Beyond Screening: An Interim Report and Analysis of a Multimodal Initiative to Decrease Colon Cancer Mortality.

BACKGROUND: Colon cancer, a potentially preventable and curable cancer, remains one of the leading causes of cancer-related death in the United States. In 2010 the researchers undertook a multifaceted initiative to reduce colon cancer mortality rates by 50% over 10 years. METHODS: A baseline literature review of preventable causes of colon cancer mortality and review of 50 deaths from colon cancer in one institution identified a set of care process improvements that could be implemented to decrease colon cancer mortality. In 2017 a second mortality review identified a second set of care process improvements that were subsequently implemented. Compliance with these processes was monitored along with age and gender-adjusted mortality rates. RESULTS: Identified care process improvements included improving the follow-up of patients with rectal bleeding and presumed iron deficiency anemia and improving the reliability of postsurgical surveillance for cancer recurrence, decreasing elapsed time from surgery to chemotherapy, increasing surgical referrals for patients with advanced colon cancer, increasing the upper age limit and overall rate of colon cancer screening, increasing vitamin D and aspirin use, and monitoring and increasing the adenoma detection rate. Compliance with these processes improved for most measures, including screening (73.7% to 79.9%), adenoma detection rates on screening colonoscopy (30% to 36% for women and 42% to 49% for men), and chemotherapy within 35 days of surgery for colon cancer (39.0% to 51.9%). Age- and gender-adjusted mortality decreased from 13.8 per 100,000 in 2009-2011 to 10.5 per 100,000 in 2016-2018. CONCLUSIONS: This quality improvement program was feasible to implement, resulted in process improvements, and decreased colon cancer mortality over seven years.

Asthma population management: development and validation of a practical 3-level risk stratification scheme.

OBJECTIVE: To define and validate a practical risk stratification scheme based on administrative data for use in identifying patients at high, medium, and low risk of requiring emergency hospital care for asthma. STUDY DESIGN: Retrospective cohort. PATIENTS AND METHODS: Predictors in 1999 were evaluated in relation to 2000 asthma emergency hospital care (any asthma hospitalization or emergency department visit) in a training set (n = 8789, 2000 emergency hospital care = 5.5%) and a testing set (n = 6104, 2000 emergency hospital care = 7.9%). Logistic regression was used to assign risk points in the training set, and positive and negative predictive values, sensitivities, and specificities were calculated in the training and testing sets. RESULTS: High risk was defined as asthma emergency hospital care in the previous year or use of >14 beta-agonist canisters and oral corticosteroid use; medium risk was defined as no emergency hospital care but use of either >14 beta-agonist canisters or oral corticosteroids; and low risk was defined as none of the above. For the high-risk groups in the training and testing sets, positive predictive values were 12.9% and 22.0%, sensitivities were 24.8% and 25.4%, specificities were 90.3% and 92.0%, and negative predictive values were 95.4% and 93.2%, respectively. The medium-risk groups identified another 32.6% of patients in the training set and 28.3% in the testing set requiring subsequent asthma emergency hospital care. CONCLUSION: This simple risk stratification scheme is useful for identifying patients from administrative data who are at increased risk of experiencing emergency hospital care for asthma.

Risk factors for asthma hospitalizations in a managed care organization: development of a clinical prediction rule.

OBJECTIVE: To use a computerized administrative database to develop and validate a clinical prediction rule for the occurrence of asthma hospitalizations. STUDY DESIGN: Retrospective cohort. METHODS: Subjects included asthmatic patients ages 3 to 64 who were continuously enrolled in the Southern California Kaiser Permanente managed care organization in both 1998 and 1999. Data were based on linkage of a hospital discharge database, diagnosis and procedures database, membership database, and prescription database. The outcome was any 1999 hospitalization with a primary diagnosis of asthma. The outcome was evaluated and modeled separately for children (ages 3-17) and adults (ages 18-64). RESULTS: Univariate analyses showed that hospitalized children were younger than nonhospitalized children. Adults and children hospitalized in 1999 had lower mean household incomes, were more likely to have required an emergency department visit or hospitalization in 1998, used more beta-agonists and oral corticosteroids in 1998, and had more 1998 prescribers than nonhospitalized patients. In multivariable analysis, independent predictors of 1999 hospitalization in children included age and 1998 hospitalizations, beta-agonist dispensings, total anti-inflammatory dispensings, and number of prescribers. Among adults, 1998 hospitalizations and oral steroid dispensings as well as income were independent predictors of hospitalization in 1999. The prediction rules developed in this study identified the 11% to 13% of adults or children with an approximately 6-fold higher likelihood for being hospitalized in the following year. CONCLUSION: These models can be used to identify high-risk asthmatic patients in whom targeted intervention might reduce asthma morbidity and cost of care.