Bruxvoort K, Adams JL, Liu V, Gould MK. Anakinra or high-dose corticosteroids in COVID-19 pneumonia patients who deteriorate on low-dose dexamethasone: an observational study of comparative effectiveness. Int J Infect Dis 2023; 126:87-93. [PMID: 36403818 PMCID: PMC9673073 DOI: 10.1016/j.ijid.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/28/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To assess whether escalating to high-dose corticosteroids or anakinra compared with continuing low-dose corticosteroids reduced mortality in patients with severe COVID-19 whose respiratory function deteriorated while receiving dexamethasone 6 mg daily. METHODS We conducted a retrospective cohort study between March 1 to December 31, 2020, of hospitalized patients with confirmed COVID-19 pneumonia. In-hospital death was analyzed using logistic regression with inverse probability of treatment weighting of receiving anakinra, high-dose corticosteroid (dexamethasone >10 mg daily), or remaining on low-dose corticosteroids on the day of first respiratory deterioration. RESULTS We analyzed 6671 patients whose respiratory status deteriorated while receiving dexamethasone 6 mg daily for COVID-19 pneumonia, of whom 6265 stayed on low-dose corticosteroids, 232 were escalated to high-dose corticosteroids, and 174 to anakinra in addition to corticosteroids. The propensity score-adjusted odds of death were higher in the anakinra (odds ratio [OR] 1.76; 95% CI 1.13-2.72) and high-dose corticosteroid groups (OR 1.53; 95% CI 1.14-2.07) compared with those who continued low-dose corticosteroids on the day of respiratory deterioration. The odds of hospital-acquired infections were also higher in the anakinra (OR 2.00; 95% CI 1.28-3.11) and high-dose corticosteroid groups (OR 1.43; 95% CI 1.00-2.04) compared with low-dose corticosteroid group. CONCLUSION Our findings do not support escalating patients with COVID-19 pneumonia who deteriorate on low-dose corticosteroids to high-dose corticosteroids or anakinra.
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Affiliation(s)
- Annette Langer-Gould
- Department of Neurology, Southern California Permanente Medical Group, Los Angeles, USA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA.
| | - Stanley Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Laura C Myers
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, USA
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - John D Greene
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, USA
| | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Katia Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
| | - Vincent Liu
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, USA
| | - Michael K Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
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Langer-Gould A, Xu S, Myers LC, Chen A, Greene JD, Creekmur B, Bruxvoort K, Adams JL, Liu V, Gould MK. High-dose corticosteroids in patients hospitalized for COVID-19 pneumonia: an observational study of comparative effectiveness. Int J Infect Dis 2022; 125:184-191. [PMID: 36404464 PMCID: PMC9621697 DOI: 10.1016/j.ijid.2022.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To assess whether high- compared with low-dose corticosteroids started upon hospitalization reduce mortality in patients with severe COVID-19 pneumonia or in subgroups stratified by severity of respiratory impairment on admission. METHODS We conducted a retrospective cohort study of patients with confirmed SARS-CoV-2 infection who required oxygen supplementation upon hospitalization between March 1 and December 31, 2020. In-hospital death was analyzed using logistic regression with inverse probability of treatment weighting of receiving low- or high-dose corticosteroid (dexamethasone 6-10 mg daily or >10-20 mg daily or other corticosteroid equivalents). RESULTS We analyzed 13,366 patients who received low-dose and 948 who received high-dose corticosteroids, of whom 31.3% and 40.4% had severe respiratory impairment (>15 l/min of oxygen or mechanical ventilation) upon admission, respectively. There were no differences in the propensity score-adjusted odds of death (odds ratio 1.17, 95% CI 0.72-1.90) or infections (odds ratio 0.70, 95% CI 0.44-1.11) for patients who received high-dose compared with low-dose corticosteroids, beginning on the day of admission. No significant differences in subgroups stratified by severity of respiratory impairment were found. CONCLUSION Initiating high-dose compared with low-dose corticosteroids among newly hospitalized patients with COVID-19 pneumonia did not improve survival. However, benefit of high-dose corticosteroids in specific subgroups cannot be excluded.
