Reduced emergency department use among insured individuals receiving extended-release buprenorphine in a health system setting.

Introduction: Extended-release buprenorphine (XR-Bup) is associated with reduced opioid use and opioid negative urine drug screens. Little is known about its use in outpatient addiction care provided within health systems. Methods: Individuals prescribed XR-Bup were identified from electronic health records; chart abstraction was conducted. Primary outcome was all-cause emergency department (ED) use. Secondary outcomes included ED use or inpatient stays for mental health or substance use, ED use for any other cause, discontinuation reasons, and drug substitution. Statistical comparisons used nonparametric tests from related samples (McNemar's test and Wilcoxon matched pair tests) to test outcomes six months prior and 6 months following XR-Bup initiation. Results: 152 individuals had an XR-Bup order, 126 received >1 injection. Among those consistently insured 6 months prior to and following XR-Bup initiation (n=99), the mean number of injections following initiation was 3.95; one-third received 6 doses in the 6 months. The proportion of individuals using ED services for all causes declined (41% prior vs. 28% following XR-Bup initiation, p<.05); similar results were found for secondary ED use outcomes. The proportion of individuals requiring inpatient treatment for mental health or substance use also declined (46% vs. 16%, p<.01). Common reasons for discontinuing XR-Bup included losing insurance (21%) or cost (11%). The most common non-prescribed substances used during treatment were opioids (n=31) and THC (n=20). Conclusions: In this non-randomized retrospective observational study, use of XR-Bup was associated with reduced ED use 6 months following initiation. XR-Bup may help health systems reduce use of costly ED services.

Examining the Association Between Social Needs and Care Gap Closure Among Older Adults Receiving Dental Care.

Introduction: The authors of this study sought to (1) describe the prevalence of social needs and (2) determine whether social needs were associated with closure of care gaps among patients aged ≥65 years seeking dental care. Methods: In this retrospective cross-sectional study, the authors identified 754 Kaiser Permanente Northwest patients aged ≥65 years who completed an index dental visit; had at least 1 of 23 preventive care gaps (e.g., flu vaccination) or disease management care gaps (e.g., diabetes HbA1c screening test) documented in their medical record; and had completed a social needs assessment through survey evaluating financial strain, food insecurity, housing needs, social isolation, and transportation needs. The authors described the prevalence of social needs at the index visit and then used logistic regression to evaluate the association between the number of social needs (0, 1, ≥2) and closure of all care gaps over the following 60 days (yes versus no), adjusting for patient characteristics. Identification and closure of care gap were assessed through Kaiser Permanente Northwest's Panel Support Tool. Results: Approximately 28% of patients reported ≥1 social needs. The prevalence of social needs was as follows: social isolation, 13.7%; financial strain, 11.3%; food insecurity, 7.7%; transportation needs, 5.4%; and housing needs, 3.3%. Those with 1 social need were more likely to close care gaps than those with no social needs (OR=1.82, 95% CI=1.17, 2.85). No significant association was found with care gap closure among those with ≥2 versus zero social needs. Conclusions: The prevalence of social needs was nearly 30% among patients aged ≥65 years with dental and medical coverage. Patients with 1 social need were more likely than those with no social needs to close all care gaps after their visit.

Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?

Abstract Social needs, such as social isolation and food insecurity, are important individual-level social determinants of health, especially for adults ages 65 years and older. These needs may be associated with future health care utilization, but this research area has not been studied extensively. The objective of this study was to examine the independent association of 5 individual social needs with future (1) emergency department (ED) visits and (2) hospital admissions. This observational study included 9649 Kaiser Permanente Northwest (KPNW) Medicare members who completed the Medicare Total Health Assessment (MTHA) quality improvement survey between August 17, 2020 and January 31, 2022. The 5 social needs assessed by the MTHA, defined as binary measures (yes/no), included (1) financial strain, (2) food insecurity, (3) housing instability, (4) social isolation, and (5) transportation needs. ED utilization (yes/no) and hospitalization (yes/no), the current study outcome measures, were measured in the 12 months after MTHA assessment. In multivariable analyses, 3 of the 5 social needs were significantly associated with higher ED utilization: financial strain (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.11-1.76, P < 0.05), housing instability (OR = 1.43, 95% CI = 1.02-1.99, P < 0.05), and social isolation (OR = 1.19, 95% CI = 1.05-1.34, P < 0.05), and 1, financial strain, was significantly associated with hospital admissions (OR = 1.66, 95% CI = 1.23-2.23, P < 0.05). The study results identified which social needs are most strongly associated with future ED utilization and hospital admissions. Further research is needed to better understand whether addressing social needs is associated with improved patient-level health outcomes over time.

