The Permanente journal最新文献

Introduction: The COVID-19 pandemic rapidly expanded telehealth services when in-person care was limited. Using primary care data from a large federally qualified health center in Washington state, this study aimed to: 1) describe trends in telehealth use among adult patients, and 2) provide disaggregated patient characteristic data associated with telehealth use, with a focus on patients speaking Asian Indian languages.

Methods: The authors conducted a retrospective cross-sectional study using electronic health data from adult patients seen at the partner health center between January 1, 2020 and December 31, 2022. Multivariable logistic models for each year generated adjusted odds ratios and 95% confidence intervals for characteristics associated with completing a telehealth visit (video or phone). A subgroup analysis on telehealth use among patients speaking languages commonly spoken in India was also completed.

Results: The study included 653,378 primary care encounters from 127,146 unique adults (mean age 50; 56% female; nearly one-third Hispanic or Latino). Top 5 languages spoken were English, Spanish, Russian, Punjabi, and Vietnamese. Telehealth use peaked in 2020 and declined in subsequent years, while in-person visits were highest in 2021. Lower odds of telehealth use associated with being younger, identifying as a racial or ethnic minority, preferring a language other than English, residing in a rural county, identifying as male or Gender X, and lacking insurance.

Discussion: The findings highlighted disparities in telehealth use across demographic and linguistic lines, including among Asian Indian language speakers, echoing concerns of inequitable access.

Conclusion: Findings can guide strategies to improve telehealth services for underrepresented groups.

Introduction: Understanding how patients and health care professionals seek and interpret health information online helps to mitigate knowledge gaps at decision points, leading to improved shared decision-making and better health outcomes. The objective of this study was to improve decision-making by identifing themes in how patients, practitioners, and health care researchers seek health information online.

Methods: This qualitative focus group study occurred from October 2024 to February 2025. An inductive thematic analysis was used to identify emerging themes directly from the sessions.

Results: A total of 31 participants took part in 7 focus group sessions. Of the participants, 65% were female, 52% self-identified as White, and 62% were between 18 and 34 years. Regarding level of education, 4 participants (13%) had a high school diploma/general educational development degree, although 81% had a bachelor's or graduate-level degree. Four participants (13%) were nonnative English speakers. Three major themes emerged surrounding online sources, social media usage, and trust.

Discussion and conclusion: This study revealed critical divergences in online health information-seeking across stakeholder groups. Patients increasingly rely on social media platforms like Reddit and TikTok for peer-driven narratives, whereas practitioners are more inclined to exclusively consult peer-reviewed literature. This divide creates information asymmetry that can undermine shared decision-making when patients are informed by experiential knowledge that practitioners lack or dismiss. All groups began online searches with Google but followed distinct pathways and relied primarily on surface-level credibility markers rather than systematic evaluation. To bridge these divides, the authors recommend integrating patient-sourced information training into medical education, incorporating information-seeking discussions into clinical encounters, and developing resources that bridge experiential and clinical knowledge. Researchers should also accelerate evidence translation through rapid translation mechanisms and partnerships with trusted platforms. As artificial intelligence tools increasingly shape health information access, understanding these evolving patterns remains essential for effective collaborative decision-making and potentially improved health outcomes.

This case highlighted a value-based approach to abrupt-onset obsessive-compulsive disorder (OCD) consistent with a possible pediatric acute-onset neuropsychiatric syndrome (PANS) presentation, where timely intervention facilitated recovery while avoiding unnecessary and costly levels of care. The authors have described a 14-year-old male who developed sudden, severe OCD symptoms following influenza A infection. His presentation included functional decline, poor insight, and complex family dynamics. Traditional pediatric OCD was considered but deemed less likely due to the abrupt onset, absence of family history, and persistence of symptoms postinfection. Minimal treatment engagement and refusal of medication necessitated an extended involuntary hold and court-approved pharmacotherapy due to illness severity and medical complications. With initiation of fluoxetine during inpatient treatment, the patient stabilized and transitioned to intensive outpatient therapy. This case underscored the importance of recognizing PANS as a potential diagnostic framework, ensuring appropriate evaluation of underlying causes, and implementing timely, decisive treatment. As antibody testing, including central nervous system and cerebrospinal fluid autoantibody testing, were not obtained, the diagnostic certainty was best characterized as a possible PANS presentation. Lastly, this case illustrated a value-based care model, emphasizing efficient diagnostic testing, judicious use of higher levels of care, and coordinated transitions that reduced cost without compromising outcomes.

