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1.  Financial Implications of the Continuity of Primary Care 
The Permanente Journal  2015;19(1):4-10.
Using British Columbia Ministry of Health administrative databases for fiscal year 2010–2011 and generalized linear models, cost ratios were estimated for 10 cost-related predictor variables, including patients’ attachment to the practice. Across 8 medical conditions patients’ attachment to the practice had the strongest relationship to costs. Higher attachment was associated with lower costs. Extrapolation of the findings indicated an increase of 5% in overall attachment level for the selected high-care-needs patients and could have resulted in an estimated cost avoidance of $142 million Canadian for fiscal year 2010–2011.
Background:
The objective of this study was to assess the financial implications of the continuity of care, for patients with high care needs, by examining the cost of government-funded health care services in British Columbia, Canada.
Methods:
Using British Columbia Ministry of Health administrative databases for fiscal year 2010–2011 and generalized linear models, we estimated cost ratios for 10 cost-related predictor variables, including patients’ attachment to the practice. Patients were selected and divided into groups on the basis of their Resource Utilization Band (RUB) and placement in provincial registries for 8 chronic conditions (1,619,941 patients). The final dataset included all high- and very-high-care-needs patients in British Columbia (ie, RUB categories 4 and 5) in 1 or more of the 8 registries who met the screening criteria (222,779 patients).
Results:
Of the 10 predictors, across 8 medical conditions and both RUBs, patients’ attachment to the practice had the strongest relationship to costs (correlations = −0.168 to −0.322). Higher attachment was associated with lower costs. Extrapolation of the findings indicated that an increase of 5% in the overall attachment level, for the selected high-care-needs patients, could have resulted in an estimated cost avoidance of $142 million Canadian for fiscal year 2010–2011.
Conclusions:
Continuity of care, defined as a patient’s attachment to his/her primary care practice, can reduce health care costs over time and across chronic conditions. Health care policy makers may wish to consider creating opportunities for primary care physicians to increase the attachment that their high-care-needs patients have to their practices.
doi:10.7812/TPP/14-107
PMCID: PMC4315369  PMID: 25431998
2.  Efficacy and Utility of Phone Call Follow-up after Pediatric General Surgery versus Traditional Clinic Follow-up 
The Permanente Journal  2015;19(1):11-14.
The authors conducted a retrospective review of the charts of patients in a large academic practice who underwent select surgical procedures and they contacted those patients’ families by telephone 2 weeks after intervention. Six months after implementation, overall postoperative appointments decreased from 55.5% to 35.5%, and 62.6% of patients had a successful postoperative phone call follow-up. A satisfaction survey revealed that 93% of patients were highly satisfied.
Context:
Typical follow-up for surgical procedures consists of an interim history and brief focused physical examination. These appointments occupy clinic resources, require a time investment by the family, and rarely identify problems. Previous studies have demonstrated the safety of a postoperative phone call.
Objective:
Compare a traditional in-person clinic postoperative visit with postoperative phone call follow-up regarding patient satisfaction, rate of successful follow-up, and clinic resource utilization in a large academic practice.
Design:
A retrospective review of charts of patients who underwent select surgical procedures, along with a review of the clinic schedule for the same time period.
Main Outcome Measures:
Efficacy, patient/family satisfaction, and impact on the clinic.
Methods:
Families were contacted by telephone two weeks after select surgical procedures to assess for complications and questions. Cohorts of patients six months before and six months after implementation were assessed for main outcome measures.
Results:
Before implementation, 55.5% of patients (427/769) who had one of the select surgical procedures were seen in the clinic postoperatively, and 62.6% (435/695) had a successful postoperative phone call follow-up. There were also 1090 overall scheduled postoperative appointments. Six months after implementation, overall postoperative appointments decreased 35.5% to 703. Overall, postoperative-scheduled visits decreased by 6% compared with new visits and other general follow-up visits, which each increased by 3%. A satisfaction survey revealed that 93% of patients (n = 231) were highly satisfied with the process. A hospital cost analysis suggested an 89% cost savings ($101.75 per patient for clinic visit vs $12.50 per patient for phone call follow-up).
Conclusion:
Postoperative phone call follow-up is an effective tool that improves patient and physician efficiency and satisfaction.
doi:10.7812/TPP/14-017
PMCID: PMC4315370  PMID: 25663201
3.  Elderly Patients with Glioblastoma Multiforme Treated with Concurrent Temozolomide and Standard- versus Abbreviated-Course Radiotherapy 
The Permanente Journal  2015;19(1):15-20.
This study reviewed outcomes from 2003 to 2012 of elderly patients aged ≥ 65 with newly diagnosed glioblastoma multiforme treated with concurrent temozolomide and either standard-course radiotherapy (SRT) or abbreviated-course radiotherapy. Multivariate analysis of the entire cohort found those patients receiving SRT, Karnofsky Performance Score of 70 or higher, and more extensive surgery were associated with longer survival time.
Context:
Glioblastoma multiforme (GBM) is an aggressive neoplasm, with controversy regarding treatment in elderly patients.
Objective:
To review outcomes of elderly patients aged ≥ 65 with newly diagnosed GBM treated with concurrent temozolomide and either standard-course radiotherapy (SRT) or abbreviated-course radiotherapy (ART).
Design:
Retrospective review from 2003 to 2012.