Risk management actions following genetic testing in the Cancer Health Assessments Reaching Many (CHARM) Study: A prospective cohort study.

BACKGROUND: Genetic testing can identify cancer risk early, enabling prevention and early detection. We describe use of risk management interventions following genetic testing in the Cancer Health Assessment Reaching Many (CHARM) study. CHARM assessed risk and provided genetic testing to low income, low literacy, and other underserved populations that historically face barriers to accessing cancer genetic services. METHODS: CHARM was implemented in Kaiser Permanente Northwest (KPNW) and Denver Health (DH) between 2018 and 2020. We identified post-testing screening (mammography, breast MRI, colonoscopy) and surgical (mastectomy, oophorectomy) procedures using electronic health records. We examined utilization in participants who did and did not receive actionable risk management recommendations from study genetic counselors following national guidelines. RESULTS: CHARM participants were followed for an average of 15.4 months (range: 0.4-27.8 months) after results disclosure. Less than 2% (11/680) received actionable risk management recommendations (i.e., could be completed in the initial years following testing) based on their test result. Among those who received actionable recommendations, risk management utilization was moderate (54.5%, 6/11 completed any procedure) and varied by procedure (mammogram: 0/3; MRI: 2/4; colonoscopy: 4/5; mastectomy: 1/5; oophorectomy: 0/3). Cancer screening and surgery procedures were rare in participants without actionable recommendations. CONCLUSION: Though the number of participants who received actionable risk management recommendations was small, our results suggest that implementing CHARM's risk assessment and testing model increased access to evidence-based genetic services and provided opportunities for patients to engage in recommended preventive care, without encouraging risk management overuse.

Longitudinal adherence to breast cancer surveillance following cancer genetic testing in an integrated health care system.

PURPOSE: Screening with mammography and breast magnetic resonance imaging (MRI) is an important risk management strategy for individuals with inherited pathogenic variants (PVs) in genes associated with increased breast cancer risk. We describe longitudinal screening adherence in individuals who underwent cancer genetic testing as part of usual care in a vertically integrated health system. METHODS: We determined the proportion time covered (PTC) by annual mammography and breast MRI for individuals with PVs in TP53, BRCA1, BRCA2, PALB2, NF1, CHEK2, and ATM. We determined time covered by biennial mammography beginning at age 50 years for individuals who received negative results, uncertain results, or with PVs in genes without specific breast cancer screening recommendations. RESULTS: One hundred and forty individuals had PVs in TP53, BRCA1, BRCA2, PALB2, NF1, CHEK2, or ATM. Among these individuals, average PTC was 48% (range 0-99%) for annual screening mammography and 34% (range 0-100%) for annual breast MRI. Average PTC was highest for individuals with PVs in CHEK2 (N = 14) and lowest for individuals with PVs in TP53 (N = 3). Average PTC for biennial mammography (N = 1,027) was 49% (0-100%). CONCLUSION: Longitudinal screening adherence in individuals with PVs in breast cancer associated genes, as measured by the proportion of time covered, is low; adherence to annual breast MRI falls below that of annual mammography. Additional research should examine screening behavior in individuals with PVs in breast cancer associated genes with a goal of developing interventions to improve adherence to recommended risk management.

The Association Between Social Isolation and Memory Loss Among Older Adults.

