Publications by authors named "In-Lu Amy Liu"

31 Publications

Trends in Influenza Vaccine Uptake and Severe Influenza-Related Outcomes at Kaiser Permanente Southern California, 2007-2017.

Perm J 2021 May;25

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.

Introduction: Major efforts to increase influenza vaccine uptake among Kaiser Permanente Southern California (KPSC) members have been undertaken in recent years. However, whether these improvements translate to a decline in severe influenza-related outcomes has not been examined. We aimed to understand the impact of the influenza vaccination program at KPSC by examining influenza vaccine uptake and 3 severe influenza-related outcomes.

Methods: We conducted an ecologic trend analysis to understand influenza vaccine uptake and influenza-related hospitalization, intensive care unit (ICU) admission, and mortality for each influenza season (2007-2017). The same cohort was followed from the influenza season to the noninfluenza season immediately afterward while using the noninfluenza season as the comparison group. We also assessed the within-season correlation between influenza vaccine uptake and influenza-related outcomes.

Results: Influenza vaccine uptake rose from 23.9% to 45.5%, and all 3 influenza-related outcome rates declined (hospitalization: 35.4-26.8/10,000 patients; ICU: 5.9-5.2/10,000 patients; and mortality: 3.4-2.3/10,000 patients). Influenza vaccine uptake was negatively correlated with hospitalization (-0.32, p < 0.001) and mortality (-0.29, p = 0.001). However, once we adjusted for the noninfluenza season, the results of the correlation analysis were no longer statistically significant.

Conclusion: Although we could not establish a statistically significant inverse relationship between influenza vaccination and severe influenza-related outcomes over the study period, our findings indicate an overall decline in influenza-related outcomes over the study period, suggesting improvements in both preventive and acute care quality at KPSC.
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http://dx.doi.org/10.7812/TPP/20.154DOI Listing
May 2021

Characteristics of patients discharged and readmitted after COVID-19 hospitalisation within a large integrated health system in the United States.

Infect Dis (Lond) 2021 May 8:1-5. Epub 2021 May 8.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.

Background: Limited studies have explored post-discharge outcomes following Coronavirus Disease 2019 (COVID-19) hospitalisation. We sought to characterise patients discharged following a COVID-19 hospitalisation within a large integrated health system in the United States.

Methods: We performed a retrospective study of 2180 COVID-19 patients discharged between 1 April 2020 and 31 July 2020. The primary endpoint was all-cause observation stay or inpatient readmission within 30 days from discharge. Bivariate and multivariable logistic regression analyses were performed to estimate the association between key socio-demographic and clinical characteristics with risk of 30-day readmission.

Results: The 30-day readmission rate was 7.6% ( = 166); 30-day mortality rate was 1% ( = 19). Most readmissions were respiratory-related (58%) and occurred at a median time of 5 days post discharge. Adjusted models showed that prior hospitalisations (Odds Ratio = 2.36, [95% Confidence Interval: 1.59-3.50]), chronic pulmonary disease (1.57 [1.09-2.28]), and discharge to home health (1.46 [1.01-2.11]) were significantly associated with 30-day readmission. Longer duration from diagnosis to index admission was borderline associated with lower odds of readmission (0.95 [0.91-1.00]).

Conclusion: Readmission and mortality rates for COVID-19 following discharge are low. Most readmissions occur early and are due to respiratory causes and may reflect the prolonged acute disease course.
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http://dx.doi.org/10.1080/23744235.2021.1924398DOI Listing
May 2021

Effect of Physical Activity Coaching on Acute Care and Survival Among Patients With Chronic Obstructive Pulmonary Disease: A Pragmatic Randomized Clinical Trial.

JAMA Netw Open 2019 08 2;2(8):e199657. Epub 2019 Aug 2.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena.

Importance: While observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD), there are no population-based trials to date testing the effectiveness of physical activity (PA) interventions to reduce acute care use or improve survival.

Objective: To evaluate the long-term effectiveness of a community-based PA coaching intervention in patients with COPD.

Design, Setting, And Participants: Pragmatic randomized clinical trial with preconsent randomization to the 12-month Walk On! (WO) intervention or standard care (SC). Enrollment occurred from July 1, 2015, to July 31, 2017; follow-up ended in July 2018. The setting was Kaiser Permanente Southern California sites. Participants were patients 40 years or older who had any COPD-related acute care use in the previous 12 months; only patients assigned to WO were approached for consent to participate in intervention activities.

Interventions: The WO intervention included collaborative monitoring of PA step counts, semiautomated step goal recommendations, individualized reinforcement, and peer/family support. Standard COPD care could include referrals to pulmonary rehabilitation.

Main Outcomes And Measures: The primary outcome was a composite binary measure of all-cause hospitalizations, observation stays, emergency department visits, and death using adjusted logistic regression in the 12 months after randomization. Secondary outcomes included self-reported PA, COPD-related acute care use, symptoms, quality of life, and cardiometabolic markers.

Results: All 2707 eligible patients (baseline mean [SD] age, 72 [10] years; 53.7% female; 74.3% of white race/ethnicity; and baseline mean [SD] percent forced expiratory volume in the first second of expiration predicted, 61.0 [22.5]) were randomly assigned to WO (n = 1358) or SC (n = 1349). The intent-to-treat analysis showed no differences between WO and SC on the primary all-cause composite outcome (odds ratio [OR], 1.09; 95% CI, 0.92-1.28; P = .33) or in the individual outcomes. Prespecified, as-treated analyses compared outcomes between all SC and 321 WO patients who participated in any intervention activities (23.6% [321 of 1358] uptake). The as-treated, propensity score-weighted model showed nonsignificant positive estimates in favor of WO participants compared with SC on all-cause hospitalizations (OR, 0.84; 95% CI, 0.65-1.10; P = .21) and death (OR, 0.62; 95% CI, 0.35-1.11; P = .11). More WO participants reported engaging in PA compared with SC (47.4% [152 of 321] vs 30.7% [414 of 1349]; P < .001) and had improvements in the Patient-Reported Outcomes Measurement Information System 10 physical health domain at 6 months. There were no group differences in other secondary outcomes.

Conclusions And Relevance: Participation in a PA coaching program by patients with a history of COPD exacerbations was insufficient to effect improvements in acute care use or survival in the primary analysis.

Trial Registration: ClinicalTrials.gov identifier: NCT02478359.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.9657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704745PMC
August 2019

End-of-Life Care in Patients Exposed to Home-Based Palliative Care vs Hospice Only.

J Am Geriatr Soc 2019 06 4;67(6):1226-1233. Epub 2019 Mar 4.

Pasadena Regional Office, Kaiser Permanente Southern California, Pasadena, CA.

Objectives: The current evidence base regarding the effectiveness of home-based palliative care (HomePal) on outcomes of importance to multiple stakeholders remains limited. The purpose of this study was to compare end-of-life care in decedents who received HomePal with two cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal-HO).

