The Permanente journal最新文献

Introduction: As airway management becomes more complex with the adoption of new technologies and strategies, it is important to ensure that emergency medicine residents, the future of the specialty, receive extensive training. This study was designed to understand the prevailing airway management practices and training within emergency medicine residency programs.

Methods: A survey consisting of 19 multiple-choice questions was sent to program directors of 258 emergency medicine residency programs in the United States.

Results: A total of 63 emergency medicine residency programs completed the airway survey, a response rate of 24%. Programs from all regions of the country are represented, most of them from university-based teaching hospitals (40%) and 3-year programs (78%). The majority of programs provide their residents with 50-100 intubations (50.8%) during their training. Pediatric intubations remain scarce with 54.1% of programs having only 5-10 pediatric intubations per resident. The emergency medicine team manages 93.6% of all trauma intubations, and residents complete 81% to 100% of all the department's intubations 88.9% of the time. Video laryngoscopy is on the rise, with GlideScope^® (93.7%) and C-Mac^® (55.6%) being the most common devices available. Overall, programs use both succinylcholine and rocuronium equally, but there is a trend toward using rocuronium more frequently than succinylcholine. By employing different teaching modalities, multiple times a year, residency programs expose residents to a variety of backup tools and surgical airway techniques.

Conclusions: Emergency medicine residents are exposed to multiple advanced airway adjuncts and comprehensive airway curriculums as emergency airway management practices evolve and become more complex.

Background: Peyronie's disease (PD) is a progressive fibrotic disorder of the penis that can induce pain and erectile dysfunction and has various treatment modalities, including surgical, pharmaceutical, and Clostridium histolyticum injection therapies.

Methods: The authors used electronic medical records from Kaiser Permanente Southern California, an integrated health care system that consists of 15 medical centers, and identified patients diagnosed with stable PD without concomitant erectile dysfunction from January 1, 2004, to December 31, 2020. Baseline characteristics between surgical and injection groups were compared using Chi-squared and Kruskal-Wallis tests. Multivariable logistic regression with adjustment of confounders was implemented to identify which variables may influence whether patients received injection or surgical therapy.

Results: A total of 11,706 patients with PD were identified. The rate of new PD diagnosis per 100,000 patients increased by 0.37 every year, P < .05. The incident rate (per 1000 eligible patients) of surgical management declined on average by 0.40 each year (P < .001), although there was an increase rate of 1.19 for injection therapy (P < .001). On multivariable modeling, patients 45-54 years of age were more likely to receive injection therapy as the primary treatment for PD (adjusted odds ratio = 2.77; P = .002; confidence interval = 1.34-5.73).

Conclusion: This study illustrates that pentoxifylline is now more frequently used than colchicine and vitamin E as oral treatments for PD, while collagenase C. histolyticum injection therapy is now more prevalently employed than surgical intervention as the therapeutic approach for PD.

Introduction: The COVID-19 pandemic forced a rapid shift toward virtual modalities for the treatment of depression in primary care.

Methods: Participants were adults 18 years and older with a new episode of depression diagnosed in primary care between March 1, 2020, and May 21, 2021, and moderate-to-severe symptoms of depression at the time of diagnosis (N = 9619). Outcomes were 1) antidepressant medications prescribed and dispensed (referred to as received), as well as adherence to those medications; 2) referrals made to depression-related services and the receipt of those services; and 3) a follow-up visit completed with the diagnosing practitioner regardless of treatment actions.

Results: Patients were 42.4 ± 17.8 years old, and 77.6% had moderate-to-severe symptoms at diagnosis. Most patients were women (70.4%), 48.2% were Hispanic, and 8.4% were Black. Telephone visits were associated with 64% increased odds of having an antidepressant prescribed when compared to in-person visits. However, patients prescribed an antidepressant during a telephone visit were 52% less likely to receive this prescription when compared to patients who were prescribed an antidepressant during an in-person visit. Telephone and video visits were associated with 48% and 37% decreased odds, respectively, of having a follow-up visit with the prescribing practitioner when compared to an in-person visit.

Conclusion: Telemedicine for depression in adult primary care may result in greater antidepressant prescribing than in-person care, but these medications are less likely to be received. This study's findings suggest that health systems should adjust electronic decision support tools (such as mail-order pharmacies) to ensure virtual care decisions are implemented.

Objectives: The purpose of this report was to summarize implementation of universal screening and treatment pathways for youth vaping in a large, community-based health care system in the United States.

Methods: Data were obtained as a part of routine clinical care and were extracted from medical records weekly for 4 years. Variables reported include number of teens screened, teens who tested positive, referrals, and quit rates, as well as gender and race or ethnicity.