INTRODUCTION: Social isolation among older individuals is associated with poor health outcomes. However, less is known about the association between social isolation and memory loss, specifically among Medicare enrollees in large, integrated health care systems. METHODS: We conducted a cross-sectional, observational study. From a cohort of 46,240 Medicare members aged 65 years and older at Kaiser Permanente Northwest (KPNW) who completed a health questionnaire, we compared self-reported memory loss of those who reported feeling lonely or socially isolated and those who did not, adjusting for demographic factors, health conditions, and use of health services in the 12 months before the survey. RESULTS: Patients who reported sometimes experiencing social isolation were more likely than those who rarely or never experienced social isolation to report memory loss in both unadjusted (odds ratio [ORsometimes]: 2.56, 95% CI= 2.42-2.70, P = 0.0076) and adjusted (ORsometimes: 2.45, 95% CI= 2.32-2.60, P = 0.0298) logistic regression models. Similarly, those who reported social isolation often or always were more likely to report memory loss than those who reported rarely or never experiencing isolation in both unadjusted (ORoften/always: 5.50, 95% CI = 5.06-5.99, P < 0.0001) and adjusted logistic regression models (ORoften/always: 5.20, 95% CI = 4.75-5.68, P < 0.0001). CONCLUSIONS: The strong association between social isolation and memory loss suggests the need to develop interventions to reduce isolation and to evaluate their effects on potential future memory loss.

Identifying appropriate comparison groups for health system interventions in the COVID-19 era.

Introduction: COVID-19 has created additional challenges for the analysis of non-randomized interventions in health system settings. Our objective is to evaluate these challenges and identify lessons learned from the analysis of a medically tailored meals (MTM) intervention at Kaiser Permanente Northwest (KPNW) that began in April 2020. Methods: We identified both a historical and concurrent comparison group. The historical comparison group included patients living in the same area as the MTM recipients prior to COVID-19. The concurrent comparison group included patients admitted to contracted non-KPNW hospitals or admitted to a KPNW facility and living outside the service area for the intervention but otherwise eligible. We used two alternative propensity score methods in response to the loss of sample size with exact matching to evaluate the intervention. Results: We identified 452 patients who received the intervention, 3873 patients in the historical comparison group, and 5333 in the concurrent comparison group. We were able to mostly achieve balance on observable characteristics for the intervention and the two comparison groups. Conclusions: Lessons learned included: (a) The use of two different comparison groups helped to triangulate results; (b) the meaning of utilization measures changed pre- and post-COVID-19; and (c) that balance on observable characteristics can be achieved, especially when the comparison groups are meaningfully larger than the intervention group. These findings may inform the design for future evaluations of interventions during COVID-19.

An accessible, relational, inclusive, and actionable (ARIA) model of genetic counseling compared with usual care: Results of a randomized controlled trial.

PURPOSE: Effective approaches to communicate genomic information are needed to ensure equitable care. In a randomized controlled superiority trial, we tested a novel practice model that aims to make genetic counseling inclusive, by making the communication accessible, relational, and actionable (ARIA). METHODS: In total, 696 English- and Spanish-speaking patients aged 18 to 49 years, enriched for individuals from historically underserved backgrounds, were randomized in 1:1 ratio to ARIA or usual care. Primary outcomes were accuracy of recall, communication satisfaction, and perceived understanding. In total, 33 participants completed qualitative interviews. RESULTS: Recall and understanding were high for all participants. ARIA participants scored higher on the relationship scale of communication satisfaction (mean difference = 0.09, 95% CI = <0.01 to 0.17). Moderator analyses of communication satisfaction showed that those with lower health literacy reported less communication difficulty in ARIA and those using medical interpreters reported greater communication ease in ARIA. No significant difference was found on other primary and secondary outcomes. Qualitative data enhanced understanding of how and why ARIA can be effective. CONCLUSION: This study provides evidence that a genetic counseling intervention that focuses on specific communication skills to enhance relationship-building, patient engagement, and comprehension can be effective with all patients and may be especially valuable for patients of lower health literacy and Spanish-speakers who use a medical interpreter.

The Association Between Social Isolation and Memory Loss Among Older Adults.

INTRODUCTION: Social isolation among older individuals is associated with poor health outcomes. However, less is known about the association between social isolation and memory loss, specifically among Medicare enrollees in large, integrated health care systems. METHODS: We conducted a cross-sectional, observational study. From a cohort of 46,240 Medicare members aged 65 years and older at Kaiser Permanente Northwest (KPNW) who completed a health questionnaire, we compared self-reported memory loss of those who reported feeling lonely or socially isolated and those who did not, adjusting for demographic factors, health conditions, and use of health services in the 12 months before the survey. RESULTS: Patients who reported sometimes experiencing social isolation were more likely than those who rarely or never experienced social isolation to report memory loss in both unadjusted (odds ratio [ORsometimes]: 2.56, 95% CI= 2.42-2.70, P = 0.0076) and adjusted (ORsometimes: 2.45, 95% CI= 2.32-2.60, P = .0298) logistic regression models. Similarly, those who reported social isolation often or always were more likely to report memory loss than those who reported rarely or never experiencing isolation in both unadjusted (ORoften/always: 5.50, 95% CI = 5.06-5.99, P < .0001) and adjusted logistic regression models (ORoften/always: 5.20, 95% CI = 4.75-5.68, P < .0001). CONCLUSIONS: The strong association between social isolation and memory loss suggest the need to develop interventions to reduce isolation and to evaluate their effects on potential future memory loss.

