The Permanente journal最新文献

{"title":"Diversity in Combating Complex, Chronic, and Costly Conditions Using a Learning Health System Approach: A Scoping Review.","authors":"Rebekah A Davis, Kathryn Sine, Ella Burguera-Couce, Jabeen Ahmad, Brant J Oliver","doi":"10.7812/TPP/24.012","DOIUrl":"10.7812/TPP/24.012","url":null,"abstract":"<p><strong>Introduction: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Discussion: </strong>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.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"245-261"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404638/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141902943","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Trends in Substance Use Disorder-Related Emergency Department Visits in California: An Analysis of 46 Million Visits From 2006 to 2011.","authors":"Jordan Shin, Soheil Saadat, Shahram Lotfipour, Joseph Zakaria, Tim Bruckner, Bharath Chakravarthy","doi":"10.7812/TPP/23.181","DOIUrl":"10.7812/TPP/23.181","url":null,"abstract":"<p><strong>Introduction: </strong>To better understand the development of the growing opioid crisis in the early 21st century, the authors studied trends in substance use disorder among 46,132,211 emergency department (ED) visit discharges in California between 2006 and 2011.</p><p><strong>Methods: </strong>Utilizing the California State Emergency Department Database, the authors identified substance use based on International Classification of Diseases, Ninth Revision codes. Tabular and multivariable analysis methods were applied. ED visits were considered clustered at the level of patient.</p><p><strong>Results: </strong>The authors observed a notable increase in substance use prevalence from 7.32 ± 6.07 to 12.21 ± 9.35 per 1000 ED visits. Nonopioid substance use was more prevalent among individuals aged ≤ 50 years old. Opioid use disorder (OUD) was associated with a higher mortality rate in the ED. In 2011, OUD was significantly higher among American Indians visiting the ED. A multivariable analysis revealed that OUD was an independent predictor for increased ED visits after controlling for demographic factors.</p><p><strong>Discussion: </strong>Despite an overall decrease in mortality rate, opioid-related ED visits showed a higher mortality rate, underscoring the grave consequences of OUD. Nonopioid substance use was prevalent among younger age groups, suggesting a need for age-specific interventions. A major finding was the elevated OUD among American Indians, indicating persistent health disparities impacting this demographic. OUD was an independent risk factor for excess ED visits, which could strain health care systems. The authors suggest strategies like nonopioid pain management, community-level programs, and bridging ED with outpatient treatment facilities to mitigate the opioid crisis and ED overutilization.</p><p><strong>Conclusion: </strong>These findings advocate for tailored public health strategies, addressing the underlying disparities to combat the opioid epidemic effectively.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"69-75"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404660/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141727817","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Hybrid Markov-SPC Approach to Assess Cost Differences in Urgent Care Utilization Using Patient-Reported Data in Inflammatory Bowel Disease.","authors":"Brant J Oliver, Gil Y Melmed, Corey A Siegel, Alice M Kennedy, James Testaverde, Ridhima Oberai, S Alandra Weaver, Christopher Almario","doi":"10.7812/TPP/24.024","DOIUrl":"10.7812/TPP/24.024","url":null,"abstract":"<p><strong>Background: </strong>Cost is a key outcome in quality and value, but it is often difficult to estimate reliably and efficiently for use in real-time improvement efforts. We describe a method using patient-reported outcomes (PROs), Markov modeling, and statistical process control (SPC) analytics in a real-time cost-estimation prototype designed to assess cost differences between usual care and improvement conditions in a national multicenter improvement collaborative-the IBD Qorus Learning Health System (LHS).</p><p><strong>Methods: </strong>The IBD Qorus Learning Health System (LHS) collects PRO data, including emergency department utilization and hospitalizations from patients prior to their clinical visits. This data is aggregated monthly at center and collaborative levels, visualized using Statistical Process Control (SPC) analytics, and used to inform improvement efforts. A Markov model was developed by Almario et al to estimate annualized per patient cost differences between usual care (baseline) and improvement (intervention) time periods and then replicated at monthly intervals. We then applied moving average SPC analyses to visualize monthly iterative cost estimations and assess the variation and statistical reliability of these estimates over time.</p><p><strong>Results: </strong>We have developed a real-time Markov-informed SPC visualization prototype which uses PRO data to analyze and monitor monthly annualized per patient cost savings estimations over time for the IBD Qorus LHS. Validation of this prototype using claims data is currently underway.</p><p><strong>Conclusion: </strong>This new approach using PRO data and hybrid Markov-SPC analysis can analyze and visualize near real-time estimates of cost differences over time. Pending successful validation against a claims data standard, this approach could more comprehensively inform improvement, advocacy, and strategic planning efforts.