Design: Retrospective cohorts from an ongoing study of care transition from hospital to home. Data were collected from 2011 to 2016.

Setting: Kaiser Permanente Southern California.

Participants: Decedents 65 and older who received HomePal (n = 7177) after a hospitalization and two comparison cohorts (HO only = 25 102; No HomePal-HO = 22 472).

Measurements: Utilization data were extracted from administrative, clinical, and claims databases, and death data were obtained from state and national indices. Days at home was calculated as days not spent in the hospital or in a skilled nursing facility (SNF).

Results: Patients who received HomePal were enrolled for a median of 43 days and had comparable length of stay on hospice as patients who enrolled only in hospice (median days = 13 vs 12). Deaths at home were comparable between HomePal and HO (59% vs 60%) and were higher compared with No HomePal-HO (16%). For patients who survived at least 6 months after HomePal admission (n = 2289), the mean number of days at home in the last 6 months of life was 163 ± 30 vs 161 ± 30 (HO) vs 149 ± 40 (No HomePal-HO). Similar trends were also noted for the last 30 days of life, 25 ± 8 (HomePal, n = 5516), 24 ± 8 (HO), and 18 ± 11 (No HomePal-HO); HomePal patients had a significantly lower risk of hospitalizations (relative risk [RR] = .58-.87) and SNF stays (RR = .32-.77) compared with both HO and No HomePal-HO patients.

Conclusion: Earlier comprehensive palliative care in patients' home in place of or preceding hospice is associated with fewer hospitalizations and SNF stays and more time at home in the final 6 months of life. J Am Geriatr Soc, 2019.
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http://dx.doi.org/10.1111/jgs.15844DOI Listing
June 2019

Risk factors for medication non-adherence among atrial fibrillation patients.

BMC Cardiovasc Disord 2019 02 11;19(1):38. Epub 2019 Feb 11.

Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA.

Background: Atrial fibrillation (AF) patients are routinely prescribed medications to prevent and treat complications, including those from common co-occurring comorbidities. However, adherence to such medications may be suboptimal. Therefore, we sought to identify risk factors for general medication non-adherence in a population of patients with atrial fibrillation.

Methods: Data were collected from a large, ethnically-diverse cohort of Kaiser Permanente Northern and Southern California adult members with incident diagnosed AF between January 1, 2006 and June 30, 2009. Self-reported questionnaires were completed between May 1, 2010 and September 30, 2010, assessing patient socio-demographics, health behaviors, health status, medical history and medication adherence. Medication adherence was assessed using a previously validated 3-item questionnaire. Medication non-adherence was defined as either taking medication(s) as the doctor prescribed 75% of the time or less, or forgetting or choosing to skip one or more medication(s) once per week or more. Electronic health records were used to obtain additional data on medical history. Multivariable logistic regression analyses examined the associations between patient characteristics and self-reported general medication adherence among patients with complete questionnaire data.

Results: Among 12,159 patients with complete questionnaire data, 6.3% (n = 771) reported medication non-adherence. Minority race/ethnicity versus non-Hispanic white, not married/with partner versus married/with partner, physical inactivity versus physically active, alcohol use versus no alcohol use, any days of self-reported poor physical health, mental health and/or sleep quality in the past 30 days versus 0 days, memory decline versus no memory decline, inadequate versus adequate health literacy, low-dose aspirin use versus no low-dose aspirin use, and diabetes mellitus were associated with higher adjusted odds of non-adherence, whereas, ages 65-84 years versus < 65 years of age, a Charlson Comorbidity Index score ≥ 3 versus 0, and hypertension were associated with lower adjusted odds of non-adherence.

Conclusions: Several potentially preventable and/or modifiable risk factors related to medication non-adherence and a few non-modifiable risk factors were identified. These risk factors should be considered when assessing medication adherence among patients diagnosed with AF.
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http://dx.doi.org/10.1186/s12872-019-1019-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371431PMC
February 2019

Safety of Influenza Vaccination Administered During Hospitalization.

Mayo Clin Proc 2019 03 8;94(3):397-407. Epub 2019 Jan 8.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.

Objective: To determine whether influenza vaccination during hospitalization increases health care utilization, fever, and infection evaluations postdischarge.

Patients And Methods: This retrospective cohort study conducted at Kaiser Permanente Southern California included patients aged 6 months or older hospitalized in a Kaiser Permanente Southern California facility with admission and discharge dates between September 1 and March 31 of the following calendar year, from 2011 to 2014. All influenza vaccinations administered during the period of August 1 to April 30 for influenza seasons 2011-2012, 2012-2013, and 2013-2014 were identified. We compared the risk of outcomes of interest between those who received influenza vaccination during their hospitalization vs those who were never vaccinated that season or were vaccinated at other times using propensity score analyses with inverse probability of treatment weighting. Outcomes of interest included rates of outpatient and emergency department visits, readmissions, fever, and clinical laboratory evaluations for infection (urine, blood, and wound culture; complete blood cell count) in the 7 days following discharge.

Results: We included in the study 290,149 hospitalizations among 255,737 patients. In adjusted analyses, we found no increased risk of readmissions (relative risk [RR], 0.88; 95% CI, 0.83-0.95), outpatient visits (RR, 0.97; 95% CI, 0.95-0.99), fever (RR, 0.80; 95% CI, 0.68-0.93), and clinical evaluations for infection (RR, 0.95; 95% CI, 0.92-0.98) among those vaccinated during hospitalization compared with those who were never vaccinated or were vaccinated at other times.

Conclusion: Our findings provide reassurance about the safety of influenza vaccination during hospitalization. Every contact with a health care professional, including during a hospitalization, is an opportunity to vaccinate.
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http://dx.doi.org/10.1016/j.mayocp.2018.11.024DOI Listing
March 2019

Impact of Inpatient Palliative Care on Quality of End-of-Life Care and Downstream Acute and Postacute Care Utilization.

J Palliat Med 2018 07 13;21(7):913-923. Epub 2018 Mar 13.

3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California.

Background: Additional evidence is needed regarding the impact of inpatient palliative care (IPC) on the quality of end-of-life care and downstream utilization.

Aim: Examine the effects of IPC on quality of end-of-life care and acute and postacute care use in a large integrated system.

Design: Retrospective cohort design.

Setting/participants: Adult decedents from January 1, 2012, to December 31, 2014, who had at least one hospitalization at 11 Kaiser Permanente Southern California medical centers in the 12 months before death and not hospitalized for a trauma-related condition or receiving home-based PC or hospice were included in the cohort.

Materials And Methods: Inverse probability of treatment weighting of propensity scores was used to compare outcomes between patients exposed to IPC (n = 3742) and controls (n = 12,755) who never received IPC before death.

