Sample records for como modificador permanente
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TUBERCULOSIS COMO ENFERMEDAD OCUPACIONAL
Mendoza-Ticona, Alberto
2014-01-01
Existe evidencia suficiente para declarar a la tuberculosis como enfermedad ocupacional en diversos profesionales especialmente entre los trabajadores de salud. En el Perú están normados y reglamentados los derechos laborales inherentes a la tuberculosis como enfermedad ocupacional, como la cobertura por discapacidad temporal o permanente. Sin embargo, estos derechos aún no han sido suficientemente socializados. En este trabajo se presenta información sobre el riesgo de adquirir tuberculosis en el lugar de trabajo, se revisan las evidencias para declarar a la tuberculosis como enfermedad ocupacional en trabajadores de salud y se presenta la legislación peruana vigente al respecto. PMID:22858771
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Kaiser Permanente Northwest's Center for Health Research was created to study health maintenance organizations by scientists were recruited from a variety of fields to study a range of health and medical care issues.
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Kaiser Permanente Medical Care Programs (KP-MCP)
The Division of Research within KP-MCP conducts, publishes, and disseminates high-quality epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and the society at large.
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Investing in Obesity Treatment: Kaiser Permanente's Approach to Chronic Disease Management.
Tsai, Adam G; Histon, Trina; Donahoo, W Troy; Hashmi, Shahid; Murali, Sameer; Latare, Peggy; Oliver, Lajune; Slovis, Jennifer; Grall, Sarah; Fisher, David; Solomon, Loel
2016-09-01
Kaiser Permanente, an integrated health care delivery system in the USA, takes a "whole systems" approach to the chronic disease of obesity that begins with efforts to prevent it by modifying the environment in communities and schools. Aggressive case-finding and substantial investment in intensive lifestyle modification programs target individuals at high risk of diabetes and other weight-related conditions. Kaiser Permanente regions are increasingly standardizing their approach when patients with obesity require treatment intensification using medically supervised diets, prescription medication to treat obesity, or weight loss surgery.
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Schilling, Lisa; Chase, Alide; Kehrli, Sommer; Liu, Amy Y; Stiefel, Matt; Brentari, Ruth
2010-11-01
By 2004, senior leaders at Kaiser Permanente, the largest not-for-profit health plan in the United States, recognizing variations across service areas in quality, safety, service, and efficiency, began developing a performance improvement (PI) system to realizing best-in-class quality performance across all 35 medical centers. MEASURING SYSTEMWIDE PERFORMANCE: In 2005, a Web-based data dashboard, "Big Q," which tracks the performance of each medical center and service area against external benchmarks and internal goals, was created. PLANNING FOR PI AND BENCHMARKING PERFORMANCE: In 2006, Kaiser Permanente national and regional continued planning the PI system, and in 2007, quality, medical group, operations, and information technology leaders benchmarked five high-performing organizations to identify capabilities required to achieve consistent best-in-class organizational performance. THE PI SYSTEM: The PI system addresses the six capabilities: leadership priority setting, a systems approach to improvement, measurement capability, a learning organization, improvement capacity, and a culture of improvement. PI "deep experts" (mentors) consult with national, regional, and local leaders, and more than 500 improvement advisors are trained to manage portfolios of 90-120 day improvement initiatives at medical centers. Between the second quarter of 2008 and the first quarter of 2009, performance across all Kaiser Permanente medical centers improved on the Big Q metrics. The lessons learned in implementing and sustaining PI as it becomes fully integrated into all levels of Kaiser Permanente can be generalized to other health care systems, hospitals, and other health care organizations.
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Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization.
Schilling, Lisa; Dearing, James W; Staley, Paul; Harvey, Patti; Fahey, Linda; Kuruppu, Francesca
2011-12-01
In 2006, recognizing variations in performance in quality, safety, service, and efficiency, Kaiser Permanente leaders initiated the development of a performance improvement (PI) system. Kaiser Permanente has implemented a strategy for creating the systemic capacity for continuous improvement that characterizes a learning organization. Six "building blocks" were identified to enable Kaiser Permanente to make the transition to becoming a learning organization: real-time sharing of meaningful performance data; formal training in problem-solving methodology; workforce engagement and informal knowledge sharing; leadership structures, beliefs, and behaviors; internal and external benchmarking; and technical knowledge sharing. Putting each building block into place required multiple complex strategies combining top-down and bottom-up approaches. Although the strategies have largely been successful, challenges remain. The demand for real-time meaningful performance data can conflict with prioritized changes to health information systems. It is an ongoing challenge to teach PI, change management, innovation, and project management to all managers and staff without consuming too much training time. Challenges with workforce engagement include low initial use of tools intended to disseminate information through virtual social networking. Uptake of knowledge-sharing technologies is still primarily by innovators and early adopters. Leaders adopt new behaviors at varying speeds and have a range of abilities to foster an environment that is psychologically safe and stimulates inquiry. A learning organization has the capability to improve, and it develops structures and processes that facilitate the acquisition and sharing of knowledge.
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Breast cancer genetics and managed care. The Kaiser Permanente experience.
Kutner, S E
1999-12-01
In 1996, with evolution of the science of cancer genetics and the advent of commercially available BRCA1 and later BRCA2 testing, Kaiser Permanente began to apply these advances in clinical practice. Recommendations for referral to genetic counseling were developed in 1997 as the Clinical Practice Guidelines for Referral for Genetic Counseling for Inherited Susceptibility for Breast and Ovarian Cancer. Implementation of these guidelines with associated protocols in Kaiser Permanente's Northern California Region has occupied the ensuing years and includes dissemination of the high-risk guidelines for breast and ovarian cancer, dissemination of patient and physician educational materials on the breast cancer guidelines, monthly classes and taped healthphone messages for patients, interactive videoconferencing for physicians, a training seminar for medical geneticists who will counsel patients at risk, publication of articles on breast cancer and genetic risk in health plan member- and physician-directed magazines, identification and training of clinical specialists and supporting clinicians to care for patients before and after counseling, individual counseling and testing of patients and families, and development of a data registry. Implementing the guidelines helped us communicate the uncertainty surrounding breast cancer testing, and we were obliged to learn more about ethical, legal, societal, and insurance controversies surrounding genetic testing. Given the lack of effective prevention for breast or ovarian cancer and the difficulty of treatment, the appropriate use of genetics in patient care is essential. In the near future, we will see the need for cancer genetics to become an integral part of practice throughout the spectrum of health care. We at Kaiser Permanente feel that the breast cancer guideline project is the first step in this process.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Edwards, D.; Yoshimura, A.; Butler, D.
This report describes the results of a Cooperative Research and Development Agreement between Sandia National Laboratories and Kaiser Permanente Southern California to develop a prototype computer model of Kaiser Permanente`s health care delivery system. As a discrete event simulation, SimHCO models for each of 100,000 patients the progression of disease, individual resource usage, and patient choices in a competitive environment. SimHCO is implemented in the object-oriented programming language C{sup 2}, stressing reusable knowledge and reusable software components. The versioned implementation of SimHCO showed that the object-oriented framework allows the program to grow in complexity in an incremental way. Furthermore, timingmore » calculations showed that SimHCO runs in a reasonable time on typical workstations, and that a second phase model will scale proportionally and run within the system constraints of contemporary computer technology.« less
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Edwards, D.; Yoshimura, A.; Butler, D.
1996-11-01
This report describes the results of a Cooperative Research and Development Agreement between Sandia National Laboratories and Kaiser Permanente Southern California to develop a prototype computer model of Kaiser Permanente`s health care delivery system. As a discrete event simulation, SimHCO models for each of 100,000 patients the progression of disease, individual resource usage, and patient choices in a competitive environment. SimHCO is implemented in the object-oriented programming language C++, stressing reusable knowledge and reusable software components. The versioned implementation of SimHCO showed that the object-oriented framework allows the program to grow in complexity in an incremental way. Furthermore, timing calculationsmore » showed that SimHCO runs in a reasonable time on typical workstations, and that a second phase model will scale proportionally and run within the system constraints of contemporary computer technology. This report is published as two documents: Model Overview and Domain Analysis. A separate Kaiser-proprietary report contains the Disease and Health Care Organization Selection Models.« less
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The Kaiser Permanente Northwest Cardiovascular Risk Factor Management Program: A Model for All
Joyce, Jodi S; Fetter, Martina M; Klopfenstein, Dean H; Nash, Michael K
2005-01-01
Proof of the effectiveness of preventive measures that reduce established risk traits for atherothrombotic disorders has spurred attempts to systematically apply these interventions among susceptible populations. One such attempt is the Cardiovascular Risk Factor Management (CVRFM) Program, launched in 2003 to optimize clinical management and outcomes for 75,000 Kaiser Permanente Northwest Region (KPNW) members with atherosclerotic cardiovascular disease (CVD) or hypertension. The CVRFM Program is a centralized, multidisciplinary, proactive telephone-based clinical management intervention consisting of an “outreach” call, an interview, a mailed individualized care plan and information packet, regular follow-up (including protocolized medication management) and—when “goal status” is achieved—transfer of the patient to a maintenance plan. Quarterly evaluation of effectiveness entailed measurement of a range of clinical, utilization, and member satisfaction outcomes. Results by the fourth quarter were outstanding: For example, >98% of participants with coronary disease or diabetes had LDL cholesterol testing, >90% of coronary patients received aspirin or statin treatment, 99% were “extremely” or “very” satisfied with the program, and reductions were observed in the number of hospitalizations and visits to the emergency department and clinic. Mathematical models predict a decrease in myocardial infarctions and cardiovascular mortality within two years after implementing the program, the underlying principles of which should yield similar improvement in other Kaiser Permanente (KP) Regions and in other health care organizations. PMID:21660155
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Kaiser Permanente's Convergent Medical Terminology.
Dolin, Robert H; Mattison, John E; Cohn, Simon; Campbell, Keith E; Wiesenthal, Andrew M; Hochhalter, Brad; LaBerge, Diane; Barsoum, Rita; Shalaby, James; Abilla, Alan; Clements, Robert J; Correia, Carol M; Esteva, Diane; Fedack, John M; Goldberg, Bruce J; Gopalarao, Sridhar; Hafeza, Eza; Hendler, Peter; Hernandez, Enrique; Kamangar, Ron; Kahn, Rafique A; Kurtovich, Georgina; Lazzareschi, Gerry; Lee, Moon H; Lee, Tracy; Levy, David; Lukoff, Jonathan Y; Lundberg, Cyndie; Madden, Michael P; Ngo, Trongtu L; Nguyen, Ben T; Patel, Nikhilkumar P; Resneck, Jim; Ross, David E; Schwarz, Kathleen M; Selhorst, Charles C; Snyder, Aaron; Umarji, Mohamed I; Vilner, Max; Zer-Chen, Roy; Zingo, Chris
2004-01-01
This paper describes Kaiser Permanente's (KP) enterprise-wide medical terminology solution, referred to as our Convergent Medical Terminology (CMT). Initially developed to serve the needs of a regional electronic health record, CMT has evolved into a core KP asset, serving as the common terminology across all applications. CMT serves as the definitive source of concept definitions for the organization, provides a consistent structure and access method to all codes used by the organization, and is KP's language of interoperability, with cross-mappings to regional ancillary systems and administrative billing codes. The core of CMT is comprised of SNOMED CT, laboratory LOINC, and First DataBank drug terminology. These are integrated into a single poly-hierarchically structured knowledge base. Cross map sets provide bi-directional translations between CMT and ancillary applications and administrative billing codes. Context sets provide subsets of CMT for use in specific contexts. Our experience with CMT has lead us to conclude that a successful terminology solution requires that: (1) usability considerations are an organizational priority; (2) "interface" terminology is differentiated from "reference" terminology; (3) it be easy for clinicians to find the concepts they need; (4) the immediate value of coded data be apparent to clinician user; (5) there be a well defined approach to terminology extensions. Over the past several years, there has been substantial progress made in the domain coverage and standardization of medical terminology. KP has learned to exploit that terminology in ways that are clinician-acceptable and that provide powerful options for data analysis and reporting.
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Tuso, Philip; Huynh, Dan Ngoc; Garofalo, Lynn; Lindsay, Gail; Watson, Heather L; Lenaburg, Douglas L; Lau, Helen; Florence, Brandy; Jones, Jason; Harvey, Patti; Kanter, Michael H
2013-01-01
In 2011, Kaiser Permanente Northwest Region (KPNW) won the Lawrence Patient Safety Award for its innovative work in reducing hospital readmission rates. In 2012, Kaiser Permanente Southern California (KPSC) won the Transfer Projects Lawrence Safety Award for the successful implementation of the KPNW Region’s “transitional care” bundle to a Region that was almost 8 times the size of KPNW. The KPSC Transition in Care Program consists of 6 KPNW bundle elements and 2 additional bundle elements added by the KPSC team. The 6 KPNW bundle elements were risk stratification, standardized discharge summary, medication reconciliation, a postdischarge phone call, timely follow-up with a primary care physician, and a special transition phone number on discharge instructions. The 2 additional bundle elements added by KPSC were palliative care consult if indicated and a complex-case conference. KPSC has implemented most of the KPNW and KPSC bundle elements during the first quarter of 2012 for our Medicare risk population at all of our 13 medical centers. Each year, KPSC discharges approximately 40,000 Medicare risk patients. After implementation of bundle elements, KPSC Medicare risk all-cause 30-day Healthcare Effectiveness Data and Information Set readmissions observed-over-expected ratio and readmission rates from December 2010 to November 2012 decreased from approximately 1.0 to 0.80 and 12.8% to 11%, respectively. PMID:24355891
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Achieving Kaiser Permanente Quality
McHugh, Matthew D.; Aiken, Linda H.; Eckenhoff, Myra E.; Burns, Lawton R.
2015-01-01
Background The Kaiser Permanente model of integrated health delivery is highly regarded for high quality and efficient health care. Efforts to reproduce Kaiser’s success have mostly failed. One factor that has received little attention and that could explain Kaiser’s advantage is its commitment to and investment in nursing as a key component of organizational culture and patient-centered care. Purpose The aim of this study was to investigate the role of Kaiser’s nursing organization in promoting quality of care. Methodology This was a cross-sectional analysis of linked secondary data from multiple sources, including a detailed survey of nurses, for 564 adult, general acute care hospitals from California, Florida, Pennsylvania, and New Jersey in 2006–2007. We used logistic regression models to examine whether patient (mortality and failure-to-rescue) and nurse (burnout, job satisfaction, and intent-to-leave) outcomes in Kaiser hospitals were better than in non-Kaiser hospitals. We then assessed whether differences in nursing explained outcomes differences between Kaiser and other hospitals. Finally, we examined whether Kaiser hospitals compared favorably with hospitals known for having excellent nurse work environments — Magnet hospitals. Findings Patient and nurse outcomes in Kaiser hospitals were significantly better compared with non-Magnet hospitals. Kaiser hospitals had significantly better nurse work environments, staffing levels, and more nurses with bachelor’s degrees. Differences in nursing explained a significant proportion of the Kaiser outcomes advantage. Kaiser hospital outcomes were comparable to Magnet hospitals, where better outcomes have been largely explained by differences in nursing. Implications An important element in Kaiser’s success is its investment in professional nursing, which may not be evident to systems seeking to achieve Kaiser’s advantage. Our results suggest that a possible strategy for achieving outcomes like Kaiser
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Kaiser Permanente National Hand Hygiene Program
Barnes, Sue; Barron, Dana; Becker, Linda; Canola, Teresa; Salemi, Charles
2004-01-01
Objective: Hand hygiene has historically been identified as an important intervention for preventing infection acquired in health care settings. Recently, the advent of waterless, alcohol-based skin degermer and elimination of artificial nails have been recognized as other important interventions for preventing infection. Supplied with this information, the National Infection Control Peer Group convened a KP Hand Hygiene Work Group, which, in August 2001, launched a National Hand Hygiene Program initiative titled “Infection Control: It’s In Our Hands” to increase compliance with hand hygiene throughout the Kaiser Permanente (KP) organization. Design: The infection control initiative was designed to include employee and physician education as well as to implement standard hand hygiene products (eg, alcohol degermers), eliminate use of artificial nails, and monitor outcomes. Results: From 2001 through September 2003, the National KP Hand Hygiene Work Group coordinated implementation of the Hand Hygiene initiative throughout the KP organization. To date, outcome monitoring has shown a 26% increase in compliance with hand hygiene as well as a decrease in the number of bloodstream infections and methycillin-resistant Staphylococcus aureus (MRSA) infections. As of May 2003, use of artificial nails had been reduced by 97% nationwide. Conclusions: Endorsement of this Hand Hygiene Program initiative by KP leadership has led to implementation of the initiative at all medical centers throughout the KP organization. Outcome indicators to date suggest that the initiative has been successful; final outcome monitoring will be completed in December 2003. PMID:26704605
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Making the business case for hospital information systems--a Kaiser Permanente investment decision.
Garrido, Terhilda; Raymond, Brian; Jamieson, Laura; Liang, Louise; Wiesenthal, Andrew
2004-01-01
Further evidence in favor of the clinical IT business case is set forth in Kaiser Permanente's cost/benefit analysis for an electronic hospital information system. This article reviews the business case for an inpatient electronic medical record system, including 36 categories of quantifiable benefits that contribute to a positive cumulative net cash flow within an 8.5 year period. However, the business case hinges on several contingent success factors: leadership commitment, timely implementation, partnership with labor, coding compliance, and workflow redesign. The issues and constraints that impact the potential transferability of this business case across delivery systems raise questions that merit further attention.
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Viewing Kaiser Permanente via the logistician lens.
Towill, Denis R
2006-01-01
The aim of this paper is to undertake a holistic comparison between NHS and Kaiser Permanente (KP) healthcare delivery systems. The paper reviews in detail the many papers and communications published on KP via the "logistics lens" which is focussed on smooth patient flow from onset of problem to completion of treatment. The paper finds that healthcare "best practice" is readily related to conventional supply chain performance metrics and engineering change model attributes. Much of the apparent success of KP is due to cultural and organisational factors. A noteworthy example deserving wide dissemination and application is in the effectiveness of interfaces between clinicians and managers. This review exposes the need for the NHS to be driven by end-to-end processing times rather than the present salami principle of separating in-patient, out-patient and other queues into neat statistics, which can be meaningless to an individual patient. Introduces clinicians and healthcare professionals to a range of tools and techniques for engineering "best practice". This method is well understood and proven in other areas of application. Particular aspects of the KP study are thus confirmatory of what is actually happening in small pockets of the NHS. The paper provides a new perspective on the performance of healthcare supply chains. New knowledge and deeper understanding of the mechanisms of success emerge from a study adopting a different viewpoint.
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Responding to the Language Challenge: Kaiser Permanente's Approach
Meyers, Kate; Tang, Gayle; Fernandez, Alicia
2009-01-01
Objective: To inform current debates on improving health care quality for patients with limited English proficiency by identifying the drivers and processes for one large health care delivery system's implementation of particular models, key success factors, and remaining challenges for the field. Study Design: A qualitative case study of the Kaiser Permanente (KP) San Francisco Medical Center's approach to developing linguistic access services and subsequent organizationwide initiatives. Methods: We conducted semistructured interviews with eight current and former clinical and administrative leaders from the KP San Francisco Medical Center and national headquarters. Interviews were analyzed for key themes. Results: KP San Francisco Medical Center developed linguistic and cultural services in response to a confluence of external and internal factors, including changing demographics, care quality challenges, and patient and clinician satisfaction issues. Early strategies included development of language-specific care modules focused on Chinese- and Spanish-speaking members while meeting broader linguistic access and cultural-competency needs through a centralized Multicultural Services Center. Additional approaches across KP regions have focused on improving interpreter services, optimizing use of bilingual staff, and creating a translation infrastructure to improve quality and reduce redundancy in written translation efforts. Conclusions: KP's experiences developing linguistic and cultural care and services since the 1990s provide lessons about decision-making processes and approaches that may guide other health systems, insurers, and policy makers striving to improve care quality and safety for patients with limited English proficiency. PMID:20740094
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Sim, John J; Rutkowski, Mark P; Selevan, David C; Batech, Michael; Timmins, Royann; Slezak, Jeff M; Jacobsen, Steven J; Kanter, Michael H
2015-11-01
Chronic kidney disease is highly prevalent but is challenging to diagnose because of the need to establish chronicity. Within the current healthcare environment, a single abnormal creatinine measurement often can go without a follow-up, which can lead to missed diagnoses or diagnostic errors. The Kaiser Permanente Southern California creatinine safety program (the Creatinine SureNet) was created to help ensure that all single abnormal creatinine results had a follow-up evaluation. In the period February 1, 2010, to March 1, 2014, the electronic health records were used to capture individuals with single abnormal creatinine results that went >90 days without a repeat measurement. A coordinated effort among a centralized regional nurse and providers was used to communicate with patients and order a repeat creatinine measurement. A total of 12,396 individuals were identified (84% ambulatory care encounters). A total of 6981 individuals (52%) followed up with a repeat measurement. Female patients, non-Hispanic whites, and older individuals were more likely to obtain a repeat measurement. Subsequently, 3668 individuals had chronic kidney disease confirmed. Within 6 months, 1550 patients had chart documentation of their chronic kidney disease and 336 patients had a nephrology consultation. The ambulatory care environment, given its high volume and various prioritizations, is an under-recognized area where diagnostic errors are not uncommon and failure to follow up on abnormal test results can occur routinely. The Kaiser Permanente Southern California Creatinine SureNet program leverages the electronic health records and its multidisciplinary resources in an effort to ensure that patients with potential chronic kidney disease are identified and managed properly. Copyright © 2015 Elsevier Inc. All rights reserved.
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Age and correlation of the Calera Limestone in the Permanente terrane of northern California
Sliter, William V.; McGann, Mary
1992-01-01
Planktonic foraminifers indicate that outcrops of Calera Limestone from the Permanente terrane in the Franciscan Complex of northern California range in age from possibly as old as Barremian to late Turonian. Underlying black limestone, which is devoid of planktonic foraminifers, presumably is Barremian in age or older. The top of the sequence exposed in major quarries is always faulted. Improved biostratigraphic resolution shows two patterns of missing time intervals. The primary pattern, which is found at all localities and involves missing planktonic foraminiferal zones in the late Aptian to early Albian and the late Albian, is linked to paleoceanographic changes in the Cretaceous Pacific Ocean. The secondary pattern, which is found at the scattered outcrops outside the major quarries and involves missing zones in the Albian and Cenomanian, suggests the results of a common tectonic history related to the accretion of a large seamount.
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Séror, Ann C
2002-12-01
The Internet and emergent telecommunications infrastructures are transforming the future of health care management. The costs of health care delivery systems, products, and services continue to rise everywhere, but performance of health care delivery is associated with institutional and ideological considerations as well as availability of financial and technological resources. to identify the effects of ideological differences on health care market infrastructures including the Internet and telecommunications technologies by a comparative case analysis of two large health care organizations: the British National Health Service and the California-based Kaiser Permanente health maintenance organization. A qualitative comparative analysis focusing on the British National Health Service and the Kaiser Permanente health maintenance organization to show how system infrastructures vary according to market dynamics dominated by health care institutions ("push") or by consumer demand ("pull"). System control mechanisms may be technologically embedded, institutional, or behavioral. The analysis suggests that telecommunications technologies and the Internet may contribute significantly to health care system performance in a context of ideological diversity. The study offers evidence to validate alternative models of health care governance: the national constitution model, and the enterprise business contract model. This evidence also suggests important questions for health care policy makers as well as researchers in telecommunications, organizational theory, and health care management.
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The Kaiser Permanente Northern California Adult Member Health Survey.
Gordon, Nancy; Lin, Teresa
2016-01-01
The Kaiser Permanente Northern California (KPNC) Member Health Survey (MHS) is used to describe sociodemographic and health-related characteristics of the adult membership of this large, integrated health care delivery system to monitor trends over time, identify health disparities, and conduct research. To provide an overview of the KPNC MHS and share findings that illustrate how survey statistics and data have been and can be used for research and programmatic purposes. The MHS is a large-scale, institutional review board-approved survey of English-speaking KPNC adult members. The confidential survey has been conducted by mail triennially starting in 1993 with independent age-sex and geographically stratified random samples, with an option for online completion starting in 2005. The full survey sample and survey data are linkable at the individual level to Health Plan and geocoded data. Respondents are assigned weighting factors for their survey year and additional weighting factors for analysis of pooled survey data. Statistics from the 1999, 2002, 2005, 2008, and 2011 surveys show trends in sociodemographic and health-related characteristics and access to the Internet and e-mail for the adult membership aged 25 to 79 years and for 6 age-sex subgroups. Pooled data from the 2008 and 2011 surveys show many significant differences in these characteristics across the 5 largest race/ethnic groups in KPNC (non-Hispanic whites, blacks, Latinos, Filipinos, and Chinese). The KPNC MHS has yielded unique insights and provides an opportunity for researchers and public health organizations outside of KPNC to leverage our survey-generated statistics and collaborate on epidemiologic and health services research studies.
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MSN, Gayle Tang; Lanza, Oscar; Rodriguez, Fátima Marinely; Chang, Annie
2011-01-01
Patient–clinician language concordance is a critical component of the language access equation and is considered the gold standard for communication. As a result of lack of validated testing standards, measures, and tools, Kaiser Permanente developed the Clinician Cultural and Linguistic Assessment Initiative to ensure verifiable linguistic proficiency in clinical encounters and has established a standard level whereby the clinician is deemed to have a qualifying level of proficiency in communicating directly with patients independent of an interpreter. Our benchmarking efforts in language concordance have been rooted with the key aim to identify talented bilingual and bicultural clinician workforce and to establish the systems foundation to coordinate appropriate language services. We share accomplishments, lessons learned, and promising practices to inform future efforts in language concordance. PMID:21228282
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Paxton, Elizabeth W; Kiley, Mary-Lou; Love, Rebecca; Barber, Thomas C; Funahashi, Tadashi T; Inacio, Maria C S
2013-06-01
In response to the increased volume, risk, and cost of medical devices, in 2001 Kaiser Permanente (KP) developed implant registries to enhance patient safety and quality, and to evaluate cost-effectiveness. Using an integrated electronic health record system, administrative databases, and other institutional databases, orthopedic, cardiology, and vascular implant registries were developed in 2001, 2006, and 2011, respectively. These registries monitor patients, implants, clinical practices, and surgical outcomes for KP's 9 million members. Critical to registry success is surgeon leadership and engagement; each geographical region has a surgeon champion who provides feedback on registry initiatives and disseminates registry findings. The registries enhance patient safety by providing a variety of clinical decision tools such as risk calculators, quality reports, risk-adjusted medical center reports, summaries of surgeon data, and infection control reports to registry stakeholders. The registries are used to immediately identify patients with recalled devices, evaluate new and established device technology, and identify outlier implants. The registries contribute to cost-effectiveness initiatives through collaboration with sourcing and contracting groups and confirming adherence to device formulary guidelines. Research studies based on registry data have directly influenced clinical best practices. Registries are important tools to evaluate longitudinal device performance and safety, study the clinical indications for and outcomes of device implantation, respond promptly to recalls and advisories, and contribute to the overall high quality of care of our patients.
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2002-01-01
Background The Internet and emergent telecommunications infrastructures are transforming the future of health care management. The costs of health care delivery systems, products, and services continue to rise everywhere, but performance of health care delivery is associated with institutional and ideological considerations as well as availability of financial and technological resources. Objective To identify the effects of ideological differences on health care market infrastructures including the Internet and telecommunications technologies by a comparative case analysis of two large health care organizations: the British National Health Service and the California-based Kaiser Permanente health maintenance organization. Methods A qualitative comparative analysis focusing on the British National Health Service and the Kaiser Permanente health maintenance organization to show how system infrastructures vary according to market dynamics dominated by health care institutions ("push") or by consumer demand ("pull"). System control mechanisms may be technologically embedded, institutional, or behavioral. Results The analysis suggests that telecommunications technologies and the Internet may contribute significantly to health care system performance in a context of ideological diversity. Conclusions The study offers evidence to validate alternative models of health care governance: the national constitution model, and the enterprise business contract model. This evidence also suggests important questions for health care policy makers as well as researchers in telecommunications, organizational theory, and health care management. PMID:12554552
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Munro, Malcolm G
2013-01-01
Acute uterine bleeding unrelated to pregnancy has been defined as bleeding “sufficient in volume as to, in the opinion of the treating clinician, require urgent or emergent intervention.” The Southern California Permanente Medical Group updated its guidelines for the management of this condition on the basis of the best available evidence, as identified in a systematic review of the available literature. Given the paucity of studies evaluating this condition, the guidelines, by necessity, include recommendations largely based on opinion or other sources such as case series that are, in general, categorized as low-quality evidence. Medical interventions with single or combined gonadal steroidal agents administered parenterally or orally show promise, but more high-quality studies are needed to better define the appropriate drugs, dose, and administrative scheduling. There is also some evidence that intrauterine tamponade may be useful in at least selected cases. Special attention must be paid to both diagnosing and treating inherited disorders of hemostasis, such as von Willebrand disease, that may otherwise be underdiagnosed in both adolescent and adult women. PMID:24355890
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Collmann, Jeff; Cooper, Ted
2007-01-01
This case study describes and analyzes a breach of the confidentiality and integrity of personally identified health information (e.g. appointment details, answers to patients' questions, medical advice) for over 800 Kaiser Permanente (KP) members through KP Online, a web-enabled health care portal. The authors obtained and analyzed multiple types of qualitative data about this incident including interviews with KP staff, incident reports, root cause analyses, and media reports. Reasons at multiple levels account for the breach, including the architecture of the information system, the motivations of individual staff members, and differences among the subcultures of individual groups within as well as technical and social relations across the Kaiser IT program. None of these reasons could be classified, strictly speaking, as "security violations." This case study, thus, suggests that, to protect sensitive patient information, health care organizations should build safe organizational contexts for complex health information systems in addition to complying with good information security practice and regulations such as the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
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Otte-Trojel, Terese; Rundall, Thomas G; de Bont, Antoinette; van de Klundert, Joris; Reed, Mary E
2015-12-16
Patient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited. This paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development? We identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of
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Paxton, Elizabeth W; Inacio, Maria Cs; Kiley, Mary-Lou
2012-01-01
Considering the high cost, volume, and patient safety issues associated with medical devices, monitoring of medical device performance is critical to ensure patient safety and quality of care. The purpose of this article is to describe the Kaiser Permanente (KP) implant registries and to highlight the benefits of these implant registries on patient safety, quality, cost effectiveness, and research. Eight KP implant registries leverage the integrated health care system's administrative databases and electronic health records system. Registry data collected undergo quality control and validation as well as statistical analysis. Patient safety has been enhanced through identification of affected patients during major recalls, identification of risk factors associated with outcomes of interest, development of risk calculators, and surveillance programs for infections and adverse events. Effective quality improvement activities included medical center- and surgeon-specific profiles for use in benchmarking reports, and changes in practice related to registry information output. Among the cost-effectiveness strategies employed were collaborations with sourcing and contracting groups, and assistance in adherence to formulary device guidelines. Research studies using registry data included postoperative complications, resource utilization, infection risk factors, thromboembolic prophylaxis, effects of surgical delay on concurrent injuries, and sports injury patterns. The unique KP implant registries provide important information and affect several areas of our organization, including patient safety, quality improvement, cost-effectiveness, and research.
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Kaiser Permanente Northern California pregnancy database: Description and proof of concept study.
Zerbo, Ousseny; Chan, Berwick; Goddard, Kristin; Lewis, Ned; Bok, Karin; Klein, Nicola P; Baxter, Roger
2016-11-04
We describe the establishment of a dynamic database linking mothers to newborns with the goal of studying vaccine safety in both pregnant women and their children and provide results of a study utilizing this database as a proof of concept. All Kaiser Permanente Northern California (KPNC) live births and their mothers were eligible for inclusion in the pregnancy database. We used the medical record number (MRN), a unique identifier, to retrieve information about events that occurred during the pregnancy and at delivery and linked this same MRN to newborns for post-partum follow up. We conducted a retrospective cohort study to evaluate the association between receipt of tetanus, diphtheria and acellular pertussis (Tdap) vaccine during pregnancy and fever 0-3days after the first dose of diphtheria tetanus and acellular pertussis (DTaP) vaccine in the infant. The study included infants who were born at ⩾37weeks gestation from January 1, 2009 - October 1, 2015 and who received their first DTaP vaccine between 6 and 10weeks of age. We utilized diagnostic codes from inpatient, emergency department, outpatient clinics, and telephone calls. We identified fever using ICD 9 code 780.6, recorded temperature ⩾101 degree Fahrenheit, or parental report. The database contained the starting and ending date of each pregnancy and basic demographic characteristics of mothers and infants. There were 859,699 women and 873,753 children in the database as of January 2016. The proof of concept study included 148,699 infants. In a multivariable logistic regression analysis, Tdap vaccination during pregnancy was not associated with infant fever 0-3daysafter first dose of DTaP (adjusted odds ratio=0.92, 95% CI 0.82-1.04). The KPNC pregnancy database can be used for studies investigating exposure during pregnancy and outcomes in mothers and/or infants, particularly monitoring vaccine safety and effectiveness. Copyright © 2016 Elsevier Ltd. All rights reserved.
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ERIC Educational Resources Information Center
Kerchner, Charles T.
2008-01-01
Reporting on a talk the author gave some months ago, the headline in "La Opinion," Los Angeles' premier Spanish language newspaper, declared the city's school system "en crisis permanente." No one wrote in to disagree. Indeed, at the end of "Learning from L.A.: Institutional Change in American Public Education" (Harvard Education Press) the author…
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Bouhaddou, Omar; Bennett, Jamie; Cromwell, Tim; Nixon, Graham; Teal, Jennifer; Davis, Mike; Smith, Robert; Fischetti, Linda; Parker, David; Gillen, Zachary; Mattison, John
2011-01-01
The Nationwide Health Information Network allow for the secure exchange of Electronic Health Records over the Internet. The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente, participated in an implementation of the NwHIN specifications in San Diego, California. This paper focuses primarily on patient involvement. Specifically, it describes how the shared patients were identified, were invited to participate and to provide consent for disclosing parts of their medical record, and were matched across organizations. A total 1,144 were identified as shared patients. Invitation letters containing consent forms were mailed and resulted in 42% participation. Invalid consent forms were a significant issue (25%). Initially, the identity matching algorithms yielded low success rate (5%). However, elimination of certain traits and abbreviations and probabilistic algorithms have significantly increased matching rate. Access to information from external sources better informs providers, improves decisions and efficiency, and helps meet the meaningful use criteria.
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Maeda, Jared Lane K; Lee, Karen M; Horberg, Michael
2014-01-01
Because of rising health care costs, wide variations in quality, and increased patient complexity, the US health care system is undergoing rapid changes that include payment reform and movement toward integrated delivery systems. Well-established integrated delivery systems, such as Kaiser Permanente (KP), should work to identify the specific system-level factors that result in superior patient outcomes in response to policymakers' concerns. Comparative health systems research can provide insights into which particular aspects of the integrated delivery system result in improved care delivery. To provide a baseline understanding of comparative health systems research related to integrated delivery systems and KP. Systematic literature review. We conducted a literature search on PubMed and the KP Publications Library. Studies that compared KP as a system or organization with other health care systems or across KP facilities internally were included. The literature search identified 1605 articles, of which 65 met the study inclusion criteria and were examined by 3 reviewers. Most comparative health systems studies focused on intra-KP comparisons (n = 42). Fewer studies compared KP with other US (n = 15) or international (n = 12) health care systems. Several themes emerged from the literature as possible factors that may contribute to improved care delivery in integrated delivery systems. Of all studies published by or about KP, only a small proportion of articles (4%) was identified as being comparative health systems research. Additional empirical studies that compare the specific factors of the integrated delivery system model with other systems of care are needed to better understand the "system-level" factors that result in improved and/or diminished care delivery.
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Bouhaddou, Omar; Bennett, Jamie; Cromwell, Tim; Nixon, Graham; Teal, Jennifer; Davis, Mike; Smith, Robert; Fischetti, Linda; Parker, David; Gillen, Zachary; Mattison, John
2011-01-01
The Nationwide Health Information Network allow for the secure exchange of Electronic Health Records over the Internet. The Department of Veterans Affairs, Department of Defense, and Kaiser Permanente, participated in an implementation of the NwHIN specifications in San Diego, California. This paper focuses primarily on patient involvement. Specifically, it describes how the shared patients were identified, were invited to participate and to provide consent for disclosing parts of their medical record, and were matched across organizations. A total 1,144 were identified as shared patients. Invitation letters containing consent forms were mailed and resulted in 42% participation. Invalid consent forms were a significant issue (25%). Initially, the identity matching algorithms yielded low success rate (5%). However, elimination of certain traits and abbreviations and probabilistic algorithms have significantly increased matching rate. Access to information from external sources better informs providers, improves decisions and efficiency, and helps meet the meaningful use criteria. PMID:22195064
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Hinchman, Josephine; Beno, Luke; Mims, Adrienne
2006-01-01
Context: The rate of overweight (OW) in children in the United States has more than tripled since 1980. The health consequences of pediatric OW include type 2 diabetes and significant illness later in life. Treating pediatric OW is a necessity; however, health care clinicians have minimal access to successful and comprehensive treatment modalities for addressing it. Objective: Kaiser Permanente of Georgia (KPGA) offers a group medical appointment clinic, Operation Zero (O.Z.), as a referral program for preadolescent and adolescent patients who are in the 85th or higher percentile for body mass index (BMI) for their age. The eight-session clinic uses a family-oriented approach and provides a supportive group environment with interactive learning, games, physical activity, and creative problem solving. The goal of the program is to improve lifestyle behaviors for nutrition and physical activity. Clinically, meeting these goals can manifest as reductions in body fat (BF), waist size, and BMI-for-age percentile. Two implementation models help improve dissemination of the program within KPGA. Design: Baseline and eight-week postclinical outcomes for O.Z. participants were analyzed to determine program effectiveness. A retrospective analysis with a control group looked at long-term clinical outcomes to determine weight maintenance. Main outcome measures were weight, BMI-for-age percentile, waist size, and percentage of body fat (%BF). Results: At eight weeks after program completion compared with baseline, there were significant reductions in %BF and waist size for the total sample and specifically for adolescents, preteens, and participants who attended six or more sessions. Among O.Z. participants, there were insignificant increases in weight at six months after program participation and BMI-for-age percentile at one year after participation. At six months, the mean change in weight and BMI in the O.Z. group was statistically less than the mean change in the control
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MacEachin, S Rachel; Lopez, Connie M; Powell, Kimberly J; Corbett, Nancy L
2009-01-01
Electronic fetal monitoring has historically been interpreted with wide variation between and within disciplines on the obstetric healthcare team. This leads to inconsistent decision making in response to tracing interpretation. To implement a multidisciplinary electronic fetal monitoring training program, utilizing the best evidence available, enabling standardization of fetal heart rate interpretation to promote patient safety. Local multidisciplinary expertise along with an outside consultant collaborated over a series of meetings to create a multimedia instructional electronic fetal monitoring training program. After production was complete, a series of conferences attended by nurses, certified nurse midwives, and physician champions, from each hospital, attended to learn how to facilitate training at their own perinatal units. All healthcare personnel across the Kaiser Permanente perinatal program were trained in NICHD nomenclature, emergency response, interpretation guidelines, and how to create local collaborative practice agreements. Metrics for program effectiveness were measured through program evaluations from attendees, the Safety Attitudes Questionnaire. Program evaluations rendered very positive scores from both physicians and clinicians. Comparing baseline to 4 years later, the perception of safety from the staff has increased over 10% in 5 out of the 6 factors analyzed. Active participation from all disciplines in this training series has highlighted the importance of teamwork and communication. The Fetal Heart Rate Collaborative Practice Project continues to evolve utilizing other educational modalities, such as online EFM education and unit-based interdisciplinary tracing reviews.
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Recent DDT and PCB contamination in the sediment and biota of the Como Bay (Lake Como, Italy).
Bettinetti, R; Quadroni, S; Boggio, E; Galassi, S
2016-01-15
Due to its peculiar geographical and morphological characteristics, Lake Como (Northern Italy) represents an interesting study-case for investigating the sub-basin scale circulation of persistent organic pollutants (POPs) that, despite being banned since the 1970s, have reached surprisingly high concentrations in some southern alpine lakes as a consequence of their release from melting glaciers in recent years. In particular, the Como Bay, which is located in the city of Como, seems noteworthy because its waters have a longer residence time than the other areas of the lake. The analyses of the historical concentration of PCBs, pp′DDT and its metabolites in a sediment core sampled from the Como Bay covering a time-period from their ban to recent times, showed that the DDTs have never experienced a significant (p < 0.05) decrease over time, with concentrations of the most abundant homologue, pp′DDE, ranging from 27 to 75 ng g(-1) d.w. Conversely PCBs significantly (p < 0.05) decreased towards recent times, reaching concentrations around 80 ng g(-1) d.w. The contribution of high altitude and local sources was recorded also in the food web: both zooplankton and the zooplanktivorous fish agone were mainly contaminated by pp′DDE (81.4 ng g(-1) w.w. and 534.6 ng g(-1) w.w. respectively) and by the PCB metabolite hexa-CB (449.7 ng g(-1) w.w. and 1672.1 ng g(-1) w.w. respectively). The DDT concentrations in the agone (sampled during the years 2006–2009) never exceeded the limits for human consumption in Italy, while concentrations of six selected PCBs exceeded human health advisory recommendations in one of the fish samples analysed, when it was approximately two times higher than the recommended value of 125 ng g(-1) w.w.
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Continuing education in health from the perspective of Augustine of Hippo.
Fernandes, Fabíola Chaves; Cortez, Elaine Antunes; Laprovita, Daniel; Almeida, Lidiane Peixoto de; Ferreira, Aline Figueiredo; Corvino, Marcos Paulo Fonseca
2017-01-01
To reflect about continuing education from the perspective of Augustine of Hippo and his theories based on the construction of knowledge and the learning process. This is a theoretical reflection study whose aim is to propose dimensions of analysis, emphasizing the history and challenges of continuing education. Such dimensions analyze the production of knowledge in Augustinian pedagogy, its historical aspects and its close relationship with lifelong education in health professions. The results show the difficulty of continuing education to reach adequate importance in health services, and that of academia in appropriating the thoughts of renowned philosophers such as Augustine. This is a result of ignorance about the convergence of these principles and their relevance. Continuing education and Augustinian pedagogy walk hand in hand in terms of care, meeting the needs that originate from practice and that are reflected in it, challenging isolated knowledge and putting different areas of knowledge to work together. Refletir sobre a educação permanente na perspectiva de Agostinho de Hipona e suas teorias pautadas na construção do conhecimento e no processo de aprendizagem. Trata-se de uma reflexão teórica cujo intuito é propor dimensões de análise, enfatizando a história e os desafios da educação permanente. Tais dimensões analisam a produção do conhecimento na pedagogia agostiniana, seus aspectos históricos e sua relação próxima com a educação permanente em saúde. Revela a dificuldade da educação permanente em ter sua dimensão alcançada noserviço de saúde, tal qual a da academia de apropriar-se do pensamento de filósofos renomados como Agostinho, fruto do desconhecimento da convergência desses pressupostos e de sua relevância. Considera-se que a educação permanente e a pedagogia agostiniana caminham juntas no cuidar, atendendo às necessidades advindas da prática e nela refletida, confrontando os saberes isolados e com eles operando
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C-A1-02: Evaluating Kaiser Permanente Georgia’s Worksite Wellness Programs in the Atlanta Area
Roblin, Douglas; Robinson, Brandi; Benjamin-Stone, Staycee
2010-01-01
Background/Aims: There are few prospective evaluations of the effectiveness of worksite wellness programs in achieving improved lifestyle and health. Our study has two objectives: to assess the cross-sectional associations of biometric status, lifestyle, and health obtained at a wellness program’s enrollment session, and to assess changes in biometric status, lifestyle, and health between the enrollment and 6-month disenrollment sessions. Methods: For this prospective cohort study, participants were recruited from Kaiser Permanente Georgia (KPG) subscribers who were employed at a mid-sized private employer group. Participants completed a biometric assessment and written survey. The biometric measures included height, weight, blood pressure, hip/waist ratio, and total cholesterol. The written survey included measures of: health (SF-12), patient activation (PAM-13), leisure physical activity (BRFSS), food screeners (Block), and work presenteeism (SPS-6) and absenteeism. Over the next 6 months, participants will attend seminars on exercise, weight loss, and healthy cooking and eating. The biometric assessment and survey be repeated in February 2010. Results: Of the 63 eligible KPG subscribers, 60 (41 females and 19 males) consented to participate. Participant ages ranged from 28–77 years. Overall, physical and emotional health, activation, leisure physical activity, dietary intake, and BMI were comparable to results obtained among relatively healthy, low risk working age adults in a 2005 survey of KPG subscribers in large group employers. Total cholesterol was significantly (p<0.05), positively associated with percent fat in diet; and, percent fat in diet was significantly, inversely associated with activation. Participants with 1 or more days absent from work in the most recent 4-week period reported significantly higher total cholesterol and percent fat in diet and significantly lower activation. Participants with high levels of presenteeism were significantly
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LA BIOÉTICA COMO QUEHACER FILOSÓFICO
Ferrer, Jorge José
2009-01-01
El artículo examina el estatuto epistemológico de la bioética como disciplina académica. El autor sostiene que el estatuto epistemológico de un discurso lo determina la pregunta fundamental que se plantea y la respuesta que se busca, focos integradores del discurso. En el caso de la bioética, la pregunta fundamental es de índole moral. La bioética es pues una disciplina ética que tiene su hogar epistemológico en la filosofía. El autor también defiende el concepto de “éticas aplicadas”. Sugiere finalmente que el método de la bioética, sobre todo la que se hace desde nuestras latitudes, debería adoptar el círculo hermenéutico como metodología para su filosofar. PMID:20463860
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Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H
2017-01-01
Objectives: The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Methods: Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Results: Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Conclusion: Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening. PMID:28241912
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Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H
2017-01-01
The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening.
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Como Podar Arboles (Spanish Version), How to Prune Trees
Maureen McDonough; Russell; Lisa Burban; Lee Nancarrow; United States Department of Agriculture, Forest Service, Northeastern Area, State and Private Forestry
2004-01-01
Introduccion, El proposito de la poda es tener plantas fuertes, sanas y atractivas. Esta meta se puede alcanzar sabiendo como, cuando y por que podar, y siguiendo unos cuantos principios muy sencillos.
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Effects of H sub 2 S addition on the performance of fresh vs. used CoMo catalysts
DOE Office of Scientific and Technical Information (OSTI.GOV)
Rankel, L.A.
1991-01-01
When a Co/Mo catalyst is used for processing vanadium-containing heavy oils, vanadium deposits on the catalyst. As the amount of vanadium on the CoMo catalyst increases, the catalytic effects of CoMo decline and the presence of vanadium starts to influence the hydroprocessing products. Model feeds have been used to explore the changes in the catalytic activity of CoMo, aged CoMo, and VS{sub x} on alumina. Desulfurization, denitrogenation, deoxygenation, aromatics hydrogenation, and metals removal were monitored. This paper reports that, upon the addition of hydrogen sulfide to hydrogen, improvements in the catalysts for aromatics hydrogenation, denitrogenation and metals removal were observed.
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Microwave effects on NiMoS and CoMoS single-sheet catalysts.
Borges, I; Silva, Alexander M; Modesto-Costa, Lucas
2018-05-04
Single-sheet nanoclusters of MoS 2 , NiMoS or CoMoS are widely used in hydrodesulfurization (HDS) catalysis in the petroleum industry. In HDS reactions under microwave irradiation, experiments indirectly pointed out that for pristine MoS 2 reaction rates are accelerated because hot spots are generated on the catalyst bed. In this work, we investigated NiMoS and CoMoS isolated single-sheet substituted catalysts before and after thiophene adsorption focusing on quantifying the effect of microwave irradiation. For that purpose, density functional theory (DFT) molecular charge densities of each system were decomposed according to the distributed multipole analysis (DMA) of Stone. Site dipole values of each system were directly associated with a larger or smaller interaction with the microwave field according to a proposed general approach. We showed that microwave enhancement of HDS reaction rates can occur more efficiently in the CoMoS and NiMoS promoted clusters compared to pristine MoS 2 in the following order: CoMoS > NiMoS > MoS 2 . The atomic origin of the catalyst hot spots induced by microwaves was clearly established in the promoted clusters.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Veen, J.A.R. van; Hendriks, P.A.J.M.; Beens, H.
1992-01-01
A suite of 11 CoMo/Al{sub 2}O{sub 4} (and one CoMo/SiO{sub 2}) catalysts has been prepared employing four preparation routes, viz. one sequential-impregnation route and three different coimpregnation routes. Speciation of the Co present in the oxidic precursors (octahedral vs tetrahedral Co) and in the activated, sulfided catalysts (CoMoS, Co{sub 9}S{sub 8}, and unsulfided Co) was effected with the aid of {sup 57}Co Moessbauer emission spectroscopy (MES). A linear relation between the thiophene-hydrodesulfurization (HDS) activity and wt% Co-in-CoMoS was observed for each preparation route, but no unique correlation was found to exist. This was traced to the fact that the preparationmore » routes differ in the amount of CoMoS I and CoMoS II they produce in the activated catalyst. Although these two phases differ in specific activity, CoMoS II being twice as active in thiophene HDS as CoMoS I, they cannot be distinguished on the basis of their Moessbauer parameters. It appears that octahedral Co is easier to sulfide than tetrahedral Co, but a substantial fraction of the latter is also found to be capable of entering CoMoS upon sulfidation. The reduced effectiveness of high-loading catalysts is traced to their being prone to CoMoO{sub 4} formation in the calcination step. A rationalization of this behavior is offered.« less
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Como Lo Hago Yo: Myelomeningocele
Lazareff, Jorge
2014-01-01
Fortificación con ádico fólico es efectiva, pero aún falta conciencia en los jóvenes. La legalidad del aborto aumenta la importancia de la consulta prenatal. Realizo la cirugía bajo microcoscopio por razones didácticas. Irrigación continua para reducir la temperatura del tejido. Trato a la plaqueta como tejido viable. No suturo la plaqueta. No cierro músculo. ATB por una semana después de cirugía. Hidrocefalia: Válvula en todos los casos de ventriculomegalia. Médula anclada: Desanclar una sola vez. Chiari II: Revisar la válvula. Incluir en el seguimiento rendimiento escolar, puede indicar obstrucción de la válvula o médula anclada. PMID:24791217
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Federal Register 2010, 2011, 2012, 2013, 2014
2010-04-22
... Slingsby Systems, Inc., Jupiter, Florida. TA-W-72,372: Kaiser Permanente, Corona, California, covered by TA-W- 71,894: Kaiser Permanente, Corona, California. TA-W-72,432: Matthew Bender and Company, Inc...
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Cúmulos globulares como trazadores de bimodalidad estelar en galaxias cD
NASA Astrophysics Data System (ADS)
Forte, J. C.
Se muestra que tanto la forma de los perfiles de brillo como de color observados en dos galaxias arquetípicas de tipo cD (NGC 1399 y NGC 4486) son compatibles con la presencia de poblaciones estelares bi-modales que comparten la misma distribución espacial y composición química de las familias dominantes de cúmulos globulares asociadas con ellas. El modelo resultante también predice una variación de la frecuencia específica de los cúmulos como función del radio galactocéntrico. Se discute este resultado en el contexto de una variedad de escenarios astrofísicos que intentan describir la formación de galaxias cD.
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Valorisation of Como Historical Cadastral Maps Through Modern Web Geoservices
NASA Astrophysics Data System (ADS)
Brovelli, M. A.; Minghini, M.; Zamboni, G.
2012-07-01
Cartographic cultural heritage preserved in worldwide archives is often stored in the original paper version only, thus restricting both the chances of utilization and the range of possible users. The Web C.A.R.T.E. system addressed this issue with regard to the precious cadastral maps preserved at the State Archive of Como. Aim of the project was to improve the visibility and accessibility of this heritage using the latest free and open source tools for processing, cataloguing and web publishing the maps. The resulting architecture should therefore assist the State Archive of Como in managing its cartographic contents. After a pre-processing consisting of digitization and georeferencing steps, maps were provided with metadata, compiled according to the current Italian standards and managed through an ad hoc version of the GeoNetwork Opensource geocatalog software. A dedicated MapFish-based webGIS client, with an optimized version also for mobile platforms, was built for maps publication and 2D navigation. A module for 3D visualization of cadastral maps was finally developed using the NASA World Wind Virtual Globe. Thanks to a temporal slidebar, time was also included in the system producing a 4D Graphical User Interface. The overall architecture was totally built with free and open source software and allows a direct and intuitive consultation of historical maps. Besides the notable advantage of keeping original paper maps intact, the system greatly simplifies the work of the State Archive of Como common users and together widens the same range of users thanks to the modernization of map consultation tools.
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Balamurugan, Jayaraman; Li, Chao; Peera, Shaik Gouse; Kim, Nam Hoon; Lee, Joong Hee
2017-09-21
Layered transition metal sulfides (TMS) are emerging as advanced materials for energy storage and conversion applications. In this work, we report a facile and cost-effective anion exchange technique to fabricate a layered, multifaceted, free standing, ultra-thin ternary cobalt molybdenum sulfide nanosheet (Co-Mo-S NS) architecture grown on a 3D porous Ni foam substrate. The unique Co-Mo layered double hydroxides are first synthesized as precursors and consequently transformed into ultra-thin Co-Mo-S NS. When employed as an electrode for supercapacitors, the Co-Mo-S NS delivered an ultra-high specific capacitance of 2343 F g -1 at a current density of 1 mA cm -2 with tremendous rate capability and extraordinary cycling performance (96.6% capacitance retention after 20 000 cycles). Furthermore, assembled Co-Mo-S/nitrogen doped graphene nanosheets (NGNS) in an asymmetric supercapacitor (ASC) device delivered an excellent energy density of 89.6 Wh kg -1 , an amazing power density of 20.07 kW kg -1 , and superior cycling performance (86.8% capacitance retention after 50 000 cycles). Such exceptional electrochemical performance of Co-Mo-S NS is ascribed to the good electrical contact with the 3D Ni foam, ultra-high contact area with the electrolyte, and enhanced architectural softening during the charging/discharging process. It is expected that the fabricated, unique, ultra-thin Co-Mo-S NS have great potential for future energy storage devices.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Muralidhar, G.; Massoth, F.E.; Shabtai, J.
1984-01-01
C-S hydrogenolysis (HDS) of thiophene, hydrogenation (HYD) of 1-hexene, and hydrocracking (HCG) of 2,4,4-trimethyl-1-pentene, were used as separate model test reactions to differentiate and assess the catalytic functionalities of sulfided CoMo catalysts, and their dependence on the nature of the support and incorporation of additives. Rate constants and relative catalyst activities for these three reaction types were determined. HDS and HYD activities of CoMo supported on different types of Al/sub 2/O/sub 3/ were higher, while the HCG activity was lower compared with CoMo supported on SiO/sub 2/-Al/sub 2/O/sub 3/, SiO/sub 2/-MgO, or TiO/sub 2/. For SiO/sub 2/-Al/sub 2/O/sub 3/ supportsmore » both HDS and HYD activities decreased with increase in SiO/sub 2/ content from 10 to 75%, while HCG activity showed the opposite trend. Additives to a finished CoMo catalyst at 0.5% level caused variations in HDS and HCG activities, while HYD was essentially unaffected. HDS was promoted by NH/sub 4/HF/sub 2/ and NH/sub 4/Cl, but depressed by NaNO/sub 3/, Ca(NO/sub 3/)/sub 2/, and H/sub 3/BO/sub 3/. HCG was promoted by NH/sub 4/HF/sub 2/, NH/sub 4/Cl, and H/sub 3/BO/sub 3/. Additives at 5% level, prior to or after CoMo impregnation, showed a strong depressing effect on HDS and a lesser effect on HYD, while HCG was strongly promoted by NH/sub 4/HF/sub 2/, Ti isopropoxide, and H/sub 3/BO/sub 3/. The changes in catalytic functionalities are rationalized in terms of different interactions between CoMo phase, support, and additives. 3 tables, 1 figure.« less
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Thermophysical properties of undercooled liquid Co-Mo alloys
NASA Astrophysics Data System (ADS)
Han, X. J.; Wei, B.
2003-05-01
Using electromagnetic levitation in combination with the oscillating drop technique and drop calorimeter method, the surface tensions and specific heats of undercooled liquid Co-10 wt% Mo, Co-26.3 wt% Mo, and Co-37.6 wt% Mo alloys were measured. The containerless state during levitation produces substantial undercoolings up to 223 K (0.13TL), 213 K (0.13TL) and 110 K (0.07TL) respectively for these three alloys. In their respective undercooling ranges, the surface tensions were determined to be 1895 m 0.31(T m 1744), 1932 m 0.33(T m 1682), and 1989 m 0.34(T m 1607) mN mу. According to the Butler equation, the surface tensions of these three Co-Mo alloys were also calculated, and the results agree well with the experimental data. The specific heats of these three alloys are determined to be 41.85, 43.75 and 44.92 J molу Kу. Based on the determined surface tensions and specific heats, the changes in thermodynamics functions such as enthalpy, entropy and Gibbs free energy are predicted. Furthermore, the crystal nucleation, dendrite growth and Marangoni convection of undercooled Co-Mo alloys are investigated in the light of these measured thermophysical properties.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Fiveland, W.A.; Oberjohn, W.J.; Cornelius, D.K.
1985-12-01
This report summarizes the work conducted during a 30-month contract with the United States Department of Energy (DOE) Pittsburgh Energy Technology Center (PETC). The general objective is to develop and verify a computer code capable of modeling the major aspects of pulverized coal combustion. Achieving this objective will lead to design methods applicable to industrial and utility furnaces. The combustion model (COMO) is based mainly on an existing Babcock and Wilcox (B and W) computer program. The model consists of a number of relatively independent modules that represent the major processes involved in pulverized coal combustion: flow, heterogeneous and homogeneousmore » chemical reaction, and heat transfer. As models are improved or as new ones are developed, this modular structure allows portions of the COMO model to be updated with minimal impact on the remainder of the program. The report consists of two volumes. This volume (Volume 1) contains a technical summary of the COMO model, results of predictions for gas phase combustion, pulverized coal combustion, and a detailed description of the COMO model. Volume 2 is the Users Guide for COMO and contains detailed instructions for preparing the input data and a description of the program output. Several example cases have been included to aid the user in usage of the computer program for pulverized coal applications. 66 refs., 41 figs., 21 tabs.« less
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Morphological investigation of nanostructured CoMo catalysts
NASA Astrophysics Data System (ADS)
Pawelec, B.; Castaño, P.; Zepeda, T. A.
2008-04-01
This work reports the morphological investigation of nanostructured sulfided CoMo catalysts by means of high-resolution transmission electron microscopy (HRTEM). The catalysts were supported on Ti-modified hexagonal mesoporous silica (HMS-Ti) and P-modified HMS-Ti (P/HMS-Ti) materials. The oxide precursors were characterized by specific surface area (S BET), temperature-programmed reduction (TPR), diffuse reflectance infrared Fourier transform spectroscopy in the OH region (DRIFTS-OH) and X-ray photoelectron spectroscopy (XPS) in order to elucidate the influence of the impregnation sequence (successive vs. simultaneous) and the effect of P-incorporation into HMS-Ti material on the morphology of calcined CoMo catalysts. Both TPR and XPS measurements indicate that the catalysts prepared by successive impregnation possess well-dispersed MoO 3 and CoO phases, whereas their counterparts prepared by simultaneous impregnation additionally possess the CoMoO 4 phase. For all sulfided catalysts, the presence of MoS 2 phase with particle size in the range 3.3-4.4 nm was confirmed by HRTEM. Catalytic activity was evaluated in the reaction of hydrodesulfurization (HDS) of dibenzothiophene (DBT) carried out in a flow reactor at 593 K and hydrogen pressure of 5.5 MPa. P-incorporation into the HMS-Ti material led to an overall increase in HDS activity and the hydrogenation ability of the sulfided catalysts. All catalysts proved to be stable during 10 h time-on-stream (TOS) operation. The activity of sulfide catalysts in the target reaction depends linearly on the surface exposure of Co species in the oxide precursors, as determined by XPS, and on the morphology of the sulfide form of catalysts (surface density of MoS 2 particles and their sizes) as determined by HRTEM.
