Safety and Efficacy of Intramuscular Tixagevimab-Cilgavimab in Prevention of COVID-19 in Patients Who Are Immunocompromised.

INTRODUCTION: Patients who are immunocompromised face an increased chance of severe COVID-19 infection compared with patients who are immunocompetent. However, vaccine efficacy for COVID-19 appears to be lower in patients who are immunocompromised. Tixagevimab-cilgavimab are monoclonal antibodies designed to enhance immune defense against COVID-19. Nevertheless, the safety and efficacy of tixagevimab-cilgavimab specifically in patients who are immunocompromised remains unknown. METHODS: The authors conducted a retrospective case study of patients who were immunocompromised and received tixagevimab-cilgavimab between January 3, 2022 to July 31, 2022 at Kaiser Permanente Southern California. All patients were monitored for 180 days following tixagevimab-cilgavimab administration. Patients who were immunocompromised included those with solid tumors, hematologic malignancies, primary immunodeficiencies, recipients of solid organ or hematopoietic stem cell transplants, and patients undergoing treatment with immunosuppressive medications (eg, chemotherapy, high-dose corticosteroids, tumor necrosis factor blockers, and certain biologic agents). RESULTS: A total of 2352 patients who were immunocompromised were included in the study. Among them, 101 patients (4.3%) tested positive for COVID-19, and 13 patients (0.6%) required COVID-19-related hospital admissions. Notably, no deaths were reported within 180 days following tixagevimab-cilgavimab administration. Additionally, 4 patients (0.17%) sought same-day medical care after receiving tixagevimab-cilgavimab. Within 30 days, there were 39 non-COVID-19-related hospital admissions (1.7%) and within 7 days, 11 hospital admissions (0.5%) occurred after tixagevimab-cilgavimab administration. DISCUSSION: Tixagevimab-cilgavimab demonstrated a low incidence of COVID-19 and COVID-19-related hospital admissions in patients who were immunocompromised, with no reported mortality. Furthermore, there were no significant adverse effects associated with the use of these monoclonal antibodies. CONCLUSION: Tixagevimab-cilgavimab exhibited a low incidence of COVID-19 and adverse effects in patients who were immunocompromised.

Investigating Mortality Disparities Among Insured Patients With Colon Cancer Treated in an Integrated Health care System and Other Private Settings.

BACKGROUND: Lower socioeconomic status (SES) affects health care delivery and is associated with worse outcomes. Integrated healthcare systems (IHS) may help reduce barriers to health care and affect outcomes. Our aim was to compare outcomes of colon cancer cases diagnosed at the largest IHS in California, Kaiser Permanente Southern California (KPSC), to other insured patients (OI) to determine how SES influences mortality. METHODS: This retrospective cohort study included insured adults in southern California diagnosed with colon cancer between 2009 and 2014, using data from the California Cancer Registry, and followed through 2017. Main outcome was all-cause mortality. Person-year mortality rates were calculated for two groups, KPSC and OI. Multivariable hazard ratios were calculated for association between SES quintiles and mortality. RESULTS: Total of 15 923 patients were diagnosed with colon cancer, 4195 patients (26.3%) within KPSC and 11 728 patients (73.7%) in OI. The overall mortality rate per 1000 person-years (PY) was lower in KPSC [103.8/1000 PY (95% CI:98.5-109.3)] compared to OI [139.3/1000 PY (95% CI:135.2-143.4)]. Compared to the highest SES group, the lowest SES group did not experience higher mortality risk in the KPSC population, after adjusting for race/ethnicity and other factors (HR, 95% CI = 1.13, .93-1.38). However, in OI patients, lowest and lower-middle SES groups had higher mortality risk compared to the highest SES group (HR, 95% CI = 1.26, 1.13-1.40 and 1.28, 1.16-1.41, respectively). DISCUSSION: Lower SES was associated with higher mortality risk within the OI group; however, within KPSC no such association was observed. Care coordination in IHS settings mitigate SES-related mortality differences.

To scan or not to scan: Use of transient elastography in an integrated health system.