Main Outcome Measure:
Survival, comparing treatment regimens. One hundred patients received SRT (median dose = 60 Gy), and 29 received ART (median dose = 35 Gy). O6-methylguanine-DNA methyltransferase (MGMT) status was available for 26 SRT and 13 ART recipients.
Results:
Median age was 70 years. Median follow-up was 11 months. At analysis, 3 patients were alive. Multivariate analysis of the entire cohort found SRT (hazard ratio [HR] = 0.421, p = 0.0001), Karnofsky Performance Score of 70 or higher (HR = 1.894, p = 0.0031), and more extensive surgery (HR = 0.466, p = 0.0023) were associated with longer survival time, but age was not. Median time to death with SRT was 13 months versus 5.4 months with ART, but the latter had worse prognostic factors, including lower Karnofsky Performance Scores, fewer gross total resections, and higher recursive partitioning analysis class. Recipients of SRT with methylated MGMT promoter had a trend toward longer survival compared with unmethylated MGMT (p = 0.06), but ART recipients had shorter survival with MGMT methylation (p = 0.02).
Conclusion:
Elderly patients with multiple poor prognostic factors given ART had short survival times. Relative to other variables, MGMT status may not predict outcome for these patients.
doi:10.7812/TPP/14-083
PMCID: PMC4315371  PMID: 25663202
4.  Risk Factors for Neck Hematoma after Thyroid or Parathyroid Surgery: Ten-Year Analysis of the Nationwide Inpatient Sample Database 
The Permanente Journal  2015;19(1):22-28.
Postoperative neck hematoma is a well-known complication of thyroid and parathyroid surgery. A retrospective analysis was performed of hospital discharge data from the Nationwide Inpatient Sample database of 147,344 thyroid and parathyroid operations performed nationwide between 2000 and 2009. Overall incidence of postoperative neck hematoma was 1.5%. In multivariate analysis, ≥ age 65, male sex, African-American race, being from the South, a comorbidity score of > 3, history of alcohol abuse, Graves disease, and substernal thyroidectomy were associated with a higher risk of neck hematoma.
Context:
Postoperative neck hematoma is a well-known complication of thyroid and parathyroid surgery. Better understanding of risk factors for hematoma formation will help define high-risk populations.
Objective:
To examine possible risk factors for neck hematoma after thyroid or parathyroid surgery.
Design:
Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample database.
Methods:
Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedures codes, we identified adults who underwent thyroid or parathyroid surgery and in whom neck hematoma subsequently developed. Information about demographic, clinical, and hospital characteristics was collected. Multivariate regression analyses were used to predict independent risk factors for neck hematoma.
Results:
We identified 147,344 thyroid and parathyroid operations performed nationwide between 2000 and 2009. Overall incidence of postoperative neck hematoma was 1.5% (n = 2210). In multivariate analysis, age 65 years and older (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.4–2.1), male sex (OR = 1.3, 95% CI = 1.2–1.4), African-American race (OR = 1.5, 95% CI = 1.2–1.7), being from the South (OR = 1.3, 95% CI = 1–1.4), comorbidity score of 3 or more (OR = 2, 95% CI = 1.6–2.6), history of alcohol abuse (OR = 2.7, 95% CI = 1.6–2.5), Graves disease (OR = 3, 95% CI = 2.1–4.1), and substernal thyroidectomy (OR = 3.3, 95% CI = 2.8–3.9) were associated with a higher risk of neck hematoma.
Conclusion:
We identified demographic and clinical factors associated with increased risk of neck hematoma after thyroid or parathyroid surgery.
doi:10.7812/TPP/14-085
PMCID: PMC4315372  PMID: 25663203
5.  Upstream Discussion Provided in the Ambulatory Setting to Assist Patients with Chronic Kidney Disease Considering Dialysis 
The Permanente Journal  2015;19(1):30-33.
The authors randomly assigned patients with Stage 4 or 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups. The test group received an additional nephrology consult with an interdisciplinary team and reported help in forming a treatment plan, felt well understood, and had the opportunity to thoroughly discuss questions. They had a decrease in beginning dialysis, clinic visits, hospital admissions, days hospitalized, and emergency room visits.
Objectives:
Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care and often occurs during an acute hospitalization. We conducted a “test-of-change” pilot study to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist patients with chronic kidney disease considering treatment choices.
Methods:
We randomly assigned patients with Stage 4 or Stage 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups. The test group received the additional nephrology consult and met with an interdisciplinary team composed of a nephrologist, social worker, and clinical ethicist, and the control group did not. Qualitative data were collected in 2012 and 2013 via oral questionnaire. Both groups received a 6-month follow-up assessment.
Results:
Patients who received the nephrology consult reported that they experienced help in forming a treatment plan, felt well understood, and had the opportunity to thoroughly discuss questions. The controls had a 26% increased probability of beginning dialysis and had a statistically significant increase in dialysis and clinic visits (p < 0.10 and p < 0.05). Controls also were likelier than the test group to be admitted to the hospital (0.5 vs 0.2 admissions per patient in the test group), spend more days hospitalized (2.8 vs 0.5 bed days per patient), and visit the emergency room (0.73 vs 0.66 visits per patient) and clinic (6.6 vs 3.6 visits per patient).
Conclusions:
An additional nephrology consultation proved helpful both qualitatively and quantitatively.
doi:10.7812/TPP/14-053
PMCID: PMC4315373  PMID: 25432000
6.  Nasal Methicillin-Resistant Staphylococcus aureus Polymerase Chain Reaction: A Potential Use in Guiding Antibiotic Therapy for Pneumonia 
The Permanente Journal  2015;19(1):34-36.