Results: Patients who received IPC were more likely to enroll in home-based PC or hospice (69% vs. 43%) and were less likely to die in a hospital (15% vs. 29%) or intensive care (2% vs. 9%) compared with controls (all, p < 0.001). IPC exposure was associated with higher risk for rehospitalization (HR: 1.18, 95% CI 1.11-1.25) and more frequent emergency department visits (RR: 1.16, 95% CI 1.07-1.26) with no increase in postacute care use compared with controls. Stratified analyses showed that IPC effects on acute care utilization were dependent on code status.

Conclusion: IPC exposure was associated with higher enrollment in home-based PC/hospice and more deaths at home. The increased acute care utilization by the IPC group may reflect persistent confounding by indication.
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http://dx.doi.org/10.1089/jpm.2017.0275DOI Listing
July 2018

Health Literacy and Awareness of Atrial Fibrillation.

J Am Heart Assoc 2017 Apr 11;6(4). Epub 2017 Apr 11.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA

Background: Atrial fibrillation (AF) is the most common clinically significant arrhythmia in adults and a major risk factor for ischemic stroke. Nonetheless, previous research suggests that many individuals diagnosed with AF lack awareness about their diagnosis and inadequate health literacy may be an important contributing factor to this finding.

Methods And Results: We examined the association between health literacy and awareness of an AF diagnosis in a large, ethnically diverse cohort of Kaiser Permanente Northern and Southern California adults diagnosed with AF between January 1, 2006 and June 30, 2009. Using self-reported questionnaire data completed between May 1, 2010 and September 30, 2010, awareness of an AF diagnosis was evaluated using the question "Have you ever been told by a doctor or other health professional that you have a heart rhythm problem called atrial fibrillation or atrial flutter?" and health literacy was assessed using a validated 3-item instrument examining problems because of reading, understanding, and filling out medical forms. Of the 12 517 patients diagnosed with AF, 14.5% were not aware of their AF diagnosis and 20.4% had inadequate health literacy. Patients with inadequate health literacy were less likely to be aware of their AF diagnosis compared with patients with adequate health literacy (prevalence ratio=0.96; 95% CI [0.94, 0.98]), adjusting for sociodemographics, health behaviors, and clinical characteristics.

Conclusions: Lower health literacy is independently associated with less awareness of AF diagnosis. Strategies designed to increase patient awareness of AF and its complications are warranted among individuals with limited health literacy.
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http://dx.doi.org/10.1161/JAHA.116.005128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5533014PMC
April 2017

Physical activity assessed in routine care predicts mortality after a COPD hospitalisation.

ERJ Open Res 2016 Jan 17;2(1). Epub 2016 Mar 17.

Dept of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.

The independent relationship between physical inactivity and risk of death after an index chronic obstructive pulmonary disease (COPD) hospitalisation is unknown. We conducted a retrospective cohort study in a large integrated healthcare system. Patients were included if they were hospitalised for COPD between January 1, 2011 and December 31, 2011. All-cause mortality in the 12 months after discharge was the primary outcome. Physical activity, expressed as self-reported minutes of moderate to vigorous physical activity (MVPA), was routinely assessed at outpatient visits prior to hospitalisation. 1727 (73%) patients were inactive (0 min of MVPA per week), 412 (17%) were insufficiently active (1-149 min of MVPA per week) and 231 (10%) were active (≥150 min of MVPA per week). Adjusted Cox regression models assessed risk of death across the MVPA categories. Among 2370 patients (55% females and mean age 73±11 years), there were 464 (20%) deaths. Patients who were insufficiently active or active had a 28% (adjusted HR 0.72 (95% CI 0.54-0.97), p=0.03) and 47% (adjusted HR 0.53 (95% CI 0.34-0.84), p<0.01) lower risk of death, respectively, in the 12 months following an index COPD hospitalisation compared to inactive patients. Any level of MVPA is associated with lower risk of all-cause mortality after a COPD hospitalisation. Routine assessment of physical activity in clinical care would identify persons at high risk for dying after COPD hospitalisation.
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http://dx.doi.org/10.1183/23120541.00062-2015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005157PMC
January 2016

The Relationship of Parathyroidectomy and Bisphosphonates With Fracture Risk in Primary Hyperparathyroidism: An Observational Study.

Ann Intern Med 2016 Jun 5;164(11):715-23. Epub 2016 Apr 5.

Background: The comparative effectiveness of surgical and medical treatments on fracture risk in primary hyperparathyroidism (PHPT) is unknown.

Objective: To measure the relationship of parathyroidectomy and bisphosphonates with skeletal outcomes in patients with PHPT.

Design: Retrospective cohort study.

Setting: An integrated health care delivery system.

Participants: All enrollees with biochemically confirmed PHPT from 1995 to 2010.

Measurements: Bone mineral density (BMD) changes and fracture rate.

Results: In 2013 patients with serial bone density examinations, total hip BMD increased transiently in women with parathyroidectomy (4.2% at <2 years) and bisphosphonates (3.6% at <2 years) and declined progressively in both women and men without these treatments (-6.6% and -7.6%, respectively, at >8 years). In 6272 patients followed for fracture, the absolute risk for hip fracture at 10 years was 20.4 events per 1000 patients who had parathyroidectomy and 85.5 events per 1000 patients treated with bisphosphonates compared with 55.9 events per 1000 patients without these treatments. The risk for any fracture at 10 years was 156.8 events per 1000 patients who had parathyroidectomy and 302.5 events per 1000 patients treated with bisphosphonates compared with 206.1 events per 1000 patients without these treatments. In analyses stratified by baseline BMD status, parathyroidectomy was associated with reduced fracture risk in both osteopenic and osteoporotic patients, whereas bisphosphonates were associated with increased fracture risk in these patients. Parathyroidectomy was associated with fracture risk reduction in patients regardless of whether they satisfied criteria from consensus guidelines for surgery.

Limitation: Retrospective study design and nonrandom treatment assignment.

Conclusion: Parathyroidectomy was associated with reduced fracture risk, and bisphosphonate treatment was not superior to observation.

Primary Funding Source: National Institute on Aging.
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http://dx.doi.org/10.7326/M15-1232DOI Listing
June 2016

Automated Outreach for Cardiovascular-Related Medication Refill Reminders.

J Clin Hypertens (Greenwich) 2016 07 6;18(7):641-6. Epub 2015 Nov 6.

Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.