BACKGROUND: Non-invasive tests, such as Fibrosis-4 index and transient elastography (commonly FibroScan), are utilized in clinical pathways to risk stratify and diagnose non-alcoholic fatty liver disease (NAFLD). In 2018, a clinical decision support tool (CDST) was implemented to guide primary care providers (PCPs) on use of FibroScan for NAFLD. AIM: To analyze how this CDST impacted health care utilization and patient outcomes. METHODS: We performed a retrospective review of adults who had FibroScan for NAFLD indication from January 2015 to December 2017 (pre-CDST) or January 2018 to December 2020 (post-CDST). Outcomes included FibroScan result, laboratory tests, imaging studies, specialty referral, patient morbidity and mortality. RESULTS: We identified 958 patients who had FibroScan, 115 before and 843 after the CDST was implemented. The percentage of FibroScans ordered by PCPs increased from 33% to 67.1%. The percentage of patients diagnosed with early F1 fibrosis, on a scale from F0 to F4, increased from 7.8% to 14.2%. Those diagnosed with advanced F4 fibrosis decreased from 28.7% to 16.5%. There were fewer laboratory tests, imaging studies and biopsy after the CDST was implemented. Though there were more specialty referrals placed after the CDST was implemented, multivariate analysis revealed that healthcare utilization aligned with fibrosis score, whereby patients with more advanced disease had more referrals. Very few patients were hospitalized or died. CONCLUSION: This CDST empowered PCPs to diagnose and manage patients with NAFLD with appropriate allocation of care towards patients with more advanced disease.

The Impact of Primary Care Practitioner Intervention as an Adjunct to a Diabetes Case Management System.

Objective The objective of this study was to assess whether additional primary care practitioner (PCP) contacts beyond the intake visit are associated with reduced hemoglobin A1c in patients with type 2 diabetes actively engaged in the Kaiser Permanente case management system. Methods This retrospective cohort study using the Kaiser Permanente electronic health record explored the effect of enhanced PCP contact among adult patients with type 2 diabetes actively working with diabetes case managers (defined as ≥ 4 case manager contacts during the study period). Results A total of 837 patients met the inclusion and exclusion criteria. On average, patients with the highest PCP contact, < 7 contacts, had Ac levels 0.53 lower than those in the lowest PCP contact quartile, < 3 contacts (p = 0.0007). A1c decreased an average of 0.20 when the PCP contact quartile was one quartile higher (p = 0.0004). Holding the baseline A1c constant, the A1c decreased an average of 0.15 when the PCP contact quartile was one quartile higher (p = 0.0024). A1c change was significantly correlated with baseline A1c; A1c decreased by 0.64 more as the baseline A1c level increased by 1 (p < 0.0001). Additionally, the A1c level decreased by 0.02 more when patient age increased by 1 (p < 0.0001). Metformin use was associated with a decrease of A1c by 0.40 (p = 0.0057), whereas insulin use was associated with an increase of A1c by 0.29 (p = 0.0280). Conclusion In summary, a significant reduction was observed in A1c in patients with increased PCP contacts. This effect was seen in patients already receiving recommended case manager support.

Retreatment of Stress Urinary Incontinence After Midurethral Sling With Prior Urethral Bulking.

IMPORTANCE: There is limited current literature regarding the retreatment of stress urinary incontinence (SUI) after midurethral sling (MUS) placement with prior urethral bulking. OBJECTIVE: The objective was to evaluate the retreatment and perioperative complications of MUS placement with prior urethral bulking compared with MUS placement without prior urethral bulking. STUDY DESIGN: This was a retrospective cohort study of patients within the Southern California Permanente Medical Group who underwent MUS placement from January 2009 to December 2020. Patients who underwent prior urethral bulking were compared with a control group without prior urethral bulking in a 1:1 ratio matched by age and MUS procedure date. The primary outcome was the retreatment of SUI after MUS placement with prior urethral bulking. Secondary outcomes were perioperative complications. Regression models were used to evaluate associations between retreatment and perioperative complications while controlling for confounding variables. RESULTS: Eighty-five patients who underwent MUS placement with prior urethral bulking were identified and matched with 85 control patients who underwent MUS placement without prior urethral bulking. Patients who underwent MUS placement without prior urethral bulking were more likely to have concomitant surgery. Linear regression analysis controlling for the effect of concomitant surgery revealed no difference in estimated blood loss and operative time between the 2 groups. In logistic regression analysis, there was no difference in the retreatment rate and perioperative complications between groups. CONCLUSION: We found that the unique treatment combination of MUS placement with prior urethral bulking for recurrent SUI seems to have a similar retreatment rate and perioperative complications as MUS placement without prior urethral bulking.

