PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (761)
 

Clipboard (0)
None

Select a Filter Below

Journals
Year of Publication
more »
1.  Characteristics of Newly Enrolled Members of an Integrated Delivery System after the Affordable Care Act 
The Permanente Journal  2015;19(3):4-10.
Of 89,289 newly enrolled non-Medicare members, 25.3% completed the Brief Health Questionnaire between 1/1/2014, and 8/31/2014. Of these, 3593 respondents were insured through Medicaid, 9434 through the individual health exchange, and 9521 through primarily commercial plans. Of Medicaid, exchange, and commercial members, 19.5%, 7.1%, and 5.3%, respectively, self-reported fair or poor health; 12.9%, 2.0%, and 3.3% of each group self-reported 2 or more Emergency Department visits during the previous year; and 8.1%, 4.3%, and 4.4% self-reported an inpatient admission during the previous year.
Context:
Little is known about the health status and care needs of new enrollees in health plans since implementation of the Affordable Care Act.
Objective:
To describe characteristics of new members of an integrated delivery system during early phases of implementation of the act.
Design:
Descriptive analysis of ongoing collection of operational data.
Main Outcome Measures:
The 11-question Brief Health Questionnaire, which was administered to new members of Kaiser Permanente Colorado who had benefits effective on or after January 1, 2014. Bivariate analyses compared characteristics of new enrollees by benefit.
Results:
Of 89,289 newly enrolled non-Medicare members, 22,548 (25.3%) completed the Brief Health Questionnaire between January 1, 2014, and August 31, 2014. Of these, 3593 respondents were insured through Medicaid, 9434 through the individual health exchange, and 9521 through primarily commercial plans. Of Medicaid, exchange, and commercial members, 19.5%, 7.1%, and 5.3%, respectively, self-reported fair or poor health; 12.9%, 2.0%, and 3.3% of each group self-reported 2 or more Emergency Department visits during the previous year; and 8.1%, 4.3%, and 4.4% self-reported an inpatient admission during the previous year. During the preceding year, 31.5% of Medicaid, 30.8% of exchange, and 12.6% of commercial members were uninsured longer than 8 months.
Conclusion:
Systematic collection of patients’ self-reported information can enhance traditional approaches to initiating care, inform operational planning, and describe newly enrolled populations. Newly enrolled Medicaid beneficiaries may have more initial health care needs than new exchange or commercial members; however, health differences between the latter two groups are subtle.
doi:10.7812/TPP/14-193
PMCID: PMC4500475  PMID: 26057681
2.  A Metrics Taxonomy and Reporting Strategy for Rule-Based Alerts 
The Permanente Journal  2015;19(3):11-19.
An action-oriented alerts taxonomy according to structure, actions, and implicit intended process outcomes using a set of 333 rule-based alerts at Kaiser Permanente Northwest (KPNW) was developed. The authors identified 9 major and 17 overall classes of alerts and developed a specific metric approach for 5 of these classes, including the 3 most numerous ones in KPNW, accounting for 224 (67%) of the alerts.
Context:
Because institutions rely on rule-based alerts as an important component of their safety and quality strategies, they should determine whether the alerts achieve the expected benefit.
Objective:
To develop and to test a method of reporting outcome metrics for rule-based electronic health record alerts on a large scale.
Methods:
We empirically developed an action-oriented alerts taxonomy according to structure, actions, and implicit intended process outcomes using a set of 333 rule-based alerts at Kaiser Permanente Northwest. Next we developed a method for producing metrics reports for alert classes. Finally, we applied this method to alert taxa.
Main Outcome Measures:
Outcome measures were the successful development of a rule-based alerts taxonomy and the demonstration of its application in a reporting strategy.
Results:
We identified 9 major and 17 overall classes of alerts. We developed a specific metric approach for 5 of these classes, including the 3 most numerous ones in our institution, accounting for 224 (67%) of our alerts. Some alert classes do not readily lend themselves to this approach.
Conclusions:
We developed a taxonomy for rule-based alerts and demonstrated its application in developing outcome metrics reports on a large scale. This information allows tuning or retiring alerts and may inform the need to develop complementary or alternative approaches to address organizational imperatives. A method that assigns alerts to classes each amenable to a particular reporting strategy could reduce the difficulty of producing metrics reports.
doi:10.7812/TPP/14-227
PMCID: PMC4500476  PMID: 26057684
3.  “Getting off the Bus Closer to Your Destination”: Patients’ Views about Pharmacogenetic Testing 
The Permanente Journal  2015;19(3):21-27.
The authors conducted focus groups with patients prescribed antidepressants (pilot session plus 2 focus groups, n = 27); patients prescribed carbamazepine (2 focus groups, n = 17); and healthy patients (2 focus groups, n = 17). Although participants understood the potential advantages of pharmacogenetic testing, many felt that the risks (discrimination, stigmatization, physician overreliance on genomic results, and denial of certain medications) may outweigh the benefits. These concerns were shared across groups but were more strongly expressed among participants with chronic mental health diagnoses.
Context:
Pharmacogenetic testing, a form of precision medicine, has the potential to optimize medication choice and dosing. Yet, relatively little is known about the views of patients—particularly those with chronic psychiatric conditions—with respect to such testing.
