Comparing Kaiser Permanente Members to the General Population: Implications for Generalizability of Research

ImportanceClinical decision support (CDS) could help emergency department (ED) physicians treat patients with heart failure (HF) by estimating risk, collating relevant history, and assisting with medication prescribing if physicians’ perspectives inform its design and implementation.ObjectiveTo evaluate CDS usability and workflow integration in the hands of ED physician end users who use it in clinical practice.Design, Setting, and ParticipantsThis mixed-methods qualitative study administered semistructured interviews to ED physicians from 2 community EDs of Kaiser Permanente Northern California in 2023. The interview guide, based on the Usability Heuristics for User Interface Design and the Sociotechnical Environment models, yielded themes used to construct an electronic survey instrument sent to all ED physicians.Main Outcomes and MeasuresMain outcomes were physicians’ perceptions of using CDS to complement clinical decision-making, usability, and integration into ED clinical workflow.ResultsSeven key informant physicians (5 [71.4%] female, median [IQR] 15.0 [9.5-15.0] years in practice) were interviewed and survey responses from 51 physicians (23 [45.1%] female, median [IQR] 14.0 [9.5-17.0] years in practice) were received from EDs piloting the CDS intervention. Response rate was 67.1% (51 of 76). Physicians suggested changes to CDS accessibility, functionality, and workflow integration. Most agreed that CDS would improve patient care and fewer than half of physicians expressed hesitation about their capacity to consistently comply with its recommendations, citing workload concerns. Physicians preferred a passive prompt that encouraged, but did not mandate, interaction with the CDS.Conclusions and RelevanceIn this qualitative study of physicians who were using a novel CDS intervention to assist with ED management of patients with acute HF, several opportunities were identified to improve usability as well as several key barriers and facilitators to CDS implementation.

Section: Study Design and Settingmentioning

confidence: 67%

Section: Methodsmentioning

confidence: 99%

Physicians’ Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED

Casey,

Reed,

LeMaster

et al. 2023

“…KPNC members are covered through employer-sponsored insurance, Medicaid, Medicare, and individual plans. The membership is sociodemographically representative of the northern California population with the exception of income, as members slightly underrepresent individuals with very low income (<200% below the federal poverty level) . The KPNC Institutional Review Board approved this study with a waiver of the requirement for informed consent because it was a data-only study with no participant contact.…”

Section: Methodsmentioning

confidence: 99%

Structural Racism and Adolescent Mental Health Disparities in Northern California

Acker,

Aghaee,

Mujahid

et al. 2023

ImportanceUnderstanding how structural racism is associated with adolescent mental health is critical to advance health equity.ObjectiveTo assess associations between neighborhood privilege, measured by the Index of Concentration at the Extremes (ICE) and adolescent depressive symptoms, suicidality, and related racial and ethnic disparities.Design, Setting, and ParticipantsThis was a retrospective cohort study using electronic health records of adolescents aged 12 to 16 years who attended well-teen visits between 2017 and 2021. Kaiser Permanente Northern California is an integrated health care delivery system serving 4.6 million members. The cohort included 34 252 individuals born singleton at an affiliated facility from January 1, 2005, to December 31, 2009, and who had completed at least 1 mental health screener during a well-teen visit by November 23, 2021.ExposuresAmerican Community Survey 2016 to 2021 5-year estimates were used to calculate ICE scores for adolescents’ residential census tract at ages 10 to 11. Three ICE measures were used as proxies of structural racism: racial privilege (ICE–race and ethnicity; hereinafter ICE–race), economic privilege (ICE–income), and combined economic and racial privilege (ICE–income plus race and ethnicity; herinafter ICE–income plus race). ICE scores were categorized into quintiles based on California statewide distributions.Main Outcomes and MeasuresDepressive symptoms and suicidality were assessed through self-report screeners during well-teen visits. Depressive symptoms were considered to be present if patients had a score on the Patient Health Questionnaire-2 of 3 or higher (the tool uses a Likert scale to determine the frequency [0 = not at all; 3 = nearly every day] that they had depressed mood and lack of pleasure in usual activities in the past 2 weeks; responses were summed and dichotomized).ResultsAnalyses included 34 252 adolescents (12-16 years of age; mean [SD] age, 13.7 [0.8] years; 17 557 [51.3%] male, 7284 [21.3%] Asian or Pacific Islander, 2587 [7.6%] Black], 9061 [26.5%] Hispanic, 75 [0.2%] American Indian or Indigenous, 12 176 [35.5%] White, and 3069 [9%] other or unknown). Risks of depressive symptoms and suicidality generally increased with each level of declining neighborhood privilege. Adjusted risk ratios comparing adolescents from neighborhoods with the least to most racial and economic privilege were 1.37 (95% CI, 1.20-1.55) for depressive symptoms and 1.59 (95% CI, 1.23-2.05) for suicidality. Racial disparities between Black and White youth and Hispanic and White youth decreased after adjusting for each ICE measure, and became nonsignificant in models adjusting for ICE–race and ICE–income plus race.Conclusions and RelevanceIn this cohort study, lower neighborhood privilege was associated with greater risks of adolescent depressive symptoms and suicidality. Furthermore, adjusting for neighborhood privilege reduced mental health disparities affecting Black and Hispanic adolescents. These findings suggest that efforts to promote equity in adolescent mental health should extend beyond the clinical setting and consider the inequitable neighborhood contexts that are shaped by structural racism.