This is a retrospective study of adult patients admitted to a large urban hospital, who had a nasal methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) test and a lower respiratory tract culture within 48 hours of admission that the culture yielded Staphylococcus aureus. Results showed high sensitivity (93.3%) and negative predictive value (95.2%) of nasal PCR for MRSA in the lower respiratory tract. A nasal MRSA PCR test could guide the discontinuation of MRSA-directed empiric antibiotic therapy in patients who are unlikely to be infected with this organism.
Context:
The role at admission of nasal polymerase chain reaction (PCR) for patients with methicillin-resistant Staphylococcus aureus (MRSA) in guiding antibiotic therapy for lower respiratory tract infection is unknown.
Objective:
To determine whether nasal MRSA PCR at admission can predict the absence of MRSA in lower respiratory tract secretions.
Design:
We performed a retrospective study of adult patients admitted to a large urban hospital. Patients had a nasal MRSA PCR test and a lower respiratory tract culture obtained within 48 hours of admission and the culture yielded S aureus.
Main outcome measures:
Sensitivity, specificity, and positive and negative predictive values.
Results:
Our results showed high sensitivity (93.3%) and negative predictive value (95.2%) of nasal PCR for MRSA in the lower respiratory tract.
Conclusion:
With its high sensitivity and negative predictive value, a nasal MRSA PCR test performed within 48 hours of hospital admission could help guide the discontinuation of MRSA-directed empiric antibiotic therapy in patients who are unlikely to be infected with this organism. A prospective study is needed to confirm these findings.
doi:10.7812/TPP/14-101
PMCID: PMC4315374  PMID: 25432002
7.  Passive Cigarette Smoke Exposure and Other Risk Factors for Invasive Pneumococcal Disease in Children: A Case-Control Study 
The Permanente Journal  2015;19(1):38-43.
In a population-based, case-control study, 171 children, aged 0 to 12 years, with culture-confirmed invasive pneumococcal disease during the years 1994 to 2004 were identified. Two controls were matched to each case. The authors reviewed medical records of subjects and family members for information on household cigarette smoke exposure within 2 years of the diagnosis. Passive cigarette smoke exposure was not associated with invasive pneumococcal disease in this pediatric population.
Objective:
To investigate whether passive cigarette smoke exposure increases the risk of invasive pneumococcal disease in children.
Methods:
In a population-based case-control study, 171 children aged 0 to 12 years with culture-confirmed invasive pneumococcal disease during the years 1994 to 2004 were identified. Two controls were matched to each case on age and patterns of Health Plan membership. We reviewed medical records of subjects and family members for information on household cigarette smoke exposure within 2 years of the diagnosis of invasive pneumococcal disease. We collected information on sex, race, pneumococcal vaccination, selected medical conditions, and medications in the 3 months before the diagnosis.
Results:
Similar proportions of cases (25%) and controls (30%) had definite or probable passive smoke exposure (odds ratio [OR] = 0.76, 95% confidence interval [CI] = 0.47–1.2). Cases of invasive pneumococcal disease were more likely to be nonwhite than controls (OR = 4.4, 95% CI = 2.3–8.2). Elevated risk of invasive pneumococcal disease was found in subjects with recent pulmonary diagnoses (OR = 2.2, 95% CI = 1.2–4.0) and recent antibiotic use (OR = 1.6, 95% CI = 1.1–2.3).
Conclusions:
Passive cigarette smoke exposure was not associated with invasive pneumococcal disease in this pediatric population. Invasive pneumococcal disease was associated with recent pulmonary diagnoses and recent antibiotic use.
doi:10.7812/TPP/14-010
PMCID: PMC4315375  PMID: 25431997
8.  Trends in the Frequency of Original Research in Acne Vulgaris, Rosacea, Dermatitis, Psoriasis, Skin Cancer, and Skin Infections, 1970–2010 
The Permanente Journal  2015;19(1):44-47.
A retrospective review of the Journal of the American Academy of Dermatology and the Archives of Dermatology was performed using the MEDLINE database for all original research articles published between 1970 and 2010. The frequency of research into acne vulgaris and rosacea decreased from 24% to 5.1%, psoriasis research increased from 17.6% to 26.5% (most likely because of the discovery of biologics), and skin cancer research increased from 4% to 48% (paralleling the increasing incidence of skin cancer).
Context:
Medical journals have allowed researchers to share their latest discoveries, especially in the most common diseases affecting patients worldwide.
Objective:
To analyze trends in the frequency of original research into common dermatologic diseases from 1970 to 2010.
Design:
A retrospective review of the Journal of the American Academy of Dermatology and the Archives of Dermatology was performed using the MEDLINE database. All original research articles published between 1970 and 2010, by quinquennium, dealing with acne vulgaris, rosacea, skin cancer, dermatitis, psoriasis, or skin infections were included.
Main Outcome Measure:
Total number of publications dealing with each dermatologic topic considered.
Results:
The frequency of research into acne vulgaris and rosacea decreased from 24% in 1970 to 5.1% in 2010. Psoriasis research increased in frequency from 17.6% to 26.5% from 2000 to 2010, and skin cancer research increased from 4% in 1970 to 48% in 2010.
