Delving into the Data of Diabetes – A Research Roundup

by

By Muriel LaMois and Natalie Kish

The Centers for Disease Control and Prevention recognizes November as National Diabetes Month. It represents a time to increase awareness for and understanding of living with diabetes. Nationwide, nearly one out of 11 people has diabetes, and more than one-third of adults are pre-diabetic. Kaiser Permanente treats many of its members with these conditions, and researchers across the organization study diabetes-related health issues to determine how to better serve these individuals.

Stabilizing Trends in New Cases of Diabetes

Several Kaiser Permanente regions participated in a study published in January 2015 aimed at determining trends in new diabetes cases in 11 integrated health systems from 2006 through 2011. After analyzing the health records of approximately seven million newly diagnosed diabetic patients aged 20 and older, researchers found no statistically significant increase in the number of diabetes cases between 2006 and 2010 – with the exception of a small rise in cases in 2011. However, they found significant increases in diabetes cases for certain groups, including racial and ethnic minorities, older adults, males, and people with higher body mass indices. Despite the relatively stable overall rate of new cases, these results suggest that new cases of diabetes are appearing more often in certain populations than in others. Gregory Nichols, PhD, Senior Investigator with Kaiser Permanente’s Center for Health Research, led the study.

Regional Trends in Existing Cases of Diabetes: In Northern California Ethnic Disparities Reduced

Andrew Karter, PhD, and researchers from the Division of Research, conducted a study to evaluate ethnic differences in the severity of existing diabetes-related complications. Study participants included Kaiser Permanente Northern California members with diabetes who were at least 60 years old in 2010. The complications included: myocardial infarction, stroke, heart failure, amputation, end-stage renal disease, advanced diabetic eye disease, and hypoglycemic events. Among those who were studied, 32 percent of patients had at least one complication in the past two years, with eye disease and heart failure occurring most often. Karter and his team also found that certain ethnic groups were more likely to have diabetes-related complications. According to the research, Whites have the highest prevalence for most diabetes-related complications and Asians and Filipinos have the lowest prevalence. The differences in the prevalence of complications between ethnic minorities were modest. These results suggest Northern California is making progress toward reducing health disparities of diabetes-related complications among existing patients who already have diabetes.

Kaiser Permanente Southern California Improves Detection of Diabetes-Related Eye Disease

Diabetic retinopathy is the leading cause of blindness among adults in the United States. A project conducted in Kaiser Permanente’s Southern California medical centers sought to improve diagnostic accuracy of this condition by implementing a centralized reading center that assigned a single team of technicians to assess images for diabetic retinopathy for all of the region’s facilities. The center allowed for physicians to have more time for patients who needed to see them; specially trained technicians to provide more consistent and accurate readings; and photographers to get feedback that improved their images. Most importantly, it allowed more patients with diabetes to learn whether they have potentially sight-threatening retinopathy, and receive appropriate education and treatment. Recently the retinopathy center initiative received the David M. Lawrence Patient Safety Award in recognition of the project’s impact on improving the safety of care for patients and accelerating the rate and scope of patient-safety improvements at Kaiser Permanente.

 

The Quest for Quality Care: Informing Clinical Decisions in an Integrated Health Care System

by

horbergEver-expanding health care costs have led to increased scrutiny of treatments and a new emphasis on value. In response, providers are seeking to improve clinical decision making by considering various factors, such as the effectiveness of different interventions, side effects, and how patients want to live their lives. Bringing these variables together is an example of the intersection of comparative effectiveness research and shared decision making between clinicians and patients.

Comparative effectiveness research allows healthcare professionals to compare different drugs, technologies, and care processes to ensure that they are best serving patients. Kaiser Permanente’s integrated health system, serving 10.1 million people across the nation, is uniquely suited for this kind of research. Michael Horberg, MD, MAS, one of the organization’s leaders in this space, discussed why this is true.

Michael Horberg, MD, MAS is the Executive Director of Research for Kaiser Permanente’s Mid-Atlantic Permanente Medical Group and Mid-Atlantic Permanente Research Institute

What role does an integrated health system with shared decision making like KP play in comparative effectiveness research?

Our goal is to conduct comparative effectiveness research on established processes or technologies to improve patient care.