The objective of this study was to evaluate the effectiveness of an automated telephone system reminding patients with hypertension and/or cardiovascular disease to obtain overdue medication refills. The authors compared the intervention with usual care among patients with an overdue prescription for a statin or lisinopril-hydrochlorothiazide (lisinopril-HCTZ). The primary outcome was refill rate at 2 weeks. Secondary outcomes included time to refill and change in low-density lipoprotein cholesterol and blood pressure. Significantly more patients who received a reminder call refilled their prescription compared with the usual-care group (statin cohort: 30.3% vs 24.9% [P<.0001]; lisinopril-HCTZ cohort: 30.7% vs 24.2% [P<.0001]). The median time to refill was shorter in patients receiving the reminder call (statin cohort: 29 vs 36 days [P<.0001]; lisinopril-HCTZ cohort: 24 vs 31 days [P<.0001]). There were no statistically significant differences in mean low-density lipoprotein cholesterol and blood pressure. These findings suggest the need for interventions that have a longer-term impact.
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http://dx.doi.org/10.1111/jch.12723DOI Listing
July 2016

Recent Trends in the Identification of Incidental Pulmonary Nodules.

Am J Respir Crit Care Med 2015 Nov;192(10):1208-14

4 Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California.

Rationale: Pulmonary nodules are common incidental findings, but information about their incidence in the era of computed tomography (CT) is lacking.

Objectives: To examine recent trends in pulmonary nodule identification.

Methods: We used electronic health records and natural language processing to identify members of an integrated health system who had nodules measuring 4 to 30 mm. We calculated rates of chest CT imaging, nodule identification, and receipt of a new lung cancer diagnosis within 2 years of nodule identification, and standardized rates by age and sex to estimate the frequency of nodule identification in the U.S. population in 2010.

Measurements And Main Results: Between 2006 and 2012, more than 200,000 adult members underwent 415,581 chest CT examinations. The annual frequency of chest CT imaging increased from 1.3 to 1.9% for all adult members, whereas the frequency of nodule identification increased from 24 to 31% for all scans performed. The annual rate of chest CT increased from 15.4 to 20.7 per 1,000 person-years, and the rate of nodule identification increased from 3.9 to 6.6 per 1,000 person-years, whereas the rate of a new lung cancer diagnosis remained stable. By extrapolation, more than 4.8 million Americans underwent at least one chest CT scan and 1.57 million had a nodule identified, including 63,000 who received a new lung cancer diagnosis within 2 years.

Conclusions: Incidental pulmonary nodules are an increasingly common consequence of routine medical care, with an incidence that is much greater than recognized previously. More frequent nodule identification has not been accompanied by increases in the diagnosis of cancerous nodules.
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http://dx.doi.org/10.1164/rccm.201505-0990OCDOI Listing
November 2015

Impact of pulmonary rehabilitation on hospitalizations for chronic obstructive pulmonary disease among members of an integrated health care system.

J Cardiopulm Rehabil Prev 2015 Sep-Oct;35(5):356-66

Department of Research and Evaluation (Drs Nguyen and Gould and Mss Liu and Lee), and Pulmonary and Critical Care, Kaiser Permanente Southern California (Dr Harrington), Pasadena.

Purpose: The evidence regarding the effects of pulmonary rehabilitation (PR) on health care resource use remains limited. This retrospective study evaluated the effects of PR on the primary outcome of all-cause hospitalizations and secondary outcomes of other health care use, exercise capacity, health-related quality of life (HRQOL), and body weight in patients with chronic obstructive pulmonary disease (COPD) in a large integrated health care system.

Methods: The PR cohort included 558 patients with a COPD diagnosis, age ≥ 40 years, who were treated with a bronchodilator or steroid inhaler, participated in 1 of 13 PR programs between January 1, 2008, and August 1, 2013, and were continuously enrolled in the health plan ≥ 12 months prior to and after PR. Two non-PR control cohorts were assembled for comparison. Data were extracted from electronic health records. The 6-minute walk test and St. George's Respiratory Questionnaire results were available for a subset.

Results: The proportion of patients who were hospitalized 12 months post-PR was lower compared with the 12 months prior (37% vs 45%, P = .001) while emergency department use was not different (52% vs 54%). Patients who declined PR for logistical reasons had a 40% higher risk of hospitalization than PR participants (relative risk = 1.40, 95% CI: 0.96-2.06, P = .08). There were significant improvements in the 6-minute walk test distance (+43 m) and the St. George's Respiratory Questionnaire total score (-9.6 points) but minimal changes in weight.

Conclusions: Our finding that participation in PR is associated with reductions in hospitalizations corroborates previous studies. A notable strength of this study is the capture of complete utilization data.
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http://dx.doi.org/10.1097/HCR.0000000000000128DOI Listing
June 2016

Risk of Herpes Zoster and Disseminated Varicella Zoster in Patients Taking Immunosuppressant Drugs at the Time of Zoster Vaccination.

Mayo Clin Proc 2015 Jul 4;90(7):865-73. Epub 2015 Jun 4.

Research and Evaluation, Kaiser Permanente Southern California, Pasadena.

Objective: To determine the risks associated with zoster vaccine when administered to patients taking immunosuppressant medications.

Patients And Methods: Patients enrolled in 1 of 7 managed care organizations affiliated with the Vaccine Safety Datalink between January 1, 2006, and December 31, 2009, were eligible. The exposure of interest was zoster vaccination in patients with current or remote immunosuppressant drug use. The primary outcomes were disseminated varicella zoster virus (VZV) and herpes zoster in the 42 days after vaccination. Automated data were collected on immunosuppressant drugs and baseline medical conditions. A logistic regression model using inverse probability treatment weights was used to estimate the odds of developing VZV or herpes zoster.

Results: A total of 14,554 individuals had an immunosuppressant medication dispensed around the time of vaccination, including 4826 with current use and 9728 with remote use. Most patients were taking low-dose corticosteroids. No cases of disseminated VZV were found in the current or remote users. The risk of herpes zoster was elevated in the 42 days after vaccination in current vs remote users (adjusted odds ratio, 2.99; 95% CI, 1.58-5.70).

Conclusion: We found that patients taking immunosuppressant medications at the time of vaccination had a modest increased risk of herpes zoster in the 42 days after vaccination. The development of herpes zoster within 42 days after vaccination suggests that this is more likely due to reactivation of latent zoster virus than dissemination of the vaccine-derived varicella virus. These findings support the current zoster vaccination guidelines.
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http://dx.doi.org/10.1016/j.mayocp.2015.04.021DOI Listing
July 2015

Inpatient admission for febrile seizure and subsequent outcomes do not differ in children with vaccine-associated versus non-vaccine associated febrile seizures.

Vaccine 2014 Nov 5;32(48):6408-14. Epub 2014 Oct 5.

Department of Research & Evaluation, Kaiser Permanente Southern California, USA. Electronic address:

Introduction: Recent data suggest that the risk factors for febrile seizure (FS) can differ depending on whether the FS was vaccine-associated (VA) or not. As such, there also may be differences in the risk of inpatient admission and/or the incidence of FS-related subsequent outcomes following the index FS depending on whether it was VA or non-vaccine associated (NVA). This could have useful clinical implications including caregiver education and planning for follow-up care.

