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INTRODUCTION: Adverse social determinants of health have been shown to be associated with a greater chance of developing chronic conditions. Although there has been increased focus on screening for health-related social needs (HRSNs) in health care delivery systems, it is seldom examined if the provision of needed services to address HRSNs is sufficiently available in communities where patients reside. METHODS: The authors used geospatial analysis to determine how well a newly formed health system and community-based organizations (CBOs) social care coordination network covered the areas in which a high number of patients experiencing HRSNs live. Geospatial clusters (hotspots) were constructed for Kaiser Permanente Northwest members experiencing any of the following 4 HRSNs: transportation needs, housing instability, food insecurity, or financial strain. Next, a geospatial polygon was calculated indicating whether a member could reach a social care provider within 30 minutes of travel time. RESULTS: A total of 185,535 Kaiser Permanente Northwest members completed a HRSN screener between April 2022 and April 2023. Overall, the authors found that among Kaiser Permanente Northwest members experiencing any of the 4 HRSNs, 97% to 98% of them were within 30 minutes of a social care provider. A small percentage of members who lived greater than 30 minutes to a social care provider were primarily located in rural areas. DISCUSSION AND CONCLUSION: This study demonstrates the importance of health system and community-based organization partnerships and investment in community resources to develop social care coordination networks, as well as how patient-level HRSN can be used to assess the coverage and representativeness of the network. [ABSTRACT FROM AUTHOR]

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

We examined the patient activation measure's (PAM's) association with process and health outcomes among adults with chronic conditions. Patients with high PAM scores were sig nificantly more likely to perform self-management behaviors, use self-management services, and report high medication adherence, compared to patients with the lowest PAM scores. This population was 10 times more likely to report high patient-satisfaction scores, 5 times more likely to report high quality-of-life scores, and reported significantly higher physical and mental functional status scores, compared to those with the lowest scores. These results suggest that PAM scores are associated with key process and health outcome measures. [ABSTRACT FROM AUTHOR]

Introduction: Oral health is an important component of overall health, and preventive dental care is essential for maintaining good oral health. However, many patients face significant barriers to preventive dental care. We examined prevalence of and factors associated with no recent preventive dental care in an adult health plan population. Methods: For this cross-sectional study, we used data for 19,672 Kaiser Permanente members aged 25-85 who participated in the 2014/2015 or 2017 Member Health Survey (MHS) and 20,329 Medicaid members who completed an intake questionnaire. We estimated percentages of adults with no preventive dental care (teeth cleaning and examination by a dental professional) in the prior 12 months, overall and among four racial groups, by age, sex, education, income, and dental care cost factors. We used logistic regression to model associations of sociodemographic and cost factors with no preventive dental care. We also examined lack of preventive dental care in subgroups at elevated risk for periodontal disease. Results: Overall prevalence of no preventive dental care was 21%, with significant differences by race (non-Hispanic White, 19.6%; African-American/Black, 29.3%; Latinx, 24.9%, Asian American/Pacific Islander, 19.6%). Adults with lower educational attainment and household income and dental care cost barriers were more likely to lack preventive dental care. Racial and socioeconomic factors remained significant in the multivariable models. Lack of preventive dental care was fairly common among adults with diabetes, prediabetes, hypertension, smokers, frequent consumption of sugary beverages, and Medicaid coverage. Conclusion: Oral health care should be better integrated with primary medical care to promote adult total health. [ABSTRACT FROM AUTHOR]

Introduction: Use of kidney replacement therapy (KRT) prediction models for guiding arteriovenous fistula (AVF) referrals in advanced chronic kidney disease (CKD) is unknown. We aimed to compare a hypothetical approach using a KRT prediction model developed in Kaiser Permanente Northwest to estimated glomerular filtration rate (eGFR) for AVF referrals. Methods: Our retrospective cohort consisted of patients with stage G4 CKD in Kaiser Permanente Northwest followed by nephrology. Two-year KRT risk was calculated at each nephrology visit up to 2 years from entrance into cohort based on a previously published model. We calculated sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) based on several 2-year KRT risk and eGFR cutoffs for outcome of hemodialysis at 18 months. We compared an approach of AVF referral using 2-year KRT risk and eGFR cutoffs using decision curve analysis. Results: Two-year KRT risk better discriminated progression to hemodialysis compared to eGFR,15 mL/min (AUC 0.60 vs 0.69 at 2-year KRT risk. 20% and 0.69 at 2-year KRT risk. 40%, p50.003 and 0.006, respectively) but not to eGFR of 20mL/min (AUC 0.64, p50.16 and 0.19, respectively). Decision curve analysis showed that AVF referral guided by 2-year KRT risk score resulted in higher net benefit compared to eGFR at low thresholds for referral. Conclusion: In stage G4 CKD, a 2-year KRT risk model better predicted progression to KRT at 18 months compared to an eGFR of 15mL/min but not to 20 mL/min and may improve timely referral for AVF placement in patients at lower thresholds for referral. [ABSTRACT FROM AUTHOR]