Conclusions:
Topics that experienced early advancements in research, such as acne vulgaris and rosacea, demonstrated a decreasing trend in the frequency of publication. Published psoriasis research has increased in frequency since 2000, most likely because of the discovery of biologics. Finally, skin cancer research has continued to increase in frequency of publication, paralleling the increasing incidence of skin cancer.
doi:10.7812/TPP/14-104
PMCID: PMC4315376  PMID: 25663204
9.  Intervention to Reduce Inappropriate Ionized Calcium Ordering Practices: A Quality-Improvement Project 
The Permanente Journal  2015;19(1):49-51.
The authors hypothesized that most ionized calcium (iCa) tests are ordered for routine monitoring in asymptomatic patients and results do not influence clinical management. On retrospective review of clinical records they identified the first 100 consecutive patients admitted to the hospital internal medicine (HIM) services during January 2012 with an iCa test ordered during their hospitalization. An educational intervention regarding the appropriateness of iCa testing was undertaken targeting HIM clinicians. They then assessed the first 100 consecutive patients admitted to HIM services during November 2012. HIM services were responsible for 38% of iCa measurements before the educational intervention and 13% after, which represented a 66% reduction.
Context:
The importance of an abnormal ionized calcium (iCa) measurement in noncritically ill patients is unclear. Furthermore, iCa monitoring is more expensive than measurement of total calcium and consumes more laboratory resources. We hypothesize that most iCa tests are ordered for routine monitoring in asymptomatic patients, and results do not influence clinical management.
Objective:
To characterize and to intervene on iCa test-ordering practices among our institution’s hospital-based internal medicine clinicians.
Design:
A quality-improvement project, with retrospective review of clinical records. We retrospectively identified the first 100 consecutive patients admitted to our hospital internal medicine (HIM) services during January 2012 with an iCa test ordered during their hospitalization. We reviewed clinical records to determine the appropriateness of iCa test ordering and of the ordering department. An educational intervention regarding the appropriateness of iCa testing was undertaken targeting HIM clinicians.
Main Outcome Measures:
The effect of the intervention was assessed by identifying a sample of the first 100 consecutive patients admitted to HIM services during November 2012 and by comparing the proportion of iCa tests ordered by HIM clinicians before and after the intervention.
Results:
HIM services were responsible for 38% of iCa measurements before the educational intervention, with the remainder originating primarily from the Emergency Department (29%) and intensive care units (28%). After the intervention, the internal medicine services were responsible for 13% of iCa measurements, which represented a 66% reduction (p = 0.0007).
Conclusion:
A simple intervention based on clinician education can reduce the frequency of routine iCa monitoring in stable hospitalized patients.
doi:10.7812/TPP/14-108
PMCID: PMC4315377  PMID: 25663205
10.  Temporal Comorbidity of Mental Disorder and Ulcerative Colitis 
The Permanente Journal  2015;19(1):52-57.
The authors used physician diagnoses from Calgary, Alberta, for patient visits from fiscal years 1994 to 2009 for treatment of any presenting concern (763,449 patients) to identify 5113 patients with a diagnosis of ulcerative colitis, and found 4192 patients also had a diagnosis of a mental disorder. Patients with mental disorder had a significantly higher annual prevalence. The mental disorder grouping neuroses/depression was most likely to arise before diagnosis of ulcerative colitis.
Objectives:
Ulcerative colitis is an inflammatory bowel disease that rarely exists in isolation in affected patients. We examined the association of ulcerative colitis and International Classification of Diseases mental disorder, as well as the temporal comorbidity of three broad International Classification of Diseases groupings of mental disorders in patients with ulcerative colitis to determine if mental disorder is more likely to occur before or after ulcerative colitis.
Methods:
We used physician diagnoses from the regional health zone of Calgary, Alberta, for patient visits from fiscal years 1994 to 2009 for treatment of any presenting concern in that Calgary health zone (763,449 patients) to identify 5113 patients age younger than 1 year to age 92 years (2120 males, average age = 47 years; 2993 females, average age = 48 years) with a diagnosis of ulcerative colitis.
Results:
The 16-year cumulative prevalence of ulcerative colitis was 0.0058%, or 58 cases per 10,000 persons (95% confidence interval = 56–60 per 10,000). Although the cumulative prevalence of mental disorder in the overall sample was 5390 per 10,000 (53.9%), we found that 4192 patients with ulcerative colitis (82%) also had a diagnosis of a mental disorder. By annual rate of ulcerative colitis, patients with mental disorder had a significantly higher annual prevalence. The mental disorder grouping neuroses/depressive disorders was most likely to arise before ulcerative colitis (odds ratio = 1.87 for males; 2.24 for females).
Conclusions:
A temporal association was observed between specific groups of International Classification of Diseases mental disorder and ulcerative colitis, indicating a possible etiologic relationship between the disorders or their treatments, or both.
doi:10.7812/TPP/14-120
PMCID: PMC4315378  PMID: 25663206
11.  High Amount of Dietary Fiber Not Harmful But Favorable for Crohn Disease 
The Permanente Journal  2015;19(1):58-61.
Current chronic diseases are a reflection of the Westernized diet that features a decreased consumption of indigestible dietary fiber metabolized by gut bacteria to butyrate, which has a critical role in colonic homeostasis. The authors report on initiating a semivegetarian diet (SVD) for patients with inflammatory bowel disease. There was no untoward effect of the SVD. The remission rate with combined infliximab and SVD for patients with newly diagnosed Crohn Disease was 100%. Maintenance of remission on SVD without scheduled maintenance therapy with biologic drugs was 92% at 2 years. The authors recommend a high fiber intake to treat Crohn Disease.