Methods: This cohort study consisted of 3348 children who experienced an index FS between 6 months up to 3 years of age from July 1, 2003 through December 31, 2011. The index FS was determined to be VA-FS or NVA-FS; inpatient admission for FS, recurrent FS, and diagnosis of epilepsy were compared between exposure groups. Hazard ratios and relative risk estimates comparing between VA-FS and NVA-FS were estimated by Cox proportional models and Robust Poisson regression models, adjusted for race, sex, age at first FS, birth weight, gestational age, maternal age, and 1- and 5-min Apgar scores.

Results: The mean age at index FS was 1.5 years; the mean length of follow-up was 2.3 years. Of all index FS, 383 (11.4%) were VA and 2965 were NVA. Among index FS, 264 (7.9%) were admitted as inpatients. Subsequently, 703 (21.0%) children developed at least one recurrent FS, where the number of recurrences ranged from 0 to 9 events. Overall, 144 (4.3%) children were diagnosed with epilepsy during the follow-up period. In adjusted analyses, VA-FS did not differ in the risk for any of the outcomes of interest compared with NVA-FS.

Discussion: The risk of hospitalization for index FS or select subsequent FS outcomes did not differ between VA or NVA-FS. This suggests that the follow-up care of children with VA-FS does not warrant attention beyond that for NVA-FS.
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http://dx.doi.org/10.1016/j.vaccine.2014.09.055DOI Listing
November 2014

Adherence to statins and LDL-cholesterol goal attainment.

Am J Manag Care 2014 Apr 1;20(4):e105-12. Epub 2014 Apr 1.

Kaiser Permanente Southern California Department of Research and Evaluation, 100 S. Los Robles, 2nd Fl, Pasadena, CA 91101. E-mail:

Objectives: To examine the relationship between low-density lipoprotein cholesterol (LDL-C) goal attainment and adherence to statin medications in patients with coronary artery disease (CAD).

Study Design: Cross-sectional study of CAD patients 18 years of age or older in an integrated healthcare system.

Methods: Patients dispensed 2 or more statin prescriptions between May 2009 and May 2010, were identified. Medication possession ratio (MPR) was calculated to estimate adherence. The LDL-C value closest to May 27, 2010, was used to determine goal. Adherence and LDL-C goal were defined as 80% or greater MPR and less than 100 mg/dL or less than 70 mg/dL, respectively. Electronic medical records were used to identify patient demographics and clinical information. Logistic regression was used to estimate the effect of these factors on goal attainment.

Results: A total of 67,100 CAD patients were identified. Overall, 85.8% had LDL-C less than 100 mg/dL, 32.4% had LDL less than 70 mg/dL, and 79.8% were adherent to their statin medication. Over 65% of patients not at LDL-C goal less than 100 mg/dL were adherent. Among patients with LDL-C less than 100 mg/dL, 17.9% were not adherent. Increasing medication adherence was associated with improved LDL-C levels. Adherence to statins, male sex, Asian and Hispanic race/ethnicity, a higher number of concurrent prescriptions, higher Charlson Comorbidity Index, and hypertension were associated with LDL-C goal attainment.

Conclusions: Incorporating LDL-C levels and medication adherence at the point of care allows providers to focus interventions to address either adherence challenges or the need for medication titration in an effort to improve LDL-C goal attainment and ultimately reduce morbidity and mortality.
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April 2014

Simvastatin is associated with reduced risk of acute pancreatitis: findings from a regional integrated healthcare system.

Gut 2015 Jan 17;64(1):133-8. Epub 2014 Apr 17.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA.

Objective: To characterise the relationship between simvastatin and risk of acute pancreatitis (AP).

Design: We conducted a retrospective cohort study (2006-2012) on data from an integrated healthcare system in southern California. Exposure to simvastatin was calculated from time of initial dispensation until 60 days following prescription termination. AP cases were defined by ICD-9 CM 577.0 and serum lipase≥3 times normal. Patients were censored at death, last follow-up, and onset of AP or end-of-study. Incidence rate of pancreatitis among simvastatin users was compared with the adult reference population. Robust Poisson regression was used to generate risk ratio (RR) estimates for simvastatin use adjusted for age, gender, race/ethnicity, gallstone-related disorders, hypertriglyceridaemia, smoking and alcohol dependence. Analysis was repeated for atorvastatin.

Results: Among 3,967,859 adult patients (median duration of follow-up of 3.4 years), 6399 developed an initial episode of AP. A total of 707,236 patients received simvastatin during the study period. Patients that received simvastatin were more likely to have gallstone-related disorders, alcohol dependence or hypertriglyceridaemia compared with the reference population. Nevertheless, risk of AP was significantly reduced with simvastatin use, crude incidence rate ratio 0.626 (95% CL 0.588, 0.668), p<0.0001. In multivariate analysis, simvastatin was independently associated with reduced risk of pancreatitis, adjusted RR 0.29 (95% CL 0.27, 0.31) after adjusting for age, gender, race/ethnicity, gallstone disorders, alcohol dependence, smoking and hypertriglyceridaemia. Similar results were noted with atorvastatin, adjusted RR 0.33(0.29, 0.38).

Conclusions: Use of simvastatin was independently associated with reduced risk of AP in this integrated healthcare setting. Similar findings for atorvastatin suggest a possible class effect.
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http://dx.doi.org/10.1136/gutjnl-2013-306564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877305PMC
January 2015

Postlicensure surveillance for pre-specified adverse events following the 13-valent pneumococcal conjugate vaccine in children.

Vaccine 2013 May 8;31(22):2578-83. Epub 2013 Apr 8.

Kaiser Permanente, Southern California, Pasadena, CA 91101, USA.

Although no increased risk was detected for serious adverse events in the prelicensure trials for the 13-valent pneumococcal vaccine, Prevnar 13(®) (PCV13), continued monitoring of rare but serious adverse events is necessary. A surveillance system using cohort study design was set up to monitor safety of PCV13 immediately after it was included in the childhood immunization program in the United States. The exposed population included children of 1 month to 2 years old who received PCV13 from April, 2010 to January, 2012 from the eight managed care organizations participating in the Vaccine Safety Datalink Project in the United States. The historical unexposed population was children of the same age who received the 7-valent pneumococcal conjugate vaccine Prevnar 7(®) (PCV7) in 2007 (or 2005 depending on the outcome of interest) to 2009. The risk of pre-specified adverse events in the risk window following PCV13 was repeatedly compared to that in the historical comparison group. The number of doses included in the study was 599,229. No increased risk was found for febrile seizures, urticaria or angioneurotic edema, asthma, thrombocytopenia, or anaphylaxis. An increased risk for encephalopathy was not confirmed following the medical record review. The relative risk for Kawasaki disease in 0-28 days following vaccination was 1.94 (95% confidence interval: 0.79-4.86), comparing PCV13 to PCV7. Comparing to PCV7 vaccine, we identified no significant increased risk of pre-specified adverse events in the Vaccine Safety Datalink study cohort. The possible association between PCV13 and Kawasaki disease may deserve further investigation.
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http://dx.doi.org/10.1016/j.vaccine.2013.03.040DOI Listing
May 2013

Incidence and prevalence of primary hyperparathyroidism in a racially mixed population.