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":"28 3","pages":"234-244"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404662/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142296128","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Thiazide Discontinuation in Chronic Kidney Disease Hypertension Management: A Retrospective Chart Review.","authors":"Kirsten Dalangin Vea, Leigh Anh Nguyen, Kristine McGill, Jong C Park, David Selevan","doi":"10.7812/TPP/23.143","DOIUrl":"10.7812/TPP/23.143","url":null,"abstract":"<p><strong>Introduction: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"37-45"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404643/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141564423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Establishing a Regional Health System and Community-Based Organization Social Care Coordination Network: An Application of Geospatial Analysis.","authors":"Stephanie L Fitzpatrick, Matthew P Banegas, David M Mosen, Jackson L Voelkel, Erin M Keast, Akiko Betcher, Catherine Potter","doi":"10.7812/TPP/24.052","DOIUrl":"10.7812/TPP/24.052","url":null,"abstract":"<p><strong>Introduction: </strong>Adverse social determinants of health have been shown to be associated with a greater chance of developing chronic conditions. Although there has been increased focus on screening for health-related social needs (HRSNs) in health care delivery systems, it is seldom examined if the provision of needed services to address HRSNs is sufficiently available in communities where patients reside.</p><p><strong>Methods: </strong>The authors used geospatial analysis to determine how well a newly formed health system and community-based organizations (CBOs) social care coordination network covered the areas in which a high number of patients experiencing HRSNs live. Geospatial clusters (hotspots) were constructed for Kaiser Permanente Northwest members experiencing any of the following 4 HRSNs: transportation needs, housing instability, food insecurity, or financial strain. Next, a geospatial polygon was calculated indicating whether a member could reach a social care provider within 30 minutes of travel time.</p><p><strong>Results: </strong>A total of 185,535 Kaiser Permanente Northwest members completed a HRSN screener between April 2022 and April 2023. Overall, the authors found that among Kaiser Permanente Northwest members experiencing any of the 4 HRSNs, 97% to 98% of them were within 30 minutes of a social care provider. A small percentage of members who lived greater than 30 minutes to a social care provider were primarily located in rural areas.</p><p><strong>Discussion and conclusion: </strong>This study demonstrates the importance of health system and community-based organization partnerships and investment in community resources to develop social care coordination networks, as well as how patient-level HRSN can be used to assess the coverage and representativeness of the network.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"157-162"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404631/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141989001","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Classification Accuracy and Description of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in an Integrated Health Care System, 2006-2017.","authors":"Elizabeth G Liles, Stephanie A Irving, Padma Koppolu, Bradley Crane, Allison L Naleway, Neon B Brooks, Julianne Gee, Elizabeth R Unger, Michelle L Henninger","doi":"10.7812/TPP/23.170","DOIUrl":"10.7812/TPP/23.170","url":null,"abstract":"<p><strong>Introduction: </strong>Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic illness characterized by marked functional limitations and fatigue. Electronic health records can be used to estimate incidence of ME/CFS but may have limitations.</p><p><strong>Methods: </strong>The authors used International Classification of Diseases (ICD) diagnosis codes to identify all presumptive cases of ME/CFS among 9- to 39-year-olds from 2006 to 2017. The authors randomly selected 200 cases for medical record review to classify cases as confirmed, probable, or possible, based on which and how many current clinical criteria they met, and to further characterize their illness. The authors calculated crude annual rates of ME/CFS coding stratified by age and sex using only those ICD codes that had identified confirmed, probable, or possible ME/CFS cases in the medical record review.</p><p><strong>Results: </strong>The authors identified 522 individuals with presumptive ME/CFS based on having ≥ 1 ICD codes for ME/CFS in their electronic medical record. Of the 200 cases selected, records were available and reviewed for 188. Thirty (15%) were confirmed or probable ME/CFS cases, 39 (19%) were possible cases, 119 (60%) were not cases, and 12 (6%) had no medical record available. Confirmed/probable cases commonly had chronic pain (80%) or anxiety/depression (70%), and only 13 (43%) had completed a sleep study. Overall, 37 per 100,000 had ICD codes that identified confirmed, probable, or possible ME/CFS. Rates increased between 2006 and 2017, with the largest absolute increase among those 30-39 years old.</p><p><strong>Conclusions: </strong>Using ICD diagnosis codes alone inaccurately estimates ME/CFS incidence.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"46-57"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404641/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141564386","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multidisciplinary Management of Pregnancy in Patients With Osteogenesis Imperfecta Type 3.","authors":"Ekta Partani, Megan L Stephenson","doi":"10.7812/TPP/23.168","DOIUrl":"10.7812/TPP/23.168","url":null,"abstract":"","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"190-193"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404651/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141564421","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparing Hospital Length of Stay Between Persons With LEP and English-Speaking Patients in a Large Rural Academic Medical Center.","authors":"Samuel B Verkhovsky, Lixi Kong, Brant J Oliver","doi":"10.7812/TPP/23.155","DOIUrl":"10.7812/TPP/23.155","url":null,"abstract":"<p><strong>Background: </strong>Patients with limited English proficiency that are hospitalized without regular access to professional medical interpreters have a longer length of stay (LOS).