Results: Of the 16,671 visits, 12,165 (73%) teens were screened, 632 (5.2%) teens screened positive, and of those who screened positive, 128 (20%) referrals were placed. For those who were referred, 40 teens (31.3%) quit vaping (abstinence for at least 3 weeks) and 21 (16%) decided to receive nicotine replacement therapy (nicotine patches, gum, or lozenges).

Conclusions: This study outlines a screening and intervening pathway that can be used in other health care systems in the United States and beyond. Teen vaping can be addressed before it becomes a serious addiction. Institutions can experience cost-saving benefits in that increasing outreach efforts and education would ultimately reduce the number of inpatient/emergency department visits/hospitalizations related to vaping.

Introduction: Intensive outpatient programs (IOPs) have been shown to reduce posttraumatic stress disorder (PTSD) symptoms in veteran populations. The aim of this study was to examine the association between IOP participation and inpatient psychiatric and mental health-related emergency department (ED) encounters among patients with PTSD.

Methods: This is a retrospective cohort study among 258 adults with PTSD who participated in the IOP at Kaiser Permanente Oakland Medical Center between January 1, 2017, and December 31, 2018. The authors compared changes in inpatient psychiatric hospitalizations and mental health-related ED encounters from the year before vs after the first IOP engagement. Bivariate analyses comparing ED and inpatient utilization pre- and post-IOP engagement, stratified by sociodemographic variables were conducted using paired t-tests and McNemar's test. Conditional multivariable logistic regression was performed to assess the odds of psychiatric utilization.

Results: Participants were more likely to have ≥ 1 inpatient psychiatric encounter (28.7% vs 15.9%; p < 0.01) and ≥ 1 mental health-related ED encounter (24.8% vs 18.2%; p = 0.04) pre-IOP vs post-IOP. The authors' multivariable analysis demonstrated that patients experienced a 56% reduction in the odds of inpatient psychiatric encounters (adjusted odds ratio = 0.42, 95% confidence interval: 0.26-0.68, p < 0.01) and a 35% reduction in mental health-related ED encounters (adjusted odds ratio = 0.63, 95% confidence interval: 0.40-1.00, p = 0.05) post-IOP vs pre-IOP.

Discussion: This study demonstrated a significant reduction in inpatient psychiatric hospitalizations and mental health-related ED visits among patients with PTSD in the year following participation in an IOP.

Conclusion: These findings support the use of IOPs for patients with PTSD to reduce the likelihood of intensive service use.

Background: Lupus nephritis (LN) is the most common cause of kidney injury in systemic lupus erythematosus and associated with higher morbidity and mortality. Low medication adherence correlates with adverse clinical outcomes.

Methods: In a large, integrated health system at Kaiser Permanente East Bay Area, the authors identified mycophenolate mofetil (MMF) prescriptions for LN and collected patient demographics, medication adherence, and copay data. They interviewed patients with low medication adherence rates to understand contributing factors, such as side effects, cost, refill processes, and laboratory draws. Adherence was defined as a proportion of days covered at > 80%. The proportion of days covered is the number of days covered by a medication divided by the number of days in a defined period.

Results: Between November 30, 2021, and November 30, 2022, the authors identified 36 patients with LN on MMF. Almost a third (11/36) of these patients were nonadherent to medication. More than half (7/11) of these patients agreed to be interviewed. They identified the following causes of medication nonadherence: forgetfulness (57%, or 4/7), incomplete laboratory work (28%, or 2/7), medication cost (14%, or 1/7), and intentionally missed doses (14%, or 1/7). No patients identified medication side effects as a cause. The median 30-day copay for MMF was $4.55, and 28% (2/7) of patients paid $0 for their medications.

Conclusions: In the authors' integrated health system, 69% of their patients with LN on MMF were adherent to their medication regimen. Forgetfulness was a challenge for the nonadherent patients. Kaiser Permanente East Bay Area provides convenient refills and laboratory draws; this likely facilitates medication adherence.

Background: Patient-centered care (PCC) has been called for as a solution to improving care quality and patient outcomes. Patient experience, termed care experience, is a measurable aspect of PCC and aligns with coproduction. Identifying patterns of positivity and high performers is a Positive Deviance approach that can inform strategic improvement of the care experience.

Objective: To identify the characteristics of positive deviances from voluntary, unsolicited compliments from patients and family members about their care experiences.

Methods: The authors conducted a mixed-method analysis, including content and a thematic analysis of unsolicited comments from patients and families, submitted between January 2021 and January 2022. After removing duplicates and miscategorized comments, 213 compliments were included in the analysis using a single, blinded inductive coding to synthesize thematic statements.

