The Permanente journal最新文献

Introduction: Prior studies have reported learning curves as surgeons adopt new technology/techniques. The authors sought to evaluate revision risk following primary total knee arthroplasty (TKA) to assess whether a learning curve was observed as surgeons transitioned to 1) a new implant from the same manufacturer and 2) a new implant from a new manufacturer.

Methods: Patients ≥ 18 years of age who underwent primary fixed bearing, posterior stabilized, fully cemented TKA with patella resurfacing were identified using a US integrated health care system's total joint replacement registry (2009-2023). The exposure groups were categorized in these groups: baseline implant (reference), first 50 TKA with new implant (≤ 50), second 50 (51-100), third 50 (101-150), and the remainder (> 150). A multiple Cox proportional hazard regression was used to evaluate revision risk with adjustment for confounders.

Results: The intra-manufacturer cohort comprised 42,743 TKA. A higher revision risk was observed for the ≤ 50 group compared to the baseline group (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.01-1.86); no other differences were observed after the first 50 TKA (51-100: HR, 0.98; 95% CI, 0.71-1.34; 101-150: HR, 0.95; 95% CI, 0.69-1.32; > 150: HR, 0.99; 95% CI, 0.79-1.34). However, the association was no longer significant after excluding the TKA performed with the Attune fixed bearing tray, which has been associated with a higher risk of revision in the total joint replacement registry. The inter-manufacturer cohort comprised 19,817 TKA. No differences were observed when comparing a new manufacturer to the baseline manufacturer.

Discussion: Surgeons should be cautious for the first several TKA when transitioning to a new implant given the relationship between surgeon and implant on revision risk.

Level of evidence: Level III.

Background: Medicare recently began reimbursing for new advanced primary care management (APCM) services, which builds directly on the design of principal, chronic, and transitional care management. As APCM is anticipated to achieve similar goals and can be used similarly to predecessor services, practice and policy leaders would benefit from insight about collective use of principal, chronic, and transitional care management as APCM adoption begins in the United States.

Methods: Using data encompassing 100% of professional services billed to and reimbursed by Medicare, the authors combined principal, chronic, and transitional care management together as coordination services for evaluation. The authors calculated cumulative sum of service counts and respective reimbursements overall and stratified by clinical specialty and place of service.

Results: A total of 25,269,895 coordination services corresponding to $2,257,471,660 were provided by clinicians to Medicare beneficiaries between 2020 and 2023. Coordination services were most frequently delivered by primary care clinicians, which as a group accounted for 17,210,579 (68%) of services, compared to medical subspecialists, which accounted for 5,718,337 (23%) services, and other specialists, which accounted for 2,340,980 (9%) of services. With respect to place of service, most coordination services occurred in physician offices (21,895,715; 87%) as compared to hospital outpatient departments (757,571; 3%), homes (949,373; 4%), or other care sites (1,667,236; 6%).

Conclusion: This study corroborated the potential benefit of policy decisions to target new coordination services (ie, APCM) toward primary care clinicians, while also highlighting the need to design policies in ways that engage non-primary care clinicians for common chronic conditions.

Background: Proteinuria is associated with substantial cardiovascular and renal morbidity, mortality, and increased rates of hospitalization. It serves as an early indicator of chronic kidney disease (CKD).

Objectives: This review examined the relationship between proteinuria, CKD, and major adverse cardiovascular events, summarized evidence-based therapies, identified gaps in screening, and presented a quality improvement (QI) project from Kaiser Permanente East Bay.

Methods: The authors conducted a literature review and a QI project using the Kaiser Permanente national CKD staging algorithm. Patients aged 18-75 years old with CKD stages 3 or 4 were identified and categorized by comorbidities. Screening rates were analyzed.

Results: All patients with diabetes and CKD 3 and 4 received proteinuria screening. Screening rates were lower among patients with hypertension and without diabetes.

Conclusions: Early detection and intervention can reduce major adverse cardiovascular events and CKD progression. The QI project highlights effective workflows and the need to expand screening protocols to broader populations.

The Mediterranean diet (MD) is a dietary pattern for which the health benefits in prevention of cardiovascular disease, cancer, and metabolic disorders have been well-substantiated. However, emerging clinical literature has shown its promise in reducing risk and disease activity in many autoimmune diseases. This review focuses on literature about components of the MD and their role in modulating inflammatory pathways implicated in autoimmune disease. This review also focuses on literature assessing the MD's associations with clinical outcomes in rheumatoid arthritis (RA), a systemic autoimmune condition primarily affecting one's joints. The core components of the MD (such as whole grains, fish, olive oil, yogurt, cheese, and moderate red wine consumption) have been seen to reduce laboratory and clinical markers of inflammation through a number of mechanisms. Recent population-based cohort studies and randomized clinical trials have been more equivocal in their findings. This suggests that although the MD may have statistically significant impacts on RA risk and symptom severity, these effects are of uncertain clinical significance. This highlights the ongoing need for high-quality clinical research on lifestyle interventions in RA and other autoimmune diseases, along with the continued importance of emphasizing lifestyle-based interventions in the management of chronic disease.