“…We conducted a retrospective cohort study of adults initiating PrEP in Kaiser Permanente Southern California (KPSC) using EHRs. KPSC is an integrated health care delivery system providing services to approximately 4.8 million diverse members that is representative of the communities in the Southern California service area . Members’ receipt of health care services are tracked in KPSC’s EHR system.…”

Section: Methodsmentioning

confidence: 99%

Use of Tenofovir Alafenamide Fumarate for HIV Pre-Exposure Prophylaxis and Incidence of Hypertension and Initiation of Statins

Rivera,

Pak,

Mefford

et al. 2023

ImportancePre-exposure prophylaxis (PrEP) is an important tool for preventing HIV infection. However, PrEP’s impact on cardiometabolic health is understudied.ObjectiveTo examine the risk of incident hypertension and statin initiation among adult (age ≥18 years) health plan members starting PrEP with tenofovir alafenamide fumarate (TAF) compared with propensity score–matched adults taking tenofovir disoproxil fumarate (TDF).Design, Setting, and ParticipantsThis retrospective cohort study used electronic health records (EHRs) from Kaiser Permanente Southern California. Adult members starting PrEP in Kaiser Permanente Southern California between October 2019 and May 2022 were included. Propensity score matching with multiple imputation (50 matched data sets) was conducted to generate 1 TAF:4 TDF matched data sets with balanced baseline covariates.ExposuresPrEP initiation with either TAF or TDF during the study period.Main Outcomes and MeasuresIncident hypertension and statin initiation within 2 years of PrEP initiation were ascertained through blood pressure and outpatient pharmacy records, respectively. Risk differences and odds ratios (ORs) were estimated using logistic regression and g-computation.ResultsA total of 6824 eligible individuals were identified (mean [SD] age, 33.9 [10.3] years; 6618 [97%] male). This pool was used to generate 2 cohorts without baseline hypertension or statin use for matching (hypertension: n = 5523; statin: n = 6149) In both cohorts, those starting PrEP with TAF were older and were more likely to be non-Hispanic White compared with those starting with TDF. In matched analysis adjusting for baseline covariates, TAF use was associated with elevated risk of incident hypertension (TAF: n = 371; risk difference, 0.81 [95% CI, 0.12-1.50]; OR, 1.64 [95% CI, 1.05-2.56]). TAF use was also associated with elevated risk of statin initiation (TAF: n = 382; risk difference, 0.85 [95% CI, 0.37-1.33]; OR, 2.33 [95% CI, 1.41-3.85]). Subgroup analyses restricted to individuals 40 years and older at PrEP initiation showed similar results with larger risk difference in statin initiation (risk difference, 4.24 [95% CI, 1.82-6.26]; OR, 3.05 [95% CI, 1.64-5.67]).Conclusions and RelevanceIn this study of people taking PrEP, TAF use was found to be associated with higher incident hypertension and statin initiation compared with TDF use, especially in those 40 years or older. Continued monitoring of blood pressure and lipids for TAF users is warranted.