Objective:
To explore patients’ beliefs and attitudes regarding pharmacogenetic testing, with the goal of informing policy development and implementation.
Design:
Qualitative study design using semistructured focus groups with adults enrolled in Group Health Cooperative, a large health maintenance organization in the Pacific Northwest. We conducted focus groups with patients prescribed antidepressants (pilot session plus 2 focus groups, n = 27); patients prescribed carbamazepine (2 focus groups, n = 17); and healthy patients (2 focus groups, n = 17).
Results:
Although participants understood the potential advantages of pharmacogenetic testing, many felt that the risks (discrimination, stigmatization, physician overreliance on genomic results, and denial of certain medications) may outweigh the benefits. These concerns were shared across groups but were more strongly expressed among participants with chronic mental health diagnoses.
Conclusion:
Clinical implementation of pharmacogenetic testing must address patient concerns about privacy, discrimination, quality of care, and erosion of the physician-patient relationship.
doi:10.7812/TPP/15-046
PMCID: PMC4500477  PMID: 26057686
4.  A Community-Based Hip Fracture Registry: Population, Methods, and Outcomes 
The Permanente Journal  2015;19(3):29-36.
Cases of hip fracture recorded from 1/2009 to 12/2011 were ascertained using the Kaiser Permanente Hip Fracture Registry. The registry collects information on patient, procedure, surgeon, facility, and surgical outcomes. The population (N = 12,562) was predominantly white, women, and older (≥ 75 years), and 32% had at least 5 comorbidities. The average length of follow-up was 1.1 years. Hemiarthroplasty was the most common procedure (33.1%). Most fractures were treated by medium-volume surgeons at high-volume facilities. The 90-day readmission rate was 22.1%, and the mortality rate was 12.3%.
Introduction:
Hip fracture is associated with substantial morbidity and mortality. A large integrated health care system developed a registry to characterize its current patient population with hip fractures. This report describes the population, methods used, and outcomes of patients registered during the initial three years (2009–2011).
Methods:
Cases of hip fracture recorded from January 2009 through December 2011 were ascertained using the Kaiser Permanente Hip Fracture Registry. The registry collects information on patient, procedure, surgeon, facility, and surgical outcomes. Outcomes monitored included length of stay, readmissions, mortality, revisions, surgical site infections, deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, dislocations, and myocardial infarction.
Results:
The population (N = 12,562) was predominantly white (77.8%), women (68.6%), and older (71.6% aged ≥ 75 years), and 32% had at least 5 comorbidities. The average length of follow-up was 1.1 years (standard deviation = 0.9). The most prevalent comorbidities were hypertension (70.8%) and anemia (29.4%). Femoral neck fractures (54.6%) were the most common fracture type. Hemiarthroplasty was the most common procedure (33.1%). Most fractures were treated by medium-volume (10 to 29 cases per year) surgeons (68.4%) at high-volume (≥ 130 cases per year) facilities (63.0%). The 90-day readmission rate was 22.1%, and the mortality rate was 12.3%. The most common postoperative complications were pneumonia (11.4%) and pressure ulcers (2.9%). There were 2.2 revisions per 100 observation years.
Conclusion:
A hip fracture registry provides important information regarding patient characteristics, intraoperative practices, and postoperative outcomes, which can be analyzed, interpreted, and used to reduce morbidity and mortality.
doi:10.7812/TPP/14-231
PMCID: PMC4500478  PMID: 26057682
5.  Utility of the Multinational Association for Supportive Care in Cancer (MASCC) Risk Index Score as a Criterion for Nonadmission in Febrile Neutropenic Patients with Solid Tumors 
The Permanente Journal  2015;19(3):37-47.
Febrile neutropenic episodes in patients with solid tumors were identified electronically from 10/1/2008 to 11/15/2010. Inclusion criteria were met in 198 episodes. Sensitivity, specificity, and positive and negative predictive values of the MASCC risk index score vs complications were, respectively, 94%, 29.6%, 57.7%, and 82.9%. An MASCC risk index score of 21 or greater could not be used as a criterion for “no complication/ do not admit.” Inability to eat should be an admission criterion.
Objectives:
This retrospective study was initiated in febrile neutropenic inpatients with solid tumors in 4 community hospitals, to discover how the Multinational Association for Supportive Care in Cancer (MASCC) risk index score (RIS) of 21 or greater correlated with complications occurring in 198 episodes: whether it could help determine which patients not to admit, the savings of not admitting patients without complications, and whether an algorithm could facilitate management of those not admitted.
Methods:
Febrile neutropenic episodes in patients with solid tumors were identified electronically between October 1, 2008, and November 15, 2010. Electronic charts were reviewed manually for inclusion criteria and data extraction. Episodes were stratified by an MASCC RIS below 21 or 21 or greater. Complications were correlated with the index.
Results:
Inclusion criteria were met in 198 episodes. Sensitivity, specificity, and positive and negative predictive values of the MASCC RIS vs complications were 94%, 29.6%, 57.7%, and 82.9%, respectively. In episodes with an RIS 21 or greater, 42.3% had complications, misclassifying to low risk 69 episodes with complications. “Unable to eat” correlated with complications in 84% of episodes. In 3 patients stratified to no complication, a complication developed 24 hours after admission.