Results: The main campus received the most compliments by location (89%); the most widely used patient sentiment was thankful (36.8%). Compassionate (26.8%), together with six others: competent (11.6%), communication (10.6%), cared for (8.5%), care team (8.0%), and supportive (8.0%), made up approximately 80% of drivers of care quality. Physicians (37.3%) and nurses (34.2%) were the most complimented personnel, although surgery (17.0%) were the most complimented services team. Similar characteristics were reported for exemplary individuals and their associated care teams.

Conclusion: The results align with previously reported work by the Beryl Institute and CMS 5-star rating on key drivers of patient experience. This approach provides a method by which exemplars can be identified within health systems, and that information is used to guide improvement and organizational planning.

Introduction: Limited research has examined how technology and digital literacy may affect patients' use of video visits. This study explored the relationship of demographic factors and patient-reported confidence in digital literacy skills to access to video visits among patients who never used them during the COVID-19 pandemic.

Methods: Using existing survey data, the current study examined data from respondents who did not engage in video appointments but instead attended face-to-face appointments between April and December 2020 for nonemergent health concerns. A multivariable logistic regression model was used to investigate whether demographic and social determinants of health factors, context of care (primary care or psychiatry/psychology), and digital literacy confidence were associated with video visit engagement. Collinearity was assessed using the variance inflation factor.

Results: This study found that living in rural areas and having a self-reported lack of confidence in logging video appointments using the Mayo Clinic patient portal were associated with persistent nonuse of video appointments in a cohort of patients who did not use video visits at this institution during the early part of the COVID-19 pandemic.

Discussion: The research findings reported herein reveal that individuals living in rural areas and those who lack confidence in logging into patient portals to access video visits tend to persistently avoid using video appointments. More investment is needed at the federal and corporate levels to improve digital connectivity. Digital navigators and community involvement can promote digital adoption.

Conclusion: To encourage digital competency in rural communities, it is important to implement support strategies through community stakeholders and other resources.

Introduction: The purpose of this scoping review was to investigate in the literature how a learning health system (LHS) can be implemented in cases of complex, costly, chronic (3C) conditions.

Methods: A scoping review of literature published in English since 2007 was conducted using Medline, Cumulative Index to Nursing and Allied Health Literature, and Scopus. Two authors screened the resulting articles and two authors extracted study details on the structure, process, and outcome of each LHS. Eligibility criteria included studies of LHSs that focused on populations experiencing a complex chronic health condition. A narrative synthesis of data was conducted using deductive qualitative methods.

Results: Application of the authors' search strategy resulted in 656 publications that were analyzed for this review. The authors included 17 studies that focused on 13 LHSs. The structure of the LHSs had many components, and many included data from either patient surveys or patient charts. The processes varied widely, from engaging patients in the process to exclusively analyzing the data. The outcomes were largely patient-reported, though several clinical outcomes were also used to benchmark the success of the LHS.

Discussion: Our review shows that LHS definitions, structures, processes, and outcomes in 3C applications vary widely. Many have shown substantial potential to be implemented and improve care in 3C populations. To deliver on this goal, future work will need to focus on better specification, formalization, and definition of LHS approaches, as well as better design of their structures, processes, and outcomes to fit the needs of the intended population.

Introduction: Thiazides are utilized in general hypertension management, however, their role in chronic kidney disease (CKD) hypertension management remains unclear. Although data support thiazide efficacy in advanced CKD, the adverse effect profile (including estimated glomerular filtration rate [eGFR] decline and electrolyte abnormalities) may lead to thiazide discontinuation. The authors assessed the thiazide discontinuation rate in Kaiser Permanente Southern California members with moderate-to-severe CKD and hypertension.

Methods: This study was a multicenter retrospective analysis evaluating Kaiser Permanente Southern California members with hypertension and CKD 3B or 4 who filled a thiazide prescription in 2021, with follow-up through 2022. The outcomes were thiazide discontinuation rate, reason for thiazide discontinuation, time to thiazide discontinuation, and discontinuing practitioner specialty. Mean changes in blood pressure and eGFR from baseline were also evaluated.

Results: Of the 401 patients followed for 1 year after thiazide initiation, 65 patients discontinued a thiazide (discontinuation rate: 16.2%, mean time to discontinuation: 7.5 months). Of the 201 patients followed for 2 years after thiazide initiation, 57 patients discontinued a thiazide (discontinuation rate: 28.4%, mean time to discontinuation: 15.5 months). The most commonly documented thiazide discontinuation reason was increased serum creatinine (30% of total reasons at 1 year and 39% of total reasons at 2 years).

Conclusion: Most patients with hypertension and CKD 3B or 4 continued on a thiazide with favorable blood pressure lowering effects and modest eGFR decline. Thiazides may be considered viable antihypertensive options with close renal function monitoring for patients with moderate-to-severe CKD.