The key aspects of clinical decision making are the patients’ wants, needs, aspirations, and their life stage. Research can always be very biological—for example, Drug A lowered blood pressure more than Drug B, so Drug A is superior—that doesn’t consider other factors, such as how often Drug A has to be taken. Drug A may be successful under ideal circumstances, but it may not produce the same effect in real-life situations, and FDA’s approval of a drug and patients’ willingness to take the drug don’t always align.

What’s important is synthesizing information for patients. In a non-integrated system, there isn’t a systematic way to make the decision between Drug A and Drug B. There is also not a method to weigh this data. In small fee-for-service practices, the doctors’ decisions may be based on a small sample of patients or lobbying by drug companies. At KP, we can collect information from a large sample of patients without industry influence and make more well-informed decisions.

Many stakeholders believe that comparative effectiveness research will have a moderate to substantial impact on healthcare decision making in the next five years. Where do you see it by 2020?

Comparative effectiveness is going to be critical, especially as patients become more engaged in care and more drugs, technology, and care processes become available.

Because patients are the center of care, we will see more talk about how to bring them into the decision making process and into research. A lot of the questions research scientists think are very clear in our minds can be broadened by incorporating patients’ perspectives.

We will also start to see a lot of people and organizations talking about the effectiveness of different technologies and practices. For example, in pharmaceuticals, we will see more studies comparing generic medications and branded prescriptions, as well as comparing different branded drugs. As we observe just minor gradations of improvement of one product over a previous product, people will start asking about the significance and magnitude of the added benefit or if there is any extra value at all.

To learn more about comparative effectiveness research at KP, please see the pages for the Mid-Atlantic Permanente Research Institute and the Center for Effectiveness and Safety Research.

Preventive Screening is Gleaning for Good Health

by

ClinicalGuidelines-300x200Kaiser Permanente promotes wellness, delivers high quality care, and manages chronic disease in order to improve total health. Screening for health conditions is fundamental to this goal. This month, the Institute for Health Policy highlights Kaiser Permanente’s efforts to increase access to and quality of screenings as a way to better manage the health of our members.

Alcohol as a Vital Sign

The Kaiser Permanente Northern California Division of Research measured the results of Alcohol as a Vital Sign, a screening program in which medical assistants ask patients about their drinking behavior. The purpose of this program is to identify unhealthy levels of alcohol consumption and risk of alcohol dependency. Patient responses inform physician conversations — if patients report having unhealthy drinking levels, physicians can discuss the risks of overconsumption and the benefits of reducing consumption. Kaiser Permanente rolled out Alcohol as a Vital Sign across Northern California in 2013. Thus far, the program has shown positive results: 85 percent of the Northern California region’s patients have been screened for alcohol consumption, equal to the screening levels for smoking and exercise.

Higher Quality Colonoscopies, Lower Risk of Death from Colorectal Cancer

A recent study by Douglas A. Corley, MD, PhD, MPH, from the Kaiser Permanente Northern California Division of Research and Reinier G. S. Meester, MsC, from Erasmus University showed that improving colonoscopy adenoma detection rates (ADRs) may have long-term health benefits. Compared to unscreened patients, patients screened with low ADR colonoscopies had a 22 percent reduction in lifetime colorectal cancer incidence and a 57 percent reduction in colorectal cancer mortality. As ADRs increased, patients’ risks decreased further, the authors found. Patients screened with the highest ADR colonoscopies had much larger total reductions of incidence and death, compared to no screening, of 63 percent and 83 percent, respectively – additional relative reductions of 53 percent and 60 percent beyond those achieved with the lowest ADR tests. Although higher ADR colonoscopies are more expensive, researchers project these costs are almost completely offset by reductions in cancer treatment costs.

Expanded Blood Pressure Screenings for Hypertension Detection

Joel Handler, MD, and researchers from Kaiser Permanente Southern California’s Department of Research & Evaluation, were recently covered for their publication in The Journal of Clinical Hypertension. The team studied the benefits of screening for high blood pressure in non-primary care settings. To do so, they analyzed health records of Kaiser Permanente Southern California patients with hypertension to see if the condition was diagnosed during a primary care or specialty care visit. The study yielded two main findings. First, of hypertensive patients, 17 percent were diagnosed in specialty settings. Second, both primary care and non-primary care settings had comparable percentages of false positives, i.e. patients diagnosed with hypertension who did not have high blood pressure during follow-up. These results suggest that extending blood pressure screenings to non-primary care settings may be an effective way to detect hypertension, particularly for patients who do not regularly use primary care.