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Affiliation(s)
- Annette Langer-Gould
- Southern California Permanente Medical Group, Neurology Department, Kaiser Permanente Southern California, Los Angeles, USA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA.
| | - Stanley Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Laura C Myers
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, USA
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - John D Greene
- Division of Research and The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, USA
| | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Katia Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
| | - Vincent Liu
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
| | - Michael K Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
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Huang BZ, Creekmur B, Yoo MS, Broder B, Subject C, Sharp AL. Healthcare Utilization Among Patients Diagnosed with COVID-19 in a Large Integrated Health System. J Gen Intern Med 2022; 37:830-837. [PMID: 34993879 PMCID: PMC8735886 DOI: 10.1007/s11606-021-07139-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/03/2021] [Indexed: 02/01/2023]
Abstract
Background The demands for healthcare resources following a COVID-19 diagnosis are substantial, but not currently quantified. Objective To describe trends in healthcare utilization within 180 days for patients diagnosed with COVID-19 and identify patient factors associated with increased healthcare use. Design Observational cohort study. Patients A total of 64,011 patients with a test-confirmed COVID-19 diagnosis from March to September 2020 in a large integrated healthcare system in Southern California. Main Measures Overall healthcare utilization during the 180 days following COVID-19 diagnosis, as well as encounter types and reasons for visits during the first 30 days. Poisson regression was used to identify patient factors associated with higher utilization. Analyses were performed separately for patients who were and were not hospitalized for COVID-19. Key Results Healthcare utilization was about twice as high for hospitalized patients compared to non-hospitalized patients in all time periods. The average number of visits was highest in the first 30 days (hospitalized: 12.3 visits/30 person-days; non-hospitalized: 6.6) and gradually decreased over time. In the first 30 days, the majority of healthcare visits were telehealth encounters (hospitalized: 9.0 visits; non-hospitalized: 5.6 visits), and the most prevalent reasons for visits were COVID-related diagnoses, COVID-related symptoms, and respiratory-related conditions. For hospitalized patients, older age (≥65: RR 1.27, 95% CI 1.15–1.41), female gender (RR 1.07, 95% CI 1.05–1.09), and higher BMI (≥40: RR 1.07, 95% CI 1.03–1.10) were associated with higher total utilization. For non-hospitalized patients, older age, female gender, higher BMI, non-white race/ethnicity, former smoking, and greater number of pre-existing comorbidities were all associated with increased utilization. Conclusions Patients with COVID-19 seek healthcare frequently within 30 days of diagnosis, placing high demands on health systems. Identifying ways to support patients diagnosed with COVID-19 while adequately providing the usual recommended care to our communities will be important as we recover from the pandemic. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07139-z.
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Affiliation(s)
- Brian Z. Huang
- grid.280062.e0000 0000 9957 7758Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
- grid.42505.360000 0001 2156 6853Department of Population and Public Health Sciences, Keck School of Medicine of USC, CA Los Angeles, USA
| | - Beth Creekmur
- grid.280062.e0000 0000 9957 7758Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
| | - Michael S. Yoo
- grid.414908.00000 0004 0445 0834The Permanente Medical Group, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA USA
| | - Benjamin Broder
- Southern California Permanente Medical Group, Baldwin Park Medical Center, Baldwin Park, CA USA
| | - Christopher Subject
- grid.414855.90000 0004 0445 0551Southern California Permanente Medical Group, Los Angeles Medical Center, Los Angeles, CA USA
| | - Adam L. Sharp
- grid.280062.e0000 0000 9957 7758Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
- grid.414855.90000 0004 0445 0551Southern California Permanente Medical Group, Los Angeles Medical Center, Los Angeles, CA USA
- grid.19006.3e0000 0000 9632 6718Departments of Clinical Science & Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA
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8
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Kohn R, Vachani A, Small D, Stephens-Shields AJ, Sheu D, Madden VL, Bayes BA, Chowdhury M, Friday S, Kim J, Gould MK, Ismail MH, Creekmur B, Facktor MA, Collins C, Blessing KK, Neslund-Dudas CM, Simoff MJ, Alleman ER, Epstein LH, Horst MA, Scott ME, Volpp KG, Halpern SD, Hart JL. Comparing Smoking Cessation Interventions among Underserved Patients Referred for Lung Cancer Screening: A Pragmatic Trial Protocol. Ann Am Thorac Soc 2022; 19:303-314. [PMID: 34384042 PMCID: PMC8867367 DOI: 10.1513/annalsats.202104-499sd] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023] Open