Multicancer detection (MCD) tests are an emerging innovation in cancer screening that use blood samples to detect multiple cancer types at once, potentially identifying malignancies earlier and with greater accessibility than traditional, site-specific screening methods. Several tests have demonstrated the ability to detect cancer signals and suggest tissue of origin, which may enhance screening for cancers with existing screening tests and fill critical gaps for cancers lacking effective screening modalities. However, MCD testing raises concerns about the potential for substantial harm, including false-positive test results leading to short-term emotional distress and wasteful and potentially risky testing, unwarranted reassurance when results are falsely negative, the identification of indolent cancers (overdiagnosis), and increased strain on health care resources. Unclear follow-up protocols and limited harms reporting further complicate their use. Equity issues persist, as clinical trials may lack diverse representation and potentially miss population-specific risks. To ensure that MCD tests provide a net benefit to patients and to minimize the burden on health systems, rigorous evaluation, transparent harms reporting, and the implementation of robust practices for follow-up and shared decision-making are essential. As these tests evolve and their use becomes more widespread, careful integration into existing screening practices will be key to maximizing benefit while minimizing unintended consequences.

Background: The emergency department (ED) discharge process in British Columbia (BC), Canada is inconsistent across multiple health authorities, leading to variability in patient experiences and outcomes. This study aimed to identify key factors for a high-quality ED discharge process across BC.

Methods: A qualitative study was conducted with 21 patient participants and ED health care practitioners through semistructured Zoom interviews. Transcripts were thematically analyzed.

Results: Key recommendations included providing standardized discharge resources in multiple languages, generating automated discharge summaries, involving caregivers for continuity of care, ensuring time to answer patient questions, integrating follow-up reminders via text, and improving connections to social resources. A cultural shift emphasizing collaboration among ED leaders, clinicians, patient participants, and electronic health record developers is needed to enhance discharge practices.

Conclusion: Insights from diverse partners highlight actionable steps to improve ED discharge in BC. Health care authorities and hospitals should support the adoption of best practices to enhance patient care and outcomes. Several actionable items were identified for implementation and/or further investigation.

Background: Inquiring about a patient's adverse childhood experiences (ACEs) and assessment for mental health conditions such as depression and anxiety using trauma-informed care (TIC) approaches may enhance maternity care quality. This study aimed to evaluate the feasibility of a TIC program that integrated mental health and ACE assessment by examining patient and physician perspectives following clinical implementation in a primary care setting.

Methods: In this exploratory quality improvement project, a maternity care clinic in Calgary, Alberta, implemented a TIC program to assess and address patients' mental health and ACEs between July 2017 and January 2018. Patients' and physicians' perspectives of the program were also attained to understand the feasibility of implementation and use.

Results: Patients responded positively to their clinic's use of the TIC program and discussions about their mental health and ACEs with their physicians. They reported feelings of safety, respect, understanding, and receiving informed care. Patients also reported that discussing their ACEs encouraged them to engage in related conversations in their personal lives, seek parenting resources, and expand their knowledge about their ACEs. Physicians reported improved confidence in discussing their patients' ACEs and routine integration of the assessment tools into clinical practice.

Conclusion: Integrating ACE and mental health assessment into routine maternity care through the TIC program was associated with positive perceptions from both patients and physicians. Enhanced communication, improved patient-physician relationships, and more optimal patient-centered care resulted. By incorporating these tools into maternity care, health care practitioners can more effectively identify psychosocial risks early, thus supporting improved maternal and fetal health outcomes.

Introduction: Head and neck cancer (HNC) is associated with poor health outcomes. The receipt of regular dental care may increase the likelihood of diagnosing HNC earlier but has not been studied extensively. The authors' objective was to examine the association of receipt of dental care with late-stage HNC, adjusting for key covariate measures.