Current chronic diseases are a reflection of the westernized diet that features a decreased consumption of dietary fiber. Indigestible dietary fiber is metabolized by gut bacteria, including Faecalibacterium prausnitzii, to butyrate, which has a critical role in colonic homeostasis owing to a variety of functions. Dietary fiber intake has been significantly inversely associated with the risk of chronic diseases. Crohn disease (CD) is not an exception. However, even authors who reported the inverse association between dietary fiber and a risk of CD made no recommendation of dietary fiber intake to CD patients. Some correspondence was against advocating high fiber intake in CD.
We initiated a semivegetarian diet (SVD), namely a lacto-ovo-vegetarian diet, for patients with inflammatory bowel disease. Our SVD contains 32.4 g of dietary fiber in 2000 kcal. There was no untoward effect of the SVD. The remission rate with combined infliximab and SVD for newly diagnosed CD patients was 100%. Maintenance of remission on SVD without scheduled maintenance therapy with biologic drugs was 92% at 2 years. These excellent short- and long-term results can be explained partly by SVD. The fecal bacterial count of F prausnitzii in patients with CD is significantly lower than in healthy controls. Diet reviews recommend plant-based diets to treat and to prevent a variety of chronic diseases. SVD belongs to plant-based diets that inevitably contain considerable amounts of dietary fiber. Our clinical experience and available data provide a rationale to recommend a high fiber intake to treat CD.
doi:10.7812/TPP/14-124
PMCID: PMC4315379  PMID: 25663207
12.  A Plant-Based Diet, Atherogenesis, and Coronary Artery Disease Prevention 
The Permanente Journal  2015;19(1):62-67.
Atherosclerosis associated with high dietary intake of meats, fat, and carbohydrates remains the leading cause of mortality in the US. Polyphenols derived from dietary plant intake have protective effects on vascular endothelial cells, possibly as antioxidants that prevent oxidation of low-density lipoprotein. This review provides a mechanistic perspective of the evidence for protection by a plant-based diet against atherosclerotic coronary artery disease.
A plant-based diet is increasingly becoming recognized as a healthier alternative to a diet laden with meat. Atherosclerosis associated with high dietary intake of meat, fat, and carbohydrates remains the leading cause of mortality in the US. This condition results from progressive damage to the endothelial cells lining the vascular system, including the heart, leading to endothelial dysfunction. In addition to genetic factors associated with endothelial dysfunction, many dietary and other lifestyle factors, such as tobacco use, high meat and fat intake, and oxidative stress, are implicated in atherogenesis. Polyphenols derived from dietary plant intake have protective effects on vascular endothelial cells, possibly as antioxidants that prevent the oxidation of low-density lipoprotein. Recently, metabolites of L-carnitine, such as trimethylamine-N-oxide, that result from ingestion of red meat have been identified as a potential predictive marker of coronary artery disease (CAD). Metabolism of L-carnitine by the intestinal microbiome is associated with atherosclerosis in omnivores but not in vegetarians, supporting CAD benefits of a plant-based diet. Trimethylamine-N-oxide may cause atherosclerosis via macrophage activation. We suggest that a shift toward a plant-based diet may confer protective effects against atherosclerotic CAD by increasing endothelial protective factors in the circulation while reducing factors that are injurious to endothelial cells. The relative ratio of protective factors to injurious endothelial exposure may be a novel approach to assessing an objective dietary benefit from a plant-based diet. This review provides a mechanistic perspective of the evidence for protection by a plant-based diet against atherosclerotic CAD.
doi:10.7812/TPP/14-036
PMCID: PMC4315380  PMID: 25431999
13.  Acupuncture Safety in Patients Receiving Anticoagulants: A Systematic Review 
The Permanente Journal  2015;19(1):68-73.
A search of PubMed, EMBASE, and Google Scholar revealed 39 citations of which 7 provided reporting quality sufficient to assess acupuncture safety in 384 anticoagulated patients (3974 treatments). Acupuncture appears to be safe in anticoagulated patients, assuming appropriate needling location and depth. The observed 0.003% complication rate is lower than the previously reported 12.3% following hip/knee replacement, and 6% following acupuncture in a prospective study of 229,230 all-type patients.
Introduction:
Theoretically, acupuncture in anticoagulated patients could increase bleeding risk. However, precise estimates of bleeding complication rates from acupuncture in anticoagulated patients have not been systematically examined.
Objective:
To critically evaluate evidence for safety of acupuncture in anticoagulated patients.
Methods:
We searched PubMed, EMBASE, the Physiotherapy Evidence Database, and Google Scholar.
Results:
Of 39 potentially relevant citations, 11 met inclusion criteria: 2 randomized trials, 4 case series, and 5 case reports. Seven provided reporting quality sufficient to assess acupuncture safety in 384 anticoagulated patients (3974 treatments). Minor-moderate bleeding related to acupuncture in an anticoagulated patient occurred in one case: a large hip hematoma, managed with vitamin K reversal and warfarin discontinuation following reevaluation of its medical justification. Blood-spot bleeding, typical for any needling/injection and controlled with pressure/cotton, occurred in 51 (14.6%) of 350 treatments among a case series of 229 patients. Bleeding deemed unrelated to acupuncture during anticoagulation, and more likely resulting from inappropriately deep needling damaging tissue or from complex anticoagulation regimens, occurred in 5 patients. No bleeding was reported in 2 studies (74 anticoagulated patients): 1 case report and 1 randomized trial prospectively monitoring acupuncture-associated bleeding as an explicit end point. Altogether, 1 moderate bleeding event occurred in 3974 treatments (0.003%).