Risk-reducing surgery in unaffected individuals receiving cancer genetic testing in an integrated health care system.

BACKGROUND: Germline genetic testing enables primary cancer prevention, including through prophylactic surgery. We examined risk-reducing surgeries in unaffected individuals tested for hereditary cancer susceptibly between 2010 and 2018 in the Kaiser Permanente Northwest health system. METHODS: We used an internal genetic testing database to create a cohort of individuals who received tests including one or more high-penetrance hereditary cancer susceptibility gene. We then identified, after testing, bilateral mastectomy, bilateral salpingo-oophorectomy (BSO), and total hysterectomy procedures in electronic health record and claims data through 2019. We describe surgery utilization by genetic test results and National Comprehensive Cancer Network (NCCN) guidelines. RESULTS: The cohort included 1020 individuals, 16% with pathogenic/likely pathogenic (P/LP) variants in one or more of the following genes: BRCA1, BRCA2, CHEK2, APC, MUTYH, ATM, MSH2, PALB2, BRIP1, MLH1, MSH6, EPCAM, FLCN, RAD51C, RAD51D, or TP53. Among individuals with P/LP variants making them candidates for mastectomy, BSO, or hysterectomy per NCCN guidelines, 34% (33/97), 24% (23/94), and 8% (1/12), respectively, underwent surgery during follow-up. Fifty-three percent (18/37) of hysterectomies were among APC, BRCA1, and BRCA2 P/LP variant heterozygotes, typically concurrent with BSO. Three individuals with variants of uncertain significance (only) and 22 with negative results had prophylactic surgery after genetic testing. CONCLUSIONS: Uptake of risk-reducing surgery following usual care genetic testing appears to be lower than in studies that actively recruit high-risk patients and provide testing and follow-up care in specialized settings. Factors in addition to genetic test results and NCCN guidelines motivate prophylactic surgery use and deserve further study.

The Cancer Financial Experience (CAFÉ) study: randomized controlled trial of a financial navigation intervention to address cancer-related financial hardship.

BACKGROUND: There is an urgent need for evidence on how interventions can prevent or mitigate cancer-related financial hardship. Our objectives are to compare self-reported financial hardship, quality of life, and health services use between patients receiving a financial navigation intervention versus a comparison group at 12 months follow-up, and to assess patient-level factors associated with dose received of a financial navigation intervention. METHODS: The Cancer Financial Experience (CAFÉ) study is a multi-site randomized controlled trial (RCT) with individual-level randomization. Participants will be offered either brief (one financial navigation cycle, Arm 2) or extended (three financial navigation cycles, Arm 3) financial navigation. The intervention period for both Arms 2 and 3 is 6 months. The comparison group (Arm 1) will receive enhanced usual care. The setting for the CAFÉ study is the medical oncology and radiation oncology clinics at two integrated health systems in the Pacific Northwest. Inclusion criteria includes age 18 or older with a recent cancer diagnosis and visit to a study clinic as identified through administrative data. Outcomes will be assessed at 12-month follow-up. Primary outcomes are self-reported financial distress and health-related quality of life. Secondary outcomes are delayed or foregone care; receipt of medical financial assistance; and account delinquency. A mixed methods exploratory analysis will investigate factors associated with total intervention dose received. DISCUSSION: The CAFÉ study will provide much-needed early trial evidence on the impact of financial navigation in reducing cancer-related financial hardship. It is theory-informed, clinic-based, aligned with patient preferences, and has been developed following preliminary qualitative studies and stakeholder input. By design, it will provide prospective evidence on the potential benefits of financial navigation on patient-relevant cancer outcomes. The CAFÉ trial's strengths include its broad inclusion criteria, its equity-focused sampling plan, its novel intervention developed in partnership with clinical and operations stakeholders, and mixed methods secondary analyses related to intervention dose offered and dose received. The resulting analytic dataset will allow for rich mixed methods analysis and provide critical information related to implementation of the intervention should it prove effective. TRIAL REGISTRATION: ClinicalTrials.gov NCT05018000 . August 23, 2021.