Social isolation among individuals ages 65 years and older is associated with poor health outcomes. However, little is known about health care utilization patterns of socially isolated individuals. This retrospective, observational study evaluated associations between social isolation and hospital and emergency department (ED) utilization among Medicare patients ages 65 years and older. In a cohort of 18,557 Medicare members age 65 years and older at Kaiser Permanente Northwest, the authors compared rates of hospitalization and ED visits in the 12 months following a baseline survey between respondents who reported feeling lonely or socially isolated and those who did not, controlling for demographic and health variables and utilization in the 12 months prior to the survey. Statistical analysis was conducted in February 2020. In adjusted models, those who reported "sometimes" experiencing social isolation were more likely to have at least 1 hospital admission (odds ratio [ORsometimes]: 1.17, 95% confidence interval [CI]: 1.01–1.35, P = 0.04), than those who "rarely" or "never" experienced social isolation. Those who experienced social isolation "sometimes" or "often/always" were more likely to have at least 1 ED visit (ORsometimes: 1.28, 95% CI: 1.15–1.41, P < 0.0001, and ORoften/always: 1.51, 95% CI: 1.25–1.84, P < 0.0001, respectively) than those who "rarely" or "never" experienced social isolation. These findings suggest that self-reported social isolation may be predictive of future hospital admissions and ED utilization. Research is needed to determine how addressing social isolation needs within the health care system affects health care utilization and health outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Health systems and prescribers need additional tools to reduce the risk of opioid dependence, abuse, and overdose. Identifying opioid-naive individuals who are at risk of opioid dependence could allow for the development of needed interventions. Methods: We conducted a retrospective cohort analysis of 23,804 adults in an integrated health system who had received a first opioid prescription between 2010 and 2015. We compared the demographic, clinical, and prescribing characteristics of individuals who later received a third opioid dispense at least 27 days later, indicating long-term opioid use, with those who did not. Results: The strongest predictors of continued opioid use were an initial prescription dosage of 90 morphine milligram equivalence or more; prescription of extended-release opioids, rather than short-release; and being prescribed outside of a hospital setting. Patients with a third prescription were also more likely to be older than 45 years, white, and non-Hispanic and to have physical comorbidities or prior substance abuse or mental health diagnoses. Discussion: Our findings are largely consistent with prior research but provide new insight into differences in continued opioid use by opioid type, prescribing location, ethnicity, and comorbidities. Together with previous research, our data support a pattern of higher opioid use among older adults but higher rates of diagnosed opioid abuse among younger adults. Conclusions: By identifying population characteristics associated with continued opioid use following a first prescription, our data pave the way for quality improvement interventions that target individuals who are at higher risk of opioid dependence. [ABSTRACT FROM AUTHOR]

Introduction: Unmet social and economic needs are associated with poor health outcomes, but little is known about how these needs are predictive of future healthcare utilization. This study examined the association of social and economic needs identified during medical visits with future hospitalizations and emergency department visits.Methods: Individuals with electronic health record-coded social and economic needs during a primary care, emergency department, or urgent care visit at Kaiser Permanente Northwest from October 1, 2016 to November 31, 2017 (case patients) were identified, as well as individuals who had visits during that time period but had no electronic health record-coded needs (control patients). The 2 groups were compared on sociodemographic characteristics, comorbidities, and healthcare utilization in the prior year. Finally, logistic regression assessed the relationship between documented needs and hospitalizations and emergency department visits in the 12 months following the index visit, controlling for sociodemographic characteristics, comorbidities, and prior healthcare utilization. Statistical analysis was completed in April 2019.Results: Case patients differed significantly from control patients on sociodemographic characteristics and had higher rates of comorbidities and prior healthcare utilization. Social and economic needs documented during the index visit were associated with significantly higher rates of hospitalization and emergency department visits in the 12 months following the visit, controlling for sociodemographic characteristics, comorbidities, and prior utilization.Conclusions: These results demonstrate that documented social and economic needs are a powerful predictor of future hospitalization and emergency department use and suggest the need for research into whether interventions to address these needs can influence healthcare utilization. [ABSTRACT FROM AUTHOR]