Purpose: Insight about episode spending after elective procedures has driven interest in bundling reimbursement for surgical procedures. However, little is known about episode spending for health systems (payments) and patients (out-of-pocket [OOP] expenses) after unplanned, nonelective procedures such as hand trauma.

Methods: The authors used 2019-2022 national claims to conduct a cohort study of patients undergoing flexor tendon repair, open reduction internal fixation (ORIF) of a distal radius fracture, and replantation/revascularization. The authors constructed 90-day episodes spanning surgical procedures and postoperative care. The authors calculated episode spending from the perspectives of the health system (payments) and patients (OOP expenses). Multivariable regression models were used to examine the association between patient characteristics and spending.

Results: Among 21,753 patients, 90-day postoperative spending varied by procedure type. Median payment was $14,263 for ORIF of distal radius fractures, $11,541 for flexor tendon repairs, and $25,700 for revascularization/replantation. Compared to ORIF of distal radius fractures, flexor tendon repairs were associated with 18% lower payments (cost ratio, 0.82; 95% confidence interval [CI], 0.80-0.83), while revascularization/replantation was associated with 7% lower payments (cost ratio, 0.93; 95% CI, 0.90-0.97). Patients with at least one comorbidity had 4% greater payments compared to patients with no comorbidities (cost ratio, 1.04; 95% CI, 1.03-1.06). However, inpatient procedures were 388% more expensive than outpatient procedures (cost ratio, 3.77; 95% CI, 3.77-3.99). The authors also found variation in patient OOP expenses based on procedure type.

Conclusions: There was heterogeneity in health system and patient spending after hand trauma due to procedure type. This highlighted that any future payment or practice redesign for hand trauma episodes should be stratified by procedure type.

Introduction: Pharmacist intervention can improve blood pressure (BP) control during scheduled pharmacy appointments; however, remote pharmacist impact during in-person nurse visits remains unclear. This study evaluated whether real-time remote consultations with clinical pharmacy specialists (CPSs) during nurse visits improve BP outcomes for patients.

Methods: This retrospective cohort study included adult patients with hypertension and a repeat BP of 140-179/90-109 mmHg during a nurse visit from November 2023 to August 2024. Exclusion criteria included pregnancy, hospice/palliative care, and estimated glomerular filtration rate < 30 mL/min/1.73 m². The intervention group received immediate CPS consultation via secure chat; the control group received usual care from the "Doctor of the Day." Outcomes included time to BP goal (≤ 140/90 mmHg), medication optimization, BP change from baseline, BP goal attainment, and enrollment in remote BP monitoring (RBPM).

Results: Among 1726 patients (1466 control; 260 intervention), time to BP control was similar between groups (31.93 vs 31.21 days, respectively). The intervention group had significantly higher rates of medication optimization (35.5% vs 62.3%) and RBPM enrollment (6.6% vs 63.1%). BP goal attainment (87.1% vs 88.2%) and BP reductions were comparable between control and intervention groups (systolic: -23.06 vs -24.91 mmHg; diastolic: -9.76 vs -8.27 mmHg, respectively).

Discussion: The integration of remote CPS consultation into nurse visit appointments demonstrated higher rates of medication optimization and RBPM enrollment while providing similar BP control outcomes as compared to usual care.

Conclusion: The remote pharmacy hypertension consult service demonstrated a substantial impact by transforming ambulatory care practice and expanding access to care through use of remote technology.

Background: Opioids are highly effective for pain management but carry risks. Naloxone quickly reverses opioid overdoses by blocking opioid receptors in the brain. Despite its effectiveness, naloxone remains underutilized. Kaiser Permanente created the Interregional Pharmacy Opioid Use Improvement Group to support safe opioid prescribing and increase appropriate naloxone prescribing.

Methods: This retrospective study included Kaiser Permanente Georgia members who were 18 years or older and filling chronic opioid therapy of ≥ 50 morphine milligram equivalents (MME) averaged over the previous 90 days. The primary objective was to compare the number of patients who filled a naloxone prescription within the last 24 months as of March 31, 2023 (preintervention) vs as of December 31, 2023 (postintervention). The secondary outcome was to compare the naloxone fill rates based on intervention type.

Results: As of March 31, 2023, 122 out of 399 patients (30.6%) had filled naloxone prescriptions compared to 241 out of 356 patients (67.7%) as of December 31, 2023 (30.6% vs 67.7%; P < .0001). Out of 56 patients who received only a secure email, 42 (75%) filled their prescriptions. For patients who spoke directly with a pharmacist or technician, 91 (91%) filled their prescriptions. Among patients who were not directly reached and received a voicemail, 15 (41%) filled their prescriptions.