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Geophysical investigations of the Olonium Roman site (Northern Como Lake)
NASA Astrophysics Data System (ADS)
Arlsan, Ermanno; Biella, Giancarlo; Boniolo, Graziano; Caporusso, Donatella; de Franco, Roberto; Lozej, Alfredo; Veronese, Luigi
1999-03-01
The study area is located at S. Agata (Gera Lario), a small center at the northern end of Como Lake, near the junction of Valchiavenna and Valtellina Valleys. This site played a strategic role since ancient times, providing the control on the communications routes to both the Como Lake and the Spluga and Septimer alpine passes. Since the end of the last century archaeological findings are reported in literature, also supported, from the early XI century, by archival documents confirming the existence of the `Olonium' settlement, an administrative and fiscal center of primary importance, as well as a parish amongst the most influential in the Como Lake area. Within an area of 45,000 m 2 an electrical survey has been carried out in conjunction with magnetic and GPR investigations. These studies have indicated the presence of a number of sub-areas characterized by significant anomalies defined by the overlapping of the results obtained from two or more geophysical methods. In two of such sub-areas, excavation tests have been conducted, which have brought to light a number of archaeological findings of interest. In one of the two sub-areas, which is characterized by the superimposition of electrical and radar anomalies, a deposit of large pebbles has been found. The origin of this deposit has not been ascertained, whether it is of fluvial origin, related to the deviation of the Adda river in the Pian di Spagna region in Roman times, or it is part of reclamation works, still of Roman times, of paleolacustrine marshes. The overlapping stratigraphy, however, suggests the development of fluvial channels between Roman and Low-Medieval times. In the other sub-area, excavations were carried out on sites defined by electrical and radar anomalies, and confirmed by the results from magnetic survey. The excavations brought to light, below the fluvial deposits, a large medieval edifice, which could be identified as the S. Stefano church abandoned in 1444. The church is built on
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Corrado, Giovanni; Durante, Alessandro; Genchi, Vincenzo; Trabattoni, Loris; Beretta, Sandro; Rovelli, Enza; Foglia-Manzillo, Giovanni; Ferrari, Giovanni
2016-08-01
The prognosis for abdominal aortic aneurysm (AAA) rupture is poor. Long-term follow-up of population-based randomized trials has demonstrated that ultrasound (US) screening for abdominal aortic aneurysms (AAAs) measuring 3 cm or greater decreases AAA-related mortality rates and is cost-effective. We though to prospectively perform during a 26-month period a limited US examination of the infrarenal aorta in volunteers of both gender aged 60-85 years without history of AAA living in the area of Como, Italy. From September 2010 to November 2013 ComoCuore, a no-profit nongovernmental association, enrolled 1555 people (aged 68.8 ± 6.8 years; 48.6 % males). Clinical data and a US imaging of the aorta were collected for each participant. AAA was found in 22 volunteers (1.4 %) mainly males (2.5 % in males vs. 0.4 % in females p = 0.005). Overall, the prevalence of cardiovascular risk factors was higher in patients with vs. without AAA (mean 2.9 ± 3.0 vs. 1.4 ± 1.0 respectively, p < 0.0001). Independent predictors of AAA on multivariate analysis were age (OR 1.14, 1.06-1.22; p < 0.0001), male gender (OR 8.23, 1.79-37.91; p = 0.007), and both current (OR 4.98, 1.57-15.79; p = 0.007) and previous smoking (OR 2.76, 1.12-8.94; p = 0.03). Our study confirms the feasibility of one time US screening for AAA in a large cohort of asymptomatic people. Independent predictors of AAA were male sex, older age and a history of smoking. Accordingly to recent data the prevalence of AAA seems to be declining, maybe due to a reduction of smoking in Italy.
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Informacion Bibliografica Educativa (Bibliographic Educational Information). No. 12.
ERIC Educational Resources Information Center
Ministerio de Educacion Nacional, Bogota (Colombia). Centro Nacional de Documentacion e Informacion Pedagogica.
The document contains six papers in Spanish which focus on the developmental and other aspects of education permanente. The first paper, The Concept of Education Permanente, discusses the concept as a new dimension in the area of education, capable of limiting inequalities in the presentation of education in general. Descriptions of 20…
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78 FR 38287 - Bitterroot National Forest, Darby Ranger District, Como Forest Health Project
Federal Register 2010, 2011, 2012, 2013, 2014
2013-06-26
... DEPARTMENT OF AGRICULTURE Forest Service Bitterroot National Forest, Darby Ranger District, Como Forest Health Project AGENCY: Forest Service. ACTION: Notice; Correction. SUMMARY: The Department of Agriculture (USDA), Forest Service, Bitterroot National Forest, Darby Ranger District published a document in...
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78 FR 36163 - Bitterroot National Forest, Darby Ranger District, Como Forest Health Project
Federal Register 2010, 2011, 2012, 2013, 2014
2013-06-17
... Lake Como and Lost Horse Roads, about XX miles northwest of Darby in Ravalli County, Montana. The... Lost Horse Road, about three miles northwest of Darby, Montana (R22W,T4N, Sec. 13, 24, 25, 36; R21W,T4N...
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Grytdal, Scott P; DeBess, Emilio; Lee, Lore E; Blythe, David; Ryan, Patricia; Biggs, Christianne; Cameron, Miriam; Schmidt, Mark; Parashar, Umesh D; Hall, Aron J
2016-01-01
Noroviruses and other viral pathogens are increasingly recognized as frequent causes of acute gastroenteritis (AGE). However, few laboratory-based data are available on the incidence of AGE caused by viral pathogens in the U.S. This study examined stool specimens submitted for routine clinical diagnostics from patients enrolled in Kaiser Permanente (KP) health plans in metro Portland, OR, and the Maryland, District of Columbia, and northern Virginia geographic areas to estimate the incidence of viral enteropathogens in these populations. Over a one-year study period, participating laboratories randomly selected stools submitted for routine clinical diagnostics for inclusion in the study along with accompanying demographic and clinical data. Selected stools were tested for norovirus, rotavirus, sapovirus, and astrovirus using standardized real-time RT-PCR protocols. Each KP site provided administrative data which were used in conjunction with previously published data on healthcare utilization to extrapolate pathogen detection rates into population-based incidence rates. A total of 1,099 specimens collected during August 2012 to September 2013 were included. Mean age of patients providing stool specimens was 46 years (range: 0-98 years). Noroviruses were the most common viral pathogen identified among patients with AGE (n = 63 specimens, 6% of specimens tested). In addition, 22 (2%) of specimens were positive for rotavirus; 19 (2%) were positive for sapovirus; and 7 (1%) were positive for astrovirus. Incidence of norovirus-associated outpatient visits was 5.6 per 1,000 person-years; incidence of norovirus disease in the community was estimated to be 69.5 per 1,000 person-years. Norovirus incidence was highest among children <5 years of age (outpatient incidence = 25.6 per 1,000 person-years; community incidence = 152.2 per 1,000 person-years), followed by older adults aged >65 years (outpatient incidence = 7.8 per 1,000 person-years; community incidence = 75.8 per 1
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Combat Identification Systems COMO Integrated Air Defense Model Evaluation (CISE) Study
1989-02-01
use K or IR , whichever one applies) E-6 CAA-SR-89- 3 Subroutine PDECLR 1/21/88 Before label 1000 Insert: IF (IR.GT.10) IR a 10 These changes were made...Internal Distribution: Unclassified Library 2 F-2 CAA-SR-89- 3 GLOSSARY 1. ABBREVIATIONS, ACRONYMS, AND SHORT TERMS ADM2 Air Defense Models Modification...STUDY REPORT ’ , CAA-Sn-89- 3 i , .- CD o COMBAT IDENTIFICATION SYSTEMS N COMO INTEGRATED AIR DEFENSE MODEL EVALUATION (CISE) STUDY FEBRUARY 1989
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Grytdal, Scott P.; Biggs, Christianne; Cameron, Miriam; Schmidt, Mark; Parashar, Umesh D.; Hall, Aron J.
2016-01-01
Noroviruses and other viral pathogens are increasingly recognized as frequent causes of acute gastroenteritis (AGE). However, few laboratory-based data are available on the incidence of AGE caused by viral pathogens in the U.S. This study examined stool specimens submitted for routine clinical diagnostics from patients enrolled in Kaiser Permanente (KP) health plans in metro Portland, OR, and the Maryland, District of Columbia, and northern Virginia geographic areas to estimate the incidence of viral enteropathogens in these populations. Over a one-year study period, participating laboratories randomly selected stools submitted for routine clinical diagnostics for inclusion in the study along with accompanying demographic and clinical data. Selected stools were tested for norovirus, rotavirus, sapovirus, and astrovirus using standardized real-time RT-PCR protocols. Each KP site provided administrative data which were used in conjunction with previously published data on healthcare utilization to extrapolate pathogen detection rates into population-based incidence rates. A total of 1,099 specimens collected during August 2012 to September 2013 were included. Mean age of patients providing stool specimens was 46 years (range: 0–98 years). Noroviruses were the most common viral pathogen identified among patients with AGE (n = 63 specimens, 6% of specimens tested). In addition, 22 (2%) of specimens were positive for rotavirus; 19 (2%) were positive for sapovirus; and 7 (1%) were positive for astrovirus. Incidence of norovirus-associated outpatient visits was 5.6 per 1,000 person-years; incidence of norovirus disease in the community was estimated to be 69.5 per 1,000 person-years. Norovirus incidence was highest among children <5 years of age (outpatient incidence = 25.6 per 1,000 person-years; community incidence = 152.2 per 1,000 person-years), followed by older adults aged >65 years (outpatient incidence = 7.8 per 1,000 person-years; community incidence = 75.8 per
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Field technique of permeability tests in highly fissured limestone strata
NASA Astrophysics Data System (ADS)
Al-Salihi, Adnan; Asaad, Abdulah
2002-05-01
Résumé.L'étude de dispositifs de dénoyage est nécessaire pour l'amélioration de sites avant la construction de certaines structures. L'étude de dispositifs de dénoyage efficaces exige d'estimer la valeur du coefficient de perméabilité in situ. Les relations disponibles pour estimer le coefficient de perméabilité ont été développées sur la base de mesures et de conditions de terrain limitées, et les prédictions varient de plusieurs ordres de grandeur. C'est pourquoi il est nécessaire de réaliser des mesures de perméabilité sur le terrain et de déterminer la relation qui permet le meilleur ajustement de ces mesures avant l'étude du dispositif de dénoyage pour des conditions locales et géologiques spécifiques. Ce papier présente des mesures de perméabilité sur le terrain dans des niveaux calcaires complexes chaotiques et diagénétisés. Il propose également une analyse comparative de plusieurs relations disponibles dans la littérature destinées à prédire le coefficient de perméabilité in situ. L'analyse est faite en conditions permanentes et non permanentes. Les résultats montrent que la valeur du coefficient de perméabilité dépend du niveau de la nappe, qui est affecté par le régime de marées. On montre que l'équation de l'US Navy donne la meilleure corrélation avec les mesures de terrain. Resumen.El diseño de sistemas de desecado es necesario para mejorar las condiciones de un emplazamiento antes de la construcción de determinadas estructuras. El diseño de un sistema eficiente de desecado requiere de la estimación del valor de la permeabilidad in-situ. Las relaciones disponibles para tal fin han sido desarrolladas bajo condiciones y medidas de campo limitadas; sus predicciones varían en algunos órdenes de magnitud. Por tanto, es necesario tomar medidas de permeabilidad en campo y determinar la relación que reproduce mejor dichas medidas como paso previo al diseño de un sistema de desecado en condiciones geol
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Alejarse como proceso social: niños y ancianos «abandonados» en Ayacucho1
Leinaweaver, Jessaca
2013-01-01
En investigaciones previas sobre el acogimiento familiar y la adopción en Ayacucho, se ha podido descubrir cómo los ayacuchanos adquieren y producen relaciones sociales. Mientras negocian creativamente los discursos y espacios construidos simultáneamente por instituciones, comunidades, y estructuras sociales, van adquiriendo nuevas formas de relacionarse. Este artículo discute el proceso opuesto: el deshacerse de relaciones de parentesco, y el proceso social del abandono o alejamiento. Cuando se aleja a una persona de su familia o su comunidad, los que se quedan en ella llegan a entenderse como ciertos tipos de personas. En los estudios de caso discutidos aquí, recopilados a través de una detallada y cuidadosa observación participante y de entrevistas etnográficas grabadas entre 2001 y 2007, se puede ver cómo, después de un alejamiento social, los individuos que alejan se reinterpretan como sujetos que se encuentran superándose o volviéndose modernos, o bien sacrificándose. PMID:25177044
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NASA Astrophysics Data System (ADS)
Xu, Xuejun; Si, Zhichun; Liu, Liping; Wang, Zehao; Chen, Ze; Ran, Rui; He, Yonghong; Weng, Duan
2018-03-01
Noble metal free MoS2/g-C3N4 catalyst has attracted intense attentions for visible light photocatalytic hydrogen evolution as a result of its earth abundance, low cost and unique heterojunctions stacked with two dimensional sheets. However, the low charge separation efficiency resulted from the poor conductivity of g-C3N4 and MoS2, and lack of abundant active sites from coordinative unsaturated atoms in MoS2, restricts the photocatalytic hydrogen evolution activity and stability enhancement of MoS2/C3N4 composite catalysts. Herein, CoMoS2/rGO/g-C3N4 catalysts with ternary heterojunctions are prepared by facile solvothermal method, which exhibit high visible light photocatalytic activity and stability for hydrogen evolution. The optimal hydrogen evolution rate of CoMoS2/rGO/g-C3N4 catalysts is 684 μmol g-1 h-1 when the content of CoMoS2 is 2% and the content of rGO is 0.5%. The stability of CoMoS2/rGO/C3N4 catalysts just decrease about 3% after 4 cycling runs for 16 h. The good catalytic performances of catalysts are attributed to the synergistic effect among the g-C3N4 nanosheets, rGO nanosheets and CoMoS2 nanosheets. The high conductivity of rGO nanosheets enhances the electron-hole separation and charge transfer, and Co doping increases the active sites for hydrogen evolution due to the increase of unsaturated atoms in CoMoS2 nanosheets.
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Resultados do desenvolvimento de um propulsor à plasma no Brasil
NASA Astrophysics Data System (ADS)
Ferreira, I. S.; Ferreira, J. L.
2003-08-01
Uma das partes mais importantes de um satélite é o controle de atitude do mesmo. E se tratando de um satélite científico, a atenção para este sistema deve ser redobrada. Uma possibilidade atraente para executar esta tarefa é a propulsão elétrica. Aqui, mostraremos resultados obtidos pelo propulsor à plasma PHALL-01, desenvolvido na Universidade de Brasília entre 2000 e 2003. Este é derivado do propulsor russo SPT-100 (Stationary Plasma Thruster), mas com o emprego inovador de um arranjo de imãs permanentes como fonte do campo magnético, este último o agente da aceleração do plasma. Esta alteração foi motivada pelo objetivo de que o mesmo operasse com o mínimo de potência elétrica. A partir da formulação teórica do mecanismo de aceleração, tendo como base as equações da magnetohidrodinâmica, pode-se obter vínculos sob os quais o propulsor pudesse ser construído. O mais forte destes é o que dita a topologia do campo magnético. Sendo assim, foram realizadas simulações computacionais, que definiram a geometria do propulsor. Após construído, este foi diagnosticado usando-se sondas de Langmuir e analisadores de energia. Como resultados, obtivemos a distribuição espacial da temperatura, densidade e potencial do plasma, bem como a distribuição angular do feixe produzido pelo mesmo em vários regimes de operação. O espectro de energia do feixe de plasma também foi medido, indicando íons de até 560eV. Combinando estes resultados, calculou-se o empuxo do propulsor: 84mN; e o impulso específico: 1083s. Estes demonstram que o mesmo estará qualificado, num futuro próximo, para o emprego no controle de atitude de satélites científicos, ou até mesmo como parte do conjunto propulsor primário, responsáveis pela transferência de órbitas.
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Como Lo Hago Yo: Mielomeningocele En Bolivia
Dabdoub, Carlos F.; Dabdoub, Carlos B.; Villavicencio, Ramiro; Quevedo, Germán
2014-01-01
Introducción: Las malformaciones del tubo neural (MTN) representan la segunda causa más frecuente de anomalías congénitas, luego de las cardiopatías. En este grupo se destaca el mielomeningocele (MMC) por su mayor incidencia, y por ser la más incapacitante y la más compleja entre todas las demás malformaciones del sistema nervioso c`entral (SNC). En Bolivia, como en muchos países de Sudamérica, los bajos niveles socio-culturales y la debilidad en el sistema sanitario, hacen que su incidencia y su morbilidad, sean mayores que en las naciones más desarrolladas. Material y Métodos: Se realizó un estudio retrospectivo y descriptivo de 70 casos de MMC, atendidos por un equipo multidisciplinario en el Hospital Universitario Japonés (HUJ) de Santa Cruz de la Sierra, entre 2008-2011. De ellos, 60 fueron intervenidos quirúrgicamente. Resultados: Se realizaron controles prenatales sólo en 27 mujeres (38.6%), diagnosticándose una disrafia espinal en apenas dos casos (7.4%). La edad de ingreso del MMC en su mayoría fue después de las 24 horas (65.6%), predominando su localización en la región lumbosacra (64.3%). De ellos, 67.2% eran abiertos, presentando un 32.9% un daño neurológico motor parcial mientras que 47.1% tenían paraplejia por debajo de la lesión. De los 70 casos, tres (4.3%) no fueron intervenidos, por presentar defectos congénitos severos o estado general grave. Las principales complicaciones posoperatorias inmediatas fueron: dehiscencia de sutura y/o infección de la herida (16.6%), fístula de líquido cefalorraquídeo (LCR) (10%) e infección del SNC (11.7%). La mortalidad general y postoperatoria fue de 7.1% y 3.3%, respectivamente. Al mes de vida presentaban hidrocefalia un 80% de los pacientes operados, colocándose una derivación ventriculoperitoneal (DVP) de presión media. De 9 pacientes que tuvieron un acompanamiento de dos o más años, seis presentaron una médula anclada, que fueron intervenidas quirúrgicamente. Conclusi
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ERIC Educational Resources Information Center
Department of Education, Washington, DC.
This booklet, written in Spanish, is intended to be used with a set of slides as part of a presentation to students on "How To Apply for Federal Student Aid" ("Como Solicitar la Asistencia Economica Federal para Estudiantes"). The first part of the book is a script based on the slides. After the script is a guide to hosting a financial aid…
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Strandberg-Larsen, Martin
2011-02-01
The positive outcomes of coordination of healthcare services are to an increasing extent becoming clear. However the complexity of the field is an inhibiting factor for vigorously designed trial studies. Conceptual clarity and a consistent theoretical frame-work are thus needed. While researchers respond to these needs, patients and providers face the multiple challenges of today's healthcare environment. Decision makers, planners and managers need evidence based policy options and information on the scope of the integrated care challenges they are facing. The US managed care organization Kaiser Permanente has been put forward as an example for European healthcare systems to follow, although the evidence base is far from conclusive. The thesis has five objectives: 1) To contribute to the understanding of the concept of integration in healthcare systems and to identify measurement methods to capture the multi-dimensional aspects of integrated healthcare delivery. 2) To assess the level of integration of the Danish healthcare system. 3) To assess the use of joint health plans as a tool for coordination between the regional and local level in the Danish healthcare system. 4) To compare the inputs and performance of the Danish healthcare system and the managed care organization Kaiser Permanente, California, US. 5) To compare primary care clinicians' perception of clinical integration in two healthcare systems: Kaiser Permanente, Northern California and the Danish healthcare system. Further to examine the associations between specific organizational factors and clinical integration within each system. The literature was systematically searched to identify methods for measurement of integrated healthcare delivery. A national cross-sectional survey was conducted among major professional stake-holders at five different levels of the Danish healthcare system. The survey data were used to allow for analysis of the level of integration achieved. Data from the survey were
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L'education permanente: Principe revolutionnaire et pratiques conservatrices
NASA Astrophysics Data System (ADS)
Gelpi, Ettore
1994-05-01
Education, whether formal or non-formal, does not always adapt to dynamic cultural change or to shifting social needs, and is thus responsible for the crisis in education and for growing unmet demand. The industrial and technical revolutions have led to the spread of education, which is nonetheless marred by social injustice at national and international levels. A further contradiction is that the interests of the participants are insufficiently considered, and the question should be asked to what extent education violates respect for the rights of individuals and peoples. The educational crisis results also form the world crisis in ideologies, to which education frequently offers a reply which is regrettably academic. Research is restrained in the interests of reinforcing dependency, thus becoming a possible accomplice or prisoner of conservatism. Education is in part responsible for growing inequalities: therein resides the individual and collective challenge to fight against its use as an instrument of domination. The concept of the learner as educator overturns that of our societies in crisis. In order to realise it, a "planetary" approach is necessary, aware of the military and industrial origins of education. The transformation of drill into creativity is an arduous task but more than ever necessary.
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Prepaid group practice staffing and U.S. physician supply: lessons for workforce policy.
Weiner, Jonathan P
2004-01-01
This paper describes staffing at eight large prepaid group practices (PGPs) serving more than eight million enrollees at Kaiser Permanente and two other health maintenance organizations (HMOs). Even after characteristics of the patient populations and outside referrals are accounted for, these PGPs have a physician-to-population ratio that is 22-37 percent below the national rate. Two decades of historical data at Kaiser Permanente indicate that its rate of specialist growth was far higher than that of primary care. The study suggests that efficient systems of care can readily meet the demands of patient populations with workforce staffing ratios below current U.S. levels.
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Rascón-Martínez, Dulce María; Guzmán-Sánchez, Joaquín Antonio; Corral-Urdapilleta, Nora Paulina; Arguelles-Uribe, Gema Damaris; Velázquez-Loeza, Jazmín; Soto-Palma, Gustavo; Carrillo-Torres, Orlando
Observar el comportamiento de la gabapentina para aminorar la hipertensión reactiva secundaria a ansiedad y dolor en pacientes sometidos a cirugía oftálmica, así como el consumo de opiáceos entre los grupos. Ensayo clínico controlado aleatorizado y doble ciego que analizó a 125 pacientes divididos en tres grupos: grupo A, gabapentina 300 mg; grupo B, gabapentina 450 mg; grupo C, amaranto en grageas como control 2 horas antes del procedimiento quirúrgico. Se utilizó la prueba de ji al cuadrado para variables sociodemográficas y ANOVA de un factor para variables numéricas continuas. Se consideró como significativo un valor de p < 0.05 para un estudio de dos colas con un poder beta del 80%. La ansiedad y la analgesia transoperatoria y posoperatoria tuvieron diferencias significativas entre los grupos. Se encontró menor consumo de opiáceos en los grupos que usaron gabapentina. La gabapentina por vía oral, 300 o 450 mg, 2 horas antes de la cirugía, reduce el dolor, la ansiedad y el consumo de opiáceos durante el posoperatorio en pacientes sometidos a cirugía oftalmológica. Copyright: © 2018 SecretarÍa de Salud
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NASA Astrophysics Data System (ADS)
Höbig, N.; Martinelli, E.; Motella, S.; Michetti, A. M.; Livio, F.; Tinner, W.; Reicherter, K.; Castelletti, L.
2012-04-01
Lake Como (northern Italy) is the deepest Italian lake, reaching a depth of about 425 m. The lambda-shaped lake expands about 45 km in NE-SW direction. Southwards of the hydrologically closed western branch, two sediment cores of 70 m (S1) and 65 m length (S2) were taken in the year 2005 close to the cathedral of Como (Piazza Verdi). The drilling sites are located in the middle of the Southern Alps, some 300 m from the present-day lakeshore. The cores provide the first detailed Late Glacial to Holocene multi-proxy record for the Lake Como basin. Our research is aimed at investigating the environmental and geological evolution of the Insubria Region. The multi-proxy study of the stratigraphic sequences contain geophysical, geotechnical, sedimentological, paleobotanical, and radiocarbon analyses. They have been performed for core S1 and are still in progress on core S2. With this data the working group focuses on two main issues. The first topic is the reconstruction of the natural and anthropogenic processes controlling the ground subsidence in the Como urban area (e.g., Comerci et al., 2007) and another aim is to reconstruct vegetation and land-use dynamics. In particular, 150 samples of vegetal macroremains have been collected in the palustrine deposits along S1 core, down to 31,00 m. Below this depth (dated 14C 12,496 ± 55 yr BP - 15,050 - 14,250 cal yr BP), the amount of plant macroremains in the sediment drops dramatically. The taxonomic determination was carried out on more than 800 macroremains. They are represented by fragments of wood, leaves, needles, seeds, fruits, mosses and tiny charcoals (Motella, 2009, unpublished PhD Thesis). Picea/Larix, Pinus sp., Juniperus with Betula, found in the deeper levels (30.80 - 30.00 m), are the first arboreal taxa that colonized the shores of Lake Como, and show that the reforestation began in this area about 16,000 years ago. During the early Holocene (25.10 m) Abies alba expanded and further upwards the sequence
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Como os Alunos do Ensino Médio da Rede Estadual de São Paulo obtém Conhecimentos Astronômicos?
NASA Astrophysics Data System (ADS)
da Cunha, W. S.; Voelzke, M. R.; Amaral, L. H.
2005-08-01
Atualmente vivencia-se um mundo globalizado onde os computadores e a internet permitiram um acesso rápido e seguro a todo tipo de informação e conhecimento. O presente trabalho visa analisar a maneira pela qual alunos de segundo grau da rede estadual da cidade de São Paulo obtiveram, caso tenham, conhecimentos básicos de astronomia quanto aos fenômenos celestes que os rodeiam, tais como a sucessão dos dias e das estações do ano, além de questioná~los sobre fatos genéricos tais como: o que vem a ser o Sol, o Big Bang, o que ocasionou a extinção dos dinossauros. Para tanto foi elaborado um formulário constando de questões de múltipla escolha, o qual foi aplicado no primeiro colegial diurno da Escola Estadual Guilherme de Almeida. Num espaço amostral de 44 alunos constatou-se que 41% dos alunos adquiriram seus conhecimentos astronômicos na escola e 59% através da mídia em geral. Neste mesmo espaço amostral apenas 11% dos alunos usaram computadores na escola, 41% na residência, 5% no trabalho e 43% não utilizaram. O presente estudo revelou também que para 50% dos alunos o professor jamais utilizou um programa de computador a respeito de astronomia ou fez alguma apresentação sobre o tema. Embora em sua fase inicial este estudo revela claramente que a maioria dos alunos não obtém na escola seus conhecimentos astronômicos, estes provém de fontes não especificamente didático-pedagógicas tais como filmes e revistas populares que não raramente geram conhecimentos incompletos e em muitos casos inclusive falhos.
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XAS Study at Mo and Co K-Edges of the Sulfidation of a CoMo / Al2O3 Hydrotreating Catalyst
DOE Office of Scientific and Technical Information (OSTI.GOV)
Pichon, C.; Gandubert, A. D.; Legens, C.
2007-02-02
Because of its impact on environment, the removal of sulfur is an indispensable step, called hydrotreatment, in the refining of petroleum. One of the most commonly used hydrotreating catalysts is CoMo-type catalyst which is composed of molybdenum disulfide slabs promoted by cobalt atoms (CoMoS phase) and well dispersed on a high specific area alumina. As far as the highest sulfur content allowed in gasoline and diesel is continually decreasing, more and more efficient and active hydrotreating catalysts are required. In order to optimize the reactivity of the CoMo-type catalyst in hydrotreatment, a better understanding of the processes used to producemore » the active phase (CoMoS slabs) of the catalyst is necessary. The study reported here deals with the sulfiding mechanism of the slabs and the influence of temperature on the phenomenon. Ex situ X-ray absorption spectroscopy (XANES and EXAFS) was used to study the evolution of the structure of CoMo-type catalyst sulfided at various temperatures (from 293 to 873 K). XAS analysis was performed at both molybdenum and cobalt K-edges to obtain a cross-characterization of the sulfidation of the slabs. It evidenced the formation of various compounds, including two molybdenum oxides, MoS3 (or MoS3-like compound) and Co9S8, at specific steps of the sulfiding process. It showed the role of intermediate played by MoS3 (or MoS3-like compound) during the formation of the slabs and the competition between the appearance of promoted slabs (CoMoS phase) and Co9S8. At last, it leaded to the proposal of a mechanism for the sulfidation of the catalyst.« less
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Information Placement and Retrieval Through NHIN (InfoPRN)
2011-05-01
and FISMA. Dr. Steffensen will contact NMDS (Captain Bensic), JTF CapMed , and perhaps Kaiser Permanente to ascertain their interest in...activities, project stakeholders, critical project deliverables and milestones were defined and agreed upon. Therefore, the Integrated Master
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Yu, Junhua; Shah, Bijal M; Ip, Eric J; Chan, James
2013-03-01
It has been demonstrated in previous studies that pharmacist management of patients with type 2 diabetes mellitus (T2DM) in the outpatient setting not only improves diabetes-related clinical outcomes such as hemoglobin A1c but also blood pressure (BP), total cholesterol (TC), and quality of life. Improved control of BP and TC has been shown to reduce the risks of cardiovascular disease (CVD), which has placed a heavy economic burden on the health care system. However, no study has evaluated the cost-effectiveness of pharmacist intervention programs with respect to the long-term preventive effects on CVD outcomes among T2DM patients. To (a) quantify the long-term preventive effects of pharmacist intervention on CVD outcomes among T2DM patients using evidence from a matched cohort study in the outpatient primary care setting and (b) assess the relative cost-effectiveness of adding a clinical pharmacist to the primary care team for the management of patients with T2DM based on improvement in CVD risks with the aid of an economic model. Clinical data between the periods of June 2007 to February 2010 were collected from electronic medical records at 2 separate clinics at Kaiser Permanente (KP) Northern California, 1 with primary care physicians only (control group) and the other with the addition of a pharmacist (enhanced care group). Patients in the enhanced care group were matched 1:1 with patients in the control group according to baseline characteristics that included age, gender, A1c, and Charlson comorbidity score. The estimated 10-year CVD risk for both groups was calculated by the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine (version 2) based on age, sex, race, smoking status, atrial fibrillation, duration of diabetes, levels of A1c, systolic BP (SBP) and TC, and high-density lipoprotein cholesterol (HDL-C) observed at 12 months. There was no statistical difference in the baseline clinical inputs to the Risk Engine (A1c [P=0.115], SBP [P=0
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Telescópio de pequeno porte como suporte ao ensino em cidades com intensa poluição luminosa II
NASA Astrophysics Data System (ADS)
Pereira, P. C. R.; Santos-Júnior, J. M.; Cruz, W. S.
2003-08-01
Para a maioria dos estudantes, sua passagem pelo ensino formal fundamental envolve a transmissão de fatos que devem ser guardados para um exame, a habilidade para lembrar fórmulas e, eventualmente, a repetição de experimentos que devem produzir resultados exigidos pelo professor. O resultado deste modelo de ensino, ao longo dos anos, é conhecido por todos: desconhecimento e descontentamento, por parte dos estudantes, de temas relativos ao papel e aos processos da ciência. Acreditamos que a Astronomia, pelo seu caráter observacional, é uma das áreas do conhecimento que pode contribuir neste cenário. A Fundação Planetário da Cidade do Rio de Janeiro possui um telescópio Meade LX-200 (25cm) que, juntamente com as câmeras CCD ST-7E e ST8E, tem sido utilizado em projetos voltados aos estudantes do ensino médio desde o ano 2000. Tais projetos envolvem a condução de um projeto de pesquisa observacional num nível apropriado, e possibilitam o contato com técnicas e novas tecnologias: computador, software para manipulação de dados e gráficos, programas de tratamento e redução de dados, uso de equipamentos óptico-eletrônicos (telescópio e CCD), bem como o processo de aquisição de conhecimento. Dentro da proposta dos anos anteriores, priorizamos projetos de uma noite, ou seja, procuramos trabalhar com fenômenos que apresentem variabilidade com intervalo de recorrência relativamente curto. Em todos os casos, optamos pela fotometria diferencial, que tem se mostrado bastante eficiente para o céu luminoso como o da cidade do Rio de Janeiro. Neste painel, apresentamos alguns dos projetos desenvolvidos no último ano, com 25 estudantes. Apresentamos os resultados da observação da variável pulsante AI Vel (V = 6,6) e da variável cataclísmica FO Aqr (V = 13,5), e do monitoramento do trânsito da lua de Júpiter, Europa, ocorrido em 30 de abril de 2003. As curvas de luz produzidas para as primeiras estão concordantes com as da literatura, assim
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Meet your senior's online needs to compete in Medicare marketplace.
1997-12-01
As more seniors turn to the Internet for health care information and services, is your organization prepared to meet their needs? Kaiser Permanente is reaching the cyber-senior market on the World Wide Web with interactive online services, including discussion groups with providers.
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Physician involvement in disease management as part of the CCM.
Wallace, Paul J
2005-01-01
Phase I of the voluntary chronic care improvement (CCI-I) under traditional fee-for-service Medicare initiative seeks to extend the benefits of disease management to an elderly population with comorbid chronic medical conditions. Active, sustained involvement of treating physicians, a historical deficit of disease management programs, is a CCI-I program goal. During the last decade, Kaiser Permanente, an integrated health care delivery system with more than 60 years of experience in managing the care of individuals and populations, has applied the chronic care model (CCM) to develop care management strategies for populations of patients with chronic medical conditions. Physician leadership and involvement have been key to successfully incorporating these practices into care. The scope of physician involvement in leading, developing, and delivering chronic illness care management at Kaiser Permanente is described as a basis for identifying opportunities to involve practicing physicians in the CCI-I.
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Physician Involvement in Disease Management as Part of the CCM
Wallace, Paul J.
2005-01-01
Phase I of the voluntary chronic care improvement (CCI-I) under traditional fee-for-service Medicare initiative seeks to extend the benefits of disease management to an elderly population with comorbid chronic medical conditions. Active, sustained involvement of treating physicians, a historical deficit of disease management programs, is a CCI-I program goal. During the last decade, Kaiser Permanente, an integrated health care delivery system with more than 60 years of experience in managing the care of individuals and populations, has applied the chronic care model (CCM) to develop care management strategies for populations of patients with chronic medical conditions. Physician leadership and involvement have been key to successfully incorporating these practices into care. The scope of physician involvement in leading, developing, and delivering chronic illness care management at Kaiser Permanente is described as a basis for identifying opportunities to involve practicing physicians in the CCI-I. PMID:17288075
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TPMG Northern California appointments and advice call center.
Conolly, Patricia; Levine, Leslie; Amaral, Debra J; Fireman, Bruce H; Driscoll, Tom
2005-08-01
Kaiser Permanente (KP) has been developing its use of call centers as a way to provide an expansive set of healthcare services to KP members efficiently and cost effectively. Since 1995, when The Permanente Medical Group (TPMG) began to consolidate primary care phone services into three physical call centers, the TPMG Appointments and Advice Call Center (AACC) has become the "front office" for primary care services across approximately 89% of Northern California. The AACC provides primary care phone service for approximately 3 million Kaiser Foundation Health Plan members in Northern California and responds to approximately 1 million calls per month across the three AACC sites. A database records each caller's identity as well as the day, time, and duration of each call; reason for calling; services provided to callers as a result of calls; and clinical outcomes of calls. We here summarize this information for the period 2000 through 2003.
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NASA Astrophysics Data System (ADS)
Damasio, Felipe; Allain, Olivier; Antunes Rodrigues, Adriano
2013-07-01
The study reported in this work takes place since 2009 at the Federal Institute of Education, Science and Technology of Santa Catarina, Campus Araranguá. Our main goal is to help form teachers, training undergraduate students in Natural Sciences with specialization in Physics as science communicators, as well as to promote actions of broader scientific popularization in the region of the town of Araranguá through an Astronomy Club called CA2. Among the actions of scientific popularization that the students promote are: video production, radio broadcasts, lectures, nightly observations, preparation and exhibition of posters, physics teaching for children, continuing education activities for teachers and regular physics teaching using Astronomy as a theme. The Club's teacher education and scientific dissemination work is based on the Theory of Meaningful Learning, always trying to reach the student's predisposition to learn and produce potentially meaningful material, the two essential conditions for meaningful learning to occur. O estudo que este trabalho relata ocorre desde 2009 no Instituto Federal de Educação, Ciência e Tecnologia de Santa Catarina, campus Araranguá. Nele procura-se formar divulgadores científicos durante a formação inicial de docentes do curso de Licenciatura em Ciências da Natureza com habilitação em Física, além de promover ações de divulgação científica para o público geral da região da cidade de Araranguá por meio de um Clube de Astronomia chamado CA² (Clube de Astronomia de Araranguá). Entre as ações de divulgação científica que os licenciandos promovem estão: produção de vídeos, programas de rádio, palestras, observações noturnas, confecção e exposição de pôsteres, ensino de física para crianças, formação continuada de professores em atividades e ensino de Física regular utilizando a Astronomia como tema gerador. O trabalho de formação docente e divulgação científica do Clube fundamenta
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Clinical pharmacy travel medicine services: a new frontier.
Jackson, Adam B; Humphries, Tammy L; Nelson, Kent M; Helling, Dennis K
2004-12-01
Travel to remote destinations has increased dramatically in recent years. The Clinical Pharmacy International Travel Clinic (CPITC) was established in 1991 in the Kaiser Permanente Colorado Region to provide pre-travel advice to members to decrease their risk of travel-related diseases. The CPITC is unique from other travel medicine clinics because it is a pharmacist-run telepharmacy service. The team includes an infectious diseases physician, an infectious diseases clinical pharmacy specialist, 4 clinical pharmacists, and a pharmacy technician. The clinical pharmacists provide consultations via telephone. Both patient- and trip-related information are gathered to assess the traveler's health risks. Recommendations are provided regarding food- and water-borne diseases, insect-borne diseases, sexually transmitted diseases, and diseases related to animal bites. Additionally, detailed information is provided on vaccines that may be needed to protect travelers against various diseases. The travel consult is documented electronically. A copy of the consult, along with a booklet that provides travel information, is mailed to the patient. Success of the CPITC is demonstrated in several ways. The clinic initially served Kaiser Permanente members in the Colorado Region. The service has expanded and now also provides travel consults to Kaiser Permanente members in the Northwest and Ohio Regions. Patient satisfaction is high, and significant cost-savings have been realized secondary to avoiding the use of unnecessary vaccinations and medications. The CPITC allows resources to be leveraged and provides one center where individuals trained in travel medicine provide information to members, thus improving efficiency and decreasing cost.
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Pathways: improving outcomes, not just 'cookbook medicine'.
O'Malley, S
1997-04-01
A Kaiser Permanente medical director cites four benefits to be derived from using clinical guidelines: better outcomes, faster patient recovery, reduced costs, and increased physician accountability. And, he notes, physicians are free to deviate from the guidelines--so long as they can justify their actions.
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A Utilização da Astronomia como Tema Interdisciplinar e Aplicações de Objetos de Aprendizagem
NASA Astrophysics Data System (ADS)
da Silva, L. A.; Voelzke, M. R.
2008-09-01
Este trabalho visa analisar a possibilidade de relacionar conteúdos aplicados no ensino fundamental e médio de forma interdisciplinar por intermédio da astronomia, com a intervenção de objetos de aprendizagem que possam integrar as disciplinas e a utilização de recursos tecnológicos. Em uma pesquisa prévia com 20 professores de uma escola estadual situada na cidade de Guarulhos foi observado que apenas 25% dos professores utilizam algum recurso tecnológico para o desenvolvimento de conteúdos pertinentes à sua disciplina, tais como sites e softwares educativos, sendo que a maioria absoluta continua ensinando apenas com livros didáticos. A maior parte dos professores apresenta dificuldades em trabalhar sua disciplina de forma interdisciplinar, ou seja, 75% dos professores preferem aplicar os conteúdos seguindo uma hierarquia linear de tópicos, evitando a discussão de temas que de alguma forma estão relacionados. A astronomia pode vir à fascinar o ser humano e despertar sua curiosidade promovendo um maior interesse no aprendizado, podendo favorecer análises interdisciplinares de forma lógica e objetiva, desta forma colocar a astronomia como tema motivador interdisciplinar, pode ser relevante no que se refere ao distanciamento da fragmentação dos conteúdos. No Estado de São Paulo, a implantação da proposta curricular no ensino fundamental e médio mostra claramente a inserção da astronomia na maior parte das séries, principalmente na 6ª série em que todo o bimestre se fala de astronomia.
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RODRÍGUEZ, Yarimar ROSA; DÍAZ, Nelson VARAS
2009-01-01
El proceso de estigmatización asume una devaluación de la persona debido a una característica o marca que haya sido identificada socialmente y que permita que se le describa como diferente. Desde que se desató la epidemia del VIH/SIDA, vivir con la enfermedad ha sido señalado de manera social como una marca estigmatizante. Las manifestaciones de dicha estigmatización se han documentado entre profesionales de la salud. Este estigma puede afectar los servicios de salud que las personas que viven con VIH/SIDA reciben de estos profesionales. Los objetivos de esta investigación fueron explorar: 1) la percepción que tienen estudiantes y profesionales de la salud sobre su nivel de competencia para ofrecer servicios a personas que viven con VIH/SIDA, 2) las opiniones de éstos sobre el tipo de adiestramiento profesional recibido y la necesidad del mismo, y 3) la manifestación de actitudes estigmatizantes como indicadores de necesidad de adiestramiento profesional. La muestra total del estudio estuvo compuesta por 80 de diversas profesiones de la salud. Los resultados reflejan que algunos/as de los/as participantes han recibido formación en VIH pero ésta no ha sido suficiente para contrarrestar las nociones estigmatizantes. Discutimos las implicaciones de los resultados para investigaciones futuras y el desarrollo de intervenciones con vías de minimizar las nociones estigmatizantes en los escenarios de salud. PMID:20011236
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DM programs take different roads to CHF success.
2001-02-01
Improving CHF outcomes: There's no single right way. But there are some elements in common, as suggested by the experience of Duke, Kaiser Permanente, and First Priority Health. The challenge is to identify high-risk patients and provide as comprehensive an array of services as possible.
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Maternal Infection during Pregnancy and Autism Spectrum Disorders
ERIC Educational Resources Information Center
Zerbo, Ousseny; Qian, Yinge; Yoshida, Cathleen; Grether, Judith K.; Van de Water, Judy; Croen, Lisa A.
2015-01-01
We conducted a nested case-control study including 407 cases and 2,075 frequency matched controls to investigate the association between maternal infections during pregnancy and risk of autism spectrum disorders (ASD). Cases, controls, and maternal infections were ascertained from Kaiser Permanente Northern California clinical databases. No…
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Developing a data infrastructure for a learning health system: the PORTAL network
McGlynn, Elizabeth A; Lieu, Tracy A; Durham, Mary L; Bauck, Alan; Laws, Reesa; Go, Alan S; Chen, Jersey; Feigelson, Heather Spencer; Corley, Douglas A; Young, Deborah Rohm; Nelson, Andrew F; Davidson, Arthur J; Morales, Leo S; Kahn, Michael G
2014-01-01
The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings. PMID:24821738
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Leveraging Geographic Information Systems in an Integrated Health Care Delivery Organization
Clift, Kathryn; Scott, Luther; Johnson, Michael; Gonzalez, Carlos
2014-01-01
A handful of the many changes resulting from the Affordable Care Act underscore the need for a geographic understanding of existing and prospective member communities. Health exchanges require that health provider networks are geographically accessible to underserved populations, and nonprofit hospitals nationwide are required to conduct community health needs assessments every three years. Beyond these requirements, health care providers are using maps and spatial analysis to better address health outcomes that are related in complex ways to social and economic factors. Kaiser Permanente is applying geographic information systems, with spatial analytics and map-based visualizations, to data sourced from its electronic medical records and from publicly and commercially available datasets. The results are helping to shape an understanding of the health needs of Kaiser Permanente members in the context of their communities. This understanding is part of a strategy to inform partnerships and interventions in and beyond traditional care delivery settings. PMID:24694317
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Joint Venture Arrangement for RN to BSN: A Model of Synergy between Academia and Service.
ERIC Educational Resources Information Center
Bargagliotti, L. Antoinette; And Others
1991-01-01
Joint venture among educational and practice institutions is well on its way toward becoming the norm in nursing education and practice. Kaiser Permanente and the University of San Francisco School of Nursing offer a venture that allows registered nurses to pursue a bachelor of science in nursing degree. (JOW)
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Community Resources for Promoting Youth Nutrition and Physical Activity
ERIC Educational Resources Information Center
Moore, Kelly R.; McGowan, Melissa K.; Donato, Karen A.; Kollipara, Sobha; Roubideaux, Yvette
2009-01-01
Childhood obesity is a national public health crisis. The National Diabetes Education Program (NDEP), the National Institutes of Health and Kaiser Permanente have developed community tools and resources for children and families to lower their risk for obesity through healthier, active lifestyles. The authors describe innovative practices and…
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NASA Astrophysics Data System (ADS)
Martinelli, Elisa; Michetti, Alessandro Maria; Colombaroli, Daniele; Mazzola, Eleonora; Motella De Carlo, Sila; Livio, Franz; Gilli, Adrian; Ferrario, Maria Francesca; Höbig, Nicole; Brunamonte, Fabio; Castelletti, Lanfredo; Tinner, Willy
2017-04-01
Combined pollen, charcoal and modeling evidence from the Insubria Region suggests that fire was a major driver of late Holocene vegetation change. However, the extent and timing of fire response dynamics are not clear yet. We use lacustrine sediments from Lago di Como (N-Italy, S-Alps) to assess if the reconstructed vegetation and fire dynamics were relevant at large scales and if they coincided in time with those observed at smaller sites. The lake, due to its size (142 km2) and economic potential, was very attractive for early land use and human presence in this area is well documented since ca. 10,000 yrs ago (Mesolithic). We used pollen, plant macrofossils and charcoal to reconstruct the vegetation composition and fire activity. During the Younger Dryas and the Early Holocene until ca. 8000 cal BP natural dynamics prevailed. Subsequently, land use and slash-and-burn activities increased at the Mesolithic-Neolithic transition and became widespread around ca. 6500 cal BP. Microscopic charcoal and numerical analyses demonstrate that anthropogenic fires had a determinant influence on long-term vegetation dynamics at regional scales in Insubria. Microscopic charcoal and pollen and spores indicative of land use show that human pressure intensified after ca. 5300 cal yr BP and even more since ca. 4300 cal yr BP. Our results suggest that important species which disappeared or were strongly reduced by land use and fire (e.g. Abies alba, Tilia, Ulmus) will potentially reestablish in the Lago di Como area and elsewhere in Insubria, if land abandonment initiated in the 1950s will continue.
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Restorative Integral Support (RIS) for Older Adults Experiencing Co-Occurring Disorders
ERIC Educational Resources Information Center
Larkin, Heather; MacFarland, Nicole S.
2012-01-01
The Restorative Integral Support (RIS) model is a whole person response that assists people to overcome adversity. The Adverse Childhood Experiences (ACE) Study conducted by Kaiser Permanente and the Centers for Disease Control and Prevention shows the association between stressors in childhood and multiple later-life health and social problems.…
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Trapped in a Local History: Why Did Extramural Fail to Engage in the Era of Engagement?
ERIC Educational Resources Information Center
Duke, Chris
2008-01-01
Extramural liberal adult education (LAE), as conceived in the particular UK tradition, was doomed by its high-minded origins and its privileged status, and contributed little to the new concepts of "éducation permanente," lifelong learning, the knowledge society, the learning society and region, or to the new understandings of university…
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A Single Subject Evaluation of the K-P Diet for Hyperkinesis.
ERIC Educational Resources Information Center
Burlton-Bennet, Jocelyn A.; Robinson, Viviane M. J.
1987-01-01
A single subject ABAB design was employed to determine the effectiveness of the Feingold Kaiser Permanente (K-P) diet in the treatment of a six-year-old hyperkinetic male. Results indicated the K-P diet was effective in controlling the subject's hyperkinesis, nutritionally adequate, and moderately difficult to implement. (Author/DB)
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Formation des enseignants dans une perspective d'education permanente au benin
NASA Astrophysics Data System (ADS)
Agboton, Sébastien; Moussa, Yaya Mede
1994-05-01
The history of teacher training in Benin, which provides evidence of social and cultural change, suggests that a system of lifelong education should be introduced which unites formal, non-formal and informal education, all of which already exist in embryo. The education originally given to every member of society was a continuing progression from initiate to initiator, a lifelong education that involved, among other things, knowledge of agricultural production. This traditional system was disrupted by the reorganization of teacher training after 1945. Recurrent training of teachers remained inadequate because of limited external funding for in-service training, the lack of teachers, the suspension of recruitment and the closure of teacher training colleges. The 1975 reform, through the initiative known as Operation Education and Development, envisaged links between school and social environment, allying intellectual work with production. This meant a radical change in the role of the teacher, who was confronted with technical advance and was obliged to enter a difficult continuing process of self-training. Furthermore, population growth and the restrictions imposed by the World Bank have brought about developments in both lifelong learning and apprenticeship. These two elements are brought together under an initiative known as Production Scolaire Artisanale, designed for out-of-school learners and artisans. The author concludes that the creation of a coherent system of voluntary education would be possible in a society that was itself favourably disposed to education.
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NASA Astrophysics Data System (ADS)
Yazami, Rachid
This paper reviews the main areas of research performed at different Laboratories of the Institut National Polytechnique de Grenoble (INPG) over the past 20 years, specifically on cabonaceous materials for electrode applications in lithium batteries. The most significant event was the discovery in the early 1980s of reversible lithium intercalation into graphite in polymer electrolytes, which led to the use of this material in today's lithium-ion batteries. Important work was also carried out on positive electrode for primary and secondary batteries, especially graphite oxide and graphite fluoride. Most of these results were presented at the 10 IMLB series Symposia, which started in Rome in 1982 and were back to Como, Italy, in 2000.
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Antenatal Ultrasound and Risk of Autism Spectrum Disorders
ERIC Educational Resources Information Center
Grether, Judith K.; Li, Sherian Xu; Yoshida, Cathleen K.; Croen, Lisa A.
2010-01-01
We evaluated antenatal ultrasound (U/S) exposure as a risk factor for autism spectrum disorders (ASD), comparing affected singleton children and control children born 1995-1999 and enrolled in the Kaiser Permanente health care system. Among children with ASD (n = 362) and controls (n = 393), 13% had no antenatal exposure to U/S examinations;…
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Developing a data infrastructure for a learning health system: the PORTAL network.
McGlynn, Elizabeth A; Lieu, Tracy A; Durham, Mary L; Bauck, Alan; Laws, Reesa; Go, Alan S; Chen, Jersey; Feigelson, Heather Spencer; Corley, Douglas A; Young, Deborah Rohm; Nelson, Andrew F; Davidson, Arthur J; Morales, Leo S; Kahn, Michael G
2014-01-01
The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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What Does Professionalism Mean to the Physician?
Kanter, Michael H; Nguyen, Miki; Klau, Marc H; Spiegel, Nancy H; Ambrosini, Virginia L
2013-01-01
Professionalism, which is a core competency for physicians, can be described as a spectrum of behaviors and may have a significant impact on the problems in today’s changing health care climate. In this article, we discuss the meaning of professionalism and its role in the Southern California Permanente Medical Group (SCPMG) and consider how it may be applied to integrated care delivery systems such as Kaiser Permanente. To understand professionalism, one must consider Stern’s definition, which consists of four principles: excellence, humanism, accountability, and altruism. SCPMG has taken three of these principles—excellence, accountability, and altruism—and divided the fourth, humanism, into another three principles similar to those identified by the University of California Los Angeles Task Force on Professionalism: humanitarianism, respect for others, and honor and integrity. SCPMG has a rich history and culture of promoting clinical excellence and professionalism, as evidenced by the programs and initiatives described throughout this article. Indeed, the SCPMG experience validates professionalism as a core physician competency comprising a set of behaviors that are continually refined. PMID:24355895
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Consider outsourcing IT projects when cutting-edge technology, specialized focus are needed.
1999-05-01
Looking outside to meet information technology needs proves a smart way to avert extra staffing costs. Kaiser Permanente saves thousands each year by contracting out cutting-edge IT projects instead of hiring more full-time staff it doesn't need. Learn how the organization incorporates outsourcing and other temporary work methods into its IT staffing strategy.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Dabros, Trine Marie Hartmann; Gaur, Abhijeet; Pintos, Delfina Garcia
Here in this work, density functional theory (DFT), catalytic activity tests, and in-situ X-ray absorption spectroscopy (XAS) was performed to gain detailed insights into the activity and stability of MoS 2, Ni-MoS 2, and Co-MoS 2 catalysts used for hydrodeoxygenation (HDO) of ethylene glycol upon variation of the partial pressures of H 2O and H 2S. The results show high water tolerance of the catalysts and highlight the importance of promotion and H 2S level during HDO. DFT calculations unraveled that the active edge of MoS 2 could be stabilized against SO exchanges by increasing the partial pressure of Hmore » 2S or by promotion with either Ni or Co. The Mo, NiMo, and CoMo catalysts of the present study were all active and fairly selective for ethylene glycol HDO at 400 °C, 27 bar H 2, and 550–2200 ppm H 2S, and conversions of ≈50–100%. The unpromoted Mo/MgAl 2O 4 catalyst had a lower stability and activity per gram catalyst than the promoted analogues. The NiMo and CoMo catalysts produced ethane, ethylene, and C1 cracking products with a C 2/C 1 ratio of 1.5–2.0 at 550 ppm H 2S. This ratio of HDO to cracking could be increased to ≈2 at 2200 ppm H 2S which also stabilized the activity. Removing H 2S from the feed caused severe catalyst deactivation. Both DFT and catalytic activity tests indicated that increasing the H 2S concentration increased the concentration of SH groups on the catalyst, which correspondingly activated and stabilized the catalytic HDO performance. In-situ XAS further supported that the catalysts were tolerant towards water when exposed to increasing water concentration with H2O/H2S ratios up to 300 at 400–450 °C. Raman spectroscopy and XAS showed that MoS2 was present in the prepared catalysts as small and highly dispersed particles, probably owing to a strong interaction with the support. Linear combination fitting (LCF) analysis of the X-ray absorption near edge structure (XANES) spectra obtained during in-situ sulfidation
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Dabros, Trine Marie Hartmann; Gaur, Abhijeet; Pintos, Delfina Garcia; ...
2017-12-10
Here in this work, density functional theory (DFT), catalytic activity tests, and in-situ X-ray absorption spectroscopy (XAS) was performed to gain detailed insights into the activity and stability of MoS 2, Ni-MoS 2, and Co-MoS 2 catalysts used for hydrodeoxygenation (HDO) of ethylene glycol upon variation of the partial pressures of H 2O and H 2S. The results show high water tolerance of the catalysts and highlight the importance of promotion and H 2S level during HDO. DFT calculations unraveled that the active edge of MoS 2 could be stabilized against SO exchanges by increasing the partial pressure of Hmore » 2S or by promotion with either Ni or Co. The Mo, NiMo, and CoMo catalysts of the present study were all active and fairly selective for ethylene glycol HDO at 400 °C, 27 bar H 2, and 550–2200 ppm H 2S, and conversions of ≈50–100%. The unpromoted Mo/MgAl 2O 4 catalyst had a lower stability and activity per gram catalyst than the promoted analogues. The NiMo and CoMo catalysts produced ethane, ethylene, and C1 cracking products with a C 2/C 1 ratio of 1.5–2.0 at 550 ppm H 2S. This ratio of HDO to cracking could be increased to ≈2 at 2200 ppm H 2S which also stabilized the activity. Removing H 2S from the feed caused severe catalyst deactivation. Both DFT and catalytic activity tests indicated that increasing the H 2S concentration increased the concentration of SH groups on the catalyst, which correspondingly activated and stabilized the catalytic HDO performance. In-situ XAS further supported that the catalysts were tolerant towards water when exposed to increasing water concentration with H2O/H2S ratios up to 300 at 400–450 °C. Raman spectroscopy and XAS showed that MoS2 was present in the prepared catalysts as small and highly dispersed particles, probably owing to a strong interaction with the support. Linear combination fitting (LCF) analysis of the X-ray absorption near edge structure (XANES) spectra obtained during in-situ sulfidation
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Evaluation of a surveillance case definition for anogenital warts, Kaiser Permanente northwest.
Naleway, Allison L; Weinmann, Sheila; Crane, Brad; Gee, Julianne; Markowitz, Lauri E; Dunne, Eileen F
2014-08-01
Most studies of anogenital wart (AGW) epidemiology have used large clinical or administrative databases and unconfirmed case definitions based on combinations of diagnosis and procedure codes. We developed and validated an AGW case definition using a combination of diagnosis codes and other information available in the electronic medical record (provider type, laboratory testing). We calculated the positive predictive value (PPV) of this case definition compared with manual medical record review in a random sample of 250 cases. Using this case definition, we calculated the annual age- and sex-stratified prevalence of AGW among individuals 11 through 30 years of age from 2000 through 2005. We identified 2730 individuals who met the case definition. The PPV of the case definition was 82%, and the average annual prevalence was 4.16 per 1000. Prevalence of AGW was higher in females compared with males in every age group, with the exception of the 27- to 30-year-olds. Among females, prevalence peaked in the 19- to 22-year-olds, and among males, the peak was observed in 23- to 26-year-olds. The case definition developed in this study is the first to be validated with medical record review and has a good PPV for the detection of AGW. The prevalence rates observed in this study were higher than other published rates, but the age- and sex-specific patterns observed were consistent with previous reports.
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Surveillance lessons from first-wave pandemic (H1N1) 2009, Northern California, USA.
Baxter, Roger
2010-03-01
After the appearance of pandemic (H1N1) 2009 in April 2009, influenza activity was monitored within the Kaiser Permanente Northern California division by using laboratory, pharmacy, telephone calls, and utilization (services patients received) data. A combination of testing and utilization data showed a pattern of disease activity, but this pattern may have been affected by public perception of the epidemic.
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Winter, Peggi
2016-01-01
Nursing professional practice models continue to shape how we practice nursing by putting families and members at the heart of everything we do. Faced with enormous challenges around healthcare reform, models create frameworks for practice by unifying, uniting, and guiding our nurses. The Kaiser Permanente Practice model was developed to ensure consistency for nursing practice across the continuum. Four key pillars support this practice model and the work of nursing: quality and safety, leadership, professional development, and research/evidence-based practice. These four pillars form the foundation that makes transformational practice possible and aligns nursing with Kaiser Permanente's mission. The purpose of this article is to discuss the pillar of professional development and the components of the Nursing Professional Development: Scope and Standards of Practice model (American Nurses Association & National Nursing Staff Development Organization, 2010) and place them in a five-level development framework. This process allowed us to identify the current organizational level of practice, prioritize each nursing professional development component, and design an operational strategy to move nursing professional development toward a level of high performance. This process is suggested for nursing professional development specialists.
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NASA Astrophysics Data System (ADS)
Fekih, Z.; Ghellai, N.; Fortas, G.; Chiboub, N.; Sam, S.; Chabanne-sari, N. E.; Gabouze, N.
In this work, thin films of metal alloys (Co-Mo) have been electrodeposited onto silicon (Si) surface. The effects of two different additives (H3BO3 and Na2CO3) and the pH of the solution on the electrochemically deposited films (morphology, stochiometry…) have been investigated. The properties of the deposits were characterized by using X-Rays Diffraction (XRD), Scanning Electron Microscopy (SEM) and Energy Dispersive X-ray Spectroscopy (EDS). The results show that the morphology and the film composition depend on both the pH of the solution and the additives. The presence of boric acid favors the Mo deposition. Crack-free homogeneous deposits with a low percentage of molybdenum can be easily obtained from high pH bath. The deposits were shown to exhibits a good crystalline structure.