Conclusion:
Acupuncture appears to be safe in anticoagulated patients, assuming appropriate needling location and depth. The observed 0.003% complication rate is lower than the previously reported 12.3% following hip/knee replacement in a randomized trial of 27,360 anticoagulated patients, and 6% following acupuncture in a prospective study of 229,230 all-type patients. Prospective trials would help confirm our findings.
doi:10.7812/TPP/14-057
PMCID: PMC4315381  PMID: 25432001
14.  An Idiosyncratic Reaction to Clopidogrel 
The Permanente Journal  2015;19(1):74-76.
Clopidogrel is an irreversible antiplatelet agent that antagonizes the adenosine diphosphate P2Y12 receptor on platelets disrupting fibrinogen—platelet complex formation. The authors report on a rare but clinically significant case of clopidogrel-induced hepatotoxicity in an elderly white woman.
Clopidogrel is an irreversible antiplatelet agent belonging to the thienopyridine group that acts to antagonize the adenosine diphosphate P2Y12 receptor on platelets. It thus inhibits the activation of platelet glycoprotein GPIIb/IIIa complex, which is essential for fibrinogen—platelet complex formation. Clopidogrel has widely replaced ticlopidine because of a much better clinical safety profile. Clopidogrel is a prodrug that requires hepatic activation to exert its antiplatelet effect. Hepatotoxicity with use of clopidogrel is a rare but clinically significant phenomenon. We report a case of clopidogrel-induced hepatotoxicity in an elderly white woman.
doi:10.7812/TPP/14-040
PMCID: PMC4315382  PMID: 25663208
15.  Pemphigus Vulgaris with Tense Bullae 
The Permanente Journal  2015;19(1):77-78.
A 51-year old woman with a history of type II diabetes mellitus and dyslipidemia presented with painful lips with swelling and crusting. One year after onset of mucosal lesions, she developed an abdominal eruption with several tense vesicles and bullae on an erythematous base.
We report a case of a 51-year-old woman with a history of type II diabetes mellitus and dyslipidemia presenting with pain, swelling, and crusting of the lips. One year after onset of mucosal lesions, she developed an abdominal eruption with several tense vesicles and bullae on an erythematous base. The hematoxylin and eosin stain sample was consistent with a diagnosis of pemphigus vulgaris. The tense bullae of our patient highlight a rare phenotype of pemphigus vulgaris, which fits the mucocutaneous type because of involvement of the oral mucosa, with the exception of the findings of tense bullae.
doi:10.7812/TPP/14-131
PMCID: PMC4315383  PMID: 25663209
16.  Adult Intussusception 
The Permanente Journal  2015;19(1):79-81.
This report presents the case of a 37-year-old man with multiple Emergency Department visits for abdominal pain and with negative results for prior imaging studies, who was eventually diagnosed with intussusception after 5 years of recurrent symptoms. The case is followed by a review of the literature.
Recurrent abdominal pain is a common and challenging presenting chief complaint in the Emergency Department. Intussusception in adults, although rare, is an important etiology to consider. The diagnosis can often be delayed because of the nonspecific and intermittent nature of symptoms in adults. This report presents the case of a 37-year-old man with multiple Emergency Department visits for abdominal pain and with negative results for prior imaging studies, who was eventually diagnosed with intussusception after 5 years of recurrent symptoms. The case study is followed by a review of the literature regarding the diagnosis and management of intussusception in adults.
doi:10.7812/TPP/14-125
PMCID: PMC4315384  PMID: 25663210
17.  Image Diagnosis: Weber Syndrome: A Rare Presentation of Acute Leukemia—A Case Report and Review of the Literature 
The Permanente Journal  2015;19(1):83-85.
For two weeks before presentation, a 13-year-old boy had fever, fatigue, and breathlessness, and painless lymphadenopathy on both sides of his neck, axilla, and groin. He developed drooping of the right upper eyelid. Non-contrast computed tomography scans of the head showed multiple hemorrhages.
doi:10.7812/TPP/14-126
PMCID: PMC4315385  PMID: 25663211
18.  Harnessing the Affordable Care Act to Catalyze Delivery System Reform and Strengthen Emergency Care in America 
The Permanente Journal  2015;19(1):86-89.
As health care reform in the US evolves beyond insurance reform to encompass delivery-system reform, the opportunity arises to harness the Affordable Care Act to strengthen patient care in America. This article describes the innovations of the surgicalist and acute care surgeon that have emerged to promote teamwork, to reduce readmissions, and to strengthen emergency care.
As health care reform in the US evolves beyond insurance reform to encompass delivery system reform, the opportunity arises to harness the Affordable Care Act to strengthen patient care in America. One area for dedicated individuals to lead this effort is by improving transitions in patient care across the continuum of team members, specialties, settings, and systems. This article will describe innovations of the surgicalist and acute care surgeon that have emerged in response to the challenges facing surgery in specialization, geography, and the need to comply with health care reform mandates. Three ways will be described to integrate these innovations with pilot programs in the Affordable Care Act: to promote teamwork, to reduce readmissions, and to strengthen emergency care because the key location where the joint efforts intersect most acutely with patient need is in our nation’s Emergency Departments.
doi:10.7812/TPP/14-168
PMCID: PMC4315386  PMID: 25663212
19.  Agents for Change: Nonphysician Medical Providers and Health Care Quality 
The Permanente Journal  2015;19(1):90-93.