Conclusions:
An MASCC RIS of 21 or greater could not be used as a criterion for “no complication/do not admit.” Inability to eat should be an admission criterion. Savings of approximately $1 million per 100 uncomplicated admissions could be realized if appropriate criteria for nonadmission could be devised. An algorithm to facilitate outpatient management is suggested.
doi:10.7812/TPP/14-188
PMCID: PMC4500479  PMID: 26176568
6.  Evidence-Based Referral: Effects of the Revised “Youth Fit 4 Life” Protocol on Physical Activity Outputs 
The Permanente Journal  2015;19(3):48-53.
The authors contrasted 2 physical activity/nutrition treatments on the basis of social cognitive and self-efficacy theory, and a comparison condition, on time in moderate-to-vigorous physical activity (MVPA) during the 45-min/day physical activity segment of elementary after-school care. The Revised Youth Fit 4 Life protocol that sought to maximize participants’ cardiovascular physical activity appeared to improve upon the Original Youth Fit For Life treatment on time in MVPA. Thus, pediatricians might have confidence in referring their patients to such evidence-based approaches.
Background:
Lack of physical activity is prevalent in youths. Pediatricians seek referrals to reliably increase outputs, especially in their overweight and underactive patients.
Objective:
Within a randomized controlled trial, we contrasted 2 physical activity/nutrition treatments on the basis of social cognitive and self-efficacy theory, and a comparison condition, on time in moderate-to-vigorous physical activity (MVPA) during the 45-min/day physical activity segment of elementary afterschool care.
Methods:
In youths ranging in age from 9 to 12 years (9.7 ± 0.8 years, overall), the Original Youth Fit For Life treatment (Original YFFL; n = 49), the Revised Youth Fit 4 Life treatment (Revised YF4L, n = 43), and a comparison condition of typical care (Comparison, n = 46) were contrasted using a 3 (groups) × 2 (sexes) analysis of variance incorporating means of 3 accelerometer measurements over 12 weeks.
Results:
There was a significantly greater amount of time in MVPA in the Revised YF4L group than either the Original YFFL or Comparison groups (F2, 132 = 281.20, p < 0.001). Boys completed significantly more time in MVPA than girls (F2, 132 = 16.43, p < 0.001); however, there was not a significant group × sex interaction. Supplementary analyses indicated sedentary time was significantly less by 29% in the Revised YF4L when contrasted with the Comparison group.
Conclusion:
The Revised YF4L protocol that sought to maximize participants’ cardiovascular physical activity appeared to improve upon the Original YFFL treatment on time in MVPA. Thus, pediatricians might have confidence in referring their patients to such evidence-based approaches. Future research should also evaluate the effects of YF4L on psychosocial predictors of physical activity and change in body mass index.
doi:10.7812/TPP/14-228
PMCID: PMC4500480  PMID: 26057685
7.  Relationship between Participation in Patient- and Family-Centered Care Training and Communication Adaptability among Medical Students: Changing Hearts, Changing Minds 
The Permanente Journal  2015;19(3):54-58.
A census of 43 third-year medical students at the University of New Mexico School of Medicine participated in Parents Reaching Out: Families as Faculty program during their pediatric rotation. Analysis of variance revealed statistical significance for the factor “appropriate disclosure” (meaning students have become more sensitive to the level of intimacy that the other person is seeking and the student is willing to offer more information). There was a positive correlation between pretest and posttests in social experience, wit, and social confirmation.
Background:
Patient- and family-centered care (PFCC) training is an important component of many medical school curricula in the US.
Purpose:
To determine if an existing quantitative measure of communication adaptability can be used to determine skills acquired by medical students after PFCC training.
Methods:
A census was conducted of 43 third-year medical students at the University of New Mexico School of Medicine, Albuquerque, NM. Students participated in the Families as Faculty program of Parents Reaching Out during their pediatric rotation. A pretest and posttest of Duran’s 1983 Communicative Adaptability Scale was performed.
Results:
A one-way analysis of variance was conducted and revealed that there was statistical significance for the factor called appropriate disclosure (p = 0.04). When mean plot was conducted, there was a positive correlation between pretest and posttests in social experience, wit, and social confirmation. There was a negative correlation for articulation and social composure, which was not significant.
Conclusion:
The Communicative Adaptability Scale was an effective way to evaluate communication skills that students acquire from PFCC training. An increase in appropriate disclosure is an important gain because it means students have become more sensitive to the level of intimacy that the other person is seeking and the student is willing to offer more information. Information sharing is one of the core concepts of PFCC. Finally, the negative correlation for articulation and social composure indicate that Families as Faculty may increase anxiety for medical students, so this is an area of the education that may need to be revisited.
doi:10.7812/TPP/14-110
PMCID: PMC4500481  PMID: 26176569
8.  A Ten-Year Case-Control Study of Passive Smoke Exposure as a Risk Factor for Pertussis in Children 
The Permanente Journal  2015;19(3):59-63.
The authors conducted a matched case-control study of laboratory-confirmed pertussis cases, occurring from 1/1/1996 to 12/31/2005, in children up to 12 years of age who were members of a large managed care organization. Sixty-five laboratoryconfirmed cases of pertussis were identified. Using multivariable conditional logistic regression analysis, the authors did not detect a statistically significant association between pertussis and household passive exposure to cigarette smoking.
