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Background Racial disparities exist in outcomes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Objective To evaluate the contribution of race/ethnicity in SARS-CoV-2 testing, infection, and outcomes. Design Retrospective cohort study (1 February 2020 to 31 May 2020). Setting Integrated health care delivery system in Northern California. Participants Adult health plan members. Measurements Age, sex, neighborhood deprivation index, comorbid conditions, acute physiology indices, and race/ethnicity; SARS-CoV-2 testing and incidence of positive test results; and hospitalization, illness severity, and mortality. Results Among 3 481 716 eligible members, 42.0% were White, 6.4% African American, 19.9% Hispanic, and 18.6% Asian; 13.0% were of other or unknown race. Of eligible members, 91 212 (2.6%) were tested for SARS-CoV-2 infection and 3686 had positive results (overall incidence, 105.9 per 100 000 persons; by racial group, White, 55.1; African American, 123.1; Hispanic, 219.6; Asian, 111.7; other/unknown, 79.3). African American persons had the highest unadjusted testing and mortality rates, White persons had the lowest testing rates, and those with other or unknown race had the lowest mortality rates. Compared with White persons, adjusted testing rates among non-White persons were marginally higher, but infection rates were significantly higher; adjusted odds ratios [aORs] for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 2.01 (95% CI, 1.75 to 2.31), 3.93 (CI, 3.59 to 4.30), 2.19 (CI, 1.98 to 2.42), and 1.57 (CI, 1.38 to 1.78), respectively. Geographic analyses showed that infections clustered in areas with higher proportions of non-White persons. Compared with White persons, adjusted hospitalization rates for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 1.47 (CI, 1.03 to 2.09), 1.42 (CI, 1.11 to 1.82), 1.47 (CI, 1.13 to 1.92), and 1.03 (CI, 0.72 to 1.46), respectively. Adjusted analyses showed no racial differences in inpatient mortality or total mortality during the study period. For testing, comorbid conditions made the greatest relative contribution to model explanatory power (77.9%); race only accounted for 8.1%. Likelihood of infection was largely due to race (80.3%). For other outcomes, age was most important; race only contributed 4.5% for hospitalization, 12.8% for admission illness severity, 2.3% for in-hospital death, and 0.4% for any death. Limitation The study involved an insured population in a highly integrated health system. Conclusion Race was the most important predictor of SARS-CoV-2 infection. After infection, race was associated with increased hospitalization risk but not mortality. Primary funding source The Permanente Medical Group, Inc.

Background Serum thyroid-stimulating hormone (TSH) reference intervals are dependent on population characteristics, including prevalent thyroid disease and iodine status. Studies in the US have demonstrated increasing TSH levels with age, and the American Thyroid Association recommends higher TSH goals for older patients taking thyroid supplementation, but few laboratories offer age-specific reference intervals for TSH. Our objective was to establish TSH reference ranges in our racially diverse population in northern California. Methods Data mining of electronic medical records was used with the a posteriori approach to select a euthyroid reference population for TSH reference intervals. A report gathered all TSH results from 2 weeks from >1 year in the past, excluding results from patients with thyroid-related disease or medication use at any time before or after the TSH test. Results The reference population numbered 33038 and consisted of approximately 44% of the total TSH results reported in the selected time periods. The population identified as 46.5% white, 18.3% Asian, 17.0% Hispanic/Latino, 8.0% black/African American, and 10.3% other or unknown. These data demonstrate an increase in the median and 97.5 percentile of TSH levels with increasing age in adults. No clinically significant difference was seen between female and male individuals or between the self-identified races, except for lower TSH levels in the black/African American population. Conclusions The a posteriori approach using data mining for disease-specific criteria proved to be an efficient method for obtaining a large healthy reference population. Age-specific TSH reference ranges could prevent inappropriate diagnoses of subclinical hypothyroidism in older patients.

Background Efficient tools are needed to stage liver disease before treatment of patients infected with hepatitis C virus (HCV). Compared to biopsy, several studies demonstrated favorable performance of noninvasive multianalyte serum fibrosis marker panels [fibrosis-4 (FIB-4) index] and aspartate aminotransferase (AST)-to-platelet ratio index (APRI), but suggested cutoffs vary widely. Our objective was to evaluate FIB-4 index and APRI and their component tests for staging fibrosis in our HCV-infected population and to determine practical cutoffs to help triage an influx of patients requiring treatment. Methods Transient elastography (TE) results from 1731 HCV-infected patients were mapped to an F0–F4 equivalent scale. Each patient's APRI and FIB-4 index were calculated. Areas under the receiver operator curve (AUROCs) and false-positive and false-negative rates were calculated to retrospectively compare the performance of the indices and their component tests. Results The highest AUROCs for distinguishing severe (F3–F4) from mild-to-moderate (F0–F2) fibrosis had overlapping 95% CIs: APRI (0.77; 0.74–0.79), FIB-4 index (0.76; 0.73–0.78), and AST (0.74; 0.72–0.77). Cutoffs had false-negative rates of 2.7%–2.8% and false-positive rates of 6.4%–7.4% for all 3 markers. Conclusions AST was as effective as FIB-4 index and APRI at predicting fibrosis. Published cutoffs for APRI and FIB-4 index would have been inappropriate in our population, with false-negative rates as high as 11%. For our purposes, no serum fibrosis marker was sufficiently sensitive to rule-out significant fibrosis, but cutoffs developed for AST, FIB-4 index, and APRI all had specificities of 79.2%–80.3% for ruling-in severe fibrosis and could be used to triage 1/3 of our population for treatment without waiting for TE or liver biopsy.