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Les déformations eburnéennes de l'unité birrimienne de la comoé (côte d'ivoire)
NASA Astrophysics Data System (ADS)
Vidal, M.
The analysis of Eburnean strain fields in the Upper (?) Birrimian Comoé Unit shows four great stages of tectogenesis: an early cleavage subparallel to stratification which results from synkinematic granitoïd intrusions; a folding (N40°E to N60°E); a transcurrent faulting period, essentially ductile N-S sinistral; N120°E schistosity, and a N110°E transcurrent ductile sinistral (?) faulting phase. The importance of the sinistral N-S faulting system and, to a lesser extent, the N120°E schistosity direction, is shown. The probable rôle of these directions (particularly N-S) from Liberian to Upper Cretaceous is shown by the within-plate tectonic occurrences in the West-African craton.
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2014-03-01
the war. Even the Procuraduría de los Derechos Humanos (PDH, or Human Rights Ombudsman), which was established in 1985, was infested with racist...Procuraduría de los Derechos Humanos (PDH)145 The PDH’s purpose was to document human rights abuses in order to promote their reduction and eventual...conditions. In addition to the Madres, the Asamblea Permanente por los Derechos 61 Fagen
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Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott
2016-10-01
The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models. The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US News & World Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p < 0.0001), US News & World Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p < 0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p < 0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index. The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value
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Nguyen-Huynh, Mai N; Klingman, Jeffrey G; Avins, Andrew L; Rao, Vivek A; Eaton, Abigail; Bhopale, Sunil; Kim, Anne C; Morehouse, John W; Flint, Alexander C
2018-01-01
Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California's Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. This study included 310 patients treated with alteplase in the pre-EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline ( P <0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior ( P <0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% ( P <0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P =0.29). Introduction
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NASA Astrophysics Data System (ADS)
Terrana, Silvia; Brunamonte, Fabio; Frascoli, Francesca; Ferrario, Maria Francesca; Michetti, Alessandro Maria; Pozzi, Andrea; Gambillara, Roberto; Binda, Gilberto
2016-04-01
One of the greatest environmental and social-economics threats is climate change. This topic, in the next few years, will have a significant impact on the availability of water resources of many regions. This is compounded by the strong anthropization of water systems that shows an intensification of conflicts for water resource exploitation. Therefore, it is necessary a sustainable manage of natural resources thorough knowledge of the hosting territories. The development of investigation and data processing methods are essential to reduce costs for the suitable use and protection of resources. Identify a sample area for testing the best approach is crucial. This research aims to find a valid methodology for the characterization, modeling and management of subalpine urban aquifers, and the urban district of Como appears perfect. The city of Como is located at the southern end of the western sector of Lake Como (N Italy). It is a coastal town, placed on a small alluvial plain, therefore in close communication with the lake. The plain is drained by two streams, which are presently artificially buried, and have an underground flow path in the urban section till the mouth. This city area, so, is suitable for this project as it is intensely urbanized, its dimensions is not too extensive and it is characterized by two aquifers very important and little known. These are a shallow aquifer and a deep aquifer, which are important not only for any water supply, but also for the stability of the ground subsidence in the city. This research is also the opportunity to work in a particular well-known area with high scientific significance; however, there is complete absence of information regarding the deep aquifer. Great importance has also the chosen and used of the more powerful open source software for this type of area, such as PHREEQC, EnvironInsite, PHREEQE etc., used for geological and geochemical data processing. The main goal of this preliminary work is the
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Estimación de pequeñas perturbaciones en satélites geocéntricos como un problema inverso
NASA Astrophysics Data System (ADS)
Zadunaisky, P. E.
El movimiento geocéntrico de un satélite artificial es simulado automáticamente por un sistema de ecuaciones diferenciales de segundo orden que incluyen dos funciones perturbadoras. La primera representa el segundo término del potencial gravitatorio de la Tierra y la segunda corresponde al frenado atmosférico. Asumiendo como conocidas, por hipótesis o por mediciones, la posición y velocidad del satélite en instantes sucesivos se estiman las perturbaciones a intervalos sucesivos por un método determinístico. Para ilustrar el método y comprobar la precisión de nuestros resultados hemos simulado dos ejemplos incluyendo valores conocidos de las perturbaciones que luego comparamos con los resultados de nuestro método. El método puede aplicarse por ejemplo para el intervalo de una revolución satelital lo cual permitiría el diseño inmediato de una maniobra correctiva de la órbita satelital.
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Pseudoaneurisma de aorta abdominal como complicação de pancreatite crônica: relato de caso
Barbosa, Eduardo Carvalho Horta; Nóbrega, Leonardo Pires de Sá; Rodrigues, Daniel Augusto de Souza; Cunha, Josué Rafael Ferreira; Kalume, Claudio Eluan
2017-01-01
Resumo A pancreatite crônica é uma enfermidade associada a diversas complicações vasculares, como pseudocisto hemorrágico, trombose do sistema venoso portal e formações varicosas e pseudoaneurismáticas. O pseudoaneurisma de aorta abdominal secundário à pancreatite crônica é uma complicação rara, de difícil suspeição clínica, que requer tratamento complexo. A fisiopatologia dessa condição envolve a corrosão enzimática tecidual após a liberação e ativação de enzimas exócrinas proteolíticas das células acinares do pâncreas. O presente estudo relata o caso de um paciente de 52 anos, etilista crônico, internado com dor abdominal difusa, cuja propedêutica revelou se tratar de um pseudoaneurisma em aorta infrarrenal. Optou-se pelo tratamento cirúrgico convencional, levando-se em consideração a idade, as condições clínicas do paciente e a disponibilidade de endopróteses compatíveis com o diâmetro da aorta. PMID:29930654
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Dillon, Mark T; Ake, Christopher F; Burke, Mary F; Singh, Anshuman; Yian, Edward H; Paxton, Elizabeth W; Navarro, Ronald A
2015-06-01
Shoulder arthroplasty is being performed in the United States with increasing frequency. We describe the medium-term findings from a large integrated healthcare system shoulder arthroplasty registry. Shoulder arthroplasty cases registered between January 2005 and June 2013 were included for analysis. The registry included patient characteristics, surgical information, implant data, attrition, and patient outcomes such as surgical site infections, venous thromboembolism, and revision procedures. During the study period, 6,336 primary cases were registered. Median follow-up time for all primaries was 3.3 years; 461 cases were lost to follow-up by ending of health plan membership. Primary cases were predominantly female (56%) and white (81%), with an average age of 70 years. The most common reason for surgery was osteoarthritis in 60% of cases, followed by acute fracture (17%) and rotator cuff tear arthropathy (15%). In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported, with glenoid wear being the most common reason. Most arthroplasties were elective procedures: over half performed for osteoarthritis. Glenoid wear was the most common reason for revision of primary shoulder arthroplasty in elective cases.
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Sidney, S; Beck, J E; Tekawa, I S; Quesenberry, C P; Friedman, G D
1997-01-01
OBJECTIVES: The purpose of this study was to examine the relationship of marijuana use to mortality. METHODS: The study population comprised 65171 Kaiser Permanente Medical Care Program enrollees, aged 15 through 49 years, who completed questionnaires about smoking habits, including marijuana use, between 1979 and 1985. Mortality follow-up was conducted through 1991. RESULTS: Compared with nonuse or experimentation (lifetime use six or fewer times), current marijuana use was not associated with a significantly increased risk of non-acquired immunodeficiency syndrome (AIDS) mortality in men (relative risk [RR] = 1.12, 95% confidence interval [CI] = 0.89, 1.39) or of total mortality in women (RR = 1.09, 95% CI = 0.80, 1.48). Current marijuana use was associated with increased risk of AIDS mortality in men (RR = 1.90, 95% CI = 1.33, 2.73), an association that probably was not causal but most likely represented uncontrolled confounding by male homosexual behavior. This interpretation was supported by the lack of association of marijuana use with AIDS mortality in men from a Kaiser Permanente AIDS database. Relative risks for ever use of marijuana were similar. CONCLUSIONS: Marijuana use in a prepaid health care-based study cohort had little effect on non-AIDS mortality in men and on total mortality in women. PMID:9146436
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Schmittdiel, Julie A.; Adams, Sara R.; Goler, Nancy; Sanna, Rashel S.; Boccio, Mindy; Bellamy, David J.; Brown, Susan D.; Neugebauer, Romain S.; Ferrara, Assiamira
2016-01-01
Objective To evaluate the impact of a population-based telephonic wellness coaching program on weight loss. Methods Individual-level segmented regression analysis of interrupted time series data comparing the BMI trajectories in the 12 months before vs. the 12 months after initiating coaching among a cohort of Kaiser Permanente Northern California (KPNC) members (n=954) participating in The Permanente Medical Group (TPMG) Wellness Coaching program in 2011. The control group was a 20:1 propensity-score matched control group (n=19,080) matched with coaching participants based on baseline demographic and clinical characteristics. Results Wellness coaching participants had a significant upward trend in BMI in the 12 months before their first Wellness coaching session, and a significant downward trend in BMI in the 12 months after their first session equivalent to a clinically significant reduction of greater than one unit of baseline BMI (p<.01 for both). The control group did not have statistically significant decreases in BMI during the post-period. Conclusions Wellness coaching has a positive impact on BMI reduction that is both statistically and clinically significant. Future research and quality improvement efforts should focus on disseminating Wellness coaching for weight loss in diabetes patients and those at risk for developing the disease. PMID:28124501
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Optimal Data Transmission on MIMO OFDM Channels
2008-12-01
Channel State Information dB decibel DFT Discrete Fourier Transform DWTS Digital Wideband Transmission System ETSI European Telecommunications...me facultaram durante a minha infância e juventude , que em conjunto com seu permanente apoio e amor me permitiram sonhar e voar tão alto. Agradeço...transmitter, it is far simpler to build such a system using an IDFT chip, generate the overall OFDM signal in baseband and digital format, and finally
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Mazzoni, Michela; Boggio, Emanuela; Manca, Marina; Piscia, Roberta; Quadroni, Silvia; Bellasi, Arianna; Bettinetti, Roberta
2018-05-30
Despite DDT and PCB having been banned for about 40 years, they are still detectable in the environment. In the present research we specifically investigated the trophic transfer of these organochlorine contaminants (OC) through a pelagic food web of a deep lake in Northern Italy (Lake Como) over time. Zooplankton and fish were sampled each season of a year and OC concentrations and the carbon and nitrogen isotopic ratios were measured. By using stable isotopes, the direct trophic relationship between pelagic zooplankton and zooplanktivorous fish was confirmed for Alosa agone only in summer. Based on this result, the biomagnification factor normalized on the trophic level (BMF TL ) for organic contaminants was calculated. BMF TL values were within the range 0.9-1.9 for DDT isomers and 1.6-4.9 for some PCB congeners (PCB 95, PCB 101, PCB 149, PCB 153, PCB 138 - present both in zooplankton and in fish and representing >60% of the PCB contamination), confirming the biomagnification of these compounds in one of the two zooplanktivorous fish species of the lake. Copyright © 2018. Published by Elsevier B.V.
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Ramirez-Valles, Jesus; Kuhns, Lisa M.; Manjarrez, Dianna
2013-01-01
In this paper we describe the development and dissemination of a film-based educational intervention to reduce negative attitudes towards gay and bisexual men and transgender women (GBT) and people living with HIV/AIDS (PLWHA) in Latino communities, with a focus on youth. The intervention, Tal Como Somos/Just as We Are, is based on stigma and attribution theories, extensive formative research, and community input. Evaluation findings among educators and school youth suggest the film has the potential to effectively impact attitudes towards GBT and PLWHA. The film and intervention are being disseminated using diffusion of innovations theory through community-based organizations, schools, television broadcasting and film festivals. PMID:24377496
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Gage, Julia C; Hunt, William C; Schiffman, Mark; Katki, Hormuzd A; Cheung, Li A; Myers, Orrin; Cuzick, Jack; Wentzensen, Nicolas; Kinney, Walter; Castle, Philip E; Wheeler, Cosette M
2016-12-01
To compare the risks of histologic high-grade cervical intraepithelial neoplasia (CIN) or worse after different cervical cancer screening test results between two of the largest U.S. clinical practice research data sets. The New Mexico Human Papillomavirus (HPV) Pap Registry is a statewide registry representing a diverse population experiencing varied clinical practice delivery. Kaiser Permanente Northern California is a large integrated health care delivery system practicing routine HPV cotesting since 2003. In this retrospective cohort study, a logistic-Weibull survival model was used to estimate and compare the cumulative 3- and 5-year risks of histologic CIN 3 or worse among women aged 21-64 years screened in 2007-2011 in the New Mexico HPV Pap Registry and 2003-2013 in Kaiser Permanente Northern California. Results were stratified by age and baseline screening result: negative cytology, atypical squamous cells of undetermined significance (ASC-US) (with or without HPV triage), low-grade squamous intraepithelial lesion, and high-grade squamous intraepithelial lesion. There were 453,618 women in the New Mexico HPV Pap Registry and 1,307,528 women at Kaiser Permanente Northern California. The 5-year CIN 3 or worse risks were similar within screening results across populations: cytology negative (0.52% and 0.30%, respectively, P<.001), HPV-negative and ASC-US (0.72% and 0.49%, respectively, P=.5), ASC-US (3.4% and 3.4%, respectively, P=.8), HPV-positive and ASC-US (7.7% and 7.1%, respectively, P=.3), low-grade squamous intraepithelial lesion (6.5% and 5.4%, respectively, P=.009), and high-grade squamous intraepithelial lesion (53.1% and 50.4%, respectively, P=.2). Cervical intraepithelial neoplasia grade 2 or worse risks and 3-year risks had similar trends across populations. Age-stratified analyses showed more variability, especially among women aged younger than 30 years, but patterns of risk stratification were comparable. Current U.S. cervical screening and
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Mind-Body Training for At-Risk Populations: Preventive Medicine at its Best.
Elder, Charles
2017-01-01
This article is a companion to "Transcendental meditation and reduced trauma symptoms in female inmates: A randomized controlled pilot study," available at: www.thepermanentejournal.org/issues/2017/6290-meditation.html, and on page 39 and to "Reduced trauma symptoms and perceived stress in male prison inmates through the Transcendental Meditation program: A randomized controlled trial," available at: www.thepermanentejournal.org/issues/2016/fall/6227-incarcerated-healthcare.html and in the Fall 2016 issue of The Permanente Journal.
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Association between personal health record enrollment and patient loyalty.
Turley, Marianne; Garrido, Terhilda; Lowenthal, Alex; Zhou, Yi Yvonne
2012-07-01
To examine the association between patient loyalty, as measured by member retention in the health plan, and access to My Health Manager (MHM), Kaiser Permanente's PHR, which is linked to its electronic health record, KP HealthConnect. We conducted a retrospective cohort observational quality improvement project from the third quarter of 2005 to the fourth quarter of 2008 for approximately 394,000 Kaiser Permanente Northwest members. To control for self-selection bias, we used propensity scores to perform exact 1-to-1 matching without replacement between MHM users and nonusers. We estimated retention rates of the matched data and assessed the association between MHM use and retention versus voluntary termination. We also estimated odds ratios of significant variables impacting member retention. The probability of remaining a member or being involuntarily terminated versus voluntary termination was 96.7% for users (95% confidence interval [CI], 96.6%-96.7%) and 92.2% for nonusers (95% CI, 92.1%-92.4%; P <.001). In the logistic model, MHM use was a significant predictor; only tenure and illness burden were stronger predictors. Users were 2.578 (95% CI, 2.487%-2.671%) times more likely to choose to remain members than were nonusers. The impact was more substantial among newer members. MHM use was significantly associated with voluntary membership retention. An indicator of patient loyalty, retention is critical to healthcare organizations.
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Monroe, C Douglas; Chin, Karen Y
2013-05-01
The specialty pharmaceuticals market is expanding more rapidly than the traditional pharmaceuticals market. Specialty pharmacy operations have evolved to deliver selected medications and associated clinical services. The growing role of specialty drugs requires new approaches to managing the use of these drugs. The focus, expectations, and emphasis in specialty drug management in an integrated health care delivery system such as Kaiser Permanente (KP) can vary as compared with more conventional health care systems. The KP Specialty Pharmacy (KP-SP) serves KP members across the United States. This descriptive account addresses the impetus for specialty drug management within KP, the use of tools such as an electronic health record (EHR) system and process management software, the KP-SP approach for specialty pharmacy services, and the emphasis on quality measurement of services provided. Kaiser Permanente's integrated system enables KP-SP pharmacists to coordinate the provision of specialty drugs while monitoring laboratory values, physician visits, and most other relevant elements of the patient's therapy. Process management software facilitates the counseling of patients, promotion of adherence, and interventions to resolve clinical, logistic, or pharmacy benefit issues. The integrated EHR affords KP-SP pharmacists advantages for care management that should become available to more health care systems with broadened adoption of EHRs. The KP-SP experience may help to establish models for clinical pharmacy services as health care systems and information systems become more integrated.
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Schmittdiel, Julie A; Adams, Sara R; Goler, Nancy; Sanna, Rashel S; Boccio, Mindy; Bellamy, David J; Brown, Susan D; Neugebauer, Romain S; Ferrara, Assiamira
2017-02-01
To evaluate the impact of a population-based telephonic wellness coaching program on weight loss. Individual-level segmented regression analysis of interrupted time series data comparing the BMI trajectories in the 12 months before versus the 12 months after initiating coaching among a cohort of Kaiser Permanente Northern California members (n = 954) participating in The Permanente Medical Group Wellness Coaching program in 2011. The control group was a 20:1 propensity-score matched control group (n = 19,080) matched with coaching participants based on baseline demographic and clinical characteristics. Wellness coaching participants had a significant upward trend in BMI in the 12 months before their first wellness coaching session and a significant downward trend in BMI in the 12 months after their first session equivalent to a clinically significant reduction of greater than one unit of baseline BMI (P < 0.01 for both). The control group did not have statistically significant decreases in BMI during the post-period. Wellness coaching has a positive impact on BMI reduction that is both statistically and clinically significant. Future research and quality improvement efforts should focus on disseminating wellness coaching for weight loss in patients with diabetes and those at risk for developing the disease. © 2017 The Authors. Obesity published by Wiley Periodicals, Inc. on behalf of The Obesity Society (TOS).
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Bojcic, Jamie L; Sue, Valerie M; Huon, Tomy S; Maletis, Gregory B; Inacio, Maria C S
2014-01-01
This study compared response rates of paper and electronic versions of the Knee injury Osteoarthritis and Outcome Score questionnaire and examined the characteristics of patients who responded to each survey method. A total of 1486 patients registered by the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry between 2005 and 2010 were included in this study. Response rates by survey modality for the overall cohort, by the specific time periods, and by age and sex at time of anterior cruciate ligament reconstruction were compared using χ(2) tests or the Fisher exact test when appropriate. Independent Student t tests were used to compare the Knee injury Osteoarthritis and Outcome Scores of survey respondents. The overall survey response rate was 42%. The 36% response rate in the electronic-survey group was significantly higher than the 22% response rate in the paper-survey group (p < 0.001). The electronic response rate was also significantly higher than the paper response rate at all follow-up times (35% vs 25% at 1 year, p = 0.004, 38% vs 20% at 2 years, p < 0.001, and 35% vs 21% at 3 years; p < 0.001) and among all age groups 19 years and older. Although the electronic survey produced higher response rates, it is not sufficient alone to replace the traditional paper version among this Kaiser Permanente population.
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Using Population Dose to Evaluate Community-level Health Initiatives.
Harner, Lisa T; Kuo, Elena S; Cheadle, Allen; Rauzon, Suzanne; Schwartz, Pamela M; Parnell, Barbara; Kelly, Cheryl; Solomon, Loel
2018-05-01
Successful community-level health initiatives require implementing an effective portfolio of strategies and understanding their impact on population health. These factors are complicated by the heterogeneity of overlapping multicomponent strategies and availability of population-level data that align with the initiatives. To address these complexities, the population dose methodology was developed for planning and evaluating multicomponent community initiatives. Building on the population dose methodology previously developed, this paper operationalizes dose estimates of one initiative targeting youth physical activity as part of the Kaiser Permanente Community Health Initiative, a multicomponent community-level obesity prevention initiative. The technical details needed to operationalize the population dose method are explained, and the use of population dose as an interim proxy for population-level survey data is introduced. The alignment of the estimated impact from strategy-level data analysis using the dose methodology and the data from the population-level survey suggest that dose is useful for conducting real-time evaluation of multiple heterogeneous strategies, and as a viable proxy for existing population-level surveys when robust strategy-level evaluation data are collected. This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health. Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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Quelques facteurs sociaux agissant sur la formation permanente et l'education informelle en Algerie
NASA Astrophysics Data System (ADS)
Haddab, Mustapha
1994-05-01
This article attempts an analysis of the conditions under which a certain degree of educational pluralism has begun, tentatively, to be seen in Algeria in association with the political and socio-economic changes that have taken place since 1988. After a long period of centralism codified in the National Charter of 1976, during which the public education system had become all but the only provider of education, in demand largely on account of the diplomas and certificates which it awarded, various social factors (including growth in unemployment among young people and those with qualifications, development of voluntary associations, inflexibility of public schools, various effects of the "language conflict" on the educational system, etc.) have since led to the appearance of varying educational activities. Some of these make up for the inadequacy of the public schools; others, less well established, respond to the emergence of the need for "lifelong education" or provide complementary training for social groups which may have a political or religious motivation. These tendencies are limited to the development of voluntary associations in Algeria.
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Ramirez-Valles, Jesus; Kuhns, Lisa M; Manjarrez, Dianna
2014-04-01
In this article, the authors describe the development and dissemination of a film-based educational intervention to reduce negative attitudes toward gay and bisexual men, transgender women, and people living with HIV/AIDS in Latino communities, with a focus on youth. The intervention, Tal Como Somos/Just as We Are, is based on stigma and attribution theories, extensive formative research, and community input. Evaluation findings among educators and school youth suggest the film has the potential to effectively influence attitudes toward gay and bisexual men, transgender women, and people living with HIV/AIDS. The film and intervention are being disseminated using diffusion of innovations theory through community-based organizations, schools, television broadcasting, and film festivals.
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2011-10-01
de 2012 à Londres, les Jeux du Commonwealth de 2015 à Toronto et la gestion des cas d’urgence transfrontaliers...tels que les Jeux olympiques. La gestion de la sécurité lors d’événements comme Vancouver 2010 et les sommets du G8 et du G20 est un enjeu... des plans de gestion des mesures d’urgence et de continuité des opérations, une structure permanente a été mise sur pied
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[The Internet and shared decision-making between patients and healthcare providers].
Silber, Denise
2009-10-01
Insurance companies like Kaiser Permanente in the United States remunerate physicians for their email correspondence with patients, increasing the efficiency of office visits. A survey by the French National Board of Physicians regarding the computerization of medical practices in April 2009, confirms that both physicians and patients in France are very favorable to the development of these tools. When patients can manage and/or access their medical files and determine which providers can access them, they become a true partner.
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Staszak-Jirkovský, Jakub; Malliakas, Christos D.; Lopes, Pietro P.; ...
2015-11-30
Three of the fundamental catalytic limitations that have plagued the electrochemical production of hydrogen for decades still remain: low efficiency, short lifetime of catalysts and a lack of low-cost materials. Here, we address these three challenges by establishing and exploring an intimate functional link between the reactivity and stability of crystalline (CoS 2 and MoS 2) and amorphous (CoS x and MoS x) hydrogen evolution catalysts. We propose that Co 2+ and Mo 4+ centers promote the initial discharge of water (alkaline solutions) or hydronium ions (acid solutions). We establish that although CoS x materials are more active than MoSmore » x they are also less stable, suggesting that the active sites are defects formed after dissolution of Co and Mo cations. Finally, by combining the higher activity of CoS x building blocks with the higher stability of MoS x units into a compact and robust CoMoS x structure, we are able to design a low-cost alternative to noble metal catalysts for efficient electrocatalytic production of hydrogen in both alkaline and acidic environments.« less
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Janoff, Shannon L; Perrin, Nancy A; Coplan, Paul M; Chilcoat, Howard D; Campbell, Cynthia I; Green, Carla A
2016-05-14
Addiction, overdoses and deaths resulting from prescription opioids have increased dramatically over the last decade. In response, several manufacturers have developed formulations of opioids with abuse-deterrent properties. For many of these products, the Food and Drug Administration (FDA) recognized the formulation with labeling claims and mandated post-marketing studies to assess the abuse-deterrent effects. In response, we assess differences in rates of opioid-related overdoses and poisonings prior to and following the introduction of a formulation of OxyContin® with abuse-deterrent properties. To assess effects of this formulation, electronic medical record (EMR) data from Kaiser Permanente Northwest (KPNW) and Kaiser Permanente Northern California (KPNC) are linked to state death data and compared to chart audits. Overdose and poisoning events will be categorized by intentionality and number of agents involved, including illicit drugs and alcohol. Using 6-month intervals over a 10-year period, trends will be compared in rates of opioid-related overdoses and poisoning events associated with OxyContin® to rates of events associated with other oxycodone and opioid formulations. Qualitative interviews with patients and relatives of deceased patients will be conducted to capture circumstances surrounding events. This study assesses and tracks changes in opioid-related overdoses and poisoning events prior to and following the introduction of OxyContin® with abuse-deterrent properties. Public health significance is high because these medications are designed to reduce abuse-related behaviors that lead to important adverse outcomes, including overdoses and deaths.
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Rapid spread of complex change: a case study in inpatient palliative care.
Della Penna, Richard; Martel, Helene; Neuwirth, Esther B; Rice, Jennifer; Filipski, Marta I; Green, Jennifer; Bellows, Jim
2009-12-29
Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.
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Ismail, Mohamed H; Ho, Ngoc J; Lara, Nancy Irazu
2013-01-01
Kaiser Permanente measures how often tobacco users are offered strategies to quit but not the success of such strategies. To compare tobacco abstinence rates for participants of the Kaiser Permanente Riverside (California) Medical Center's Freedom from Tobacco Class in 2008, before direct physician involvement, and in 2009, after direct physician involvement, and to compare other variables affecting these rates. In a retrospective study, participants were divided into two groups based on year of participation. Data were collected using electronic medical records and phone interviews. Tobacco use status between both groups at 1, 3, 6, and 12 months after the classes started and within groups by sex, number of classes attended, medication received, and class teacher. The 12-month abstinence rates were 27% in 2008 and 33% in 2009 (p = 0.3). The abstinence rate for men improved from 23% to 38% (2008 vs 2009; p = 0.05), whereas for women it was 30% vs 27% (p = 0.7). Abstinence rates decreased over time for the group as a whole (p < 0.001). Attendance of 6 or more classes was associated with higher abstinence rates. There was no significant impact on abstinence rates due to age, body mass index, class teacher, or medications used. Direct physician involvement improved men's but not women's abstinence rates among class participants. The relapse rate was significant over the first year after the class. Further research is needed to study the difference between sexes and the factors affecting relapse.
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DIABETES MELLITUS COMO FACTOR DE RIESGO DE DEMENCIA EN LA POBLACIÓN ADULTA MAYOR MEXICANA
Silvia, Mejía-Arango; Clemente, y Zúñiga-Gil
2012-01-01
Introduccion La diabetes mellitus y las demencias constituyen dos problemas crecientes de salud entre la población adulta mayor del mundo y en particular de los paises en desarrollo. Hacen falta estudios longitudinales sobre el papel de la diabetes como factor de riesgo para demencia. Objetivo Determinar el riesgo de demencia en sujetos Mexicanos con diabetes mellitus tipo 2. Materiales y Metodos Los sujetos diabéticos libres de demencia pertenecientes al Estudio Nacional de Salud y Envejecimiento en México fueron evaluados a los dos años de la línea de base. Se estudió el papel de los factores sociodemográficos, de otras comorbilidades y del tipo de tratamiento en la conversión a demencia. Resultados Durante la línea de base 749 sujetos (13.8%) tuvieron diabetes. El riesgo de desarrollar demencia en estos individuos fue el doble (RR, 2.08 IC 95%, 1.59–2.73). Se encontró un riesgo mayor en individuos de 80 años y más (RR 2.44 IC 95%, 1.46–4.08), en los hombres (RR, 2.25 IC 95%, 1.46–3.49) y en sujetos con nivel educativo menor de 7 años. El estar bajo tratamiento con insulina incrementó el riesgo de demencia (RR, 2.83, IC 95%, 1.58–5.06). Las otras comorbilidades que aumentaron el riesgo de demencia en los pacientes diabéticos fueron la hipertensión (RR, 2.75, IC 95%, 1.86–4.06) y la depresión (RR, 3.78, 95% IC 2.37–6.04). Conclusión Los sujetos con diabetes mellitus tienen un riesgo mayor de desarrollar demencia, La baja escolaridad y otras comorbilidades altamente prevalentes en la población Mexicana contribuyen a la asociación diabetes-demencia. PMID:21948010
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Achieving performance breakthroughs in an HMO business process through quality planning.
Hanan, K B
1993-01-01
Kaiser Permanente's Georgia Region commissioned a quality planning team to design a new process to improve payments to its suppliers and vendors. The result of the team's effort was a 73 percent reduction in cycle time. This team's experiences point to the advantages of process redesign as a quality planning model, as well as some general guidelines for its most effective use in teams. If quality planning project teams are carefully configured, sufficiently expert in the existing process, and properly supported by management, organizations can achieve potentially dramatic improvements in process performance using this approach.
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Does Consuming Sugar and Artificial Sweeteners Change Taste Preferences?
Bartolotto, Carole
2015-01-01
Americans consume 22.3 teaspoons of added caloric sweeteners a day. Sweeteners range from 180 to 13,000 times sweeter than sugar. In summer 2014, 20 people from Kaiser Permanente California facilities cut out all added sugars and artificial sweeteners for 2 weeks: 95% of participants found that sweet foods and drinks tasted sweeter or too sweet, 75% found that other foods tasted sweeter, and 95% said moving forward they would use less or even no sugar. Additionally, 86.6% of participants stopped craving sugar after 6 days.
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Caloyeras, John P; Kanter, Michael; Ives, Nicole; Kim, Chong Y; Kanzaria, Hemal K; Berry, Sandra H; Brook, Robert H
2016-01-01
For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system. Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers. Primary measure was satisfaction with one's day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income. Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2-9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income. It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.
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Caloyeras, John P; Kanter, Michael; Ives, Nicole; Kim, Chong Y; Kanzaria, Hemal K; Berry, Sandra H; Brook, Robert H
2016-01-01
Context: For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. Objective: To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system. Design: Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers. Main Outcome Measures: Primary measure was satisfaction with one’s day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income. Results: Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2–9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income. Conclusion: It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction. PMID:27057819
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Kuntz, Jennifer L; Johnson, Eric S; Raebel, Marsha A; Petrik, Amanda F; Yang, Xiuhai; Thorp, Micah L; Spindel, Steven J; Neil, Nancy; Smith, David H
2012-10-01
To describe the epidemiology and healthcare costs of Clostridium difficile infection (CDI) identified in the outpatient setting. Population-based, retrospective cohort study. Kaiser Permanente Colorado and Kaiser Permanente Northwest members between June 1, 2005, and September 30, 2008. We identified persons with incident CDI and classified CDI by whether it was identified in the outpatient or inpatient healthcare setting. We collected information about baseline variables and follow-up healthcare utilization, costs, and outcomes among patients with CDI. We compared characteristics of patients with CDI identified in the outpatient versus inpatient setting. We identified 3,067 incident CDIs; 56% were identified in the outpatient setting. Few strong, independent predictors of diagnostic setting were identified, although a previous stay in a nonacute healthcare institution (odds ratio [OR], 1.45 [95% confidence interval (CI), 1.13-1.86]) was statistically associated with outpatient-identified CDI, as was age from 50 to 59 years (OR, 1.64 [95% CI, 1.18-2.29]), 60 to 69 years (OR, 1.37 [95% CI, 1.03-1.82]), and 70 to 79 years (OR, 1.36 [95% CI, 1.06-1.74]), when compared with persons aged 80-89 years. We found that more than one-half of incident CDIs in this population were identified in the outpatient setting. Patients with outpatient-identified CDI were younger with fewer comorbidities, although they frequently had previous exposure to healthcare. These data suggest that practitioners should be aware of CDI and obtain appropriate diagnostic testing on outpatients with CDI symptoms.
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Caregiver involvement in a large clinical systems project.
Sales, S.; Mathews, P.; Gamblin, D.; Gee, S.
1994-01-01
The Kaiser Permanente Northern California Region (KPNCR) CareGiver Workstation (CGW) Project's mission is to develop and implement a clinical workstation system that will enhance each caregiver-member interaction and aid in the decision-making processes of direct patient care in the inpatient and outpatient settings. The requirements analysis approach for CareGiver Workstation (CGW) is based on the belief that extensive caregiver involvement will provide a better understanding of the diverse needs of Kaiser Permanente Northern California Region (KPNCR). In order to involve as many caregivers as reasonably possible, CGW included a 16 member caregiver core team and 6 different Medical Centers in the requirements definition process. The Medical Centers are referred to as "focus facilities". A "focus group" (caregiver team) at each selected focus facility consisted of a site coordinator and a 24-30 person multidisciplinary team involving physicians, nurses, therapists and other caregivers. The Medical Center selection process identified facilities that provided the best cross-sectional representation of KPNCR. The Lead Focus Facility participated in the initial round of requirements definition activities. These sessions assisted in the design of a simulation that was used at five additional Medical Centers to validate requirements. The five additional Focus Facilities participated in simulation review sessions. Feedback from these sessions was used to revise the simulation and update the requirements document. Caregivers from all six focus facilities and other identified groups participated in a requirements survey to assist CGW with identification of high priority features. Caregiver commitment and continuing involvement are essential for the success of CGW.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:7949953
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Ismail, Mohamed H; Ho, Ngoc J; Lara, Nancy Irazu
2013-01-01
Context Kaiser Permanente measures how often tobacco users are offered strategies to quit but not the success of such strategies. Objective: To compare tobacco abstinence rates for participants of the Kaiser Permanente Riverside (California) Medical Center’s Freedom from Tobacco Class in 2008, before direct physician involvement, and in 2009, after direct physician involvement, and to compare other variables affecting these rates. Design: In a retrospective study, participants were divided into two groups based on year of participation. Data were collected using electronic medical records and phone interviews. Main Outcome Measures: Tobacco use status between both groups at 1, 3, 6, and 12 months after the classes started and within groups by sex, number of classes attended, medication received, and class teacher. Results: The 12-month abstinence rates were 27% in 2008 and 33% in 2009 (p = 0.3). The abstinence rate for men improved from 23% to 38% (2008 vs 2009; p = 0.05), whereas for women it was 30% vs 27% (p = 0.7). Abstinence rates decreased over time for the group as a whole (p < 0.001). Attendance of 6 or more classes was associated with higher abstinence rates. There was no significant impact on abstinence rates due to age, body mass index, class teacher, or medications used. Conclusion: Direct physician involvement improved men’s but not women’s abstinence rates among class participants. The relapse rate was significant over the first year after the class. Further research is needed to study the difference between sexes and the factors affecting relapse. PMID:23704836
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Incidence of Parkinson's disease: variation by age, gender, and race/ethnicity.
Van Den Eeden, Stephen K; Tanner, Caroline M; Bernstein, Allan L; Fross, Robin D; Leimpeter, Amethyst; Bloch, Daniel A; Nelson, Lorene M
2003-06-01
The goal of this study was to estimate the incidence of Parkinson's disease by age, gender, and ethnicity. Newly diagnosed Parkinson's disease cases in 1994-1995 were identified among members of the Kaiser Permanente Medical Care Program of Northern California, a large health maintenance organization. Each case met modified standardized criteria/Hughes diagnostic criteria as applied by a movement disorder specialist. Incidence rates per 100,000 person-years were calculated using the Kaiser Permanente membership information as the denominator and adjusted for age and/or gender using the direct method of standardization. A total of 588 newly diagnosed (incident) cases of Parkinson's disease were identified, which gave an overall annualized age- and gender-adjusted incidence rate of 13.4 per 100,000 (95% confidence interval (CI): 11.4, 15.5). The incidence rapidly increased over the age of 60 years, with only 4% of the cases being under the age of 50 years. The rate for men (19.0 per 100,000, 95% CI: 16.1, 21.8) was 91% higher than that for women (9.9 per 100,000, 95% CI: 7.6, 12.2). The age- and gender-adjusted rate per 100,000 was highest among Hispanics (16.6, 95% CI: 12.0, 21.3), followed by non-Hispanic Whites (13.6, 95% CI: 11.5, 15.7), Asians (11.3, 95% CI: 7.2, 15.3), and Blacks (10.2, 95% CI: 6.4, 14.0). These data suggest that the incidence of Parkinson's disease varies by race/ethnicity.
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Garrido, Terhilda; Kumar, Sudheen; Lekas, John; Lindberg, Mark; Kadiyala, Dhanyaja; Whippy, Alan; Crawford, Barbara; Weissberg, Jed
2014-01-01
Using electronic health records (EHR) to automate publicly reported quality measures is receiving increasing attention and is one of the promises of EHR implementation. Kaiser Permanente has fully or partly automated six of 13 the joint commission measure sets. We describe our experience with automation and the resulting time savings: a reduction by approximately 50% of abstractor time required for one measure set alone (surgical care improvement project). However, our experience illustrates the gap between the current and desired states of automated public quality reporting, which has important implications for measure developers, accrediting entities, EHR vendors, public/private payers, and government. PMID:23831833
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Zerbo, Ousseny; Qian, Yinge; Yoshida, Cathleen; Fireman, Bruce H; Klein, Nicola P; Croen, Lisa A
2017-01-02
Maternal infections and fever during pregnancy are associated with increased risk for autism spectrum disorders (ASDs). To our knowledge, no study has investigated the association between influenza vaccination during pregnancy and ASD. To investigate the association between influenza infection and vaccination during pregnancy and ASD risk. This cohort study included 196 929 children born at Kaiser Permanente Northern California from January 1, 2000 to December 31, 2010, at a gestational age of at least 24 weeks. Data on maternal influenza infection and vaccination from conception date to delivery date, obtained from Kaiser Permanente Northern California inpatient and outpatient databases. Influenza infection was defined by the International Classification of Diseases, Ninth Revision, Clinical Modification codes or positive influenza laboratory test results. Clinical diagnoses of ASDs identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes 299.0, 299.8, or 299.9 recorded in Kaiser Permanente Northern California electronic medical records on at least 2 occasions any time from birth through June 2015. Within this cohort of 196 929 children, influenza was diagnosed in 1400 (0.7%) mothers and 45 231 (23%) received an influenza vaccination during pregnancy. The mean (SD) ages of vaccinated and unvaccinated women were 31.6 (5.2) and 30.4 (5.6) years, respectively. A total number of 3101 (1.6%) children were diagnosed with ASD. After adjusting for covariates, we found that maternal influenza infection (adjusted hazard ratio, 1.04; 95% CI, 0.68-1.58) or influenza vaccination (adjusted hazard ratio, 1.10; 95% CI, 1.00-1.21) anytime during pregnancy was not associated with increased ASD risk. In trimester-specific analyses, first-trimester influenza vaccination was the only period associated with increased ASD risk (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39). However, this association could be due to chance (P = 0.1) if
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Fatigue in children and adolescents with cancer from the perspective of health professionals.
Silva, Michele Cristina Miyauti da; Lopes, Luís Carlos; Nascimento, Lucila Castanheira; Lima, Regina Aparecida Garcia de
2016-08-29
to investigate health professionals' knowledge about the concept, assessment and intervention in fatigue in children and adolescents with cancer. exploratory study with qualitative approach, with 53 health professionals (10 nurses, 33 assistant nurses, 3 physicians, 3 nutritionists, 2 psychologists and 2 physical therapists). Semi structured interviews were held, which were recorded and analyzed by means of inductive thematic content analysis. the data were organized around three themes: knowledge of health professionals about fatigue; identification of fatigue and interventions to relieve fatigue. the results indicate the health professionals' limited knowledge about fatigue, as well as the lack of investment in their training and continuing education. Most of all, the lack of research on the theme in the Brazilian context remains a barrier to support improvements in care for this symptom in children and adolescents with cancer. investigar quais conhecimentos os profissionais de saúde têm acerca do conhecimento, avaliação e intervenção sobre a fadiga em crianças e adolescentes com câncer. estudo exploratório com abordagem qualitativa, realizado com 53 profissionais de saúde (10 enfermeiros, 33 auxiliares de enfermagem, 3 médicos, 3 nutricionistas, 2 psicólogos e 2 fisioterapeutas). Foram conduzidas entrevistas semiestruturadas as quais foram gravadas e analisadas por meio do modelo de análise de conteúdo do tipo temática indutiva. os dados foram organizados ao redor de três temas: conhecimento dos profissionais da saúde sobre fadiga; identificação da fadiga e intervenções para o alívio da fadiga. os achados apontam para o conhecimento limitado dos profissionais de saúde sobre fadiga, bem como para o pouco investimento em educação continuada e permanente. Sobretudo, a escassez de estudos sobre o assunto no cenário brasileiro ainda é uma barreira para oferecer subsídios para melhoria deste sintoma em crianças e adolescentes com c
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NASA Astrophysics Data System (ADS)
Roncoli, Carla; Kirshen, Paul; Etkin, Derek; Sanon, Moussa; Somé, Léopold; Dembélé, Youssouf; Sanfo, Bienvenue J.; Zoungrana, Jacqueline; Hoogenboom, Gerrit
2009-10-01
This study focuses on the potential role of technical and institutional innovations for improving water management in a multi-user context in Burkina Faso. We focus on a system centered on three reservoirs that capture the waters of the Upper Comoé River Basin and servicing a diversity of users, including a sugar manufacturing company, a urban water supply utility, a farmer cooperative, and other downstream users. Due to variable and declining rainfall and expanding users’ needs, drastic fluctuations in water supply and demand occur during each dry season. A decision support tool was developed through participatory research to enable users to assess the impact of alternative release and diversion schedules on deficits faced by each user. The tool is meant to be applied in the context of consultative planning by a local user committee that has been created by a new national integrated water management policy. We contend that both solid science and good governance are instrumental in realizing efficient and equitable water management and adaptation to climate variability and change. But, while modeling tools and negotiation platforms may assist users in managing climate risk, they also introduce additional uncertainties into the deliberative process. It is therefore imperative to understand how these technological and institutional innovations frame water use issues and decisions to ensure that such framing is consistent with the goals of integrated water resource management.
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External Validation of Early Weight Loss Nomograms for Exclusively Breastfed Newborns.
Schaefer, Eric W; Flaherman, Valerie J; Kuzniewicz, Michael W; Li, Sherian X; Walsh, Eileen M; Paul, Ian M
2015-12-01
Nomograms that show hour-by-hour percentiles of weight loss during the birth hospitalization were recently developed to aid clinical care of breastfeeding newborns. The nomograms for breastfed neonates were based on a sample of 108,907 newborns delivered at 14 Kaiser Permanente medical centers in Northern California (United States). The objective of this study was to externally validate the published nomograms for newborn weight loss using data from a geographically distinct population. Data were compiled from the Penn State Milton S. Hershey Medical Center located in Hershey, PA. For singleton neonates delivered at ≥36 weeks of gestation between January 2013 and September 2014, weights were obtained between 6 hours and 48 hours (vaginal delivery) or 60 hours (cesarean delivery) for neonates who were exclusively breastfeeding. Quantile regression methods appropriate for repeated measures were used to estimate 50th, 75th, 90th, and 95th percentiles of weight loss as a function of time after birth. These percentile estimates were compared with the published nomograms. Of the 1,587 newborns who met inclusion criteria, 1,148 were delivered vaginally, and 439 were delivered via cesarean section. These newborns contributed 1,815 weights for vaginal deliveries (1.6 per newborn) and 893 weights for cesarean deliveries (2.0 per newborn). Percentile estimates from this Penn State sample were similar to the published nomograms. Deviations in percentile estimates for the Penn State sample were similar to deviations observed after fitting the same model separately to each medical center that made up the Kaiser Permanente sample. The published newborn weight loss nomograms for breastfed neonates were externally validated in a geographically distinct population.
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Sutherland, Elizabeth G; Ritenbaugh, Cheryl; Kiley, Susan J; Vuckovic, Nancy; Elder, Charles
2009-08-01
The purpose of this study was to evaluate an energy healing treatment for possible inclusion as a Kaiser Permanente Northwest (KPNW) Pain Clinic provided therapy, and to identify the appropriate number of treatment sessions for a Pain Clinic protocol, should the intervention prove successful. In addition, our intent was to document the full range of outcomes experienced by patients undergoing energy healing, including whole-person and transformative outcomes should they occur. The setting for this study was Kaiser Permanente Northwest Pain Clinic. Thirteen (13) patients with chronic headache who were members of the KPNW Health Plan were recruited through flyers or mailings. Thirteen (13) participants received at least three energy healing sessions at approximately weekly intervals. Assessments were based on pre- and post-treatment qualitative interviews. The treatment consisted of three Healing Touch sessions provided by a Certified Healing Touch Practitioner. Treatments contained elements common to all sessions, and elements that were tailored to the individual subject. Twelve (12) of 13 participants experienced improvement in frequency, intensity, or duration of pain after three treatments. In addition, 11 of 13 participants experienced profound shifts in their view of themselves, their lives, and their potential for healing and transformation. These changes lasted from 24 hours to more than 6 months at follow-up. Energy healing can be an important addition to pain management services. More in-depth qualitative research is needed to explore the diversity of outcomes facilitated by energy healing treatments. Furthermore, the development of new instrumentation is warranted to capture outcomes that reflect transformative change and changes at the level of the whole person.
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Prevalence of prostatitis-like symptoms in a managed care population.
Clemens, J Quentin; Meenan, Richard T; O'Keeffe-Rosetti, Maureen C; Gao, Sara Y; Brown, Sheila O; Calhoun, Elizabeth A
2006-08-01
We calculated the prevalence of symptoms typically associated with chronic prostatitis/chronic pelvic pain syndrome in men in a managed care population in the Pacific Northwest. A questionnaire mailing to 5,000 male enrollees 25 to 80 years old in the Kaiser Permanente Northwest (Portland, Oregon) health plan was performed. The questionnaires included screening questions about the presence, duration and severity of pelvic pain, and the National Institutes of Health Chronic Prostatitis Symptom Index. Chronic prostatitis/chronic pelvic pain syndrome symptoms were defined in 2 ways: 1) presence of any of the following for a duration of 3 or more months: pain in the perineum, testicles, tip of penis, pubic or bladder area, dysuria, ejaculatory pain; and 2) perineal and/or ejaculatory pain, and a National Institutes of Health Chronic Prostatitis Symptom Index total pain score of 4 or more. Prevalence estimates were age adjusted to the total Kaiser Permanente Northwest male population. A total of 1,550 questionnaires were returned. The prevalence of chronic prostatitis/chronic pelvic pain syndrome symptoms was 7.5% for definition 1 and 5.9% for definition 2. Mean National Institutes of Health Chronic Prostatitis Symptom Index scores were 17 for definitions 1 and 2. Of those with prostatitis-like symptoms, 30% met criteria for having both definitions present. The prevalence of prostatitis-like symptoms using either of the 2 diagnoses was 11.2%. This population based study indicates that approximately 1 in 9 men have prostatitis-like symptoms. Application of 2 different definitions for prostatitis-like symptoms identified unique groups of men, with limited overlap in the groups.
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Ritenbaugh, Cheryl; Kiley, Susan J.; Vuckovic, Nancy; Elder, Charles
2009-01-01
Abstract Objectives The purpose of this study was to evaluate an energy healing treatment for possible inclusion as a Kaiser Permanente Northwest (KPNW) Pain Clinic provided therapy, and to identify the appropriate number of treatment sessions for a Pain Clinic protocol, should the intervention prove successful. In addition, our intent was to document the full range of outcomes experienced by patients undergoing energy healing, including whole-person and transformative outcomes should they occur. Setting The setting for this study was Kaiser Permanente Northwest Pain Clinic. Participants Thirteen (13) patients with chronic headache who were members of the KPNW Health Plan were recruited through flyers or mailings. Methods Thirteen (13) participants received at least three energy healing sessions at approximately weekly intervals. Assessments were based on pre- and post-treatment qualitative interviews. Intervention The treatment consisted of three Healing Touch sessions provided by a Certified Healing Touch Practitioner. Treatments contained elements common to all sessions, and elements that were tailored to the individual subject. Results Twelve (12) of 13 participants experienced improvement in frequency, intensity, or duration of pain after three treatments. In addition, 11 of 13 participants experienced profound shifts in their view of themselves, their lives, and their potential for healing and transformation. These changes lasted from 24 hours to more than 6 months at follow-up. Conclusions Energy healing can be an important addition to pain management services. More in-depth qualitative research is needed to explore the diversity of outcomes facilitated by energy healing treatments. Furthermore, the development of new instrumentation is warranted to capture outcomes that reflect transformative change and changes at the level of the whole person. PMID:19678772
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Neonatal hyperbilirubinemia and risk of autism spectrum disorders.
Croen, Lisa A; Yoshida, Cathleen K; Odouli, Roxana; Newman, Thomas B
2005-02-01
To investigate the association between neonatal hyperbilirubinemia and autism spectrum disorders (ASD). We conducted a large case-control study nested within the cohort of singleton term infants born between 1995 and 1998 at a northern California Kaiser Permanente hospital. Case subjects (n = 338) were children with an ASD diagnosis recorded in Kaiser Permanente outpatient databases; control subjects (n = 1817) were children without an ASD diagnosis, who were randomly sampled and frequency-matched to case subjects according to gender, birth year, and birth hospital. Approximately 28% of case and control subjects received > or =1 bilirubin test in the first 30 days of life. No case-control differences were observed for maximal bilirubin levels of > or =15 mg/dL (10.1% vs 12.1%), > or =20 mg/dL (2.1% vs 2.5%), or > or =25 mg/dL (0.3% vs 0.2%). Compared with children whose maximal neonatal bilirubin levels were <15 mg/dL or not measured, children with any degree of bilirubin level elevation were not at increased risk of ASD, after adjustment for gender, birth facility, maternal age, maternal race/ethnicity, maternal education, and gestational age (for bilirubin levels of 15-19.9 mg/dL: odds ratio: 0.7; 95% confidence interval: 0.5-1.2; for bilirubin levels of 20-24.9 mg/dL: odds ratio: 0.7; 95% confidence interval: 0.3-1.6; for bilirubin levels of > or =25 mg/dL: odds ratio: 1.1; 95% confidence interval: 0.1-11.2). These data suggest that neonatal hyperbilirubinemia is not a risk factor for ASD.
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Olry de Labry Lima, Antonio; Moya Garrido, María Natividad; Espín Balbino, Jaime
2014-04-01
Realise a review of studies of economic evaluation about the ambulatory monitoring of capillary glucose (AMGC) in diabetic type II persons. A review of the literature was conducted, in MedLine, various websites, referenced paper and provided by expert's persons. Five studies concluded that the AMGC was a cost-effective strategic, of this papers use Kaiser Permanente data base, its make that these studies could be considered a solely one study. The rest of the papers did not find difference in the AMGC use. The use of AMGC has an uncertainty efficiency. More studies are needed. Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
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Secure e-mailing between physicians and patients: transformational change in ambulatory care.
Garrido, Terhilda; Meng, Di; Wang, Jian J; Palen, Ted E; Kanter, Michael H
2014-01-01
Secure e-mailing between Kaiser Permanente physicians and patients is widespread; primary care providers receive an average of 5 e-mails from patients each workday. However, on average, secure e-mailing with patients has not substantially impacted primary care provider workloads. Secure e-mail has been associated with increased member retention and improved quality of care. Separate studies associated patient portal and secure e-mail use with both decreased and increased use of other health care services, such as office visits, telephone encounters, emergency department visits, and hospitalizations. Directions for future research include more granular analysis of associations between patient-physician secure e-mail and health care utilization.
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Transforming care delivery through health information technology.
Wheatley, Benjamin
2013-01-01
The slow but progressive adoption of health information technology (IT) nationwide promises to usher in a new era in health care. Electronic health record systems provide a complete patient record at the point of care and can help to alleviate some of the challenges of a fragmented delivery system, such as drug-drug interactions. Moreover, health IT promotes evidence-based practice by identifying gaps in recommended treatment and providing clinical decision-support tools. In addition, the data collected through digital records can be used to monitor patient outcomes and identify potential improvements in care protocols. Kaiser Permanente continues to advance its capability in each of these areas.
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Can disease management reduce health care costs by improving quality?
Fireman, Bruce; Bartlett, Joan; Selby, Joe
2004-01-01
Disease management (DM) promises to achieve cost savings by improving the quality of care for chronic diseases. During the past decade the Permanente Medical Group in Northern California has implemented extensive DM programs. Examining quality indicators, utilization, and costs for 1996-2002 for adults with four conditions, we find evidence of substantial quality improvement but not cost savings. The causal pathway--from improved care to reduced morbidity to cost savings--has not produced sufficient savings to offset the rising costs of improved care. We conclude that the rationale for DM programs, like the rationale for any medical treatments, should rest on their effectiveness and value.
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Secure E-mailing Between Physicians and Patients
Garrido, Terhilda; Meng, Di; Wang, Jian J.; Palen, Ted E.; Kanter, Michael H.
2014-01-01
Secure e-mailing between Kaiser Permanente physicians and patients is widespread; primary care providers receive an average of 5 e-mails from patients each workday. However, on average, secure e-mailing with patients has not substantially impacted primary care provider workloads. Secure e-mail has been associated with increased member retention and improved quality of care. Separate studies associated patient portal and secure e-mail use with both decreased and increased use of other health care services, such as office visits, telephone encounters, emergency department visits, and hospitalizations. Directions for future research include more granular analysis of associations between patient-physician secure e-mail and health care utilization. PMID:24887522
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NASA Astrophysics Data System (ADS)
Allen, M. P.; Horvath, J. E.
La observación detallada de los pulsos en varios pulsares jóvenes (τ < 105 yr) permitió detectar varios aumentos en la frecuencia de emisión gliches con cambios permanentes en Δ {˙ Ω} / {˙ Ω}. A través de las ecuaciones de movimiento se investiga, utilizando parametrizaciones simples, la hipótesis de que el ángulo entre Ω y el dipolo magnético M sea responsable de ese comportamiento. Se derivan curvas analíticas para la evolución de Ω (t) y se estudia la posibilidad de describir un conjunto de observables (incluyendo el braking index n) con estos modelos.
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Garrido, Terhilda; Barbeau, Rosemarie
2010-01-01
Kaiser Permanente (KP) has a long-standing commitment to conduct research and report publicly. Simultaneously, it faces a different imperative: harnessing information systems to leverage internal improvements in outcomes, efficiency, and costs. Now that KP HealthConnect, the KP electronic health record, is fully implemented, research challenges at KP are moving away from issues of data access and toward the mechanisms through which raw data create meaningful clinical knowledge that is based on rigorous research. In this report we describe a model for research—the Northern California Division of Research Perinatal Research Unit—that leverages internal and external resources to fulfill these twin missions. PMID:20844705
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Successful practices in the use of secure e-mail.
Johnson, Laura W; Garrido, Terhilda; Christensen, Kate; Handley, Matt
2014-01-01
Physician use of secure e-mail with patients is anticipated to increase under Stage 2 Meaningful Use requirements, but little is known about how physicians can successfully incorporate it into daily work. We interviewed 27 "super user" physicians at Kaiser Permanente and Group Health who were identified by leaders as being technologically, operationally, and clinically adept and as having high levels of secure e-mail use with patients. They highly valued the use of secure e-mail with patients, despite concerns about a lack of adequate time to respond, and provided tips for using it successfully. They identified benefits that included better care and improved relationships with their patients.
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Puccio, Francis; Fuller-Tyszkiewicz, Matthew; Ong, Deborah; Krug, Isabel
2016-05-01
Undertake a meta-analysis to provide a quantitative synthesis of longitudinal studies that assessed the direction of effects between eating pathology and depression. A second aim was to use meta-regression to account for heterogeneity in terms of study-level effect modifiers. A systematic review was conducted on 42 studies that assessed the longitudinal relationship between eating pathology and depression. Of these 42 studies, multilevel random-effects meta-analyses were conducted on 30 eligible studies. Meta-analysis results showed that eating pathology was a risk factor for depression (rm = 0.13) and that depression was a risk factor for eating pathology (rm = 0.16). Meta-regression analyses showed that these effects were significantly stronger for studies that operationalized eating pathology as an eating disorder diagnosis versus eating pathology symptoms, and for studies that operationalized the respective outcome measure as a categorical variable (e.g., a diagnosis of a disorder or where symptoms were "present"/"absent") versus a continuous measure. Results also showed that in relation to eating pathology type, the effect of an eating disorder diagnosis and bulimic symptoms on depression was significantly stronger for younger participants. Eating pathology and depression are concurrent risk factors for each other, suggesting that future research would benefit from identifying factors that are etiological to the development of both constructs. Llevar a cabo un meta-análisis para proporcionar una síntesis cuantitativa de los estudios longitudinales que evaluaron la dirección de los efectos entre la alimentación patológica y la depresión. Un segundo objetivo fue utilizar la meta-regresión para dar cuenta de la heterogeneidad en términos de modificadores del efecto a nivel de estudio. MÉTODO: Una revisión sistemática se llevó a cabo en 42 estudios que evaluaron la relación longitudinal entre la alimentación patológica y la depresión. De
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ERIC Educational Resources Information Center
Lind, Patricia; Germano, Catherine
These five learning modules use text interspersed with illustrations and reinforcement exercises to instruct dental aide and dental hygiene students about jaw bones and gums, dental deposits, and dental instruments. The first four modules were prepared by Patricia Lind in both Spanish and English. "The Gum and Bone of Permanent Teeth"…
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Psychiatric and Medical Conditions in Transition-Aged Individuals With ASD.
Davignon, Meghan N; Qian, Yinge; Massolo, Maria; Croen, Lisa A
2018-04-01
Children with autism spectrum disorder (ASD) have a variety of medical and psychiatric conditions and an increased use of health care services. There is limited information about the prevalence of psychiatric and medical conditions in adolescents and young adults with ASD. Our objective was to describe the frequency of medical and psychiatric conditions in a large population of diverse, insured transition-aged individuals with ASD. Participants included Kaiser Permanente Northern California members who were enrolled from 2013 to 2015 and who were 14 to 25 years old. Individuals with ASD ( n = 4123) were compared with peers with attention-deficit/hyperactivity disorder ( n = 20 615), diabetes mellitus ( n = 2156), and typical controls with neither condition ( n = 20 615). Over one-third (34%) of individuals with ASD had a co-occurring psychiatric condition; the most commonly reported medical conditions included infections (42%), obesity (25%), neurologic conditions (18%), allergy and/or immunologic conditions (16%), musculoskeletal conditions (15%), and gastrointestinal (11%) conditions. After controlling for sex, age, race, and duration of Kaiser Permanente Northern California membership, most psychiatric conditions were significantly more common in the ASD group than in each comparison group, and most medical conditions were significantly more common in the ASD group than in the attention-deficit/hyperactivity disorder and typical control groups but were similar to or significantly less common than the diabetes mellitus group. Although more research is needed to identify factors contributing to this excess burden of disease, there is a pressing need for all clinicians to approach ASD as a chronic health condition requiring regular follow-up and routine screening and treatment of medical and psychiatric issues. Copyright © 2018 by the American Academy of Pediatrics.
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The Risk of Dupuytren Diagnosis in Obese Individuals.