Nonphysician medical providers may be the first caregivers to encounter the patient and can act as agents for change for an organization’s quality-improvement mandate by supporting best practices through the promotion of guidelines/protocols and playing active roles in patient engagement and organizational quality-improvement efforts.
Quality medical care is a clinical and public health imperative, but defining quality and achieving improved, measureable outcomes are extremely complex challenges. Adherence to best practice invariably improves outcomes. Nonphysician medical providers (NPMPs), such as physician assistants and advanced practice nurses (eg, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, and certified nurse midwives), may be the first caregivers to encounter the patient and can act as agents for change for an organization’s quality-improvement mandate. NPMPs are well positioned to both initiate and ensure optimal adherence to best practices and care processes from the moment of initial contact because they have robust clinical training and are integral to trainee/staff education and the timely delivery of care. The health care quality aspects that the practicing NPMP can affect are objective, appreciative, and perceptive. As bedside practitioners and participants in the administrative and team process, NPMPs can fine-tune care delivery, avoiding the problem areas defined by the Institute of Medicine: misuse, overuse, and underuse of care. This commentary explores how NPMPs can affect quality by 1) supporting best practices through the promotion of guidelines and protocols, and 2) playing active, if not leadership, roles in patient engagement and organizational quality-improvement efforts.
doi:10.7812/TPP/14-095
PMCID: PMC4315387  PMID: 25663213
20.  No Laughing Matter 
The Permanente Journal  2015;19(1):94-95.
A cough, then breathlessness; laughter then breathlessness. Is the cause the tubes or the gut?
doi:10.7812/TPP/14-128
PMCID: PMC4315388  PMID: 25663214
21.  Image Diagnosis: aVR, the Forgotten Lead 
The Permanente Journal  2015;19(1):e101-e102.
The 12-lead electrocardiogram has been referred to as an “11-lead study” on the basis of the false assumption that lead aVR yields only limited information. However, it can provide information in the management of several medical conditions.
doi:10.7812/TPP/14-099
PMCID: PMC4315389  PMID: 25663215
22.  Mindfulness-Based Stress Reduction in an Integrated Care Delivery System: One-Year Impacts on Patient-Centered Outcomes and Health Care Utilization 
The Permanente Journal  2014;18(4):4-9.
Mindfulness-based stress reduction (MBSR) programs have demonstrated clinical effectiveness for both mental and physical health conditions. Less research exists on health services utilization, self-efficacy, or work productivity outcomes. A prospective single cohort design evaluated an 8-week MBSR program for 38 Kaiser Permanente Colorado members with chronic pain, chronic illness, or stress-related problems. Repeated measures analyzed at 8 weeks and 1 year showed significant improvements in self-reported mental and physical function, pain, psychological symptoms, and self-efficacy, but not in work productivity. There were also significant decreases at 1 year for visits to: primary care, specialty care, and the Emergency Department, and for hospital admissions.
Background:
Mindfulness-based stress reduction (MBSR) programs have demonstrated clinical effectiveness for both mental and physical health conditions. Less research exists on health services utilization, self-efficacy, or work productivity outcomes.
Objective:
To assess one-year outcomes of MBSR in patients with chronic pain, chronic illness, or stress-related problems, measuring functional status, pain, self-efficacy, depression, anxiety, somatization, psychological distress, work productivity, and changes in health services utilization.
Methods:
A prospective single cohort design evaluated an eight-week MBSR program for Kaiser Permanente Colorado members. Patient-reported measures were collected at baseline, eight weeks, and one year following MBSR. Differences in health services utilization were compared from six months before MBSR to six months following the one-year anniversary of MBSR.
Results:
Most of the 38 participants were white (28; 74%), female (30; 79%), employed part-time (35; 92%), and average age 52.6 years, with multiple comorbidities (averaging 16.4 unique diagnoses), the most common being joint or back pain (28; 74%) and psychological disorder (20; 53%). Repeated measures analyses at 8 weeks (n = 26) and at 1 year (n = 24) showed significant improvements in self-reported mental and physical function, pain, psychological symptoms, and self-efficacy, but not work productivity. Significant decreases at 1 year were observed for visits in primary care (−50%, p < 0.0001), specialty care (−38%, p = 0.0004), and the Emergency Department (−50%, p = 0.04), and for hospital admissions (−80%, p = 0.02).
Conclusion:
The MBSR program was associated with improvements in several patient-centered outcomes over 1 year and reductions in health services utilization up to 18 months.
doi:10.7812/TPP/14-014
PMCID: PMC4206164
23.  Improving Appropriate Use of Pulmonary Computed Tomography Angiography by Increasing the Serum D-Dimer Threshold and Assessing Clinical Probability 
The Permanente Journal  2014;18(4):10-15.
A retrospective review was conducted of all patients undergoing pulmonary computed tomography angiogram during 2 separate 12-month intervals: 1 before the implementation of an increased D-dimer threshold and recommendation for formal clinical probability assessment, and the other after regional implementation. The prevalence of pulmonary embolism detected by computed tomography angiography increased from 4.7% to 11.7%, but only 4% of patients had a formal clinical probability assessment recorded in their electronic medical record.