Abstract
Smoking burdens are greatest among underserved patients. Lung cancer screening (LCS) reduces mortality among individuals at risk for smoking-associated lung cancer. Although LCS programs must offer smoking cessation support, the interventions that best promote cessation among underserved patients in this setting are unknown. This stakeholder-engaged, pragmatic randomized clinical trial will compare the effectiveness of four interventions promoting smoking cessation among underserved patients referred for LCS. By using an additive study design, all four arms provide standard "ask-advise-refer" care. Arm 2 adds free or subsidized pharmacologic cessation aids, arm 3 adds financial incentives up to $600 for cessation, and arm 4 adds a mobile device-delivered episodic future thinking tool to promote attention to long-term health goals. We hypothesize that smoking abstinence rates will be higher with the addition of each intervention when compared with arm 1. We will enroll 3,200 adults with LCS orders at four U.S. health systems. Eligible patients include those who smoke at least one cigarette daily and self-identify as a member of an underserved group (i.e., is Black or Latinx, is a rural resident, completed a high school education or less, and/or has a household income <200% of the federal poverty line). The primary outcome is biochemically confirmed smoking abstinence sustained through 6 months. Secondary outcomes include abstinence sustained through 12 months, other smoking-related clinical outcomes, and patient-reported outcomes. This pragmatic randomized clinical trial will identify the most effective smoking cessation strategies that LCS programs can implement to reduce smoking burdens affecting underserved populations. Clinical trial registered with clinicaltrials.gov (NCT04798664). Date of registration: March 12, 2021. Date of trial launch: May 17, 2021.
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Affiliation(s)
- Rachel Kohn
- Palliative and Advanced Illness Research Center
- Department of Medicine
- Leonard Davis Institute of Health Economics
| | | | - Dylan Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | - Jannie Kim
- Palliative and Advanced Illness Research Center
| | - Michael K. Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | | | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, Riverside, California
| | | | | | - Kristina K. Blessing
- Investigator Initiated Research Operations, Geisinger Health System, Danville, Pennsylvania
| | | | - Michael J. Simoff
- Henry Ford Cancer Institute, and
- Department of Pulmonary and Critical Care Medicine, Henry Ford Health System, Detroit, Michigan
| | | | - Leonard H. Epstein
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Michael A. Horst
- Lancaster General Health Research Institute, University of Pennsylvania Health System, Lancaster, Pennsylvania
| | - Michael E. Scott
- The Center for Black Health and Equity, Durham, North Carolina; and
| | - Kevin G. Volpp
- Department of Medicine
- Leonard Davis Institute of Health Economics
- Department of Medical Ethics and Health Policy, and
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Scott D. Halpern
- Palliative and Advanced Illness Research Center
- Department of Medicine
- Leonard Davis Institute of Health Economics
- Department of Biostatistics, Epidemiology and Informatics
- Department of Medical Ethics and Health Policy, and
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joanna L. Hart
- Palliative and Advanced Illness Research Center
- Department of Medicine
- Leonard Davis Institute of Health Economics
- Department of Medical Ethics and Health Policy, and
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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An J, Zhou H, Wei R, Luong TQ, Gould MK, Mefford MT, Harrison TN, Creekmur B, Lee MS, Sim JJ, Brettler JW, Martin JP, Ong-Su AL, Reynolds K. COVID-19 morbidity and mortality associated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers use among 14,129 patients with hypertension from a US integrated healthcare system. Int J Cardiol Hypertens 2021; 9:100088. [PMID: 34155486 PMCID: PMC8204813 DOI: 10.1016/j.ijchy.2021.100088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Although recent evidence suggests no increased risk of severe COVID-19 outcomes associated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) use, the relationship is less clear among patients with hypertension and diverse racial/ethnic groups. This study evaluates the risk of hospitalization and mortality among patients with hypertension and COVID-19 in a large US integrated healthcare system. METHODS Patients with hypertension and COVID-19 (between March 1- September 1, 2020) on ACEIs or ARBs were compared with patients on other frequently used antihypertensive