Hacquebord, Jacques H; Chiu, Vicki Y; Harness, Neil G
2017-03-01
Dupuytren disease is a common benign fibroproliferative disorder causing thickening and shortening of the palmar fascia of the hand. The exact etiology of the disease is unclear but known risk factors such as increased age, male sex, and northern European ethnicity have been established. A link between body mass index (BMI) and Dupuytren disease has not been established previously. The purpose of this study was to test the hypothesis that lower BMI is associated with increased risk for Dupuytren disease diagnosis. After we obtained institutional review board approval, we performed a retrospective review using an electronic medical record and an administrative database from Kaiser Permanente Southern California to identify all enrolled patients there between 2007 and 2014 who were diagnosed with Dupuytren disease. Basic demographic data including age, sex, ethnicity, and BMI were collected. Bivariate and multivariable logistical regression analyses were performed to evaluate for associations between Dupuytren disease and BMI. A total of 2,049,803 patients aged 18 years and older were enrolled in Kaiser Permanente Southern California from 2007 to 2014. During that period, 14,844 patients were identified as having Dupuytren disease. The data were consistent with well-defined demographic trends in Dupuytren disease, with increased rates seen in males, Caucasians, and patients aged 50 years and older. In the multivariable analysis, when controlling for age, race, and sex, the risk of Dupuytren disease was inversely proportional to BMI. The current study showed that higher BMI is associated with decreased odds of having Dupuytren disease. Further work will be required to determine the cause for the apparent relationship between Dupuytren disease and BMI and whether physiologic factors related to obesity may be protective against the development of Dupuytren disease. Prognostic II. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All
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The Effect of Guided Care Teams on the Use of Health Services
Boult, Chad; Reider, Lisa; Leff, Bruce; Frick, Kevin D.; Boyd, Cynthia M.; Wolff, Jennifer L.; Frey, Katherine; Karm, Lya; Wegener, Stephen T.; Mroz, Tracy; Scharfstein, Daniel O.
2015-01-01
Background The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multimorbid older patients’ use of health services. Methods Eligible patients from 3 health care systems in the Baltimore, Maryland–Washington, DC, area were cluster-randomized to receive guided care or usual care for 20 months between November 1, 2006, and June 30, 2008. Eight services of a guided care nurse working in partnership with patients’ primary care physicians were provided: comprehensive assessment, evidence-based care planning, monthly monitoring of symptoms and adherence, transitional care, coordination of health care professionals, support for self-management, support for family caregivers, and enhanced access to community services. Outcome measures were frequency of use of emergency departments, hospitals, skilled nursing facilities, home health agencies, primary care physician services, and specialty physician services. Results The study included 850 older patients at high risk for using health care heavily in the future. The only statistically significant overall effect of guided care in the whole sample was a reduction in episodes of home health care (odds ratio, 0.70; 95% confidence interval, 0.53–0.93). In a preplanned analysis, guided care also reduced skilled nursing facility admissions (odds ratio, 0.53; 95% confidence interval,0.31–0.89) and days (0.48; 0.28–0.84) among Kaiser-Permanente patients. Conclusions Guided care reduces the use of home health care but has little effect on the use of other health services in the short run. Its positive effect on Kaiser-Permanente patients’ use of skilled nursing facilities and other health services is intriguing. Trial Registration clinicaltrials.gov Identifier: NCT00121940 PMID:21403043
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Code-based Diagnostic Algorithms for Idiopathic Pulmonary Fibrosis. Case Validation and Improvement.
Ley, Brett; Urbania, Thomas; Husson, Gail; Vittinghoff, Eric; Brush, David R; Eisner, Mark D; Iribarren, Carlos; Collard, Harold R
2017-06-01
Population-based studies of idiopathic pulmonary fibrosis (IPF) in the United States have been limited by reliance on diagnostic code-based algorithms that lack clinical validation. To validate a well-accepted International Classification of Diseases, Ninth Revision, code-based algorithm for IPF using patient-level information and to develop a modified algorithm for IPF with enhanced predictive value. The traditional IPF algorithm was used to identify potential cases of IPF in the Kaiser Permanente Northern California adult population from 2000 to 2014. Incidence and prevalence were determined overall and by age, sex, and race/ethnicity. A validation subset of cases (n = 150) underwent expert medical record and chest computed tomography review. A modified IPF algorithm was then derived and validated to optimize positive predictive value. From 2000 to 2014, the traditional IPF algorithm identified 2,608 cases among 5,389,627 at-risk adults in the Kaiser Permanente Northern California population. Annual incidence was 6.8/100,000 person-years (95% confidence interval [CI], 6.1-7.7) and was higher in patients with older age, male sex, and white race. The positive predictive value of the IPF algorithm was only 42.2% (95% CI, 30.6 to 54.6%); sensitivity was 55.6% (95% CI, 21.2 to 86.3%). The corrected incidence was estimated at 5.6/100,000 person-years (95% CI, 2.6-10.3). A modified IPF algorithm had improved positive predictive value but reduced sensitivity compared with the traditional algorithm. A well-accepted International Classification of Diseases, Ninth Revision, code-based IPF algorithm performs poorly, falsely classifying many non-IPF cases as IPF and missing a substantial proportion of IPF cases. A modification of the IPF algorithm may be useful for future population-based studies of IPF.
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Nelson, Ian R; Chen, Jason; Love, Rebecca; Davis, Brent R; Maletis, Gregory B; Funahashi, Tadashi T
2016-03-01
Anterior cruciate ligament reconstructions (ACLRs) in skeletally immature patients are increasing. The purpose of this study is to describe the demographics, graft usage, revision, and re-operation rates in skeletally immature ACLRs in the Kaiser Permanente healthcare system. Skeletally immature patients (<17.0 years old with open physes) were identified using the Kaiser Permanente ACLR registry. Multi-ligament reconstructions and physeal-sparing ACLRs were excluded. Aseptic revision and same-knee re-operation were the outcomes of interest. Exposure of interest was graft type; bone-patellar-tendon-bone (BPTB) autograft, hamstring autograft, and any type of allograft. Age, gender, body mass index (BMI), and race were evaluated as confounders. Cox proportional hazard models stratified by surgeon were used to analyse the risk of revision and re-operation. A total of 534 primary ACLR cases were evaluated with a mean follow-up of 2.9 years. The majority were hamstring autografts (n = 388, 72.7%), male (n = 339, 63.9%), and White (n = 232, 43.4%). Median age was 14.9 years, and median BMI was 21.9 kg/m(2). There were 44 (8.2%) aseptic revisions and 48 (9.0%) same-knee re-operations. The incidence rate for revision was BPTB autograft 5.5%, hamstring autograft 7.5%, and allograft 13.2%. After adjusting for confounders and surgeon clustering effect, the risk of aseptic revision and revision between allograft and hamstring autograft did not reach statistical significance. Graft selection differs in skeletally immature patients with a preponderance of surgeries being performed with hamstring tendon autografts. High revision rates were identified for all graft types used, though differences in revision rates across different graft types did not reach statistical significance. Surgeons should be aware of high rates of revision in this skeletally immature young population, although type of graft used did not appear to make a difference. III.
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Gupta, Nigel; Kiley, Mary Lou; Anthony, Faith; Young, Charlie; Brar, Somjot; Kwaku, Kevin
2016-03-09
The purpose of this study is to describe key elements, clinical outcomes, and potential uses of the Kaiser Permanente-Cardiac Device Registry. This is a cohort study of implantable cardioverter defibrillators (ICD), pacemakers (PM), and cardiac resynchronization therapy (CRT) devices implanted between January 1, 2007 and December 31, 2013 by ≈400 physicians in 6 US geographical regions. Registry data variables, including patient characteristics, comorbidities, indication for procedures, complications, and revisions, were captured using the healthcare system's electronic medical record. Outcomes were identified using electronic screening algorithms and adjudicated via chart review. There were 11 924 ICDs, 33 519 PMs, 4472 CRTs, and 66 067 leads registered. A higher proportion of devices were implanted in males: 75.1% (ICD), 55.0% (PM), and 66.7% (CRT), with mean patient age 63.2 years (ICD), 75.2 (PM), and 67.2 (CRT). The 30-day postoperative incidence of tamponade, hematoma, and pneumothorax were ≤0.3% (ICD), ≤0.6% (PM), and ≤0.4% (CRT). Device failures requiring revision occurred at a rate of 2.17% for ICDs, 0.85% for PMs, and 4.93% for CRTs, per 100 patient observation years. Superficial infection rates were <0.03% for all devices; deep infection rates were 0.6% (ICD), 0.5% (PM), and 1.0% (CRT). Results were used to monitor vendor-specific variations and were systematically shared with individual regions to address potential variations in outcomes, utilization, and to assist with the management of device recalls. The Kaiser Permanente-Cardiac Device Registry is a robust tool to monitor postprocedural patient outcomes and postmarket surveillance of implants and potentially change practice patterns. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
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Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott
2016-01-01
Background The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals while creating financial incentives for quality improvement and fostering increased transparency. Limited information is available comparing hospital performance across healthcare business models. Study Design 2015 hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Results Of 3089 hospitals with Total Performance Scores (TPS), categories of representative healthcare business models included 104 Physician-owned Surgical Hospitals (POSH), 111 University HealthSystem Consortium (UHC), 14 US News & World Report Honor Roll (USNWR) Hospitals, 33 Kaiser Permanente, and 124 Pioneer Accountable Care Organization affiliated hospitals. Estimated mean TPS for POSH (64.4, 95% CI 61.83, 66.38) and Kaiser (60.79, 95% CI 56.56, 65.03) were significantly higher compared to all remaining hospitals while UHC members (36.8, 95% CI 34.51, 39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included POSH (mean 2.32, p<0.0001), USNWR honorees (mean 2.24, p 0.0140) and UHC members (mean =1.99, p<0.0001) while Kaiser Permanente hospitals had lower case mix value (mean =1.54, p<0.0001). Re-estimation of TPS did not change the original results after adjustment for differences in hospital case mix index. Conclusions The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals may guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals. PMID:27502368
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Nurse Knowledge Exchange Plus: Human-Centered Implementation for Spread and Sustainability.
Lin, Mike; Heisler, Scott; Fahey, Linda; McGinnis, Juli; Whiffen, Teri L
2015-07-01
Kaiser Permanente implemented a new model of nursing communication at shift change-in the bedside nursing report known as the Nurse Knowledge Exchange (NKE) in 2004-but noted variations in its spread and sustainability across medical centers five years later. The six core elements of NKEplus were as follows: team rounding in the last hour before shift changes, pre-shift patient assignments that limit the number of departing nurses at shift change, unit support for uninterrupted bedside reporting, standardization for report and safety check formats, and collaboration with patients to update in-room care boards. In January 2011 Kaiser Permanente Southern California (KPSC; Pasadena) began implementing NKEplus in 125 nursing units across 14 hospitals, with the use of human-centered design principles: creating shared understanding of the need for change, minimum specifications, and customization by frontline staff. Champion teams on each nursing unit designed and pilot tested unit-specific versions of NKEplus for four to eight weeks. Implementation occurred in waves and proceeded from medical/surgical units to specialty units. Traditional performance improvement strategies of accountability, measurement, and management were also applied. By the end of 2012, 100% of the 64 medical/surgical units and 47 (77.0%) of the 61 specialty units in KPSC medical centers implemented NKEplus-as had all but 1 of the specialty units by May 2013. The mean KPSC score on the NKEplus nursing behavior bundle improved from 65.9% in 2010 to 71.3% in the first quarter of 2014. The mean KPSC Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score for nurse communication improved from 73.1% in 2010 to 76.4% in the first quarter of 2014 (p < . 001). Human-centered implementation appeared to help spread a new model of nursing handoffs and change the culture of professional nursing practice related to shift change.
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Richter, Jack; McFarland, Lela; Bredfeldt, Christine
2012-01-01
Background/Aims Integrating data across systems can be a daunting process. The traditional method of moving data to a common location, mapping fields with different formats and meanings, and performing data cleaning activities to ensure valid and reliable integration across systems can be both expensive and extremely time consuming. As the scope of needed research data increases, the traditional methodology may not be sustainable. Data Virtualization provides an alternative to traditional methods that may reduce the effort required to integrate data across disparate systems. Objective Our goal was to survey new methods in data integration, cloud computing, enterprise data management and virtual data management for opportunities to increase the efficiency of producing VDW and similar data sets. Methods Kaiser Permanente Information Technology (KPIT), in collaboration with the Mid-Atlantic Permanente Research Institute (MAPRI) reviewed methodologies in the burgeoning field of Data Virtualization. We identified potential strengths and weaknesses of new approaches to data integration. For each method, we evaluated its potential application for producing effective research data sets. Results Data Virtualization provides opportunities to reduce the amount of data movement required to integrate data sources on different platforms in order to produce research data sets. Additionally, Data Virtualization also includes methods for managing “fuzzy” matching used to match fields known to have poor reliability such as names, addresses and social security numbers. These methods could improve the efficiency of integrating state and federal data such as patient race, death, and tumors with internal electronic health record data. Discussion The emerging field of Data Virtualization has considerable potential for increasing the efficiency of producing research data sets. An important next step will be to develop a proof of concept project that will help us understand to benefits
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Eaton, Abigail; Lewis, Ned; Fireman, Bruce; Hansen, John; Baxter, Roger; Gee, Julianne; Klein, Nicola P
2018-05-03
Following the H1N1 influenza pandemic in 2009, pregnant women were recommended to receive both seasonal (TIV) and H1N1 influenza vaccines. This study presents incidence of adverse birth and pregnancy outcomes among a population of pregnant women immunized with TIV and H1N1 vaccines at Kaiser Permanente Northern California during 2009-2010. We telephone surveyed pregnant Kaiser Permanente Northern California members to assess non-medically-attended reactions following H1N1, TIV or both vaccines during 2009-2010 (n=5365) in a separate study. Here we assessed preterm birth (<37weeks), very preterm birth (<32weeks), low birth weight (<2500 g, LBW), very low birth weight (<1500g), small for gestational age, spontaneous abortions, stillbirths and congenital anomalies among this cohort by comparing incidence and 95% confidence intervals between the following immunization groups: TIV only, H1N1 only, H1N1 prior to TIV immunization, TIV prior to H1N1 and both immunizations given at the same time. Results did not vary significantly between groups. Comparing H1N1 with TIV, incidence were similar for preterm births (6.37vs 6.28/100 births), very preterm births (5.30vs 8.29/1000 births), LBW (4.19vs 2.90/100 births), very LBW (4.54vs 5.52/1000 births), small for gestational age (9.99vs 9.24/1000 births), spontaneous abortion (7.10vs 6.83/1000 pregnancies), stillbirths (7.10vs 4.57/1000 pregnancies), and congenital anomalies (2.66vs 2.43/100 births). Although constrained by small sample size, complex vaccine groups, and differential vaccine availability during 2009-2010, this study found no difference in adverse birth outcomes between H1N1 vaccine and TIV. Copyright © 2017 Elsevier Ltd. All rights reserved.
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Harrold, Leslie R.; Salman, Craig; Shoor, Stanford; Curtis, Jeffrey R.; Asgari, Maryam M.; Gelfand, Joel M.; Wu, Jashin J.; Herrinton, Lisa J.
2017-01-01
Objective Few studies based in well-defined North American populations have examined the occurrence of juvenile idiopathic arthritis (JIA), and none has been based in an ethnically diverse population. We used computerized healthcare information from the Kaiser Permanente Northern California membership to validate JIA diagnoses and estimate the incidence and prevalence of the disease in this well-characterized population. Methods We identified children aged ≤ 15 years with ≥ 1 relevant International Classification of Diseases, 9th edition, diagnosis code of 696.0, 714, or 720 in computerized clinical encounter data during 1996–2009. In a random sample, we then reviewed the medical records to confirm the diagnosis and diagnosis date and to identify the best-performing case-finding algorithms. Finally, we used the case-finding algorithms to estimate the incidence rate and point prevalence of JIA. Results A diagnosis of JIA was confirmed in 69% of individuals with at least 1 relevant code. Forty-five percent were newly diagnosed during the study period. The age- and sex-standardized incidence rate of JIA per 100,000 person-years was 11.9 (95% CI 10.9–12.9). It was 16.4 (95% CI 14.6–18.1) in girls and 7.7 (95% CI 6.5–8.9) in boys. The peak incidence rate occurred in children aged 11–15 years. The prevalence of JIA per 100,000 persons was 44.7 (95% CI 39.1–50.2) on December 31, 2009. Conclusion The incidence rate of JIA observed in the Kaiser Permanente population, 1996–2009, was similar to that reported in Rochester, Minnesota, USA, but 2 to 3 times higher than Canadian estimates. PMID:23588938
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Chan, Leighton; Wang, Hua; Terdiman, Joe; Hoffman, Jeanne; Ciol, Marcia A; Lattimore, Bernadette Ford; Sidney, Steven; Quesenberry, Charles; Lu, Qi; Sandel, M Elizabeth
2009-11-01
To examine whether there are disparities in utilization of outpatient and home care services after stroke. Retrospective cohort study. The Kaiser Permanente of Northern California health care system, which provides health care for approximately 3.3 million members. A total of 11,119 patients hospitalized for a stroke between 1996 and 2003 and followed for 1 year. Receipt of outpatient rehabilitation (physical therapy, occupational therapy, speech pathology, or physical medicine and rehabilitation/physiatry visits), and/or home health care. There were significant differences in outpatient rehabilitation visits and home health enrollment during the year after acute care discharge for all the parameters under study. Older age and female gender were associated with less outpatient rehabilitation treatment, but these subpopulations were more likely to be enrolled in home health care. Non-whites, patients from urban areas, those with ischemic strokes, and those with longer acute care hospital stays had relatively more outpatient rehabilitation and were also more likely to be enrolled in the home health program. In addition, patients living in geographic areas with a median household income of $80,000 or more had significantly more outpatient rehabilitation visits than did patients living in lower income areas. Variations in outpatient rehabilitation visits and in home health care exist in this large integrated health system in terms of age, gender, race/ethnicity, residence area, type of stroke, and length of stay in an acute care hospital. The Kaiser Permanente integrated health care system seems to have outpatient stroke rehabilitation and home health programs that are providing care without disparities in relation to non-white populations, but other disparities appear to exist that may be related to socioeconomic factors, referral patterns, family support systems, or other cultural factors that have not been identified.
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Descompresión microvascular en espasmo hemifacial: Reporte de 13 casos y revisión de la literatura
Campero, Alvaro; Herreros, Isabel Cuervo-Arango; Barrenechea, Ignacio; Andjel, Germán; Ajler, Pablo; Rhoton, Albert
2016-01-01
Objetivo: El propósito del presente trabajo es presentar los resultados de 13 pacientes con diagnóstico de espasmo hemifacial (EHF), en los cuales se realizó una descompresión microvascular (DMV). Material y Método: Desde Junio de 2005 a Mayo de 2014, 13 pacientes con diagnóstico de EHF fueron intervenidos quirúrgicamente, realizando una DMV. Se evaluó: edad, sexo, tiempo de evolución de la sintomatología, hallazgos intraoperatorios y resultados postoperatorios. Resultados: De los 13 pacientes intervenidos, 7 fueron mujeres y 6 varones. La media de edad fue de 53 años. El tiempo medio entre el inicio de la sintomatología y la intervención quirúrgica osciló entre 3 y 9 años. En todos los casos el EHF era típico, uno de ellos con neuralgia trigeminal concomitante, observándose en todos compresión neurovascular intraoperatoria. Por orden decreciente de frecuencia la causa de la compresión fue arteria cerebelosa anteroinferior, arteria cerebelosa posteroinferior, arteria dolicomega basilar y arteria dolicomega vertebral. El seguimiento postoperatorio fue en promedio de 24 meses. El 62% presentó desaparición postquirúrgica inmediata de la sintomatología preoperatoria, el 30% desaparición tras un período de 3 semanas a 2 meses (8% con mejoría parcial), y en el 8% no hubo mejoría. En cuanto a las complicaciones postoperatorias: 3 pacientes presentaron paresia facial II-III en la escala de House-Brackman (se recuperaron en un período de 6 meses), y 1 paciente presentó fístula de líquido cefalorraquídeo. Ninguno de los pacientes de la serie presentaron hipoacusia transitorio o permanente. Conclusión: La DMV como tratamiento del EHF es un procedimiento efectivo y seguro, que permite la resolución completa de la patología en la mayoría de los casos. PMID:27127708
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Wilson, Jennifer T.; Van Metre, Peter C.; Werth, Charles J.; Yang, Yanning
2006-01-01
A previous study by the U.S. Geological Survey of impaired water bodies in Fort Worth, Texas, reported elevated but variable concentrations of particle-associated contaminants (PACs) comprising chlorinated hydrocarbons, polycyclic aromatic hydrocarbons, and trace elements in suspended and bed sediment of lakes and streams affected by urban land use. The U.S. Geological Survey, in cooperation with the City of Fort Worth, collected additional samples during October 2004 to investigate sources of PACs in the watersheds of two impaired lakes: Lake Como and Fosdic Lake. Source materials and aquatic sediment were sampled and analyzed for PACs. Source materials sampled consisted of street dust and soil from areas with residential and commercial land use and parking lot dust from sealed and unsealed parking lots. Aquatic sediment sampled consisted of bottom-sediment cores from the two lakes and suspended and streambed sediment from the influent stream of each lake. Samples were analyzed for chlorinated hydrocarbons (organochlorine pesticides and polychlorinated biphenyls), polycyclic aromatic hydrocarbons, major and trace elements, organic carbon, grain size, and radionuclides.
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Successful Practices in the Use of Secure E-mail
Johnson, Laura W; Garrido, Terhilda; Christensen, Kate; Handley, Matt
2014-01-01
Physician use of secure e-mail with patients is anticipated to increase under Stage 2 Meaningful Use requirements, but little is known about how physicians can successfully incorporate it into daily work. We interviewed 27 “super user” physicians at Kaiser Permanente and Group Health who were identified by leaders as being technologically, operationally, and clinically adept and as having high levels of secure e-mail use with patients. They highly valued the use of secure e-mail with patients, despite concerns about a lack of adequate time to respond, and provided tips for using it successfully. They identified benefits that included better care and improved relationships with their patients. PMID:24937149
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Zeitspiel ist keine Alternative - Warum der Wandel zur Pflicht wird
NASA Astrophysics Data System (ADS)
Dieper, Stephan
"Wege entstehen dadurch, dass man sie geht." (Franz Kafka) Die Welt der Digitalisierung ist voll von Wegen, die jemand gegangen ist, bevor dort ein Weg war. Manche dieser Wege stellten sich als Sackgasse heraus, manche als Abkürzung und aus anderen wurden ganze Wegenetze und Städte. Die Energiewelt wird durch den digitalen Wandel nicht verschont bleiben. Durch die intelligenten Messsysteme und die zugehörigen, neuen Strukturen werden energiefremden Wettbewerbern Chancen zum Markteintritt eröffnet. EVUs müssen sich darauf einstellen, dass der permanente Wandel nicht mehr enden wird. Doch auch den EVUs eröffnen sich Optionen. Um erfolgreich zu sein, müssen sie lernen loszugehen, ohne das genaue Ziel zu kennen.
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Career ladder program for registered nurses in ambulatory care.
Nelson, Joan; Sassaman, Becky; Phillips, Alison
2008-01-01
RN ladder programs are designed to inspire and reward clinical excellence. Kaiser Permanente Colorado's (KPCO) career ladder program emerged as a result of a labor-management partnership. Career ladder point assignments are reflective of the organization's priorities and values. KPCO's career ladder point tool awards RNs for formal and continuing education, professional presentations, organizational experience and experience as an RN, certifications and active professional memberships, leadership activities, research and publications, and nursing-related volunteer work. Participation in the RN career ladder requires that the nurse achieve a self-determined, manager-approved, measurable goal that will improve patient care. Career ladder nurses at KPCO were significantly more involved in leadership and interdisciplinary activities, quality improvement projects, and preceptorship.
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Calderon, Iracema Mp
2015-01-01
This review aims to develop a critical and current analysis of the basic structure of a Postgraduate program for proposing improvement actions and new evaluation criteria. To examine the items that are areas of concentration (AC), research lines (LP), research projects (PP), curricular structure and fundraising were consulted the Area Document, the 2013 Evaluation Report and the Assessment Sheets of Medicine III programs, evaluated in the 2010-2012 period. Consistency is recommended especially among AC, LP and PP, with genuine link between activities and permanent teachers skills and based on structured curriculum in the education of the student. The Program Proposal interfere, and much, in qualifying a program. The curriculum should provide subsidy to the formation of the researcher, through the core subjects, and development of PP, being the concept of disciplines to support lines and research projects. Fundraise should be set out in research projects and in the CV-Lattes. The area recommended that at least 40-50% of permanent teachers present fundraising and the minimum 20-25% of these teachers to have productivity scholarship PQ / CNPq during the triennium. It is necessary to promote wide discussion and find a consensus denominator for these issues. The actions should contribute to the improvement of evaluation forms and certainly for the qualification of the programs but graduate. Essa revisão tem como objetivo elaborar uma análise crítica e atual da estrutura básica de um programa de Pós-Graduação para a proposição de ações de aperfeiçoamento e novos critérios de avaliação. Para analisarem-se os itens áreas de concentração (AC), linhas de pesquisa (LP), projetos de pesquisa (PP), estrutura curricular e captação de recursos/fomentos foram consultados o documento de área, o relatório de avaliação 2013 e as fichas de avaliação dos programas da Medicina III, avaliados no triênio 2010-2012. A coerência é recomendada especialmente entre
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Neumann, M E
1999-01-01
The goals are simple: Improve well-being of the dialysis patient and reduce hospitalizations. The tools are diverse: Ultrapure dialysate. On-line blood monitoring. Biocompatible membranes. No reuse. Daily, in-center dialysis and possibly nocturnal dialysis at home. Reimbursement: Full-risk capitation, With Medicare and commercial payor rates varying on a patient-by-patient basis. Create an incubator with approximately 1,000 end-stage renal disease patients, treated at both capitated payment-exclusive dialysis units and mingled in at traditional fee-for-service clinics. Establish a team of nurses and renal care staff to direct the care plan, and put the program in place. After the first year, analyze the data and see if the end--hopefully, improved outcomes and resulting reduced hospitalizations--justifies the means--the higher cost for "optimal technologies."
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Greenlick, M R; Freeborn, D K
1986-01-01
This article explores the potential for collaboration between investigators in institutions outside of the VA and those engaged in research within the VA. The focus is on the potential for collaborative work in health services research; our perspective is that of researchers in a freestanding HMO research center affiliated with the Veterans Administration's Northwest Health Services Research and Development Field Program. The paper begins with a review of the reasons that make collaboration between VA researchers and other health services researchers so appropriate at this time. An example of collaboration is presented, drawing on the experience of the Northwest Field Program and the Kaiser Permanente Center for Health Research. Finally, some difficulties inherent in collaboration between VA and other health services researchers are discussed. PMID:3512485
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Use of electronic health records can improve the health care industry's environmental footprint.
Turley, Marianne; Porter, Catherine; Garrido, Terhilda; Gerwig, Kathy; Young, Scott; Radler, Linda; Shaber, Ruth
2011-05-01
Electronic health records have the potential to improve the environmental footprint of the health care industry. We estimate that Kaiser Permanente's electronic health record system, which covers 8.7 million beneficiaries, eliminated 1,000 tons of paper records and 68 tons of x-ray film, and that it has lowered gasoline consumption among patients who otherwise would have made trips to the doctor by at least three million gallons per year. However, the use of personal computers resulted in higher energy consumption and generated an additional 250 tons of waste. We conclude that electronic health records have a positive net effect on the environment, and that our model for evaluating their impact can be used to determine whether their use can improve communities' health.
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Como Lo Hago Yo: Lipomas Medulares
Portillo, Santiago
2014-01-01
Basados en la experiencia de 82 casos; en 5% se observaron anomalías pélvicas asociadas. En los menores de 3 años el motivo de consulta (85%) fue la tumoración. En los mayores de 3 años (42%) tenía problemas neurológicos. Solo el 24% preocupados por la tumoración. El objetivo de la cirugía es desanclar la médula y no remover la totalidad del lipoma. El lipoma de filum es el que es mas simple para operar. Aún cuando la escuela francesa propone operar solamente cuando hay síntomas favorezco cirugía preventiva. Favorezco una segunda cirugía si hay signos de anclaje postoperatorio, aún cuando observamos empeoramiento postoperatorio motor en 2.5% de los operados y urológico a largo plazo en 6% de los operados. PMID:24791218
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Does the diagnosis of breast or ovarian cancer trigger referral to genetic counseling?
Powell, C Bethan; Littell, Ramey; Hoodfar, Elizabeth; Sinclair, Fiona; Pressman, Alice
2013-03-01
Kaiser Permanente Northern California is a large integrated health care delivery system in the United States that has guidelines for referring women with newly diagnosed BRCA1-and BRCA2-associated cancers for genetic counseling. This study assesses adherence to genetic counseling referral guidelines within this health system. Chart review was performed to identify patients with cancer who met the following pathology-based Kaiser Permanente Northern California guidelines for referral for genetic counseling: invasive breast cancer, younger than age 40; nonmucinous epithelial ovarian, fallopian tube, or peritoneal cancer, younger than age 60; women with synchronous or metachronous primary cancers of the breast and ovaries; and male breast cancer. We assessed compliance with referral guidelines. An electronic notice was sent to the managing physician of patients with newly diagnosed cancer to assess the feasibility of this intervention. A total of 340 patients were identified with breast cancer at younger than age 40 or with ovarian, peritoneal, or tubal cancer between January and June, 2008. Upon chart review, 105 of these patients met pathology-based criteria for referral to genetic counseling, of whom 47 (45%) were referred within the 2-year study period. Of the 67 subjects with breast cancer, 40 subjects (60%) were referred. In contrast, only 7 (21%) of 33 patients with ovarian cancer were referred (P < 0.001). A pilot study was performed to test the feasibility of notifying managing oncologists with an electronic letter alerting them of eligibility for genetic referral of patients with new diagnosis (n = 21). In the 3 to 6 months after this notification, 12 of these 21 patients were referred for counseling including 5 of 7 patients with a diagnosis of ovarian cancer. There is a missed opportunity for referring patients to genetic counseling, especially among patients with ovarian cancer. A pilot study suggests that alerting treating physicians is a feasible
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Prevention of Vertical Transmission of Hepatitis B: An Observation Study
Kubo, Ai; Shlager, Lyle; Marks, Amy R.; Lakritz, Dena; Beaumont, Colette; Gabellini, Kim; Corley, Douglas A.
2014-01-01
Background For mothers with chronic hepatitis B virus (HBV) infection, the US Centers for Disease Control recommend immunoprophylaxis to decrease perinatal transmission; however, its effectiveness and risk factors for failure have not been well studied in community practice. Objective To investigate the effectiveness of a contemporary immunoprophylaxis protocol. Design Observational study. Setting HBV perinatal immunoprophylaxis program within Kaiser Permanente Northern California, an integrated health services delivery organization. Patients 4,446 infants born to 3,253 HBV positive mothers, between 1997-2010. Measurements Compliance with immunoprophylaxis, follow-up testing rates, maternal risk factors for HBV transmission and transmission rates. Results The infant infection rate was 0.75 per 100 births for 1997-2010 (Poisson 95% confidence interval (CI): 0.48-1.10)]. Rates were 3.37 per 100 (95% CI 2.08-5.14) for e-antigen positive mothers; and 0.04 (95% CI 0.001-0.24) for e-antigen negative mothers. Among mothers with viral load testing, the lowest level associated with transmission was 63,200,000 IU/ml. Infection rates per 100 were 3.61 (95% CI 0.75-10.56) among the 83 births to mothers with viral loads ≥50,000,000 IU/mL and 0.00 among the 831 births to mothers with viral loads <50,000,000 IU/mL, regardless of e-antigen status. Limitations Testing for HBV immunity and infection was somewhat less complete in earlier years. Viral load testing was only consistently available starting in 2007. Conclusion Pre-natal HBV screening followed by post-natal prophylaxis is highly effective in preventing vertical transmission of HBV. A negative e-antigen status or a viral load of <50,000,000 IU/mL (90.9% of women tested) identifies women at extremely low risk of transmission after immunoprophylaxis who are unlikely to benefit from further interventions. Primary Funding Source Kaiser Permanente Community Benefit Grant (CN-09LShla-01-H); National Institute of Health (K07CA
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Manual dexterity aptitude testing: a soap carving study.
Tang, Christopher G; Hilsinger, Raymond L; Cruz, Raul M; Schloegel, Luke J; Byl, Fred M; Rasgon, Barry M
2014-03-01
Currently there are few validated metrics for predicting surgical skill among otolaryngology residency applicants. To determine whether manual dexterity aptitude testing in the form of soap carving during otolaryngology residency interviews at Kaiser Permanente Medical Center Oakland predicts surgical skill at the time of graduation from otolaryngology residency programs. This study was conducted to determine how applicants with the best and worst soap carvings compared at the time of graduation with respect to various metrics including visuospatial ability and manual dexterity. Over the last 25 years, applicants to the residency program at Kaiser Permanente Oakland were required to carve soap during their residency interview. The 3 best and 3 worst soap carvings from 1990 through 2006 were determined. Of the individuals who carved those soaps, 62 qualified for the study and matriculated into otolaryngology residency programs. Surveys were sent to the 62 individuals' residency programs to evaluate those individuals on a 5-point Likert scale in various categories as well as to rank those individuals as being in the top 50% or bottom 50% of their graduating class. All else being equal, we hypothesized that applicants who had the manual dexterity and visuospatial skills to accurately carve a bar of soap would more likely possess the skills necessary to become a good surgeon. There was no difference between individuals with the best soap carvings and those with the worst soap carvings in all categories: cognitive knowledge, visuospatial ability, manual dexterity, decision making, and overall score (P > .10 for all categories). There was a 95% response rate, with 35 of 37 residency programs responding and 59 of 62 surveys returned. Manual dexterity aptitude testing in the form of soap carving does not appear to correlate with surgical skill at the time of graduation. Further studies need to be conducted to determine the role of manual dexterity and visuospatial
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Quinn, Virginia P; Nash, Rebecca; Hunkeler, Enid; Contreras, Richard; Cromwell, Lee; Becerra-Culqui, Tracy A; Getahun, Darios; Giammattei, Shawn; Lash, Timothy L; Millman, Andrea; Robinson, Brandi; Roblin, Douglas; Silverberg, Michael J; Slovis, Jennifer; Tangpricha, Vin; Tolsma, Dennis; Valentine, Cadence; Ward, Kevin; Winter, Savannah; Goodman, Michael
2017-12-27
The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population. A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016. About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%-5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers. STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg, polycythemia and bone density), overall and in relation to
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Quinn, Virginia P; Nash, Rebecca; Hunkeler, Enid; Contreras, Richard; Cromwell, Lee; Becerra-Culqui, Tracy A; Getahun, Darios; Giammattei, Shawn; Lash, Timothy L; Millman, Andrea; Robinson, Brandi; Roblin, Douglas; Silverberg, Michael J; Slovis, Jennifer; Tangpricha, Vin; Tolsma, Dennis; Valentine, Cadence; Ward, Kevin; Winter, Savannah; Goodman, Michael
2017-01-01
Purpose The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population. Participants A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016. Findings to date About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%–5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers. Future plans STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg
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Gugliemetti, G; Sukhu, R; Conca Baenas, M A.; Meeks, J; Sjoberg, D D.; Eastham, J A.; Scardino, P T.; Touijer, K
2017-01-01
Resumen Antecedentes La presencia de metástasis en los ganglios linfáticos (MGL) en la prostatectomía radical de rescate (PRs) se asocia con un mal pronóstico. Los factores predictivos de resultados en este contexto siguen siendo indeterminados. El objetivo fue evaluar el papel de número de ganglios linfáticos positivos sobre el resultado de los pacientes con MGL después de PRs y para el cáncer de próstata de radio-recurrente. Material y métodos Se analizaron los datos de una cohorte consecutiva de 215 hombres tratados con PRr en una sola institución. Se utilizaron los modelos de regresión de riesgos proporcionales de Cox univariante para la recurrencia bioquímica (RBQ) y los resultados metastásicos, con el antígeno prostático específico, la puntuación de Gleason, la extensión extraprostática, la invasión de vesículas seminales, el tiempo entre la terapia de radiación y PRr y el número de ganglios positivos como factores predictivos. Resultados De los 47 pacientes con MGL, 37 desarrollaron RBQ, 11 desarrollaron metástasis a distancia y 4 fallecieron con una mediana de seguimiento de 2,3 años para los supervivientes. El riesgo de metástasis aumentó con mayores niveles preoperatorios de PSA (HR 1,19 por 1 ng/ml; IC del 95%: 1,06, 1,34; p = 0,003). Los factores predictivos restantes no alcanzaron niveles convencionales de significación. Sin embargo, la eliminación de 3 o más ganglios linfáticos positivos demostró una asociación positiva, como se esperaba, con enfermedad metastásica (HR 3,44, IC: 0,91, 13,05; p = 0,069) en comparación con uno o dos ganglios positivos. Del mismo modo, la presencia de extensión extraprostática, invasión de vesículas seminales y grado de Gleason superior a 7 también demostraron una asociación positiva con un mayor riesgo de metástasis, con índices de riesgo de 3,97 (IC del 95% 0,50; 31,4; p = 0,2), 3,72 (IC 95% 0,80, 17,26; p = 0,1) y 1,45 (IC del 95% 0,44, 4,76; p = 0,5), respectivamente
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Maternal Infection during Pregnancy and Autism Spectrum Disorders
Zerbo, Ousseny; Qian, Yinge; Yoshida, Cathleen; Grether, Judith K.; Van de Water, Judy; Croen, Lisa A.
2014-01-01
We conducted a nested case-control study including 407 cases and 2075 frequency matched controls to investigate the association between maternal infections during pregnancy and risk of autism spectrum disorders (ASD). Cases, controls, and maternal infections were ascertained from Kaiser Permanente Northern California clinical databases. No overall association between diagnoses of any maternal infection during pregnancy and ASD (adjusted odds ratio [ORadj] = 1.15, 95% confidence interval [CI] 0.92 – 1.43). However, women with infections diagnosed during a hospital admission (ORadj= 1.48, 95% CI1.07 – 2.04), particularly bacterial infections (ORadj = 1.58, 95% CI 1.06 – 2.37), were at increased risk of delivering a child with ASD. Multiple infections during pregnancy were associated with ASD (ORadj = 1.36, 95% CI 1.05 – 1.78). PMID:24366406
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2014 Hypertension Guideline: Recommendation for a Change in Goal Systolic Blood Pressure
Handler, Joel
2015-01-01
The 2014 Kaiser Permanente Care Management Institute National Hypertension Guideline was developed to assist primary care physicians and other health care professionals in the outpatient treatment of uncomplicated hypertension in adult men and nonpregnant women aged 18 years and older. The new guideline reflects general acceptance, with minor modifications, of the “Evidence-Based Guideline” report by the panel members appointed to the National Heart, Lung, and Blood Institute 8th Joint National Committee. A major practice change is the recommendation for goal systolic blood pressure less than 150 mmHg in patients aged 60 years and older who are treated for hypertension in the absence of diabetes or chronic kidney disease. This article describes the reasons for, evidence for, and consequences of the change, and is followed by the National Guidelines handout. PMID:26057683
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Declining Effectiveness of Herpes Zoster Vaccine in Adults Aged ≥60 Years.
Tseng, Hung Fu; Harpaz, Rafael; Luo, Yi; Hales, Craig M; Sy, Lina S; Tartof, Sara Y; Bialek, Stephanie; Hechter, Rulin C; Jacobsen, Steven J
2016-06-15
Understanding long-term effectiveness of herpes zoster (HZ) vaccine is critical for determining vaccine policy. 176 078 members of Kaiser Permanente ≥60 years vaccinated with HZ vaccine and three matched unvaccinated members were included. Hazard ratios and 95% confidence intervals (CIs) associated with vaccination at each year following vaccination were estimated by Cox regression model. The effectiveness of HZ vaccine decreased from 68.7% (95% CI, 66.3%-70.9%) in the first year to 4.2% (95% CI, -24.0% to 25.9%) in the eighth year. This rapid decline in effectiveness of HZ vaccine suggests that a revaccination strategy may be needed, if feasible. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.
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Teaching-learning evaluation on the ICNP® using virtual learning environment.
Avelino, Carolina Costa Valcanti; Costa, Lívia Cristina Scalon da; Buchhorn, Soraia Matilde Marques; Nogueira, Denismar Alves; Goyatá, Sueli Leiko Takamatsu
2017-01-01
Evaluating the teaching-learning process of undergraduates and nursing professionals on the International Classification for Nursing Practice (ICNP®) through a course on Moodle Platform. Mixed research conducted with 51 nursing students and nurses. Many technological and educational resources were used. To collect data, two semi-structured questionnaires were applied and focus groups were carried out. Statistical and thematic analysis of the data was performed. There was a correlation between the Wiki variable, the Animation Video (p = 0.002) and the Arch Method (p = 0.04), as well as a correlation between the Forum, the Virtual Book (P < 0.001) and time (p = 0.009). Three topics emerged: innovation in the application of technological resources, distance education in the professional education and permanent education and the teaching-learning process on the ICNP® in a collaborative way. Teaching-learning strategies and technological resources used were pointed out as innovative and helped students have a better performance. Avaliar o ensino-aprendizagem de graduandos e profissionais de enfermagem sobre a Classificação Internacional para a Prática de Enfermagem (CIPE®) por meio de um curso na Plataforma Moodle. Pesquisa mista realizada com 51 graduandos de enfermagem e enfermeiros. Utilizaram-se diversos recursos tecnológicos e educacionais. Para a coleta de dados foram aplicados dois questionários semiestruturados e realizados grupos focais. Procedeu-se à análise estatística e temática dos dados. Houve correlação entre a variável Wiki com o Vídeo de Animação (p = 0,002) e com o Método do Arco (p = 0,04) e do Fórum com o Livro Virtual (P < 0,001) e com o tempo (p = 0,009). Três temas emergiram: inovação na aplicação de recursos tecnológicos, educação à distância na formação profissional e educação permanente e o processo de ensino-aprendizagem sobre a CIPE® de forma colaborativa. As estratégias de ensino-aprendizagem e os recursos
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NASA Astrophysics Data System (ADS)
Dcruz, Noella L.
2014-07-01
estudiantes que escribieran dos ensayos cortos de tres que se proponían. Los ensayos contenían partes descriptivas y conceptuales. Los mismos estaban destinados a servir como herramientas de enseñanza. 62% de los 106 ensayos de 55 estudiantes obtuvo grados A, B o C. 21% de los 47 encuestados que respondieron al cuestionario posterior consideró que los ensayos aumentaron su interés por la astronomía. 49% de los encuestados consideró que los ensayos no eran educacionalmente útiles y que no deben ser propuestos de nuevo. Las respuestas escritas más comunes a nuestra encuesta indicaran que los estudiantes necesitan más orientación y una mejor preparación en la redacción de ensayos exitosos. Dado que los estudiantes encontraron las piezas conceptuales de los ensayos difíciles, en el futuro vamos a ofrecer actividades pertinentes antes de los plazos de redacción para ayudar a los estudiantes a crear ensayos de mayor calidad. Nós ocasionalmente incluímos projetos em nosso curso universitário introdutório centrado no aluno para permitir aos estudantes que pertencem às carreiras não científicas explorar alguns conceitos astronômicos em mais detalhes do que o normal. Tais projetos também enfatizam eventos astronômicos em curso ou futuros. Esperamos que os alunos se sintam mais interessados na astronomia através de projetos ligados a eventos astronômicos. No termo de Primavera de 2012 (EUA), propomos ensaios curtos focados em eclipses, trânsitos e ocultações para promover o raro trânsito de Vênus que ocorreu no dia 5 de junho de 2012. Pedimos aos alunos que escrevessem dois ensaios curtos dentre três que foram propostos. Os ensaios continham partes descritivas e conceituais. Eles foram feitos para servir como ferramentas de ensino. 62% de 106 ensaios de 55 alunos ganhou graus A, B ou C. 21% dos 47 entrevistados que responderam ao levantamento posterior sentiu que os ensaios aumentaram seu interesse na astronomia. 49% dos inquiridos consideraram que os
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Habitus furibundo en el gueto estadounidense1
Bourgois, Philippe; Castrillo, Fernando Montero; Hart, Laurie; Karandinos, George
2014-01-01
Resumen Durante cinco años, un torbellino cotidiano de tiroteos, apuñalamientos y asaltos afectó a la venta de drogas al aire libre en el vecindario puertorriqueño de Filadelfia, donde residíamos y conducíamos nuestro trabajo de campo. La industria de los narcóticos ha venido a llenar el vacío que dejó la desindustrialización, convirtiendo al antiguo distrito fabril de la ciudad en un mercado de narcóticos a cielo abierto que emplea en sus niveles más bajos a jóvenes puertorriqueños y cuyos clientes son principalmente heroinómanos blancos de bajos recursos. La capacidad para movilizar la furia asegura el éxito en la economía de las drogas, garantiza protección en las cárceles y le provee un ingreso mínimo a una población de bajos recursos estigmatizada cuyos miembros frecuentemente reciben diagnósticos médicos de discapacidad cognitiva. Muchos residentes buscan alianzas en redes sociales que los comprometen a participar en intercambios solidarios de violencia auxiliar. Una dinámica de acumulación primitiva corporizada mata, hiere, discapacita o encarcela a la mayoría de estos empleados de bajo nivel y a sus clientes. Los inflados márgenes de ganancia alrededor de esta dinámica dependen de la violencia y la coerción. Un habitus furibundo impulsa a los vendedores callejeros a defender violentamente el micro monopolio de poder de sus jefes en la economía subterránea como si fuese un asunto de diversión. Estos miembros de los niveles más bajos de la industria del narcotráfico se apresuran a fraguar transacciones comerciales en ausencia de un marco legal en un ambiente de escasez que sin embargo se ve inundado por enormes flujos de dinero, drogas adictivas y armas automáticas. Tras las drásticas reformas a los programas de seguridad social, la mano izquierda del Estado, en la forma de los servicios sociales, intenta prolongar los subsidios para individuos vulnerables diagnosticándolos como discapacitados cognitivos permanentes
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Quality of Care for Work-associated Carpal Tunnel Syndrome
Nuckols, Teryl; Conlon, Craig; Robbins, Michael; Dworsky, Michael; Lai, Julie; Roth, Carol P.; Levitan, Barbara; Seabury, Seth; Seelam, Rachana; Asch, Steven M.
2017-01-01
Objective To evaluate the quality of care provided to individuals with workers’ compensation claims related to CTS and identify patient characteristics associated with receiving better care. Methods We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects’ medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality. Results Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, gender, and race/ethnicity were not associated with quality. Conclusions Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones. PMID:28045797
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Krall, M. A.; Sittig, D. F.
2001-01-01
There is very little known about the limits of alerting in the setting of the outpatient Electronic Medical Record (EMR). We are interested in how users value and prefer such alerts. One hundred Kaiser Permanente primary care clinicians were sent a four-page questionnaire. It contained questions related to the usability and usefulness of different approaches to presenting reminder and alert information. The survey also contained questions about the desirability of six categories of alerts. Forty-three of 100 questionnaires were returned. Users generally preferred an active, more intrusive interaction model for "alerts" and a passive, less intrusive model for order messages and other types of reminders and notifications. Drug related alerts were more highly rated than health maintenance or disease state reminders. Users indicated that more alerts would make the system "more useful" but "less easy to use". PMID:11825206
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Krall, M A; Sittig, D F
2001-01-01
There is very little known about the limits of alerting in the setting of the outpatient Electronic Medical Record (EMR). We are interested in how users value and prefer such alerts. One hundred Kaiser Permanente primary care clinicians were sent a four-page questionnaire. It contained questions related to the usability and usefulness of different approaches to presenting reminder and alert information. The survey also contained questions about the desirability of six categories of alerts. Forty-three of 100 questionnaires were returned. Users generally preferred an active, more intrusive interaction model for "alerts" and a passive, less intrusive model for order messages and other types of reminders and notifications. Drug related alerts were more highly rated than health maintenance or disease state reminders. Users indicated that more alerts would make the system "more useful" but "less easy to use".
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Yip, Elaine; Karimi, Sahar; Pien, Linda T
2016-04-01
Combination treatment with an inhaled corticosteroid and long-acting beta2-agonist is among the many treatment options for chronic obstructive pulmonary disease (COPD) that has been shown to improve clinical outcomes. While mometasone/formoterol does not currently have an FDA-approved indication for COPD, evidence from 2 phase 3 trials demonstrated that mometasone/formoterol can improve lung function and was well tolerated in patients with moderate-to-very severe COPD. Based on these data, a therapeutic interchange was implemented in the Kaiser Permanente Mid-Atlantic States region to convert patients with a COPD diagnosis from fluticasone/salmeterol to mometasone/formoterol. To evaluate the impact of a therapeutic interchange from fluticasone/salmeterol to mometasone/formoterol on health outcomes in patients with COPD in a large ambulatory and managed care setting. The investigators retrospectively reviewed the electronic medical records of patients with a COPD diagnosis who had a prescription for fluticasone/salmeterol converted to mometasone/formoterol between March 6, 2011, to March 6, 2013. Kaiser Permanente's Pharmacy and Therapeutics Committee provided recommended equivalent doses for conversion from fluticasone/salmeterol to mometasone/formoterol. Nonetheless, the final approval for the change in medication and selection of the dose was left to each physician's clinical judgment. Patients were excluded if they were (a) prescribed fluticasone/salmeterol 100/50 mcg, which has no equivalent mometasone/formoterol dose; (b) less than aged 18 years; or (c) prescribed fluticasone/salmeterol for a duration of less than 6 months preconversion to mometasone/formoterol. In addition, patients who left the Kaiser Permanente network or became deceased during the study period of interest were excluded. After the application of the inclusion and exclusion criteria, 521 patients were included in the data analysis. The primary endpoint was the determination of the difference
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Micoinseticidas e Micoacaricidas no Brasil: Como estamos?
USDA-ARS?s Scientific Manuscript database
Mycoinsecticides and mycoacaricides can be defined as biopesticide products based on living propagules of entomopathogenic fungi developed for inundative and inoculative biological control of insects and mites. Based on recently published data on global use of entomopathogenic fungi and a proposal f...
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Health education with older adults: action research with primary care professionals.
Mendonça, Francielle Toniolo Nicodemos Furtado de; Santos, Álvaro da Silva; Buso, Ana Luisa Zanardo; Malaquias, Bruna Stephanie Sousa
2017-01-01
To assess the development and implementation of permanent education action. Quantitative-qualitative research based on action research in three phases (diagnosis of reality, implementation of activity and evaluation), performed with health professionals and managers of basic health units. The evaluation was on the perception of changes immediately following the activity and after 120 days. In the first phase, 110 professionals took part, 36.4% of whom indicated the existence of groups for older adults at work. In the second phase, 98 professionals participated, pointing out interferences of the group in the life of older adults, items of importance and facilitation in forming groups and developing reality-based activities. The third phase showed, in the quantitative analysis, positive impact of the training, and in the qualitative analysis, reassessment of groups, greater knowledge and confidence in managing groups and increased respect for older adults. Permanent education opens pathways for the construction of differentiated care for older adults based on respect and health promotion. Avaliar o desenvolvimento e implementação de uma ação de educação permanente. Pesquisa quantitativo-qualitativa baseada na pesquisa-ação em 3 fases (diagnóstico da realidade, implementação de atividade e avaliação), realizada com profissionais de saúde e gerentes de unidades básicas. A avaliação se deu pela percepção de mudanças imediatamente à atividade e após 120 dias. Na 1ª fase, participaram 110 profissionais, dos quais 36,4% apontaram a existência de grupos para idosos no trabalho. Na 2ª fase, participaram 98 profissionais, que apontaram interferências do grupo na vida do idoso, itens de importância e facilitação para construção de grupos e atividade baseada na realidade. A 3ª fase mostrou, na análise quantitativa, impacto positivo do treinamento; e, na qualitativa, releitura dos grupos e manejo com mais conhecimento, segurança e respeito ao
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Behrens, Timothy K; Liebert, Mina L; Peterson, Hannah J; Howard Smith, Jennifer; Sutliffe, Jay T; Day, Aubrey; Mack, Jodi
2018-05-01
The purpose of this study is to examine the impact of a districtwide food best practices and preparation changes in elementary schools lunches, implemented as part of the LiveWell@School childhood obesity program, funded by LiveWell Colorado/Kaiser Permanente Community Health Initiative. Longitudinal study examining how school changes in best practices for food preparation impacted the types of side items offered from 2009 to 2015 in elementary school cafeterias in a high-need school district in southern Colorado. Specifically, this study examined changes in side items (fruits, vegetables, potatoes, breads, and desserts). In Phase 1 (2009-2010), baseline data were collected. During Phase 2 (2010-2011), breaded and processed foods (e.g., frozen nuggets, pre-packaged pizza) were removed and school chefs were trained on scratch cooking methods. Phase 3 (2011-2012) saw an increased use of fresh/frozen fruits and vegetables after a new commodity order. During Phase 4 (2013-2015), chef consulting and training took place. The frequency of side offerings was tracked across phases. Analyses were completed in Fall 2016. Because of limited sample sizes, data from Phases 2 to 4 (intervention phases) were combined for potatoes and desserts. Descriptive statistics were calculated. After adjusting for length of time for each phase, Pearson chi-square tests were conducted to examine changes in offerings of side items by phase. Fresh fruit offerings increased and canned fruit decreased in Phases 1-4 (p=0.001). A significant difference was observed for vegetables (p=0.001), with raw and steamed vegetables increasing and canned vegetables decreasing from Phase 1 to 4. Fresh potatoes (low in sodium) increased and fried potatoes (high in sodium) decreased from Phase 1 to Phases 2-4 (p=0.001). Breads were eliminated entirely in Phase 2, and dessert changes were not significant (p=0.927). This approach to promoting healthier lunch sides is a promising paradigm for improving elementary
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Biokompatible Implantate und Neuentwicklungen in der Gynäkologie
NASA Astrophysics Data System (ADS)
Jacobs, Volker R.; Kiechle, Marion
Für den Einsatz in der Gynäkologie stehen heute eine Vielzahl unterschiedlicher, biokompatibler Materialien und Implantate zur Verfügung. Auf eine Auswahl soll hier näher eingegangen werden, die die verschiedenen Materialien und Bauweisen repräsentieren. So sind Brustimplantate seit fast vier Jahrzehnten im Gebrauch für die Brustvergrösserung und den Brustwiederaufbau. Material, Bauweisen und medizinische Aspekte einschliesslich der kontroversen Diskussion um Silikon werden im folgenden erläutert. Neuere Entwicklungen von Verhütungstechniken für permanente Sterilisation wie den Filshie ClipTM für transabdominalen und den STOPTM für intraluminalen Verschluss der Eileiter oder die intrauterin plazierte Hormonspirale MirenaTM für zeitlich begrenzte Verhütung werden beschrieben. Eine neue Perspektive zur Verhinderung postoperativer intraabdominaler Adhäsionen stellt Spray-GelTM, ein Zweikomponenten Hydrogel aus Polyethylenglykol, dar.
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Data That Drive: Closing the Loop in the Learning Hospital System
Liu, Vincent X.; Morehouse, John W.; Baker, Jennifer M.; Greene, John D.; Kipnis, Patricia; Escobar, Gabriel J.
2017-01-01
The learning healthcare system describes a vision of US healthcare that capitalizes on science, information technology, incentives, and care culture to drive improvements in the quality of health care. The inpatient setting, one of the most costly and impactful domains of healthcare, is an ideal setting in which to use data and information technology to foster continuous learning and quality improvement. The rapid digitization of inpatient medicine offers incredible new opportunities to use data from routine care to generate new discovery and thus close the virtuous cycle of learning. We use an object lesson—sepsis care within the 21 hospitals of the Kaiser Permanente Northern California integrated healthcare delivery system—to offer insight into the critical elements necessary for developing a learning hospital system. We then describe how a hospital-wide data-driven approach to inpatient care can facilitate improvements in the quality of hospital care. PMID:27805797
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Outcomes in Treatment for Intradural Spinal Cord Ependymomas
DOE Office of Scientific and Technical Information (OSTI.GOV)
Volpp, P. Brian; Han, Khanh; Kagan, A. Robert
2007-11-15
Purpose: Spinal cord ependymomas are rare tumors, accounting for <2% of all primary central nervous system tumors. This study assessed the treatment outcomes for patients diagnosed with spinal cord ependymomas within the Southern California Kaiser Permanente system. Methods and Materials: We studied 23 patients treated with surgery with or without external beam radiotherapy (EBRT). The local and distant control rates and overall survival rates were determined. Results: The overall local control, overall recurrence, and 9-year overall survival rate was 96%, 17.4%, and 63.9%, respectively. Conclusions: The results of our study indicate that en bloc gross total resection should be themore » initial treatment, with radiotherapy reserved primarily for postoperative cases with unfavorable characteristics such as residual tumor, anaplastic histologic features, or piecemeal resection. Excellent local control and overall survival rates can be achieved using modern microsurgical techniques, with or without local radiotherapy.« less
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2012-01-01
Background Research suggests that ACEs have a long-term impact on the behavioral, emotional, and cognitive development of children. These disruptions can lead to adoption of unhealthy coping behaviors throughout the lifespan. The present study sought to examine psychological distress as a potential mediator of sex-specific associations between adverse childhood experiences (ACEs) and adult smoking. Method Data from 7,210 Kaiser-Permanente members in San Diego California collected between April and October 1997 were used. Results Among women, psychological distress mediated a significant portion of the association between ACEs and smoking (21% for emotional abuse, 16% for physical abuse, 15% for physical neglect, 10% for parental separation or divorce). Among men, the associations between ACEs and smoking were not significant. Conclusions These findings suggest that for women, current smoking cessation strategies may benefit from understanding the potential role of childhood trauma. PMID:22788356
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NASA Astrophysics Data System (ADS)
Lutz, Vivian A.; Subramaniam, Ajit; Negri, Rubén M.; Silva, Ricardo I.; Carreto, José I.
2006-07-01
Variations in optical properties at a coastal station (EPEA) off the North coast of Argentina (38° 28' S 57° 41' W) were studied in 2000-2001. Changes observed in the absorption by three components of seawater (phytoplankton, detritus, and chromophoric-dissolved-organic-matter or CDOM) were analysed in relation to changes in environmental conditions (temperature, stability of the water column, irradiance) and changes in the phytoplankton community structure. An annual cycle typical of temperate seas was observed in the stability of the water column, with a strong thermocline in summer and a vertically homogeneous regime in winter. The proportion of detritus absorption at the surface was related to these changes in stability of the water column, being larger in winter due probably to re-suspension from the bottom. Absorption by phytoplankton and CDOM were not related to temperature or the stability of the water column and there was no covariation in absorption by the three seawater components. On the other hand, absorption by phytoplankton was significantly related to the predominant cell-size. The percentage contribution of ultraphytoplankton (<5 μm) to total chlorophyll- a concentration varied between 6% and 46% throughout the year, being the highest during summer. Accordingly, the specific absorption coefficient of phytoplankton at 440 nm (absorption/chlorophyll- a) varied between 0.01 in July (when there was a bloom of the large diatom Coscinodiscus wailesii) and 0.09 m 2 mg Chla-1 in February (when Synechococcus spp. was predominant). The relationship between in situ and 1 km daily satellite estimated OC4V4 chlorophyll- a concentration showed a good correlation ( r2=0.94 for 9 out of the 19 data points where an exact match up could be made). Marked variations were observed when comparing 8 day-9 km binned data with the 19 points. While some of the differences are due to the highly dynamic hydrography of this region, variations in phytoplankton composition also contribute to the difference between in situ and satellite-derived values.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Centeno, A.; Laurent, E.; Delmon, B.