More than 3 million older US adults injure themselves by falling each year. Falls are a major cause of morbidity and mortality for this population, and account for nearly $30 billion in Medicare expenditures annually. Falls have been linked to frailty and vitamin D deficiency, both of which are linked to low nutrient intake and food insecurity. This retrospective, observational study is the first the authors know of to directly assess the relationship between food insecurity and falls. The study sample consisted of 26,525 Medicare Advantage members at Kaiser Permanente Northwest, a group model health maintenance organization, who had completed a quality of care survey between April 2013 and March 2017 and who maintained continuous enrollment in the 12 months prior to the survey date. Multivariable logistic regression analysis was used to assess the association between self-reported food insecurity and falls; electronic health record variables for age, sex, socioeconomic status, comorbidity, and health care utilization were included as covariates. Medicare Advantage members who reported food insecurity had 1.69 times higher odds of experiencing a fall in the past year than those without food insecurity, in adjusted analysis. Age, sex, comorbidity, and health care utilization also were significantly associated with falls. Food insecurity is significantly associated with falls among Medicare Advantage members. Routine assessment for food insecurity within the health care system, with subsequent referral to food resources, may help reduce rates of falls in older populations. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) causes more than 50,000 deaths each year in the United States but early detection through screening yields survival gains; those diagnosed with early stage disease have a 5-year survival greater than 90%, compared to 12% for those diagnosed with late stage disease. Using data from a large integrated health system, this study evaluates the cost-effectiveness of fecal immunochemical testing (FIT), a common CRC screening tool. A probabilistic decision–analytic model was used to examine the costs and outcomes of positive test results from a 1-FIT regimen compared with a 2-FIT regimen. The authors compared 5 diagnostic cutoffs of hemoglobin concentration for each test (for a total of 10 screening options). The principal outcome from the analysis was the cost per additional advanced neoplasia (AN) detected. The authors also estimated the number of cancers detected and life-years gained from detecting AN. The following costs were included: program management of the screening program, patient identification, FIT kits and their processing, and diagnostic colonoscopy following a positive FIT. Per-person costs ranged from $33 (1-FIT at 150ng/ml) to $92 (2-FIT at 50ng/ml) across screening options. Depending on willingness to pay, the 1-FIT 50 ng/ml and the 2-FIT 50 ng/ml are the dominant strategies with cost-effectiveness of $11,198 and $28,389, respectively, for an additional AN detected. The estimates of cancers avoided per 1000 screens ranged from 1.46 to 4.86, depending on the strategy and the assumptions of AN to cancer progression. [ABSTRACT FROM AUTHOR]

Objective: To assess dental providers' clinical practices and perceptions regarding adolescent vaccinations.Methods: We surveyed 234 dental providers in an integrated health care setting in Portland, Oregon, in March-April 2015. We assessed participants' knowledge of adolescent vaccines, barriers to recommending vaccines, and their perceived role in the promotion of vaccination and preventive medical care.Results: Over 80 percent of respondents correctly identified influenza, tetanus-diphtheria-acellular pertussis, and human papillomavirus as vaccinations recommended for adolescents; 60 percent correctly identified meningococcal conjugate. Forty-four percent of providers reported previously discussing vaccination with their adolescent patients. Lack of knowledge (66 percent), uncertainty about whether patients would accept recommendations (62 percent), and lack of time (61 percent) were commonly reported barriers. While few providers expressed personal concerns about the safety (13 percent) and effectiveness (10 percent) of adolescent vaccines, most believed parents had concerns about safety (70 percent) and effectiveness (60 percent). Although 80 percent endorsed the premise that providers should discuss preventive medical care with their patients, only 54 percent said they should discuss vaccinations specifically.Conclusions: Dental providers reported several barriers to recommending vaccines. While comfortable with discussing preventive medical care in general, providers are less comfortable making vaccine recommendations to their patients. Vaccine recommendations are not a traditional practice among dental providers and may require additional education and communication tools. [ABSTRACT FROM AUTHOR]