Urgent and non-emergent telehealth care for seniors: Findings from a multi-site impact study.

INTRODUCTION: The global pandemic has raised awareness of the need for alternative ways to deliver care, notably telehealth. Prior to this study, research has been mixed on its effectiveness and impact on downstream utilization, especially for seniors. Our multi-institution study of more than 300,000 telehealth visits for seniors evaluates the clinical outcomes and healthcare utilization for urgent and non-emergent symptoms. METHODS: We conducted a retrospective cohort study from November 2015 to March 2019, leveraging different models of telehealth from three health systems, comparing them to in-person visits for urgent and non-emergent needs of seniors based on International Classification of Diseases, 10th edition diagnoses. The study population was adults aged 60 years or older who had access to telehealth and were affiliated with and resided in the geographic region of the healthcare organization providing telehealth. The primary outcomes of interest were visit resolution and episodes of care for those that required follow-up. RESULTS: In total, 313,516 telehealth visits were analysed across three healthcare organizations. Telehealth encounters were successful in resolving urgent and non-emergent needs in 84.0-86.7% of cases. When visits required follow-up, over 95% were resolved in less than three visits for both telehealth and in-person cohorts. DISCUSSION: While in-person visits have traditionally been the gold standard, our results suggest that when deployed within the confines of a patient's existing primary care and health system provider, telehealth can be an effective alternative to in-person care for urgent and non-emergent needs of seniors without increasing downstream utilization.

Disparities in melanoma-specific mortality by race/ethnicity, socioeconomic status, and health care systems.

BACKGROUND: Despite encouraging trends in survival, sociodemographic inequalities persist among patients with melanoma. OBJECTIVE: We sought to quantify the effect of race/ethnicity, socioeconomic status, and health care systems on melanoma-specific mortality within an insured population of patients. METHODS: Using a retrospective cohort study, we identified insured adults diagnosed with Stage I to IV melanoma from January 1, 2009, to December 31, 2014, followed through 2017, from the California Cancer Registry. We compared melanoma-specific mortality between insured patients diagnosed within the largest vertically integrated health care system in California, Kaiser Permanente Southern California, and insured patients with other private insurance (OPI). RESULTS: Our cohort included 14,614 adults diagnosed with melanoma. Multivariable analyses demonstrated that race/ethnicity was not associated with survival disparities, while socioeconomic status was a strong predictor of melanoma-specific mortality, particularly for those with OPI. For example, hazard ratios demonstrate that the poorest patients with OPI have a 70% increased risk of dying from their melanoma compared to their wealthiest counterparts, while the poorest patients in Kaiser Permanente Southern California have no increased risk. LIMITATIONS: Our main limitation includes inadequate data for certain racial/ethnic groups, such as Native Americans. CONCLUSIONS: Our findings underscore the persistence of socioeconomic disparities within an insured population, specifically among those in non-integrated health care systems.

Clinical Outcomes of Telehealth in Patients With Coronary Artery Disease and Heart Failure During the COVID-19 Pandemic.

The COVID-19 pandemic necessitated a rapid adoption of telehealth (TH); however, its safety in subspecialty clinical practice remains uncertain. To assess the clinical outcomes associated with TH use in patients with coronary artery disease and/or heart failure during the initial phase of the COVID-19 pandemic, eligible adult patients who saw cardiologists from March 1, 2020, to August 31, 2020 (TH period) were identified. Patients were divided into two 3-month subcohorts (TH1, TH2) and compared with corresponding 2019 prepandemic subcohorts. The primary outcome was cardiovascular (CV) events within 3 months after index visits. Secondary analysis was CV events in patients aged ≥75 years within 3-month follow-up associated with TH use. Multivariable logistic regression was used to evaluate the association between TH use and CV outcomes. The study cohort included 6,485 TH and 7,557 prepandemic patients. The mean age was 70 years, with 40% of patients aged ≥75 years and 35% women. TH visits accounted for 0% of visits during the prepandemic period, compared with 68% during the TH period. Telephone visits comprised ≥92% of all TH encounters. Compared with the prepandemic period, patients seen during the TH period had fewer overall CV events (adjusted odds ratio 0.78, 95% confidence interval 0.67 to 0.90). Patients aged ≥75 years had similar findings (adjusted odds ratio 0.70, 95% confidence interval 0.55 to 0.89). Additional analysis of CV outcome events within 6 months after index visits showed similar findings. In conclusion, TH largely by way of telephone encounters can be safely incorporated into the ambulatory cardiology practice regardless of age.

