Telemedicine Familiarity and Post-Disaster Utilization of Emergency and Hospital Services for Ambulatory Care Sensitive Conditions.

INTRODUCTION: In this study, we examined the association between telemedicine use before a disaster and utilization of emergency or hospital services for ambulatory care sensitive conditions post-disaster. METHODS: Difference-in-differences analyses were conducted in 2020‒2021 to assess pre- to post-fire changes in emergency or hospital utilization for 5 ambulatory care sensitive conditions: asthma, diabetes, hypertension, coronary artery disease, and heart failure across all Kaiser Permanente Santa Rosa patients (N=108,113) based on telemedicine utilization before the 2017 Tubbs wildfire. Inverse probability of treatment weighting was employed for cohort balancing across telemedicine familiar status. RESULTS: Utilization for any ambulatory care sensitive condition increased from 9.03% pre-fire to 9.45% post-fire across the full cohort. Telemedicine familiarity (ref: not familiar) was associated with decreased absolute risk in pre- to post-fire inpatient and emergency department utilization for 4 conditions: asthma (absolute risk= -1.59%, 95% CI= -2.02%, -1.16%), diabetes (absolute risk= -0.68%, 95% CI= -0.89%, -0.47%), hypertension (absolute risk= -2.07%, 95% CI= -2.44%, -1.71%), and coronary artery disease (absolute risk= -0.43%, 95% CI= -0.61%, -0.24%). Telemedicine familiarity was associated with decreased relative change in pre- to post-fire utilization for 5 conditions: asthma (RRR=0.70, 95% CI=0.64, 0.75), diabetes (RRR=0.54, 95% CI=0.47, 0.63), hypertension (RRR=0.57, 95% CI=0.52, 0.62), heart failure (RRR=0.64, 95% CI=0.50, 0.82), and coronary artery disease (RRR=0.56, 95% CI=0.47, 0.67). Similar results were seen among patients residing in evacuation zones. CONCLUSIONS: Telemedicine familiarity pre-fire was associated with decreased inpatient and emergency department utilization for certain ambulatory care sensitive conditions for 1-year post-fire. These results suggest a role for telemedicine in preventing unnecessary emergency and hospital utilization following disasters.

Crossed Screw Fixation Versus Dorsal Plating for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Cohort Study.

Multiple fixation techniques for first metatarsophalangeal joint arthrodesis have been described with an average fusion rate of 93.5%. This retrospective cohort study assesses the association between crossed screws (vs dorsal plating) and medical comorbidities and the outcome radiographic union. Bivariate tests of association and multivariable logistic regression were employed to assess differences across fixation type and outcomes. We identified 305 patients who underwent a first metatarsophalangeal joint arthrodesis during the study period. Crossed screw fixation was used in 158 (51.8%) patients while dorsal plating (tubular or anatomic locking plate) was used in 147 (48.2%) patients. Dorsal plating was utilized more often in patients with rheumatoid arthritis (p = .019) and history of smoking (p = .044). At 12 weeks post-operatively there were no significant differences in fusion rates between the two groups (crossed screw group = 95.3% vs dorsal plate group (referent) = 93.5%, Adjusted odds ratio (AOR) 1.39, 95% confidence interval [CI] 0.45-4.26). Not smoking was associated with a greater odds of fusion at 12 weeks (96.2% for nonsmokers vs 75.0% for smokers (referent), AOR 0.07, 95% CI 0.02-0.28). Lower body mass index was associated with a greater odds of fusion at 12 weeks (AOR 0.90, 95% CI 0.82-0.99). Surgeons allowed weightbearing earlier with dorsal plate fixation (2 weeks (interquartile range [IQR] 2.6) versus 5 weeks (IQR 2.6) for crossed screw fixation, p = .001). Patients with multiple medical comorbidities were more likely to require revision surgery than patients having 0-1 comorbidities (p < .05). Crossed screws can provide an inexpensive yet effective option for first metatarsophalangeal joint arthrodesis.

Attention-Deficit/Hyperactivity Disorder Medication Adherence in the Transition to Adulthood: Associated Adverse Outcomes for Females and Other Disparities.