1995-07-01
The present work corresponds to part of a program aimed at upgrading oil obtained by pyrolysis of biomass by hydrotreatment (hydrodeoxygenation HDO). CoMo sulfide catalysts, nonsupported, supported on different supports (alumina, carbon, silica), or modified by K or Pt, were used. The authors used a model reacting mixture containing compounds representative of the molecules that must react to permit a primary stabilisation of the pyrolytic oil: 4-methy lacetophenone (4-MA), diethylsebacate (DES), and guaiacol (GUA). In the reaction of the carbonyl group of the 4-MA it is shown that no important role is played by any acid-base mechanism; dispersion determines themore » activity. Acidity of the support influences the formation of active sites for decarboxylation and hydrogenation of the carboxyl group of DES. It was confirmed that guaiacol-type molecules lead to coking reactions. The role of acidity in the mechanism of these reactions is confirmed, but the modifications made in the catalysts in this work are still not sufficient to control coke deposition. The catalysts supported on carbon lead to the direct elimination of the methoxyl group of the guaiacol. Carbon, on the whole, seems to be a promising support. This work suggests that appropriate modifications of the hydrotreating catalysts can lead to a more effective process for stabilisation of the bio-oils by reaction with hydrogen. 55 refs., 3 figs., 5 tabs.« less
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Alprazolam use and dependence. A retrospective analysis of 30 cases of withdrawal.
Dickinson, B; Rush, P A; Radcliffe, A B
1990-01-01
From 1986 to 1989, the Chemical Dependency Recovery Program at Kaiser Permanente Hospital, Fontana, California, admitted an increasing number of patients for alprazolam dependence. Severe withdrawal reactions and adverse consequences with use were reported in the literature. In this review of 30 cases of alprazolam dependence and subsequent withdrawal, there was a statistically significant increase in the number of patient hospital days, the subjective symptoms, and staff time spent with patients compared with those in alcoholic controls. Most patients with diagnosed alprazolam dependence used doses in the range recommended by the package information at the time of admission. Patients with low preadmission doses of 1 mg or less per day showed notable withdrawal symptoms. The average duration of use was 29.9 months, considerably longer than suggested effective ranges. Most patients (28) had a chemical dependence history before being placed on alprazolam therapy; 24 had a positive family history of chemical dependence; and 24 had previous or current psychiatric care. PMID:2349800
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Health and loyalty promotion visits for new enrollees: results of a randomized controlled trial.
Thompson, M; Gee, S; Larson, P; Kotz, K; Northrop, L
2001-01-01
Managed care needs effective and efficient ways to orient new members, enhance trust and loyalty, and offer prevention and self-care education and services. Recent adult enrollees of Kaiser Permanente (Northern California) were randomly assigned to one of three intervention conditions (n = 286) (individual visit with a physician, physician visit plus a visit with a health educator, a group visit of eight new members led by a physician and health educator) or a random control group (n = 278). Outcomes were gauged via pre- and post-visit questionnaires and a 20-min telephone survey at baseline and at a 6-month follow-up. Compared to controls, attendees of the three interventions had higher satisfaction, self-rated prevention knowledge, acceptance of health plan guidelines, and were more likely to plan to remain in the health plan. Group visit attendees stood out as experiencing the greatest benefits and were especially likely to report saving a telephone call or visit to their doctor by using a self-care handbook.
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Acceptance of direct physician access to a computer-based patient record in a managed care setting.
Dewey, J B; Manning, P; Brandt, S
1993-01-01
Kaiser Permanente Mid-Atlantic States has developed a fully integrated outpatient information system which currently runs on an IBM ES9000 on a VM platform written in MUMPS. The applications include Lab, Radiology, Transcription, Appointments. Pharmacy, Encounter tracking, Hospitalizations, Referrals, Phone Advice, Pap tracking, Problem list, Immunization tracking, and Patient demographics. They are department specific and require input and output from a dumb terminal. We have developed a physician's work station to access this information using PC compatible computers running Microsoft Windows and a custom Microsoft Visual Basic 2.0 environment which draws from these 14 applications giving the physician a comprehensive view of all electronic medical records. Through rapid prototyping, voluntary participation, formal training and gradual implementation we have created an enthusiastic response. 95% of our physician PC users access the system each month. The use ranges from 0.2 to 3.0 screens of data viewed per patient visit. This response continues to drive the process toward still greater user acceptance and further practice enhancement.
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Hoffmann, Thomas J; Zhan, Yiping; Kvale, Mark N; Hesselson, Stephanie E; Gollub, Jeremy; Iribarren, Carlos; Lu, Yontao; Mei, Gangwu; Purdy, Matthew M; Quesenberry, Charles; Rowell, Sarah; Shapero, Michael H; Smethurst, David; Somkin, Carol P; Van den Eeden, Stephen K; Walter, Larry; Webster, Teresa; Whitmer, Rachel A; Finn, Andrea; Schaefer, Catherine; Kwok, Pui-Yan; Risch, Neil
2011-12-01
Four custom Axiom genotyping arrays were designed for a genome-wide association (GWA) study of 100,000 participants from the Kaiser Permanente Research Program on Genes, Environment and Health. The array optimized for individuals of European race/ethnicity was previously described. Here we detail the development of three additional microarrays optimized for individuals of East Asian, African American, and Latino race/ethnicity. For these arrays, we decreased redundancy of high-performing SNPs to increase SNP capacity. The East Asian array was designed using greedy pairwise SNP selection. However, removing SNPs from the target set based on imputation coverage is more efficient than pairwise tagging. Therefore, we developed a novel hybrid SNP selection method for the African American and Latino arrays utilizing rounds of greedy pairwise SNP selection, followed by removal from the target set of SNPs covered by imputation. The arrays provide excellent genome-wide coverage and are valuable additions for large-scale GWA studies. Copyright © 2011 Elsevier Inc. All rights reserved.
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Companies commit to emergency contraception -- have you?
1999-12-01
Despite the efforts of the medical community, as well as promotional efforts by pharmaceutical companies, relatively few women in the US have heard of emergency contraceptives (ECs). Gynetics, marketer of Preven, plans to file a new drug application for a levonorgestrel EC by the end of 1999, with an anticipated approval in the second half of 2000. Women's Capital Corp., marketer of Plan B, is also aiming for a national commercial launch of its product. According to a recently published acceptability study, women will use ECs when they are made available. A survey among 235 women at 13 Kaiser Permanente medical offices in San Diego, California, regarding their experiences with ECs showed that 91% were satisfied with ECs, and 97% said they would use ECs for emergencies only--dispelling fears that women would forego use of ongoing contraception. About 70% of the women who participated in the study were using a contraceptive method when they requested ECs.
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Incidence and clinical characteristics of interstitial cystitis in the community.
Patel, Ronak; Calhoun, Elizabeth A; Meenan, Richard T; O'Keeffe Rosetti, Maureen C; Kimes, Terry; Clemens, J Quentin
2008-08-01
We utilized physician-coded diagnoses and chart reviews to estimate the incidence of interstitial cystitis (IC) in women. A computer search of the Kaiser Permanente database was performed to identify newly coded diagnoses of IC (ICD-9 code 595.1) between May 2002 and May 2005. Chart reviews were performed and patient demographics, diagnosing physicians, and symptom characteristics were recorded. The IC incidence rate was 15 per 100,000 women per year. The mean age of the patients was 51 years (range 31-81 years). The most common presenting symptoms were frequency (70%), dysuria (52%), urgency (50%), suprapubic pain (50%), nocturia (35%), and dyspareunia (13%). Cases diagnosed by primary care physicians had a shorter median symptom duration (9 months) compared with those diagnosed by urologists (1 year) and gynecologists (3 years). IC is an uncommon diagnosis in the community setting, with an incidence rate of 15 per 100,000 women per year.
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Experience using radio frequency laptops to access the electronic medical record in exam rooms.
Dworkin, L. A.; Krall, M.; Chin, H.; Robertson, N.; Harris, J.; Hughes, J.
1999-01-01
Kaiser Permanente, Northwest, evaluated the use of laptop computers to access our existing comprehensive Electronic Medical Record in exam rooms via a wireless radiofrequency (RF) network. Eleven of 22 clinicians who were offered the laptops successfully adopted their use in the exam room. These clinicians were able to increase their exam room time with the patient by almost 4 minutes (25%), apparently without lengthening their overall work day. Patient response to exam room computing was overwhelmingly positive. The RF network response time was similar to the hardwired network. Problems cited by some laptop users and many of the eleven non-adopters included battery issues, different equipment layout and function, and inadequate training. IT support needs for the RF laptops were two to four times greater than for hardwired desktops. Addressing the reliability and training issues should increase clinician acceptance, making a successful general roll-out for exam room computing more likely. PMID:10566458
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Cosgrove, Delos M; Fisher, Michael; Gabow, Patricia; Gottlieb, Gary; Halvorson, George C; James, Brent C; Kaplan, Gary S; Perlin, Jonathan B; Petzel, Robert; Steele, Glenn D; Toussaint, John S
2013-02-01
Patient-centeredness--the idea that care should be designed around patients' needs, preferences, circumstances, and well-being--is a central tenet of health care delivery. For CEOs of health care organizations, patient-centered care is also quickly becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. In A CEO Checklist for High-Value Health Care, we, as executives of eleven leading health care delivery institutions, outlined ten key strategies for reducing costs and waste while improving outcomes. In this article we describe how implementation of these strategies benefits both health care organizations and patients. For example, Kaiser Permanente's Healthy Bones Program resulted in a 30 percent reduction in hip fracture rates for at-risk patients. And at Virginia Mason Health System in Seattle, nurses reorganized care patterns and increased the time they spent on direct patient care to 90 percent. Our experiences show that patient-engaged care can be delivered in ways that simultaneously improve quality and reduce costs.
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The global diabetes model: user friendly version 3.0.
Brown, J B; Russell, A; Chan, W; Pedula, K; Aickin, M
2000-11-01
The attributes of Release 3.0 of the user friendly version (UFV) of the global diabetes model (GDM) are described and documented in detail. The GDM is a continuous, stochastic microsimulation model of type 2 diabetes. Suitable for predicting the medical futures of both individuals with diabetes and representative diabetic populations, the GDM predicts medical events (complications of diabetes), survival, utilities, and medical care costs. Incidence rate functions for microvascular and macrovascular complications are based on a combination of published studies and analyses of data describing diabetic members of Kaiser Permanente Northwest Region, a non-profit group-model health maintenance organization. Active risk factors include average blood glucose (HbAlc), systolic blood pressure (SBP), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), triglycerides, smoking status, and use of prophylactic aspirin. Events predicted include diabetic eye disease, diabetic nephropathy, peripheral neuropathy amputation, myocardial infarction, stroke, peripheral artery disease, congestive heart failure, coronary artery surgery, coronary angioplasty, and death.
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Catlin, Anita
In April 2016, the National Perinatal Association and Kaiser Permanente Northern California Nursing Research Community Benefits Grant sponsored an interdisciplinary summit to explore the needs of women who present with actual or potential pregnancy loss to the emergency department (ED). Thirty-two experts in the field of pregnancy loss, 17 of whom represented their professional organizations, participated. These experts, which included nurses, physicians, social workers, counselors, authors, and parents, worked together to create guidelines for care of women with a pregnancy loss in the ED. Recommendations for ED healthcare providers are included. Emergency department personnel agreed that improvements in care could be offered and were willing to endorse education for their staff. The guidelines delineate how to better provide physical, emotional, and bereavement support at any stage of gestational loss. Administrative support for policies in the ED is essential to ensure the delivery of family-centered, culturally sensitive practices when a pregnancy ends.
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NASA Astrophysics Data System (ADS)
Vera, Victor; Aguilar, M.; Huisacayna, J.
2008-05-01
We present a review of our efforts to introduce astronomy as scientific career in Peru, showing how our astronomy outreach programs have been one of the most important keys to reach our national astronomical scientific goals, remarking the crucial role that the celebration of the IYA2009 must play, in order to promote PhD programmes in astronomy in developing countries. We show the importance of the creation of the Seminario Permanente de Astronomía y Ciencias Espaciales (SPACE) in the Universidad Nacional Mayor de San Marcos, as an academic scientific and cultural center in Peru, to support our 26 years-old "Astronomical Fridays” which are addressed to wide range of public, from schoolchildren to scientists. We also show how important was to rediscover our ancient astronomical cultural past of Incas in order to promote the construction of a Astronomical Center located near Cusco city over 4000 meters above sea level, which includes a tourist-educational observatory, a scientific optical observatory and a solar radio observatory.
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Adverse events associated with apremilast use and withdrawal for psoriasis in a real-world setting.
Lee, Erica B; Amin, Mina; Egeberg, Alexander; Wu, Jashin J
2018-05-06
Apremilast, a phosphodiesterase-4 inhibitor, is an oral therapy for treatment of psoriasis. Its safety profile is favorable, with side effects including diarrhea, nausea, vomiting, depression, and weight decrease, primarily based on clinical trial data. However, limited research exists on the side effect frequency and subsequent adverse events (AEs) in real-world practice. This retrospective chart review included patients who presented to the dermatology clinic at Kaiser Permanente Los Angeles Medical Center and were treated with apremilast at any time between January 1, 2015 and January 11, 2018. Patients were not included if they did not have at least one follow-up by clinic visit, telephone, or email correspondence after being prescribed apremilast. A total of 77 patients were included. AEs and withdrawal due to AEs were assessed throughout the treatment period from each patient's respective medical record. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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The dissemination of clinical practice guidelines over an intranet: an evaluation.
Stolte, J. J.; Ash, J.; Chin, H.
1999-01-01
This study compares two clinical practice guideline dissemination systems. It was hypothesized that placing guidelines on an intranet would make this information easier to retrieve. Retrieval time, retrieval accuracy, and ease of use were empirically evaluated. Sixteen clinicians from Kaiser Permanente volunteered to complete tasks that measured these variables. Time values were significantly longer for tasks completed with intranet guidelines (Intranet = 6.7 minutes, Paper = 5.7 minutes). Tasks completed with paper guidelines had a significantly higher percentage of perfect scores than those completed with the intranet (Paper = 85%, Intranet = 59%). There was no significant difference in reported ease of use. Simply placing clinical information on an electronic system does not guarantee that the information will be easier to retrieve. Such information needs to be fully integrated into the clinical decision making process. Computerizing guidelines may provide a necessary initial step toward this goal, but it does not represent the final solution. PMID:10566503
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Vargas, Marco Antonio; Britto, Jorge
2016-11-03
Characterization of the scientific and technological infrastructure in health and its interactions with the industrial sector provides key elements for understanding the dynamics of innovation in health. This study conducts an exploratory analysis of the potentialities and limitations associated with scientific and technological capabilities in the health area in Brazil and the different links between the scientific and industrial sectors in health. The analysis points to important growth in internationally indexed research output, especially in certain areas such as pharmaceutics, public health, genetics, morphology, physiology, and microbiology. There has also been important growth in research groups that interact with the industrial sector in selected areas of health. The study highlights the importance of building more solid and permanent bridges between companies, research institutions, and the health system, linking the knowledge developed in research institutions to the dynamics of the industrial sector in health. Resumo: A caracterização da infraestrutura científica e tecnológica na área da saúde e das suas formas de articulação com a base produtiva representam elementos centrais na compreensão da dinâmica de inovação em saúde. Este estudo faz uma análise exploratória sobre as potencialidades e limitações associadas às capacitações científicas e tecnológicas na área da saúde no Brasil e as formas de articulação entre a base científica e a base produtiva em saúde. A análise aponta para o crescimento expressivo da produção bibliográfica com circulação internacional no campo da saúde, particularmente em determinadas áreas como farmácia, saúde coletiva, genética, morfologia, fisiologia e microbiologia. Além disso, observa-se um crescimento expressivo dos grupos de pesquisa com relacionamentos com o setor produtivo em áreas selecionadas da saúde. Destaca-se a importância da construção de pontes mais sólidas e
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Cosmic Web of Galaxies in the COMOS Field
NASA Astrophysics Data System (ADS)
Darvish, Behnam; Martin, Christopher D.; Mobasher, Bahram; Scoville, Nicholas; Sobral, David; COSMOS science Team
2017-01-01
We use a mass complete sample of galaxies with accurate photometric redshifts in the COSMOS field to estimate the density field and to extract the components of the cosmic web. The comic web extraction algorithm relies on the signs and the ratio of eigenvalues of the Hessian matrix and is enable to integrate the density field into clusters, filaments and the field. We show that at z < 0.8, the median star-formation rate in the cosmic web gradually declines from the field to clusters and this decline is especially sharp for satellite galaxies (~1 dex vs. ~0.4 dex for centrals). However, at z > 0.8, the trend flattens out. For star-forming galaxies only, the median star-formation rate declines by ~ 0.3-0.4 dex from the field to clusters for both satellites and centrals, only at z < 0.5. We argue that for satellite galaxies, the main role of the cosmic web environment is to control their star-forming/quiescent fraction, whereas for centrals, it is mainly to control their overall star-formation rate. Given these, we suggest that most satellite galaxies experience a rapid quenching mechanism as they fall from the field into clusters through the channel of filaments, whereas for central galaxies, it is mostly due to a slow quenching process. Our preliminary results highlight the importance of the large-scale cosmic web on the evolution of galaxies.
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Como Lo Hago Yo: Tratamiento Quirurgico Del Mielomeningocele
Portillo, Santiago
2014-01-01
En Argentina hay plan de fortificación con ácido fólico. Diagnostico prenatal no siempre es correcto. Cierre según técnica. Cerramos músculo. No favorecemos corpectomía temprana en casos de cifosis. Suturamos la plaqueta. Cerramos el plano muscular. Hidrocefalia: Válvula de derivación, generalmente dentro de los dos primeros meses. Ventriculostomía no está indicada. Chiari II. Laminectomia cervical alta. Siringomielia: Derivación desde la cavidad al peritoneo. PMID:24791219
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Los mitos como memoria colectiva de Los Pueblos.
NASA Astrophysics Data System (ADS)
Martín, P. T.
Myths are essentially something practical that allows those who believe in them to solve any ambiguity which could come up in their relation with nature. Since they bring information about the condition of the reality to which they belong, they are but the appropriate instrument to insert nature into culture by actually achieving an adaptation to the environment. The purpose of this essay is to show how the deification of plants, animals, and stars, which are present in the daily lives of "Amerindian" people, not only constitutes a source of rich mythology but also turns out to be an effective measure towards the continuity of social groups. Similarities or identifications between human life and the life of plants, animals and stars as well as mutual interplay are somehow present in those myths: stars which create or are changed into human being, animals or plants; human beings who create or are transformed into astral bodies; battles between peoples and stars, etc. On this base, mythology can provide not only keys to show how certain human groups have achieved their adaptation to the environment and how the different social systems and their relations to nature have developed, but also hints of changes which have taken place in other heavenly spheres such as the falling of meteors, the appearance of comets or any other significant events of this kind in the lives of these groups.
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[Parenting Information. Informacion Sobre Como Ser Padres Mejores.
ERIC Educational Resources Information Center
Moreno, Steve
These five booklets, containing information on how parenting can effect children's school achievement, are part of a series of 22 innovative booklets designed specifically to help parents understand and help their children learn. Booklet #1, "Parents--Teach Your Children to Learn [Before They Go to School]," defines intelligence and…
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NASA Astrophysics Data System (ADS)
Boudard, Emmanuel; Morlaix, Sophie
2003-09-01
This article addresses the main predictors of adult education, using statistical methods different from those generally used by social science researchers. Its aim is twofold. First, it seeks to explain in a simple and comprehensible manner the methodological value of these methods (in relation to the use of structural models); secondly, it demonstrates the concrete usefulness of these methods on the basis of a recent piece of research on the data from the International Adult Literacy Survey (IALS).
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Li, De-Kun; Chen, Hong; Ferber, Jeannette; Odouli, Roxana
2017-01-01
Data from previous studies have suggested a possible association between antibiotic use in infancy and risk of childhood obesity, with implications for health-care delivery and obesity prevention strategies. However, whether the observed association was due to antibiotic use or underlying infection, or both, is unclear. We aimed to disentangle the effect of antibiotic use in infancy from that of underlying infection on the risk of childhood obesity. In this longitudinal birth cohort study, we included infants in the Kaiser Permanente Northern California population born between Jan 1, 1997, and March 31, 2013. We used electronic medical records to ascertain data for antibiotic use, infection diagnosis, and anthropometric measurements (and thus BMI and obesity status) from birth up to age 18 years. We used standard mixed-effects logistic regression for repeated measurements to analyse multiple BMI measurements per child (median five measurements) and to obtain odds ratios (ORs) and 95% CIs for obesity risk. We also did a substudy in 547 same-sex twin pairs with discordant exposure status to substantiate our findings. 260 556 individuals were included in our analysis. After controlling for maternal age, race or ethnic origin, pre-pregnancy BMI, preterm delivery, low birthweight, maternal antibiotic use, and infection during pregnancy, infection without antibiotic use in infancy was associated with an increased risk of childhood obesity compared with controls without infection (OR 1·25, 95% CI 1·20-1·29). A clear dose-response relation was seen between infection episodes and risk of childhood obesity (p trend <0·0001). By contrast, compared with infants with untreated infection, antibiotic use during infancy was not associated with risk of childhood obesity (1·01, 0·98-1·04). Neither broad-spectrum nor narrow-spectrum antibiotics were associated with risk of childhood obesity. These findings were supported by the results of the twin set analysis. Infection
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Meikle, S F; Lyons, E; Hulac, P; Orleans, M
1998-07-01
Our purpose was to determine whether length of hospital stay after vaginal delivery as determined by the discharging physician is associated with rehospitalizations or increased outpatient contacts by mothers and neonates and to assess the impact of home health care visits. An inception cohort study of all rehospitalizations and outpatient contacts of mothers and neonates after vaginal delivery at St. Joseph Hospital, Denver, Colorado, was done from January 1, 1994, to September 30, 1995. All Kaiser Permanente mother-neonate pairs in which the delivery was vaginal (excluding those with multiple gestations or birth weight < 2500 g) were included. Length of initial hospital stay was divided into three time periods: < or = 24 hours, 25 to 48 hours, and > 48 hours. The Colorado Kaiser Permanente Perinatal Database was used to identify perinatal and demographic factors that might have increased health care use. Additional information was sought in administrative databases, bill records, and inpatient charts. Mothers were followed up for 6 weeks and neonates for 28 days after delivery. Home care visits were provided to more than half the mothers and neonates by means of a standardized protocol. The main outcome measures were rehospitalizations and outpatient visits for mothers and neonate, controlling for home care visits. A total of 4323 mother-neonate pairs were identified. For the mothers, a longer initial hospital stay (> 48 hours) was significantly associated with both readmission (P < .01) and increased outpatient care use (P = .01) in the 6-week postpartum period. Thirty-five mothers (.81%) were rehospitalized by 6 weeks. Maternal factors associated with increased outpatient contacts were preeclampsia, preterm delivery, and instrument delivery. Sixty-seven neonates (1.55%) were readmitted to the hospital. Home care visits reduced the need for both readmissions and outpatient visits. For mothers in this cohort a longer initial hospital stay was significantly
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Tuberculosis control in people living with HIV/AIDS.
Magnabosco, Gabriela Tavares; Lopes, Lívia Maria; Andrade, Rubia Laine de Paula; Brunello, Maria Eugênia Firmino; Monroe, Aline Aparecida; Villa, Tereza Cristina Scatena
2016-09-09
/aids pelos serviços do município foi considerada regular, reforçando a necessidade de melhor planejamento da assistência de forma integral, articulação dos profissionais nas equipes e entre os serviços da rede, além da formação profissional e educação permanente. faz-se necessário a implementação de estratégias que favoreçam ações compartilhadas entre os programas de tuberculose e HIV/aids e entre os diferentes serviços, com o intuito de fortalecer a rede local de atenção objetivando a produção de um cuidado singular, integral e resolutivo. analizar la oferta de acciones y servicios de salud para el control de la tuberculosis en las personas viviendo con VIH-SIDA acompañadas por los Servicios de Atención Especializada al VIH-SIDA de Ribeirao Preto, SP, Brasil. estudio cuantitativo, exploratorio, de tipo encuesta. Participaron 253 personas viviendo con VIH-SIDA seguidas por estos servicios, considerando como criterios de inclusión: individuos mayores de 18 años, residentes en el municipio y no ser del sistema de prisiones. La recolección de datos fue realizada en el periodo de enero de 2012 a mayo de 2013, por medio de entrevistas guiadas por un instrumento especifico. Los datos fueron analizados mediante indicadores y un índice compuesto. la oferta de acciones y servicios para el control de la tuberculosis en personas viviendo con VIH-SIDA fue considerada intermedia, reforzando la necesidad de mejorar la planificación de la asistencia en forma integral, la articulación de los profesionales en los equipos y entre los servicios de la red, además de la formación profesional y la educación permanente. se hace necesaria la implementación de estrategias que favorezcan las acciones compartidas entre los programas de tuberculosis y VIH-SIDA y entre los diferentes servicios, con el fin de fortalecer la red local de atención para producir un cuidado personalizado, integral y resolutivo.
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Barretta, Lidiane Miotto; Beccaria, Lúcia Marinilza; Cesarino, Cláudia Bernardi; Pinto, Maria Helena
2016-06-07
educação permanente, enfocando a prevenção das complicações. identificar el modelo, el tiempo medio de permanencia y las complicaciones del catéter venoso central en pacientes sometidos a trasplante de células madre hematopoyéticas y estimar la relación de correspondencia entre las variables: edad, sexo, diagnóstico médico, tipo de trasplante, catéter implantado y sitio de inserción. estudio retrospectivo y cuantitativo con una muestra de registros de 188 pacientes trasplantados entre 2007 y 2011. la mayoría de los pacientes utilizó el catéter Hickman con una permanencia media de 47,6 días. La complicación fiebre/bacteriemia fue significativa en los varones jóvenes con linfoma no Hodgkin sometidos a trasplante autólogo, que permanecieron con el dispositivo durante un largo período en la vena subclavia. los enfermeros deben planificar con el equipo, el tiempo de espera mínimo recomendado entre la inserción del catéter y el inicio del tratamiento de condicionamiento, así como no extender el período de permanencia del catéter y realizar su formación continua, centrándose en la prevención de complicaciones.
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1980-09-01
OF SCIENTIFIC INFORMATION SERVICES L EFENCE SDI - A USEFUL CURRENT AWARENESS SYSTEM (Dissemination Selective de L’Information, Sur la Defense: Un...Dalhousie University, Halifax, Nova Scotia. CAUTION This information is furnished with the express understanding that proprietary and patent rights will be...may add his knowledge of information exchange agreements and Canadian projects covered by these agreements. These exchange agreements are important
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The Variation of Catalyst and Carrier Gas on Anisole Deoxygenation Reaction
NASA Astrophysics Data System (ADS)
Ariyani, D.; Dwi Nugrahaningtyas, Khoirina; Heraldy, E.
2018-03-01
This research aims to determine the best catalyst and carrier gas in anisole deoxygenation reaction. The reaction was carried out over a flow system with a variation of catalyst CoMo A (CoMo/USY reduction), CoMo B (CoMo/USY oxidation-reduction), and CoMo C (CoMo/ZAA oxidation-reduction). In addition, variation of carrier gas nitrogen and hydrogen was investigated. The result was analyzed using Gas Chromatography-Mass Spectroscopy (GC-MS). The deoxygenation anisole result showed that CoMo A catalyst with hydrogen as the carrier gas has the highest total product yield (50.72 %), intermediate product yield (38.49 % in phenol and 6.99 % in benzaldehyde), and deoxygenation yield (5.24 %). The CoMo C catalyst exhibited the most selective deoxygenation product. The nitrogen carrier gas with the CoMo C catalyst has the best selectivity of benzene product (93.92 %).
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Robinson, James C
2013-05-01
Two overarching frameworks compete to address the organizational ills of the health care system. One framework diagnoses lack of coordination and prescribes integration and global payment. The other diagnoses loss of focus and prescribes specialization and episode payment. This article, based on research and interviews, assesses how the two frameworks manifest themselves at two high-volume orthopedic hospitals in Irvine, California. The Kaiser Permanente Irvine Medical Center is part of a large and diversified health system. The Hoag Orthopedic Institute is a single-specialty facility jointly owned by the physicians and the hospital. Market outcomes, such as the merger of the Hoag specialty hospital into a larger diversified health system, suggest that Kaiser's focus on coordination of patient care from preadmission to postdischarge is a key factor in its success. But Hoag's specialization also leads to improved efficiencies. The integrated approach appears to be prevailing. At the same time, large diversified organizations might obtain further efficiencies by pursuing service-line strategies as described in this article--for instance, by providing incentives for efficiency and quality for each specialty and type of care.
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Zhang, Y. Tara; Laraia, Barbara A.; Mujahid, Mahasin S.; Blanchard, Samuel D.; Warton, E. Margaret; Moffet, Howard H.; Karter, Andrew J.
2016-01-01
We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009–2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes. PMID:27160530
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Kaiser captures spirit of games.
Herreria, J
1998-01-01
With a multi-media campaign, Kaiser Permanente blitzed its market area by becoming a sponsor of the Nike World Masters Games. The advertising campaign promoted Kaiser as the exclusive health care sponsor. Company officials are counting on this campaign to leverage the health care institution's commitment to the community. In addition to the advertising, Kaiser searched for local athletes to represent its "play the sports for life" theme. As part of a promotion to award 200 athlete sponsorships to the Games, Kaiser's own master athletes were invited to tell their stories. Some of the members shared stories about such topics as experiencing an accident, receiving assistance from a Kaiser physician and incorporating a lifestyle of sport for rehabilitation. From the hundreds of letters received, two members and one employee were selected for the television spots. The sporting event reinforces Kaiser's philosophy of fitness-oriented lifestyles among its members. The Nike World Masters Games are the largest participatory multi-sport competition in the world, gathering together more than 25,000 men and women from more than 100 countries.
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Data that drive: Closing the loop in the learning hospital system.
Liu, Vincent X; Morehouse, John W; Baker, Jennifer M; Greene, John D; Kipnis, Patricia; Escobar, Gabriel J
2016-11-01
The learning healthcare system describes a vision of US healthcare that capitalizes on science, information technology, incentives, and care culture to drive improvements in the quality of health care. The inpatient setting, one of the most costly and impactful domains of healthcare, is an ideal setting in which to use data and information technology to foster continuous learning and quality improvement. The rapid digitization of inpatient medicine offers incredible new opportunities to use data from routine care to generate new discovery and thus close the virtuous cycle of learning. We use an object lesson-sepsis care within the 21 hospitals of the Kaiser Permanente Northern California integrated healthcare delivery system-to offer insight into the critical elements necessary for developing a learning hospital system. We then describe how a hospital-wide data-driven approach to inpatient care can facilitate improvements in the quality of hospital care. Journal of Hospital Medicine 2016;11:S11-S17. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.
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Comprehensive grief care for children and families: Policy and practice implications.
Griese, Brook; Burns, Michaeleen R; Farro, Samantha A; Silvern, Louise; Talmi, Ayelet
2017-01-01
Since the 1998 publication of the groundbreaking Adverse Childhood Experiences (ACE) Study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente, increased research and funding has focused on mitigating experiences that place children at risk for developmental disruption. Surprisingly, the death of a parent, sibling, or other important attachment figure-often noted as one of the most disruptive and potentially traumatic experiences for a child-has received relatively little attention in these efforts. This article explores the current landscape of support for grieving children and families- including significant barriers to care and gaps in empirical knowledge. Given the complexity of the issue and the nascent state of the childhood bereavement field, it is fertile ground for social innovations that challenge current norms. In addition, the argument is made for a strengths-based, wellness approach to childhood bereavement that seizes upon opportunities to both promote adaptive adjustment and prevent further complications of unaddressed grief and trauma. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
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NASA Astrophysics Data System (ADS)
Khan, Mansoor; Yong, Wang; Mustafa, Ehtasham
2017-07-01
After the rapid advancement in the field of power electronics devices and drives for last few decades, there are different kinds of Pulse Width Modulation techniques which have been brought to the market. The applications ranging from industrial appliances to military equipment including the home appliances. The vey common application for the PWM is three phase voltage source inverter, which is used to convert DC to AC in the homes to supply the power to the house in case electricity failure, usually named as Un-interrupted Power Supply. In this paper Space Vector Pulse Width Modulation techniques is discussed and analysed under the control technique named as Field Oriented Control. The working and implementation of this technique has been studied by implementing on the three phase bridge inverter. The technique is used to control the Permanente Magnet Synchronous Motor. The drive system is successfully implemented in MATLAB/Simulink using the mathematical equation and algorithm to achieve the satisfactory results. PI type of controller is used to tuned ers of the motothe parametr i.e. torque and current.
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NFP Investor Conference. Growth is back in sight.
Haugh, Richard
2002-06-01
In a whirlwind of high-stakes meetings in New York City in mid-May, two dozen of the nation's largest hospitals and health systems strutted their stuff with a single goal: securing their future. Their message was clear: back-to-basics works, and now it's time to grow the business. Executives from 23 providers outlined their work on increasing revenue, boosting margins and shoring up balance sheets. They presented their market positions, strategic initiatives and financial results for investment analysts, credit raters and bond traders. The third annual Non-Profit Healthcare Investor Conference was co-sponsored by the American Hospital Association, Health Forum, the Healthcare Financial Management Association and Salomon Smith Barney. The focus on growth doesn't come without challenges Several common themes emerged from the presentations, among them pressure on reimbursement, workforce shortages, liability insurance issues and capacity constraints. Yet executives agree: it all comes down to the basics, and building the strength to keep their missions alive. As Thomas Meier, vice president and treasurer of Oakland, Calif.-based Kaiser Permanente, put it: "No margin, no mission, no más."
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Physician Update: Total Health
Tuso, Phillip
2014-01-01
As an integrated prepaid health care system, Kaiser Permanente (KP) is in a unique position to demonstrate that affordability in health care can be achieved by disease prevention. During the past decade, KP has significantly improved the quality care outcomes of its members with preventable diseases. However, because of an increase in the incidence of preventable disease, and the potential long-term and short-term costs associated with the treatment of preventable disease, KP has developed a new strategy called Total Health to meet the current and future needs of its patients. Total Health means healthy people in healthy communities. KP’s strategic vision is to be a leader in Total Health by making lives better. KP hopes to make lives better by 1) measuring vital signs of health, 2) promoting healthy behaviors, 3) monitoring disease incidence, 4) spreading leading practices, and 5) creating healthy environments with our community partners. Best practices, spread to the communities we serve, will make health care more affordable, prevent preventable diseases, and save lives. PMID:24694316
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Psychotherapist mindfulness and the psychotherapy process.
Bruce, Noah; Bruce, Noah G; Shapiro, Shauna L; Constantino, Michael J; Manber, Rachel
2010-03-01
[Correction Notice: An erratum for this article was reported in Vol 47(2) of Psychotherapy: Theory, Research & Practice (see record 2010-13424-005). the order of authorship and the affiliations of the authors was incorrectly printed. The correct order and affiliations are as follows: Noah Bruce, Shauna L. Shapiro, Michael J. Constantino, and Rachel Manber; Kaiser Permanente, Santa Clara University, University of Massachusetts, Stanford University] A psychotherapist's ability to relate to his or her patients is essential for decreasing patient suffering and promoting patient growth. However, the psychotherapy field has identified few effective means for training psychotherapists in this ability. In this conceptual article, we propose that mindfulness practice may be a means for training psychotherapists to better relate to their patients. We posit that mindfulness is a means of self-attunement that increases one's ability to attune to others (in this case, patients) and that this interpersonal attunement ultimately helps patients achieve greater self-attunement that, in turn, fosters decreased symptom severity, greater well-being, and better interpersonal relationships. PsycINFO Database Record (c) 2010 APA, all rights reserved
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Implementation and Effectiveness of a Mailed FIT Outreach Program in Safety Net Clinics
Gloria Coronado, PhD, is an epidemiologist and the Mitch Greenlick Endowed Senior Investigator in Health Disparities Research at Kaiser Permanente Center for Health Research in Portland, OR. Her research focuses on understanding and addressing disparities in the occurrence and burden of disease in underserved populations, with a special emphasis on testing cancer prevention intervention in underserved and Medicaid-enrolled populations. She has developed several innovative and cost-effective interventions to improve rates of participation in cancer screening among patients served by community health centers. Her work has led to partnerships with large health plans, state institutions, and clinics who serve migrants and the uninsured. Dr. Coronado received her PhD in epidemiology from the University of Washington and became a research associate professor in the university’s Department of Epidemiology, in addition to receiving training at Stanford. She currently directs or co-directs three programs that use systems-based approaches to raise the rates of colorectal cancer screening in health plans and clinics in Washington, Oregon and California.
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Schiøtz, Michaela; Frølich, Anne; Krasnik, Allan; Taylor, Warren; Hsu, John
2012-09-01
Identify important organizational elements for providing self-management support (SMS). Semi-structured qualitative interviews conducted in two healthcare systems. Kaiser Permanente Northern California and the Danish Health Care System. 36 managers and healthcare professionals in the two healthcare systems. Elements important to providing self-management support to persons with diabetes. Healthcare professionals' provision of SMS was influenced by healthcare system organization and their perceptions of SMS, the capability and responsibility of healthcare systems, and their roles in the healthcare organization. Enabling factors for providing SMS included: strong leadership; aligned incentives; use of an integrated health information technology (HIT) system; multidisciplinary healthcare provider teams; ongoing training for healthcare professionals; outreach; and quality goals. Barriers to providing SMS included lack of collaboration between providers and skeptical attitudes towards prevention and outreach. Implementation of SMS can be improved by an understanding of the elements that enhance its provision: (1) initiatives seeking to improve collaboration and integration between providers; (2) implementation of an integrated HIT system; and (3) ongoing training of healthcare professionals.
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The Risk of Pneumonia in Older Adults Using Nonbenzodiazepine Hypnotics.
Jung, Stephen; Spence, Michele M; Escasa, Nina M; Lee, Eric A; Hui, Rita L; Gibbs, Nancy E
2016-08-01
Previous studies have shown an increased risk of pneumonia with benzodiazepines (BZD) and an increased risk of any infection with non-BZD hypnotics, but no analysis has specifically investigated the risk of pneumonia with non-BZD hypnotic use. To evaluate the risk of pneumonia associated with non-BZD hypnotic use in the elderly. This was a retrospective case-control study of members aged 65 years and older enrolled in an integrated health care system. Cases were identified as patients aged 65 years and older with a diagnosis of pneumonia from January 2011 to December 2012. Controls were matched in a 4:1 ratio to cases based on age, gender, and active enrollment. Non-BZD hypnotic exposure was evaluated for all cases and controls 1 year before the index date. Proximity of exposure to index date and duration of use were analyzed. Conditional logistic regression adjusted for covariates was performed. We identified 51,029 cases with pneumonia and matched 188,391 controls without pneumonia. Of the cases with pneumonia, 5.5% (2,790) of cases had exposure to a non-BZD hypnotic, compared with 3.4% (6,345) of controls. Non-BZD hypnotic exposure was associated with an increased risk of pneumonia (OR = 1.14; 95% CI = 1.08-1.20). When exposure was stratified by proximity to index date, only current exposure was associated with an increased risk of pneumonia (OR = 1.27; 95% CI = 1.18-1.36). Short-term exposure was associated with a relatively higher risk of pneumonia (OR = 1.57; 95% CI = 1.39-1.77) compared with long-term use (OR = 1.16; 95% CI = 1.06-1.25). Current use of non-BZD hypnotics in older adults is associated with an increased risk of pneumonia. The findings of this study provide additional support for reducing the use of non-BZD hypnotics in older adults and for pursuing safer alternatives for treating insomnia. No outside funding supported this study. At the time of this study, Jung was a PGY2 resident in drug information at Kaiser Permanente Drug Information
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One-Year Outcomes of an Integrated Multiple Sclerosis Disease Management Program.
Groeneweg, Marti; Forrester, Sara H; Arnold, Beth; Palazzo, Lorella; Zhu, Weiwei; Yoon, Paul; Scearce, Tim
2018-05-01
finding remained when the analysis was limited to MS-related visits only. Average annual health plan spend per patient on MS medications significantly increased ($55,835 after vs. $40,883 before, P < 0.001). Specialty pharmacy and chronic disease management for patients with MS can increase the proportion of patients adherent to medication. The increase in health plan spend on MS medications is not offset by savings in health care resource utilization. This study was funded by Kaiser Permanente Washington Health Research Institute and Kaiser Permanente Washington Pharmacy Administration. The authors have no disclosures to report.
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Reddy, Kavya M; Chang, Jonathan I; Shi, Jiaxiao M; Wu, Bechien U
2016-10-01
Gastric intestinal metaplasia (GIM) is a common finding from routine endoscopies. Although GIM is an early step in gastric carcinogenesis, there is controversy regarding routine surveillance of patients with GIM in regions with a low prevalence of gastric cancer. We aimed to determine the incidence of gastric cancer among patients with GIM and risk factors for gastric cancer. We performed a retrospective cohort study of patients from the Kaiser Permanente Southern California region diagnosed with GIM from 2000 through 2011. GIM was identified by a keyword search of pathology reports; gastric cancer cases were identified by cross-reference with an internal cancer registry. The incidence of gastric cancer in patients with GIM (n = 923; median age at diagnosis, 68 y) was compared with that of an age- and sex-matched reference population (controls). Risk factors such as ethnicity, smoking status, history of Helicobacter pylori infection, and family history of gastric cancer were evaluated by individual Cox proportional hazards regression. We then performed a second case-cohort study to evaluate the risk of gastric cancer based on the location and extent of GIM. The median duration of follow-up evaluation was 4.6 years (interquartile range, 3.0-6.7 y). We identified 25 patients with GIM who developed gastric cancers. Seventeen cases of cancer were diagnosed at the same time as the diagnosis of GIM. Eight cases of cancer were identified within a median time period of 4.6 years after a diagnosis of GIM (interquartile range, 2-5.7 y). The overall incidence rate for the cohort was 1.72 (95% confidence interval, 0.74-3.39). Among the risk factors evaluated, only family history (hazard ratio, 3.8; 95% confidence interval, 1.5-9.7; P = .012) and extent of GIM (odds ratio, 9.4; 95% confidence interval, 1.8-50.4) increased the risk for gastric cancer. The incidence rate for gastric cancer in patients with a positive family history was 8.12 (95% confidence interval, 1
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Profit, J; Zupancic, J A F; McCormick, M C; Richardson, D K; Escobar, G J; Tucker, J; Tarnow‐Mordi, W; Parry, G
2006-01-01
Objective To compare gestational age at discharge between infants born at 30–34+6 weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom. Design Prospective observational cohort study. Setting Fifty four United Kingdom, five California, and five Massachusetts NICUs. Subjects A total of 4359 infants who survived to discharge home after admission to an NICU. Main outcome measures Gestational age at discharge home. Results The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p = 0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI −1.2 to 3.0) days earlier in Massachusetts. Conclusions Infants of 30–34+6 weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants. PMID:16449257
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Materials Data on CoMo (SG:221) by Materials Project
DOE Office of Scientific and Technical Information (OSTI.GOV)
Kristin Persson
Computed materials data using density functional theory calculations. These calculations determine the electronic structure of bulk materials by solving approximations to the Schrodinger equation. For more information, see https://materialsproject.org/docs/calculations
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Como reembolsar sus prestamos para estudiantes (Repaying Your Student Loans).
ERIC Educational Resources Information Center
Office of Federal Student Aid (ED), Washington, DC.
This guide, written in Spanish, discusses how to repay student loans. Following a general introduction, the guide discusses the grace period before repayment and repayment requirements. Repayment plans are described for Perkins Loans, Direct Loans, and Federal Family Education Loans. Repayment options are discussed, including consolidation,…
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El Espanol como Idioma Universal (Spanish as a Universal Language)
ERIC Educational Resources Information Center
Mijares, Jose
1977-01-01
A proposal to transform Spanish into a universal language because it possesses the prerequisites: it is a living language, spoken in several countries; it is a natural language; and it uses the ordinary alphabet. Details on simplification and standardization are given. (Text is in Spanish.) (AMH)
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Scalable and expressive medical terminologies.
Mays, E; Weida, R; Dionne, R; Laker, M; White, B; Liang, C; Oles, F J
1996-01-01
The K-Rep system, based on description logic, is used to represent and reason with large and expressive controlled medical terminologies. Expressive concept descriptions incorporate semantically precise definitions composed using logical operators, together with important non-semantic information such as synonyms and codes. Examples are drawn from our experience with K-Rep in modeling the InterMed laboratory terminology and also developing a large clinical terminology now in production use at Kaiser-Permanente. System-level scalability of performance is achieved through an object-oriented database system which efficiently maps persistent memory to virtual memory. Equally important is conceptual scalability-the ability to support collaborative development, organization, and visualization of a substantial terminology as it evolves over time. K-Rep addresses this need by logically completing concept definitions and automatically classifying concepts in a taxonomy via subsumption inferences. The K-Rep system includes a general-purpose GUI environment for terminology development and browsing, a custom interface for formulary term maintenance, a C+2 application program interface, and a distributed client-server mode which provides lightweight clients with efficient run-time access to K-Rep by means of a scripting language.
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Zhang, Y Tara; Laraia, Barbara A; Mujahid, Mahasin S; Blanchard, Samuel D; Warton, E Margaret; Moffet, Howard H; Karter, Andrew J
2016-07-01
We examined whether residing within 2 miles of a new supermarket opening was longitudinally associated with a change in body mass index (BMI). We identified 12 new supermarkets that opened between 2009 and 2010 in 8 neighborhoods. Using the Kaiser Permanente Northern California Diabetes Registry, we identified members with type 2 diabetes residing continuously in any of these neighborhoods 12 months prior to the first supermarket opening until 10 months following the opening of the last supermarket. Exposure was defined as a reduction (yes/no) in travel distance to the nearest supermarket as a result of a new supermarket opening. First difference regression models were used to estimate the impact of reduced supermarket distance on BMI, adjusting for longitudinal changes in patient and neighborhood characteristics. Among patients in the exposed group, new supermarket openings reduced travel distance to the nearest supermarket by 0.7 miles on average. However, reduced distance to nearest supermarket was not associated with BMI changes. Overall, we found no evidence that reduced supermarket distance was associated with reduced levels of obesity for residents with type 2 diabetes. Published by Elsevier Ltd.
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PS3-21: Extracting Utilization Data from Clarity into VDW Using Oracle and SAS
Chimmula, Srivardhan
2013-01-01
Background/Aims The purpose of the presentation is to demonstrate how we use SAS and Oracle to load VDW_Utilization, VDW_DX, and VDW_PX tables from Clarity at the Kaiser Permanente Northern California (KPNC) Division of Research (DOR) site. Methods DOR uses the best of Oracle PL/ SQL and SAS capabilities in building Extract Transform and Load (ETL) processes. These processes extract patient encounter, diagnosis, and procedure data from Teradata-based Clarity. The data is then transformed to fit HMORN’s VDW definitions of the table. This data is then loaded into the Oracle-based VDW table on DOR’s research database and then finally a copy of the table is also created as a SAS dataset. Results DOR builds robust and efficient ETL processes that refresh VDW Utilization table on a monthly basis processing millions of records/observations. The ETL processes have the capability to identify daily changes in Clarity and update the VDW tables on a daily basis. Conclusions KPNC DOR combines the best of both Oracle and SAS worlds to build ETL processes that load the data into VDW Utilization tables efficiently.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Reynolds, P.
This project was initiated, in response to concerns that the observed excess of malignant melanoma among employees of Lawrence Livermore National Laboratory (LLNL) might reflect the incidence of disease diagnostically different than that observed in the general population. LLNL sponsored a slide review project, inviting leading dermatopathology experts to independently evaluate pathology slides from LLNL employees diagnosed with melanoma and those from a matched sample of Bay Area melanoma patients who did not work at the LLNL. The study objectives were to: Identify all 1969--1984 newly diagnosed cases of malignant melanoma among LLNL employees resident in the San Francisco-Oakland Metropolitanmore » Statistical Area, and diagnosed at facilities other than Kaiser Permanente; identify a comparison series of melanoma cases also diagnosed between 1969--1984 in non-Kaiser facilities, and matched as closely as possible to the LLNL case series by gender, race, age at diagnosis, year of diagnosis, and hospital of diagnosis; obtain pathology slides for the identified (LLNL) case and (non-LLNL) comparison patients for review by the LLNL-invited panel of dermatopathology experts; and to compare the pathologic characteristics of the case and comparison melanoma patients, as recorded by the dermatopathology panel.« less
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Bae, Esther; Dehal, Ahmed; Franz, Vanessa; Joannides, Michael; Sakis, Nicholas; Scurlock, Joshua; Nguyen, Patrick; Hussain, Farabi
2016-12-01
Although guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. We retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. Of 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. The administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use. Copyright © 2016 Elsevier Inc. All rights reserved.
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Peterson, Eric D; Spertus, John A; Cohen, David J; Hlatky, Mark A; Go, Alan S; Vickrey, Barbara G; Saver, Jeffrey L; Hinton, Patricia C
2009-11-01
The field of outcomes research seeks to define optimal treatment in practice and to promote the rapid full adoption of efficacious therapies into routine clinical care. The American Heart Association (AHA) formed the AHA Pharmaceutical Roundtable (PRT) Outcomes Research Centers Network to accelerate attainment of these goals. Participating centers were intended to carry out state-of-the-art outcomes research in cardiovascular disease and stroke, to train the next generation of investigators, and to support the formation of a collaborative research network. After a competitive application process, 4 AHA PRT Outcomes Research Centers were selected: Duke Clinical Research Institute; Saint Luke's Mid America Heart Institute; Stanford University-Kaiser Permanente of Northern California; and University of California, Los Angeles. Each center proposed between 1 and 3 projects organized around a single theme in cardiovascular disease or stroke. Additionally, each center will select and train up to 6 postdoctoral fellows over the next 4 years, and will participate in cross-collaborative activities among the centers. The AHA PRT Outcomes Research Centers Network is designed to further strengthen the field of cardiovascular disease and stroke outcomes research by fostering innovative research, supporting high quality training, and encouraging center-to-center collaborations.
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Le patrimoine astronomique provençal
NASA Astrophysics Data System (ADS)
Rous, M.; Figon, P.; Guyot, S.
2012-12-01
L'OSU OAMP/Institut Pythéas porte les missions de conservation, inventaire et valorisation du patrimoine. Suite à la fusion de l'Observatoire de Marseille et du Laboratoire d'Astronomie Spatiale en 2000 pour créer le Laboratoire d'Astrophysique de Marseille, le déménagement des équipes sur le site de Château-Gombert en 2008 a soulevé le problème du devenir des collections des deux sites d'origine. Nous ferons le bilan des actions passées en matière de conservation et de valorisation de ce riche patrimoine : versement à l'inventaire général du Ministère de la Culture, classement de 22 instruments au titre des Monuments Historiques, inventaire et numérisation des archives anciennes, montage d'expositions et réalisation du catalogue Telescopium, 400 ans de lunettes et de télescopes. Nous présenterons les actions en cours: mesures de conservation préventive, inventaire des archives et des instruments. Nous parlerons enfin des projets: création d'un espace d'exposition permanente, participation à des expositions temporaires.
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The greatest challenges reported by long-term colorectal cancer survivors with stomas.
McMullen, Carmit K; Hornbrook, Mark C; Grant, Marcia; Baldwin, Carol M; Wendel, Christopher S; Mohler, M Jane; Altschuler, Andrea; Ramirez, Michelle; Krouse, Robert S
2008-04-01
This paper presents a qualitative analysis of the greatest challenges reported by long-term colorectal cancer survivors with ostomies. Surveys that included an open-ended question about challenges of living with an ostomy were administered at three Kaiser Permanente regions: Northern California, Northwest, and Hawaii. The study was coordinated at the Southern Arizona Veterans Affairs Health Care System in Tucson. The City of Hope Quality of Life Model for Ostomy Patients provided a framework for the study's design, measures, data collection, and data analysis. The study's findings may be generalized broadly to community settings across the United States. Results replicate those of previous research among veterans, California members of the United Ostomy Association, Koreans with ostomies, and colorectal cancer survivors with ostomies residing in the United Kingdom. The greatest challenges reported by 178 colorectal cancer survivors with ostomies confirmed the Institute of Medicine's findings that survivorship is a distinct, chronic phase of cancer care and that cancer's effects are broad and pervasive. The challenges reported by study participants should inform the design, testing and integration of targeted education, early interventions, and ongoing support services for colorectal cancer patients with ostomies.
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Outcomes in Patients Treated with a Novel, Simple Method for Hemostasis of Dermal Avulsion Injuries.
Dowling, Sean Taylor; Lin, Brian Wai
2017-10-01
A recently described technique proposes a simple method to achieve permanent hemostasis of distal fingertip dermal avulsion injuries. It is simple to learn and easy to perform with readily available materials found in most emergency departments. However, long-term outcomes for patients treated with this technique have not yet been evaluated. A primary objective of the current article is to provide safety data for the technique using an off-label product indication. Emergency department of Kaiser Permanente Medical Center, San Francisco, California. Six patients were treated in the emergency department for fingertip dermal avulsion injuries using a tourniquet and tissue adhesive glue (Dermabond by Ethicon, Somerville, New Jersey). Patients were subsequently contacted to assess healing and satisfaction with cosmetic outcome through interview and photographs of their wounds at 9 months following the date of injury. All 6 patients were satisfied with the cosmetic outcome of treatment, and none received a diagnosis of serious complications. This series demonstrates cosmetic outcomes for injuries treated with the technique, highlights potential problems that may be perceived by patients during their clinical course, and creates the groundwork for a larger clinical study examining the use of the technique.
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Examining HIV Viral Load in a Matched Cohort of HIV Positive Individuals With and Without Psoriasis.
Wu, Jashin J; Gilbert, Kathleen E; Batech, Michael; Manalo, Iviensan F; Towner, William J; Raposo, Rui André Saraiva; Nixon, Douglas F; Liao, Wilson
2017-04-01
BACKGROUND: HIV-associated psoriasis is well-documented. Genetic, cellular, and cytokine profiles have been used as evidence to suggest psoriasis activates antiviral pathways. There has been a lack of epidemiologic evidence investigating whether psoriasis patients have lower HIV viral counts compared to non-psoriasis patients.
OBJECTIVE: Compare the viral load set point of HIV positive patients with and without psoriasis.
METHODS: A retrospective matched cohort study of HIV positive patients with and without psoriasis using the Kaiser Permanente Southern California Health Plan database.
RESULTS: We identified 101 HIV-positive psoriasis cases; 19 met inclusion criteria and were matched with 3-5 control patients; 94 total patients were analyzed. The mean age was 41.4 (12.07) years and 83% were male. Overall, the median log of the viral load of cases was slightly higher than controls (4.3 vs 4.2; P less than 0.01).
CONCLUSIONS: The serum viral load set point of patients with HIV and psoriasis was slightly higher than the viral load set point of HIV patients without psoriasis.
J Drugs Dermatol. 2017;16(4):372-377.
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Schiffman, Mark; Katki, Hormuzd A.; Castle, Philip E.; Fetterman, Barbara; Wentzensen, Nicolas; Poitras, Nancy E.; Lorey, Thomas; Cheung, Li C.; Kinney, Walter K.
2014-01-01
Primary human papillomavirus (HPV) testing (without concurrent Pap tests) every 3 years is under consideration in the United States as an alternative to the two recommended cervical cancer screening strategies: primary Pap testing every 3 years, or concurrent Pap and HPV testing (“cotesting”) every 5 years. Using logistic regression and Weibull survival models, we estimated and compared risks of cancer and cervical intraepithelial neoplasia grade 3 or worse (CIN3+) for the three strategies among 1011092 women aged 30 to 64 years testing HPV-negative and/or Pap-negative in routine screening at Kaiser Permanente Northern California since 2003. All statistical tests were two sided. Three-year risks following an HPV-negative result were lower than 3-year risks following a Pap-negative result (CIN3+ = 0.069% vs 0.19%, P < .0001; Cancer = 0.011% vs 0.020%, P < .0001) and 5-year risks following an HPV-negative/Pap-negative cotest (CIN3+ = 0.069% vs 0.11%, P < .0001; Cancer = 0.011% vs 0.014%, P = .21). These findings suggest that primary HPV testing merits consideration as another alternative for cervical screening. PMID:25038467
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Gage, Julia C; Schiffman, Mark; Katki, Hormuzd A; Castle, Philip E; Fetterman, Barbara; Wentzensen, Nicolas; Poitras, Nancy E; Lorey, Thomas; Cheung, Li C; Kinney, Walter K
2014-08-01
Primary human papillomavirus (HPV) testing (without concurrent Pap tests) every 3 years is under consideration in the United States as an alternative to the two recommended cervical cancer screening strategies: primary Pap testing every 3 years, or concurrent Pap and HPV testing ("cotesting") every 5 years. Using logistic regression and Weibull survival models, we estimated and compared risks of cancer and cervical intraepithelial neoplasia grade 3 or worse (CIN3+) for the three strategies among 1011092 women aged 30 to 64 years testing HPV-negative and/or Pap-negative in routine screening at Kaiser Permanente Northern California since 2003. All statistical tests were two sided. Three-year risks following an HPV-negative result were lower than 3-year risks following a Pap-negative result (CIN3+ = 0.069% vs 0.19%, P < .0001; Cancer = 0.011% vs 0.020%, P < .0001) and 5-year risks following an HPV-negative/Pap-negative cotest (CIN3+ = 0.069% vs 0.11%, P < .0001; Cancer = 0.011% vs 0.014%, P = .21). These findings suggest that primary HPV testing merits consideration as another alternative for cervical screening. © Published by Oxford University Press 2014.
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ERIC Educational Resources Information Center
Haddab, Mustapha
1994-01-01
Analyzes conditions that have led to an increase in private and collective educational initiatives in Algeria, highlighting political and socioeconomic changes since 1988. Indicates that after a long period of a public education monopoly, social factors have led to the development of alternative educational opportunities that are more responsive…
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Múltiples estados de desorden en el etanol sólido
NASA Astrophysics Data System (ADS)
Fernández-Perea, R.
El diagrama de fases del etanol por debajo de los 169 K será presentado. Se mostrará que el etanol puede solidificarse en tres fases con diversos niveles de desorden,(como un vidrio(G), como un vidrio orientacional (OG) y como un cristal de fase rotora (RP)) además de en una fase totalmente cristalina. Las estructuras de estas tres fases serán presentadas tal y como se deducen a partir de diversas medidas de difracción de neutrones al igual que las proporciones de los isómeros de dicho material en las fases desordenadas y se compararán con los resultados de la fase cristalina y del líquido superenfriado. Igualmente diversas medidas sobre su dinámica serán presentadas, tanto de dispersión de neutrones, como de capacidad calorífica y de medidas dieléctricas y comparadas con modelos teóricos y simulaciones para tratar de explicar los procesos de relajación observados y las transiciones entre las diversas fases.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Dugulan, A.I.; Overweg, A.R.; Craje, M.W.J.
2005-04-26
The behavior of CoMo/Al2O3 catalysts sulfided in H2S/H2 gas mixture, under industrial conditions, was investigated using Moessbauer emission spectroscopy (MES). An intermediate Co-Mo phase is formed after increasing the sulfidation pressure to 4 MPa, favoring the Co-Mo-S phase formation. An increase in the quadrupole splitting value of the Co-sulfide species after treatment at 573 K is proposed as a prerequisite for the formation of ideal Co-Mo-S structures.