Kaiser Permanente is taking strides to improve members’ health by advancing quality of and access to screenings. These measures may help providers deliver more informed care and patients better manage their health. Next month’s research roundup will feature studies on the relationship between research and policy. For more information on this month’s research, Please contact Al Martinez at Albert.Martinez@kp.org.

Empowering Patients to Drive Their Own Care: A Conversation with Kaiser Permanente’s Terhilda Garrido

by

Health information technology (IT) is revolutionizing how patients and physicians interact. Electronic health records (EHRs), such as Kaiser Permanente’s KP HealthConnect, allow physicians to have a more complete view of patient health information. EHRs also enable patients to have more access to their physicians through secure emails, phone calls, and video visits. To learn more about the ways KP HealthConnect impacts members and providers across Kaiser Permanente, the Institute for Health Policy spoke with Terhilda Garrido, vce president for health information technology transformation & analytics at Kaiser Permanente.

Health information technology is changing the practice of medicine across the nation. What are the most profound changes KP HealthConnect has brought to Kaiser Permanente?

Terhilda Garrido, Kaiser Permanente

Terhilda Garrido, Kaiser Permanente

Physicians now go to the computer as opposed to paper records for checking medical history, taking notes, and ordering prescriptions. Providers are alerted about patient issues and in some locations can bring in added expertise through a function called eConsult. Increasingly, our patients drive care. Patients have the ability to access their health information through kp.org. They have extremely high satisfaction with the patient portal, and those who use kp.org are 2.6 times more likely to remain Kaiser Permanente members than are non-users. Once people experience the convenience of accessing care online, they tend to stay with Kaiser Permanente.

As a result of these capabilities, outpatient primary care has changed. Half of primary care visits are now virtual. Secure emails and phone calls represent about 30 percent and 20 percent, respectively, of primary care contacts. In absolute terms, face-to-face visits per member per year are slightly decreasing, but our secure email visits per member are substantially increasing. Primary care access has improved because technology allows more contact with patients. Virtual visits replace some face-to-face visits, but primarily virtual visits occur after a face-to-face encounter has already taken place.

Have clinicians in Kaiser Permanente embraced KP HealthConnect and the changes that have come with it?

The organization has embraced the changes, but the impact on physicians is mixed. Some physicians embrace the technology because they feel it improves care for their patients, while some are still reconciling this new workflow with their already busy calendars. We are such a huge organization, so it’s not out of the ordinary to have such varying reactions. We are still trying to understand and support the best use of our providers’ time.

You have been involved with research exploring the unintentional health care disparities that can emerge with Health IT. Can you explain why these disparities occur?

We’ve conducted a few studies on eHealth disparities. After controlling for various factors, including age, sex, comorbidities, distance to a medical center, income, and education levels, researchers found that Asians, African Americans, and Latinos have lower levels of use of the patient portal. This finding shows us that there are underlying biases between non-Hispanic whites and other ethnic groups.

Recently, we’ve done focus groups with African Americans and Latinos to explore the reasons for their lower levels of enrollment. One reason for not using MyChart is the belief that the site is not secure. Other explanations include login difficulties and language issues, which Southern California has attempted to address by turning on Spanish MyChart. Fewer people cite lack of access to the technology as their reason for not using MyChart.

Are there any policies that could be implemented to help reduce eHealth disparities?

General education campaigns showing that virtual care augments rather than substitutes for in-person care would be beneficial. There are people who think virtual care is cheaper care used to keep patients out of physicians’ offices. There should be broader understanding that many of people are benefiting from virtual care, and it is still high quality care.

Also, the Centers for Medicare and Medicaid Services (CMS) could help to support appropriate funding for virtual care to help it become more mainstream. Despite the fact that the Office of the National Coordinator for Health IT (ONC) is encouraging organizations to adopt virtual care, CMS still only pays for face-to-face visits. This is contrary to the direction in which ONC is pushing healthcare. Acknowledging that virtual care is beneficial and reimbursing for it could make it more widely available and help reduce eHealth disparities.

What is the next frontier in health IT and care transformation, and how are we preparing for it?