PURPOSE: The purpose of this study was to assess the association between attention-deficit/hyperactivity disorder (ADHD) medication adherence and adverse health outcomes in older adolescents transitioning to adulthood. METHODS: In a cohort of 17-year-old adolescents with ADHD at Kaiser Permanente Northern California, we assessed medication adherence (medication possession ratio ≥70%) and any medication use and associations with adverse outcomes at 18 and 19 years of age. We conducted bivariate tests of association and multivariable logistic regression models. RESULTS: Adherence declined from 17 to 19 years of age (36.7%-19.1%, p < .001). Non-white race/ethnicity, lower estimated income, and male sex were associated with nonadherence. Model results show nonadherent females experienced several adverse outcomes: Adherence at 18 years of age (referent: nonadherence) was associated with lower odds of pregnancy (adjusted odds ratio [AOR]: .13, 95% confidence interval [CI]: .03-.54). Any use (referent: nonuse) at 18 years of age was associated with lower odds of sexually transmitted infections among females (AOR: .39, 95% CI: .19-.83), pregnancies (AOR: .26, 95% CI: .13-.50), emergency department visits (AOR: .69, 95% CI: .55-.85), and greater odds of injuries (AOR: 1.16, 95% CI: 1.02-1.32). Adherence at 19 years of age was associated with lower odds of pregnancy (AOR: .13, 95% CI: .02-.95). Any use at 19 years of age was associated with lower odds of injury in females (AOR: .77, 95% CI: .60-.99) pregnancy (AOR: .35, 95% CI: .16-.78), and, in both sexes, substance use (AOR: .71, 95% CI: .55-.92). CONCLUSIONS: Late adolescence is associated with decline in ADHD medication use and adherence. ADHD medication adherence and any ADHD medication use is associated with fewer adverse health outcomes, particularly in females.

Validation Study of Kids Hearing Game: A Self-Administered Pediatric Audiology Application.

OBJECTIVE: Conduct a comparison study between conventional audiometry and a tablet-based hearing screening application, Kids Hearing Game (KHG). If KHG measures hearing at levels comparable with conventional audiometry, it could be used to screen hearing in children. METHODS: Prospective equivalence study where measurements of pure tone hearing via KHG are compared with measurements of pure tone hearing via conventional audiometry in patients aged 6-11 years over a 4-month period. Eighteen patients completed the study. Results from 36 ears were included in the data for analysis. Decibel measurements from each frequency measured with KHG for each ear were compared with conventional audiometry. Mean measurements were calculated for each ear and frequency as well as mean differences in measurements at each ear and frequency. Tests of equivalence were used to assess mean within-subject differences in decibel measurements using a 10-dB zone of indifference. RESULTS: Mean decibel measurements using KHG for the right ear at 500, 1000, 2000, 4000, and 8000 Hz and the left ear at 1000, 2000, 4000, and 8000 Hz were found equivalent to conventional audiometry (p < 0.050). The mean decibel measurement using KHG for the left ear at 500 Hz was found not equivalent (p = 0.101). However, when left and right ear data were analyzed together, KHG was found to be equivalent to conventional audiometry across all frequencies. Eight patients having hearing loss greater than 25 dB on conventional audiometry were also identified by KHG to have hearing loss. CONCLUSION: KHG is comparable to conventional audiometry and may be used as a screening tool for children.

Evaluating the Impact of Mobile Phone Technology on Health Outcomes for Latinos with Type 2 Diabetes.

OBJECTIVES: To assess whether a Spanish-language text messaging program helps Latinos with diabetes better manage their disease. METHODS: Spanish-speaking Latinos with type 2 diabetes and HbA1c ≥ 8% (N = 38) were recruited January 1, 2016-May 31, 2016, at a large integrated healthcare delivery system. Participants received 1-3 Spanish-language text messages about diabetes self-care per day for 3 months with an optional 3-month extension. The Wilcoxon signed-rank test for paired data was used to compare pre-post intervention HbA1c. The Wilcoxon-Mann-Whitney nonparametric test was used to compare changes in HbA1c across groups. RESULTS: After 3 months, the median HbA1c reduction overall was 1.4 percentage points (IQR: 0.5-3.3, p < 0.01). Latinos having pre-intervention HbA1c > 10.0% had a greater reduction in median HbA1c (3.8, IQR: 0.5-5.3) compared with those having pre-intervention HbA1c ≤ 10.0% (0.9, IQR: 0.1-1.9, p < 0.05). This reduction in median HbA1c persisted after 6 months (1.3, IQR: 0.2-2.9, p < 0.01). CONCLUSION: A Spanish-language text messaging program was an effective way to improve glycemic control for Latinos with type 2 diabetes. POLICY IMPLICATIONS: Culturally and linguistically tailored text messaging programs for managing diabetes should be considered.