Conclusions: Pharmacy-led interventions, particularly telephone outreach, were effective at improving naloxone fill rates in patients on chronic opioid therapy of ≥ 50 morphine milligram equivalents per day. Voicemails had a lower fill rate, highlighting the importance of direct interaction in improving patient outcomes.

Introduction: Prior studies reporting the utilization of anterior cruciate ligament reconstruction (ACLR) was limited to pediatric populations or lacked accounting for the impact of the COVID-19 pandemic. In this study, the authors sought to compare the annual incidence of primary ACLR following the COVID-19 pandemic shutdown to see if utilization has rebounded to pre-pandemic levels.

Methods: The number of ACLRs performed per year from 2017 through 2023 was identified from the authors' health care system's ACLR interregional registry, and average membership per year was identified from membership records. Incidence rates per 100,000 members were calculated for each year. Poisson regression was used to evaluate year-to-year trends overall and across graft selection, age, and gender. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) are presented.

Results: In total, 23,082 ACLRs were performed from 2017 to 2023. Pre-pandemic, annual ACLR incidence increased from 47.0 per 100,000 in 2017 to 50.2 in 2019. During the pandemic (2020), this dropped by 33.9% to 33.2 per 100,000 (IRR, 0.66; 95% CI, 0.63-0.70). Post-pandemic, annual incidence increased from 38.6 to 42.3 per 100,000 from 2021 to 2023, respectively (2020 to 2021: IRR, 1.16; 95% CI, 1.10 -1.23; 2021 to 2022: IRR, 1.11; 95% CI, 1.06-1.16). However, this was still lower than the pre-pandemic incidence. In both genders, patients in the pediatric age groups had the biggest declines during the shutdown (drop off of 57% in the 10- to 14-year-old group and 40% in the 15- to 19-year-old group).

Discussion: The COVID-19 pandemic shutdown of elective orthopedic procedures led to a sharp drop in the numbers of ACLRs performed, and the United States is still in the recovery period.

Introduction: Physical activity level plays a role in modifying the likelihood of developing Alzheimer's disease and related dementias. However, little is known about how changes in housework affect cognitive function among US adults over the age of 65. This study investigates the correlation between changes in housework frequency and cognitive function over 10 years.

Methods: Data from 8141 adults aged ≥ 65 years in the Health and Retirement Study were analyzed, with changes in housework frequency categorized as "consistently high," "low to high," "high to low," and "consistently low" from 2008 to 2010. Cognitive function was measured from 2010 to 2018 using a composite score (range = 0-35), and mixed-effects linear regression models were fitted.

Results: Of 8141 participants (median age: 75 years [SD: 6.6] and 59.3% female), individuals who reported changes in housework frequency from high to low and consistently low were associated with an additional cognitive decline of 0.079 (95% CI, -0.117 to -0.042) and 0.090 (95% CI, -0.126 to -0.054), respectively, relative to those whose housework frequency remained consistently high. There was no statistically significant additional decline among adults reporting low to high frequency compared with those reporting consistently high housework frequency (β = -0.027; 95% CI, -0.074 to 0.019; P = .252). This association was similar among women and men (P_interaction = .765) and was also similar among adults aged ≥ 80 years and those aged 65-79 years (P_interaction = .069).

Conclusion: Transitioning from low to high or maintaining consistently high housework engagement in later life was associated with a delay in cognitive decline, regardless of gender and age.

Introduction: The Merit-Based Incentive Payment System (MIPS) affects Medicare reimbursements for over 600,000 clinicians, including ~ 15,000 orthopedic surgeons in the United States. MIPS policies are rapidly evolving, yet limited research exists to guide orthopedic surgeons in optimizing performance. This study evaluates whether recent MIPS policy changes have led to increased payment adjustments for orthopedic surgeons and examines the role of MIPS in enhancing care quality.

Methods: A retrospective analysis of 2021-2022 MIPS performance data from nearly 9000 orthopedic surgeons assessed the impact of policy changes on payment adjustments using McNemar's test and mixed effects logistic regression.

Results: Raising the MIPS performance threshold to 75 points significantly reduced the likelihood of receiving bonus payments (χ ² = 803.21, degrees of freedom = 1; P < .01). Surgeons in smaller practices had 60% lower odds of earning bonus payments (odds ratio, 0.40; 95% confidence interval, 0.33-0.48; P < .008), though this disparity was smaller than previously reported. The updated complex patient bonus scoring policy showed the strongest positive effect on the likelihood of receiving bonus payments (odds ratio, 6.49; 95% confidence interval, 3.31-12.76; P < .017). Nonetheless, MIPS continues to fall short in encouraging the reporting of specialty-specific, outcome-based, and patient-experience measures.

Discussion: Raising the MIPS performance threshold further may lead to greater dissatisfaction. Despite some improvements, equity gaps remain for small and rural practitioners. However, the revised complex patient bonus policy effectively rewards clinicians caring for high-risk populations.