Objective:
To determine whether the implementation of an increased D-dimer threshold value and clinical probability assessment increases the prevalence of pulmonary embolism (PE) in patients undergoing pulmonary computed tomography angiography (PCTA) in an Emergency Department setting.
Methods:
A retrospective review of all patients undergoing PCTA during 2 separate 12-month intervals, 1 before the implementation of an increased D-dimer threshold and recommendation for formal clinical probability assessment and the other after regional implementation. The primary outcome measure was the prevalence of acute PE in each of the samples.
Results:
After the implementation of the increased D-dimer threshold and recommendation for formal clinical probability assessment, the prevalence of PE detected by PCTA increased from 4.7% to 11.7% (p < 0.001). Among all PCTAs performed after the new guidelines were promulgated, 8.6% were still performed on patients who had serum D-dimer values lower than the threshold of 1.0 µg/mL. Despite the recommendation for formal clinical probability assessment before ordering a PCTA, only 4% of patients had a formal clinical probability assessment recorded in their electronic medical record.
Conclusion:
The implementation of an increased D-dimer threshold value increased the prevalence of PE in patients undergoing PCTA in an Emergency Department setting, but more consistent application of clinical probability assessment remains an elusive target.
doi:10.7812/TPP/14-007
PMCID: PMC4206165
24.  Testing for Meningitis in Children with Bronchiolitis 
The Permanente Journal  2014;18(4):16-19.
The authors present a retrospective, case-control study of hospitalized infants younger than age one year diagnosed with viral bronchiolitis who underwent lumbar puncture as part of an evaluation for meningitis. The presence of apnea, cyanosis, meningeal signs, positive urine culture results, and young age were factors found to be preliminarily associated with the performance of a lumbar puncture in the setting of bronchiolitis. Young age was the only significant clinical factor found after multivariable regression; no other demographic, clinical, laboratory, or radiologic variables were found to be significant.
Viral bronchiolitis accounts for almost 20% of all-cause hospitalizations of infants (ie, children younger than age 1 year). The annual incidence of fever in viral bronchiolitis has been documented at 23% to 31%. However the incidence of concurrent serious bacterial infections is low (1%–7%), with meningitis occurring in less than 1% to 2% of cases, but lumbar puncture is performed in up to 9% of viral bronchiolitis cases. To our knowledge, no study has examined clinical factors that influence a physician’s decision to perform a lumbar puncture in the setting of viral bronchiolitis.
We present a retrospective, case-control study of hospitalized infants younger than one year diagnosed with viral bronchiolitis who underwent lumbar puncture as part of an evaluation for meningitis. The objective of the study was to determine clinical factors that influence a physician’s decision to perform a lumbar puncture in the setting of viral bronchiolitis. Although the presence of apnea, cyanosis, meningeal signs, positive urine culture results, and young age were factors found to be preliminarily associated with the performance of a lumbar puncture in the setting of bronchiolitis, young age was the only significant clinical factor found after multivariable regression; no other demographic, clinical, laboratory, or radiologic variables were found to be significant.
doi:10.7812/TPP/14-015
PMCID: PMC4206166
25.  Impact of Implementing Glycated Hemoglobin Testing for Identification of Dysglycemia in Youth 
The Permanente Journal  2014;18(4):21-27.
At both, Kaiser Permanente Hawaii and Kaiser Permanente Northwest, fasting plasma glucose testing was significantly more common in 2009 and HbA1C testing was more common in 2012, but the characteristics of the overall population did not change. At both sites, the characteristics of youth at risk of diabetes changed substantially with a much greater proportion being female and children younger than age 10 years. The size and composition of the population of youth identified with diabetes was not affected.
Objectives:
To determine the impact of the introduction of the glycated hemoglobin (HbA1C) assay for diabetes mellitus diagnosis among children and adolescents aged 6–17 years and to describe the composition of the population of patients with, and at risk for, diabetes using fasting plasma glucose test and HbA1C assay.
Research Design and Methods:
The Kaiser Permanente Hawaii (KPHI) and Kaiser Permanente Northwest (KPNW) sites identified a 2009 and a 2012 cohort of youth who were aged 6–17 years and continuously enrolled in their cohort year and for 1 year prior. We excluded youth with a type 1 or type 2 diabetes diagnosis before their cohort year.
Results:
In both sites, fasting plasma glucose testing was significantly more common in 2009 and HbA1C testing was more common in 2012. The proportion with either test increased from 2.56% to 4.02% in KPNW and from 3.18% to 10.48% in KPHI, but the characteristics of the population did not change between 2009 and 2012. In both sites, the characteristics of youth at risk of diabetes changed substantially with a much greater proportion being female (KPNW: 39% vs 55%; KPHI: 35% vs 46%; p < 0.001 for both) and children younger than 10 (KPNW: 7% vs 32%; KPHI: 11% vs 39%; p < 0.001 for both) between 2009 and 2012. The size and composition of the population of youth identified with diabetes was not affected.
Conclusions:
Adoption of the HbA1C assay for diabetes diagnosis has increased glycemia testing among youth aged 6–17 years and has altered the composition of the population identified as at risk for diabetes. These findings have important ramifications for targeted screening and diabetes prevention efforts.
doi:10.7812/TPP/14-029
PMCID: PMC4206167

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