Preventing early-onset group B streptococcal sepsis: is there a role for rescreening near term?

Objective: The Centers for Disease Control and Prevention 2010 guidelines recommend group B streptococcus (GBS) screening at 35-37-week gestation to identify women with positive cultures who should receive intrapartum antibiotics and notes that the predictive value of a negative culture declines after 5 weeks. However, despite the lack of evidence, current guidelines do not recommend rescreening for those screened between 35 and 37 weeks. Our objectives were to investigate the rate of conversion from negative to positive results in women rescreened after appropriate screening at 35-37-week gestation and to examine the impact of rescreening on the use of intrapartum antibiotics. Additionally, we examined cases of early-onset group B streptococcal sepsis (early-onset GBS) in term neonates.Methods: We performed a retrospective cohort study of women delivering liveborn infants 1 January, 2010-31 December, 2014 in Kaiser Permanente Northern California. Data were obtained from database extraction and chart review.Results: We identified 135,585 women with GBS screening at 35-37-week gestation; 4511 (3.3%) women were rescreened. Of the 3860 (85.6%) initially screened negative, 218 (5.6%) converted to positive. Fewer women in the discordant negative to positive group received GBS prophylaxis prior to delivery compared with women with a single positive culture (65.9 versus 92.3%, p < .001). In the discordant negative to positive group, results were available at the time of delivery in 133 of 217 subjects (61.3%). There were 18 cases of early-onset GBS at term (0.10 per 1000 livebirths); the majority of cases occurred among women with negative screening.Conclusion: Our results provide support for the current CDC recommendation against rescreening near term for those women already screened at 35-37-week gestation given the low rate of conversion from negative to positive, and the extremely low rate of early-onset GBS in the screened population.

Association of NCCN-Recommended Posttreatment Surveillance With Outcomes in Patients With HPV-Associated Oropharyngeal Squamous Cell Carcinoma.

IMPORTANCE: National Comprehensive Cancer Network (NCCN) guidelines recommend routine clinical follow-up as posttreatment surveillance for patients with head and neck cancer (HNC). Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV-associated OPSCC) is a unique subset of HNC, associated with fewer recurrences and improved survival. The utility of this guideline in this patient population is unknown. OBJECTIVE: To determine adherence to the NCCN clinical follow-up guideline, frequency of recurrence detection method, classified as symptom-directed, physician-detected, or imaging-detected, and survival benefit associated with adherence to the NCCN guideline. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of patients with HPV-associated OPSCC diagnosed between January 1, 2011, and April 30, 2014, at a large integrated health care system. Multivariable analyses were conducted using the Cox proportional hazards regression model, with patient adherence to NCCN visit guidelines constructed as a time-dependent variable. All data analyses were complete on September 1, 2018. EXPOSURES: Posttreatment clinical and imaging surveillance. MAIN OUTCOMES AND MEASURES: Recurrence and overall survival. Secondary outcome was salvage therapy. RESULTS: Of the 233 study patients with HPV-associated OPSCC, the mean (SD) age at diagnosis was 60.5 (8.7) years; 201 (86.3%) were male, 189 (81.1%) were white, and 109 (46.8%) had a positive smoking history. Median follow-up time through recurrence or all-cause mortality was 4.5 years (interquartile range, 3.8-5.6). Patients demonstrated 83.0% (180 of 217) adherence to NCCN surveillance guidelines in year 1, 52.7% (106 of 201) in year 2, 73.4% (141 of 192) in year 3, 62.3% (96 of 154) in year 4, and 52.9% (45 of 85) in year 5. A total of 3358 clinical surveillance examinations were performed with 22 patients having recurrences. There were 10 symptom-directed, 1 physician-detected, and 11 imaging-detected recurrences. Of the symptom-directed recurrences, salvage therapy was attempted in 5; at the study end date, 1 was alive. Salvage neck dissection was attempted in the physician-detected recurrence; this patient subsequently died. All locoregional recurrences occurred within the first 2 years, and all salvageable recurrences within the first year. Adherence to NCCN guidelines was not protective against all-cause mortality in the multivariable Cox proportional hazards regression model (hazard ratio, 0.76; 95% CI, 0.28-2.05). CONCLUSIONS AND RELEVANCE: Among patients with HPV-associated OPSCC, clinical surveillance is of limited utility. Nearly all clinically detected recurrences were elicited by patient symptoms that prompted earlier presentation to the clinician. Adherence to the current schedule does not appear to confer survival advantage, and locoregional recurrences are almost never detected beyond 2 years. These findings support reduction of posttreatment clinical surveillance in this population.