medications. RESULTS Among 14,129 patients with hypertension and COVID-19 infection (mean age 60 years, 48% men, 58% Hispanic), 21% were admitted to the hospital within 30 days of COVID-19 infection. Of the hospitalized patients, 24% were admitted to intensive care units, 17% required mechanical ventilation, and 10% died within 30 days of COVID-19 infection. Exposure to ACEIs or ARBs prior to COVID-19 infection was not associated with an increased risk of hospitalization or all-cause mortality (rate ratios for ACEIs vs other antihypertensive medications = 0.98, 95% CI: 0.88, 1.08; ARBs vs others = 1.00, 95% CI: 0.90, 1.11) after applying inverse probability of treatment weights. These associations were consistent across racial/ethnic groups. Use of ACEIs or ARBs during hospitalization was associated with a lower risk of all-cause mortality (odds ratios for ACEIs or ARBs vs others = 0.50, 95% CI: 0.34, 0.72). CONCLUSION Our study findings support continuation of ACEI or ARB use for patients with hypertension during the COVID-19 pandemic and after COVID-19 infection.
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Affiliation(s)
- Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Hui Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Rong Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Tiffany Q. Luong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael K. Gould
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Matthew T. Mefford
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Teresa N. Harrison
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Beth Creekmur
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Ming-Sum Lee
- Southern California Permanente Medical Group, Pasadena, CA, USA
| | - John J. Sim
- Southern California Permanente Medical Group, Pasadena, CA, USA
| | | | - John P. Martin
- Southern California Permanente Medical Group, Pasadena, CA, USA
| | | | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Gould MK, Altman DE, Creekmur B, Qi L, de Bie E, Golden S, Kaplan CP, Kelly K, Miglioretti DL, Mularski RA, Musigdilok VV, Smith-Bindman R, Steltz JP, Wiener RS, Aberle DR, Dyer DS, Vachani A. Guidelines for the Evaluation of Pulmonary Nodules Detected Incidentally or by Screening: A Survey of Radiologist Awareness, Agreement, and Adherence From the Watch the Spot Trial. J Am Coll Radiol 2021; 18:545-553. [DOI: 10.1016/j.jacr.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023]
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Creekmur B, Rozema E, Musigdilok V, Gould M. P09.37 Pragmatic Trial Design to Compare Surveillance Strategies for Patients with Small Pulmonary Nodules: The Watch the Spot Trial. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2021.01.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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Rozema E, Creekmur B, Musigdilok V, Gould M. FP02.01 Patient Responses to Passive Enrollment into a Large, Pragmatic Clinical Trial: A Qualitative Content Analysis. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2021.01.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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An J, Wei R, Zhou H, Luong TQ, Gould MK, Mefford MT, Harrison TN, Creekmur B, Lee M, Sim JJ, Brettler JW, Martin JP, Ong‐Su AL, Reynolds K. Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Use and COVID-19 Infection Among 824 650 Patients With Hypertension From a US Integrated Healthcare System. J Am Heart Assoc 2021; 10:e019669. [PMID: 33307964 PMCID: PMC7955437 DOI: 10.1161/jaha.120.019669] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Jaejin An
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
| | - Rong Wei
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Hui Zhou
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Tiffany Q. Luong
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Michael K. Gould
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
| | | | | | - Beth Creekmur
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA
| | - Ming‐Sum Lee
- Southern California Permanente Medical GroupPasadenaCA
| | - John J. Sim
- Southern California Permanente Medical GroupPasadenaCA
| | | | | | | | - Kristi Reynolds
- Research & EvaluationKaiser Permanente Southern CaliforniaPasadenaCA,Kaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
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Sharp AL, Huang BZ, Broder B, Smith M, Yuen G, Subject C, Nau C, Creekmur B, Tartof S, Gould MK. Identifying patients with symptoms suspicious for COVID-19 at elevated risk of adverse events: The COVAS score. Am J Emerg Med 2020; 46:489-494. [PMID: 33189516 PMCID: PMC7642742 DOI: 10.1016/j.ajem.2020.10.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, Pasadena, CA 91101, United States of America; Southern California Permanente Medical Group, Los Angeles Medical Center, 4867 Sunset Blvd, Los Angeles, CA 90027, United States of America; Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, 98 S. Los Robles Ave., Pasadena, CA 91101, United States of America.