ORCA, a values-based decision aid for selecting additional findings from genomic sequencing in adults: Efficacy results from a randomized trial.

PURPOSE: Individuals having genomic sequencing can choose to be notified about pathogenic variants in genes unrelated to the testing indication. A decision aid can facilitate weighing one's values before making a choice about these additional results. METHODS: We conducted a randomized trial (N = 231) comparing informed values-choice congruence among adults at risk for a hereditary cancer syndrome who viewed either the Optional Results Choice Aid (ORCA) or web-based additional findings information alone. ORCA is values-focused with a low-literacy design. RESULTS: Individuals in both arms had informed values-choice congruence (75% and 73% in the decision aid and web-based groups, respectively; odds ratio [OR] = 1.10, 95% CI = 0.58-2.08). Most participants had adequate knowledge (79% and 76% in the decision aid and web-based groups, respectively; OR = 1.20, 95% CI = 0.61-2.34), with no significant difference between groups. Most had information-seeking values (97% and 98% in the decision aid and web-based groups, respectively; OR = 0.59, 95% CI = 0.10-3.61) and chose to receive additional findings. CONCLUSION: The ORCA decision aid did not significantly improve informed values-choice congruence over web-based information in this cohort of adults deciding about genomic results. Both web-based approaches may be effective for adults to decide about receiving medically actionable additional results.

Retrospective assessment of barriers and access to genetic services for hereditary cancer syndromes in an integrated health care delivery system.

BACKGROUND: A critical step in access to genetic testing for hereditary cancer syndromes is referral for genetic counseling to assess personal and family risk. Individuals meeting testing guidelines have the greatest need to be evaluated. However, referrals to genetics are underutilized in US patients with hereditary cancer syndromes, especially within traditionally underserved populations, including racial and ethnic minorities, low-income, and non-English speaking patients. METHODS: We studied existing processes for referral to genetic evaluation and testing for hereditary cancer risk to identify areas of potential improvement in delivering these services, especially for traditionally underserved patients. We conducted a retrospective review of 820 referrals to the Kaiser Permanente Northwest (KPNW) genetics department containing diagnosis codes for hereditary cancer risk. We classified referrals as high- or low-quality based on whether sufficient information was provided to determine if patients met national practice guidelines for testing. Through chart abstraction, we also assessed consistency with practice guidelines, whether the referral resulted in a visit to the genetics department for evaluation, and clinical characteristics of patients receiving genetic testing. RESULTS: Most referrals (n = 514, 63%) contained sufficient information to assess the appropriateness of referral; of those, 92% met practice guidelines for genetic testing. Half of referred patients (50%) were not offered genetic evaluation; only 31% received genetic testing. We identified several barriers to receiving genetic evaluation and testing, the biggest barrier being completion of a family history form sent to patients following the referral. Those with a referral consistent with testing guidelines, were more likely to receive genetic testing than those without (39% vs. 29%, respectively; p = 0.0058). Traditionally underserved patients were underrepresented in those receiving genetic evaluation and testing relative to the overall adult KPNW population. CONCLUSIONS: Process improvements are needed to increase access to genetic services to diagnose hereditary cancer syndromes prior to development of cancer.

Patterns of Medical Care Cost by Service Type for Patients With Recurrent and De Novo Advanced Cancer.