Increased Risk of Late-onset Streptococcus pneumoniae Meningitis in Adults With Prior Head or Spine Surgeries.

In a case-control study within the Kaiser Permanente Northern California adult population, prior head or spine surgery was associated with increased Streptococcus pneumoniae meningitis outside of the postoperative period (no prior head or spine surgery; odds ratio, 6.0 [95% confidence interval, 1.9-18.6]). Among the cases, only 33.3% had received any prior pneumococcal vaccinations.

Posttreatment surveillance PET/CT for HPV-associated oropharyngeal cancer.

BACKGROUND: Surveillance positron emission tomography-computed tomography (PET/CT) is commonly used for treatment assessment of radiation therapy in head and neck cancer. However, human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) patients represent a unique subpopulation, for which the utility of surveillance PET/CT has not been well studied. METHODS: In this retrospective chart review comprising 233 HPV+OPSCC patients, we evaluated surveillance PET/CT for diagnostic accuracy, downstream clinical impact, and survival. RESULTS: Surveillance PET/CT demonstrated 100% negative predictive value and sensitivity, 59.9% specificity, and 13.4% positive predictive value. Surveillance PET/CT led to 90 imaging studies and 31 biopsies; 91.1% and 77.4% were negative for recurrence, respectively. Surveillance PET/CT led to meaningful salvage therapy in 1.6% of cases. PET/CT-detected recurrences did not have improved survival compared to clinically detected recurrences. CONCLUSION: For HPV+OPSCC patients, surveillance PET/CTs frequently lead to unnecessary testing and rarely to meaningful disease salvage. They have no demonstrated survival benefit and should be interpreted cautiously to prevent patient harm.

Healthcare Encounters for Pokémon Go: Risks and Benefits of Playing.

OBJECTIVE: Our aim was to quantify the health risks and benefits of Pokémon Go, an augmented reality game played on the mobile phone utilizing real-world locations. MATERIALS AND METHODS: Healthcare encounters containing references to Pokémon Go in Kaiser Permanente Northern California (KPNC) from July 5, 2016 to November 5, 2016 were reviewed. Subjects were classified according to the nature of the healthcare encounter subsequent to playing Pokémon Go: adverse event/injury, self-reported benefit, or incidental mention. Comparisons were made using the Wilcoxon-Mann-Whitney nonparametric test where variables were continuous and the chi-squared or Fisher's exact test where variables were binomial. RESULTS: Of 222 Pokémon Go players reporting an adverse event or benefit, 75 (33.8%) experienced adverse events and 147 (66.2%) reported benefits. Among our cohort, 114 subjects (54.0%) were obese, and 62 (27.9%) were diabetic or prediabetic. More subjects reporting benefits had an endocrine-related comorbidity than those reporting injuries (40.1% vs. 16.0%, P < 0.001). Median family income was higher in the benefit group than in the adverse event group ($83,846 vs. $70,378, P = 0.027). Of 75 subjects having adverse events, 8 (10.7%) had severe injuries, including fractures and head trauma, with 4 (5.3%) having inpatient stays. Most adverse events were musculoskeletal or skin injuries (n = 51, 68.0%). CONCLUSIONS: Injuries were similar to those seen with other light-to-moderate outdoor physical activities. Given KPNC's membership of 3.85 million, the number of severe injuries reported was low; this suggests that the game is safe to play. Pokémon Go may be reaching a population that requires increased physical activity.

