Honoring National Diabetes Month and World Diabetes Day

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In honor of National Diabetes Month and World Diabetes Day, we wanted to highlight important research available at the Center for Total Health.  The study is one of the largest and most ethnically diverse to look at maternal diabetes as a risk factor for autism.  Many have probably heard of other suspected causes, but time and time again guests at the center are surprised to hear that children whose mothers developed gestational diabetes by the 26th week of pregnancy were at increased risk of developing autism later in life, according to a Kaiser Permanente study published in the Journal of the American Medical Association on April 14, 2015.  And that’s just a sample of the power of an electronic health record (EHR).

“Kaiser Permanente is uniquely qualified to conduct large scale studies in a real-word setting with the power of our integrated, comprehensive electronic health record,” said lead author Anny Xiang, of the Kaiser Permanente Southern California Department of Research and Evaluation.  “We can follow many women through the electronic health records and assess potential links between historical information and their own health outcomes, and their children’s health outcomes. The large size is particularly important to study rare diseases such as autism spectrum disorders. Appropriate analysis of these data can reveal important findings which could impact our approach to patient care.” She noted that this was an observational study, therefore the findings reveal associations between gestational diabetes and risk of a child developing autism rather than proving a cause and effect relationship.

Researchers examined the electronic health records of more than 322,000 ethnically diverse children born between 28 and 44 weeks at Kaiser Permanente Southern California medical centers between January 1995 and December 2009.  They followed the children for an average of 5.5 years and found that those exposed to gestational diabetes by the 26th week of pregnancy had a 63% increased risk of being diagnose with an autism spectrum disorder than children who were not exposed.  After taking into account maternal age, education, race and ethnicity, household income and other factors, the increased risk of autism associated with gestational diabetes was 42 percent.

For more information on the study, click here.

To learn more about this and other innovation at Kaiser Permanente, visit the Center for Total Health.

Hepatitis C: It’s Curable, So Let’s Find the People who Need to be Cured

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Dr. Michael Horberg is Executive Director Research, Community Benefit and Medicaid Strategy of the Mid-Atlantic Permanente Medical Group (MAPMG) and the director of the Mid-Atlantic Permanente Research Institute (MAPRI). Carla Rodriguez , PhD, MPH, and Cabell Jonas, PhD also contributed to this post. 

Too often, news coverage of hepatitis C focuses on the cost of new drugs and not the importance of determining which patients have hepatitis C and getting them into effective care.

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The Kaiser Permanente Center for Total Health regularly updates the information in our displays in collaboration with our health systems partners in Kaiser Foundation Health Plan and the Permanente Medical Groups. The Q1 2016 update focuses on Quality & Expert medicine, as led and delivered by the Mid-Atlantic Permanente Medical Group.

An estimated 50 percent to 80 percent of those with hepatitis C are unaware of their infection. Experts believe that is a group of some 800,000 people. Screening them all could prevent 120,000 deaths – not to mention stop the spread of infection to others. Simple blood testing and liver damage assessment, seems like a low price to save 120,000 lives – or thought of differently, preventing a deadly plane crash every day for the next year.

It is well known across medicine who should be screened (everyone born between 1945 and 1965, plus at-risk individuals such as those with HIV or patients on kidney dialysis, men who have sex with men, and people who have used injectable drugs now or in the past). But we at the Mid-Atlantic Permanente Research Institute (MAPRI), the institutional research arm of Kaiser Permanente of the Mid-Atlantic States and the Mid-Atlantic Permanente Medical Group (MAPMG), set out to find a way to actually make it happen. Data suggests only a few percent get screened (0.7-12.7 percent) – and less than half of those end up actually linked to care they need. If others could adopt our innovative program, the impact could be tremendous.

Knowing the problem is half the battle. We found that most doctors have a hard time remembering when to recommend their patient be screened. And, for those doctors who order the screening, patients may still not follow through because they need to complete three discrete steps (an antibody blood test, an RNA blood test, and liver imaging or biopsy). Therefore, our solution carefully addressed each problem. The solution:

  • Automated alert when doctors open charts during visits with patients who match screening criteria
  • The antibody blood test is linked to an order for the confirmatory HCV RNA test (meaning blood is collected at a single visit to the lab rather than asking the patient back for a second blood draw for the HCV RNA test)
  • Provided for a dedicated coordinator who could make sure no one fell through the cracks and helped them get the liver damage testing they may need contingent upon blood test results as well as linkage to ongoing care from their physician or a specialist
  • Offered patients a non-invasive, pain free liver damage assessment rather than a biopsy (when clinically feasible)

New peer-reviewed research shows that the integrated screening approach is working. Screenings are up dramatically, those who start step one of screening are getting a complete diagnosis and linkage to care

While the cost of treating hepatitis C is no doubt an important issue, we also need to pay attention to and champion screening advances that will help us do a better job of diagnosing and stopping the spread of this deadly virus.