J Clin Endocrinol Metab 2013 Mar 15;98(3):1122-9. Epub 2013 Feb 15.

Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California 90095, USA.

Context: The epidemiology of primary hyperparathyroidism (PHPT) has generally been studied in Caucasian populations.

Objective: The aim was to examine the incidence and prevalence of PHPT within a racially mixed population.

Design: A descriptive epidemiologic study was performed.

Patients/setting: The study population included 3.5 million enrollees within Kaiser Permanente Southern California.

Methods: All patients with at least one elevated serum calcium level (>10.5 mg/dL, 2.6 mmol/L) between 1995 and 2010 were included. Cases of PHPT were identified by electronic query of laboratory values using biochemical criteria, after exclusion of secondary or renal and tertiary hyperparathyroidism cases. The incidence and prevalence rates of PHPT were calculated according to sex, race, age group by decade, and year.

Results: Initial case finding identified 15,234 patients with chronic hypercalcemia, 13,327 (87%) of which had PHPT as defined by elevated or inappropriately normal parathyroid hormone levels. The incidence of PHPT fluctuated from 34 to 120 per 100,000 person-years (mean 66) among women, and from 13 to 36 (mean 25) among men. With advancing age, incidence increased and sex differences became pronounced (incidence 12-24 per 100,000 for both sexes younger than 50 y; 80 and 36 per 100,000 for women and men aged 50-59 y, respectively; and 196 and 95 for women and men aged 70-79 y, respectively). The incidence of PHPT was highest among blacks (92 women; 46 men, P < .0001), followed by whites (81 women; 29 men), with rates for Asians (52 women, 28 men), Hispanics (49 women, 17 men), and other races (25 women, 6 men) being lower than that for whites (P < .0001). The prevalence of PHPT tripled during the study period, increasing from 76 to 233 per 100,000 women and from 30 to 85 per 100 000 men. Racial differences in prevalence mirrored those found in incidence.

Conclusions: PHPT is the predominant cause of hypercalcemia and is increasingly prevalent. Substantial differences are found in the incidence and prevalence of PHPT between races.
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http://dx.doi.org/10.1210/jc.2012-4022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3590475PMC
March 2013

Surgery for primary hyperparathyroidism: are the consensus guidelines being followed?

Ann Surg 2012 Jun;255(6):1179-83

Division of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.

Objective: To determine parathyroidectomy (PTx) rates in patients who satisfy the consensus guidelines for surgical treatment of primary hyperparathyroidism (PHPT).

Background: Surgery for PHPT is recommended for all symptomatic patients and select asymptomatic patients meeting established consensus criteria. Adherence to the consensus guidelines has not been examined systematically, because of inadequate information regarding patients managed nonoperatively.

Methods: All nonuremic patients with PHPT during the period 1995-2008 were identified using the Kaiser Permanente-Southern California laboratory database, encompassing 3.5 million individuals annually. Multivariate logistic regression was used to examine predictors of PTx.

Results: We found 3388 patients with PHPT, of whom 265 (8%) were symptomatic (nephrolithiasis). Nephrolithiasis was predictive of PTx (OR 2.94 vs asymptomatic), with 51% of symptomatic patients undergoing surgery. Among asymptomatic patients, the proportion meeting consensus criteria was 39% during the early period (1995-2002) and 51% during the late period (2003-2008). The PTx rate for these patients exceeded that for asymptomatic patients not meeting consensus criteria but remained low (early 44% vs 19%, P < 0.0001; late 39% vs 16%, P < 0.0001). The following individual criteria were predictive of PTx: calcium >11.5 mg/dL (OR 2.27), hypercalciuria (OR 3.28, P < 0.0001), and age < 50 years (OR 1.54, P < 0.0001). However, the absolute PTx rates associated with satisfaction of these criteria were in the 50% range. Bone density scores did not influence likelihood of PTx and renal impairment predicted against PTx (OR 0.35, P < 0.0001).

Conclusions: The consensus guidelines regarding PHPT have not been followed in our study population. PTx appears to be underutilized in both asymptomatic and symptomatic patients.
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http://dx.doi.org/10.1097/SLA.0b013e31824dad7dDOI Listing
June 2012

Population-level predictors of persistent hyperparathyroidism.

Surgery 2011 Dec;150(6):1113-9

Division of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.

Background: Systematic study of outcomes of initial surgery for primary hyperparathyroidism (PHPT) has been limited by selection and self-reporting biases. To avoid these biases, we evaluated parathyroidectomy (PTx) outcomes within an integrated health care system encompassing 3.25 million enrollees.

Methods: All patients undergoing PTx for PHPT from 1995 to 2010 were studied. Persistent and recurrent disease were defined by a serum calcium level >10.5 mg/dL before or after 6 months postoperatively, respectively. The effect of demographic, clinical, and hospital volume-related variables was assessed by the use of multivariate logistic regression.

Results: A total of 1,190 initial operations for PHPT were performed at 14 hospitals. Follow-up calcium levels were available in 97% of subjects. The overall success rate was 92%, and 5% of patients developed recurrent disease. Age ≥ 70 years was predictive of persistent disease (odds ratio 1.80, P < .05). High-volume hospital (>100 cases) predicted against persistent disease (odds ratio 0.42, P < .05) and carried 96% success rate. Negative or equivocal sestamibi scan was associated with a lower success rate (success rate 89% vs 95% for positive scan, P < .05). Reoperation was performed in 12% of patients with persistent or recurrent PHPT.

Conclusion: The success rate of PTx is influenced by patient age, hospital volume, and sestamibi scan result. Surgical outcomes may be optimized by designating high-volume centers in the community setting.
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http://dx.doi.org/10.1016/j.surg.2011.09.025DOI Listing
December 2011

Underutilization of parathyroidectomy in elderly patients with primary hyperparathyroidism.

J Clin Endocrinol Metab 2010 Sep 7;95(9):4324-30. Epub 2010 Jul 7.

Endocrine Surgical Unit, Department of Surgery, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California 90095, USA.

Context: Primary hyperparathyroidism (PHPT) disproportionately affects older patients, who may face higher thresholds for surgical intervention compared to young patients.

Objective: The aim was to examine for differences in the utilization of parathyroidectomy attributable to age.

Design: We conducted a retrospective cohort study.

Participants: Patients with biochemically diagnosed PHPT during the years 1995-2008 were identified within an integrated health care delivery system in Southern California encompassing approximately 3 million individuals.

Main Outcome Measures: The outcome measures were parathyroidectomy (PTx) and time interval to surgery.