Comparison of safety and outcomes related to remdesivir treatment among dialysis patients hospitalized with COVID-19.

Background: Patients with end-stage kidney disease (ESKD) are highly susceptible to coronavirus disease 2019 (COVID-19) infection and its complications. Remdesivir has improved outcomes in COVID-19 patients but its use has been limited among ESKD patients due to insufficient data regarding safety outcomes. We sought to evaluate the safety of remdesivir among dialysis patients hospitalized with COVID-19. Methods: This retrospective cohort study was conducted among patients age ≥18 years on maintenance dialysis and hospitalized with COVID-19 between 1 May 2020 and 31 January 2021 within an integrated health system who were treated or not treated with remdesivir. The primary outcome was 30-day all-cause mortality. Secondary outcomes were intensive care unit (ICU) stay, and transaminitis (AST/ALT >5× normal). Pseudo-populations were created using inverse probability of treatment weights with propensity scoring to balance patient characteristics among the two groups. Multivariable Poisson regression with robust error was performed to estimate 30-day mortality risk ratio. Results: A total of 486 (407 hemodialysis and 79 peritoneal dialysis) patients were hospitalized with COVID-19, among which 112 patients (23%) were treated with remdesivir [median treatment four days (interquartile range 2-5)]. The 30-day mortality rate was 24.1% among remdesivir-treated and 27.8% among non-treated patients. The estimated 30-day mortality rate was 0.74 (95% confidence interval 0.52-1.05) among remdesivir treated compared with non-treated patients. Liver injury and ICU admission rates were 1.8% and 14.3% among remdesivir-treated patients compared with 2.4% and 16% among non-treated patients. Conclusion: Among dialysis patients hospitalized with COVID-19, remdesivir was not associated with higher rates of liver injury or ICU admissions, and demonstrated a trend toward lower 30-day mortality.

Real-world use patterns of angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) among patients with heart failure within a large integrated health system.

BACKGROUND: Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor (ARNI) that is now preferred in guidelines over angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for patients with heart failure with reduced ejection fraction (HFrEF). However, it has not been broadly adopted in clinical practice. OBJECTIVE: To characterize ARNI use within a large diverse real-world population and assess for any racial disparities. METHODS: We conducted a cross-sectional study within Kaiser Permanente Southern California. Adult patients with HFrEF who received ARNIs, ACEIs, or ARBs between January 1, 2014, and November 30, 2020, were identified. The prevalence of ARNI use among the cohort and patient characteristics by ARNIs vs ACEIs/ARBs use were described. Multivariable regression was performed to estimate odds ratios and 95% CIs of receiving ARNI by race and ethnicity. RESULTS: Among 12,250 patients with HFrEF receiving ACEIs, ARBs, or ARNIs, 556 (4.54%) patients received ARNIs. ARNI use among this cohort increased from 0.02% in 2015 to 7.48% in 2020. Patients receiving ARNIs were younger (aged 62 vs 69 years) and had a lower median ejection fraction (27% vs 32%) compared with patients receiving ACEIs/ARBs. They also had higher use of mineralocorticoid antagonists (24.1% vs 19.8%) and automatic implantable cardioverterdefibrillators (17.4% vs 13.3%). There were no significant differences in rate of ARNI use by race and ethnicity. CONCLUSIONS: Within a large diverse integrated health system in Southern California, the rate of ARNI use has risen over time. Patients given ARNIs were younger with fewer comorbidities, while having worse ejection fraction. Racial minorities were no less likely to receive ARNIs compared with White patients. DISCLOSURES: Dr Huang had stock ownership in Gilead and Pfizer. Dr Liang received support for article processing and medical writing.