Even in Health, Money Talks

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Last November, the  Center for Total Health commissioned a survey exploring the factors that comprise total health, as well as the barriers to achieving it. Responses from over 1,200 people of all ages and demographics made clear that stress and finances are the key factors impacting total health.

An individual’s financial situation ranked third with our respondents, behind physical and mental health, as a contributor to theirsmall infograph total health. In fact, 75 percent of survey respondents said that their financial situation is “very important” to their total health. Moreover, they believe that an improved financial situation would reduce their stress and improve their access to medical care.

In addition, respondents list stress as one of the main barriers to total health. Over 40 percent list stress from family or work as a hinderance to their total health. More than 40 percent of respondents thought that insurance-provided  stress management programs would be a key to managing stress.

For more details about the report, click here.

Kaiser Permanente also provides resources on stress at kp.org.

Research Roundup: Considering the Mind, Body and Spirit in Health Care

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Health care is not just about diagnosing and treating patients in the exam room and helping them avoid illnesses. It is also about considering the “mind, body, and spirit” together in order to encourage both physical and mental wellness. At Kaiser Permanente, our focus is the total health of patients. In this month’s research roundup, the Institute for Health Policy highlights KP research on ways to improve the well-being of our members.

Service Dogs for Veterans

Dr. Carla Green testified to an Oregon legislative subcommittee about the benefits of providing service dogs to veterans. Initial findings from the Pairing Assistance-Dogs with Soldiers (PAWS) Study showed that veterans with service dogs had fewer symptoms of post-traumatic stress disorder (PTSD), lower levels of depression, better personal relationships, and lower rates of substance abuse. In her testimony, Dr. Green described one veteran’s experience with a dog that would regularly wake him from nightmares of past traumatic events. Each dog has a one-time cost of $10,000 to breed and train. However, that may be small compared to the $5,635 to $31,695 spent on care for a veteran with PTSD, major depression, or co-occurring PTSD and major depression in the first two years after returning from combat. In order to support this kind of intervention, lawmakers need more data that service dogs are beneficial. Dr. Green’s research shows promise, and the U.S. Department of Veterans Affairs has also resumed its own research on service dogs and PTSD. With additional evidence, the government may decide to provide services dogs to veterans in the future.

Reducing the Risk of Depression Among Pregnant Women

Women with a history of depression are at greater risk of encountering the illness in the weeks before and after childbirth. Researchers in Colorado, including Dr. Arne Beck, recently published a study about using mindfulness-based cognitive theory (MBCT) for pregnant women at risk of a depressive relapse. MBCT combines mindfulness, meditation, and cognitive behavioral strategies. It also helps individuals become more aware of negative thoughts and feelings and respond to these states before they lead to depression. The intervention includes brief exercises that women can use even while handling the demands of caring for a newborn. Women who went through the intervention had a lower risk (18% compared to 30%) of developing depressive symptoms during pregnancy and six months postpartum. A larger study needs to be conducted to ensure the efficacy of this approach and to see if it is helpful for other pregnant women at risk of depression.

Mindfulness Training for Cancer Patients

In Northern California, Dr. Ai Kubo is building on the work of other Kaiser Permanente researchers who found that mindfulness-based stress reduction (MBSR) training improved the mood and quality of life of cancer patients. Standard MBSR requires over 30 hours of in-person training over 8 weeks, making it nearly impossible for busy and highly stressed caregivers or patients actively undergoing chemotherapy. Therefore the Kaiser Permanente study provided trainings through audio recordings on CDs, so that patients could listen during treatment and at home. Due to the success of this pilot study, Dr. Kubo is currently conducting a follow-up study. She is collaborating with a popular mindfulness app company, Headspace, to test if mindfulness training provided on a mobile app is accepted and helpful among cancer patients and caregivers. Dr. Kubo hopes to examine whether an 8-week regimen of mobile mindfulness exercises result in better quality of life and sleep, as well as lower levels of stress and fewer side effects from treatment.

