The Permanente journal最新文献

Introduction: Chagas disease (CD) is caused by the protozoan parasite Trypanosoma cruzi and can remain clinically silent for decades. The objectives of this study were to quantify the prevalence of CD within the membership of Kaiser Permanente Northern California, to describe the demographic and clinical characteristics of patients with CD, and to report their adverse cardiovascular outcomes.

Methods: In this cohort study from 2006 to 2022, the authors identified patients with CD by screening the electronic medical record for International Classification of Diseases, 9th Revision and 10th Revision codes. The authors obtained demographic, medical history, electrocardiographic, echocardiographic, and pharmacy data. Adverse outcomes, including all-cause mortality, heart failure hospitalization, and heart transplantation, were identified by database programming and confirmed by manual chart review.

Results: There were 53 cases of CD in total, and 75% of patients self-identified as Hispanic. The mean age was 49 years old, and 45% were female. Dyslipidemia (45%) and hypertension (32%) were common comorbidities. A total of 7 patients (13%) had a left ventricular ejection fraction < 45%. During the follow-up period, adverse outcomes included 4 cardiovascular deaths, 5 heart failure hospitalizations, and 4 heart transplantations. The prevalence of diagnosed CD in the Kaiser Permanente Northern California population has risen from 0.22 per 100,000 persons from 2006 to 2010 to 0.70 per 100,000 persons from 2018 to 2022.

Discussion: The prevalence of diagnosed CD in Kaiser Permanente Northern California increased during the study period, and patients with CD frequently had poor cardiovascular outcomes, likely due to the patients presenting with advanced disease.

Conclusion: Systematic screening and awareness are likely to facilitate early diagnosis and improve treatment to avoid chronic complications of CD.

Background: Premature coronary artery disease (premCAD) and its risk factors may not always be diagnosed or treated optimally.

Objective: This study reviewed a sample of patients with premCAD within an integrated health care system to identify opportunities for improved diagnosis and care.

Design: Retrospective chart review.

Participants: The authors reviewed a sample of 28 patients with acute myocardial infarction before age 50.

Key results: Several opportunities were found, including lack of documentation of family history of premCAD (only present in 5/28 [18%]); delays or failure to diagnose in electronic chart problem in patients with diabetes mellitus (3/15 [20%]); failure to diagnose obesity in patients with a body mass index > 30 (12/28 [43%]); and gaps in continuity of care in patients who were new members (3/28 [11%]). These findings led to several changes, including improved identification and monitoring of patients with possible diabetes mellitus and obesity; improved identification of patients with increased risk of premCAD; and improved identification of premCAD risk factors in newly enrolled members.

Conclusions: This study highlights the value of a systematic approach to identifying variability and in developing tailored strategies to improve the diagnosis and management of premCAD and reduce future incidence. This approach can be used in other settings and conditions to identify areas for system improvement.

Background: Posttraumatic stress disorder (PTSD) is often underdiagnosed based on medical records. This study aimed to estimate the prevalence and health care utilization of individuals with PTSD and other trauma-related disorders in a large, integrated health care system.

Methods: Adults (between the ages of 18 and 65) with Kaiser Permanente Northern California membership and ≥ 1 outpatient visit in 2022 were eligible. Unspecified/other specified trauma and stressor-related disorder, acute stress disorder, and PTSD were based on diagnosis codes from the International Classification of Diseases, 10th Revision, Clinical Modification. The Primary Care PTSD (PC-PTSD) Scale was used as a screening tool. Prevalence was assessed overall and among the subset of patients seen in primary care, psychiatry, and addiction medicine. To contextualize health care utilization, the authors compared patients with trauma-related disorders to those with major depressive disorder.

Results: Of the 2,128,670 eligible adults, the overall prevalence of trauma-related diagnoses and positive screening on PC-PTSD was 4.9% (103,947); 1.3% (n = 27,670) had PTSD, 1.9% (n = 41,205) had unspecified/other specified trauma and stressor-related disorder, 0.1% (n = 1818) had acute stress disorder, and 1.6% (n = 33,254) screened positive on PC-PTSD without a trauma-related International Classification of Diseases code. Prevalence of trauma-related diagnoses by department was 18.3% (n = 47,516) in psychiatry, 16.5% (n = 3816) in addiction medicine, and 3.4% (n = 67,469) in primary care. There were no clinically meaningful differences in health care utilization between those with trauma-related diagnoses compared with major depressive disorder.