Context: Central venous catheter (CVC) use is associated with increased mortality and complications in hemodialysis recipients. Although prevalent CVC use has decreased, incident use remains high. Objective: To examine characteristics associated with CVC use at initial dialysis, specifically looking at proteinuria as a predictor of interest. Design: Retrospective cohort of 918 hemodialysis recipients from Kaiser Permanente Northwest who started hemodialysis from January 1, 2004, to January 1, 2014. Main Outcome Measures: Multivariable logistic regression was used to examine an association of proteinuria with the primary outcome of CVC use. Results: More than one-third (36%) of patients in our cohort started hemodialysis with an arteriovenous fistula, and 64% started with a CVC. Proteinuria was associated with starting hemodialysis with a CVC (likelihood ratio test, p < 0.001) after adjustment for age, peripheral vascular disease, congestive heart failure, diabetes, sex, race, and length of predialysis care. However, on pairwise comparison, only patients with midgrade proteinuria (0.5-3.5 g) had lower odds of starting hemodialysis with a CVC (odds ratio = 0.39, 95% confidence interval = 0.24-0.65). Conclusion: Proteinuria was associated with use of CVC at initial hemodialysis. However, a graded association did not exist, and only patients with midgrade proteinuria had significantly lower odds of CVC use. Our findings suggest that proteinuria is an explanatory finding for CVC use but may not have pragmatic value for decision making. Patients with lower levels of proteinuria may have a higher risk of starting dialysis with a CVC. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of clinical decision support (CDS) tools on rates of vitamin D testing. Screening for vitamin D deficiency has increased in recent years, spurred by studies suggesting vitamin D's clinical benefits. Such screening, however, is often unsupported by evidence and can incur unnecessary costs.Materials and Methods: We evaluated how rates of vitamin D screening changed after we implemented 3 CDS tools in the electronic health record (EHR) of a large health plan: (1) a new vitamin D screening guideline, (2) an alert that requires clinician acknowledgement of current guidelines to continue ordering the test (a "hard stop"), and (3) a modification of laboratory ordering preference lists that eliminates shortcuts. We assessed rates of overall vitamin D screening and appropriate vitamin D screening 6 months pre- and post-intervention.Results: Vitamin D screening rates decreased from 74.0 tests to 24.2 tests per 1000 members ( P  < .0001). The proportion of appropriate vitamin D screening tests increased from 56.2% to 69.7% ( P  < .0001), and the proportion of inappropriate screening tests decreased from 43.8% pre-implementation to 30.3% post-implementation ( P  < .0001).Discussion: To our knowledge, this is the first demonstration of how CDS can reduce rates of inappropriate vitamin D screening. We used 3 straightforward, inexpensive, and replicable CDS approaches. We know of no previous research on the impact of removing options from a preference list.Conclusion: Similar approaches could be used to reduce unnecessary care and decrease costs without reducing quality of care. [ABSTRACT FROM AUTHOR]

Background: Advanced imaging and serum biomarkers are commonly used for surveillance in patients with early-stage breast cancer, despite recommendations against this practice. Incentives to perform such low-value testing may be less prominent in integrated health care delivery systems. The purpose of the current study was to evaluate and compare the use of these services within 2 integrated systems: Kaiser Permanente (KP) and Intermountain Healthcare (IH). The authors also sought to distinguish the indication for testing: diagnostic purposes or routine surveillance.Methods: Patients with American Joint Committee on Cancer stage 0 to II breast cancer diagnosed between 2009 and 2010 were identified and the use of imaging and biomarker tests over an 18-month period were quantified, starting at 1 year after diagnosis. Chart abstraction was performed on a random sample of patients who received testing to identify the indication for testing. Multivariate regression was used to explore associations with the use of nonrecommended care.Results: A total of 6585 patients were identified; 22% had stage 0 disease, 44% had stage I disease, and 34% had stage II disease. Overall, 24% of patients received at least 1 imaging test (25% at KP vs 22% at IH; P = .009) and 28% of patients received at least 1 biomarker (36% at KP vs 13% at IH; P<.001). Chart abstraction revealed that 84% of imaging tests were performed to evaluate symptoms or signs. Virtually all biomarkers were ordered for routine surveillance. Stage of disease, medical center that provided the services, and provider experience were found to be significantly associated with the use of biomarkers.Conclusions: Advanced imaging was most often performed for appropriate indications, but biomarkers were used for nonrecommended surveillance. Distinguishing between inappropriate use for surveillance and appropriate diagnostic testing is essential when evaluating adherence to recommendations. [ABSTRACT FROM AUTHOR]