Methods: This was a retrospective study of 468 Kaiser Permanente Northwest patients with HNC diagnosed between January 1, 2010 and December 31, 2023. All data elements needed for the analysis were constructed from Kaiser Permanente Northwest's electronic health record. The main outcome measure was incident late-stage HNC, defined as American Joint Committee on Cancer stage 3-4 (vs stage 0-2). The independent variable was receipt of dental care (yes, no) in the 12 months prior to cancer diagnosis. Multivariable logistic regression assessed the association between receipt of dental care and late-stage HNC diagnosis, adjusted for key covariate measures.

Results: Those who had any dental visits in the year before diagnosis (odds ratio, 0.64; 95% confidence interval, 0.43-0.95) had lower odds of being diagnosed with late-stage HNC compared to those with no dental visits, after adjusting for study covariates.

Discussion: Future research should determine whether providing ongoing dental care for populations at risk of developing HNC lowers the incidence of late-stage cancer diagnosis.

Conclusion: Patients who had any dental visits in the year prior to cancer diagnosis had lower odds of being diagnosed with late-stage HNC.

Thyroid storm is a life-threatening endocrine emergency that can result in multiorgan failure, including severe respiratory compromise. Although venoarterial extracorporeal membrane oxygenation (ECMO) has been used in some cases, the role of venovenous ECMO is even more rare. The authors reported a case of a 41-year-old female with a history of uncontrolled hypertension who presented with thyroid storm complicated by respiratory failure requiring venovenous ECMO. This case highlighted the critical management strategies, the role of extracorporeal support, and outcomes in severe thyroid storm.

Background: Trauma-informed care (TIC) provides a framework for understanding and mitigating trauma's impact on health. Integrating TIC principles into medical school education equips physicians with the skills necessary for delivering compassionate, patient-centered care.

Methods: A survey regarding experiences with TIC education was emailed to medical students and faculty at the University of Oklahoma College of Medicine. Qualitative and standard quantitative analysis of the results was performed.

Results: A significant majority of faculty (83.7%) and students (92.5%) recognized the relevance of TIC to clinical practice. However, only 37.0% of faculty reported incorporating TIC into their teaching. Despite its acknowledged importance, only 20.4% of students felt satisfied with how TIC was taught. On a Likert scale of 1-5, students reported a comfort level of 1-2 for trauma-informed screenings (31.5%) and physical examinations (62.9%). Proposed solutions to increase TIC education included the implementation of longitudinal curricula, workshops, and conversations about trauma when interacting with patients.

Conclusions: TIC is perceived as relevant to medical education and practice among students and faculty. However, its integration into the undergraduate medical education curriculum is sporadic. Although certain courses incorporate TIC, a cohesive teaching approach throughout the curriculum is lacking. There is uncertainty among faculty regarding the definition of TIC and what aspects may be lacking in the curriculum, highlighting a gap in knowledge and application. The intermittent teaching of TIC affects students' ability to fully understand the impact of trauma in the clinical setting. The authors' results supported the integration of a more comprehensive TIC education in undergraduate medical curricula.

Introduction: Readmissions are a major source of burden to patients, hospitals, and third-party payers. Remote patient monitoring (RPM) was initially implemented during the COVID-19 pandemic but was later expanded to other high-risk patients upon discharge from the hospital.

Methods: The authors used a retrospective data of convenience sample of adult patients enrolled in their RPM program from March 2024 to May 2025. Inclusion criteria included adult patients > 21 years of age, members of Geisinger Health Plan or Keystone Accountable Care Organization, high-priority diagnosis-related groups with elevated Epic readmission risk score, home internet availability, and discharge disposition to home. Exclusion criteria included patients' age < 21 years old, not members of Geisinger Health Plan or Keystone Accountable Care Organization, lack of home internet eligibility, and discharge disposition other than home. The primary outcome measure was 30-day all-cause readmissions.

Results & discussion: The analysis of patients enrolled in RPM and those who were followed afterward showed a significant reduction in 30-day readmissions, with 30% absolute reduction (11% in enrolled group vs 41% in non-enrolled group). Finally, through modeling, the authors opine on the potential effect of RPM on the national readmission landscape.

Conclusion: The RPM program provided a significant benefit to 30-day readmission among the authors' convenience sample.