OBJECTIVES: There is limited knowledge about the cost patterns of patients who receive a diagnosis of de novo and recurrent advanced cancers in the United States. METHODS: Data on patients who received a diagnosis of de novo stage IV or recurrent breast, colorectal, or lung cancer between 2000 and 2012 from 3 integrated health systems were used to estimate average annual costs for total, ambulatory, inpatient, medication, and other services during (1) 12 months preceding de novo or recurrent diagnosis (preindex) and (2) diagnosis month through 11 months after (postindex), from the payer perspective. Generalized linear regression models estimated costs adjusting for patient and clinical factors. RESULTS: Patients who developed a recurrence <1 year after their initial cancer diagnosis had significantly higher total costs in the preindex period than those with recurrence ≥1 year after initial diagnosis and those with de novo stage IV disease across all cancers (all P < .05). Patients with de novo stage IV breast and colorectal cancer had significantly higher total costs in the postindex period than patients with cancer recurrent in <1 year and ≥1 year (all P < .05), respectively. Patients in de novo stage IV and those with recurrence in ≥1 year experienced significantly higher postindex costs than the preindex period (all P < .001). CONCLUSIONS: Our findings reveal distinct cost patterns between patients with de novo stage IV, recurrent <1-year, and recurrent ≥1-year cancer, suggesting unique care trajectories that may influence resource use and planning. Future cost studies among patients with advanced cancer should account for de novo versus recurrent diagnoses and timing of recurrence to obtain estimates that accurately reflect these care pattern complexities.

Using Real-world Data for Decision Support: Recommendations from a Primary Care Provider Survey.

INTRODUCTION: The use of data from wearable sensors, smartphones, and apps holds promise as a clinical decision-making tool in health and mental health in primary care medicine. The aim of this study was to determine provider perspectives about the utility of these data for building digitally based decision-making tools. METHODS: This mixed quantitative and qualitative cross-sectional survey of a convenience sample of primary-care clinicians at Kaiser Permanente Northwest was conducted between April and July 2019 online via Institute for Translational Health Sciences' Research Electronic Data Capture. Study outcomes were 1) attitudes toward digital data, 2) willingness to use digital data to support clinical decision making, and 3) concerns and recommendations about implementing a digital tool for clinical decision making. RESULTS: This sample of 131 clinicians was largely white (n = 98) female (n = 91) physicians (n = 86). Although respondents (75.7%, n = 87) had a positive attitude toward using digital tools in their practice, 88 respondents (67.3%) voiced concerns about the possible lack of clinical utility, suspected difficulty in integration with clinical workflows, and worried about the potential burden placed on patients. Participants indicated that the accuracy of the data in detecting the need for treatment adjustments would need to be high and the tool should be clinically tested. CONCLUSIONS: Primary care providers find value in collecting real-world patient data to assist in clinical decision making, provided such information does not interfere with provider workflow or impose undue burden on patients. In addition, digital tools will need to demonstrate high accuracy, be able to integrate into current clinical workflows, and maintain the privacy and security of patients' data.

Health issues and healthcare utilization among adults who reported exposure to tear gas during 2020 Portland (OR) protests: a cross-sectional survey.

BACKGROUND: Repeated use of chemical irritants for crowd-control by local and federal law enforcement during sustained racial justice protests in the U.S. has raised concerns about potential adverse health effects. The objective of this study was to describe the health consequences of exposure to tear gas agents and associated healthcare utilization among adults reporting recent exposure to tear gas. METHODS: A cross-sectional, self-administered web-based survey of a convenience sample of 2257 adults reporting recent exposure to tear gas in Portland, Oregon (U.S.), administered between July 30, 2020-August 20, 2020. Descriptive analyses were conducted on socioeconomic characteristics, reported health issues, utilization of healthcare services, and frequency of reported exposure to tear gas. Associations between reported mental health issues, healthcare utilization and race and/or ethnic categories were assessed using a chi-square test. For tests of association, racial and/or ethnic categories were divided into White/Non-Hispanic only and all other racial/ethnic categories due to a small number of Black, American Indian or Alaska Native, Asian/Pacific Islander, Hispanic participants and participants with multiple race and/or ethnic background. Effect sizes for the differences were expressed as Cramer's V, a metric that measures associations between nominal responses. The Cochran-Armitage trend test was used to assess the relationship between health issues and the number of reported days of exposure to tear gas (i.e., a proxy dose of exposure) grouped into 1 day, 2-4 days, and ≥ 5 days. Missing data (item non-response) were omitted from the analysis. RESULTS: Almost all respondents (2116; 93.8%) reported physical (2114; 93.7%) or psychological (1635; 72.4%) health issues experienced immediately after (2105; 93.3%) or days following (1944; 86.1%) the exposure. A slightly higher proportion experienced delayed head or gastrointestinal tract issues compared with immediate complaints. The majority (1233; 54.6%) reported receiving or planning to seek medical or mental care. We observed a positive exposure-response trend for all except mouth-related delayed issues (p < 0.01). CONCLUSION: Persons who reported exposer to tear gas agents also reported physical and psychological health issues over a multiple-day period. Health issues reported increased with the frequency of reported exposure, indicating a potential dose-response; these health effects often led to healthcare utilization. This study provides evidence of potential unexpected harms of tear gas in civilians.