The next improvements will encourage self-service for patients and help them be more engaged in their care. Social networking and apps, such as glucose measurers, weight monitors, and fitness trackers, will help patients be more involved. Apple’s Health Kit is an app that combines health information from various health apps. Video visits will also become more common as we move forward. Finally, we will see more machine learning in healthcare. Technology like IBM’s Watson – a machine that can observe, interpret, evaluate, and decide – may be used to help support clinical care.

clinicshot

Improving Health Through Investments in Safety Net Clinics

by

The second installment of the Kaiser Permanente Institute for Health Policy’s Research Roundup showcases contributions to safety net clinics. In 2013, Kaiser Permanente invested $1.9 billion in a variety of ways in its communities, including support for 113 federally qualified health centers (FQHCs) and 63 free clinics. The integrated health care system continues to bolster its investment in safety net clinics to improve care delivery and access to services for vulnerable and underserved populations.

Community Health Centers’ New Medication Protocol

Rachel Gold and a team of researchers in Portland, Oregon recently received media coverage for their study on Kaiser Permanente’s Aspirin, Lisinopril, and Lipid-lowering medication (ALL) quality improvement protocol. The protocol uses EHR tools to remind providers to prescribe these medications to patients with diabetes who are at high risk for heart attacks and strokes. In an earlier study (Dudl, 2009), these drugs were shown to reduce the risk of these cardiovascular events. The health organization’s internal success with uptake of ALL medications led to a reworking of the model for use in community health clinics. To date 55 community clinics have adopted a modified ALL protocol. In Gold’s study, the percentage of diabetic patients who received the drugs at these sites grew from 45 to 63 percent from June 2011 through May 2013.

Mid-Atlantic Safety-Net Clinics

This spring, researchers from the Mid-Atlantic region published a study in the Permanente Journal reporting the results of Kaiser Permanente’s Community Ambassador Program (CAP). CAP places employees in safety net clinics in northern Virginia, Washington, D.C., and suburban Maryland to share best practices and provide resources to expand care. The results of this study showed CAP’s early successes: nearly 95 percent of clinics reported advances in patient care delivery, with quality improvements in weight screenings, adult tobacco use assessments, cervical cancer screenings, and breast cancer screenings. Clinics also reported offering more same day appointments and new services. As a result of CAP, many clinics adopted Kaiser Permanente’s evidence-based practices, and clinics were able to offer an additional 32,000 encounters.

Colorectal Cancer Screenings in Community Health Centers

Gloria Coronado and a team from Portland, Oregon were featured in a story highlighting their work to expand cancer services in federally qualified health clinics (FQHCs). Because these health centers have limited resources, many of their patients have never been screened for colon cancer or received a colonoscopy. Kaiser Permanente’s Center for Health Research investigators conducted a pilot study in one FQHC, which showed that mailing safety-net patients at-home fecal immunochemical test (FIT) kits increased colon cancer screenings rates by 40 percent. The study’s success encouraged researchers to expand their outreach from one clinic to 26 clinics, which plan to mail 20,000 FIT kits to safety net patients this year. Researchers are also helping FQHCs adopt EHR tools to track test results and follow up with patients, as well as assisting FQHCs in finding resources to provide colonoscopies to patients who have a positive result on the at-home FIT test.

Next month’s research roundup will feature research studies about interventions to maximize wellbeing. For more information on the research studies in this month’s Research Roundup, please contact Al Martinez at Albert.Martinez@kp.org.

Q&A with Felicia E. Mebane, PhD, MSPH — AcademyHealth Innovator in Residence

by

Dr. Felicia E. Mebane (introduced in this post earlier this week) understands the power of a good podcast. That’s why she created Health Services Unplugged for her fellowship with the Kaiser Permanente-funded AcademyHealth Innovators-in-Residence Program. This blog and podcast series features interviews with researchers and professionals who investigate ways to improve care for vulnerable and safety net populations.

“Podcasts are really popular right now, so I wanted to explore how that format could be used to disseminate health services research,” Mebane said.

In a recent Q&A, Dr. Mebane discussed her past and her goals for this project.

Tell us a bit about the Innovators-in-Residence program, and why you were interested in being involved.

Through its Innovators-in-Residence Program, AcademyHealth invites professionals who have interesting, creative, or innovative skills, experience, or ideas to spend one to three months completing a project and working with AcademyHealth’s staff. Financial support allows innovators to take time from their regular responsibilities, whether they already focus on health services or come from other industries.

I wanted to participate in this program because of my background and focus. As a public health communications expert with health policy training, I am always looking for opportunities to help researchers disseminate their work. Also, I think the field of health services research can be more creative so that we can better engage in public debates and influence policy.