Strategies to improve the well-being of patients can be provided alongside traditional office-based care to maintain the total health of patients. Look for next month’s research roundup on improving screenings. For more information about the research studies, please contact Al Martinez at Albert.Martinez@kp.org.

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Improving Health Through Investments in Safety Net Clinics

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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.

Research Roundup: Staying One Step Ahead of Your Health

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Close to 2,000 studies involving Kaiser Permanente (KP) clinicians and researchers are in progress at any given time across the organization’s seven regional research centers. This work helps to shape policy and practice for KP and the health care system at large as it strives to improve patient quality and satisfaction, population health, and reduce the per capita cost of care. To further this goal, each month the KP Institute for Health Policy will highlight several research studies with policy implications as part of our new research roundup series. The inaugural summary includes three studies that examine the effectiveness of steps that patients can take to help control the symptoms of a variety of health conditions.

Scanning for Alzheimer’s Disease

Rachel Whitmer from Northern California is part of a national leadership team for a study titled Imaging Dementia – Evidence for Amyloid Scanning (IDEAS), led by the Alzheimer’s Association, managed by the American College of Radiology and the ACR Imaging Network, and funded by the Centers for Medicare and Medicaid Services. Researchers will be examining a positron emission tomography (PET) scan that detects brain plaques associated with Alzheimer’s disease. The research group will determine how this scan affects doctors’ treatment plans and patient outcomes. If the PET scan is shown to be beneficial, Medicare may decide to cover it. With an early diagnosis of Alzheimer’s disease, patients can receive proper care sooner to avoid accidents from cognitive impairments and to potentially slow the progression of the disease.

Supplements for Menopause

Another study examined whether vitamin D and calcium supplements help to alleviate menopausal symptoms. Erin LeBlanc from the KP research center based in Portland, Oregon conducted a longitudinal study and found that women who took these supplements had the same number of menopausal symptoms as those who did not. Some of the symptoms included sleep disturbance, emotional well-being, and fatigue. The average age of women at the beginning of the study was 64. Dr. LeBlanc suggests that future research on the effects of supplements on menopause should include younger women to see if the results are different based on age.

Lessening the Pain of Shingles

A study from Southern California was published this month about an additional benefit of the shingles vaccination. Hung Fu Tseng and his team found that those who get shingles after receiving the vaccination (herpes zoster) have a lower risk of developing a painful complication from the condition called post-herpetic neuralgia (PHN). The Advisory Committee on Immunization Practices currently recommends the vaccination for adults over 60 years old. This research provides additional support for the vaccination, both to decrease the likelihood of getting shingles and to reduce the severity of PHN and the mental health consequences from long-term pain.

Kaiser Permanente continues to set the bar for evidence-based care. Look for next month’s research roundup: the Institute will look at three studies about investing in community clinics. If you’d like to learn more about the research studies, please contact Al Martinez at Albert.Martinez@kp.org.

International Efforts to Improve Quality and Efficiency in Health Care

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Murray Ross, PhD, vice president, Kaiser Permanente's Institute for Health Policy

Murray Ross, PhD, vice president, Kaiser Permanente’s Institute for Health Policy

Health systems across the world share a common responsibility to improve care. Rising health care costs and a growing drive for better outcomes create a need to spend health care funds efficiently and in accordance with each country’s priorities.

A response to this urgent demand requires, first, an understanding of which technologies and interventions—drugs, devices, diagnostics, and health care services—increase the quality and value of health care and, second, knowledge of policy levers that could encourage health care systems to adopt such technologies.

Comparative Effectiveness Research (CER) and Health Technology Assessment (HTA) are important tools used in different ways by countries to achieve these goals.

With support from the Kaiser Permanente Institute for Health Policy and the National Institute for Health Care Management, AcademyHealth researchers have produced a new report, “Improving Quality and Efficiency in Health Care through Comparative Effectiveness Analyses: An International Perspective,” that explores these issues. The report describes how the United States and other high-income countries assess effectiveness of new drugs, devices, procedures, diagnostics, and health care services and coverage decisions based on these assessments. The report also provides an overview of HTA activities in Europe, Canada, and Australia and examines the new public investments in CER in the United States.

The report calls for further engagement by international researchers and stakeholders to promote mutual learning.  You can read the report here.