Context:
Passive exposure to cigarette smoke in the household as a risk factor for pertussis disease has not been well characterized.
Objective:
To determine whether pertussis was associated with household secondhand smoke in children.
Methods:
We conducted a matched case-control study of laboratory-confirmed pertussis cases occurring from January 1, 1996, through December 31, 2005, in children up to 12 years of age who were members of a large managed care organization. Controls were matched one-to-one on age group and type of Health Plan account. Passive cigarette smoking was determined through a retrospective review of the medical records of cases, controls, and their respective household members.
Main Outcome Measures:
Cases of pertussis infection were identified from a microbiology laboratory database and through diagnostic codes from the International Classification of Diseases, Ninth Revision, with the diagnosis confirmed by culture or polymerase chain reaction.
Results:
Sixty-five laboratory-confirmed cases of pertussis were identified. Cases and controls were similar in sex (p = 0.73), race (p = 0.57), and receipt of pertussis antigen-containing vaccine (p = 0.24). Using multivariable conditional logistic regression analysis, we did not detect a statistically significant association between pertussis and household passive exposure to cigarette smoking (adjusted odds ratio = 1.2; 95% confidence interval = 0.5–2.9).
Conclusion:
Although we did not detect an association in this analysis, the possible relationship between passive exposure to smoking and childhood pertussis remains an important research question and should be a priority for future studies.
doi:10.7812/TPP/14-233
PMCID: PMC4500482  PMID: 26176570
9.  2014 Hypertension Guideline: Recommendation for a Change in Goal Systolic Blood Pressure 
The Permanente Journal  2015;19(3):64-68.
The 2014 Kaiser Permanente Care Management Institute National Hypertension Guideline was developed to assist primary care physicians and other health care professionals in the outpatient treatment of uncomplicated hypertension in adult men and nonpregnant women aged 18 years and older. A major practice change is the recommendation for goal systolic blood pressure less than 150 mmHg in patients aged 60 years and older who are treated for hypertension in the absence of diabetes or chronic kidney disease. This article describes the reasons for, evidence for, and consequences of the change, and includes the guideline.
The 2014 Kaiser Permanente Care Management Institute National Hypertension Guideline was developed to assist primary care physicians and other health care professionals in the outpatient treatment of uncomplicated hypertension in adult men and nonpregnant women aged 18 years and older. The new guideline reflects general acceptance, with minor modifications, of the “Evidence-Based Guideline” report by the panel members appointed to the National Heart, Lung, and Blood Institute 8th Joint National Committee. A major practice change is the recommendation for goal systolic blood pressure less than 150 mmHg in patients aged 60 years and older who are treated for hypertension in the absence of diabetes or chronic kidney disease. This article describes the reasons for, evidence for, and consequences of the change, and is followed by the National Guidelines handout.
doi:10.7812/TPP/14-226
PMCID: PMC4500483  PMID: 26057683
10.  Beer Potomania—An Unusual Cause of Hyponatremia 
The Permanente Journal  2015;19(3):74-76.
The first case of severe hyponatremia, since referred to as beer potomania, in a heavy beer drinker patient was reported in 1972. Excessive consumption of beer in particular, which has a low solute content, may result in severe hyponatremia. We report a case of severe hyponatremia that occurred in a patient who, owing to his underlying colon cancer, was drinking beer and ingesting little food.
The first case of severe hyponatremia, since referred to as beer potomania, in a heavy beer drinker patient was reported in 1972. Electrolyte abnormalities are common findings in patients with a history of heavy alcohol use. Excessive consumption of beer in particular, which has a low solute content (sodium concentration, 1.8 mEq/L and potassium concentration, 7.2 mEq/L), to the exclusion of other solute intake may result in severe hyponatremia. We report a case of severe hyponatremia that occurred in a patient who, owing to his underlying colon cancer, was drinking beer and ingesting little other food. His hyponatremia improved with increased solute intake and, upon correction of his serum sodium, he had no subsequent neurologic sequelae.
doi:10.7812/TPP/14-181
PMCID: PMC4500484  PMID: 26176571
11.  Dermatologic Diagnosis: Leukocytoclastic Vasculitis 
The Permanente Journal  2015;19(3):77-78.
Leukocytoclastic vasculitis (LCV), also termed hypersensitivity vasculitis, is a small-vessel vasculitis. The skin is the organ most commonly involved in LCV. Typical presentation is a painful, burning rash predominantly in the lower extremities. The most common skin manifestation is palpable purpura. Other skin manifestations include maculopapular rash, bullae, papules, plaques, nodules, ulcers, and livedo reticularis.
doi:10.7812/TPP/15-001
PMCID: PMC4500485  PMID: 26176572
12.  ECG Diagnosis: Hyperacute T Waves 
The Permanente Journal  2015;19(3):79.
After QT prolongation, hyperacute T waves are the earliest-described electrocardiographic sign of acute ischemia, preceding ST-segment elevation. The principle entity to exclude is hyperkalemia—this T-wave morphology may be confused with the hyperacute T wave of early transmural myocardial infarction.
doi:10.7812/TPP/14-243
PMCID: PMC4500486  PMID: 26176573
13.  Does Consuming Sugar and Artificial Sweeteners Change Taste Preferences? 
The Permanente Journal  2015;19(3):81-84.