Background: Few studies describe system-level challenges or facilitators to implementing population-based colorectal cancer (CRC) screening outreach programs. Our qualitative study explored viewpoints of multilevel stakeholders before, during, and after implementation of a centralized outreach program. Program implementation was part of a broader quality-improvement initiative. Methods: During 2008-2010, we conducted semi-structured, open-ended individual interviews and focus groups at Kaiser Permanente Northwest (KPNW), a not-for-profit group model health maintenance organization using the practical robust implementation and sustainability model to explore external and internal barriers to CRC screening. We interviewed 55 stakeholders: 8 health plan leaders, 20 primary care providers, 4 program managers, and 23 endoscopy specialists (15 gastroenterologists, 8 general surgeons), and analyzed interview transcripts to identify common as well as divergent opinions expressed by stakeholders. Results: The majority of stakeholders at various levels consistently reported that an automated telephone-reminder system to contact patients and coordinate mailing fecal tests alleviated organizational constraints on staff's time and resources. Changing to a single-sample fecal immunochemical test (FIT) lessened patient and provider concerns about feasibility and accuracy of fecal testing. The centralized telephonic outreach program did, however, result in some screening duplication and overuse. Higher rates of FIT completion and a higher proportion of positive results with FIT required more colonoscopies. Conclusions: Addressing barriers at multiple levels of a health system by changing the delivery system design to add a centralized outreach program, switching to a more accurate and easier-to-use fecal test, and providing educational and electronic support had both benefits and problematic consequences. Other health care organizations can use our results to understand the complexities of implementing centralized screening programs. [ABSTRACT FROM AUTHOR]

The article presents a study concerning the relationships between receipt of regular dental care and medical outcomes among patients with type 2 diabetes. Delivered were comparisons of hemoglobin A and low-density lipoprotein cholesterol levels against diabetes-specific hospital admissions and emergency department (ED) visits in 493 diabetic patients who have not received dental care. Results suggested that the receipt of regular dental care was associated with lower health care utilization.

Context: Perioperative hyperglycemia is a risk factor for increased morbidity and mortality. Improved glycemic control has been demonstrated to reduce surgical site infections, reduce perioperative morbidity, and reduce length of stay. However, safe and effective perioperative glycemic control can be limited by expert clinician availability. Objective: To improve quality by reliably providing safe and effective glycemic control to surgical patients with diabetes or stress hyperglycemia. Design: A designated group of pharmacists, the Glycemic Control Team (GCT), worked under protocol, on a consultation basis, to manage perioperative dysglycemia during hospitalization. We used a pre-post, observational study design to assess the effectiveness of the intervention and implementation of the GCT. Main Outcome Measures: The proportion of patients pre- and postintervention with good glycemic control and with hypoglycemia were measured and compared. We defined good glycemic control as having all, or all but one, point-of-care blood glucose values between 70-180 mg/dL in each 24-hour period. We defined hypoglycemia as having any point-of-care test glucose value <70mg/dL in any of the 3 days evaluated. Results: During the preimplementation period, 77.4% of postoperative patient days demonstrated good glycemic control. In the postimplementation period, this percentage increased to 90.3%. Over the same period, the rate of hypoglycemia decreased from 8.6% to 4.6%. Conclusion: Implementation of a pharmacist team to manage glycemic control in hospitalized, postoperative patients led to safer and better quality of glycemic care as measured by improved glycemic control and lower rates of hypoglycemia. [ABSTRACT FROM AUTHOR]

Objectives. We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services. Methods. We used a natural experimental design using Medicaid claims data (n = 22833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n=718) covering 3 years after benefit cuts. Results. Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P<.001) and expenditures (98.8%; P<.001) and in all ambulatory medical care use (77.0%; P<.01) and expenditures (114.5%; P<.01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P=.001) of unmet dental need, and only one third the odds (odds ratio=0.340; P=.001) of getting annual dental checkups relative to those retaining benefits. Conclusions. Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems. [ABSTRACT FROM AUTHOR]

Few studies have quantitatively addressed the relationship between asthma-specific quality of life and asthma control as assessed by validated tools. Questionnaires were completed at home by a random sample of 542 adult asthmatic patients. The correlations of the two asthma control tools (Asthma Control Test™ and Asthma Therapy Assessment Questionnaire™) with the quality of life tool (mini-Asthma Quality of Life Questionnaire) were strongest with the symptoms and activity domains (r = 0.63-0.77); lower with the emotions domain (r = 0.57-0.64); and lowest with the environment domain (r = 0.38-0.43). Asthma control tools reflect the symptoms and activity themes of asthma quality of life well, but reflect the environmental domain less well. [ABSTRACT FROM AUTHOR]