Research Improves Detecting Ovarian Cancer While Sparing Women Unnecessary Surgery

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Elizabeth Suh-Burgmann, MD

Elizabeth Suh-Burgmann, MD

Elizabeth (Betty) Suh-Burgmann, MD, chair of gynecological oncology for Kaiser Permanente’s Northern California Region, has been doing research to improve clinical care of gynecologic cancer throughout her career.

With ultrasounds being performed on patients more often, occasionally abnormalities are discovered that doctors weren’t initially looking for. Dr. Suh-Burgmann was interested in small, complex, ovarian masses discovered in women over age 50, who are at greater risk of ovarian cancer than younger women. While difficult to treat successfully in its later stages, ovarian cancer has a good prognosis if found early. However, the only way to know immediately if these small masses are cancerous is to remove them surgically, leading some women to have surgery for non-cancerous masses.

Dr. Suh-Burgmann reviewed the charts of approximately 1,800 KP NCAL members and identified 1,400 who had these masses. Her research showed that the rate of malignancy was quite low among the group of small, complex, ovarian masses she studied. The findings were published online Sept. 8 in the American Journal of Obstetrics and Gynecology.  We sat down with her recently to talk about her work and the findings of this study.

Q:  Your research resulted in new clinical practice guidelines. Tell us about them.

A:  In April we implemented new radiology templates and practice recommendations in Northern California that are designed to reduce the number of unnecessary surgeries while identifying cancers more readily. Providers and radiologists like using them because they have a clear, recommended, evidence-based path for what to do based on the ultrasound and clinical characteristics of masses. Our shared goal is to spare women unnecessary surgery while providing assurance that worrisome masses receive prompt evaluation.

Q:  Why is ovarian cancer so difficult to detect?

A:  Unfortunately, it’s not always possible to distinguish between cancerous and noncancerous masses accurately on an ultrasound. Furthermore, levels of the CA125 protein, which is specific to ovarian cancer, are elevated in only half of women who have early-stage disease. In the majority of women with ovarian cancer, the disease has begun to spread before they have any symptoms.

Q:  What kind of masses did you study and why?

A:  When a woman has an ovarian mass, there’s always a concern that it’s cancer. Large masses are always removed and tested, but there has been no clear guidance for what to do about smaller masses, which could be cancer or, much more likely, benign tumors or cysts. I looked at masses under 6 centimeters that radiologists described as “complex,” which means that they have ultrasound characteristics that raise some concern for cancer.

Q:  How did you do this study?

A:  With the help of Yun-Yi Hung, PhD, at the Division of Research, I looked in KP HealthConnect for women age 50 and over who had these small, complex masses, no symptoms of disease, and no elevated CA125 levels, to see what happened to them. I was here many evenings, reviewing charts. I got really efficient at it.

This is the first large, population-based study that actually looks at the risk of ovarian cancer in this group. The actual rate of malignancy was quite low. Only seven out of 1,362 of these masses were actually cancer—just one in 200. That’s a lot lower rate than most women’s-health providers have been taught to assume. Also, no masses that remained stable for more than 7 months later turned out to be a cancer or borderline tumor.

Six Burning Questions Health Care Leaders Have about ACOs

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ACO imageIf you ask health care leaders what they think about Accountable Care Organizations (ACOs), you won’t be short on answers, writes Samantha DuPont of the Kaiser Permanente Institute for Health Policy, in a recent article and video on the Institute website.

According to the Centers for Medicare and Medicaid Services, ACOs are formed by groups of doctors, hospitals, and other health care providers, coming together to provide coordinated high quality care to their patients.

Early ACOs have had mixed success, and in light of emerging research questions remain as to whether or not they will result in comprehensive delivery system and payment reform that is sustainable.

DuPont chronicles the six themes that emerged from the Institute’s work in asking leaders from across the nation their burning questions about ACOs:

1. What do ACOs look like today?

2. What factors will lead to ACO success?

2. Are current financial incentives strong enough to change provider behavior?

4. Will ACOs integrate with other types of caregivers?

5. Will ACOs successfully engage their patients?

6. What metrics will effectively measure quality?

Physical Activity Saves Lives

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We are hearing about it everywhere, and now there’s even more data to back it up. Two recent studies show physical activity reduces pulmonary disease and heart failure.

The Centers for Disease Control and Prevention has an entire plan — The National Physical Activity Plan — dedicated to making it possible for Americans to be physically active and to live and work in places that support that activity.

For info on how much physical activity is right for you and your family, check out the CDC guidelines — they have them for children and adolescents, adults, and older adults.