Americans consume 22.3 teaspoons of added caloric sweeteners a day. Sweeteners range from 180 to 13,000 times sweeter than sugar. In summer 2014, 20 people from Kaiser Permanente California facilities cut out all added sugars and artificial sweeteners for 2 weeks: 95% of participants found that sweet foods and drinks tasted sweeter or too sweet, 75% found that other foods tasted sweeter, and 95% said moving forward they would use less or even no sugar. Additionally, 86.6% of participants stopped craving sugar after 6 days.
Americans consume a lot of sugar, primarily from sweeteners that are added to processed foods and beverages. Data from the US Department of Agriculture reveals that in 2013, Americans consumed 22.3 teaspoons of added caloric sweeteners a day, which is significantly more than the American Heart Association’s recommendation. Artificial and alternative sweeteners have also been added to a plethora of foods. These sweeteners range from about 180 times sweeter to as much as 13,000 times sweeter than sugar. Consumption of both sugar and artificial sweeteners may be changing our palates or taste preferences over time, increasing our desire for sweet foods. Unfortunately, the data on this are lacking. In the summer of 2014, a group of 20 people from Kaiser Permanente facilities throughout California agreed to cut out all added sugars and artificial sweeteners for 2 weeks and then complete a survey to determine whether their taste preferences had changed. After the 2-week challenge, 95% of participants (18 out of 19 respondents) found that sweet foods and drinks tasted sweeter or too sweet, 75% (15 out of 20 respondents) found that other foods tasted sweeter, and 95% (19 out of 20 respondents) said moving forward they would use less or even no sugar. Additionally, 86.6% of participants (13 out of 15 respondents) stopped craving sugar after 6 days. Although this was a small survey, the results suggest that using a 2-week sugar challenge can help to reset taste preferences and make consuming less or no sugar easier. Physicians should consider recommending a sugar and artificial sweetener challenge to all their patients, especially those with obesity, diabetes, or cardiovascular disease.
doi:10.7812/TPP/14-229
PMCID: PMC4500487  PMID: 26176574
14.  New Kid on the Block Turns Ten! The Brief, Remarkable History of the National Physicians Alliance 
The Permanente Journal  2015;19(3):85-89.
Founded in 2005 by General Surgeon Lydia J Vaias, MD, MPH, the National Physicians Alliance is a 501c3 public charity with a mission to create research and education programs that promote health and foster active engagement of physicians with their communities to achieve high-quality, affordable health care for all. The National Physicians Alliance offers a professional home to physicians across medical specialties who share a commitment to professional integrity and health justice. As the organization celebrates its tenth birthday, the history and scope of this mission-aligned group is described.
Founded in 2005 by General Surgeon Lydia J Vaias, MD, MPH, the National Physicians Alliance is a 501c3 public charity with a mission to create research and education programs that promote health and foster active engagement of physicians with their communities to achieve high-quality, affordable health care for all. The National Physicians Alliance offers a professional home to physicians across medical specialties who share a commitment to professional integrity and health justice. As the organization celebrates its tenth birthday, the history and scope of this mission-aligned group are described.
doi:10.7812/TPP/15-031
PMCID: PMC4500488  PMID: 26176575
15.  Suicide is a Baobab Tree: A Narrative Medicine Case Study 
The Permanente Journal  2015;19(3):90-94.
Like the baobab, when suicide or a suicide attempt occurs, suicidal ideations are well cultivated and have often already been repeatedly planted. Consequently, suicide is often difficult to prevent: once the death seed is planted; it is difficult to recreate life. Every year, more than 800,000 people die by suicide worldwide.
This case study is an example of applying narrative medicine as a useful tool for health professionals to manage an existential and complex scenario such as the suicide of a sibling. Some suicides are like baobab trees—these large and resilient trees grow deep roots for many years, only spreading their limbs above ground once they are firmly established. Like the baobab, when suicide or a suicide attempt occurs, suicidal ideations are well cultivated and have often already been repeatedly planted. Consequently, suicide is often difficult to prevent: once the death seed is planted, it is difficult to recreate life.
Every year, more than 800,000 people die by suicide worldwide (1.4% of all deaths), which is approximately 1 person every 40 seconds. These unexpected deaths, predominantly occuring among young and middle-aged adults, have a continuing ripple effect and result in a huge economic, social, and psychological burden for individuals, families, communities, and countries. The complexity of suffering and pain experienced by suicidal individuals and their families, regardless of the success or failure of the suicidal act, is intensified by strong stigmas attached to traditional concepts of sin and eternal damnation. This unfortunate reality emerges in the narrative as a tragic family drama, which is permeated by deep feelings of helplessness.
But suicide is preventable. Prevention requires 3 important factors: knowledge, public support, and creation of strategies to enact social change. Now is the time to act and make suicide prevention an imperative goal.
doi:10.7812/TPP/14-201
PMCID: PMC4500489  PMID: 26176576
16.  Why a Hanging Man Dances 
The Permanente Journal  2015;19(3):95.
“Do you know why a hanging man dances?” asked Mr B. He was once an intensely independent man, now 80 years old and afflicted with end-stage lung disease. He appeared tired, repositioning himself with great effort to sitting at the edge of the bed, tightly holding onto the bed sheets as if clenching to a life that was slowly escaping him. “No. I don’t want anything that will make me live longer.”
doi:10.7812/TPP/14-230
PMCID: PMC4500490  PMID: 26176577
17.  Image Diagnosis: Inferior Mesenteric Vein Thrombosis 
The Permanente Journal  2015;19(3):e120-e121.