| | - Brian Z Huang
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, Pasadena, CA 91101, United States of America.
| | - Benjamin Broder
- Southern California Permanente Medical Group, Baldwin Park Medical Center, 1011 Baldwin Park Blvd, Baldwin, Park, CA 91706, United States of America.
| | - Matthew Smith
- Southern California Permanente Medical Group, Los Angeles Medical Center, 4867 Sunset Blvd, Los Angeles, CA 90027, United States of America.
| | - George Yuen
- Southern California Permanente Medical Group, Baldwin Park Medical Center, 1011 Baldwin Park Blvd, Baldwin, Park, CA 91706, United States of America.
| | - Christopher Subject
- Southern California Permanente Medical Group, Los Angeles Medical Center, 4867 Sunset Blvd, Los Angeles, CA 90027, United States of America.
| | - Claudia Nau
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, Pasadena, CA 91101, United States of America; Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, 98 S. Los Robles Ave., Pasadena, CA 91101, United States of America.
| | - Beth Creekmur
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, Pasadena, CA 91101, United States of America.
| | - Sara Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, Pasadena, CA 91101, United States of America.
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, Pasadena, CA 91101, United States of America; Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, 98 S. Los Robles Ave., Pasadena, CA 91101, United States of America.
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15
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Kramer BJ, Creekmur B, Mitchell MN, Saliba D. Expanding Home-Based Primary Care to American Indian Reservations and Other Rural Communities: An Observational Study. J Am Geriatr Soc 2018. [DOI: 10.1111/jgs.15193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B. Josea Kramer
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
- Division of Geriatric Medicine; David Geffen School of Medicine, University of California Los Angeles; Los Angeles California
| | | | - Michael N. Mitchell
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
| | - Debra Saliba
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
- Division of Geriatric Medicine; David Geffen School of Medicine, University of California Los Angeles; Los Angeles California
- University of California, Los Angeles/Jewish Home Borun Center for Gerontological Research; Los Angeles California
- RAND Corporation; Santa Monica California
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Kramer BJ, Cote SD, Lee DI, Creekmur B, Saliba D. Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study. Implement Sci 2017; 12:109. [PMID: 28865474 PMCID: PMC5581481 DOI: 10.1186/s13012-017-0632-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/26/2017] [Indexed: 11/28/2022] Open
Abstract
Background Veterans Health Affairs (VA) home-based primary care (HBPC) is an evidence-based interdisciplinary approach to non-institutional long-term care that was developed in urban settings to provide longitudinal care for vulnerable older patients. Under the authority of a Memorandum of Understanding between VA and Indian Health Service (IHS) to improve access to healthcare, 14 VA medical centers (VAMC) independently initiated plans to expand HBPC programs to rural American Indian reservations and 12 VAMC successfully implemented programs. The purpose of this study is to describe barriers and facilitators to implementation in rural Native communities with the aim of informing planners and policy-makers for future program expansions. Methods A qualitative comparative case study approach was used, treating each of the 14 VAMC as a case. Using the Consolidated Framework for Implementation Research (CFIR) to inform an open-ended interview guide, telephone interviews (n = 37) were conducted with HBPC staff and clinicians and local/regional managers, who participated or oversaw implementation. The interviews were transcribed, coded, and then analyzed using CFIR domains and constructs to describe and compare experiences and to identify facilitators, barriers, and adaptations that emerged in common across VAMC and HBPC programs. Results There was considerable variation in local contexts across VAMC. Nevertheless, implementation was typically facilitated by key individuals who were able to build trust and faith in VA healthcare among American Indian communities. Policy promoted clinical collaboration but collaborations generally occurred on an ad hoc basis between VA and IHS clinicians to optimize patient resources. All programs required some adaptations to address barriers in rural areas, such as distances, caseloads, or delays in hiring additional clinicians. VA funding opportunities facilitated expansion and sustainment of these programs. Conclusions Since program expansion is a responsibility of the HBPC program director, there is little sharing of lessons learned across VA facilities. Opportunities for shared learning would benefit federal healthcare organizations to expand other medical services to additional American Indian communities and other rural and underserved communities, as well as to coordinate with other healthcare organizations. The CFIR structure was an effective analytic tool to compare programs addressing multiple inner and outer settings.