¹ The authors studied the difference in LOS between English-speaking patients and patients with limited English proficiency in New Hampshire's only academic trauma medical center. The authors also examined race, ethnicity, and distance of residence from hospital.</p><p><strong>Methods: </strong>Retrospective data were queried from EPIC, the electronic medical record system used by the authors. Queried data focused on inpatient hospitalizations between January 1, 2019, and December 31, 2021. Patient primary language was grouped into English, Spanish, and other non-English language.</p><p><strong>Results: </strong>Spanish-speaking patients live on average 39.6 miles farther from a hospital than English-speaking patients and have a 0.34 lower case mix index. After English, Spanish is the second-most frequently spoken language. Regression analyses found language to be a significant factor in LOS, LOS variance, and case mix index.</p><p><strong>Discussion: </strong>A 2.34-day longer LOS for Spanish-speaking patients demonstrates an important health care disparity warranting further attention.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"270-277"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404650/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141447175","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Alkaline Phosphatase > 2000 U/L in an Infant With Stool Changes: A Case Report.","authors":"Stephen Graber, Mary Hanna","doi":"10.7812/TPP/24.016","DOIUrl":"10.7812/TPP/24.016","url":null,"abstract":"<p><p>Transient hyperphosphatasemia (TH) is a benign condition observed among healthy infants and children < 5 years old. It is characterized by an elevation in serum alkaline phosphatase (ALP) in the absence of other signs of organ disease. Prognosis is excellent, and ALP levels stabalize within 4 months. The aim of this case report is to promote broader awareness of TH so further unnecessary workup is avoided. The patient was a 12-month-old girl who presented with pale stools, a single episode of bloody stool, and elevation (incidentally found) in her ALP of 2379 IU/L. A small anal fissure was present, and the remainder of her physical examination was typical. The differential diagnosis included biliary atresia, liver disease, bone disease, and TH. Further testing was typical and included complete blood count (CBC, consisting of hemoglobin, hematocrit, white blood cell count, and platelet count), comprehensive metabolic panel (CMP, consisting of glucose, creatinine, BUN, electrolytes, and liver function markers), calcium, phosphate, parathyroid hormone, gamma-glutamyl transferase, and 25-hydroxy vitamin D. Liver ultrasound was also typical without evidence of biliary atresia. The diagnosis of TH was made. The patient was monitored clinically. Repeat blood work was completed 2 months later, with ALP levels returning to the typical range. Overall, TH is a benign self-limiting condition that can be managed by observation and serial measurement of ALP without further unnecessary investigations.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"172-176"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404655/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141564385","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Differences in Physician Burnout by Specialty: A Cross-Sectional Survey.","authors":"Farhad Ghaseminejad, Kira E Rich, Debbie Rosenbaum, Emilia Rydz, Anita Palepu, Peter Dodek, Amy Salmon, Heather A Leitch, Andrea Townson, Diane Lacaille, Vishal P Varshney, Nadia A Khan","doi":"10.7812/TPP/24.040","DOIUrl":"10.7812/TPP/24.040","url":null,"abstract":"<p><strong>Background: </strong>The prevalence of physician burnout increased notably during the COVID-19 pandemic, but whether measures of burnout differed based on physician specialty is unknown. The authors sought to determine the prevalence of burnout, worklife conflict, and intention to quit among physicians from different specialties.</p><p><strong>Methods: </strong>This is a cross-sectional online survey of physicians working at 2 urban hospitals in Vancouver, Canada, from August to October 2021. Responses were categorized by specialty (including surgical and nonsurgical), and data about whether physicians provided frontline patient care during COVID-19 were also included. Physician burnout was measured using the Maslach Burnout Inventory.</p><p><strong>Results: </strong>The survey response rate was 42% (209/498). The overall prevalence of burnout was 69%. Burnout was not significantly different by specialty or between frontline COVID-19 specialties compared with other specialties. Physicians in surgical specialties were more likely to report work-life conflict than those in nonsurgical specialties (p = 0.012). Differences in intention to quit among specialties were not statistically significant.</p><p><strong>Conclusion: </strong>During the COVID-19 pandemic, physician burnout was high across physicians, without significant differences between specialties, highlighting the need to support all physicians.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"58-68"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404628/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141564418","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}