A 59-year-old man presented to the gastroenterology clinic with 2 weeks of worsening lower back pain. There was associated poor appetite, fatigue, night sweats, and chills. The patient’s medical history was significant for well-controlled hypertension and sigmoid diverticulosis. The thrombosis probably resulted from inflammation in the adjacent diverticulum.
doi:10.7812/TPP/14-239
PMCID: PMC4500491  PMID: 26176578
18.  Pneumomediastinum Diagnosed on Ultrasound in the Emergency Department: A Case Report 
The Permanente Journal  2015;19(3):e122-e124.
A previously healthy patient was seen in the Emergency Department for evaluation of a one-month history of cough and one-day history of hemoptysis. This case report, from a pulmonologist’s perspective, includes a comprehensive review of the patient’s clinical presentation and outcome, as well as a discussion of recurrent respiratory papillomatosis.
An emergency ultrasound performed at bedside helped to confirm and expedite the diagnosis of esophageal perforation in a 23-year-old man. Early diagnosis was essential for prompt treatment and consultation because the patient’s underlying pathology created the potential for him to become critically ill. By serving as a quick, bedside tool for the diagnosis and evaluation of patients in the Emergency Department, bedside ultrasound allows emergency physicians to care for critically ill patients without delays or the need to send patients out of the department for imaging studies. Although the use of ultrasound in diagnosing soft-tissue pathologies is a core competency, the diagnosis of pneumomediastinum by ultrasound has been reported in the literature in only a few case reports. To our knowledge, this is the first published report of using ultrasound as an aid in the diagnosis of Boerhaave syndrome by diagnosing pneumomediastinum in an adult male.
doi:10.7812/TPP/14-232
PMCID: PMC4500492  PMID: 26176579
19.  Case Report: Pulmonary Papillomatosis in a Patient Presenting with Cough and Hemoptysis 
The Permanente Journal  2015;19(3):e125-e127.
An emergency ultrasound performed at bedside helped to confirm and to expedite the diagnosis of esophageal perforation in a 23-year-old man. To our knowledge, this is the first published report of using ultrasound as an aid in the diagnosis of Boerhaave syndrome by diagnosing pneumomediastinum in an adult male.
A previously healthy patient was seen in the Emergency Department for evaluation of a one-month history of cough and one-day history of hemoptysis. A computed tomography scan of the thorax found a mass on the right lower pulmonary lobe and a mass on the left upper lobe. A biopsy specimen of the right lobe lung mass, obtained during bronchoscopy, demonstrated papilloma. This case report, from a pulmonologist’s perspective, includes a comprehensive review of the patient’s clinical presentation and outcome, as well as a discussion of recurrent respiratory papillomatosis.
doi:10.7812/TPP/14-192
PMCID: PMC4500493  PMID: 26176580
20.  The Panel Management Questionnaire: A Tool to Measure Panel Management Capability 
The Permanente Journal  2015;19(2):4-9.
Primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation. The authors developed the 12-item Panel Management Questionnaire (PMQ) measuring 4 domains. Data were assembled from self-administered cross-sectional surveys of 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Staff and clinician PMQ scores in each clinic were correlated. The clinic-level median PMQ score was positively associated with a composite clinic quality measure.
Context:
To meet demands for evidence-based chronic and preventive services and to improve performance, primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation.
Objective:
To describe development and evaluation of the Panel Management Questionnaire (PMQ), a self-report tool measuring panel management capability in primary care.
Design:
Cross-sectional study for questionnaire validation.
Main Outcome Measures:
We developed the 12-item PMQ from a conceptual framework to measure 4 domains of panel management and tested the questionnaire for internal and external validity. Data were assembled from self-administered cross-sectional surveys that included the PMQ instrument sent from February 2012 through May 2012. We surveyed 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Additional data came from clinic quality measures routinely collected the quarter before the survey.
Results:
The PMQ scale demonstrated good internal consistency (Cronbach α = 0.92 and 0.84 for staff and clinicians, respectively). Staff and clinician PMQ scores in each clinic were correlated (Kendall τ = 0.45, p < 0.05). The clinic-level median PMQ score was positively associated with a composite clinic quality measure (Kendall τ = 0.42 for staff, 0.28 for clinicians).
Conclusions:
The PMQ measures self-reported panel management capability and may be a useful assessment and research tool for panel management implementation in primary care practice.
doi:10.7812/TPP/14-170
PMCID: PMC4403574  PMID: 25785637
21.  Hand-Assisted versus Straight-Laparoscopic versus Open Proctosigmoidectomy for Treatment of Sigmoid and Rectal Cancer: A Case-Matched Study of 100 Patients 
The Permanente Journal  2015;19(2):10-14.
To assess the efficacy of laparoscopic proctosigmoidectomy for cancer treatment, 25 patients who underwent hand-assisted laparoscopic resection during the study period (9/2006 – 7/2012) were matched to 25 straight-laparoscopic and 50 open-surgery cases. The patients who underwent hand-assisted resection had higher rates of preoperative cardiac disease and hypertension than did the straight-laparoscopy and open-surgery groups. Straight-laparoscopic surgery seems to provide faster convalescence compared with open surgery and hand-assisted laparoscopic surgery.