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Questioning the claims from Kaiser
Talbot-Smith, Alison; Gnani, Shamini; Pollock, Allyson M; Gray, Denis Pereira
2004-01-01
Background: The article by Feachem et al, published in the BMJ in 2002, claimed to show that, compared with the United Kingdom (UK) National Health Service (NHS), the Kaiser Permanente healthcare system in the United States (US) has similar healthcare costs per capita, and performance that is considerably better in certain respects. Aim: To assess the accuracy of Feachem et al's comparison and conclusions. Method: Detailed re-examination of the data and methods used and consideration of the 82 letters responding to the article. Results: Analyses revealed four main areas in which Feachem et al's methodology was flawed. Firstly, the populations of patients served by Kaiser Permanente and by the NHS are fundamentally different. Kaiser's patients are mainly employed, significantly younger, and significantly less socially deprived and so are healthier. Feachem et al fail to adjust adequately for these factors. Secondly, Feachem et al have wrongly inflated NHS costs by omitting substantial user charges payable by Kaiser members for care, excluding the costs of marketing and administration, and deducting the surplus from Kaiser's costs while underestimating the capital charge element of the NHS budget and other costs. They also used two methods of converting currency, the currency rate and a health purchasing power parity conversion. This is double counting. Feachem et al reported that NHS costs were 10% less per head than Kaiser. Correcting for the double currency conversion gives the NHS a 40% cost advantage such that per capita costs are $1161 and $1951 for the NHS and Kaiser, respectively. Thirdly, Feachem et al use non-standardised data for NHS bed days from the Organisation for Economic Cooperation and Development, rather than official Department of Health bed availability and activity statistics for England. Leaving aside the non-comparability of the population and lack of standardisation of the data, the result is to inflate NHS acute bed use and underestimate the
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Leutz, Walter; Nonnenkamp, Lucy; Dickinson, Lynn; Brody, Kathleen
2005-01-01
Abstract Purpose Our objective was to describe the utilization and costs of services from 1985 to 2002 of a Social Health Maintenance Organization (SHMO) demonstration project providing a benefit for home-based and community-based as well as short-term institutional (HCB) care at Kaiser Permanente Northwest (KPNW), serving the Portland, Oregon area. The HCB care benefit was offered by KPNW as a supplement to Medicare's acute care medical benefits, which KPNW provides in an HMO model. KPNW receives a monthly per capita payment from Medicare to provide medical benefits, and Medicare beneficiaries who choose to join pay a supplemental premium that covers prescription drugs, HCB care benefits, and other services. A HCB care benefit of up to $12,000 per year in services was available to SHMO members meeting requirement for nursing home certification (NHC). Methods We used aggregate data to track temporal changes in the period 1985 to 2002 on member eligibility, enrollment in HCB care plans, age, service utilization and co-payments. Trends in the overall costs and financing of the HCB care benefit were extracted from quarterly reports, management data, and finance data. Results During the time period, 14,815 members enrolled in the SHMO and membership averaged 4,531. The proportion of SHMO members aged 85 or older grew from 12 to 25%; proportion meeting requirements for NHC rose from 4 to 27%; and proportion with HCB care plans rose from 4 to 18%. Costs for the HCB care benefit rose from $21 per SHMO member per month in 1985 to $95 in 2002. The HCB care costs were equivalent to 12% to 16% of Medicare reimbursement. The HCB program costs were covered by member premiums (which rose from $49 to $180) and co-payments from members with care plans. Over the 18-year period, spending shifted from nursing homes to a range of community services, e.g. personal care, homemaking, member reimbursement, lifeline, equipment, transportation, shift care, home nursing, adult day care
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Analysis of Family Clinical, vision of service nurses.
Raimundi, Daniele Merisio; Ferreira, Francieli Furtado; Lima, Fernanda Cristina Aguiar; Siqueira, Valeria de Carvalho Araújo
2016-06-01
to know the practice of the Family Clinic in Cuiaba and its relationship with the precepts of the expanded clinic, from the perspective of the service nurses. qualitative descriptive research, data collection with semi-structured interviews and results analyzed according to the method of thematic content analysis. for nurses working in the service, this assumes a differentiated and innovative proposal, which seeks to correlate with shared management in its three spheres. Although most do not know the Enlarged Clinic term in his speech cited its main principles and its tools. The greatest potential described were related to the Support Center for Health and popular participation, and as challenges, the lack of community health worker, the national health establishment registration and the difficulty of operation due to the profile of the professionals technical level arising from secondary care. The clinic has positive aspects that can contribute to the advancement of the profession, to train health professionals and an innovative primary care model. Therefore, it emphasizes the need for implementation of continuing education in order to realize its proposal, and further studies on site. conhecer a prática da Clínica da Família em Cuiabá e sua relação com os preceitos da clínica ampliada, sob a perspectiva dos enfermeiros do serviço. pesquisa descritiva qualitativa, coleta de dados com entrevista semi-estruturada e resultados analisados segundo o método de análise de conteúdo do tipo temática. para os enfermeiros atuantes no serviço, este assume uma proposta diferenciada e inovadora, no qual busca se correlacionar com a gestão compartilhada em suas três esferas. Apesar de a maioria não conhecer o termo Clínica Ampliada em suas falas citaram seus principais preceitos e suas ferramentas. As maiores potencialidades descritas foram a relação com o Núcleo de Apoio à Saúde da Família e a participação popular, e como desafios, a falta de agente
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Silva, Cristiane Gonçalves da; Santos, Alessandro Oliveira; Licciardi, Daniele Carli; Paiva, Vera; Parker, Richard
2008-01-01
Esse artigo descreve como jovens religiosos e autoridades religiosas de sua comunidade compreendem a sexualidade, considerando suas experiências pessoais e como membros de comunidades religiosas. A análise pretende contribuir para que políticas públicas dedicadas à promoção da saúde sexual da juventude considerem a religiosidade, no contexto de um estado laico e da promoção do direito à prevenção. Foram realizadas 26 entrevistas abertas e semidirigidas em diferentes comunidades da região metropolitana da cidade de São Paulo (comunidades católicas, da umbanda, do candomblé e de diferentes denominações evangélicas) sobre iniciação sexual, casamento, gravidez, contracepção e prevenção das DST/Aids, homossexualidade, aborto e direitos humanos. Observou-se como jovens e autoridades religiosas convivem com a tensão entre tradição e modernidade e os distintos discursos sobre a sexualidade. Como sujeitos religiosos (do discurso religioso) e sujeitos sexuais (de discursos sobre sexualidade), devem ser incorporados pelos programas como sujeitos de direito nos termos de sua religiosidade.
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Religiosidade, juventude e sexualidade: entre a autonomia e a rigidez1
Silva, Cristiane Gonçalves da; Santos, Alessandro Oliveira; Licciardi, Daniele Carli; Paiva, Vera; Parker, Richard
2009-01-01
Esse artigo descreve como jovens religiosos e autoridades religiosas de sua comunidade compreendem a sexualidade, considerando suas experiências pessoais e como membros de comunidades religiosas. A análise pretende contribuir para que políticas públicas dedicadas à promoção da saúde sexual da juventude considerem a religiosidade, no contexto de um estado laico e da promoção do direito à prevenção. Foram realizadas 26 entrevistas abertas e semidirigidas em diferentes comunidades da região metropolitana da cidade de São Paulo (comunidades católicas, da umbanda, do candomblé e de diferentes denominações evangélicas) sobre iniciação sexual, casamento, gravidez, contracepção e prevenção das DST/Aids, homossexualidade, aborto e direitos humanos. Observou-se como jovens e autoridades religiosas convivem com a tensão entre tradição e modernidade e os distintos discursos sobre a sexualidade. Como sujeitos religiosos (do discurso religioso) e sujeitos sexuais (de discursos sobre sexualidade), devem ser incorporados pelos programas como sujeitos de direito nos termos de sua religiosidade. PMID:21886456
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Sistema Solar: de la observación de La Tierra a los planetas gigantes y sus lunas
NASA Astrophysics Data System (ADS)
Rodrigo, R.
La fotoquímica tiene un papel principal en la composición de las atmósferas planetarias. Se examinan diferentes procesos fotoquímicos tanto para atmósferas oxidadas como reductoras, poniendo un especial énfasis en los ciclos químicos más importantes. En este sentido, se presentan diferentes ciclos químicos capaces de producir hidrocarbonos y nitrilos en atmósferas reductoras, así como aquellos capaces de mantener las proporciones de mezcla de las moléculas que contienen oxígeno, tales como CO2, O2 y H2O. También se analizan otros procesos importantes tales como la condensación y procesos de sputtering y de sublimación que han de tenerse en cuenta cuando se realizan modelos sobre la composición atmosférica.
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El dicloruro de paraquat, comúnmente conocido como “paraquat,” es uno de los herbicidas registrados de mayor uso en los Estados Unidos. El paraquat también se conoce como Gramaxone (un producto popular de uso final
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Como pagar to educacion, 2004-2005 (Funding Your Education, 2004-2005).
ERIC Educational Resources Information Center
Office of Federal Student Aid (ED), Washington, DC.
This publication, written in Spanish, describes financial aid programs of the U.S. Department of Education and advises students about paying for college. It outlines things a student should ask about college and how to obtain financial aid, whether grants, work-study, or loans. Chapters provide information on: (1) "Education after High School";…
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"Las Charlas" como expresion oral diaria ["Chats" as Daily Oral Practice].
ERIC Educational Resources Information Center
Borden, Matt
2002-01-01
An oral practice system of "chats" in the classroom functions as an extemporaneous speaking exercise or chat (without notes or prompt sheets), occurring between two students for a minute or so at the beginning of class, following which the presenters respond to other students' questions. (CNP)
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Gray, Carolyn Steele; Mercer, Stewart; Palen, Ted; McKinstry, Brian; Hendry, Anne
2016-01-01
Information technology (IT) in healthcare, also referred to as eHealth technologies, may offer a promising solution to the provision of better care and support for people who have multiple conditions and complex care needs, and their caregivers. eHealth technologies can include electronic medical records, telemonitoring systems and web-based portals, and mobile health (mHealth) technologies that enable information sharing between providers, patients, clients and their families. IT often acts as an enabler of improved care delivery, rather than being an intervention per se. But how are different countries seeking to leverage adoption of these technologies to support people who have chronic conditions and complex care needs? This article presents three case examples from Ontario (Canada), Scotland and Kaiser Permanente Colorado (United States) to identify how these jurisdictions are currently using technology to address multimorbidity. A SWOT (strengths, weaknesses, opportunities, threats) analysis is presented for each case and a final discussion addresses the future of eHealth for complex care needs. The case reports presented in this manuscript mark the foundational work of the Multi-National eHealth Research Partnership Supporting Complex Chronic Disease and Disability (the eCCDD Network); a CIHR-funded project intended to support the international development and uptake of eHealth tools for people with complex care needs.
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The Case for Unit-Based Teams: A Model for Front-line Engagement and Performance Improvement
Cohen, Paul M; Ptaskiewicz, Mark; Mipos, Debra
2010-01-01
Unit-based teams (UBTs)—defined as natural work groups of physicians, managers, and frontline staff who work collaboratively to solve problems, improve performance, and enhance quality—were established by the 2005 national agreement between Kaiser Permanente (KP) and the Coalition of KP Unions. They use established performance-improvement techniques and employee-engagement principles (including social-movement theory) to achieve clinical and operational goals. UBT members identify performance gaps and opportunities within their purview—issues they can address in the course of the day-to-day work, such as workflow or process improvement. By focusing on clear, agreed-on goals, UBTs encourage greater accountability and allow members to perform their full scope of work. UBTs are designed to deliver measurable benefits in clinical outcomes and operations, patient-experience enhancements, and physician-team performance or work life. For many physicians, UBTs will require new ways of engaging with their teams. However, evidence suggests that with organizational and physician support, these teams can achieve their goals. This article presents case examples of successful UBTs' outcomes; physicians' comments on their experience working with teams; an overview of UBTs' employee-engagement principles; and advice on how physicians can support and participate in the work of such teams. PMID:20740124
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La guerra de los Estados Unidos contra la inmigración. Efectos paradójicos1
Massey, Douglas S.; Pren, Karen A.
2016-01-01
Resumen A finales de la década de los cincuenta, Estados Unidos permitía la entrada de aproximadamente medio millón de inmigrantes mexicanos al año, de los cuales 450.000 entraban con visados de trabajo temporal y 50.000 llegaban con visados de residentes permanentes. A mediados de los años sesenta, los cambios en la política migratoria de Estados Unidos realizados en nombre de los derechos civiles redujeron drásticamente las oportunidades de entrada legal a Estados Unidos. Se eliminaron los visados de trabajo temporal y se limitaron los visados de residentes a 20.000 por año. Con las oportunidades de entrada legal restringidas, los flujos migratorios ya establecidos simplemente continuaron, fuera de los límites legales, dando comienzo a una inesperada reacción en cadena de eventos que culminaron en una guerra total contra los inmigrantes y el rápido crecimiento -sin precedentes- de población residente no autorizada en Estados Unidos. El presente artículo demuestra que el aumento de inmigración indocumentada en los Estados Unidos y el crecimiento de la población sin papeles son un producto de políticas migratorias y fronterizas mal concebidas. PMID:27076695
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Pressman, Alice; Jacobson, Alice; Eguilos, Roderick; Gelfand, Amy; Huynh, Cynthia; Hamilton, Luisa; Avins, Andrew; Bakshi, Nandini; Merikangas, Kathleen
2016-04-01
The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan. We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008-March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race. The period prevalence of medically-ascertained migraine among KPNC adults during April 2008-March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites. We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies. © International Headache Society 2015.
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NASA Astrophysics Data System (ADS)
Hoang, Long Phan; Sacovy, Paulette; Delaplace, Jean
1983-02-01
Des rubans d'alliages amorphes Metglas du type Fe 40Ni 38Mo 4B 18 à l'état brut de trempe ont été déformés par traction à la température ambiante et l'on a suivi les variations de la résistance électrique des échantillons au cours de la déformation. Il ressort de ces essais que la déformation plastique qui est de l'ordre de 0.5% avant rupture ne se produit pas de faĉon homogène dans l'échantillon. Les mesures électriques effectuées au cours de la déformation mettent en évidence dans le domaine élastique un effet d'élastorésistance, relativement important ( K ≠ 1); elles montrent que dans le domaine plastique la déformation permanente des échantillons s'accompagne d'une diminution de la résistivité électrique du matériau. Deux hypothèses sont discutées pour expliquer cet effet inattendu, l'un qui fait appel à l'existence de volumes libres, l'autre qui suppose une cristallisation localisée du matériau sous l'effet de la contrainte.
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Bendectin and human congenital malformations.
Shiono, P H; Klebanoff, M A
1989-08-01
The relationship between Bendectin exposure during the first trimester of pregnancy and the occurrence of congenital malformations was prospectively studied in 31,564 newborns registered in the Northern California Kaiser Permanente Birth Defects Study. The odds ratio for any major malformation and Bendectin use was 1.0 (95% confidence interval 0.8-1.4). There were 58 categories of congenital malformations; three of them were statistically associated with Bendectin exposure (microcephaly--odds ratio = 5.3, 95% confidence interval = 1.8-15.6; congenital cataract--odds ratio = 5.3, 95% confidence interval = 1.2-24.3; lung malformations (ICD-8 codes 484.4-484.8)--odds ratio = 4.6, 95% confidence interval = 1.9-10.9). This is exactly the number of associations that would be expected by chance. An independent study (the Collaborative Perinatal Project) was used to determine whether vomiting during pregnancy in the absence of Bendectin use was associated with these three malformations. Two of the three (microcephaly and cataract) had strong positive associations with vomiting in the absence of Bendectin use. We conclude that there is no increase in the overall rate of major malformations after exposure to Bendectin and that the three associations found between Bendectin and individual malformations are unlikely to be causal.
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A new web-based system to improve the monitoring of snow avalanche hazard in France
NASA Astrophysics Data System (ADS)
Bourova, Ekaterina; Maldonado, Eric; Leroy, Jean-Baptiste; Alouani, Rachid; Eckert, Nicolas; Bonnefoy-Demongeot, Mylene; Deschatres, Michael
2016-05-01
Snow avalanche data in the French Alps and Pyrenees have been recorded for more than 100 years in several databases. The increasing amount of observed data required a more integrative and automated service. Here we report the comprehensive web-based Snow Avalanche Information System newly developed to this end for three important data sets: an avalanche chronicle (Enquête Permanente sur les Avalanches, EPA), an avalanche map (Carte de Localisation des Phénomènes d'Avalanche, CLPA) and a compilation of hazard and vulnerability data recorded on selected paths endangering human settlements (Sites Habités Sensibles aux Avalanches, SSA). These data sets are now integrated into a common database, enabling full interoperability between all different types of snow avalanche records: digitized geographic data, avalanche descriptive parameters, eyewitness reports, photographs, hazard and risk levels, etc. The new information system is implemented through modular components using Java-based web technologies with Spring and Hibernate frameworks. It automates the manual data entry and improves the process of information collection and sharing, enhancing user experience and data quality, and offering new outlooks to explore and exploit the huge amount of snow avalanche data available for fundamental research and more applied risk assessment.
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Economic benefit of chemical dependency treatment to employers.
Jordan, Neil; Grissom, Grant; Alonzo, Gregory; Dietzen, Laura; Sangsland, Scott
2008-04-01
Using assessment data from the Substance Abuse Treatment Support System, we estimated the economic benefit of chemical dependency treatment to employers. A cohort of individuals (N = 498) treated at Kaiser Permanente's Addiction Medicine programs in Southern California completed assessments before and at least 30 days after treatment began. Compared to intake, subsequent assessments indicated substantial reduction in the number of patients who missed work, were late for work, were less productive than usual at work, and/or had conflict with coworkers or management. The net economic value of these improvements to their employers depended upon the utilization rate of the benefit and the salary level of the employees receiving treatment. For a utilization rate of 0.9% and a mean annual salary of US$45,000, the net benefit of treatment was US$1,538 for > or = 61 days of treatment. Based solely upon these employment-related measures, without factoring in the medical cost offset or indirect benefits of treatment that may help employees to maintain higher levels of productivity, employers break even on an investment of US$30 per member per year for a chemical dependency treatment benefit if the mean annual salary of the employees participating in treatment is US$36,565.
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Silber, Jeffrey H; Lorch, Scott A; Rosenbaum, Paul R; Medoff-Cooper, Barbara; Bakewell-Sachs, Susan; Millman, Andrea; Mi, Lanyu; Even-Shoshan, Orit; Escobar, Gabriel J
2009-01-01
Objective To determine whether longer stays of premature infants allowing for increased physical maturity result in subsequent postdischarge cost savings that help counterbalance increased inpatient costs. Data Sources One thousand four hundred and two premature infants born in the Northern California Kaiser Permanente Medical Care Program between 1998 and 2002. Study Design/Methods Using multivariate matching with a time-dependent propensity score we matched 701 “Early” babies to 701 “Late” babies (developmentally similar at the time the earlier baby was sent home but who were discharged on average 3 days later) and assessed subsequent costs and clinical outcomes. Principal Findings Late babies accrued inpatient costs after the Early baby was already home, yet costs after discharge through 6 months were virtually identical across groups, as were clinical outcomes. Overall, after the Early baby went home, the Late–Early cost difference was $5,016 (p<.0001). A sensitivity analysis suggests our conclusions would not easily be altered by failure to match on some unmeasured covariate. Conclusions In a large integrated health care system, if a baby is ready for discharge (as defined by the typical criteria), staying longer increased inpatient costs but did not reduce postdischarge costs nor improve postdischarge clinical outcomes. PMID:19207592
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Zuber, Christi Dining; Moody, Louise
There is an increasing drive in health care for creativity and innovation to tackle key health challenges, improve quality and access, and reduce harm and costs. Human-centered design (HCD) is a potential approach to achieving organizational innovation. However, research suggests the nursing workforce feels unsupported to take the risks needed for innovation, and leaders may not understand the conditions required to fully support them. The aim of this study was to identify enabling conditions that support frontline nurses in their attempts to behave as champions of innovation and change. An HCD workshop was undertaken with 125 nurses employed in clinical practice at Kaiser Permanente. The workshop included empathy mapping and semistructured questions that probed participant experiences with innovation and change. The data were collated and thematic analysis undertaken through a Grounded Theory approach. The data were analyzed to identify key enabling conditions. Seven enablers emerged: personal need for a solution; challenges that have meaningful purpose; clarity of goal and control of resources; active experimentation; experiences indicating progress; positive encouragement and confidence; and provision of psychological safety. These enablers were then translated into pragmatic guidelines for leaders on how the tools of HCD may be leveraged for innovation and change in health care.
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Keegan, Theresa H M; Kurian, Allison W; Gali, Kathleen; Tao, Li; Lichtensztajn, Daphne Y; Hershman, Dawn L; Habel, Laurel A; Caan, Bette J; Gomez, Scarlett L
2015-05-01
We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer-specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.
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Risk factors for anal HPV infection and anal precancer in HIV-infected men who have sex with men.
Schwartz, Lauren M; Castle, Philip E; Follansbee, Stephen; Borgonovo, Sylvia; Fetterman, Barbara; Tokugawa, Diane; Lorey, Thomas S; Sahasrabuddhe, Vikrant V; Luhn, Patricia; Gage, Julia C; Darragh, Teresa M; Wentzensen, Nicolas
2013-12-01
Carcinogenic human papillomaviruses (HPVs) cause a large proportion of anal cancers. Human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) are at increased risk of HPV infection and anal cancer compared with HIV-negative men. We evaluated risk factors for HPV infection and anal precancer in a population of HIV-infected MSM. Our study included 305 MSM at an HIV/AIDS clinic in the Kaiser Permanente Northern California Health Maintenance Organization. Logistic regression was used to estimate associations of risk factors comparing men without anal HPV infection; men with anal HPV infection, but no precancer; and men with anal precancer. Low CD4 count (<350 cells/mm(3)) and previous chlamydia infection were associated with an increased risk of carcinogenic HPV infection (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.28-10.40 and OR, 4.24; 95% CI, 1.16-15.51, respectively). History of smoking (OR, 2.71 95% CI, 1.43-5.14), duration, recency, and dose of smoking increased the risk of anal precancer among carcinogenic HPV-positive men but had no association with HPV infection. We found distinct risk factors for anal HPV infection and anal precancer. Risk factors for HPV infection and anal precancer are similar to established risk factors for cervical cancer progression.
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Bruxvoort, Katia; Sy, Lina S; Luo, Yi; Tseng, Hung Fu
2018-04-11
The US Food and Drug Administration is charged with expanding the use of real world evidence (RWE) for regulatory decisions. As a test case for RWE to support regulatory decisions, we present the scenario of concomitant vaccination with zoster vaccine live (ZVL) and 23-valent pneumococcal polysaccharide vaccine (PPSV23). The prescribing information states that these vaccines should not be given concurrently, based on a small trial using varicella zoster virus antibody levels as a correlate of ZVL efficacy, even though ZVL protects against herpes zoster via cell-mediated immunity. We conducted an observational cohort study involving >30,000 members of Kaiser Permanente Southern California receiving concomitant ZVL and PPSV23 versus PPSV23 prior to ZVL. Occurrence of herpes zoster was assessed through electronic health records from January 1, 2007 to June 30, 2016. The adjusted hazard ratio comparing incidence rates of herpes zoster in the concomitant vaccination cohort and the prior vaccination cohort was 1.04 (95% CI: 0.92, 1.16). This RWE study provides direct evidence for a lack of vaccine interference, relying on herpes zoster occurrence rather than an intermediate marker of immunity. RWE is essential for regulators and policy makers in addressing evidentiary gaps regarding safety, effectiveness, compliance, and vaccine interactions for the new recombinant zoster vaccine.
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The response of the US Centers for Disease Control and Prevention to the obesity epidemic.
Dietz, William H
2015-03-18
The recognition of the obesity epidemic as a national problem began in 1999 with the Centers for Disease Control and Prevention's (CDC's) publication of a series of annual state-based maps that demonstrated the rapid changes in the prevalence of obesity. Increasing rates of obesity had been noted in earlier CDC studies, but the maps provided evidence of a rapid, nationwide increase. The urgent need to respond to the epidemic led to the identification of state targets and the first generation of interventions for obesity prevention and control. The CDC's role was to provide setting- and intervention-specific guidance on implementing these strategies, and to assess changes in targeted policies and behaviors. The CDC's efforts were augmented by Congressional funding for community initiatives to improve nutrition and increase physical activity. Complementary investments by Kaiser Permanente, the Robert Wood Johnson Foundation, and the Institute of Medicine improved the evidence base and provided policy recommendations that reinforced the need for a multisectoral approach. Legislative, regulatory, and voluntary initiatives enacted by President Obama's administration translated many of the strategies into effective practice. Whether current efforts to address obesity can be sustained will depend on whether they can be translated into greater grass-roots engagement consistent with a social movement.
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Red wine consumption not associated with reduced risk of colorectal cancer.
Chao, Chun; Haque, Reina; Caan, Bette J; Poon, Kwun-Yee T; Tseng, Hung-Fu; Quinn, Virginia P
2010-01-01
Red wine contains polyphenol antioxidants that inhibit colorectal cancer (CRC) development in animal studies. We investigated the effect of red wine intake on risk of CRC in the California Men's Health Study (CMHS). CMHS is a prospective, multiethnic cohort of middle-aged men who were members of the Kaiser Permanente (KP) California Health Plans and completed study questionnaires between 2002-2003. Incident CRC were identified from the health plan cancer registries through the end of 2007 (n = 287). To properly account for potential confounding by previous endoscopy screening, we restricted the primary analyses to CMHS men continuously enrolled in KP between 1998-2002 (n = 43,483 and CRC = 176). We used multivariable Cox regression to adjust for important confounders. We did not find an inverse association between moderate red wine intake and risk of CRC. The hazard ratio for consuming >/=1 drink/day (average = 2 drinks/day) was 1.16, 95% confidence intervals 0.56-2.40. There was no linear dose-response. The lack of clear association for red wine intake was consistently observed when we stratified the analyses by CRC stage at diagnosis and cancer site (colon or rectum). Moderate red wine consumption was not associated with reduced risk of colorectal cancer in this population of middle-aged men.
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Positive relationship of sleep apnea to hyperaldosteronism in an ethnically diverse population.
Sim, John J; Yan, Eric H; Liu, In Lu A; Rasgon, Scott A; Kalantar-Zadeh, Kamyar; Calhoun, David A; Derose, Stephen F
2011-08-01
Approximately, 50-60% of patients with sleep apnea have hypertension. To explore a mechanism of this relationship, we compared its prevalence in a hypertensive population with and without hyperaldosteronism. Using the Kaiser Permanente Southern California database, hypertensive individuals who had plasma aldosterone and plasma renin activity measured between 1 January 2006 and 31 December 2007 were evaluated. Hyperaldosteronism was defined as an aldosterone : renin ratio more than 30 and plasma aldosterone more than 20 ng/dl or an aldosterone : renin ratio more than 50 (ng/dl : ng/ml per h). Hypertension was identified by International Classification of Disease, Ninth Revision (ICD-9) coding and sleep apnea was defined by ICD-9 coding or procedural coding for dispensation of positive airway devices. Of 3428 hypertensive patients, 575 (17%) had hyperaldosteronism. Sleep apnea was present in 18% (105) with hyperaldosteronism vs. 9% (251) without hyperaldosteronism (P < 0.001). Odds ratio for sleep apnea in patients with hyperaldosteronism was 1.8 (95% confidence interval 1.3-2.6) after controlling for other sleep apnea risk factors. No ethnic group was at greater risk for sleep apnea. The prevalence of sleep apnea in a diverse hypertensive population is increased in patients with hyperaldosteronism, even when controlling for other sleep apnea risk factors.
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Integrated delivery systems: the cure for fragmentation.
Enthoven, Alain C
2009-12-01
Our healthcare system is fragmented, with a misalignment of incentives, or lack of coordination, that spawns inefficient allocation of resources. Fragmentation adversely impacts quality, cost, and outcomes. Eliminating waste from unnecessary, unsafe care is crucial for improving quality and reducing costs--and making the system financially sustainable. Many believe this can be achieved through greater integration of healthcare delivery, more specifically via integrated delivery systems (IDSs). An IDS is an organized, coordinated, and collaborative network that links various healthcare providers to provide a coordinated, vertical continuum of services to a particular patient population or community. It is also accountable, both clinically and fiscally, for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them. The marketplace already contains numerous styles and degrees of integration, ranging from Kaiser Permanente-style full integration, to more loosely organized individual practice associations, to public-private partnerships. Evidence suggests that IDSs can improve healthcare quality, improve outcomes, and reduce costs--especially for patients with complex needs--if properly implemented and coordinated. No single approach or public policy will fix the fragmented healthcare system, but IDSs represent an important step in the right direction.
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Lui, Camillia K; Sterling, Stacy A; Chi, Felicia W; Lu, Yun; Campbell, Cynthia I
2017-05-01
Socioeconomic status (SES) has been consistently linked to poorer access, utilization and outcomes of health care services, but this relationship has been understudied in adolescent substance abuse treatment research. This study examined SES differences in adolescent's treatment participation and long-term outcomes of abstinence and 12-step attendance over five years after treatment. Data are from 358 adolescents (ages 13-18) who were recruited at intake to substance abuse treatment between 2000 and 2002 at four Kaiser Permanente Northern California outpatient treatment programs. Follow-up interviews of adolescents and their parents were conducted at 1, 3, and 5years, with over 80% response rates across time points. Using parent SES as a proxy for adolescent SES, no socioeconomic differences were found in treatment initiation, treatment retention, or long-term abstinence from alcohol or drugs. Parent education, but not parent income, was significantly associated with 12-step attendance post-treatment such that adolescents with higher parent education were more likely to attend than those with lower parent education. Findings suggest a lack of socioeconomic disparities in substance abuse treatment participation in adolescence, but potential disparities in post-treatment 12-step attendance during the transition from adolescence to young adulthood. Copyright © 2017 Elsevier Ltd. All rights reserved.
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Somatic mutations in benign breast disease tissue and risk of subsequent invasive breast cancer.
Rohan, Thomas E; Miller, Christopher A; Li, Tiandao; Wang, Yihong; Loudig, Olivier; Ginsberg, Mindy; Glass, Andrew; Mardis, Elaine
2018-06-06
Insights into the molecular pathogenesis of breast cancer might come from molecular analysis of tissue from early stages of the disease. We conducted a case-control study nested in a cohort of women who had biopsy-confirmed benign breast disease (BBD) diagnosed between 1971 and 2006 at Kaiser Permanente Northwest and who were followed to mid-2015 to ascertain subsequent invasive breast cancer (IBC); cases (n = 218) were women with BBD who developed subsequent IBC and controls, individually matched (1:1) to cases, were women with BBD who did not develop IBC in the same follow-up interval as that for the corresponding case. Targeted sequence capture and sequencing were performed for 83 genes of importance in breast cancer. There were no significant case-control differences in mutation burden overall, for non-silent mutations, for individual genes, or with respect either to the nature of the gene mutations or to mutational enrichment at the pathway level. For seven subjects with DNA from the BBD and ipsilateral IBC, virtually no mutations were shared. This study, the first to use a targeted multi-gene sequencing approach on early breast cancer precursor lesions to investigate the genomic basis of the disease, showed that somatic mutations detected in BBD tissue were not associated with breast cancer risk.
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ERIC Educational Resources Information Center
Mansfield, Gillian; Poppi, Franca
2012-01-01
The function of English as a lingua franca for communication needs rethinking in the teaching of English as a foreign language classroom as a consequence of globalisation. The present contribution is an empirical study carried out in an Italian university environment which aims to show how teachers should take on board awareness raising activities…
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Genetic analysis of maternal ability in Iberian pigs.
Rodriguez, C; Rodrigañez, J; Silio, L
1994-01-12
cuando el crecimiento del lechón depende exclusivamente de la producción lechera de la madre. Mediante el procedimiento DFREML se han estimado parámetros genéticos para el tamaño de camada al nacimiento (LS) y peso de la camada a 21 dias (LW21) a partir de 4883 camadas (2049 para LW21) de cerdos Ibéricos. Análisis preliminares mostraron la inexistencia de efectos genéticos maternales significativos sobre ambos caracteres. El modelo ha incluido el efecto fijo de la paridera (86 niveles), orden de parto (6) y los coeficientes de consanguinidad de la madre (Fd) y de la camada (Fl) como covariables, y tres efectos aleatorios: valor genético aditivo, ambiente permanente y residuo. La heredabilidad y repetibilidad estimadas fueron 0,064 y 0,126 (LS) y 0,163 y 0,270 (LW21). Las correlaciones genética y fenotipica fueron 0,214 y 0,043. La depresión consanguinea por 10 % de aumento de Fd o Fl fue -0,150 y -0,170 lechones vivos para LS y -0,983 y - 1,023 kg para LW21. Cuando el modelo para LW21 incluyó como covariables la consanguinidad de la madre y el número de lechones criados, la heredabilidad y repetibilidad estimadas fueron 0,243 y 0,431. Se efectuó un análisis complementario mediante un modelo con efectos maternos de registros de peso a 21 dias de 26206 lechones nacidos de 1317 cerdas. Las estimas de heredabilidad, heredabilidad maternal y coeficiente de ambiente común de camada fueron 0,019, 0,163 y 0,128 respectivamente, reforzando la evidencia de variabilidad genética para la aptitud lechera en cerdas Ibéricas. Los valores de depresión consanguinea estimados para el peso del lechón a 21 dias fueron -0,072 y -0,098 kg por 10 % de aumento de consanguinidad de la madre o del individuo. 1994 Blackwell Verlag GmbH.
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Helenistic Encomium: A Reflection on Comics and Rhetoric
ERIC Educational Resources Information Center
Helms, Jason
2009-01-01
This video reflection starts in a presentation on comics at the Thomas R. Watson Conference last October, which prompted the author to explore the etymology of cosmos and comos through an alternate reading of Gorgias' "Encomium of Helen". The author then works with comos, as revelry, to offer thoughts on comics as a form of multimodal composition…
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Cuauhtemoc Saenz-Romero; Gerald E. Rehfeldt; Nicholas L. Crookston; Pierre Duval; Jean Beaulieu
2009-01-01
El cambio climatico, conocido comunmente como calentamiento global, es el incremento de la temperatura a nivel mundial y los cambios que de ello derivan, causados por el "efecto invernadero" del bioxido de carbono (CO2) y otros gases emitidos a la atmosfera. El uso de combustibles fosiles (carbon y derivados del petroleo, como gasolina, diesel, combustoleo y...
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Uso de terreno urbano y rural en Puerto Rico
Sebastian Martinuzzi; William A. Gould; Olga M. Ramos Gonzalez; Maya Quinones; Michael E. Jimenez
2008-01-01
El Proyecto de Analisis de Gap de Puerto Rico (PRGAP) (Gould et al. 2008) desarrollo tres usos de terrenos para Puerto Rico: Urbano, Suburbano, y Rural (Martinuzzi et al. 2007). Estas regiones tambien pueden ser consideradas como urbano, densamente-poblado rural, y escasamente-poblado rural, o como urbano y area silvestre con una interfase de area silvestre-urbana. La...
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Contributions of local knowledge to the physical limnology of Lake Como, Italy.
Laborde, Sarah; Imberger, Jörg; Toussaint, Sandy
2012-04-24
This article shows how local knowledge may be valuably integrated into a scientific approach in the study of large and complex hydrological systems where data collection at high resolution is a challenge. This claim is supported through a study of the hydrodynamics of a large lake where qualitative data collected from professional fishers was combined with theory to develop a hypothesis that was then verified by numerical modeling. First the fishermen's narratives were found to describe with accuracy internal wave motions that were evident in water column temperature records, which revealed their practical knowledge of the lake's hydrodynamics. Second, local knowledge accounts emphasized the recurrent formation of mesoscale gyres and return flows in certain zones of the lake in stratified conditions, which did not appear in the physical data because of limitations of sampling resolution. We hypothesized that these features developed predominantly because of the interaction of wind-driven internal motions with the lake's bathymetry, and the Earth's rotation in the widest areas of the basin. Numerical simulation results corroborated the fishers' descriptions of the flow paths and supported the hypothesis about their formation. We conclude that the collaboration between scientific and local knowledge groups, although an unusual approach for a physical discipline of the geosciences, is worth exploring in the pursuit of a more comprehensive understanding of complex geophysical systems such as large lakes.
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Management, Maintenance, and Upkeep of the Baseline COMO III Air Defense Model.
1986-10-20
weapon subsystems. The sensor subsystems include passive, infrared (IR), television, and a nonimaging sensor and observer, typically the vehicle driver...initially scheduled from the enter game event (DGO) and is rescheduled on a cyclic basis. When radar target detection occurs, the optical search process (DG9...one search cycle in elevation by the track radar/gunner’s optics . DG1 constantly monitors the radar surveillance search volume and when a higher
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Como Lo Hago Yo: Defectos Del Cierre Del Tubo Neural En Nicaragua
Gonzalez, Juan Bosco
2014-01-01
En Nicaragua no hay un plan de forltificación de alimentos con ácido fólico. Las madres son muy jóvenes. En La Mascota operamos mas de cuarenta niños por año. Derivación tardía es un problema. La infección preoperatoria tiene que ser descartada. Vancomicina y Ceftriaxone estan indicadas. Estricta regla de asepsia operatoria. Suturamos la plaqueta para asemejar su forma al cilindro normal de la médula. No ceramos la capa de músculo. PMID:24791221
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DESAFÍOS ÉTICOS DE LA INVESTIGACIÓN CON ANIMALES, MANIPULACIÓN GENÉTICA
Yunta, Eduardo Rodríguez
2012-01-01
En la investigación con animales existen cuestionamientos éticos tanto en el uso como modelos de enfermedades humanas y requisito previo para ensayos en humanos como en la introducción de modificaciones genéticas. Algunos de estos cuestionamientos son: no representar exactamente la condición humana como modelos, realizar pruebas de toxicidad con grave daño para los animales, alterar su naturaleza mediante modificaciones genéticas, riesgos de la introducción de organismos genéticamente modificados. El uso de animales en investigación para beneficio humano, impone al ser humano la responsabilidad moral de respetarlo, no haciéndoles sufrir innecesariamente, al estar trabajando con seres vivientes y sentientes. PMID:23338641
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Reis, Mario S; Moreira Dos Santos, Antonio F
Por s culos, acreditou-se que o magnetismo s se manifestava em metais, como aqueles contendo ferro; hoje, a imagem mais comum de um m talvez seja a daquelas plaquinhas flex veis coladas geladeira com propagandas dos mais diversos tipos. O leitor conseguiria imaginar um material puramente org nico daqueles que formam os seres vivos como magn tico? E m s do tamanho de mol culas? fato: ambos existem. Esses novos materiais, conhecidos como magnetos moleculares, descobertos e desenvolvidos em v rios laborat rios do mundo, j re nem longa lista de aplica es, do tratamento do c ncer a refrigeradoresmore » ecol gicos, passando pela transmiss o de eletricidade sem perda de calor e a fabrica o de computadores extremamente velozes.« less
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Family history of zoster and risk of developing herpes zoster.
Tseng, Hung Fu; Chi, Margaret; Hung, Peggy; Harpaz, Rafael; Schmid, D Scott; LaRussa, Philip; Sy, Lina S; Luo, Yi; Holmquist, Kimberly; Takhar, Harpreet; Jacobsen, Steven J
2018-01-01
Studies have investigated a possible association between family history of HZ and the occurrence of HZ. However, the results were inconclusive and susceptible to bias. We evaluated this association in an elderly population. The matched case-control study conducted at Kaiser Permanente Southern California in 2012-2015 included 656 incident HZ patients ≥60 whose skin lesion tested positive for varicella zoster virus by polymerase chain reaction. Half of the HZ patients were vaccinated with zoster vaccine as achieved by stratified sampling. The controls were randomly selected and 1:1 matched to the cases on sex, age (±1year), and zoster vaccination (±3 months of the case's vaccination date). Conditional logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI). Having any blood relative with a history of HZ was associated with a slightly increased risk of HZ (adjusted OR=1.37, 95% CI 1.05-1.79). The adjusted OR associated with having one and two categories of first-degree blood relatives with a history of HZ was 1.30 (95% CI: 0.97-1.73) and 2.53 (95% CI: 1.17-5.44), respectively. Our results suggested a weak association between the development of HZ and a positive family history of HZ among the elderly population. Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.
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Tseng, Hung Fu; Chi, Margaret; Smith, Ning; Marcy, Stephen M; Sy, Lina S; Jacobsen, Steven J
2012-07-15
The benefit of vaccinating immunocompetent patients who have had shingles has not been examined. The study assessed the association between vaccination and the incidence of herpes zoster recurrence among persons with a recent episode of clinically diagnosed herpes zoster. This is a matched cohort study in Kaiser Permanente Southern California. Study populations were immunocompetent elderly individuals ≥ 60 years old with a recent episode of herpes zoster. Incidence of recurrent herpes zoster was compared between the vaccinated and the unvaccinated matched cohorts. A total of 1036 vaccinated and 5180 unvaccinated members were included. On the basis of clinically confirmed cases, the incidence of recurrent herpes zoster among persons aged <70 years was 0.99 (95% confidence interval [CI], .02-5.54) and 2.20 (95% CI, 1.10-3.93) cases per 1000 person-years in the vaccinated and unvaccinated cohorts, respectively. The adjusted hazard ratio was 0.39 (95% CI, .05-4.45) among persons aged <70 years and 1.05 (95% CI, .30-3.69) among persons aged ≥ 70 years. The risk of herpes zoster recurrence following a recent initial episode is fairly low among immunocompetent adults, regardless of vaccination status. Such a low risk suggests that one should evaluate the necessity of immediately vaccinating immunocompetent patients who had a recent herpes zoster episode.
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Tsai, Jerry; Shaul, Donald B; Sydorak, Roman M; Lau, Stanley T; Akmal, Yasir; Rodriguez, Karen
2013-01-01
Increasing popularity of strong magnets as toys has led to their ingestion by children, putting them at risk of potentially harmful gastrointestinal tract injuries. To heighten physician awareness of the potential complications of magnetic foreign body ingestion, and to provide an updated algorithm for management of a patient who is suspected to have ingested magnets. A retrospective review of magnet ingestions treated over a two-year period at our institutions in the Southern California Permanente Medical Group. Data including patient demographics, clinical information, radiologic images, and surgical records were used to propose a management strategy. Five patients, aged 15 months to 18 years, presented with abdominal symptoms after magnet ingestion. Four of the 5 patients suffered serious complications, including bowel necrosis, perforation, fistula formation, and obstruction. All patients were successfully treated with laparoscopic-assisted exploration with or without endoscopy. Total days in the hospital averaged 5.2 days (range = 3 to 9 days). Average time to discharge following surgery was 4 days (range = 2 to 7 days). Ex vivo experimentation with toy magnetic beads were performed to reveal characteristics of the magnetic toys. Physicians should have a heightened sense of caution when treating a patient in whom magnetic foreign body ingestion is suspected, because of the potential gastrointestinal complications. An updated management strategy is proposed that both prevents delays in surgical care and avoids unnecessary surgical exploration.
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Traumatismes Oculaires par Petards: Bilan sur Trois Annees
Zouaoui-Kesraoui, N.; Derdour, A.
2009-01-01
Summary Les accidents dus aux pétards sont des accidents graves. Leur recrudescence ces dernières années en Algérie, essentiellement durant les fêtes du Mawlid Ennabaoui (fête de la naissance du prophète), mérite à notre sens d'entreprendre des bilans exhaustifs dont celui-ci dans le but d'une sensibilisation de toutes les compétences concernées. Nous avons réuni sur trois années consécutives (2002, 2003, 2004) 60 dossiers de malades ayant subi des accidents oculaires par pétards. Nos patients sont répartis en 42 consultations pour blessures légères et 18 hospitalisations pour blessures graves. Parmi ces derniers, neuf ont présenté des complications et séquelles graves (cinq cas de cécité par atrophie du globe oculaire, trois cas de cécité cornéenne et un cas de cécité par trou maculaire). Dans tous ces cas l'incapacité permanente partielle est au minimum de 30%. Au vu de ces données nous proposons des mesures d'éducation sanitaire et une sensibilisation du grand public aux traumatismes oculaires, par le biais de mé dias appropriés: radio, télévision, affiches. PMID:21991157
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Zouaoui-Kesraoui, N; Derdour, A
2009-06-30
Les accidents dus aux pétards sont des accidents graves. Leur recrudescence ces dernières années en Algérie, essentiellement durant les fêtes du Mawlid Ennabaoui (fête de la naissance du prophète), mérite à notre sens d'entreprendre des bilans exhaustifs dont celui-ci dans le but d'une sensibilisation de toutes les compétences concernées. Nous avons réuni sur trois années consécutives (2002, 2003, 2004) 60 dossiers de malades ayant subi des accidents oculaires par pétards. Nos patients sont répartis en 42 consultations pour blessures légères et 18 hospitalisations pour blessures graves. Parmi ces derniers, neuf ont présenté des complications et séquelles graves (cinq cas de cécité par atrophie du globe oculaire, trois cas de cécité cornéenne et un cas de cécité par trou maculaire). Dans tous ces cas l'incapacité permanente partielle est au minimum de 30%. Au vu de ces données nous proposons des mesures d'éducation sanitaire et une sensibilisation du grand public aux traumatismes oculaires, par le biais de mé dias appropriés: radio, télévision, affiches.
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Mouchawar, Judy; Hensley-Alford, Sharon; Laurion, Suzanne; Ellis, Jennifer; Kulchak-Rahm, Alanna; Finucane, Melissa L; Meenan, Richard; Axell, Lisen; Pollack, Rebecca; Ritzwoller, Debra
2005-03-01
To describe the impact of Myriad Genetics, Inc.'s direct-to-consumer advertising (DTC-ad) campaign on cancer genetic services within two Managed Care Organizations, Kaiser Permanente Colorado (KPCO), Denver, Colorado, where the ad campaign occurred, and Henry Ford Health System (HFHS), Detroit, Michigan, where there were no advertisements. The main outcome measures were the changes in number and pretest mutation probability of referrals approved for cancer genetic services at KPCO and HFHS during the campaign versus the year prior, and mutation probability of those undergoing testing. At KPCO, referrals increased 244% during the DTC-ad compared to the same time period a year earlier (P value<0.001). The proportion of referrals at high pretest probability of a mutation (10% or greater) dropped from 69% the previous year to 48% during the campaign (P value<0.001). There was no significant change in pretest mutation probability among women who underwent testing between the two time periods. HFHS reported no significant change between the two time periods for numbers or mutation probability of referrals, or for mutation probability of women tested. The DTC-ad caused significant increase in demand for cancer genetic services. In the face of potential future DTC-ad for inherited cancer risk, providers and payers need to consider the delivery of genetic services and genetic education for persons of all risk levels.
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Pressman, Alice; Jacobson, Alice; Eguilos, Roderick; Gelfand, Amy; Huynh, Cynthia; Hamilton, Luisa; Avins, Andrew; Bakshi, Nandini; Merikangas, Kathleen
2016-01-01
Introduction The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan. Methods We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008–March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race. Results The period prevalence of medically-ascertained migraine among KPNC adults during April 2008–March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites. Conclusions We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies. PMID:26069243
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Antidepressant Medication Use, Depression and the Risk of Preeclampsia
Avalos, Lyndsay Ammon; Chen, Hong Y.; Li, De-Kun
2018-01-01
Objective To assess the effects of depression and antidepressant medication use during pregnancy on the risk of preeclampsia. Methods We conducted a retrospective, population-based cohort study linking automated clinical and pharmacy databases including comprehensive electronic medical records of 21,589 pregnant Kaiser Permanente Northern California members between 2010 and 2012. Results The overall risk of preeclampsia was 4.5%. The timing of antidepressant medication exposure was an important factor. A significant increase in the risk of preeclampsia emerged for women with a depression diagnosis who took antidepressant medications during the second trimester compared to women with untreated depression (adjusted Relative Risk (aRR): 1.6, 95% CI: 1.06, 2.39), and to women without depression (aRR: 1.70, 95% CI: 1.30, 2.23). Similar associations existed for women who took antidepressant medications, but without depression. In contrast, depressed women with psychotherapy showed no increased risk of preeclampsia compared to women with untreated depression or no depression. There was also a statistically significant relationship between the duration of antidepressant medication use and preeclampsia. The observed association appeared stronger for SSRI use, although a non-significant trend was also noted for use of NDRIs and SNRIs. Conclusion Study findings suggest that the antidepressant use during pregnancy may increase the risk of preeclampsia, especially the use during the second trimester. PMID:25778691
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Cigarette Smoking and the Risk of Barrett's Esophagus
Kubo, Ai; Levin, T.R.; Block, Gladys; Rumore, Gregory; Quesenberry, Charles P.; Buffler, Patricia; Corley, Douglas A.
2008-01-01
Introduction We examined the association between smoking and the risk of Barrett's esophagus (BE), a metaplastic precursor to esophageal adenocarcinoma. Methods We conducted a case-control study within the Kaiser Permanente Northern California population. Patients with a new diagnosis of BE (n=320) were matched to persons with gastroesophageal reflux disease (GERD) (n=316) and to population controls (n=317). Information was collected using validated questionnaires from direct in-person interviews and electronic databases. Analyses used multivariate unconditional logistic regression that controlled for age, gender, race and education. Results Ever smoking status, smoking intensity (pack-years), and smoking cessation were not associated with the risk of BE. Stratified analyses suggested that ever smoking may be associated with an increased risk of BE among some groups (compared to population controls): persons with long-segment Barrett's esophagus (odds ratio [OR]=1.72, 95% confidence interval [CI] 1.12-2.63); subjects without GERD symptoms (OR=3.98, 95% CI 1.58-10.0); obese subjects (OR=3.38, 95%CI 1.46-7.82); and persons with a large abdominal circumference (OR=3.02, 95%CI (1.18-2.75)). Conclusion Smoking was not a strong or consistent risk factor for BE in a large community-based study, although associations may be present in some population subgroups. PMID:18853262
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Kurian, Allison W.; Gali, Kathleen; Tao, Li; Lichtensztajn, Daphne Y.; Hershman, Dawn L.; Habel, Laurel A.; Caan, Bette J.; Gomez, Scarlett L.
2015-01-01
Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment. Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010. Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival. Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients. PMID:25790426
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Reavis, James A; Looman, Jan; Franco, Kristina A; Rojas, Briana
2013-01-01
Background: Empirical research associated with the Kaiser Permanente and Centers for Disease Control and Prevention Adverse Childhood Experiences (ACE) Study has demonstrated that ACE are associated with a range of negative outcomes in adulthood, including physical and mental health disorders and aggressive behavior. Methods: Subjects from 4 different offender groups (N = 151) who were referred for treatment at an outpatient clinic in San Diego, CA, subsequent to conviction in criminal court, completed the ACE Questionnaire. Groups (nonsexual child abusers, domestic violence offenders, sexual offenders, and stalkers) were compared on the incidence of ACE, and comparisons were made between the group offenders and a normative sample. Results: Results indicated that the offender group reported nearly four times as many adverse events in childhood than an adult male normative sample. Eight of ten events were found at significantly higher levels among the criminal population. In addition, convicted sexual offenders and child abusers were more likely to report experiencing sexual abuse in childhood than other offender types. Conclusions: On the basis of a review of the literature and current findings, criminal behavior can be added to the host of negative outcomes associated with scores on the ACE Questionnaire. Childhood adversity is associated with adult criminality. We suggest that to decrease criminal recidivism, treatment interventions must focus on the effects of early life experiences. PMID:23704843
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Selection bias between 2 Medicare capitated benefit programs.
Leutz, Walter; Brody, Kathleen K; Nonnenkamp, Lucy L; Perrin, Nancy A
2007-04-01
To assess enrollment selection bias between a standard Medicare health maintenance organization (HMO) and a higher-priced social health maintenance organization (SHMO) offering full prescription drug and unique home-based and community-based benefits and to assess how adverse selection was handled through SHMO finances. Kaiser Permanente Northwest offered the dual-choice option in the greater Portland region from 1985 to 2002. Analysis focused on 3 "choice points" when options were clear and highlighted for beneficiaries. Data collected included age and sex, utilization 1 year before and after the choice points, health status data at enrollment (1999-2002 only), mortality, and cost and revenues. Data were extracted from health plan databases. Hospital, pharmacy, and nursing facility utilization for 1 year before and after the choice points are compared for HMO and SHMO choosers. Health and functional status data are compared from 1999 to 2002. Utilization and mortality data are controlled by age and sex. SHMO joiners evidenced adverse selection, while healthier members tended to stay in the HMO, with leaner benefits. Despite adverse selection, the health plan maintained margins in the SHMO, assisted by frailty-adjusted Medicare payments and member premiums. This high-low option strategy sought to offer the "right care at the right time" and may be a model for managed care organizations to serve aging and disabled beneficiaries under Medicare's new special needs plan option.
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Hechter, Rulin C; Chao, Chun; Sy, Lina S; Ackerson, Bradley K; Slezak, Jeff M; Sidell, Margo A; Jacobsen, Steven J
2013-09-01
We examined whether maternal utilization of preventive care and history of sexually transmitted infections (STIs) predicted quadrivalent human papillomavirus vaccine (HPV4) uptake among adolescent boys 1 year following the recommendation for permissive use of HPV4 for males. We linked maternal information with electronic health records of 254 489 boys aged 9 to 17 years who enrolled in Kaiser Permanente Southern California health plan from October 21, 2009, through December 21, 2010. We used multivariable Poisson regression with robust error variance to examine whether HPV4 initiation was associated with maternal uptake of influenza vaccine, Papanicolaou (Pap) screening, and history of STIs. We identified a modest but statistically significant association between initiation of HPV4 series and maternal receipt of influenza vaccine (rate ratio [RR] = 1.16; 95% confidence interval [CI] = 1.07, 1.26) and Pap screening (RR = 1.13; 95% CI = 1.01, 1.26). Boys whose mothers had a history of genital warts were more likely to initiate HPV4 (RR = 1.47; 95% CI = 0.93, 2.34), although the association did not reach statistical significance (P = .1). Maternal utilization of preventive care and history of genital warts may influence HPV4 uptake among adolescent boys. The important role of maternal health characteristics and health behaviors needs be considered in intervention efforts to increase vaccine uptake among boys.
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Foss Durant, Anne; McDermott, Shawna; Kinney, Gwendolyn; Triner, Trudy
2015-01-01
In early 2010, leaders within Kaiser Permanente (KP) Northern California's Patient Care Services division embarked on a journey to embrace and embed core tenets of Caring Science into the practice, environment, and culture of the organization. Caring Science is based on the philosophy of Human Caring, a theory articulated by Jean Watson, PhD, RN, AHN-BC, FAAN, as a foundational covenant to guide nursing as a discipline and a profession. Since 2010, Caring Science has enabled KP Northern California to demonstrate its commitment to being an authentic person- and family-centric organization that promotes and advocates for total health. This commitment empowers KP caregivers to balance the art and science of clinical judgment by considering the needs of the whole person, honoring the unique perception of health and healing that each member or patient holds, and engaging with them to make decisions that nurture their well-being. The intent of this article is two-fold: 1) to provide context and background on how a professional practice framework was used to transform the ethic of caring-healing practice, environment, and culture across multiple hospitals within an integrated delivery system; and 2) to provide evidence on how integration of Caring Science across administrative, operational, and clinical areas appears to contribute to meaningful patient quality and health outcomes.
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Tamayo, Aracely; Mujahid, Mahasin S; Laraia, Barbara; Warton, E Margaret; Blanchard, Samuel D; Kelly, Maggi; Moffet, Howard H; Adler, Nancy; Schillinger, Dean; Karter, Andrew J
2016-10-01
While stress has been linked to poor health outcomes, little is known about the impact of objective measures of neighborhood crime on stress in patients with chronic disease. Using the Kaiser Permanente Diabetes Study of Northern California (DISTANCE), we examined associations between police-recorded crime (2005-2007) and stress (Perceived Stress Scale-4) in four large Northern California cities (Oakland, Sacramento, San Francisco, and San Jose). We performed stratified analysis by gender and race/ethnicity using generalized linear regression models. In our study sample (n = 3188, mean age 59, range 30-77), 10 % reported high stress. In adjusted analyses, higher neighborhood all crimes rate was associated with modest increase in high stress for African-American (OR = 1.10; 95 % CI 1.02-1.22) and Latina women (OR = 1.36; 95 % CI 1.10-1.67) and property crime showed similar associations with stress for these groups of women. Visible crime was associated with stress only for Latina women (OR = 1.43; 95 % CI 1.14-1.78). We found no association between crime and stress among men or other racial/ethnic groups of women. High crime levels may disproportionately impact health among certain subpopulations. Studies using additional measures of stress are necessary to differentiate the health impact of crime-related stress from other forms of stressors among individuals living with diabetes.
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Banerjee, Souvik; Garrison, Louis P; Flum, David R; Arterburn, David E
2017-09-01
The aim of this study was to compare the cost and health care utilization of patients with obesity and type 2 diabetes mellitus (T2DM) randomized into either Roux-en-Y gastric bypass (RYGB) surgery or an intensive lifestyle and medical intervention (ILMI). This analysis (N = 745) is based on 2-year follow-up of a small randomized controlled trial (RCT); adult patients with obesity and T2DM were recruited between 2011 and 2012 from Kaiser Permanente Washington. Comparisons were made for patients randomized into either RYGB (N = 15) or ILMI (N = 17). There were no significant cost savings for RYGB versus ILMI patients through the follow-up years. Pharmacy cost was lower for RYGB versus ILMI patients by about $900 in year 2 versus year 0; however, inpatient and emergency room costs were higher for surgery patients in follow-up years relative to year 0. Median total cost for nonrandomized patients was higher in year 0 and in year 2 compared to randomized patients. Bariatric surgery is not cost saving in the short term. Moreover, the costs of patients who enter into RCTs of RYGB may differ from the costs of those who do not enter RCTs, suggesting use of caution when using such data to draw inferences about the general population with obesity. © 2017 The Obesity Society.
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LaMere, Brandon J.; Kornegay, Janet; Fetterman, Barbara; Sadorra, Mark; Shieh, Jen; Castle, Philip E.
2009-01-01
Human papillomavirus (HPV) genotyping could be clinically useful, depending on the results of large, prospective studies like the HPV Persistence and Progression cohort. The cohort is based on genotyping and follow-up of Hybrid Capture-positive women at Kaiser Permanente, Northern California. HPV DNA testing by Hybrid Capture 2 requires denaturation with alkali, possibly damaging the DNA for optimal PCR-based genotyping. A feasibility study was conducted on paired aliquots of anonymized specimens from 100 women with low-grade intraepithelial lesion cytology. Test aliquots were left in denaturant for 10 or 18 hours at 4°C and then neutralized; comparison aliquots were not denatured but diluted to match the timing, temperature, concentration and salt conditions of the treated specimens. The masked aliquots were tested using a commercialized PCR-based assay that detects of 37 HPV genotypes. There was no overall effect of treatment on test positivity or number of types. HPV16 was marginally more likely to be detected in untreated versus treated aliquots (P = 0.09) but HPV45 was marginally more likely to be detected in treated than untreated aliquots (P = 0.07), suggesting that these differences represented chance (intra-test variability). It can be concluded that residual Hybrid Capture-positive specimens can be accurately genotyped by PCR after Hybrid Capture 2 processing. PMID:17673302
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Durant, Anne Foss; McDermott, Shawna; Kinney, Gwendolyn; Triner, Trudy
2015-01-01
In early 2010, leaders within Kaiser Permanente (KP) Northern California’s Patient Care Services division embarked on a journey to embrace and embed core tenets of Caring Science into the practice, environment, and culture of the organization. Caring Science is based on the philosophy of Human Caring, a theory articulated by Jean Watson, PhD, RN, AHN-BC, FAAN, as a foundational covenant to guide nursing as a discipline and a profession. Since 2010, Caring Science has enabled KP Northern California to demonstrate its commitment to being an authentic person- and family-centric organization that promotes and advocates for total health. This commitment empowers KP caregivers to balance the art and science of clinical judgment by considering the needs of the whole person, honoring the unique perception of health and healing that each member or patient holds, and engaging with them to make decisions that nurture their well-being. The intent of this article is two-fold: 1) to provide context and background on how a professional practice framework was used to transform the ethic of caring-healing practice, environment, and culture across multiple hospitals within an integrated delivery system; and 2) to provide evidence on how integration of Caring Science across administrative, operational, and clinical areas appears to contribute to meaningful patient quality and health outcomes. PMID:26828076
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Infants 1-90 days old hospitalized with human rhinovirus infection.