Association Between Commonly Prescribed Opioids and Androgen Deficiency in Men: A Retrospective Cohort Analysis.

Objective: Androgen deficiency is common among men who use opioids daily for chronic pain. In previous studies, we found that long-acting opioids are associated with greater odds of androgen suppression than equipotent doses of short-acting opioids. Here we examined whether specific commonly prescribed opioids were associated with greater odds of androgen deficiency compared to hydrocodone. Design: Retrospective cohort study. Setting and Patients: Within a large, integrated health care delivery system, this study was comprised of men ages 18-80 on a stable regimen of a single opioid for chronic non-cancer pain. Methods: Morning serum total testosterone levels were measured in subjects prescribed one opioid for at least 90 days. The association between individual opioids and androgen deficiency was assessed with logistic regression, controlling for dose, obesity, age, hypertension, hyperlipidemia, and diabetes, using hydrocodone as a referent. Results: This study included 1,159 men. Men on fentanyl (odds ratio [OR] 25.7, 95% CI 2.82-234.97), methadone (OR 7.33, 95% CI 3.29-16.33), or oxycodone (OR 3.15, 95% CI 1.87-5.33) were more likely to be androgen deficient than men on hydrocodone. Increases in dose affected the odds of androgen deficiency differently for different opioids. Increased doses of hydrocodone (OR 1.18 per 10-mg increase in drug, 95% CI 1.09-1.28) and oxycodone (OR 1.01, 95% CI 1.00-1.02) were associated with increased odds of androgen deficiency. Conclusions: Our results suggest that certain opioids are associated with increased odds of androgen deficiency compared with hydrocodone. Transdermal fentanyl, methadone and oxycodone were associated with higher odds of androgen deficiency than hydrocodone.

Elucidating risk factors for androgen deficiency associated with daily opioid use.

BACKGROUND: Opioids can suppress testosterone in men, which can lead to extensive morbidity. Identifying risk factors for androgen deficiency in men using daily opioids could improve monitoring and safety. METHODS: In a retrospective cohort study, we used Kaiser Permanente Northern California databases to identify men on stable doses of opioids. These subjects had no diagnoses of cancer or endocrine disorders except treated primary hypothyroidism. Subjects were divided into those using long-acting opioids and short-acting opioids. Total testosterone was measured in blood drawn in the morning while the subjects were on their regular dose of opioid. The association between opioid duration of action and androgen deficiency, controlling for dose, body mass index, age, diabetes, hyperlipidemia, and hypertension, was assessed using logistic regression. RESULTS: The study included 1585 men. Men on long-acting opioids were more likely to be androgen deficient than men on short-acting opioids (57% vs 35%, P < 0.001; odds ratio [OR] 3.39; 95% confidence interval [CI], 2.39-4.77). As dose increased, the odds of androgen deficiency increased; however, dose was more strongly associated with androgen deficiency in men on short-acting opioids (OR 1.16; 95% CI, 1.09-1.23, for each 10-mg increase in dose) than in men on long-acting opioids (OR 1.01; 95% CI, 1.01-1.02). CONCLUSION: Use of long-acting opioids is a key risk factor in the development of androgen deficiency. Dose was significantly associated with androgen deficiency, but more so for men on short-acting than on long-acting opioids.

Skin disorders associated with obesity in children and adolescents: a population-based study.