Objective:
The laparoscopic approach is increasingly used for surgical treatment of colorectal cancer. The aim of this study was to assess the efficacy of laparoscopic proctosigmoidectomy for cancer treatment by comparing postoperative outcomes among three groups: hand-assisted laparoscopic resection, conventional straight-laparoscopic resection, and open resection.
Methods:
Patients who underwent hand-assisted proctosigmoidectomy because of rectal or sigmoid adenocarcinoma between September 2006 and July 2012 were case-matched to their straight-laparoscopy and open-surgery counterparts. Tumor location, tumor stage, resection type, and year of surgery were the matching criteria. Patients who had an abdominoperineal resection were excluded from the study.
Results:
Twenty-five patients underwent hand-assisted laparoscopic resection during the study period and were matched to 25 straight-laparoscopic and 50 open-surgery cases. The patients who underwent hand-assisted resection had higher rates of preoperative cardiac disease and hypertension than did the straight-laparoscopy and open-surgery groups (76% vs 64% vs 26%; p < 0.0001 and 72% vs 68% vs 42%; p = 0.02, respectively). A history of previous abdominal operations was highest in the straight-laparoscopy group (p = 0.01). The mean estimated blood loss was lowest in the straight-laparoscopy group (p = 0.01). The straight-laparoscopy group had the shortest median length of postoperative hospital stay (p = 0.04). Disease-free survival and overall survival was similar among the groups.
Conclusions:
Although both hand-assisted and straight-laparoscopic proctosigmoidectomy appear to be as safe and effective as open surgery in short-term and midterm outcomes, straight-laparoscopic surgery seems to provide faster convalescence compared with open surgery and hand-assisted laparoscopic surgery.
doi:10.7812/TPP/14-102
PMCID: PMC4403575  PMID: 25902342
22.  Big Data, Miniregistries: A Rapid-Turnaround Solution to Get Quality Improvement Data into the Hands of Medical Specialists 
The Permanente Journal  2015;19(2):15-21.
The cost to build and to maintain traditional registries for many dire, complex, low-frequency conditions is prohibitive. The authors used accessible technology to develop a platform that would generate miniregistries (small, routinely updated datasets) for surveillance, to identify patients who were missing elected utilization and to influence clinicians to change practices to improve care. The platform, tested in 5 medical specialty departments, enabled the specialists to rapidly and effectively communicate clinical questions, knowledge of disease, clinical workflows, and improve opportunities. Each miniregistry required 1 to 2 hours of collaboration by a specialist. Turnaround was 1 to 14 days.
Context:
Disease registries enable priority setting and batching of clinical tasks, such as reaching out to patients who have missed a routine laboratory test. Building disease registries requires collaboration among professionals in medicine, population science, and information technology. Specialty care addresses many complex, uncommon conditions, and these conditions are diverse. The cost to build and maintain traditional registries for many diverse, complex, low-frequency conditions is prohibitive.
Objective:
To develop and to test the Specialty Miniregistries platform, a collaborative interface designed to streamline the medical specialist’s contributions to the science and management of population health.
Design:
We used accessible technology to develop a platform that would generate miniregistries (small, routinely updated datasets) for surveillance, to identify patients who were missing expected utilization, and to influence clinicians and others to change practices to improve care. The platform was composed of staff, technology, and structured collaborations, organized into a workflow. The platform was tested in five medical specialty departments.
Main Outcome Measure:
Proof of concept.
Results:
The platform enabled medical specialists to rapidly and effectively communicate clinical questions, knowledge of disease, clinical workflows, and improvement opportunities. Their knowledge was used to build and to deploy the miniregistries. Each miniregistry required 1 to 2 hours of collaboration by a medical specialist. Turnaround was 1 to 14 days.
Conclusions:
The Specialty Miniregistries platform is useful for low-volume questions that often occur in specialty care, and it requires low levels of investment. The efficient organization of information workers to support accountable care is an emerging question.
doi:10.7812/TPP/14-118
PMCID: PMC4403576  PMID: 25785640
23.  Expanding Access to Care and Improving Quality in the Mid-Atlantic States Safety-Net Clinics: Kaiser Permanente’s Community Ambassador Program 
The Permanente Journal  2015;19(2):22-27.
The Community Ambassador Program (CAP) in the Mid-Atlantic States Region places Kaiser Permanente-employed nurse practitioners, midwives, and physician assistants to work in the safety-net clinics and share best practices through a long-term community collaboration. The authors conducted an evaluation of 18 safety-net clinics that participated in the CAP in 2012. The Community Ambassadors provided an estimated 32,249 encounters to 11,988 patients. Performance was at or near 90% for 2 adult quality measures (weight screening and tobacco use assessment). For breast cancer screenings, however, performance among the Community Ambassadors was much lower (48%). The program expanded access and improved quality of care.
Context:
As part of its longstanding commitment to improve the health of the communities it serves, Kaiser Permanente (KP) established the Community Ambassador Program (CAP) in the Mid-Atlantic States Region. The CAP places KP-employed nurse practitioners, midwives, and physician assistants to work in the safety-net clinics and to share best practices through a long-term community collaboration.