The purpose of this study was to identify determinants of asthma control. Questionnaires were completed by a random sample of 570 members of a large managed care organization who were ≥35 years of age with utilization suggestive of active asthma. Asthma control was assessed buy the Asthma Control Test (ACT). Independent relationships were found between lower ACT scores and oral corticosteroid use (p < 0.0001), COPD (p < 0.0001), absence of regular specialist care (p = 0.006), higher BMI (p = 0.01), gastroesophageal reflux (p = 0.02), not being Caucasian (p = 0.04), and low income (p = 0.04). [ABSTRACT FROM AUTHOR]

The study examines the association of patient activation measure (PAM) with process and health outcomes among adults with chronic conditions. The importance of PAM which assesses a person's knowledge, skill, and confidence for managing one's own healthcare is discussed. The link between PAM scores and these process and outcome measures bolsters the case for the potential use of the PAM as the type of patient-focused quality measures recommended by the Institute of Medicine.

Objective.-To determine if differences between English- and Spanish-speaking parents in ratings of their children's health care can be explained by need for interpretive services. Methods - Using the Consumer Assessment of Health Plans Survey-Child-Survey (CAHPS), reports about provider communication were compared among 3 groups of parents enrolled in a Medicaid managed care health plan: 1) English speakers, 2) Spanish speakers with no self-reported need for interpretive services, and 3) Spanish speakers with self- reported need for interpretive services. Parents were asked to report how well their providers 1) listened carefully to what was being said, 2) explained things in a way that could be understood, 3) respected their comments and concerns, and 4) spent enough time during medical encounters. Multivariate logistic regression was used to compare the ratings of each of the 3 groups while controlling for child's gender, parent's gender, parent's educational attainment, child's health status, and survey year. Results-Spanish-speaking parents in need of interpretive services were less likely to report that providers spent enough time with their children (odds ratio = 0.34, 95% confidence interval = 0.17-0.68) compared to English-speaking parents. There was no statistically significant difference found between Spanish-speaking parents with no need of interpretive services and English-speaking parents. conclusions.-Among Spanish- versus English-speaking parents, differences in ratings of whether providers spent enough time with children during medical encounters appear to be explained, in part, by need for interpretive services. No other differences in ratings of provider communication were found. [ABSTRACT FROM AUTHOR]

Abstract: This prospective cohort study compares 200 hospitalized, HIV-infected patients (Hispanic, African American, and white)from May 1992 to October 1998 to assess mortality (versus survival) over 75 months of follow-up. The relative risk of six-year mortality for each ethnic group is compared using Cox proportional hazards models after controlling for sociodemographic and clinical characteristics, access to general medical care, and HIV-specific treatment. The median survival of Hispanics (15.5 months) was significantly (p < 0.05) shorter than that of whites (23.8); survival for African Americans (35.1) did not differ from whites. In multivariate analysis, the adjusted relative risk of six-year mortality for Hispanics compared with whites was 2.14 (95 percent confidence interval = 1.26-3.66). The poor outcomes of Hispanics was not explained by access to general care or by HIV-specific treatment. [ABSTRACT FROM AUTHOR]

Purpose: Advanced imaging is commonly used for staging of early-stage breast cancer, despite recommendations against this practice. The objective of this study was to evaluate and compare use of imaging for staging of breast cancer in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was routine or used for diagnostic purposes. Methods: We identified patients with stages 0 to IIB breast cancer diagnosed between 2010 and 2012. Using KP and IH electronic health records, we identified use of computed tomography, positron emission tomography, or bone scintigraphy 30 days before diagnosis to 30 days postsurgery. We performed chart abstraction on a random sample of patients who received a presurgical imaging test to identify indication. Results: For the sample of 10,010 patients, mean age at diagnosis was 60 years (range, 22 to 99 years); with 21 % stage 0, 47% stage I, and 32% stage II. Overall, 15% of patients (n = 1,480) received at least one imaging test during the staging window, 15% at KP and 14% at IH (P = .5). Eight percent of patients received imaging before surgery, and 7% postsurgery. We found significant intraregional variation in imaging use. Chart abstraction (n = 129, 16% of patients who received presurgical imaging) revealed that 48% of presurgical imaging was diagnostic. Conclusion: Use of imaging for staging of low-risk breast cancer was similar in both systems, and slightly lower than has been reported in the literature. Approximately half of imaging tests were ordered in response to a sign or symptom. [ABSTRACT FROM AUTHOR]