Same day discharge after pediatric laparoscopic appendectomy in community hospitals.

INTRODUCTION: Same-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units. METHODS: Patients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units. RESULTS: There were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference. CONCLUSION: Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.

Antibiotic practice patterns with procalcitonin levels in patients with acute lower respiratory tract infection.

OBJECTIVES: Procalcitonin (PCT) testing is FDA approved to guide antibiotic therapy in patients with lower respiratory tract infection (LRTI). However, its utilization and impact on real-world antibiotic prescribing behavior are unknown. We investigated the rate of PCT testing to evaluate an association between initial PCT level and antibiotic prescription patterns for patients with suspected LRTI within a large integrated health system. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study (January 1, 2016, through December 31, 2017) was performed in patients 18 years and older who were hospitalized with LRTI and had a PCT measurement. Antibiotic changes were noted before and 36 hours after initial PCT results. Antibiotic concordance was determined using a PCT cutoff value of 0.25 mcg/L. Concordance was defined as (1) patients received antibiotics after a PCT of at least 0.25 mcg/L resulted or (2) antibiotics were withheld after a PCT less than 0.25 mcg/L resulted. RESULTS: PCT testing occurred in 18% of hospitalized patients with LRTI. Among 1606 patients, antibiotic concordance with PCT results was 55%. Among the discordant population, 77% of patients received antibiotics in the setting of a low PCT level compared with 23% who did not receive antibiotics at a high PCT level. There were no statistical differences between LRTI types between patients with PCT-discordant and PCT-concordant care. CONCLUSIONS: Within a real-world environment of patients hospitalized with LRTI, PCT testing was low and the PCT levels did not appear to influence antibiotic prescribing behavior. Our findings suggest that clinicians continue to prioritize clinical judgment over initial PCT levels when prescribing antibiotics for suspected LRTIs.

Parathyroidectomy for nephrolithiasis in primary hyperparathyroidism: Beneficial but not a panacea.

BACKGROUND: Nephrolithiasis is a classic indication for parathyroidectomy in primary hyperparathyroidism patients; however, the effects of parathyroidectomy on nephrolithiasis recurrence are not well studied. The aim was to determine effect of parathyroidectomy on time to first nephrolithiasis recurrence and recurrence rate per patient-years. METHODS: A retrospective cohort study of patients diagnosed with primary hyperparathyroidism and at least one episode of nephrolithiasis was performed. The patients were divided into observation, presurgery, and postsurgery groups. Endpoints were time to first recurrence of nephrolithiasis and average recurrence rate per patient-years. RESULTS: The cohort was comprised of 1,252 patients. In addition, 334 (27%) patients underwent parathyroidectomy and 918 (73%) were observed. The surgical and nonsurgical groups differed significantly in age, sex, Charlson, calcium, and primary hyperparathyroidism level. Overall recurrence rate was 31.3%. The 5-, 10-, and 15-year recurrence-free survival rates were 74.4%, 56.3%, 49.5%, respectively (presurgery), 82.4%, 70.9%, 62.8%, respectively (postsurgery; P < .0001), and 86.3%, 77.7%, and 70.6%, respectively (observation). The presurgery group had an increased risk of first recurrence compared with the observation group (hazard ratio 1.89; 95% confidence interval, 1.44-2.47). The average recurrence rates among all surgical patients who recurred were 1 event per 4.3 patient-years presurgery versus 1 event per 6.7 patient-years postsurgery (P = .0001). CONCLUSION: Recurrent nephrolithiasis is a significant problem in patients with primary hyperparathyroidism. Parathyroidectomy prolongs the time to first recurrence and decreases the number of re-recurrences over time but does not eliminate recurrences. Observation may also be a reasonable approach in selected patients.

Population-Based Incidence, Severity, and Risk Factors Associated with Treated Acute-Onset COVID-19 mRNA Vaccination-Associated Hypersensitivity Reactions.