Objective:
To share the early experiences of the CAP and describe the initial results of the program’s impact on the safety-net clinics.
Methods:
We conducted an evaluation of 18 safety-net clinics that participated in the CAP in 2012 to determine the program’s early impact in expanding access to care, increasing the capacity of safety-net providers, and improving the quality of care on evidence-based measures in the year following program implementation. The safety-net clinics are comprised of federally qualified health centers, free clinics, and other community-based organizations. The clinics were asked to respond to questions regarding their evidence-based practices promoted by KP and on primary care-related utilization.
Results:
The Community Ambassadors provided an estimated 32,249 encounters to 11,988 patients. Performance by the Community Ambassadors was at or near 90% for 2 adult quality measures (weight screening and tobacco use assessment). For breast cancer screenings, however, performance among the Community Ambassadors was much lower (48%).
Conclusion:
The CAP demonstrated some early success in expanding access and improving quality of care on several key measures for certain subpopulations. Despite these achievements, opportunities remain for quality improvement, expanded capacity, and enhanced data reporting infrastructure.
doi:10.7812/TPP/14-109
PMCID: PMC4403577  PMID: 25785638
24.  Alcohol Intake, Beverage Choice, and Cancer: A Cohort Study in a Large Kaiser Permanente Population 
The Permanente Journal  2015;19(2):28-34.
The authors studied incident cancer risk from 1978 to 1985 and through follow-up in 2012 relative to light-to-moderate and heavy drinking and to the choice of alcoholic beverage in a cohort of 124,193 persons. With lifelong abstainers as referent, heavy drinking (≥ 3 drinks per day) was associated with increased risk of 5 cancer types: upper airway/digestive tract, lung, female breast, colorectal, and melanoma, with light-to-moderate drinking related to all but lung cancer.
Context:
Heavy intake of alcoholic beverages is associated with an increased risk of developing several types of cancers at specific body sites. However, evidence is conflicting regarding alcohol-associated cancers in other sites of the body as well as the role played by choice of wine, liquor, or beer.
Objective:
To study incident cancer risk from 1978 to 1985 and through follow-up in 2012 relative to light-to-moderate and heavy drinking and to the choice of alcoholic beverage in a cohort of 124,193 persons.
Design:
Cohort.
Main Outcome Measures:
1) Cox proportional hazards models controlled for 7 covariates to analyze alcohol-associated risk of any cancer and multiple specific types. 2) Similar analyses in strata of drinkers with or without a preponderant choice of wine, liquor, or beer and with or without inferred likelihood of underreporting.
Results:
With lifelong abstainers as referent, heavy drinking (≥ 3 drinks per day) was associated with increased risk of 5 cancer types: upper airway/digestive tract, lung, female breast, colorectal, and melanoma, with light-to-moderate drinking related to all but lung cancer. No significantly increased risk was seen for 12 other cancer sites: stomach, pancreas, liver, brain, thyroid, kidney, bladder, prostate, ovary, uterine body, cervix, and hematologic system. For all cancers combined there was a progressive relationship with all levels of alcohol drinking. These associations were largely independent of smoking, but among light-to-moderate drinkers there was evidence of confounding by inferred underreporting. Beverage choice played no major independent role.
Conclusion:
Heavy alcohol drinking is related to increased risk of some cancer types but not others. Because of probable confounding, the role of light-to-moderate drinking remains unclear.
doi:10.7812/TPP/14-189
PMCID: PMC4403578  PMID: 25785639
25.  Maintenance of Certification Part IV Quality-Improvement Project for Hypertension Control: A Preliminary Retrospective Analysis 
The Permanente Journal  2015;19(2):36-40.
Fifty-two American Board of Family Medicine and 19 American Board of Internal Medicine certified physicians completed projects to increase the percentage of hypertensive patients on their patient panels who had controlled blood pressure. Mean panel blood pressure control improved from 79.49% to 84.64%. The choice of improvement option was not associated with the level of improvement or with the participant’s perception of the workload related to completing the project.
Context:
A Maintenance of Certification Part IV project was created on the basis of an existing, multifaceted hypertension improvement program.
Objective:
To evaluate the impact of the Maintenance of Certification project, the effects of the improvement options on blood pressure control in hypertensive patients, and the participants’ perception of the workload related to participation in the project.
Design:
Nonexperimental retrospective analysis.
Setting:
Kaiser Permanente hospitals and medical office buildings in Northern California.
Intervention:
Participants used one or more options from a defined menu of strategies to attempt to increase the percentage of hypertensive patients on their patient panels who had controlled blood pressure.
Main Outcome Measure:
Proportion of hypertensive patients with blood pressure ≤ 139/89 mm Hg.
Results:
Fifty-two American Board of Family Medicine and 19 American Board of Internal Medicine certified physicians completed projects. Mean panel blood pressure control improved from 79.49% (standard deviation [SD] = 11.32) to 84.64% (SD = 7.80). The choice of improvement option was not associated with the level of improvement or with the participants’ perception of the workload related to completing the project.
Conclusion:
Project participants improved the care of their patients without an increased perceived burden to their practice. We found no association between the choice of improvement option and either the level of improvement or the perception of workload.
doi:10.7812/TPP/14-121
PMCID: PMC4403579  PMID: 25785642

Results 1-25 (761)