Results: We found 3388 patients with PHPT, 964 (28%) of whom underwent PTx. Patients aged 60+ yr comprised 60% of the study cohort. The likelihood of PTx decreased linearly among patients aged 60+ when compared to patients aged 50-59, an effect that persisted in multivariate analysis: odds ratio 0.68 for ages 60-69 (P < 0.05); 0.41 for ages 70-79 (P < 0.0001), and 0.11 for age 80+ (P < 0.0001). The PTx rate for patients aged 70+ was 14%. Among patients meeting 2002 consensus criteria for surgical treatment, 45% of those aged 60-69 and 24% of those aged 70+ underwent PTx. A Cox proportional hazards model showed that patients aged 60+ experienced significantly longer delays from diagnosis to surgery compared to young patients (P < 0.0001).

Conclusions: PHPT is undertreated in the elderly. We observed a progressive age-related decline in PTx rate that renders patients aged 70+ unlikely to have definitive treatment, irrespective of comorbidity and eligibility for surgery.
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http://dx.doi.org/10.1210/jc.2009-2819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936062PMC
September 2010

Accuracy of influenza vaccination status in a computer-based immunization tracking system of a managed care organization.

Vaccine 2010 Jul 8;28(32):5254-9. Epub 2010 Jun 8.

Kaiser Permanente Southern California, 100 South Los Robles Ave., Pasadena, CA 91101, USA.

Influenza vaccine safety and effectiveness studies conducted using electronic medical records rely on accurate assessment of influenza vaccination status. However, influenza immunization in non-traditional settings (e.g., the workplace) may not be captured in patient immunization tracking systems. We compared influenza vaccination status from electronic records with self-reported vaccination status for five hundred and two 50-79 years olds enrolled in a large managed care organization. Influenza vaccination status in the medical record had a high positive predictive value and specificity (both >99%). The negative predictive value was 80% and sensitivity was 78%. These data suggest that an electronic record of influenza vaccination reliably indicates immunization, while the absence of such a record is only moderately accurate, partly due to vaccines received in non-traditional settings.
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http://dx.doi.org/10.1016/j.vaccine.2010.05.061DOI Listing
July 2010

Close or positive margins after mastectomy for DCIS: pattern of relapse and potential indications for radiotherapy.

Int J Radiat Oncol Biol Phys 2008 Nov;72(4):1016-20

Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, CA, USA.

Purpose: Mastectomies result in very high local control rates for pure ductal carcinoma in situ; however, close or involved tumor margins are occasionally encountered. Data regarding the patterns of relapse in this setting are limited.

Methods And Materials: Between 1994 and 2002, the pathology reports of 574 patients who had undergone mastectomy at our institution for pure ductal carcinoma in situ were retrospectively reviewed. Of the 574 patients, 84 were found to have margins of <10 mm. Of the 84 patients, 4 underwent postoperative radiotherapy and were excluded, leaving 80 patients for this analysis. Of the 80 patients, 31 had margins <2 mm and 49 had margins of 2.1-10 mm. High-grade disease was observed in 47 patients; 45 patients had comedonecrosis; and 30 had multifocal disease. Of the 80 patients, 51 were <60 years of age.

Results: With a median follow-up of 61 months, 6 (7.5%) of the 80 patients developed local recurrence. Of the 31 patients with a margin of
Conclusion: The findings of this review suggest that patients with pure ductal carcinoma in situ who undergo mastectomy with a margin of <2 mm have a greater-than-expected incidence of local recurrence. Patients with additional unfavorable features such as high-grade disease, comedonecrosis, and age <60 years are particularly at risk of local recurrence. These patients might benefit from postmastectomy radiotherapy.
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http://dx.doi.org/10.1016/j.ijrobp.2008.06.1954DOI Listing
November 2008

Experience using peripherally inserted central venous catheters for outpatient parenteral antibiotic therapy in children at a community hospital.

Pediatr Infect Dis J 2008 Dec;27(12):1069-72

Department of Pediatrics, Kaiser Permanente, Anaheim, CA, USA.

Background: Outpatient parenteral antibiotic therapy with peripherally inserted central catheters (PICCs) is safe, clinically effective, and cost effective in pediatric populations cared for at academic and free-standing pediatric hospitals. Our study evaluates the transferability of these findings to a community hospital setting.

Methods: Data were retrospectively collected on PICCs used in children at a community hospital from December 2003 to September 2006. The Fisher exact test and a logistic regression were used for statistical analysis.

Results: Thirty-nine PICCs were placed in 34 patients. The total number of catheter days at home was 800 (mean 20.5 +/- 13.9). We demonstrated a 97% success rate in completing therapy at home, with 82.3% completion with a single PICC. Our overall complication rate was 33.3%, consisting of occlusion, accidental displacement, cracks in the catheters, and local irritation. There were no instances of phlebitis or suspected or confirmed catheter infection or sepsis. There were no statistically significant differences in these values compared with reports from major pediatric centers. The cost savings was $1070 per day of home health care when compared with costs of inpatient hospitalization.

Conclusions: We believe that this is the first study to demonstrate the effectiveness of PICC use for outpatient parenteral antibiotic therapy in pediatric patients in a community hospital setting, and demonstrates the ability for this to be done at the standard of care expected at major pediatric centers.
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http://dx.doi.org/10.1097/INF.0b013e31817d32f2DOI Listing
December 2008

Effect of bone mineral density and parathyroidectomy on fracture risk in primary hyperparathyroidism.

World J Surg 2009 Mar;33(3):406-11

Department of Surgery, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Boulevard, Los Angeles, CA 90027, USA.

Background: Bone mineral density is one parameter used to decide whether patients with primary hyperparathyroidism (PHPT) should undergo parathyroidectomy. However, the influence of bone mineral density and parathyroidectomy on subsequent fracture risk is unclear.

Methods: The authors conducted a retrospective cohort study of patients with PHPT based on administrative discharge abstract data. The dual energy x-ray absorptiometry (DEXA) scan T-scores at the femur were collected by chart review, and 10-year fracture-free survival (FFS) was the main outcome measured.

Results: A total of 533 patients were identified, most of them > or = 50 years old (89%) and female (87%). Seventeen percent of the patients were black. Mean initial calcium, parathormone, and creatinine levels were 11.1 mg/dl, 116 pg/ml, and 0.9 mg/dl, respectively. Parathyroidectomy was performed in 159 (30%) patients, and 374 (70%) were observed. The 10-year FFS after PHPT diagnosis was 94% in patients treated with parathyroidectomy and 81% in those observed (p = 0.006). Compared to observation, parathyroidectomy improved the 10-year FFS by 9.1% (p = 0.99), 12% (p = 0.92), and 12% (p = 0.02) in patients with normal bones (T-score > or = -1.0), osteopenia (T-score < or = -1.0, > or = -2.5), and osteoporosis (T-score < -2.5), respectively. On multivariate analysis, parathyroidectomy was independently associated with decreased fracture risk (HR = 0.41; 95%CI 0.18, 0.93), whereas non-black race (HR = 2.94; 95%CI 1.04, 8.30) and T-score < -2.5 (HR = 2.29; 95%CI 1.08, 4.88) remained independently associated with increased fracture risk.