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Affiliation(s)
- B Josea Kramer
- VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, 16111, St (11E), North Hills, Plummer, CA, 91343, USA. .,David Geffen School of Medicine at UCLA, Division of Geriatric Medicine, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA, 90095, USA.
| | - Sarah D Cote
- Rio Hondo College, Institutional Research & Planning, 3600 Workman Mill Road, Whittier, CA, 90601, USA
| | - Diane I Lee
- VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, 16111, St (11E), North Hills, Plummer, CA, 91343, USA
| | - Beth Creekmur
- Kaiser Permanente Research, Department of Research and Evaluation, 100 South Los Robles, Pasadena, CA, 91101, USA
| | - Debra Saliba
- VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, 16111, St (11E), North Hills, Plummer, CA, 91343, USA.,David Geffen School of Medicine at UCLA, Division of Geriatric Medicine, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA, 90095, USA.,UCLA/Jewish Home Borun Center for Gerontological Research, 10945 LeConte Ave, Suite 2339, Los Angeles, CA, 90095, USA.,RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
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Kramer BJ, Creekmur B, Howe JL, Trudeau S, Douglas JR, Garner K, Bales C, Callaway-Lane C, Barczi S. Veterans Affairs Geriatric Scholars Program: Enhancing Existing Primary Care Clinician Skills in Caring for Older Veterans. J Am Geriatr Soc 2016; 64:2343-2348. [DOI: 10.1111/jgs.14382] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B. Josea Kramer
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
- Division of Geriatric Medicine; David Geffen School of Medicine; University of California, Los Angeles; Los Angeles California
| | - Beth Creekmur
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
| | - Judith L. Howe
- Geriatric Research Education and Clinical Center; Veterans Integrated Service Network 2; James J. Peters Veterans Affairs Medical Center; Bronx New York
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York City New York
- Department of Preventive Medicine; Icahn School of Medicine at Mount Sinai; New York City New York
| | - Scott Trudeau
- New England Geriatric Research Education and Clinical Center; Bedford Veterans Affairs Medical Center; Bedford Massachusetts
- Department of Occupational Therapy; Tufts University; Medford Massachusetts
- Productive Aging and Interprofessional Collaborative Practice; American Occupational Therapy Association; Bethesda Maryland
| | - Joseph R. Douglas
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
| | - Kimberly Garner
- Geriatric Research Education and Clinical Center; Veterans Integrated Service Network 16; Central Arkansas Veterans Healthcare System; Little Rock Arkansas
- Department of Geriatrics; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Connie Bales
- Geriatric Research Education and Clinical Center; Durham Veterans Affairs Medical Center; Durham North Carolina
- School of Medicine; Duke University; Durham North Carolina
| | - Carol Callaway-Lane
- School of Nursing; Vanderbilt University; Nashville Tennessee
- Geriatric Research Education and Clinical Center; Tennessee Valley Healthcare System; Nashville Tennessee
| | - Steven Barczi
- Geriatric Research Education and Clinical Center; William S. Middleton Memorial Veterans Hospital; Madison Wisconsin
- Division of Geriatrics; School of Medicine and Public Health; University of Wisconsin; Madison Wisconsin
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Abstract
Home-based primary care (HBPC) is an effective model of noninstitutional long-term care developed in the Department of Veterans Affairs (VA) to provide ongoing care to homebound persons. Significant rural populations of American Indians have limited access to services designed for frail older adults. Fourteen Veterans Affairs Medical Centers (VAMCs) initiated efforts to expand access to HBPC in concert with local tribes and Indian Health Service (IHS) facilities. This study characterizes the resulting emerging models of HBPC and co-management. Using an observational design, key respondent telephone interviews (n = 37) were conducted with stakeholders representing the 14 VAMCs to describe these HBPC programs, and HBPC models were