BACKGROUND: COVID-19 mRNA vaccination-associated acute-onset hypersensitivity reactions have caused anxiety and may be contributing to vaccine hesitancy. OBJECTIVE: To determine the incidence, severity, and risk factors for treated acute-onset COVID-19 mRNA vaccination-associated hypersensitivity reactions in a well-characterized population. METHODS: All Kaiser Permanente Southern California (KPSC) members who received COVID-19 mRNA vaccinations between December 15, 2020, and March 11, 2021, at a KPSC facility were identified and characterized, along with all treated acute-onset vaccination-associated hypersensitivity events. RESULTS: We identified 391,123 unique vaccine recipients (59.18% female, age 64.19 ± 17.86 years); 215,156 received 2 doses (53.54% Moderna), 157,615 only a first dose (50.13% Moderna) (1961 [1.46%] >2 weeks late getting a second dose), and 18,352 (74.43% Moderna) only a second dose. Only 104 (0.028%) (85.58% female, age 53.18 ± 15.96 years) had treated first dose events, 68 (0.030%) Moderna. Only 32 (0.014%) (93.75% female, age 57.28 ± 17.09 years) had treated second dose events, 21 (0.016%) Moderna. Only 2 (0.00033%) vaccinations resulted in anaphylaxis. Only 27 (20.77%) of those with treated first dose reactions failed to get a second dose. Only 6 of 77 (7.8%) with first dose reactions also had second dose reactions. Individuals with treated events were more likely to be female (P < .0001), younger (P < .0001), and had more pre-existing drug "allergies" (2.11 ± 2.12 vs 1.02 ± 1.41 [P < .0001] for average recipients). CONCLUSIONS: Treated acute-onset hypersensitivity events were mostly benign, more common with first COVID-19 mRNA vaccine doses, more likely to occur in younger females with typical risk factors associated with multiple drug intolerance syndrome, and very unlikely to be primarily immunologically mediated.

Influence of health care systems on mortality in adult patients with cancer.

OBJECTIVES: We compared all-cause mortality in insured patients with cancer who were diagnosed in Kaiser Permanente Southern California (KPSC), the largest integrated health care delivery system in southern California, with that in patients diagnosed in hospitals that serve other private insurance (OPI) plans. STUDY DESIGN: Retrospective cohort study. METHODS: Using the California Cancer Registry, we conducted a cohort analysis of all insured adults diagnosed between 2009 and 2014 with 8 common cancers (breast, prostate, lung, colon, melanoma, endometrium, kidney, and bladder) and followed them through December 2017. The cohort comprised 164,197 patients with cancer. We calculated person-year mortality rates by health care system (KPSC and OPI), and we estimated adjusted HRs for the association between overall mortality and health care system using Cox proportional hazards models accounting for race/ethnicity, demographics, cancer site, tumor characteristics, payer, cancer treatments, and socioeconomic status. RESULTS: We observed 41,727 deaths during the 9 years of follow-up. We found that the patients diagnosed in KPSC had lower overall mortality rates than in the OPI group, a difference that also held within each age category, racial/ethnic group, and stage at diagnosis. In multivariable models adjusting for relevant covariates, African American/Black patients (adjusted HR, 1.14; 95% CI, 1.06-1.21) and Hispanic patients (adjusted HR, 1.23; 95% CI, 1.16-1.30) in the OPI group had dramatically higher mortality risks than those diagnosed in KPSC. CONCLUSIONS: Among insured patients with cancer in southern California, those diagnosed within KPSC had lower overall mortality compared with the OPI group. Furthermore, this protective effect was greatest for African American/Black patients and Hispanic patients.

Patterns of overall mortality by race/ethnicity and socioeconomic status in insured cancer patients in Southern California.