Bender, Jeffrey M; Taylor, Charla S; Cumpio, Joven; Novak, Susan M; She, Rosemary C; Steinberg, Evan A; Marlowe, Elizabeth M
2014-09-01
Human rhinovirus (HRV) is a common cause of respiratory illness in children. The impact of HRV infection on 1- to 90-day-old infants is unclear. We hypothesized that HRV infection would be clinically similar to respiratory syncytial virus (RSV) infection in the hospitalized infants. We conducted a retrospective study of hospitalized infants, who were 1-90 days old, with HRV or RSV within the Southern California Kaiser Permanente network over a 1-year period (August 2010 to October 2011). We identified 245 hospitalized infants who underwent respiratory virus testing. HRV was found in 52 infants (21%) compared to 79 infants (32%) with RSV (P = 0.008). Infants with HRV infection experienced longer hospital stays compared to those with RSV (median length of stay 4 days vs. 3 days, P = 0.009) and had fewer short hospital stays ≤3 days (P = 0.029). There was a trend in infants with HRV infection to be younger (P = 0.071) and have more fevers (P = 0.052). Recent advances in diagnostics allow for identification of a broad range of viral pathogens in infants. Compared to RSV, HRV was associated with longer hospital stays. Additional studies and improved, more specific testing, methods are needed to further define the effects of HRV infection in infants 1-90 days old. © 2014 Wiley Periodicals, Inc.
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Effect of influenza vaccination on hospitalizations in persons aged 50 years and older.
Baxter, Roger; Ray, G Thomas; Fireman, Bruce H
2010-10-21
To estimate influenza vaccine effectiveness (VE) in preventing hospitalizations in persons over 50 years of age. We performed a retrospective, population based study, using a "difference-in-differences" approach to determine the association between hospitalization and prior vaccination. We examined this association when influenza was not circulating and compared it to the association found when influenza was circulating. VE was estimated from the difference in the association between hospitalization and prior vaccination, inside vs. outside influenza seasons. Kaiser Permanente in Northern California. Health plan members aged 50 years and older during the September 1997 to August 2008 study period, when there were about 68,000 pneumonia hospitalizations in 10 million person-years. Vaccination was associated with lower risk of hospitalization for pneumonia and influenza, even before flu season, presumably due to unmeasured confounders. When influenza arrived the hospitalization-vaccination association strengthened, yielding an adjusted VE estimate of 12.4% (95% CI: 1.6-22.0) in persons aged 50-64, and 8.5% (95% CI: 3.3-13.5) in those aged 65 years and older. There was no significant effect on hospitalizations for ischemic heart disease (IHD), congestive heart failure (CHF), cerebrovascular disease (CVD), or trauma. Influenza vaccination has a modest but significant effect on prevention of hospitalization for pneumonia and influenza in persons 50 years of age and older. Copyright © 2010 Elsevier Ltd. All rights reserved.
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America's "undiscovered" laboratory for health services research.
Gimbel, Ronald W; Pangaro, Louis; Barbour, Galen
2010-08-01
Debate over reforming the nation's healthcare system has stimulated a need for health services research (HSR) models that are nationally applicable. Toward this end, the authors identify the Military Health System (MHS) as America's "undiscovered" laboratory for HSR. Although many may confuse the MHS with the Department of Veterans Affairs (VA), the 2 systems vary dramatically with respect to their beneficiary populations, access to care, and other important attributes. In this article, the authors describe key characteristics of the MHS including its large beneficiary base, its direct care operating environment, its dedicated medical school and graduate education programs, and its fully operational integrated health information system. Although a few health systems (eg, Kaiser Permanente, Partners Healthcare, and Department of Veterans Affairs) possess some characteristics, no other has all of these components in place. This article sets the stage for contemporary HSR studies with broad applicability to current issues in American healthcare that could be performed within the MHS. Inclusion of the MHS environment in HSR studies of health services delivery modalities, adoption of health information technology, access to care, relationship of medical education to effective safe care delivery, health disparities, child health, and behavioral health would provide strong underpinnings for proposed changes in American healthcare delivery. Finally, the article highlights current regulatory barriers to research within the MHS whereas suggesting steps to minimize their impact in conducting HSR.
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Food Environment and Weight Change: Does Residential Mobility Matter?
Laraia, Barbara A.; Downing, Janelle M.; Zhang, Y. Tara; Dow, William H.; Kelly, Maggi; Blanchard, Samuel D.; Adler, Nancy; Schillinger, Dean; Moffet, Howard; Warton, E. Margaret; Karter, Andrew J.
2017-01-01
Abstract Associations between neighborhood food environment and adult body mass index (BMI; weight (kg)/height (m)2) derived using cross-sectional or longitudinal random-effects models may be biased due to unmeasured confounding and measurement and methodological limitations. In this study, we assessed the within-individual association between change in food environment from 2006 to 2011 and change in BMI among adults with type 2 diabetes using clinical data from the Kaiser Permanente Diabetes Registry collected from 2007 to 2011. Healthy food environment was measured using the kernel density of healthful food venues. Fixed-effects models with a 1-year-lagged BMI were estimated. Separate models were fitted for persons who moved and those who did not. Sensitivity analysis using different lag times and kernel density bandwidths were tested to establish the consistency of findings. On average, patients lost 1 pound (0.45 kg) for each standard-deviation improvement in their food environment. This relationship held for persons who remained in the same location throughout the 5-year study period but not among persons who moved. Proximity to food venues that promote nutritious foods alone may not translate into clinically meaningful diet-related health changes. Community-level policies for improving the food environment need multifaceted strategies to invoke clinically meaningful change in BMI among adult patients with diabetes. PMID:28387785
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Parthasarathy, Sujaya; Altschuler, Andrea; Silverberg, Michael J.; Storholm, Erik; Campbell, Cynthia I.
2016-01-01
Objectives. To examine changes in HIV-positive patient enrollment in a large health care delivery system before and after key Affordable Care Act (ACA) provisions went into effect in 2014. Methods. Analyses compared HIV-positive patients newly enrolled in Kaiser Permanente Northern California between January and June 2012 (n = 339) to those newly enrolled between January and June 2014 through the California insurance exchange or via other mechanisms (n = 549). Results. After the ACA, the HIV-positive patient enrollment increased. These new enrollees were more likely to be male (93.6% vs 89.1%; P = .01), to be enrolled in high-deductible benefit plans (≥ $1000; 18.8% vs 5.5%; P = .01), and to have better HIV viral control (HIV RNA levels below limits of quantification 79.5% vs 73.6%; P = .05) compared with pre-ACA new enrollees. Among post-ACA new enrollees, there were more patients in the lowest and highest age groups. Post-ACA exchange enrollees (22%) were more likely to be male and to have high-deductible plans than those enrolled through other mechanisms. Conclusions. More men, higher deductibles, and better HIV viral control characterize newly enrolled HIV-positive patients after the ACA in California. Public health implications. Evolving characteristics of HIV-positive enrollees may affect HIV policy, patient care needs, and service utilization. PMID:27077361
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Kolasinski, Vallerie A; Price, David W
2015-01-01
Context: A Maintenance of Certification Part IV project was created on the basis of an existing, multifaceted hypertension improvement program. Objective: To evaluate the impact of the Maintenance of Certification project, the effects of the improvement options on blood pressure control in hypertensive patients, and the participants’ perception of the workload related to participation in the project. Design: Nonexperimental retrospective analysis. Setting: Kaiser Permanente hospitals and medical office buildings in Northern California. Intervention: Participants used one or more options from a defined menu of strategies to attempt to increase the percentage of hypertensive patients on their patient panels who had controlled blood pressure. Main Outcome Measure: Proportion of hypertensive patients with blood pressure ≤ 139/89 mm Hg. Results: Fifty-two American Board of Family Medicine and 19 American Board of Internal Medicine certified physicians completed projects. Mean panel blood pressure control improved from 79.49% (standard deviation [SD] = 11.32) to 84.64% (SD = 7.80). The choice of improvement option was not associated with the level of improvement or with the participants’ perception of the workload related to completing the project. Conclusion: Project participants improved the care of their patients without an increased perceived burden to their practice. We found no association between the choice of improvement option and either the level of improvement or the perception of workload. PMID:25785642
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Leonard, M; Graham, S; Bonacum, D
2004-10-01
Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common "critical language" to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.
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Lyles, Courtney R.; Karter, Andrew J.; Young, Bessie A.; Spigner, Clarence; Grembowski, David; Schillinger, Dean; Adler, Nancy
2011-01-01
Objective We examined provider-level factors and reported discrimination in the healthcare setting. Methods With data from the Diabetes Study of Northern California (DISTANCE)—a race-stratified survey of diabetes patients in Kaiser Permanente Northern California—we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables including racial concordance. Results Subjects (n=12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2% to 8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR=0.09; 95% CI: 0.01–0.67), those rating their provider higher on communication (OR=0.70; 95% CI: 0.66–0.74) were less likely to report discrimination, while those with more visits (OR=1.10; 95% CI: 1.03–1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity. Conclusions Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination. Practice Implications Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment. PMID:21605956
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Evaluation of a Pilot Implementation to Integrate Alcohol-Related Care within Primary Care
Bobb, Jennifer F.; Lee, Amy K.; Lapham, Gwen T.; Oliver, Malia; Ludman, Evette; Achtmeyer, Carol; Parrish, Rebecca; Caldeiro, Ryan M.; Lozano, Paula; Richards, Julie E.; Bradley, Katharine A.
2017-01-01
Alcohol use is a major cause of disability and death worldwide. To improve prevention and treatment addressing unhealthy alcohol use, experts recommend that alcohol-related care be integrated into primary care (PC). However, few healthcare systems do so. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington partnered to design a high-quality Program of Sustained Patient-centered Alcohol-related Care (SPARC). Here, we describe the SPARC pilot implementation, evaluate its effectiveness within three large pilot sites, and describe the qualitative findings on barriers and facilitators. Across the three sites (N = 74,225 PC patients), alcohol screening increased from 8.9% of patients pre-implementation to 62% post-implementation (p < 0.0001), with a corresponding increase in assessment for alcohol use disorders (AUD) from 1.2 to 75 patients per 10,000 seen (p < 0.0001). Increases were sustained over a year later, with screening at 84.5% and an assessment rate of 81 patients per 10,000 seen across all sites. In addition, there was a 50% increase in the number of new AUD diagnoses (p = 0.0002), and a non-statistically significant 54% increase in treatment within 14 days of new diagnoses (p = 0.083). The pilot informed an ongoing stepped-wedge trial in the remaining 22 PC sites. PMID:28885557
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Medication Exposure in Pregnancy Risk Evaluation Program
Andrade, Susan E.; Davis, Robert L.; Cheetham, T. Craig; Cooper, William O.; Li, De-Kun; Amini, Thushi; Beaton, Sarah J.; Dublin, Sascha; Hammad, Tarek A.; Pawloski, Pamala A.; Raebel, Marsha A.; Smith, David H.; Staffa, Judy A.; Toh, Sengwee; Dashevsky, Inna; Haffenreffer, Katherine; Lane, Kimberly; Platt, Richard; Scott, Pamela E.
2011-01-01
To describe a program to study medication safety in pregnancy, the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). MEPREP is a multi-site collaborative research program developed to enable the conduct of studies of medication use and outcomes in pregnancy. Collaborators include the U.S. Food and Drug Administration and researchers at the HMO Research Network, Kaiser Permanente Northern and Southern California, and Vanderbilt University. Datasets have been created at each site linking healthcare data for women delivering an infant between January 1, 2001 and December 31, 2008 and infants born to these women. Standardized data files include maternal and infant characteristics, medication use, and medical care at 11 health plans within 9 states; birth certificate data were obtained from the state departments of public health. MEPREP currently involves more than 20 medication safety researchers and includes data for 1,221,156 children delivered to 933,917 mothers. Current studies include evaluations of the prevalence and patterns of use of specific medications and a validation study of data elements in the administrative and birth certificate data files. MEPREP can support multiple studies by providing information on a large, ethnically and geographically diverse population. This partnership combines clinical and research expertise and data resources to enable the evaluation of outcomes associated with medication use during pregnancy. PMID:22002179
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Medication Exposure in Pregnancy Risk Evaluation Program.
Andrade, Susan E; Davis, Robert L; Cheetham, T Craig; Cooper, William O; Li, De-Kun; Amini, Thushi; Beaton, Sarah J; Dublin, Sascha; Hammad, Tarek A; Pawloski, Pamala A; Raebel, Marsha A; Smith, David H; Staffa, Judy A; Toh, Sengwee; Dashevsky, Inna; Haffenreffer, Katherine; Lane, Kimberly; Platt, Richard; Scott, Pamela E
2012-10-01
To describe a program to study medication safety in pregnancy, the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). MEPREP is a multi-site collaborative research program developed to enable the conduct of studies of medication use and outcomes in pregnancy. Collaborators include the U.S. Food and Drug Administration and researchers at the HMO Research Network, Kaiser Permanente Northern and Southern California, and Vanderbilt University. Datasets have been created at each site linking healthcare data for women delivering an infant between January 1, 2001 and December 31, 2008 and infants born to these women. Standardized data files include maternal and infant characteristics, medication use, and medical care at 11 health plans within 9 states; birth certificate data were obtained from the state departments of public health. MEPREP currently involves more than 20 medication safety researchers and includes data for 1,221,156 children delivered to 933,917 mothers. Current studies include evaluations of the prevalence and patterns of use of specific medications and a validation study of data elements in the administrative and birth certificate data files. MEPREP can support multiple studies by providing information on a large, ethnically and geographically diverse population. This partnership combines clinical and research expertise and data resources to enable the evaluation of outcomes associated with medication use during pregnancy.
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Adjaye-Gbewonyo, Dzifa; Bednarczyk, Robert A; Davis, Robert L; Omer, Saad B
2014-02-01
To validate classification of race/ethnicity based on the Bayesian Improved Surname Geocoding method (BISG) and assess variations in validity by gender and age. Secondary data on members of Kaiser Permanente Georgia, an integrated managed care organization, through 2010. For 191,494 members with self-reported race/ethnicity, probabilities for belonging to each of six race/ethnicity categories predicted from the BISG algorithm were used to assign individuals to a race/ethnicity category over a range of cutoffs greater than a probability of 0.50. Overall as well as gender- and age-stratified sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Receiver operating characteristic (ROC) curves were generated and used to identify optimal cutoffs for race/ethnicity assignment. The overall cutoffs for assignment that optimized sensitivity and specificity ranged from 0.50 to 0.57 for the four main racial/ethnic categories (White, Black, Asian/Pacific Islander, Hispanic). Corresponding sensitivity, specificity, PPV, and NPV ranged from 64.4 to 81.4 percent, 80.8 to 99.7 percent, 75.0 to 91.6 percent, and 79.4 to 98.0 percent, respectively. Accuracy of assignment was better among males and individuals of 65 years or older. BISG may be useful for classifying race/ethnicity of health plan members when needed for health care studies. © Health Research and Educational Trust.
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Dose as a Tool for Planning and Implementing Community-Based Health Strategies.
Kuo, Elena S; Harner, Lisa T; Frost, Madeline C; Cheadle, Allen; Schwartz, Pamela M
2018-05-01
A major challenge in community-based health promotion is implementing strategies that could realistically improve health at the population level. Population dose methodology was developed to help understand the combined impact of multiple strategies on population-level health behaviors. This paper describes one potential use of dose: as a tool for working collaboratively with communities to increase impact when planning and implementing community-level initiatives. Findings are presented from interviews conducted with 11 coordinators who used dose for planning and implementing local efforts with community coalitions. During early-stage planning, dose was used as a tool for strategic planning, and as a framework to build consensus among coalition partners. During implementation, a dose lens was used to revise strategies to increase their reach (the number of people exposed to the intervention) or strength (the relative change in behavior for each exposed person) to create population-level impact. A case study is presented, illustrating how some community coalitions and evaluators currently integrate dose into the planning and implementation of place-based healthy eating and active living strategies. Finally, a planning checklist was developed for program coordinators and evaluators. This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health. Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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"Como Si Nada": Enduring Violence and Diabetes among Rural Women in Southern Mexico.
Montesi, Laura
2018-04-01
Rural women in Southern Mexico link their diabetes to distressful life experiences rooted in ordinary violence. While much has been written on the use that diabetes sufferers make of their morbid condition as an idiom of distress, I investigate the personal and social effects that such an idiom has on women. As I illustrate, diabetes reflects an ambivalence that helps women to speak about the unspeakable and, at the same time, reinforces their ideas of culpability, namely that they are to blame for both the gendered violence that they endure and the diabetes from which they suffer.
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Como Ayudar a sus Hijos a Aprender Ciencia (Helping Your Child Learn Science).
ERIC Educational Resources Information Center
Paulu, Nancy; Martin, Margery
Because most parents say they do not or cannot help their children with science, this booklet was designed to help them do so, easily and with pleasure for both parent and child. The introduction presents information on why and how parents should help their children and provides a general orientation to the ideas and activities offered in the…
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Populações estelares do bojo galáctico
NASA Astrophysics Data System (ADS)
Escudero, A. V.; Costa, R. D. D.; Maciel, W. J.
2003-08-01
Os estudos mais recentes do bojo galáctico têm enfocado essencialmente as abundâncias químicas de elementos pesados, como o ferro, obtidos a partir das estrelas nas regiões centrais da galáxia. Elementos leves, como hélio, nitrogênio, oxigênio e argônio ainda são pouco estudados nestas regiões, devido à difícil determinação de suas abundâncias a partir de estrelas. Nestas condições as nebulosas planetárias desempenham um importante papel, pois permitem a determinação de abundâncias destes elementos usando técnicas de espectroscopia nebular. Neste trabalho, reportamos a análise das abundâncias químicas de uma nova amostra de nebulosas planetárias do bojo, bem como os resultados preliminares de um código numérico destinado a modelar a evolução química desta região. Usamos como vínculos observacionais os resultados obtidos das nebulosas planetárias, bem como de abundâncias estelares da região do bojo, obtidas da literatura. A partir deste modelo da evolução química e dos vínculos observacionais foi possível fazer um diagnóstico mais preciso das populações que constituem o bojo galáctico. O estudo destas populações que compõem a região central de nossa galáxia é de extrema importância para o maior entendimento da evolução química e dinâmica da galáxia como um todo. Por isto, verificamos a importância dos modelos de formação simples e mista utilizados para explicar características da população da região central da galáxia. Algumas destas características são: uma grande dispersão nos valores das abundâncias químicas e um grande espalhamento nas correlações entre as abundâcias de nitrogênio e oxigênio. Estas peculiaridades são dificilmente reproduzidas por modelos de formação simples, e portanto são importantes indícios da validade dos modelos de formação mista, tais como um rápido colapso do bojo seguido de uma evolução secular. (FAPESP, CNPq)
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Percepção Astronômica de Alunos do Ensino Médio da Rede Estadual de São Paulo
NASA Astrophysics Data System (ADS)
de Oliveira, E. F.; Voelzke, M. R.; Amaral, L. H.
2005-08-01
Embora a astronomia seja uma das ciências mais antigas da humanidade e muitos dos conceitos astronômicos serem populares, principalmente nesta época de alta globalização do conhecimento por intermédio de eficientes meios de comunicação e de obtenção da informação, notadamente através da internet, observa-se que uma parcela significativa dos estudantes encontra-se à margem dessas informações. O presente trabalho visa analisar o nível de conhecimento básico dos alunos de Ensino Médio da rede estadual da cidade de Suzano quanto aos fenômenos astronômicos que os rodeiam, tais como a sucessão dos dias e das estações do ano, além de questioná-los sobre fatos genéricos tais como: quais são os astros que se encontram mais próximos do planeta Terra, o que vem a ser o Sol, o Big Bang, um ano-luz, uma estrela cadente, a estrela de Bélem e o que ocasionou a extinção dos dinossauros. Para tanto foi elaborado um formulário constando de questões de múltipla escolha, o qual foi aplicado no primeiro colegial noturno da Escola Estadual Batista Renzi. Num espaço amostral de 34 alunos constatou-se que apenas 29,4% compreendiam a sucessão dos dias da semana, que apenas 20,6% explicaram corretamente as estações do ano, que apenas 20,6% tinham idéia de quais são os objetos celestes mais próximos da Terra, em contraposição 67,6% sabiam classificar corretamente o Sol como estrela, 55,9% relacionavam o Big Bang à origem do universo, apenas 20,6% identificavam um ano-luz como unidade de distância, 32,4% reconheciam uma estrela cadente como meteoro, 41,2% consideravam a estrela de Belém como um cometa e 50,0% explicaram corretamente a extinção dos dinossauros. A presente análise será expandida para as demais classes de primeiro colegial, não somente do período noturno, mas também do diurno da Escola Estadual Batista Renzi, bem como o formulário será devidamente ampliado. Já nesta primeira fase nota-se claramente o pequeno discernimento
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Conhecimento Científico e Cotidiano em Astronomia: Uma Investigação com Alunos da Educação Básica
NASA Astrophysics Data System (ADS)
Vieira, J. B.; Longhini, M. D.
2011-12-01
Este texto apresenta resultados de uma investigação que teve como objetivo, investigar como os conhecimentos científicos e do cotidiano relacionados a essa área de conhecimento apresentam na escola de Educação Básica, especialmente, em alunos do Ensino Médio prestes a deixar Educação Básica. Para realização da pesquisa, utilizamos como recurso metodológico a aplicação de um questionário estruturado contendo 47 questões, organizadas em duas categorias: Conhecimento Cotidiano e Conhecimento Científico. As questões da categoria “Conhecimento Cotidiano” possuíam afirmações relacionadas a crendices, contos populares, especulações e temáticas do gênero, as quais, geralmente, estão fora do círculo de discussão da comunidade científica, talvez por não serem consideradas como objeto de estudo da ciência. As questões da categoria “Conhecimento Científico” são relacionadas a conteúdos específicos de Astronomia, as quais são compartilhadas pela comunidade científica e aceitas, pelo menos provisoriamente, como possuindo fundamentação científica. Concluímos que, possuem ainda concepções de temas Astronômicos persistentes à mudança, por exemplo, fases da Lua relacionadas à melhor período para corte de cabelo e também para plantio; estrela cadente e ocasião perfeita para se fazer um pedido. Entretanto, podemos observar no que diz respeito a mitos e superstições, que quase não existe influência destes entre os alunos. Portanto, ao trabalharmos com os alunos determinados conceitos científicos, é importante lembrarmos que o professor não opera no vazio; os alunos são sujeitos de saberes, práticas e, dessa forma constroem e reconstroem saberes. Cabe ao professor ouvir os estudantes reconstruindo junto deles conceitos científicos. Acreditamos que o ensino de Ciências na Educação Básica deve lidar criticamente com o conhecimento cotidiano e científico e, assim, efetivar a Ciência como disciplina educativa
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On Ensino de Astronomia: Desafios para Implantação
NASA Astrophysics Data System (ADS)
Faria, R. Z.; Voelzke, M. R.
2008-09-01
Em 2002 o ensino de Astronomia foi proposto como um dos temas estruturadores pelos Parâmetros Curriculares Nacionais e sugerido como facilitador para que o aluno compreendesse a Física como construção humana e parte do seu mundo vivencial, mas raramente seus conceitos foram ensinados. A presente pesquisa discute dois aspectos relacionados à abordagem de Astronomia. O primeiro aspecto é se ela está sendo abordada pelos professores do Ensino Médio e o segundo, aborda a maneira como ela está sendo ensinada. Optou-se pela aplicação de um questionário a partir do 2° semestre de 2006 e durante o ano de 2007 com professores que ministram a disciplina de Física, os quais trabalham em escolas estaduais em Rio Grande da Serra, Ribeirão Pires e Mauá no estado São Paulo. Dos 66,2% dos professores que responderam ao questionário nos municípios de Rio Grande da Serra, Ribeirão Pires e Mauá, 57,4% não aplicaram nenhum tópico de astronomia, 70,2% não utilizaram laboratório, 89,4% não utilizaram qualquer tipo de programa computacional, 83,0% nunca fizeram visitas com alunos a museus e planetários e 38,3% não indicaram qualquer tipo de livro ou revista referente à astronomia aos seus alunos. Mesmo considerando a Astronomia um conteúdo potencialmente significativo, esta não fez parte dos planejamentos escolares. Portanto são necessárias propostas que visem estratégias para a educação continuada dos professores como, por exemplo, cursos específicos sobre o ensino em Astronomia.
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Heilmann, Rachel M F; Campbell, Stephanie M; Kroner, Beverly A; Proksel, Jenel R; Billups, Sarah J; Witt, Daniel M; Helling, Dennis K
2013-01-01
The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.
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Rectal Cancer Survivors' Participation in Productive Activities.
Hornbrook, Mark C; Grant, Marcia; Wendel, Christopher; Bulkley, Joanna E; Mcmullen, Carmit K; Altschuler, Andrea; Temple, Larissa Kf; Herrinton, Lisa J; Krouse, Robert S
2017-01-01
Rectal cancer and its treatment impair survivors' productivity. To assess determinants of market and nonmarket employment, job search, volunteering, and homemaking among survivors five years or longer after diagnosis. We mailed questionnaires to 1063 survivors who were members of Kaiser Permanente (Northern California, Northwest) during 2010 and 2011. Productive activities, functional health status, and bowel management at the time of the survey. Response rate was 60.5% (577/953). Higher comorbidity burdens were associated with lower productivity for men and women rectal cancer survivors. Productive survivors were younger and had lower disease stage and age at diagnosis, higher household income and educational attainment, and fewer comorbidity burdens and workplace adjustments than did nonproductive survivors (p < 0.05 each; 2-sided). Productive rectal cancer survivors were evenly split by sex. Staying productive is associated with better mental health for rectal cancer survivors. Rectal cancer survivors with multiple chronic conditions, higher disease stage, lower productive activities, and older age need better access to medical care and closer monitoring of the quality of their care, including self-care. To capture the full extent of the involvement of survivors in all types of productive activities, research should routinely include measures of employment, searching for employment, homemaking, and volunteering. Counting market and nonmarket productive activities is innovative and recognizes the continuum of contributions survivors make to families and society. Health care systems should routinely monitor rectal cancer survivors' medical care access, comorbidities, health-related quality of life, and productive activities.
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Factors associated with frailty in chronically ill older adults.
Hackstaff, Lynn
2009-01-01
An ex post facto analysis of a secondary dataset examined relationships between physical frailty, depression, and the self-perceived domains of health status and quality-of-life in older adults. The randomized sample included 992 community-dwelling, chronically ill, and functionally impaired adults age 65 and older who received care from a Southern California Kaiser Permanente medical center between 1998 and 2002. Physical frailty represents a level of physiologic vulnerability and functional loss that results in dependence on others for basic, daily living needs (Fried et al., 2001). The purpose of the study was to identify possible intervention junctures related to self-efficacy of older adults in order to help optimize their functionality. Multivariate correlation analyses showed statistically significant positive correlations between frailty level and depression (r = .18; p = < .05), number of medical conditions (r = .09; p = < .05), and self-rated quality-of-life (r = .24; p = < .05). Frailty level showed a statistically significant negative correlation with self-perceived health status (r = -.25; p = < .05). Notably, no statistically significant correlation was found between age and frailty level (r = -.03; p = < .05). In linear regression, self-perceived health status had a partial variance with frailty level (part r = -.18). The significant correlations found support further research to identify interventions to help vulnerable, older adults challenge self-perceived capabilities so that they may achieve optimum functionality through increased physical activity earlier on, and increased self-efficacy to support successful adaptation to aging-related losses.
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Thompson, Mark G; Li, De-Kun; Shifflett, Pat; Sokolow, Leslie Z; Ferber, Jeannette R; Kurosky, Samantha; Bozeman, Sam; Reynolds, Sue B; Odouli, Roxana; Henninger, Michelle L; Kauffman, Tia L; Avalos, Lyndsay A; Ball, Sarah; Williams, Jennifer L; Irving, Stephanie A; Shay, David K; Naleway, Allison L
2014-02-01
Although vaccination with trivalent inactivated influenza vaccine (TIV) is recommended for all pregnant women, no vaccine effectiveness (VE) studies of TIV in pregnant women have assessed laboratory-confirmed influenza outcomes. We conducted a case-control study over 2 influenza seasons (2010-2011 and 2011-2012) among Kaiser Permanente health plan members in 2 metropolitan areas in California and Oregon. We compared the proportion vaccinated among 100 influenza cases (confirmed by reverse transcription polymerase chain reaction) with the proportions vaccinated among 192 controls with acute respiratory illness (ARI) who tested negative for influenza and 200 controls without ARI (matched by season, site, and trimester). Among influenza cases, 42% were vaccinated during the study season compared to 58% and 63% vaccinated among influenza-negative controls and matched ARI-negative controls, respectively. The adjusted VE of the current season vaccine against influenza A and B was 44% (95% confidence interval [CI], 5%-67%) using the influenza-negative controls and 53% (95% CI, 24%-72%) using the ARI-negative controls. Receipt of the prior season's vaccine, however, had an effect similar to receipt of the current season's vaccine. As such, vaccination in either or both seasons had statistically similar adjusted VE using influenza-negative controls (VE point estimates range = 51%-76%) and ARI-negative controls (48%-76%). Influenza vaccination reduced the risk of ARI associated with laboratory-confirmed influenza among pregnant women by about one-half, similar to VE observed among all adults during these seasons.
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Tsai, Jerry; Shaul, Donald B; Sydorak, Roman M; Lau, Stanley T; Akmal, Yasir; Rodriguez, Karen
2013-01-01
Context: Increasing popularity of strong magnets as toys has led to their ingestion by children, putting them at risk of potentially harmful gastrointestinal tract injuries. Objectives: To heighten physician awareness of the potential complications of magnetic foreign body ingestion, and to provide an updated algorithm for management of a patient who is suspected to have ingested magnets. Design: A retrospective review of magnet ingestions treated over a two-year period at our institutions in the Southern California Permanente Medical Group. Data including patient demographics, clinical information, radiologic images, and surgical records were used to propose a management strategy. Results: Five patients, aged 15 months to 18 years, presented with abdominal symptoms after magnet ingestion. Four of the 5 patients suffered serious complications, including bowel necrosis, perforation, fistula formation, and obstruction. All patients were successfully treated with laparoscopic-assisted exploration with or without endoscopy. Total days in the hospital averaged 5.2 days (range = 3 to 9 days). Average time to discharge following surgery was 4 days (range = 2 to 7 days). Ex vivo experimentation with toy magnetic beads were performed to reveal characteristics of the magnetic toys. Conclusions: Physicians should have a heightened sense of caution when treating a patient in whom magnetic foreign body ingestion is suspected, because of the potential gastrointestinal complications. An updated management strategy is proposed that both prevents delays in surgical care and avoids unnecessary surgical exploration. PMID:23596362
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Profil épidémiologique de l'insuffisance rénale terminale à l'hôpital Militaire de Rabat, Maroc
Asserraji, Mohammed; Maoujoud, Omar; Belarbi, Marouane; Oualim, Zouhir
2015-01-01
L'Insuffisance rénale chronique terminale (IRCT) est un enjeu majeur de sante publique au Maroc à cause de ses conséquences médicales et socioéconomiques. L'objectif de ce travail est d’évaluer le profil épidémiologique de l'IRCT à l'hôpital militaire de rabat, Maroc. Il s'agit d'une enquête rétrospective pendant quatre ans (1er janvier 2007 au 31 décembre 2010). Tous les cas d'IRCT (diminution permanente du débit de filtration glomérulaire (DFG) < 15 ml/min/1.73m2, pendant ≥ 3 mois) ont été inclus. 203 patients ont commencé la dialyse durant cette période, 130 hommes (64%) et 73 femmes (36%), l’âge moyen était de 49,92 ans (06 - 80 ans). la néphropathie d'origine indéterminée représente la première cause d'IRCT dans notre série (27,1%) suivie de la néphropathie diabétique (24,6%), des glomérulonéphrites chroniques (22,7) et de la néphropathie d'origine vasculaire (10,8%). 131 patients (64,5%) n'ont pas eu de suivi néphrologique pré dialytique. une prise en charge globale de cette pathologie est nécessaire. PMID:26309471
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Makhija, Sonia K; Gilbert, Gregg H; Rindal, D Brad; Benjamin, Paul; Richman, Joshua S; Pihlstrom, Daniel J; Qvist, Vibeke
2009-01-01
Background Practice-based research networks offer important opportunities to move recent advances into routine clinical practice. If their findings are not only generalizable to dental practices at large, but can also elucidate how practice characteristics are related to treatment outcome, their importance is even further elevated. Our objective was to determine whether we met a key objective for The Dental Practice-Based Research Network (DPBRN): to recruit a diverse range of practitioner-investigators interested in doing DPBRN studies. Methods DPBRN participants completed an enrollment questionnaire about their practices and themselves. To date, more than 1100 practitioners from the five participating regions have completed the questionnaire. The regions consist of: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates, and Scandinavia (Denmark, Norway, and Sweden). We tested the hypothesis that there are statistically significant differences in key characteristics among DPBRN practices, based on responses from dentists who participated in DPBRN's first network-wide study (n = 546). Results There were statistically significant, substantive regional differences among DPBRN-participating dentists, their practices, and their patient populations. Conclusion Although as a group, participants have much in common with practices at large; their substantial diversity offers important advantages, such as being able to evaluate how practice differences may affect treatment outcomes, while simultaneously offering generalizability to dentists at large. This should help foster knowledge transfer in both the research-to-practice and practice-to-research directions. PMID:19832991
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Doubeni, Chyke A.; Jensen, Christopher D.; Fedewa, Stacey A.; Quinn, Virginia P.; Zauber, Ann G.; Schottinger, Joanne E.; Corley, Douglas A.; Levin, Theodore R.
2017-01-01
Introduction Fecal immunochemical tests (FITs) are widely used in colorectal cancer (CRC) screening, but hemoglobin degradation, due to exposure of the collected sample to high temperatures, could reduce test sensitivity. We examined the relation of ambient temperature exposure with FIT positivity rate and sensitivity. Methods This was a retrospective cohort study of patients 50 to 75 years in Kaiser Permanente Northern California’s CRC screening program, which began mailing FIT kits annually to screen-eligible members in 2007. Primary outcomes were FIT positivity rate and sensitivity to detect CRC. Predictors were month, season, and daily ambient temperatures of test result dates based on US National Oceanic and Atmospheric Administration data. Results Patients (n =472,542) completed 1,141,162 FITs. Weekly test positivity rate ranged from 2.6% to 8.0% (median, 4.4%) and varied significantly by month (June/July vs December/January rate ratio [RR] =0.79, 95% confidence interval [CI], 0.76 to 0.83) and season. FIT sensitivity was lower in June/July (74.5%; 95% CI, 72.5 to 76.6) than January/December (78.9%; 95% CI, 77.0 to 80.7). Conclusions FITs completed during high ambient temperatures had lower positivity rates and lower sensitivity. Changing kit design, specimen transportation practices, or avoiding periods of high ambient temperatures may help optimize FIT performance, but may also increase testing complexity and reduce patient adherence, requiring careful study. PMID:28076249
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Clinician’s use of automated reports of estimated glomerular filtration rate: A qualitative study
2012-01-01
Background There is a growing awareness in primary care of the importance of identifying patients with chronic kidney disease (CKD) so that they can receive appropriate clinical care; one method that has been widely embraced is the use of automated reporting of estimated glomerular filtration rate (eGFR) by clinical laboratories. We undertook a qualitative study to examine how clinicians use eGFR in clinical decision making, patient communication issues, barriers to use of eGFR, and suggestions to improve the clinical usefulness of eGFR reports. Methods Our study used qualitative methods with structured interviews among primary care clinicians including both physicians and allied health providers, recruited from Kaiser Permanente Northwest, a non-profit health maintenance organization. Results We found that clinicians generally held favorable views toward eGFR reporting but did not use eGFR to replace serum creatinine in their clinical decision-making. Clinicians used eGFR as a tool to help identify CKD, educate patients about their kidney function and make treatment decisions. Barriers noted by several clinicians included a desire for greater education regarding care for patients with CKD and tools to facilitate discussion of eGFR findings with patients. Conclusions The manner in which clinicians use eGFRs appears to be more complex than previously understood, and our study illustrates some of the efforts that might be usefully undertaken (e.g. specific clinician education) when encouraging further promulgation of eGFR reporting and usage. PMID:23173944
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Effects of dietary fiber, fats, and meat intakes on the risk of Barrett’s Esophagus
Kubo, Ai; Block, Gladys; Quesenberry, Charles P.; Buffler, Patricia; Corley, Douglas A.
2009-01-01
Animal and human models suggest associations between fat intake, fiber intake and the risk of esophageal adenocarcinoma. We evaluated whether these factors may act early in the carcinogenic pathway as a risk factor for Barrett’s esophagus, a potentially premalignant precursor to esophageal adenocarcinoma using a case-control design within the Kaiser Permanente, Northern California population. Incident Barrett’s esophagus cases (n=296) were matched to persons with gastroesophageal reflux disease (GERD) (n=308), and to population controls (n=309). Higher intakes of omega-3-fatty-acids (cases vs. population controls; OR=0.46, 95% CI 0.22–0.97, 4th vs. 1st quartiles of intake), polyunsaturated fat, total fiber (OR=0.34, 95% CI 0.15–0.76), and fiber from fruits and vegetables (OR=0.47 95% CI 0.25–0.88) were associated with a lower risk of Barrett’s esophagus. Higher meat intakes were associated with a lower risk of long-segment Barrett’s esophagus (OR=0.25, 95% CI 0.09–0.72). In contrast, higher trans-fat intakes were associated with increased risk (OR=1.11; 95% CI 1.03–1.21 per gram/day). Total fat intake, barbecued foods, and fiber intake from sources other than fruits and vegetables were not associated with Barrett’s esophagus. Future studies to evaluate whether dietary interventions might influence the risk of Barrett’s esophagus or esophageal adenocarcinoma in high risk persons are needed. PMID:19838934
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Family Characteristics Associated with Likelihood of Varicella Vaccination.
Weinmann, Sheila; Mullooly, John P; Drew, Lois; Chun, Colleen S
2016-01-01
The introduction of the varicella vaccine as a routine pediatric immunization in the US, in 1995, provided an opportunity to assess factors associated with uptake of new vaccines in the member population of the Kaiser Permanente Northwest (KPNW) Health Plan. Identify factors associated with varicella vaccination in the KPNW population in the first five years after varicella vaccine was introduced. A retrospective cohort of children under age 13 years between June 1995 and December 1999, without a history of varicella disease was identified using KPNW automated data. Membership records were linked to vaccine databases. Cox regression was used to estimate likelihood of varicella vaccination during the study period in relation to age, sex, primary clinician's specialty, and Medicaid eligibility. For a subset whose parents answered a behavioral health survey, additional demographic and behavioral characteristics were evaluated. Varicella vaccination. We identified 88,646 children under age 13 years without a history of varicella; 22% were vaccinated during the study period. Varicella vaccination was more likely among children who were born after 1995, were not Medicaid recipients, or had pediatricians as primary clinicians. In the survey-linked cohort, positively associated family characteristics included smaller family size; higher socioeconomic status; and parents who were older, were college graduates, reported excellent health, and received influenza vaccination. Understanding predictors of early varicella vaccine-era vaccine acceptance may help in planning for introduction of new vaccines to routine schedules.
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Family Characteristics Associated with Likelihood of Varicella Vaccination
Weinmann, Sheila; Mullooly, John P; Drew, Lois; Chun, Colleen S
2016-01-01
Context: The introduction of the varicella vaccine as a routine pediatric immunization in the US, in 1995, provided an opportunity to assess factors associated with uptake of new vaccines in the member population of the Kaiser Permanente Northwest (KPNW) Health Plan. Objective: Identify factors associated with varicella vaccination in the KPNW population in the first five years after varicella vaccine was introduced. Design: A retrospective cohort of children under age 13 years between June 1995 and December 1999, without a history of varicella disease was identified using KPNW automated data. Membership records were linked to vaccine databases. Cox regression was used to estimate likelihood of varicella vaccination during the study period in relation to age, sex, primary clinician’s specialty, and Medicaid eligibility. For a subset whose parents answered a behavioral health survey, additional demographic and behavioral characteristics were evaluated. Main Outcome Measure: Varicella vaccination. Results: We identified 88,646 children under age 13 years without a history of varicella; 22% were vaccinated during the study period. Varicella vaccination was more likely among children who were born after 1995, were not Medicaid recipients, or had pediatricians as primary clinicians. In the survey-linked cohort, positively associated family characteristics included smaller family size; higher socioeconomic status; and parents who were older, were college graduates, reported excellent health, and received influenza vaccination. Conclusion: Understanding predictors of early varicella vaccine-era vaccine acceptance may help in planning for introduction of new vaccines to routine schedules. PMID:27104589
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Pneumococcal Conjugate Vaccines and Otitis Media: An Appraisal of the Clinical Trials
Fletcher, Mark A.; Fritzell, Bernard
2012-01-01
Streptococcus pneumoniae is the predominant otitis media pathogen and its prevention through effective vaccination could diminish childhood illness and antibiotic use. This paper reviews 5 pneumococcal conjugate vaccine (PCV) trials that used otitis media as an endpoint: Northern California Kaiser Permanente (NCKP; vaccine, 7-valent PCV [PCV7]-CRM); Finnish Otitis Media (FinOM; vaccines, PCV7-CRM or PCV7-OMPC); Native American Trial (vaccine, PCV7-CRM); Pneumococcal Otitis Efficacy Trial (POET; vaccine, 11-valent PCV [PCV11]-PD). For the microbiological endpoint, vaccine efficacy against vaccine-serotype pneumococcal otitis media was about 60% across trials. Against the clinical endpoint of all episodes, vaccine efficacy was 7% (PCV7-CRM/NCKP), 6% (PCV7-CRM/FinOM), −1% (PCV7-OMPC/FinOM), and −0.4% (PCV7-CRM/Native American Trial); 34% against first episodes of ear, nose, and throat specialist-referral cases (PCV11-PD/POET). Both follow-up through 2 years of age, for the 5 trials, and long-term follow-up, for PCV7-CRM/NCKP and PCV7-CRM/FinOM, demonstrated greater vaccine efficacy against recurrent AOM and tympanostomy-tube placement, suggesting that vaccination against early episodes of AOM may prevent subsequent episodes of complicated otitis media. Although study designs varied by primary endpoint measured, age at follow-up, source of middle-ear fluid for culture, case ascertainment, and type of randomization, each clinical trial demonstrated vaccine efficacy against microbiological and/or clinical otitis media. PMID:22701486
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Chao, Chun; Sy, Lina S.; Ackerson, Bradley K.; Slezak, Jeff M.; Sidell, Margo A.; Jacobsen, Steven J.
2013-01-01
Objectives. We examined whether maternal utilization of preventive care and history of sexually transmitted infections (STIs) predicted quadrivalent human papillomavirus vaccine (HPV4) uptake among adolescent boys 1 year following the recommendation for permissive use of HPV4 for males. Methods. We linked maternal information with electronic health records of 254 489 boys aged 9 to 17 years who enrolled in Kaiser Permanente Southern California health plan from October 21, 2009, through December 21, 2010. We used multivariable Poisson regression with robust error variance to examine whether HPV4 initiation was associated with maternal uptake of influenza vaccine, Papanicolaou (Pap) screening, and history of STIs. Results. We identified a modest but statistically significant association between initiation of HPV4 series and maternal receipt of influenza vaccine (rate ratio [RR] = 1.16; 95% confidence interval [CI] = 1.07, 1.26) and Pap screening (RR = 1.13; 95% CI = 1.01, 1.26). Boys whose mothers had a history of genital warts were more likely to initiate HPV4 (RR = 1.47; 95% CI = 0.93, 2.34), although the association did not reach statistical significance (P = .1). Conclusions. Maternal utilization of preventive care and history of genital warts may influence HPV4 uptake among adolescent boys. The important role of maternal health characteristics and health behaviors needs be considered in intervention efforts to increase vaccine uptake among boys. PMID:23865707
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Shared familial transmission of autism spectrum and attention-deficit/hyperactivity disorders.
Musser, Erica D; Hawkey, Elizabeth; Kachan-Liu, Svetlana S; Lees, Paul; Roullet, Jean-Baptiste; Goddard, Katrina; Steiner, Robert D; Nigg, Joel T
2014-07-01
To determine whether familial transmission is shared between autism spectrum disorders and attention-deficit/hyperactivity disorder, we assessed the prevalence, rates of comorbidity, and familial transmission of both disorders in a large population-based sample of children during a recent 7 year period. Study participants included all children born to parents with the Kaiser Permanente Northwest (KPNW) Health Plan between 1 January 1998 and 31 December 2004 (n = 35,073). Children and mothers with physician-identified autism spectrum disorders (ASD) and/or attention-deficit/hyperactivity disorder (ADHD) were identified via electronic medical records maintained for all KPNW members. Among children aged 6-12 years, prevalence was 2.0% for ADHD and 0.8% for ASD; within those groups, 0.2% of the full sample (19% of the ASD sample and 9.6% of the ADHD sample) had co-occurring ASD and ADHD, when all children were included. When mothers had a diagnosis of ADHD, first born offspring were at 6-fold risk of ADHD alone (OR = 5.02, p < .0001) and at 2.5-fold risk of ASD alone (OR = 2.52, p < .01). Results were not accounted for by maternal age, child gestational age, child gender, and child race. Autism spectrum disorders shares familial transmission with ADHD. ADHD and ASD have a partially overlapping diathesis. © 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health.
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Association of Proteinuria with Central Venous Catheter Use at Initial Hemodialysis.
Park, Ken J; Johnson, Eric S; Smith, Ning; Mosen, David M; Thorp, Micah L
2017-01-01
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. To examine characteristics associated with CVC use at initial dialysis, specifically looking at proteinuria as a predictor of interest. Retrospective cohort of 918 hemodialysis recipients from Kaiser Permanente Northwest who started hemodialysis from January 1, 2004, to January 1, 2014. Multivariable logistic regression was used to examine an association of proteinuria with the primary outcome of CVC use. 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). 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.
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Tseng, Chin-Hsiao
2013-10-01
The association between pioglitazone and ovarian cancer has not been studied. The reimbursement databases of all Taiwanese patients with a diagnosis of diabetes and under oral anti-diabetic agents or insulin from 1996 to 2009 were retrieved from the National Health Insurance. An entry date was set at 1 January 2006 and a total of 546,632 female patients with type 2 diabetes were followed up for ovarian cancer incidence until the end of 2009. Incidences for ever-users, never-users and subgroups of pioglitazone exposure [using cutoffs of the Kaiser Permanente Northern California study and tertile cutoffs derived from the databases] were calculated and the hazard ratios were estimated by Cox regression in unadjusted, age-adjusted and fully adjusted models. There were 30,783 ever-users and 515,849 never-users, with respective numbers of incident ovarian cancer of 49 (0.16%) and 946 (0.18%), and respective incidence of 43.08 and 51.47 per 100,000 person-years. The overall hazard ratios (95% confidence intervals) in unadjusted, age-adjusted and fully adjusted models were 0.822 (0.616-1.095), 0.823 (0.617-1.097) and 0.968 (0.718-1.305), respectively. In the dose-response analyses, none of the categories showed a significant hazard ratio, and all P-trends were >0.05 without statistical significance. This study does not support a positive or negative association between pioglitazone use and ovarian cancer in female patients with type 2 diabetes. © 2013.
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Physicians' Perceptions of Volunteer Service at Safety-Net Clinics.
Mcgeehan, Laura; Takehara, Michael A; Daroszewski, Ellen
2017-01-01
Volunteer physicians are crucial for the operation of safety-net clinics, which provide medical care for uninsured and underinsured populations. Thus, identifying ways to maximize the number of physicians volunteering at such clinics is an important goal. To investigate the perceptions, motivations, functions, and barriers associated with physician volunteering in four safety-net clinics in San Bernardino County, Southern California, a location of great medical need with many barriers to care. The study participants are physicians belonging to the Southern California Permanente Medical Group who use a combination of discretionary time (during regular work hours) and personal time in evening and weekend hours to volunteer their services. The experimental design incorporates a mixed methodology: an online survey of 31 physicians and follow-up interviews with 8 of them. Physicians conveyed uniformly positive perceptions of their volunteer service, and most were motivated by humanitarian or prosocial desires. Volunteering also provided a protective "escape hatch" from the pressures of the physicians' regular jobs. Physicians cited few challenges to volunteering. The most common personal barrier was a lack of time. The most common professional barriers were organizational and supply issues at the clinic, along with the patients' social, transportation, and financial challenges. The results suggest that appealing to physicians' values and faith, and highlighting the burnout-prevention qualities of volunteering, may be key to recruitment and retention of volunteer physicians who serve underserved and underinsured populations in community clinics.
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Physicians’ Perceptions of Volunteer Service at Safety-Net Clinics
McGeehan, Laura; Takehara, Michael A; Daroszewski, Ellen
2017-01-01
Background: Volunteer physicians are crucial for the operation of safety-net clinics, which provide medical care for uninsured and underinsured populations. Thus, identifying ways to maximize the number of physicians volunteering at such clinics is an important goal. Objective: To investigate the perceptions, motivations, functions, and barriers associated with physician volunteering in four safety-net clinics in San Bernardino County, Southern California, a location of great medical need with many barriers to care. Methods: The study participants are physicians belonging to the Southern California Permanente Medical Group who use a combination of discretionary time (during regular work hours) and personal time in evening and weekend hours to volunteer their services. The experimental design incorporates a mixed methodology: an online survey of 31 physicians and follow-up interviews with 8 of them. Results: Physicians conveyed uniformly positive perceptions of their volunteer service, and most were motivated by humanitarian or prosocial desires. Volunteering also provided a protective “escape hatch” from the pressures of the physicians’ regular jobs. Physicians cited few challenges to volunteering. The most common personal barrier was a lack of time. The most common professional barriers were organizational and supply issues at the clinic, along with the patients’ social, transportation, and financial challenges. Conclusion: The results suggest that appealing to physicians’ values and faith, and highlighting the burnout-prevention qualities of volunteering, may be key to recruitment and retention of volunteer physicians who serve underserved and underinsured populations in community clinics. PMID:28241907
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Narva, Andrew S
2009-12-01
Clinical guidelines for the care of patients with progressive chronic kidney disease (CKD) have been developed by a broad range of organizations within the kidney community. Despite consensus among these guidelines and significant effort on the part of federal agencies, voluntary health organizations, and professional groups, existing data suggest that much work remains to achieve acceptable levels of recommended care. Several small studies have described CKD interventions to improve outcomes, but there are few examples of large-scale attempts to improve CKD care in a systematic way. Southern California Kaiser Permanente has developed a population management approach to CKD in a health maintenance organization setting that has improved outcomes. The Indian Health Service, an agency of the Public Health Service that provides direct care to American Indians and Alaska Natives, has enhanced its diabetes care delivery system to address the renal complications of diabetes. This effort may explain a significant decrease in the incidence rate of ESRD among American Indians with diabetes. Because much of the burden of CKD falls on ethnic and racial groups with decreased access to care, enhancing CKD care in the primary setting may offer the best opportunity to improve outcomes. The National Kidney Disease Education Program in collaboration with community heath centers has developed a model to improve outcomes through application of the chronic care model to CKD management in primary settings that serve high-risk populations.
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Kane, Gerald C; Fichman, Robert G; Gallaugher, John; Glaser, John
2009-11-01
Before the Internet, organizations had far more time to monitor and respond to community activity, but that luxury is long gone, leaving them in dire need of a coherent outreach strategy, fresh skills, and adaptive tactics. Drawing on the authors' study of more than two dozen firms, this article describes the changes wrought by social media in particular and shows managers how to take advantage of them--lessons that Kaiser Permanente, Domino's, and others learned the hard way. Social media platforms enhance the power of communities by promoting deep relationships, facilitating rapid organization, improving the creation and synthesis of knowledge, and enabling robust filtering of information. The authors cite many examples from the health care industry, where social media participation is vigorous and influential. For instance, members of Sermo, an online network exclusively for doctors, used the site to call attention to and organize against insurers' proposed reimbursement cuts. And on PatientsLikeMe, where people share details about their chronic diseases and the treatments they've pursued, charts and progress curves help members visualize their own complex histories and allow comparisons and feedback among peers. As you modernize your company's approach to community outreach, you'll need to assemble a social media team equipped to identify new opportunities for engagement and prevent brand damage. In the most successful firms the authors studied, community management was a dedicated function, combining marketing, public relations, and information technology skills.
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Sandhoff, Brian G; Nies, Leslie K; Olson, Kari L; Nash, James D; Rasmussen, Jon R; Merenich, John A
2007-01-01
A clinical pharmacy service for managing the treatment of coronary artery disease in a health maintenance organization is described. Despite the proven benefits of aggressive risk factor modification for patients with coronary artery disease (CAD), there remains a treatment gap between consensus- and evidence-based recommendations and their application in patient care. In 1998, Kaiser Permanente of Colorado developed the Clinical Pharmacy Cardiac Risk Service (CPCRS) to focus on the long-term management of patients with CAD to improve clinical outcomes. The primary goals of the CPCRS are to increase the number of CAD patients on lipid-lowering therapy, manage medications shown to decrease the risk of future CAD-related events, assist in the monitoring and control of other diseases that increase cardiovascular risk, provide patient education and recommendations for nonpharmacologic therapy, and act as a CAD information resource for physicians and other health care providers. Using an electronic medical record and tracking database, the service works in close collaboration with primary care physicians, cardiologists, cardiac rehabilitation nurses, and other health care providers to reduce cardiac risk in the CAD population. Particular attention is given to dyslipidemia, blood pressure, diabetes mellitus, and tobacco cessation. Treatment with evidence-based regimens is initiated and adjusted as necessary. Over 11,000 patients are currently being followed by the CPCRS. A clinical pharmacy service in a large health maintenance organization provides cardiac risk reduction for patients with CAD and helps close treatment gaps that may exist for these patients.
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A Survey of Parents with Children on the Autism Spectrum: Experience with Services and Treatments.
Becerra, Tracy A; Massolo, Maria L; Yau, Vincent M; Owen-Smith, Ashli A; Lynch, Frances L; Crawford, Phillip M; Pearson, Kathryn A; Pomichowski, Magdalena E; Quinn, Virginia P; Yoshida, Cathleen K; Croen, Lisa A
2017-01-01
Autism spectrum disorders (ASD) are lifelong neurodevelopmental disorders, and little is known about how parents address the health and psychosocial consequences of ASD. Few studies have examined use of various treatments and services in a large, diverse sample of children with ASD and their families. This paper presents methods to create an autism research resource across multiple large health delivery systems and describes services and treatments used by children with ASD and their families. Four study sites conducted a Web survey of parents of children and adolescents with ASD who were members of Kaiser Permanente. We tabulated data distributions of survey responses and calculated χ 2 statistics for differences between responders and nonresponders. The children of the 1155 respondents were racially and ethnically diverse (55% white, 6% black, 5% Asian, 9% multiracial, 24% Hispanic) and representative of the total population invited to participate with respect to child sex (83% male), child age (57% < 10 years), and ASD diagnosis (64% autistic disorder). The most frequently used services and treatments were Individualized Education Programs (85%), family physician visits (78%), and occupational and speech therapy (55% and 60%, respectively). Home-based programs frequently included implementation of social skills training (44%) and behavior management (42%). Prescription medication use was high (48%). Caregivers reported disruption of personal and family routines because of problem behaviors. These survey data help to elucidate parents' experiences with health services for their children with ASD and serve as a potential resource for future research.
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Cain, Carol H; Neuwirth, Estee; Bellows, Jim; Zuber, Christi; Green, Jennifer
2012-01-01
Little is known about patient perspectives of the transition from hospital to home. To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews. Kaiser Permanente's Southern California, Colorado, and Hawaii regions. Twenty-four adult inpatients hospitalized for a range of acute and chronic conditions and characterized by variety in diagnoses, illness severity, planned or unplanned hospitalization, age, and ability to self manage. During the hospital-to-home transition, patients and caregivers expressed or demonstrated experiences in 6 domains: 1) translating knowledge into safe, health-promoting actions at home; 2) inclusion of caregivers at every step of the transition process; 3) having readily available problem-solving resources; 4) feeling connected to and trusting providers; 5) transitioning from illness-defined experience to "normal" life; and 6) anticipating needs after discharge and making arrangements to meet them. The work of transitioning occurs for patients and caregivers in the hours and days after they return home and is fraught with challenges. Reducing readmissions will remain challenging without a broadened understanding of the types of support and coaching patients need after discharge. We are piloting strategies such as risk stratification and tailoring of care, a specialized phone number for recently discharged patients, standardized same-day discharge summaries to primary care providers, medication reconciliation, follow-up phone calls, and scheduling appointments before discharge. Copyright © 2012 Society of Hospital Medicine.
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Low Back Imaging When Not Indicated: A Descriptive Cross-System Analysis.
Gold, Rachel; Esterberg, Elizabeth; Hollombe, Celine; Arkind, Jill; Vakarcs, Patricia A; Tran, Huong; Burdick, Tim; Devoe, Jennifer E; Horberg, Michael A
2016-01-01
Guideline-discordant imaging to evaluate incident low back pain is common. We compared rates of guideline-discordant imaging in patients with low back pain in two care delivery systems with differing abilities to track care through an electronic health record (EHR), and in their patients' insurance status, to measure the association between these factors and rates of ordered low back imaging. We used data from two Kaiser Permanente (KP) Regions and from OCHIN, a community health center network. We extracted data on imaging performed after index visits for low back pain from June 1, 2011, to May 31, 2012, in these systems. Adjusted logistic regression measured associations between system-level factors and imaging rates. Imaging rates for incident low back pain using 2 national quality metrics: Clinical Quality Measure 0052, a measure for assessing Meaningful Use of EHRs, and the Healthcare Effectiveness Data and Information Set measure "Use of Imaging Studies for Low Back Pain." Among 19,503 KP patients and 2694 OCHIN patients with incident low back pain, ordered imaging was higher among men and whites but did not differ across health care systems. OCHIN's publicly insured patients had higher rates of imaging compared with those with private or no insurance. Rates of ordered imaging to evaluate incident low back pain among uninsured OCHIN patients were lower than in KP overall; among insured OCHIN patients, rates were higher than in KP overall. Research is needed to establish causality and develop interventions.
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Case-control study of medical comorbidities in women with interstitial cystitis.
Clemens, J Quentin; Meenan, Richard T; O'Keeffe Rosetti, Maureen C; Kimes, Teresa A; Calhoun, Elizabeth A
2008-06-01
We used physician assigned diagnoses in an electronic medical record to assess comorbidities associated with interstitial cystitis. A computer search of the administrative database at Kaiser Permanente Northwest, Portland, Oregon was performed for May 1, 1998 to April 30, 2003. All women with a medical record diagnosis of interstitial cystitis (ICD-9 code 595.1) were identified. These cases were then matched with 3 controls each based on age and duration in the health plan. The medical diagnoses (using ICD-9 codes restricted to 3 digits) assigned to these 2 groups were compared using the OR. A total of 239 cases and 717 matched controls were analyzed. There were 23 diagnoses that were significantly more common in cases than in controls (p < or = 0.005). Seven of these 23 diagnoses were other urological or gynecological codes used to describe pelvic symptoms. Additional specific conditions associated with interstitial cystitis were gastritis (OR 12.2), child abuse (OR 9.3), fibromyalgia (OR 3.0), anxiety disorder (OR 2.8), headache (OR 2.5), esophageal reflux (OR 2.2), unspecified back disorder (OR 2.2) and depression (OR 2.0). A diagnosis of interstitial cystitis was associated with multiple other unexplained physical symptoms and certain psychiatric conditions. Studies to explore the possible biological explanations for these associations are needed. Interstitial cystitis was also associated with a history of child abuse, although 96% of patients with IC did not have this diagnosis.
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Looking at Graduate Medical Education Through a Different Lens: A Health Care System's Perspective.