Examining the association of medical-dental integration with closure of medical care gaps among the elderly population.

BACKGROUND: The integration of medical and dental care in the dental setting offers a unique opportunity to close medical care gaps, such as providing immunizations and laboratory-based tests, compared with traditional nonintegrated settings. METHODS: We used a matched cohort study design among patients 65 years or older (n = 2,578) with an index dental visit to the Kaiser Permanente Northwest medical-dental integration (MDI) program from June 1, 2018, through December 31, 2019. MDI patients were matched 1:1 to non-MDI controls (n = 2,578) on 14 characteristics. The Kaiser Permanente Northwest MDI program focuses on closing 23 preventive (for example, flu vaccines) and disease management care gaps (for example, glycated hemoglobin testing) within the dental setting. The closure of all care gaps (yes versus no) was the outcome for the analysis. Multivariable logistic regression was used to evaluate the association between exposure to the MDI program and level of office integration (least, moderate, and most integration) with closure of care gaps. All data were obtained through Kaiser Permanente Northwest's electronic health record. RESULTS: MDI patients had significantly higher odds (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.29 to 1.65) of closing all medical care gaps than non-MDI patients. Greater MDI integration was associated with significantly higher odds of gap closure compared with non-MDI (least integration: OR, 1.18, 95% CI, 1.02 to 1.37; moderate integration: OR, 1.70, 95% CI, 1.36 to 2.12; most integration: OR, 2.08, 95% CI, 1.73 to 2.50). CONCLUSIONS: Patients receiving dental care in an MDI program had higher odds of closing medical care gaps compared with similar patients receiving dental care in a non-MDI program. PRACTICAL IMPLICATIONS: MDI is effective at facilitating delivery of preventive and disease management medical services.

Validity of the Exercise Vital Sign Tool to Assess Physical Activity.

INTRODUCTION: Assessment and counseling by healthcare providers can successfully increase physical activity; however, a valid instrument to effectively measure physical activity is needed. This study examines the validity of the Exercise Vital Sign tool by comparing Exercise Vital Sign data collected at Kaiser Permanente Northwest with accelerometry data. METHODS: Participants (n=521) completed accelerometer monitoring and had ≥1 Exercise Vital Sign measurement in their electronic medical record. Using accelerometry as the gold standard, the association between moderate-to-vigorous physical activity minutes per week estimated through Exercise Vital Sign and that estimated through accelerometry was examined using the Spearman correlation coefficient. Comparability of moderate-to-vigorous physical activity categories (inactive, lowly active, moderately active, sufficiently active) was assessed using simple and weighted κ statistics. Sensitivity, specificity, and positive and negative predictive values were calculated. The study was conducted in 2012-2015, with analysis in 2019-2020. RESULTS: Average accelerometry-based moderate-to-vigorous physical activity was 212 minutes per week, and 57% of the participants were considered sufficiently active. Exercise Vital Sign‒based moderate-to-vigorous physical activity averaged 170 minutes per week, and 53% of the participants were active. There was a positive correlation between the moderate-to-vigorous physical activity minutes per week reported through Exercise Vital Sign and that reported through accelerometry (r =0.38, p<0.0001). A fair agreement was observed between Exercise Vital Sign‒ and accelerometry-based moderate-to-vigorous physical activity categories (weighted κ=0.29), with the highest agreement occurring for those with physical activity level ≥150 minutes per week. The positive correlation increased when moderate-to-vigorous physical activity was examined dichotomously (<150 or ≥150 minutes per week, κ=0.34). The sensitivity, specificity, positive predictive value, and negative predictive value for Exercise Vital Sign (when compared with those of accelerometry) were 67%, 68%, 61%, and 73%, respectively. CONCLUSIONS: The Exercise Vital Sign is a useful physical activity assessment tool that correctly identifies the majority of adults who do and do not meet physical activity guidelines.

The influence of multi-morbidities on colorectal cancer screening recommendations and completion.

