The Permanente journal最新文献

Introduction: In 2016, the Centers for Medicare & Medicaid Services started reimbursing practitioners for their time spent providing advance care planning (ACP) with patients. This study assessed utilization of this policy by examining trends in ACP billing across medical specialties from 2016 to 2021 and differences in ACP service volume by metropolitan status.

Methods: The authors analyzed Centers for Medicare & Medicaid Services Medicare Provider Utilization and Payment files (2016-2021) from 6 specialty groups using corresponding Healthcare Common Procedure Coding System codes to derive trends in the percentage of practitioners billing any ACP visit. Wilcoxon tests were conducted to compare the average number of visits by metropolitan status.

Results: The percentage of practitioners billing ACP visits tripled from 1.76% in 2016 to 4.56% in 2021, with the highest percentage among hospice and palliative medicine practitioners (36.94%) in 2021. ACP service volume was similar by metropolitan status for hospice and palliative medicine, but it was higher in nonmetropolitan regions for cancer-related specialties, non-cancer terminal disease specialties, and primary and geriatrics care.

Discussion: This nationwide analysis showed low adoption of ACP billing by 2021, and it varied widely across specialties. This may reflect practical challenges of ACP related to comfort level with ACP discussion and documentation burden among the professional communities.

Conclusion: Despite an overall increase in the proportion of physicians billing ACP codes from 2016 to 2021, adoption remained low. Efforts are needed to address barriers to ACP and provide goal-concordant care to patients.

Introduction: The risk and benefit for patients on dialysis receiving anticoagulation (AC) therapy have not been clearly established. This study aimed to compare the rates of clinically significant thrombotic and bleeding events in patients on dialysis.

Methods: This is a retrospective cohort study conducted using Kaiser Permanente Northern California's electronic medical record database from 2013 to 2021. Patients over 18 years old on dialysis who were prescribed warfarin or apixaban were included. Patients with mechanical valves were excluded. The outcomes were analyzed using Mann-Whitney tests for continuous variables, χ² tests for categorical variables, and Kaplan-Meier method for time-to-event analysis.

Results: In the study period, 9832 patients were not on AC, and 2088 were taking apixaban or warfarin. The baseline demographics (age, Charlson Comorbidity Index, and sex) were comparable between apixaban and warfarin groups. Among the patients on anticoagulants, 181 were taking apixaban, while 1907 were taking only warfarin. The outcomes 1-3 years within the study period showed that the rates of clinically significant bleeding and thrombosis were comparable in both groups, with the exception of the rate of dialysis access thrombosis being lower in the apixaban group (7% vs 17%, P < .001).

Conclusion: In this diverse cohort, apixaban and warfarin showed no clinically significant differences in bleeding rates and lower rate of access thrombosis with apixaban. This study adds to the growing data of AC in the population with end-stage kidney disease, highlighting the need to enroll patients in an adequately powered randomized controlled trial to inform future practice.

Background: Approximately 15.5% of patients with psoriatic arthritis (PsA) are currently not diagnosed or experience delayed diagnosis with negative outcomes. This retrospective, cross-sectional study evaluated patients with psoriasis to determine what factors were associated with diagnosis of PsA.

Methods: A retrospective chart review was performed using electronic medical record from primary care clinics across the northeast Georgia region. The study population included patients with psoriasis evaluated in the clinic between January 1, 2017 and December 31, 2022. Patients with PsA were compared to those without PsA to assess for factors associated with the diagnosis of PsA.

Results: The probability of diagnosis of PsA increased with increasing number of clinic encounters (odds ratio [OR], 1.18; P < .05). Males (OR, 0.634; P < .001) were less likely to be diagnosed compared to females. Patients with Medicare (adjusted OR, 1.707; 95% confidence interval [CI], 1.027-2.837; P < .05) and commercial/private insurances (adjusted OR, 2.043; 95% CI, 1.28-3.258; P < .01) had a higher chance of being diagnosed in comparison to patients with Medicaid. Black patients were less likely to be diagnosed compared to White patients (OR, 0.231; P < .001). Hispanic patients were less likely to be diagnosed with PsA compared to patients who were not Hispanic (OR, 0.2; 95% CI, 0.07-0.51; P < .05).

Conclusions: The study highlighted potential factors associated with the diagnosis of PsA among patients with psoriasis. Sex, race, ethnicity, number of clinic encounters, and insurance type were all found to have associations with likelihood of receiving a PsA diagnosis. These findings were hypothesis-generating and suggest potential disparities in care, particularly for diverse populations, warranting further research.

Introduction: Simulation labs provide trainees the opportunity to practice procedures in a safe, controlled, nonjudgmental environment. It is unclear which teaching method leads to the highest levels of trainee skill competency when learning complex simulated procedures, such as lumbar puncture.

Methods: First-year medical students participated in a randomized controlled trial of an early-exposure simulated lumbar puncture (sLP) workshop. All were randomized to 1 of 2 teaching methods: 1) traditional "see one, do one" method or 2) Peyton's 4-step method. Students were taught how to perform an sLP based on the specific teaching method. Competence during sLP attempts was assessed using binary checklists, and student confidence was assessed using pre- and post-workshop surveys. Independent t tests and bivariate correlations were performed.