Conclusions: Parathyroidectomy decreases the risk of fracture in patients with normal, osteopenic, and osteoporotic bones. The largest impact from parathyroidectomy is in patients with osteoporosis. The highest risk of fracture is in non-blacks and in patients with osteoporosis.
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http://dx.doi.org/10.1007/s00268-008-9720-8DOI Listing
March 2009

Routine interval appendectomy in children is not indicated.

J Pediatr Surg 2007 Sep;42(9):1500-3

Division of Pediatric Surgery and Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA.

Background: This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis.

Methods: A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay.

Results: The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis.

Conclusion: Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.
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http://dx.doi.org/10.1016/j.jpedsurg.2007.04.011DOI Listing
September 2007

Pelvic floor disorders, diabetes, and obesity in women: findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study.

Diabetes Care 2007 Oct 9;30(10):2536-41. Epub 2007 Jul 9.

Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena CA 91101, USA.

Objective: We examined associations between obesity and diabetes and female pelvic floor disorders (PFDs), stress urinary incontinence (SUI), overactive bladder (OAB), and anal incontinence (AI) in community-dwelling women.

Research Design And Methods: Women were screened for PFD using a validated mailed survey. Diabetes status, glycemic control, and diabetes treatment were extracted from clinical databases, while other risk factors for PFDs were obtained through self-report. Women were categorized hierarchically as nonobese/nondiabetic (reference), nonobese/diabetic, obese/nondiabetic, and obese/diabetic.

Results: Of 3,962 women, 393 (10%) had diabetes. In unadjusted analyses, women with diabetes and women who were obese had greater odds of having PFDs. Among women with diabetes, being obese was associated with SUI and OAB. After adjusting for confounders, we found that obese/diabetic women were at the highest likelihood of having SUI (odds ratio 3.67 [95% CI 2.48-5.43]) and AI (2.09 [1.48-2.97]). The odds of having OAB among obese women was the same for obese/diabetic women (2.97 [2.08-4.36]) and obese/nondiabetic women (2.93 [2.33-3.68]). Nonobese/diabetic women had higher odds of SUI (1.90 [1.15-3.11]) but did not differ significantly in their OAB (1.45 [0.88-2.38]) and AI (1.33 [0.89-2.00]) prevalence from nonobese/nondiabetic women.

Conclusions: Given the impaired quality of life experienced by women with PFDs, health care providers should counsel women that obesity and diabetes may be independent modifiable risk factors for PFDs.
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http://dx.doi.org/10.2337/dc07-0262DOI Listing
October 2007

Prevalence of nondiabetic renal disease in diabetic patients.

Am J Nephrol 2007 9;27(3):322-8. Epub 2007 May 9.

Kaiser Permanente, Los Angeles Medical Center, Los Angeles, Calif. 90027, USA.

Background: Diabetic nephropathy is the leading cause of end-stage renal disease in the USA, yet most patients with type 2 diabetes mellitus are not formally evaluated with a renal biopsy. Our aim was to evaluate the prevalence of nondiabetic renal disease (NDRD) in patients with type 2 diabetes mellitus to determine common clinical indicators suggestive of NDRD.

Methods: A retrospective analysis was performed on biopsy reports of patients who had undergone native renal biopsy between January 1, 1995, and December 31, 2005.

Results: After exclusion of 57 patients, 233 patients with DM2 were included in our analysis. Mean age at the time of biopsy was 58.1 +/- 13.7 years, and 53.0% of the study population were male. There were 124 cases (53.2%) with a pathologic diagnosis of NDRD, 64 (27.5%) with pure diabetic glomerulosclerosis (DGS) and 45 (19.3%) with concurrent NDRD and DGS (CD). Patients with NDRD tended to be younger than those with DGS and had significantly less associated diabetic retinopathy. Focal segmental glomerulosclerosis was the most common lesion found in patients with NDRD and accounted for 21.0% of all NDRD, followed by minimal-change disease (15.3%). IgA nephropathy (15.6%) and membranous glomerulonephritis (13.3%) were the most prevalent lesions found in patients with CD.

Conclusions: The high prevalence of NDRD found in our population underscores the need for clinicians to consider renal biopsy in diabetic patients with an atypical clinical course, since additional disease-specific therapies may be helpful for this subset of the population.
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http://dx.doi.org/10.1159/000102598DOI Listing
June 2007

The effect of parathyroidectomy on bone fracture risk in patients with primary hyperparathyroidism.

Arch Surg 2006 Sep;141(9):885-9; discussion 889-91

Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA.

Background: Parathyroidectomy may increase bone density in primary hyperparathyroidism (PHPT), but it is unclear whether fracture risk is decreased.

Hypothesis: Parathyroidectomy decreases fracture risk.

Design: Retrospective cohort study with median follow-up of 6.5 years.

Setting: Twelve regional hospitals in California.

Patients: One thousand five hundred sixty-nine patients with PHPT.

Interventions: Parathyroidectomy or observation. Main Outcome Measure Fracture-free survival.

Results: Mean initial calcium, parathyroid hormone, and creatinine levels were 11.2 mg/dL (2.8 mmol/L), 123.0 pg/mL, and 0.9 mg/dL (79.6 micromol/L), respectively. Parathyroidectomy was performed in 452 (28.8%) patients, and 1117 (71.2%) were observed. The 10-year fracture-free survival after PHPT diagnosis was 73% in patients treated with parathyroidectomy compared with 59% in those observed (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.38-0.73; P < .001). Parathyroidectomy decreased the 10-year hip fracture rate by 8% (P = .001) and the upper extremity fracture rate by 3% (P = .02). Parathyroidectomy was independently associated with a decreased fracture risk (HR, 0.68; 95% CI, 0.47-0.98), whereas female sex (HR, 1.82; 95% CI, 1.19-2.80) and increased creatinine level (HR per 1-mg/dL [88.4-micromol/L] increment, 2.05; 95% CI, 1.22-3.46) remained independently associated with an increased fracture risk. Age of 50 years or older (HR, 1.62; 95% CI, 0.99-2.66), initial parathyroid hormone level (HR, 1.00; 95% CI, 0.99-1.02), and calcium level (HR, 1.02; 95% CI, 0.75-1.37) were not independently associated with fracture risk after adjusting for all other variables.

Conclusions: Parathyroidectomy is associated with a decreased risk of fracture in PHPT. The largest decrease was in hip fractures. Parathyroidectomy should be considered for all patients with PHPT to reduce fracture risk, regardless of age or calcium or parathyroid hormone levels.
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http://dx.doi.org/10.1001/archsurg.141.9.885DOI Listing
September 2006