evaluated in relation to VAMC organizational culture as revealed on the annual VA All Employee Survey. Twelve VAMCs independently developed HBPC expansion programs for American Indian veterans, and six different program models were implemented. Two models were unique to collaborations between VAMCs and tribes; in these collaborations, the tribes retained primary care responsibilities. VAMC used the other four models for delivery of care in remote rural areas to all veteran populations, American Indians and non-Indians alike. Strategies to improve access by reducing geographic barriers occur in all models. Comparing mean VAMC organizational culture ratings, as defined in the Competing Values Framework, revealed significant group differences for one of these six models. Findings from this study illustrate the flexibility of the HBPC program and opportunities for co-management and expansion of healthcare access for American Indians and non-Indians, particularly in rural areas.
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Affiliation(s)
- Betty Jo Josea Kramer
- Veterans Affairs Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California; Division of Geriatric Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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Abstract
A stimulus-response compatibility (SRC) effect is obtained when performance is better with compatible mappings than with incompatible mappings. When mappings are mixed within a task, the SRC effect is often eliminated or reversed.The present study examines how 1,600 trials with different practice tasks can affect the response selection process in these mixed mapping environments. Participants were assigned to one of three practice groups: mixed mapping, pure compatible mapping, and pure incompatible mapping. Subsequently, all participants performed an experimental session in which compatible and incompatible trials were mixed.The SRC effect was eliminated in the experimental mixed mapping session, regardless of practice condition. The results suggest that practice does not change the need to suppress the direct response selection route in a mixed mapping task. However, reaction time distributions and sequential analyses were modulated by practice condition, which indicates that the new associations acquired during practice may activate new routes that interact with preexisting ones.
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Affiliation(s)
- Beth Creekmur
- Department of Psychology, California State University Long Beach, Long Beach, CA 90840, USA.
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21
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Abstract
OBJECTIVE To determine the test-retest reliability, sensitivity and specificity, and criterion-related validity of the Risk Behavior Assessment (RBA) syphilis questions. The RBA is a standardized instrument that has been used in several studies of STDs in drug users. METHODS For the test-retest reliability study, 219 injection drug users completed the RBA twice within a 48-hour period. To determine criterion-related validity, 207 individuals, who also completed the RBA, were tested with the rapid plasma reagin test (RPR), and 206 individuals were also tested with the Serodia Treponema pallidum particle agglutination test (TP-PA). RESULTS The test-retest reliability for the question "How many times have you been told by a doctor or a nurse that you had syphilis?" was 0.78. The test-retest reliability for the question "In what year were you last treated for syphilis?" was 0.89. For the comparison of self-report with the RPR test, the sensitivity of self-report was 46.2% and the specificity was 95.7%. For the comparison of self-report with the TP-PA test, the sensitivity of self-report was 37% and the specificity was 97.7%. CONCLUSIONS Self-reports of syphilis infection history were found to have good reliability, excellent specificity, and moderate sensitivity. These characteristics need to be taken into account in any study using these self-report items.
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Affiliation(s)
- Dennis G Fisher
- Center for Behavioral Research and Services, California State University, Long Beach, California, USA.
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