Obesity in children is a major public health concern in the United States. The objectives of the current study were to determine the prevalence of various groups of cutaneous disorders in obese children and adolescents and to compare the use of dermatology services in obese subjects with that those with a normal body mass index (BMI). This was a retrospective, population-based study at the Kaiser Permanente Northern California Managed Healthcare System. The main outcome measures were the relative risk of cutaneous disorders associated with insulin resistance, androgen excess, bacterial infection, fungal infection, viral infection, inflammation, mechanical changes, and other skin conditions (hidradenitis, hyperhidrosis) in three weight groups (normal, overweight, obese) and the number of dermatology visits. A total of 248,775 subjects were included. Bivariate analyses showed a higher proportion of insulin resistance disorders, bacterial infection, fungal infection, inflammatory disorders, mechanical changes, and other skin conditions in obese subjects than in subjects with a normal BMI (p < 0.001). Disorders of androgen excess and viral infection were significantly less common in obese subjects (p < 0.001). Obese subjects had significantly lower odds of having at least one dermatology encounter than subjects with a normal BMI (odds ratio = 0.92, 95% confidence interval 0.88, 0.96, p = 0.003). Early onset obesity is associated with cutaneous disorders characterized by hyperproliferation, inflammation, bacterial and fungal infection, and mechanical changes but lower rates of disorders of androgen excess and viral infection. The use of dermatology services was not greater in obese patients. Heightened recognition and further analysis of adipose tissue as an endocrine organ that is capable of affecting the skin is warranted.

Hypogonadism in men with chronic pain linked to the use of long-acting rather than short-acting opioids.

AIM: There is a need to elucidate the variables associated with testosterone suppression among men on daily opioid therapy for chronic pain. OBJECTIVE: The objective of this study was to examine several variables related to opioid use including daily dose, duration of action (long acting vs. short acting), and specific opioid to ascertain specific influences on total serum testosterone levels in men with chronic pain who use opioids daily. SETTING: This is a retrospective cohort study of men within the Kaiser Permanente, Northern California (KPNC) health care system on some form of daily opioid use for chronic pain. PARTICIPANTS: Eighty-one men between the age of 26 and 79 years were seen in a chronic pain clinic between January 2009 and June 2010. All men were on stable dose of an opioid for at least 3 months, none with a previous diagnosis of hypogonadism. MAIN OUTCOME MEASURES: Total serum AM testosterone levels were measured at KPNC Regional Laboratory. RESULTS: Average total serum AM testosterone levels for this population showed 53% of all men receiving daily opioids were hypogonadal (AM total serum testosterone <250 ng/dL). In men receiving long-acting opioids, 74% (34/46) were hypogonadal compared with 34% (12/35) in men using short-acting opioids (hydrocodone or oxycodone) exclusively [AM total testosterone: median, 126 ng/dL; mean, 169 ng/dL (SD, 128 ng/dL) vs. median, 283 ng/dL; mean, 315 ng/dL (SD, 142 ng/dL); P<0.001]. After controlling for daily dosage and body mass index, men on long-acting opioids had 4.78 times greater odds of becoming hypogonadal than did men on short-acting opioids [95% confidence interval (CI), 1.51-15.07; P=0.008]. Body mass index was also significantly associated with hypogonadism (odds ratio, 1.13; 95% CI, 1.03-1.24; P=0.006), whereas daily dose was not (odds ratio, 1.02; 95% CI, 0.99-1.05; P=0.29). CONCLUSIONS: Among a contemporary sample of men receiving chronic daily opioids, we found a high prevalence of hypogonadism associated with duration of action, but not with total daily dose of the opioid.

Perinatal substance abuse intervention in obstetric clinics decreases adverse neonatal outcomes.

OBJECTIVE: To evaluate the effect of Early Start, a managed care organization's obstetric clinic-based perinatal substance abuse treatment program, on neonatal outcomes. STUDY DESIGN: Study subjects were 6774 female Kaiser Permanente members who delivered babies between July 1, 1995 and June 30, 1998 and were screened by completing prenatal substance abuse screening questionnaires and urine toxicology screening tests. Four groups were compared: substance abusers screened, assessed, and treated by Early Start ("SAT," n=782); substance abusers screened and assessed by Early Start who had no follow-up treatment ("SA," n=348); substance abusers who were only screened ("S," n=262); and controls who screened negative ("C," n=5382). RESULTS: Infants of SAT women had assisted ventilation rates (1.5%) similar to control infants (1.4%), but lower than the SA (4.0%, p=0.01) and S groups (3.1%, p=0.12). Similar patterns were found for low birth weight and preterm delivery. CONCLUSION: Improved neonatal outcomes were found among babies whose mothers received substance abuse treatment integrated with prenatal care. The babies of SAT women did as well as control infants on rates of assisted ventilation, low birth weight, and preterm delivery. They had lower rates of these three neonatal outcomes than infants of either SA or S women.