PURPOSE: We evaluated the influence of race/ethnicity and geocoded socioeconomic status (SES) on all-cause mortality in cancer patients with health insurance. METHODS: We identified adults diagnosed with eight common cancers from 2009 to 2014 from the California Cancer Registry and followed them through 2017 (8 years maximum). We calculated person-year mortality rates by race/ethnicity and SES. Adjusted hazard ratios for the association between overall mortality and race/ethnicity and SES were estimated using Cox proportional hazards models accounting for other demographics, stage at diagnosis, and cancer treatments. RESULTS: A total of 164,197 adults were diagnosed with cancer originating from breast, prostate, lung, colon, skin melanoma, uterus, kidney, and bladder. For all race/ethnic groups combined, the mortality rates from lowest to highest SES groups were 112.1/1000 PY (lowest); 100.2/1000 PY (lower-middle); 91.2/1000 PY (middle); 79.1/1000 PY (upper-middle); and 63.5/1000 PY (upper). These rates suggest that person with lowest SES have a markedly increased mortality risk after cancer diagnosis even if they have health insurance. In multivariable analyses, those in the lowest SES group had a 40-78% increased risk of all-cause mortality compared to those in the upper SES group across all race/ethnicities. For example, within African Americans, the adjusted mortality risk was up to 61% higher (HR 1.61, 95% CI 1.41-1.83) in the lowest SES group compared to the highest SES group. CONCLUSION: This study suggests disparities in overall mortality risk after cancer diagnoses persist even in a cohort with health insurance, and that SES is an important driver of this disparity.

WITHDRAWN: Urgent and non-emergent telehealth care for seniors: Findings from a multi-site impact study.

Ahead of Print article withdrawn by publisher.

Physician Compliance to Choosing Wisely® Initiative in Radiographic Imaging of Low Risk Prostate Cancer in an Integrated Health Care System.

INTRODUCTION: We evaluated the adherence of urologists within an integrated health care system to Choosing Wisely®, an initiative aimed at avoiding unnecessary medical tests. In urology, 2 of the guidelines state bone scans and pelvic computerized tomography scans are unnecessary in low risk prostate cancer. METHODS: We performed a retrospective study on patients diagnosed with low risk prostate cancer between January 1, 2010 and December 31, 2017 at Kaiser Permanente Southern California. All demographics and imaging data were obtained. Patients with symptoms concerning for metastatic disease or with other malignancies were excluded by chart review. Statistical analysis was employed to compare the use of bone scans and computerized tomography scans in this population before and after the Choosing Wisely guidelines were published. RESULTS: Of the 6,996 patients, 121 (1.7%) and 96 (1.4%) underwent a bone scan and computerized tomography scan, respectively. A Cochran-Armitage test showed no change after implementation of the statements. Logistic regression analysis revealed that for every point increase in prostate specific antigen, the odds ratio was 1.09 for ordering both a bone scan and computerized tomography scan. When compared to Whites, the odds ratio of having a bone scan and computerized tomography scan were 0.35 and 0.37 for Blacks, 0.30 and 0.38 for Hispanics, and 0.47 and 0.61 for Asians, respectively. CONCLUSIONS: Over the study period, there were low rates of inappropriate imaging for low risk prostate cancer. There was no change in trend after publication of the Choosing Wisely. Higher prostate specific antigen levels and White ethnicity were predictors for ordering inappropriate imaging.

Incidence of Nonalcoholic Fatty Liver Disease in Children: 2009-2018.

BACKGROUND AND OBJECTIVES: In 2007, the American Academy of Pediatrics recommended that children with obesity should be screened for nonalcoholic fatty liver disease (NAFLD). Population epidemiology reveals that NAFLD is common in children; however, little is known about rates of clinical diagnosis. In this study, we aim to determine screening practices, annual incidence, and clinical characteristics of NAFLD in children within an integrated community health system. METHODS: Using electronic health records, we identified patients newly diagnosed (aged 5-18) with NAFLD on the basis of diagnostic codes from the 9th and 10th revisions of the International Classification of Diseases. We calculated screening rates and annual incidence rates of NAFLD from January 1, 2009, to December 31, 2018. RESULTS: In this study, we evaluated 7 884 844 patient-years. Screening was performed in 54.0% of children with obesity and 24.0% of children with overweight. The results revealed 36 658 children aged 9 to 18 with overweight or obesity and alanine aminotransferase >30 U/L. Of these children, 12.3% received further workup for NAFLD. The incidence of an NAFLD diagnosis significantly increased over time, with 36.0 per 100 000 in 2009 and 58.2 per 100 000 in 2018 (P < .0001). CONCLUSIONS: Our study of a large integrated health care system in southern California revealed that the incidence of NAFLD in children is increasing, although many children may remain undiagnosed.