Conclusion: Broadly defining trauma-related disorders and substantial symptoms may provide a more accurate representation of the actual prevalence of PTSD in a health care system. These data may help health care leaders plan treatment options for this diverse group of individuals.

Introduction: The Merit-Based Incentive Payment System (MIPS) was ostensibly designed to promote better care across participants. However, MIPS risks exacerbating disparities among participants with fewer resources to invest in performance metrics like care delivery improvements or quality reporting. Unfortunately, little is known about how group practice characteristics have impacted MIPS scores and associated reimbursement over time.

Methods: The analysis involved data from the MIPS Overall Clinician Performance Database, which included information about 2019 MIPS performance among all practices and clinicians. MIPS data were combined with other datasets to assess physician group practice characteristics. Additional practice- and area-level variables were obtained from the Dartmouth Atlas and the County Health Rankings file.

Results: In the adjusted analysis, 2 practice-level characteristics (location in urban areas and larger patient populations) and 2 community-level characteristics (some college education and health care spending) were positively associated with MIPS scores. In contrast, patient population case mix and the proportion of Medicare/Medicaid dual-eligible patients were negatively associated with MIPS scores at the practice level.

Discussion: The proportion of Medicare/Medicaid dual-eligible patients, but not the proportion of Black patients, was associated with lower MIPS scores. A number of other practice- and community-level characteristics were also associated with MIPS performance. These findings underscore the potential risk that MIPS may exacerbate health disparities by penalizing practices caring for lower-income populations adversely affected by social drivers of health.

Conclusion: To address health disparities in MIPS, policymakers could consider following precedent from other payment programs and account for practice factors when evaluating MIPS performance.

Introduction: Febrile neutropenia is a serious complication in pediatric oncology. Kaiser Permanente Northern California hospitals use varying fever thresholds for admission criteria: the Kaiser Permanente Oakland hospital employs a threshold of 101.5 °F, and Kaiser Permanente Roseville and Kaiser Permanente Santa Clara use lower thresholds. This study aims to assess the potential risks associated with adopting different fever thresholds, including bacteremia, pediatric intensive care unit (PICU) transfer, septic shock, and length of hospital stay.

Methods: This retrospective cohort study includes Kaiser Permanente Northern California members aged 1 to 18 years with an oncologic diagnosis admitted to 1 of 3 Kaiser Permanente Northern California hospitals with neutropenic fever between 2016 and 2022. Patients admitted with a fever ≥ 101.5 °F (high-temperature group) were compared to those admitted with a fever < 101.5 °F (low-temperature group).

Results: The study cohort included 177 patients with a mean age of 8.2 ± 5.4 years, 59.3% male. Of these patients, 70 (39.6%) were in the low-temperature group, and 107 (60.5%) were in the high-temperature group. Overall, 24 (13.6%) patients developed bacteremia, and 24 (13.6%) required PICU transfer. Comparisons between the low- and high-temperature groups showed no statistically significant differences in rates of bacteremia (8.6% vs 16.8%, P = .12), PICU transfer (12.9% vs 14.0%, P = .83), septic shock (2.9% vs 4.7%, P = .71), or length of hospital stay (4.5 [interquartile range 2.5-8.4] vs 4.2 [interquartile range 2.6-8.1] days, P = .98).

Discussion and conclusion: Future studies with larger sample sizes are needed to validate these findings. Similar studies evaluating outcomes based on admitting temperature can shed light on the most appropriate fever threshold for admission to optimize outcomes for pediatric oncology patients.

Background: Telehealth services have expanded in recent years, showing promising potential to improve health care access. This review examined the impact of telehealth on individuals of all ages living with chronic disabilities with a focus on cost, as well as other key outcomes such as time efficiency, clinical outcomes, and patient satisfaction.

Methods: PRISMA guidelines were followed to examine US-based studies between 2018 and 2024 across 4 databases using keywords related to cost, telehealth, and disability. Studies were screened using Covidence software. Two reviewers independently assessed studies for inclusion. Data was extracted using a standardized form and thematically analyzed.

Results: Out of 230 preliminary studies, 8 met the inclusion criteria. Telehealth interventions were found to be time and cost effective with comparable clinical outcomes and high patient satisfaction for individuals of all ages with disabilities. However, some challenges of integrating processes in emergency departments resulting in longer stays and implementation issues were noted.

Discussion: Although cost benefits were evident for patients, programs, and health systems, successful implementation depends on resolving challenges related to digital infrastructure, equitable access, and patient-practitioner rapport.

Conclusion: Telehealth represents a promising approach to improving health care access for individuals with disabilities, if implementation challenges are strategically addressed.