BACKGROUND: The gap between treatment guidelines and clinical practice in prediabetes management has been identified in previous studies. The knowledge related to addressing lifestyle change during office visits in clinical practice to manage prediabetes is limited. OBJECTIVE: To describe patterns of lifestyle management addressed during office-based visits involving patients with prediabetes and identify factors associated with addressing lifestyle management during physician office visits in the USA. DESIGN: Cross-sectional study PARTICIPANTS: US National Ambulatory Medical Care Survey (NAMCS) data from 2013 to 2015 were combined to identify office-based visits involving patients with prediabetes. MAIN MEASURES: The major outcome is lifestyle management including diet/nutrition, exercise, and/or weight reduction. Patient and physician characteristics were collected for analysis. The prevalence and patterns of addressing lifestyle management during visits were estimated and described. Multivariate logistic regression model identified significant factors associated with lifestyle management. The patient visit weight was applied to all analyses to achieve nationally representative estimates. KEY RESULTS: Among 4039 office-based visits involving patients with prediabetes between 2013 and 2015, 22.8% indicated lifestyle management was addressed during the visits. Diet/nutrition, exercise, and weight reduction accounted for 86.1%, 62.6%, and 34.1% of the visits with lifestyle management addressed, respectively. Lifestyle management was more likely to be addressed during the visits involving patients with hyperlipidemia (OR = 1.74, 95% CI 1.24–2.46) and obesity (OR = 4.03, 95% CI 2.91–5.56), seeing primary physicians (vs. other specialties, OR = 1.46, 95% CI 1.03–2.08), and living in the southern region (vs. northeast, OR = 1.96, 95% CI 1.20–3.19). CONCLUSIONS: The prevalence of addressing lifestyle management during office visits involving patients with prediabetes remained low in the USA. Patients’ clinical characteristics, geographic region, and physician’s specialty were associated with addressing lifestyle management during the visits. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4724-z) contains supplementary material, which is available to authorized users.

An index case of a clinically euthyroid woman of South Asian descent was identified with discordant TSH results: undetectable TSH on our routine assay and normal TSH on an alternate assay. Low TSH concentrations due to functionally compromising TSH mutations have been reported. Here we describe a new phenomenon of functional TSH that is undetectable by 4 widely used US Food and Drug Administration (FDA)-approved TSH immunoassays marketed by a single vendor.The purpose of this study was to identify additional cases and investigate the cause of the falsely undetectable TSH.All samples with TSH results of0.01 μIU/mL were retested with a second TSH assay. Discordant samples were evaluated on up to 8 FDA-approved TSH immunoassays and the TSHβ gene was sequenced. Retrospectively, thyroid function tests, diagnoses, and medications from 1.6 million individuals were analyzed.Out of approximately 2 million individuals, we have identified a cohort of 20 hypothyroid and euthyroid patients of shared ethnicity with falsely undetectable TSH (0.01 μIU/mL) in 4 of 8 commercially available TSH assays. Half of these individuals were initially treated based on repeated falsely undetectable TSH values (7 euthyroid patients were treated with methimazole and 2 hypothyroid patients had doses of levothyroxine decreased). In all cases, a retrospective chart review revealed that clinical assessments and free T4 and total T3 results were inconsistent with the undetectable TSH results. Specific antibodies failing to detect TSH in these cases were identified in the 4 affected assays. A novel TSHβ point mutation was identified.Our data suggest that these individuals have a previously unrecognized, functionally normal, TSH variant to which some monoclonal antibodies fail to bind. To assure appropriate patient management, clinicians and laboratorians need to be aware that certain TSH variants may be undetectable in some hyperselective TSH assays.

Background: Kaiser Permanente Northern California (KPNC) is a large HMO with nearly 4 million members of diverse ethnicities and socioeconomic backgrounds in rural, suburban, and urban environments. Since the early 1990s, KPNC has had a home-based cardiac rehab program implemented by nurses with