As you mentioned, each Innovator is tasked with working on an independent project. Would you mind providing an overview of your project, Health Services Unplugged?

The current series features a recent research publication or project and connects it to something in the news or popular culture. The approach is for me and/or another guest (for example, a student or community member) to chat with the researcher about their work and a little bit about themselves. The goal is to inform audiences and to inspire them to learn more.

We also wanted to see how people would respond to this format, including how much traffic the site would get and how willing folks would be to participate. I hope this project will continue and encourage others to leverage different media tools and forums to reach their stakeholders.

Who did you interview, what projects are they focusing on, and how did you select the interviewees?

My approach was to present a broad mix of research and researchers. I started my list of potential guests by looking at recent issues of Health Affairs and Health Services Research, talking with AcademyHealth staff, and connecting with my networks. For example, the series includes professors at the Johns Hopkins Bloomberg School of Public Health and the University of Wisconsin’s School of Public Health and a director of research from the Colorado Health Institute. Guests included a grade school teacher, a graduate student and a DC Councilman. Topics included health disparities, access to care and Medicare payments to physicians.

I also wanted each episode to include something you won’t hear in a typical interview. Additional themes include career advice, interesting translation and dissemination tools, and fun facts about the researchers.

Did you intend for your podcast series to reach patients in the populations, or were you focusing on impacting the perspective of providers, policymakers, and other health professionals who serve these patients?

I initially targeted students and early career professionals engaged in health services or policy. I also see the audience including journalists, staff who support policymakers and anyone else interested in these issues. Though patients were not our initial focus, I am excited about the possibility of finding partners who want to communicate directly with them.

What advice would you offer someone interested in being involved with Health Services Unplugged (HSU) or helping translate and disseminate health services research?

If you are interested in supporting HSU or working with us, please contact me via our webpage. In addition to volunteer opportunities, we hope to eventually offer internships and other opportunities. Stay tuned to our website for announcements.

For folks who are thinking about a career in health services research, I encourage you to take a seminar or workshop or even class on communications. ALL researchers have to write and talk about their work. Being able to do both well will serve you in your career and help the field. If you are already a great communicator, think about health services as a career. Some health services or policy programs also give you a chance to focus on public relations, broadcasting or other aspects of communications.

You can listen to Dr. Mebane’s full podcasts via iTunes, Android, or RSS.

Meet the 2014-2015 AcademyHealth Innovators-in-Residence

by

Academy_HealthIn 2014, AcademyHealth’s Translation and Dissemination Institute (TDI) launched the Innovators-in-Residence Program. Funded by Kaiser Permanente, the Innovators-in-Residence program offers health professionals paid fellowships to assist AcademyHealth with distributing evidence-based health services research. During their fellowships, Innovators act as AcademyHealth consultants with responsibilities, such as leading committees and special groups, contributing to the AcademyHealth blog, and conducting seminars. Innovators also complete and present an independent project about original ways to transform research into policy and practice. Projects completed during the first year of the program focused on care delivery in safety net clinics and improving care for vulnerable populations.
 
Three fellows were selected between June 2014 and June 2015.
 

Ernest Moy, MD, MPH

Ernest Moy, MD, MPH

 
The first fellow was Ernest Moy, MD, MPH, a Medical Officer with the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. For his independent project, Dr. Moy developed a tool that assessed geographic and demographic characteristics in order to examine health disparities. Dr. Moy hopes that his model will be used in various cities to help policymakers design stronger disparity interventions.
 
AcademyHealth elected its second fellow, Linda Cummings, PhD, in January 2015. Dr. Cummings was previously Vice President for Research for America’s Essential Hospital, during which she gained experience with safety net hospitals and health disparities. For her fellowship project, which she will complete in the fall, Dr. Cummings is creating profiles outlining how three different safety net delivery systems approach research. She will release these profiles at the end of the summer. In the fall, Dr. Cummings will moderate a meeting about her project, and she will interview professionals from each of the three delivery systems. Links to her work will be posted to this page later this year.
 
Felicia Mebane, PhD, MSPH

Felicia Mebane, PhD, MSPH

 
The final 2015 fellow is Dr. Felicia Mebane, CEO of Mebane Media Communications and adjunct professor at the University of North Carolina at Chapel Hill Gillings School of Global Public Health. During her time as an Innovator-in-Residence from April to June 2015, Dr. Mebane began working on a project called Health Services Unplugged, a podcast and blog series about health services research and the professionals involved in the field.