Results: Thirty-five first-year medical students participated in the sLP workshops. There were no statistically significant differences between the "see one, do one" method and Peyton's 4-step teaching method in checklist scores (P = .121, Cohen's d = 0.540) or change in confidence (P = .631, Cohen's d = 0.164). The difference in the speed of task completion favored Peyton's teaching method (P = .044, Cohen's d = -0.711). None of these outcomes demonstrated a significant correlation with each other within the cohort, the Peyton's subgroup, or the "see one, do one" subgroup.

Discussion: In this study, the traditional "see one, do one" model and Peyton's 4-step approach produced similar skill acquisition and confidence levels among medical students during an sLP workshop. Peyton's 4-step approach led to faster procedural completion times.

Conclusion: The current study adds to the body of literature that has failed to find a notable impact in skill competence outcomes when teaching complex procedures.

Background: Previous studies have demonstrated racial and ethnic disparities in the treatment and outcomes of patients with colorectal cancer. However, none of these studies has examined whether these disparities exist in a closed health care delivery system. The aim of this study was to identify racial and ethnic disparities in rates of diagnosis, treatment, and outcomes for patients with colorectal cancer with liver metastasis (CRLM) within the Kaiser Permanente Southern California system.

Methods: The authors performed a retrospective review of 110 adult patients with CRLM who underwent surgery on both sites with curative intent at any Kaiser Permanente Southern California facility between 2010 and 2020. The authors stratified patients by race and ethnicity as Asian/Asian American, Black, Hispanic, or White individuals.

Results: There was a statistically significant difference in race and ethnicity breakdown between all Kaiser Permanente members and the patients diagnosed with CRLM (P < .01), with a lower proportion of Hispanic patients diagnosed (P < .01). Between the surgical and nonsurgical cohorts, the statistically significant difference between race and ethnicity breakdown (P = .03) was due to Hispanic patients being more likely to undergo surgery (P = .01). Between racial and ethnic groups within the surgical cohort there was no significant difference in mean age at diagnosis (P = .63), time from diagnosis to surgical resection (P = .64), proportion of synchronous vs metachronous resections (P = .53), complication rate (P = .91), recurrence rate (P = .40), or 5- and 10-year survival (P = .5 and P = .9).

Conclusion: Within a closed health care delivery system, racial and ethnic disparities in treatment and outcomes were not observed for surgical patients with CRLM. However, disparities in diagnosis for the Hispanic population persist and should be addressed.

Introduction: The COVID-19 pandemic has highlighted olfactory dysfunction (OD) as a major and often persistent symptom in affected individuals. Thus, it is important to identify demographic and clinical factors contributing to OD among patients with COVID-19.

Methods: A case-control (1:3) study was performed in adult patients with COVID-19 diagnosis between July 2020 and June 2021. Cases had OD; controls did not have OD. OD was subclassified as acute smell loss (< 3 months), chronic smell loss (> 3 months), or altered sense of smell (eg, parosmia, phantosmia). Bivariate tests and multivariable logistic regression were performed for analysis.

Results: Of the 4220 patients that met criteria, 1055 (25%) had OD. Of those with OD, 650 (61.6%) had acute smell reduction, 350 (33.2%) had chronic smell reduction, and 245 (23.2%) had altered sense of smell. Older (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.79-0.89), male (OR, 0.62; 95% CI, 0.54-0.72), and Asian (OR 0.75; 95% CI, 0.59-0.95) patients were less likely to experience OD. Having seasonal allergies (OR, 1.44; 95% CI, 1.11-1.86) and being hospitalized (OR, 1.52; 95% CI, 1.14-2.02) increased the likelihood of OD development. Compared with acute loss, chronic smell loss was likelier in older, female, non-White, hospitalized, and cerebrovascular disease patients (P < .05).

Discussion: Understanding the course of post-COVID-19 OD is becoming increasingly important and may broaden these insights.

Conclusion: Being younger, female, and atopic conferred highest likelihood of OD development after COVID-19.

Introduction: Studies show that women are underrepresented in grand rounds across academic specialties. When women are invited as speakers, they are less likely to be introduced by their professional title compared to men. The purpose of this study was to determine what factors influenced the use of professional titles when introducing speakers at grand rounds.

Methods: This was a retrospective, observational study of grand rounds from October 2017 to March 2020 for the departments of internal medicine, neurology, OB/Gyn, pediatrics, psychiatry, and surgery at a large, academic medical center in the United States. Introductions were coded for the use of speakers' title, introducer and speaker gender, introducer and speaker training level, and speaker home institution.

Results: A total of 386 unique grand rounds and invited lectureships were reviewed for a total of 717 introductions. A greater number of men spoke at grand rounds across specialties and training (55%, χ² = 450.4, P < .01). Men represented a greater proportion of invited speakers (62%, χ² = 13.23, P < .01). Overall, men and women were introduced by their professional title with similar frequency (49% women). Invited and endowed speakers were more likely to be introduced by their professional title (odds ratio, 1.85; 95% confidence interval, 1.14-3.01; P = .01). Title use and representation varied by specialty.

Conclusions: Women remain underrepresented as grand rounds and invited speakers. Men and women were introduced by their professional title with similar frequency. Differences between departments suggested that introduction protocols increased title use, and consideration of gender balance could be used to improve gender representation.