PURPOSE: Patients' chronic disease burden can influence the likelihood that providers will recommend cancer screening and that patients will participate in it. Using data from the STOP CRC pragmatic study, we examined associations between chronic disease burden and colorectal cancer screening recommendation and use. METHODS: Participating STOP CRC clinics (n = 26) received either usual care or training to implement a mailed fecal immunochemical test (FIT) outreach program. Selected clinic patients (n = 60,187 patients) were aged 50-74 and overdue for colorectal cancer screening. We used logistic regression to examine the associations between FIT recommendations and completion and patients' chronic disease burden, calculated using the Charlson Comorbidity Index and the Chronic Illness and Disability Payment System. RESULTS: For each index, FIT recommendation odds were 8-9% higher among individuals with minimal chronic disease burden and 13-23% lower among individuals with high chronic disease burden (inverted U-shaped association). Among adults who were ordered a FIT, FIT completion odds were 20% lower for individuals with any, versus no, chronic condition and diminished with increasing disease burden (inverse linear association). CONCLUSIONS: Analysis showed an inverted U-shaped association between patients' chronic disease burden and providers' recommendation of a FIT and an inverse linear association between patients' chronic disease burden and FIT completion. ClinicalTrials.gov registration: NCT01742065.

Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules.

Importance: Whether guideline-concordant lung nodule evaluations lead to better outcomes remains unknown. Objective: To examine the association between the intensity of lung nodule diagnostic evaluations and outcomes, safety, and health expenditures. Design, Setting, and Participants: This comparative effectiveness research study analyzed health plan enrollees at Kaiser Permanente Washington in Seattle, Washington, and Marshfield Clinic in Marshfield, Wisconsin, with an incidental lung nodule detected between January 1, 2005, and December 31, 2015. Included patients were 35 years or older, had no high suspicion of infection, had no history of malignant neoplasm, and had no evidence of advanced lung cancer on nodule detection. Data analysis was conducted from January 7 to August 19, 2020. Exposures: With the 2005 Fleischner Society guidelines (selected for their applicability to the time frame under investigation) as the comparator, 2 other intensities of lung nodule evaluation were defined. Guideline-concordant evaluation followed the guidelines. Less intensive evaluation was the absence of recommended testing, longer-than-recommended surveillance intervals, or less invasive testing than recommended. More intensive evaluation consisted of testing when the guidelines recommended no further testing, shorter-than-recommended surveillance intervals, or more invasive testing than recommended. Main Outcomes and Measures: The main outcome was the proportion of patients with lung cancer who had stage III or IV disease, radiation exposure, procedure-related adverse events, and health expenditures 2 years after nodule detection. Results: Among the 5057 individuals included in this comparative effectiveness research study, 1925 (38%) received guideline-concordant, 1863 (37%) less intensive, and 1269 (25%) more intensive diagnostic evaluations. The entire cohort comprised 2786 female patients (55%), and the mean (SD) age was 67 (13) years. Adjusted analyses showed that compared with guideline-concordant evaluations, less intensive evaluations were associated with fewer procedure-related adverse events (risk difference [RD], -5.9%; 95% CI, -7.2% to -4.6%), lower mean radiation exposure (-9.5 milliSieverts [mSv]; 95% CI, -10.3 mSv to -8.7 mSv), and lower mean health expenditures (-$10 916; 95% CI, -$16 112 to -$5719); no difference in stage III or IV disease was found among patients diagnosed with lung cancer (RD, 4.6%; 95% CI, -22% to +31%). More intensive evaluations were associated with more procedure-related adverse events (RD, +8.1%; 95% CI, +5.6% to +11%), higher mean radiation exposure (+6.8 mSv; 95% CI, +5.8 mSv to +7.8 mSv), and higher mean health expenditures ($20 132; 95% CI, +$14 398 to +$25 868); no difference in stage III or IV disease was observed (RD, -0.5%; 95% CI, -28% to +27%). Conclusions and Relevance: This study found inconclusive evidence of an association between less intensive diagnostic evaluations and more advanced stage at lung cancer diagnosis compared with guideline-concordant care; higher intensities of diagnostic evaluations were associated with greater procedural complications, radiation exposure, and expenditures. These findings underscore the need for more evidence on better ways to evaluate lung nodules and to avoid unnecessarily intensive diagnostic evaluations of lung nodules.