Roemer, Beth M; Azevedo, Theresa; Blumberg, Bruce
2015-09-01
In the era of the accountable care organization, U.S. models of physician practice are shifting from the solo, independent practitioner to the physician who is part of a multispecialty group practice or is employed by a health care institution, and from paper-based small offices to practice settings that emphasize technology-enabled, team-based systems of care. In this light, Kaiser Permanente's (KP's) long experience as an integrated, population-based health care delivery system makes it an increasingly relevant model in which to consider how graduate medical education (GME) can best prepare physicians for 21st-century health care. KP's multiple perspectives-as a GME setting, a health care delivery system, a health research enterprise, a community benefit organization, and the nation's largest private, multispecialty group practice of physicians-provide a multifaceted opportunity to consider GME in the context of health care transformation. The authors suggest that all participants in medical education have a role to play in preparing physicians for this future. They recommend that partnerships between universities and health care delivery systems serve as a highly effective model for education; that to better serve the needs of society, medical education institutions must adopt a broad community benefit mindset; and that, when medical groups and other institutions that employ physicians take the baton from GME, they need to commit to ongoing development and lifelong learning to enable their new physicians to reach their full potential.
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GENDER DIFFERENCES IN QUALITY OF LIFE AMONG LONG-TERM COLORECTAL CANCER SURVIVORS WITH OSTOMIES
Grant, Marcia; McMullen, Carmit K.; Altschuler, Andrea; Mohler, M. Jane; Hornbrook, Mark C.; Herrinton, Lisa J.; Wendel, Christopher S.; Baldwin, Carol M.; Krouse, Robert S.
2011-01-01
Objective To describe how gender shapes the concerns and adaptations of long-term (> 5 years) colorectal cancer (CRC) survivors with ostomies. Design Qualitative study using content analysis of focus group content. Setting Member of Kaiser Permanente, residing in either Oregon, Southwest Washington State, or Northern California. Sample Four female and four male focus groups selected from quantitative survey participants with health-related quality of life (HRQOL) scores in the highest or lowest quartile. Methods Eight focus groups, discussed challenges of living with an ostomy. Content was recorded, transcribed, and analyzed using directive and summative content analysis. Main Research Variables HRQOL domains of physical, psychological, social and spiritual well being. Findings All groups reported avoiding foods that cause gas or rapid transit, and discussed how limiting the amount of food eaten controlled the output. All groups discussed physical activities, getting support from friends and family, and the importance of being resilient. Both genders identified challenges with sexuality/intimacy. Coping and adjustment difficulties were discussed by women with men only discussing these issues to a small extent. Difficulties with sleep were primarily identified by Low HRQOL women. Problems with body image and depression were discussed only by Low HRQOL women. Conclusions Common issues included diet management, physical activity, social support and sexuality. Women with low HRQOL discussed problems with depression, body image, and sleep. Implications for Nursing Application of these gender-based differences can inform educational interventions for CRC survivors with ostomies. PMID:21875846
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Race-ethnicity on blood pressure control after ischemic stroke: a prospective cohort study.
Nguyen-Huynh, Mai N; Hills, Nancy K; Sidney, Stephen; Klingman, Jeffrey G; Johnston, S Claiborne
2017-01-01
Disparities in health care access and socioeconomic status (SES) have been associated with racial-ethnic differences in blood pressure (BP) control. We examined post-ischemic stroke BP in a multiethnic cohort with good health care access. We included all hypertensive patients (n = 2972) from a randomized quality improvement trial on secondary stroke prevention, conducted in 14 Kaiser Permanente hospitals in Northern California from 2004-2006 (QUISP). Average age 73.2 ± 12.2 years; 52% female, 66% non-Hispanic white, 14% African-American, 11% Asian, 8% Hispanic, and 1% other. Demographics, diagnoses, health care utilization, BP measurements, and medications were obtained as part of routine care. We used random effects logistic regression models to examine race as a predictor of blood pressure control (<140/90 mm Hg) at 6 months post-discharge, adjusted for SES, age, gender, dementia, antihypertensive therapy, and attendance at follow-up visits. At 6 months, BP was controlled in 52.7% of blacks compared to 61.4% of whites (OR = 0.63, 95% CI, 0.48-0.82, P = .001). Black race remained independently associated with poorer BP control in adjusted analysis, although blacks were as likely to attend post-discharge visits, and more likely to be on any antihypertensive therapy than whites. Greater difficulty in controlling BP and lifestyle differences may account for this difference. Copyright © 2016 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.
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Cheetham, T Craig; Niu, Fang; Chiang, Kevin; Yuan, Yong; Kalsekar, Anu; Hechter, Rulin; Hay, Joel W; Nyberg, Lisa
2015-08-01
Achievement of sustained virologic response (SVR) and factors associated with treatment failure in hepatitis C virus (HCV) genotype 3 have been described in tertiary and referral care settings, with rates of SVR reported to range between 72% and 89%. Fewer data exist on SVR outside of these settings. To describe rates of SVR and characterize factors associated with achievement of SVR within an integrated health care delivery system. A retrospective cohort study of genotype 3 HCV patients treated with dual therapy (pegylated interferon-alpha plus ribavirin) was conducted at Kaiser Permanente Southern California. Adult patients diagnosed with HCV and testing positive for HCV-RNA genotype 3 were identified from electronic medical records. Data were collected on patient demographics, baseline health status, and comorbid conditions. A multivariate logistic regression model was used to determine the association between baseline patient factors and SVR. A total of 484 HCV genotype 3 patients met the eligibility criteria. The median age was 49 years, and 65.7% were male. Overall, 252 (52.1%) achieved SVR. Aged ≥ 45 years and male gender were associated with lower rates of SVR; cirrhosis and chronic diseases (diabetes and chronic obstructive pulmonary disease) were also associated with lower rates of SVR. SVR was lower in patients within an integrated care delivery system than in those in tertiary and referral centers. Males and older patients had lower rates of SVR, as well as patients with cirrhosis, diabetes, and chronic obstructive pulmonary disease.
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Mun, Eluned; Umbarger, Lillian; Ceria-Ulep, Clementina; Nakatsuka, Craig
2018-01-01
Palliative Care Teams have been shown to be instrumental in the early identification of multiple aspects of advanced care planning. Despite an increased number of services to meet the rising consultation demand, it is conceivable that the numbers of palliative care consultations generated from an ICU alone could become overwhelming for an existing palliative care team. Improve end-of-life care in the ICU by incorporating basic palliative care processes into the daily routine ICU workflow, thereby reserving the palliative care team for refractory situations. A structured, palliative care, quality-improvement program was implemented and evaluated in the ICU at Kaiser Permanente Medical Center in Hawaii. This included selecting trigger criteria, a care model, forming guidelines, and developing evaluation criteria. These included the early identification of the multiple features of advanced care planning, numbers of proactive ICU and palliative care family meetings, and changes in code status and treatment upon completion of either meeting. Early identification of Goals-of-Care, advance directives, and code status by the ICU staff led to a proactive ICU family meeting with resultant increases in changes in code status and treatment. The numbers of palliative care consultations also rose, but not significantly. Palliative care processes could be incorporated into a daily ICU workflow allowing for integration of aspects of advanced care planning to be identified in a systematic and proactive manner. This reserved the palliative care team for situations when palliative care efforts performed by the ICU staff were ineffective.
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The Mt. Hood challenge: cross-testing two diabetes simulation models.
Brown, J B; Palmer, A J; Bisgaard, P; Chan, W; Pedula, K; Russell, A
2000-11-01
Starting from identical patients with type 2 diabetes, we compared the 20-year predictions of two computer simulation models, a 1998 version of the IMIB model and version 2.17 of the Global Diabetes Model (GDM). Primary measures of outcome were 20-year cumulative rates of: survival, first (incident) acute myocardial infarction (AMI), first stroke, proliferative diabetic retinopathy (PDR), macro-albuminuria (gross proteinuria, or GPR), and amputation. Standardized test patients were newly diagnosed males aged 45 or 75, with high and low levels of glycated hemoglobin (HbA(1c)), systolic blood pressure (SBP), and serum lipids. Both models generated realistic results and appropriate responses to changes in risk factors. Compared with the GDM, the IMIB model predicted much higher rates of mortality and AMI, and fewer strokes. These differences can be explained by differences in model architecture (Markov vs. microsimulation), different evidence bases for cardiovascular prediction (Framingham Heart Study cohort vs. Kaiser Permanente patients), and isolated versus interdependent prediction of cardiovascular events. Compared with IMIB, GDM predicted much higher lifetime costs, because of lower mortality and the use of a different costing method. It is feasible to cross-validate and explicate dissimilar diabetes simulation models using standardized patients. The wide differences in the model results that we observed demonstrate the need for cross-validation. We propose to hold a second 'Mt Hood Challenge' in 2001 and invite all diabetes modelers to attend.
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Immune mediated conditions in autism spectrum disorders.
Zerbo, Ousseny; Leong, Albin; Barcellos, Lisa; Bernal, Pilar; Fireman, Bruce; Croen, Lisa A
2015-05-01
We conducted a case-control study among members of Kaiser Permanente Northern California (KPNC) born between 1980 and 2003 to determine the prevalence of immune-mediated conditions in individuals with autism, investigate whether these conditions occur more often than expected, and explore the timing of onset relative to autism diagnosis. Cases were children and young adults with at least two autism diagnoses recorded in outpatient records (n=5565). Controls were children without autism randomly sampled at a ratio of 5 to 1, matched to cases on birth year, sex, and length of KPNC membership (n=27,825). The main outcomes - asthma, allergies, and autoimmune diseases - were identified from KPNC inpatient and outpatient databases. Chi-square tests were used to evaluate case-control differences. Allergies and autoimmune diseases were diagnosed significantly more often among children with autism than among controls (allergy: 20.6% vs. 17.7%, Crude odds ratio (OR)=1.22, 95% confidence interval (CI) 1.13-1.31; autoimmune disease: 1% vs. 0.76%, OR=1.36, 95% CI 1.01-1.83), and asthma was diagnosed significantly less often (13.7% vs. 15.9%; OR=0.83, 95% CI 0.76-0.90). Psoriasis occurred more than twice as often in cases than in controls (0.34% vs. 0.15%; OR=2.35, 95% CI 1.36-4.08). Our results support previous observations that children with autism have elevated prevalence of specific immune-related comorbidities. Copyright © 2015 Elsevier Inc. All rights reserved.
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Health Literacy and Outcomes among Patients with Heart Failure
Peterson, Pamela N; Shetterly, Susan M; Clarke, Christina L; Bekelman, David B; Chan, Paul S; Allen, Larry A; Matlock, Daniel D; Magid, David J; Masoudi, Frederick A
2015-01-01
Context Little is known about the impact of low health literacy among patients with heart failure (HF), a condition that requires self-management and frequent interactions with the healthcare system. Objective Evaluate the association between low health literacy and all-cause rehospitalization and mortality among outpatients with HF. Design and Setting Retrospective cohort study performed at Kaiser Permanente Colorado, an integrated managed care organization. Patients with HF were identified between Jan, 2001 and May, 2008 and followed for a mean of 1.2 years. Patients were surveyed. Health literacy was assessed using three established screening questions and categorized as adequate or low. Patients Outpatients with HF. Main Outcomes All-cause mortality and hospitalization. Results The survey response rate was 72%. Of 1494 patients, 262 (17.5%) had low health literacy. Patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education and had higher rates of coexisting illnesses. In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted 17.6% vs. 6.3%; adjusted hazard ratio [HR]: 1.61; 95% CI 1.06–2.43; p=0.026), but not hospitalization (30.5% vs. 23.2%; HR:1.04; 95% CI 0.79–1.37; p=0.760). Conclusions Among patients with HF in an integrated managed care organization, low health literacy was significantly associated with higher all-cause mortality. PMID:21521851
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Li, Guowei; Thabane, Lehana; Delate, Thomas; Witt, Daniel M.; Levine, Mitchell A. H.; Cheng, Ji; Holbrook, Anne
2016-01-01
Objectives To construct and validate a prediction model for individual combined benefit and harm outcomes (stroke with no major bleeding, major bleeding with no stroke, neither event, or both) in patients with atrial fibrillation (AF) with and without warfarin therapy. Methods Using the Kaiser Permanente Colorado databases, we included patients newly diagnosed with AF between January 1, 2005 and December 31, 2012 for model construction and validation. The primary outcome was a prediction model of composite of stroke or major bleeding using polytomous logistic regression (PLR) modelling. The secondary outcome was a prediction model of all-cause mortality using the Cox regression modelling. Results We included 9074 patients with 4537 and 4537 warfarin users and non-users, respectively. In the derivation cohort (n = 4632), there were 136 strokes (2.94%), 280 major bleedings (6.04%) and 1194 deaths (25.78%) occurred. In the prediction models, warfarin use was not significantly associated with risk of stroke, but increased the risk of major bleeding and decreased the risk of death. Both the PLR and Cox models were robust, internally and externally validated, and with acceptable model performances. Conclusions In this study, we introduce a new methodology for predicting individual combined benefit and harm outcomes associated with warfarin therapy for patients with AF. Should this approach be validated in other patient populations, it has potential advantages over existing risk stratification approaches as a patient-physician aid for shared decision-making PMID:27513986
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Diaz Bautista, Gonzalo A.
El Modelo Estandar describe todas las partculas observadas en el naturaleza hasta el momento as como las caractersticas que gobiernan a las interacciones fundamentales entre ellas. En especial es posible identicar a las interacciones electromagnetica y debil, las cuales bajo determinadas condiciones de temperatura y energa pueden ser descritas a traves de una sola teora que engloba a ambas. A esta teora se le denomina electrodebil y tiene como nalidad caracterizar las propiedades de la interaccion maniesta a partir de la mezcla de las interacciones electromagnetica y debil, la que tambien lleva como nombre interaccion electrodebil. Particularmente, los neutrinos sonmore » de especial interes ya que, por un lado, interactuan por medio de la interaccion debil muy raramente en comparacion con otras partculas y, por el otro, no son acertadamente descritos por el Modelo Estandar. Por medio de observaciones experimentales que demostraban que los neutrinos cambian de sabor al propagarse, fenomeno llamado oscilaciones de neutrinos, se pudo llegar a la conclusion de que la implicancia de este fenomeno da como consecuencia que los neutrinos efectivamente s tienen masa, algo que entra en contradiccion con la descripcion inicial del Modelo Estandar, el cual los describe como partculas sin masa. Es de esta manera que las oscilaciones de neutrinos han sido y siguen siendo en la actualidad objeto de interes en la Fsica de Altas Energas tanto teorica como experimental. A n de poder realizar mediciones precisas de oscilaciones de neutrinos, los experimentos encargados de estas mediciones deben tratar de reducir sus incertidumbres en lo posible. Una de estas proviene de la caracterizacion de las secciones de choque de los neutrinos cuando interactuan con la materia, particularmente los nucleones al interior de los nucleos atomicos. El experimento MINERA esta orientado, entre otras cosas, a hacer una correcta caracterizacion de secciones de choque neutrino-nucleon por medio del
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DEVELOPMENT OF METRICS FOR PROTOCOLS AND OTHER TECHNICAL PRODUCTS.
Veiga, Daniela Francescato; Ferreira, Lydia Masako
2015-01-01
nos critérios adotados pelas Áreas Ciências Biológicas I e Interdisciplinar. Apenas sete áreas descreveram sistema de pontuação para produtos técnicos, e as produções consideradas e a pontuação variaram amplamente. Dada à imensa gama de produções técnicas diferentes que podem ser consideradas relevantes, e que não seriam contempladas em sistema de pontuação caso fossem especificadas, foi desenvolvida para a Medicina III uma proposta de métricas em que são analisados cinco critérios específicos para cada produção: Demanda, Relevância/Impacto, Abrangência, Complexidade e Aderência ao Programa. Com base nestes critérios, cada produção pode receber de 10 a 100 pontos. Esta proposta poderá ser aplicada ao item Produção Intelectual da Ficha de Avaliação, subitem "Produção técnica, patentes e outras produções consideradas relevantes". Será considerado Muito Bom o Programa que obtiver média ≥150 pontos/docente permanente/quadriênio; Bom, média entre 100 e 149 pontos; Regular, média entre 60 e 99 pontos; Fraco, média entre 30 e 59 pontos; e Deficiente média ≤29 pontos/docente permanente/quadriênio.
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Neurobiología del autismo y TDAH mediante técnicas de neuroimagen: divergencias y convergencias
Proal, Erika; Olvera, Jorge González; Blancas, Aurea S.; Chalita, Pablo J.; Castellanos, F. Xavier
2013-01-01
En el área clínica algunos síntomas del trastorno por déficit de atención e hiperactividad (TDAH), se presentan en los pacientes con trastorno del espectro autista (TEA). Se ha demostrado que existen alteraciones en circuitos cerebrales que impactan en fallas cognitivas y de comportamiento específicas de cada uno de estos trastornos. Sin embargo, han sido poco estudiados los correlatos cerebrales que hay detrás tanto de las similitudes como de las diferencias sintomatológicas. En la presente revisión se analizaron los estudios meta-analíticos existentes estructurales y funcionales en TDAH y TEA. Por un lado, se observaron convergencias en circuitos como el dorsal atencional, de funciones ejecutivas, visual, somatomotor y circuito de activación por defecto. Estas similitudes posiblemente explican las manifestaciones comórbidas entre los trastornos como la falla en la integración de información, motricidad fina y procesos atencionales específicos. Por otro lado, específicamente en el TDAH se observan déficits en el circuito de recompensa y ventral atencional, sistemas involucrados en la medición de efectos de reforzamiento y monitoreo atencional. En TEA los circuitos más afectados fueron los implicados en procesos de cognición social y lenguaje. En conclusión, existen correlatos neuronales en TEA que explican las manifestaciones clínicas tanto convergentes como divergentes presentes en TDAH. PMID:23897144
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Raízes pós-mitológicas da Astronomia Clássica
NASA Astrophysics Data System (ADS)
di Bartolo, L.; Villas da Rocha, J. F.
2004-02-01
Apresentamos como a invenção de um modelo astronômico e cosmológico fundado em causas naturais foi um processo gestado num ambiente cultural específico, o do advento do pensamento pós-mitológico, que tem como sua raiz mais funda a trajetória particular da Grécia Antiga, com ênfase na resolução de uma grave crise social e a evolução do mundo clássico para o contexto espiritual de um império universal.
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Cosmic ray soil moisture observing systems comos in cap fields at El Reno Oklahoma
USDA-ARS?s Scientific Manuscript database
Soil water content (SWC) partitions rainfall into runoff and infiltration, modulates surface and atmospheric exchanges of water and energy, affects plant growth and crop yields, and impacts chemical and biological activities of soil, among other things. Thus, SWC, especially over large scales, is a...
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Escuelas sin Drogas. Como Actuar. Edicion 1992. (Schools without Drugs. What Works. 1992 Edition).
ERIC Educational Resources Information Center
Department of Education, Washington, DC.
Across the United States, schools and communities have found ways to turn the tide in the battle against drugs. This guidebook describes the methods they have used and the actions they have taken. The first section, "Children and Drugs" outlines the nature and extent of the drug problem and summarizes the latest research on the effects of drugs on…
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ERIC Educational Resources Information Center
Corbell, Gloria; And Others
This teacher's guide to Spanish language at the kindergarten level includes a recommended subject presentation sequence for the Spanish curriculum, a sample schedule, a grouping of students using three stations, and a classroom layout. The grouping would be effective when at least one-third of the children are Spanish-speaking or bilingual. The…
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Las líneas de aluminio neutro como diagnóstico cromosférico
NASA Astrophysics Data System (ADS)
Fernández Borda, R.; Mauas, P. J. D.
Se presenta un modelo atómico para el cálculo de las lí neas del Aluminio neutro que se forman en la cromósfera solar. En particular, se estudia la línea λ 3961 Å, que, por estar muy próxima a la lí nea H del Ca II y a Hɛ es muy frecuentemente observada. Observaciones en esta lí nea obtenidas con el espectrógrafo a instalarse en el CASLEO, serán utilizadas para el estudio de fulguraciones solares.
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NASA Astrophysics Data System (ADS)
Cordova-Santiago, Lizzette Astrid
La investigacion---accion que se llevo a cabo en la sala de clases tenia como punto de partida las creencias de la cultura de la ciencia de un grupo de estudiantes universitarios para luego examinar sus implicaciones en el proceso de aprendizaje de las Ciencias Biologicas. ¿Que se supone que hagan las creencias en relacion con el aprendizaje? ¿En que consiste incorporar este aspecto a la practica educativa universitaria? Utilizando el modelo de Kemmis y McTaggart (1987) la investigacion-accion se planteo como un proceso dinamico en cuatro momentos en espiral constituidos por la planificacion, la accion, la observacion y la reflexion. Cada una de las fases tuvo una intencion retrospectiva y prospectiva formando una espiral de autorreflexion del conocimiento y la accion. Se llevaron a cabo audio grabaciones en clases y analisis de documentos. Ademas, la profesora-investigadora hizo un portafolio para reflexionar sobre las creencias de la cultura de la ciencia que tienen los estudiantes y las creencias del aprendizaje que tiene la profesora y sobre como la comprension de estos elementos ayudo a mejorar su practica educativa a traves del tiempo. Los resultados obtenidos apuntan a que las creencias de la cultura de la ciencia que tiene el grupo de estudiantes son diversas. Ellos si creen que la ciencia tiene una cultura la cual describieron como: complicada y desconocida que evoluciona constantemente, que es un conjunto de metodos, que es altamente tecnologica, que resuelve problemas de salud, ayuda a interpretar la realidad del mundo que los rodea y su origen y que existen unas intersecciones entre la ciencia y el poder. Sobre las creencias del proceso de aprendizaje de la profesora-investigadora, estas senalan que el modelaje de actores, la vision de la academia que tiene ella asi como la participacion y negociacion entre todos los involucrados en el proceso educativo, son factores que inciden en el proceso de aprendizaje.
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Sobrevivendo a un tsunami: lecciones de Chile, Hawai y Japon
Compilado por Atwater, Brian F.; Cisternas V., Marco; Bourgeois, Joanne; Dudley, Walter C.; Hendley, James W.; Stauffer, Peter H.
1999-01-01
Este folleto contiene historias veridicas que ilustran como sobrevivir, y como no sobrevivir, a un tsunami. Esta publicacion esta dirigida a las personas que viven, trabajan o, simplemente, se divierten a lo largo de las costas que pueden ser afectadas por un tsunami. Tales costas rodean la mayor parte del Oceano Pacifico pero tambien incluyen algunas areas costeras de los Oceanos Atlantico e Indico. Aunque mucha gente llama a los tsunamis 'olas de marea', estos no estan relacionados a las mareas, sino son una serie de olas, o 'tren de olas', generalmente causadas por cambios en el nivel del fondo marino durante los terremotos. Los tsunamis tambien pueden ser generados por la erupcion de volcanes costeros, islas volconicas, deslizamientos submarinos e impactos de grandes meteoritos en el mar. Como sucedio en Sumatra en el 2004, los tsunamis pueden alcanzar alturas de 15 metros, no tan solo en la costa sino tambien kilometros tierra adentro. Los relatos presentados en este folleto fueron seleccionados de entrevistas realizadas a personas que sobrevivieron al tsunami del Oceano Pacifico de 1960. Muchas de estas personas, incluyendo a la enfermera de la foto, se enfrento a las olas generadas a poca distancia, en la costa chilena. En cambio, otros debieron hacer frente al tsunami muchas horas despues, en Hawai y Japon. La mayoria de las entrevistas fueron realizadas a fines de los anos ochenta y en los noventa. Las historias ofrecen una mezcla de lecciones de supervivencia a un tsunami. En algunos casos se presentan las acciones que confiablemente salvaron vidas: poner atencion a los avisos de la naturaleza, abandonar los bienes, dirigirse rapidamente a un sector alto y permanecer alli hasta que el tsunami realmente haya terminado. Otras historias describen como se encontro refugio al subir a construcciones y arboles o flotar sobre desechos, tacticas que tuvieron diferentes resultados y que pueden ser recomendadas solo como actos desesperados de personas atrapadas en
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Astronomia Motivadora no Ensino Fundamental
NASA Astrophysics Data System (ADS)
Melo, J.; Voelzke, M. R.
2008-09-01
O objetivo principal deste trabalho é procurar desenvolver o interesse dos alunos pelas ciências através da Astronomia. Uma pesquisa com perguntas sobre Astronomia foi realizada junto a 161 alunos do Ensino Fundamental, com o intuito de descobrir conhecimentos prévios dos alunos sobre o assunto. Constatou-se, por exemplo, que 29,3% da 6ª série responderam corretamente o que é eclipse, 30,0% da 8ª série acertaram o que a Astronomia estuda, enquanto 42,3% dos alunos da 5ª série souberam definir o Sol. Pretende-se ampliar as turmas participantes e trabalhar, principalmente de forma prática com: dimensões e escalas no Sistema Solar, construção de luneta, questões como dia e noite, estações do ano e eclipses. Busca-se abordar, também, outros conteúdos de Física tais como a óptica na construção da luneta, e a mecânica no trabalho com escalas e medidas, e ao utilizar uma luminária para representar o Sol na questão do eclipse, e de outras disciplinas como a Matemática na transformação de unidades, regras de três; Artes na modelagem ou desenho dos planetas; a própria História com relação à busca pela origem do universo, e a Informática que possibilita a busca mais rápida por informações, além de permitir simulações e visualizações de imagens importantes. Acredita-se que a Astronomia é importante no processo ensino aprendizagem, pois permite a discussão de temas curiosos como, por exemplo, a origem do universo, viagens espaciais a existência ou não de vida em outros planetas, além de temas atuais como as novas tecnologias.
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Gustinelli, Andrea; Menconi, Vasco; Prearo, Marino; Caffara, Monica; Righetti, Marzia; Scanzio, Tommaso; Raglio, Annibale; Fioravanti, Maria Letizia
2016-10-17
In recent years there has been a re-emergence of diphyllobothriasis by Diphyllobothrium latum (Cestoda: Diphyllobothriidae) in Italy, France and Switzerland, where in the past this fish-borne zoonosis was widespread and then virtually disappeared. A change in eating habits such as the consumption of raw/undercooked freshwater fish, has led to an increased risk for consumers of ingesting infective larvae of D. latum. A survey on the factors responsible for the re-emergence of human diphyllobothriasis in Italy was carried out from March 2013 to December 2014. The aim of this study was to assess the diffusion of D. latum plerocercoids in the fish populations of the sub-alpine lakes of Maggiore, Como, Iseo and Garda, updating the scarce historical data and assessing a preliminary "risk level" of the lacustrine environments and fish species under investigation. A total of 2228 fish belonging to 5 species, 690 from Lake Maggiore, 500 from Lake Como, 655 from Lake Iseo and 383 from Lake Garda were submitted to parasitological examination. The presence of D. latum plerocercoid larvae was detected in 6.6%, 25.4% and 7.6% of perch (Perca fluviatilis) from Lakes Maggiore, Como and Iseo respectively. The parasite was also present in pike (Esox lucius) with prevalence values ranging from 71.4 to 84.2% and in 3.6-3.8% of burbot (Lota lota) from Lakes Iseo and Como. Fish from Lake Garda were negative as well as sampled whitefish (Coregonus lavaretus) and shad (Alosa fallax lacustris). The results of this survey showed a widespread presence of D. latum plerocercoid larvae in Maggiore, Como and Iseo fish populations. Urban fecal contamination of water is still a key issue to be resolved, together with the improvement of communication with consumers regarding the best dietary habits and the most effective processes of parasite inactivation, required for the consumption of raw/undercooked fish caught in high-risk areas. Copyright © 2016 Elsevier B.V. All rights reserved.
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NASA Astrophysics Data System (ADS)
de Oliveira, E. F.; Voelzke, M. R.; Amaral, L. H.
2007-08-01
Embora os Parâmetros Curriculares Nacionais do Ensino Médio (PCN-EM) e as orientações complementares a esses Parâmetros (PCN+) apontem a importância de uma abordagem significativa de conceitos relacionados à astronomia nas aulas de Física, muitos estudantes terminam o Ensino Médio (EM) sem compreender a razão de certos acontecimentos de origem celeste, ainda que estes façam parte de seu cotidiano. Este trabalho tem por objetivo analisar os conhecimentos básicos em astronomia dos alunos de EM da escola estadual Batista Renzi, bem como investigar os meios através dos quais estes conhecimentos foram adquiridos. Para tanto foi elaborado um questionário de múltipla escolha aplicado a 310 alunos distribuídos entre as três séries do EM dos períodos matutino e noturno. Dessa forma, observou-se que apenas 34,5% relacionaram as estações do ano à inclinação do eixo de rotação da Terra, 21,3% indicaram a influência gravitacional da Lua e do Sol como responsáveis pelo fenômeno das marés, 24,5% indicaram corretamente quais são os objetos celestes mais próximos da Terra, 36,1% identificaram ano-luz como uma medida de distância e 34,2% reconheceram uma estrela cadente como meteoro. Em contrapartida, 67,1% compreendiam a sucessão entre dia e noite, 73,9% identificaram o Sol como estrela e 52,3% relacionaram o Big Bang à origem do Universo. Além disso, foram comparadas as respostas de alunos de diferentes séries e períodos, observando-se, dentre outras coisas, que os estudantes do terceiro ano apresentam um percentual de acertos semelhante ao dos alunos do primeiro, caracterizando que a abordagem de tópicos relacionados à astronomia no EM não tem contribuído para uma maior compreensão dos fenômenos e conceitos.
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NASA Astrophysics Data System (ADS)
dos Santos Leão, Demetrius
2013-07-01
The aim of this article is to present part of the results obtained by the intervention made from the author's Master degree project, which consisted in the development of a set of Astronomy classes for first year of High School students from a private school in the "Distrito Federal", Brasilia, Brazil, making use of a didactical material called mini-planetarium (MP) as the main resource. Using Paulo Freire's contextualization and dialogicity ideas as a theoretical framework guided by these lessons, it was proposed to the students the assembly and application of that resource in a planetarium session. During the project, some subjects such as the apparent trajectory of stars through Brasilia's sky, the location of the cardinal points beginning from the Southern Cross constellation, the color of stars and the stars being seen from a particular place were emphasized. It was found that the students showed an improvement of their understanding about these subjects, as well as a significant excitement with the developed methodology. El objetivo de este trabajo es presentar algunos de los resultados obtenidos en el proyecto de la tesis de maestría del autor, que incluyó el desarrollo de algunas clases de Astronomía, con estudiantes del primer año del bachillerato de una escuela privada del Distrito Federal (Brasilia, Brasil), utilizando como materia prima didáctica el recurso llamado miniplanetario (MP). Utilizando como base teórica orientadora de esas clases las ideas de contextualización y dialógica de Paulo Freire, fue propuesto a los estudiantes el montaje y la utilización de este recurso en una función de planetario. Durante el proyecto, se enfatizaron asuntos tales como la trayectoria aparente de las estrellas del cielo de Brasilia, la ubicación de los puntos cardinales a partir de la constelación de la Cruz del Sur, los colores de las estrellas y las estrellas vistas desde una localidad determinada. Se constató que los estudiantes mostraron una mejora
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NASA Astrophysics Data System (ADS)
Dias, Claudio André C. M.; Santa Rita, Josué R.
2008-12-01
Astronomy is considered among the first sciences that man dominated, however, the basic skills for the construction of knowledge, relatively to the contents "Earth and the Universe" are not being developed properly for the majority of students concluding the high school level. The students are concluding this teaching cycle without proper knowledge of several subjects in the area of Astronomy, which are mandatory in the national Curricular National Parameters (PCN). Because of this discrepancy, this work stresses the need of the incorporation of a specific subject of Astronomy in the high school, in order to reduce the gap between what is taught and which should be taught. La Astronomía es considerada una de las primeras ciencias que el hombre dominó. Sin embargo, las habilidades básicas para la construcción del conocimento, relativo al eje temático "Tierra y Universo", no vienen siendo trabajadas adecuadamente con la mayoría de los alumnos que concluyen el ciclo escolar medio. Los alumnos están concluyendo este nivel de enseñanza sin conocimentos de varios temas en el área de Astronomía, que son obligatorios según los Parámetros Curriculares Nacionales (PCN). En virtud de esta discrepancia, este trabajo enfatiza la necesidad de incorporar una disciplina específica de Astronomía em el ciclo medio, em pro de la reducción de las distorsiones entre lo que es enseñado y lo que se debe enseñar. A Astronomia é considerada uma das primeiras ciências que o homem dominou, porém as competências básicas para a construção do conhecimento, relativo ao eixo temático "Terra e Universo", não vêm sendo trabalhadas a contento com a maioria dos alunos que concluem o ensino médio. Os alunos estão concluindo este nível de ensino sem conhecimento de vários temas na área de Astronomia, que são obrigatórios nos Parâmetros Curriculares Nacionais (PCN). Em virtude desta discrepância, este trabalho vem evidenciar a necessidade da incorporação de uma disciplina específica de Astronomia, no ensino médio, em prol da redução das distorções entre o que é ensinado e o que se deve ensinar.
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A Visão do Universo Segundo a Concepção de um Grupo de Alunos do Ensino Médio de São Paulo
NASA Astrophysics Data System (ADS)
Araújo, M. A. A.; Elias, D. C. N.; Amaral, L. H.; Araújo, M. S. T.; Voelzke, M. R.
2005-12-01
Nesse trabalho foi identificada por meio de um questionário a visão de mundo sobre o Universo espaço e tempo entre 270 estudantes de Ensino Médio de três escolas de São Paulo. Constatou-se pouco conhecimento dos temas investigados sendo que apenas 20% dos alunos relacionaram as semanas com as fases da lua enquanto 28% associaram as estações do ano à inclinação do eixo de rotação da Terra e 23% tinham noções das distâncias entre objetos celestes próximos da Terra. Enquanto 56% conseguiram relacionar o Big Bang com a origem do Universo verificou-se que 37% reconheciam ano-luz como unidade de distância e 60% reconheciam o Sol como uma estrela. Apesar de 60% dos alunos indicarem a escola como principal fonte dos conhecimentos de astronomia seus conceitos ainda são inadequados havendo necessidade de aprimoramento da abordagem desses conteúdos pois apesar de popular a astronomia é veiculada de maneira pouco esclarecedora e com imprecissões.
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Walker, Janiece L.; Harrison, Tracie C.; Hendrickson, Sherry G.
2012-01-01
There is a dearth of literature examining how adversity shapes the experiences of pain and/or suffering in a middle aged Mexican American women. The purpose of this qualitative descriptive study was to understand pain and suffering from a life course perspective as described by a Mexican American woman aging with early onset mobility impairment. This Hispanic woman experienced episodes of abuse and rejection over the life course, which may have significantly influenced her pain and suffering experience in adulthood. This adds to the literature on how adversity influences later life pain experience and provides insight on why pharmacological treatment alone may not be as successful as a holistic intervention. Hay escasez de literatura que examine cómo la adversidad da forma a las experiencias de dolor y / o sufrimiento en mujeres mexicana-americana mayores de edad. El propósito de este estudio descriptivo cualitativo fue comprender el dolor y el sufrimiento desde una perspectiva de ciclo de vida como descrito por una mujer mexicana-americana envejeciendo con inicio temprano de deterioro de movilidad. Esta Latina experimentó episodios de maltrato y rechazo, que se percibió haber afectado su experiencia de dolor y sufrimiento luego como adulta. Este estudio aumenta la literatura sobre cómo la adversidad influya la experiencia de dolor más tarde en la vida, y nos permite comprender mejor como el tratamiento farmacológico por sí solo no es tan exitoso como pueda ser una intervención integral. PMID:24830728
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Domínguez, Raúl; Garnacho-Castaño, Manuel Vicente; Maté-Muñoz, José Luis
2016-06-30
La fuerza influye directamente en el estado de salud y en la capacidad de fitness, motivo por el que el entrenamiento contra resistencias o resistance training (RT) se incluye dentro de aquellos programas de ejercicio encaminados a mejorar la salud y calidad de vida. Debido a que muchasenfermedades cursan con alteración de la masa y funcionalidad muscular y a que el RT es la principal modalidad de ejercicio encaminada a mejorar la función muscular, el objetivo de la presente revisión bibliográfica ha sido exponer las evidencias actuales sobre las adaptaciones delRT, así como su posible aplicación en patologías como la obesidad, diabetes, dislipemia, hipertensión, cáncer, Parkinson, esclerosis múltiple o fibromialgia. El RT en estas enfermedades puede aumentar los niveles de masa muscular, disminuyendo los niveles de masa grasa, los nivelesde ácidos grasos en sangre y la glucemia, incrementando la sensibilidad a la insulina, y disminuyendo los niveles de citokinas inflamatorias. El RT, además, mejora el gasto cardiaco y la funcionalidad endotelial, regulando la tensión arterial e incrementando el consumo de oxígeno. Las ganancias de fuerza muscular mejoran la funcionalidad y la calidad de vida, especialmente en población con una afectación neuromuscular grave, como pudieran ser los enfermos de esclerosis múltiple, fibromialgia o Parkinson. Por ello, el RT debe ser incorporado como parte del tratamiento en las personas que presentan determinado tipo de patologías.
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Zubiaga, Lorea; Ruiz-Tovar, Jaime; Giner, Lorena; González, Juan; Aguilar, María Del Mar; García, Alejandro; Calpena, Rafael; Durán, Manuel
2016-07-19
Introducción y objetivo: el IMC puede resultar engañoso para ciertas complexiones corporales, por lo que se han propuesto otros parámetros como la adiposidad (calculada a través de fórmula CUN-BAE,) el índice de Framingham de riesgo cardiovascular (IF) y el índice aterogénico (IA) (rCT/HDL-c) como predictores de riesgo cardiovascular. Se propone comparar estos factores como marcadores de éxito terapéutico tras cirugía en pacientes obesos sometidos a gastrectomía vertical laparoscópica (GVL) como procedimiento de cirugía bariátrica.Material y métodos: realizamos un estudio observacional prospectivo de pacientes sometidos a GVL y con un periodo de seguimiento mínimo de 1 año. Analizamos la evolución de IMC, adiposidad, IF e IA.Resultados: analizamos 140 pacientes. El IMC preoperatorio fue de 49,1 kg/m2, con una adiposidad del 54,8%, un IF 7,54% y un IA de 4,2. A los 12 meses el IMC era de 28,4 kg/m2, con una adiposidad del 39,4%, un IF del 3,7% y un IA de 1,64. En función de estos resultados, a los 12 meses el IMC medio está en rango de sobrepeso, la adiposidad en niveles de obesidad (obesidad: > 25% en hombres y > 35% en mujeres), el IF en rango de riesgo cardiovascular bajo (< 5%) y el IA dentro del rango de normalidad (< 3). Correlacionando estos parámetros observamos que el IMC se correlaciona con la adiposidad tanto en valores preoperatorios (Pearson 0,486; p = 0,004), posoperatorios (Pearson 0,957; p < 0,001), como en la diferencia entre ambos (Pearson 0,606; p = 0,017), lo cual es lógico, porque el IMC se incluye en la fórmula CUN-BAE para el cálculo de la adiposidad. En los valores posoperatorios se objetiva una correlación de la adiposidad con el IF (Pearson 0,814, p = 0,036) y con el IA (Pearson 0,517; p = 0,049). En los valores preoperatorios no se objetivan dichas correlaciones. El IMC no se correlacionó con la adiposidad.Conclusión: la adiposidad se correlaciona con índices de riesgo cardiovascular, como el índice de
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Winthrop, Kevin L; Baxter, Roger; Liu, Liyan; McFarland, Bentson; Austin, Donald; Varley, Cara; Radcliffe, LeAnn; Suhler, Eric; Choi, Dongsoek; Herrinton, Lisa J
2011-03-01
Anti-tumor necrosis factor-alpha (anti-TNF) therapies are associated with severe mycobacterial infections in rheumatoid arthritis patients. We developed and validated electronic record search algorithms for these serious infections. The study used electronic clinical, microbiologic, and pharmacy records from Kaiser Permanente Northern California (KPNC) and the Portland Veterans Affairs Medical Center (PVAMC). We identified suspect tuberculosis and nontuberculous mycobacteria (NTM) cases using inpatient and outpatient diagnostic codes, culture results, and anti-tuberculous medication dispensing. We manually reviewed records to validate our case-finding algorithms. We identified 64 tuberculosis and 367 NTM potential cases, respectively. For tuberculosis, diagnostic code positive predictive value (PPV) was 54% at KPNC and 9% at PVAMC. Adding medication dispensings improved these to 87% and 46%, respectively. Positive tuberculosis cultures had a PPV of 100% with sensitivities of 79% (KPNC) and 55% (PVAMC). For NTM, the PPV of diagnostic codes was 91% (KPNC) and 76% (PVAMC). At KPNC, ≥ 1 positive NTM culture was sensitive (100%) and specific (PPV, 74%) if non-pathogenic species were excluded; at PVAMC, ≥1 positive NTM culture identified 76% of cases with PPV of 41%. Application of the American Thoracic Society NTM microbiology criteria yielded the highest PPV (100% KPNC, 78% PVAMC). The sensitivity and predictive value of electronic microbiologic data for tuberculosis and NTM infections is generally high, but varies with different facilities or models of care. Unlike NTM, tuberculosis diagnostic codes have poor PPV, and in the absence of laboratory data, should be combined with anti-tuberculous therapy dispensings for pharmacoepidemiologic research. Copyright © 2010 John Wiley & Sons, Ltd.
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Miller-Rosales, Chris; Sterling, Stacy A; Wood, Sabrina B; Ross, Thekla; Makki, Mojdeh; Zamudio, Cindy; Kane, Irene M; Richardson, Megan C; Samayoa, Claudia; Charvat-Aguilar, Nancy; Lu, Wendy Y; Vo, Michelle; Whelan, Kimberly; Uratsu, Connie S; Grant, Richard W
2017-12-01
Cardiovascular disease (CVD) is the leading cause of death in the US. Many patients do not benefit from traditional disease management approaches to CVD risk reduction. Here we describe the rationale, development, and implementation of a multi-component behavioral intervention targeting patients who have persistently not met goals of CVD risk factor control. Informed by published evidence, relevant theoretical frameworks, stakeholder advice, and patient input, we developed a group-based intervention (Changing Results: Engage and Activate to Enhance Wellness; "CREATE Wellness") to address the complex needs of patients with elevated or unmeasured CVD-related risk factors. We are testing this intervention in a randomized trial among patients with persistent (i.e > 2 years) sub-optimal risk factor control despite being enrolled in an advanced and highly successful CVD disease management program. The CREATE Wellness intervention is designed as a 3 session, group-based intervention combining proven elements of patient activation, health system engagement skills training, shared decision making, care planning, and identification of lifestyle change barriers. Our key learnings in designing the intervention included the value of multi-level stakeholder input and the importance of pragmatic skills training to address barriers to care. The CREATE Wellness intervention represents an evidence-based, patient-centered approach for patients not responding to traditional disease management. The trial is currently underway at three medical facilities within Kaiser Permanente Northern California and next steps include an evaluation of efficacy, adaptation for non-English speaking patient populations, and modification of the curriculum for web- or phone-based versions. NCT02302612.
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Design and implementation of population-based specialty care programs.
Botts, Sheila R; Gee, Michael T; Chang, Christopher C; Young, Iris; Saito, Logan; Lyman, Alfred E
2017-09-15
The development, implementation, and scaling of 3 population-based specialty care programs in a large integrated healthcare system are reviewed, and the role of clinical pharmacy services in ensuring safe, effective, and affordable care is highlighted. The Kaiser Permanente (KP) integrated healthcare delivery model allows for rapid development and expansion of innovative population management programs involving pharmacy services. Clinical pharmacists have assumed integral roles in improving the safety and effectiveness of high-complexity, high-cost care for specialty populations. These roles require an appropriate practice scope and are supported by an advanced electronic health record with disease registries and electronic surveillance tools for care-gap identification. The 3 specialty population programs described were implemented to address variation or unrecognized gaps in care for at-risk specialty populations. The Home Phototherapy Program has leveraged internal partnerships with clinical pharmacists to improve access to cost-effective nonpharmacologic interventions for psoriasis and other skin disorders. The Multiple Sclerosis Care Program has incorporated clinical pharmacists into neurology care in order to apply clinical guidelines in a systematic manner. The KP SureNet program has used clinical pharmacists and data analytics to identify opportunities to prevent drug-related adverse outcomes and ensure timely follow-up. Specialty care programs improve quality, cost outcomes, and the patient experience by appropriating resources to provide systematic and targeted care to high-risk patients. KP leverages an integration of people, processes, and technology to develop and scale population-based specialty care. Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
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Rectal Cancer Survivors’ Participation in Productive Activities
Hornbrook, Mark C; Grant, Marcia; Wendel, Christopher; Bulkley, Joanna E; McMullen, Carmit K; Altschuler, Andrea; Temple, Larissa KF; Herrinton, Lisa J; Krouse, Robert S
2018-01-01
Context Rectal cancer and its treatment impair survivors’ productivity. Objective To assess determinants of market and nonmarket employment, job search, volunteering, and homemaking among survivors five years or longer after diagnosis. Design We mailed questionnaires to 1063 survivors who were members of Kaiser Permanente (Northern California, Northwest) during 2010 and 2011. Main Outcome Measures Productive activities, functional health status, and bowel management at the time of the survey. Results Response rate was 60.5% (577/953). Higher comorbidity burdens were associated with lower productivity for men and women rectal cancer survivors. Productive survivors were younger and had lower disease stage and age at diagnosis, higher household income and educational attainment, and fewer comorbidity burdens and workplace adjustments than did nonproductive survivors (p < 0.05 each; 2-sided). Productive rectal cancer survivors were evenly split by sex. Conclusion Staying productive is associated with better mental health for rectal cancer survivors. Rectal cancer survivors with multiple chronic conditions, higher disease stage, lower productive activities, and older age need better access to medical care and closer monitoring of the quality of their care, including self-care. To capture the full extent of the involvement of survivors in all types of productive activities, research should routinely include measures of employment, searching for employment, homemaking, and volunteering. Counting market and nonmarket productive activities is innovative and recognizes the continuum of contributions survivors make to families and society. Health care systems should routinely monitor rectal cancer survivors’ medical care access, comorbidities, health-related quality of life, and productive activities. PMID:29236653
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Hepatitis C screening trends in a large integrated health system
Linas, Benjamin P.; Hu, Haihong; Barter, Devra M.; Horberg, Michael
2014-01-01
Background As new hepatitis C virus (HCV) therapies emerge, only 1–12% of individuals are screened in the U.S. for HCV infection. Presently, HCV screening trends are unknown. Methods We utilized the Kaiser Permanente Mid-Atlantic States’ (KPMAS) data repository to investigate HCV antibody screening between 1/1/2003 and 12/31/2012. We identified the proportion screened for HCV and 5-year cumulative incidence of screening, the screening positivity rate, the provider types performing HCV screening, patient-level factors associated with being screened, and trends in screening over time. Results 444,594 patients met the inclusion criteria. Overall, 15.8% of the cohort was ever screened for HCV. Adult primary care and obstetrics and gynecology providers performed 75.9% of all screening. The overall test positivity rate was 3.8%. Screening was more frequent in younger age groups (p<0.0001) and those with a documented history of illicit drug use (p<0.0001). Patients with missing drug use history (46.7%) were least likely to be screened (p<0.0001). While the rate of HCV screening increased in the later years of the study, among those enrolled in KPMAS 2009–2012, only 11.8% were screened by the end of follow-up. Conclusion Screening for HCV is increasing, but remains incomplete. Targeting screening to those with a history of injection drug will not likely expand screening, as nearly half of patients have no documented drug use history. Routine screening is likely the most effective approach to expand HCV screening. PMID:24486288
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Hepatitis C screening trends in a large integrated health system.
Linas, Benjamin P; Hu, Haihong; Barter, Devra M; Horberg, Michael
2014-05-01
As new hepatitis C virus (HCV) therapies emerge, only 1%-12% of individuals are screened in the US for HCV infection. Presently, HCV screening trends are unknown. We utilized the Kaiser Permanente Mid-Atlantic States' (KPMAS) data repository to investigate HCV antibody screening between January 1, 2003 and December 31, 2012. We identified the proportion screened for HCV and 5-year cumulative incidence of screening, the screening positivity rate, the provider types performing HCV screening, patient-level factors associated with being screened, and trends in screening over time. There were 444,594 patients who met the inclusion criteria. Overall, 15.8% of the cohort was ever screened for HCV. Adult primary care and obstetrics and gynecology providers performed 75.9% of all screening. The overall test positivity rate was 3.8%. Screening was more frequent in younger age groups (P <.0001) and those with a documented history of illicit drug use (P <.0001). Patients with missing drug use history (46.7%) were least likely to be screened (P <.0001). While the rate of HCV screening increased in the later years of the study among those enrolled in KPMAS 2009-2012, only 11.8% were screened by the end of follow-up. Screening for HCV is increasing but remains incomplete. Targeting screening to those with a history of injection drug will not likely expand screening, as nearly half of patients have no documented drug use history. Routine screening is likely the most effective approach to expand HCV screening. Copyright © 2014. Published by Elsevier Inc.
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Baxter, Roger; Hansen, John; Timbol, Julius; Pool, Vitali; Greenberg, David P; Johnson, David R; Decker, Michael D
2016-11-01
An observational post-licensure (Phase IV) retrospective large-database safety study was conducted at Kaiser Permanente, a US integrated medical care organization, to assess the safety of Tetanus Toxoid, Reduced Diphtheria Toxoid and 5-Component Acellular Pertussis Vaccine (Tdap5) administered as part of routine healthcare among adolescents and adults. We evaluated incidence rates of various clinical events resulting in outpatient clinic, emergency department (ED), and hospital visits during various time intervals (windows) following Tdap5 vaccination using 2 pharmacoepidemiological methods (risk interval and historic cohort) and several screening thresholds. Plausible outcomes of interest with elevated incidence rate ratios (IRRs) were further evaluated by reviewing individual patient records to confirm the diagnosis, timing (temporal relationship), alternative etiology, and other health record details to discern possible relatedness of the health events to vaccination. Overall, 124,139 people received Tdap5 vaccine from September 2005 through mid-October 2006, and 203,154 in the comparison cohort received a tetanus and diphtheria toxoid adsorbed vaccine (and no live virus vaccine) during the year prior to initiation of this study. In the outpatient, ED and hospital databases, respectively, we identified 11/26, 179/700 and 187/700 unique health outcomes with IRRs significantly >1.0. Among the same unique health outcomes in the outpatient, ED, and hospital databases, 9, 146, and 385, respectively, had IRRs significantly <1.0. Further scrutiny of the outcomes with elevated IRRs did not reveal unexpected signals of adverse outcomes related to vaccination. In conclusion, Tdap5 vaccine was found to be safe among this large population of adolescents and adults.
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Automated outreach to increase primary adherence to cholesterol-lowering medications.
Derose, Stephen F; Green, Kelley; Marrett, Elizabeth; Tunceli, Kaan; Cheetham, T Craig; Chiu, Vicki Y; Harrison, Teresa N; Reynolds, Kristi; Vansomphone, Southida S; Scott, Ronald D
2013-01-14
Primary nonadherence occurs when new prescriptions are not dispensed. Little is known about how to reduce primary nonadherence. We performed a randomized controlled trial to evaluate an automated system to decrease primary nonadherence to statins for lowering cholesterol. Adult members of Kaiser Permanente Southern California with no history of statin use within the past year who did not fill a statin prescription after 1 to 2 weeks were passively enrolled. The intervention group received automated telephone calls followed 1 week later by letters for continued nonadherence; the control group received no outreach. The primary outcome was a statin dispensed up to 2 weeks after delivery of the letter. Secondary outcomes included refills at intervals up to 1 year. Intervention effectiveness was determined by intent-to-treat analysis and Fisher exact test. Subgroups were examined using logistic regression. There were 2606 participants in the intervention group and 2610 in the control group. Statins were dispensed to 42.3% of intervention participants and 26.0% of control participants (absolute difference, 16.3%; P < .001). The relative risk for the intervention vs control group was 1.63 (95% CI, 1.50-1.76). Intervention effectiveness varied slightly by age (P = .045) but was effective across all age strata. Differences in the frequency of statin dispensations persisted up to 1 year (P < .001). The intervention was effective in reducing primary nonadherence to statin medications. Because of low marginal costs for outreach, this strategy appears feasible for reducing primary nonadherence. This approach may generalize well to other medications and chronic conditions.
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A Survey of Parents with Children on the Autism Spectrum: Experience with Services and Treatments
Becerra, Tracy A; Massolo, Maria L; Yau, Vincent M; Owen-Smith, Ashli A; Lynch, Frances L; Crawford, Phillip M; Pearson, Kathryn A; Pomichowski, Magdalena E; Quinn, Virginia P; Yoshida, Cathleen K; Croen, Lisa A
2017-01-01
Introduction Autism spectrum disorders (ASD) are lifelong neurodevelopmental disorders, and little is known about how parents address the health and psychosocial consequences of ASD. Few studies have examined use of various treatments and services in a large, diverse sample of children with ASD and their families. Objective This paper presents methods to create an autism research resource across multiple large health delivery systems and describes services and treatments used by children with ASD and their families. Methods Four study sites conducted a Web survey of parents of children and adolescents with ASD who were members of Kaiser Permanente. We tabulated data distributions of survey responses and calculated χ2 statistics for differences between responders and nonresponders. Results The children of the 1155 respondents were racially and ethnically diverse (55% white, 6% black, 5% Asian, 9% multiracial, 24% Hispanic) and representative of the total population invited to participate with respect to child sex (83% male), child age (57% < 10 years), and ASD diagnosis (64% autistic disorder). The most frequently used services and treatments were Individualized Education Programs (85%), family physician visits (78%), and occupational and speech therapy (55% and 60%, respectively). Home-based programs frequently included implementation of social skills training (44%) and behavior management (42%). Prescription medication use was high (48%). Caregivers reported disruption of personal and family routines because of problem behaviors. Conclusion These survey data help to elucidate parents’ experiences with health services for their children with ASD and serve as a potential resource for future research. PMID:28488981
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Lu, Ake Tzu-Hui; Austin, Erin; Bonner, Ashley; Huang, Hsin-Hsiung; Cantor, Rita M
2014-09-01
Machine learning methods (MLMs), designed to develop models using high-dimensional predictors, have been used to analyze genome-wide genetic and genomic data to predict risks for complex traits. We summarize the results from six contributions to our Genetic Analysis Workshop 18 working group; these investigators applied MLMs and data mining to analyses of rare and common genetic variants measured in pedigrees. To develop risk profiles, group members analyzed blood pressure traits along with single-nucleotide polymorphisms and rare variant genotypes derived from sequence and imputation analyses in large Mexican American pedigrees. Supervised MLMs included penalized regression with varying penalties, support vector machines, and permanental classification. Unsupervised MLMs included sparse principal components analysis and sparse graphical models. Entropy-based components analyses were also used to mine these data. None of the investigators fully capitalized on the genetic information provided by the complete pedigrees. Their approaches either corrected for the nonindependence of the individuals within the pedigrees or analyzed only those who were independent. Some methods allowed for covariate adjustment, whereas others did not. We evaluated these methods using a variety of metrics. Four contributors conducted primary analyses on the real data, and the other two research groups used the simulated data with and without knowledge of the underlying simulation model. One group used the answers to the simulated data to assess power and type I errors. Although the MLMs applied were substantially different, each research group concluded that MLMs have advantages over standard statistical approaches with these high-dimensional data. © 2014 WILEY PERIODICALS, INC.
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Kuntz, Jennifer L; Smith, David H; Petrik, Amanda F; Yang, Xiuhai; Thorp, Micah L; Barton, Tracy; Barton, Karen; Labreche, Matthew; Spindel, Steven J; Johnson, Eric S
2016-01-01
Increasing morbidity and health care costs related to Clostridium difficile infection (CDI) have heightened interest in methods to identify patients who would most benefit from interventions to mitigate the likelihood of CDI. To develop a risk score that can be calculated upon hospital admission and used by antimicrobial stewards, including pharmacists and clinicians, to identify patients at risk for CDI who would benefit from enhanced antibiotic review and patient education. We assembled a cohort of Kaiser Permanente Northwest patients with a hospital admission from July 1, 2005, through December 30, 2012, and identified CDI in the six months following hospital admission. Using Cox regression, we constructed a score to identify patients at high risk for CDI on the basis of preadmission characteristics. We calculated and plotted the observed six-month CDI risk for each decile of predicted risk. We identified 721 CDIs following 54,186 hospital admissions-a 6-month incidence of 13.3 CDIs/1000 patient admissions. Patients with the highest predicted risk of CDI had an observed incidence of 53 CDIs/1000 patient admissions. The score differentiated between patients who do and do not develop CDI, with values for the extended C-statistic of 0.75. Predicted risk for CDI agreed closely with observed risk. Our risk score accurately predicted six-month risk for CDI using preadmission characteristics. Accurate predictions among the highest-risk patient subgroups allow for the identification of patients who could be targeted for and who would likely benefit from review of inpatient antibiotic use or enhanced educational efforts at the time of discharge planning.
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Association between mandibular retrognathia and TMJ disorders in adult females.
Miller, James R; Burgess, Jeffrey A; Critchlow, Cathy W
2004-01-01
This study assesses the association between temporomandibular joint (TMJ) disorders and mandibular retrognathia. We conducted a case-control study among women, aged 18-70 years, recruited from Kaiser Permanente Northwest Division (KPNW, Portland, OR) and Group Health Cooperative of Puget Sound (GHC, Seattle, WA). Cases (N= 160) were women seeking treatment for TMJ disorders at KPNW and GHC clinics. Controls (N=151) were women without TMJ disorders, selected from among adult female dental hygiene patients at KPNW or GHC enrollees. Case status was determined by questionnaire; mandibular sagittal position (orthognathic, mildly retrognathic, severely retrognathic, or prognathic) was measured using digitized facial photographs. Odds ratios (OR) and associated 95 percent confidence intervals (CI) estimated the magnitude of the association between TMJ disorders and mandibular sagittal position. Women with TMJ disorders were 4.0 times (95% CI=1.5, 10.8) more likely than controls to have severe retrognathia; no association with mild retrognathia or prognathia was seen. Results were similar when cases were restricted to those with recent onset of TMJ pain (OR=6.3; 95% CI=1.8, 21.8). We found a strong association between TMJ disorders and severe mandibular retrognathia in adult females. In some women this likely resulted from TMJ disorders influencing mandibular development over time. However, among a subset of women, our data support the reverse hypothesis--that severe mandibular retrognathia may influence the development of TMJ disorders. Despite this strong association, abnormal mandibular position contributed only a small portion to the overall rate at which women sought treatment for TMJ disorders.
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Pressman, Alice R; Lo, Joan C; Chandra, Malini; Ettinger, Bruce
2011-01-01
Area under the receiver operating characteristics (AUROC) curve is often used to evaluate risk models. However, reclassification tests provide an alternative assessment of model performance. We performed both evaluations on results from FRAX (World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK), a fracture risk tool, using Kaiser Permanente Northern California women older than 50yr with bone mineral density (BMD) measured during 1997-2003. We compared FRAX performance with and without BMD in the model. Among 94,489 women with mean follow-up of 6.6yr, 1579 (1.7%) sustained a hip fracture. Overall, AUROCs were 0.83 and 0.84 for FRAX without and with BMD, suggesting that BMD did not contribute to model performance. AUROC decreased with increasing age, and BMD contributed significantly to higher AUROC among those aged 70yr and older. Using an 81% sensitivity threshold (optimum level from receiver operating characteristic curve, corresponding to 1.2% cutoff), 35% of those categorized above were reassigned below when BMD was added. In contrast, only 10% of those categorized below were reassigned to the higher risk category when BMD was added. The net reclassification improvement was 5.5% (p<0.01). Two versions of this risk tool have similar AUROCs, but alternative assessments indicate that addition of BMD improves performance. Multiple methods should be used to evaluate risk tool performance with less reliance on AUROC alone. Copyright © 2011 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.
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Katon, Wayne; Unützer, Jürgen; Wells, Kenneth; Jones, Loretta
2010-01-01
To describe the history and evolution of the collaborative depression care model and new research aimed at enhancing dissemination. Four keynote speakers from the 2009 NIMH Annual Mental Health Services Meeting collaborated in this article in order to describe the history and evolution of collaborative depression care, adaptation of collaborative care to new populations and medical settings, and optimal ways to enhance dissemination of this model. Extensive evidence across 37 randomized trials has shown the effectiveness of collaborative care vs. usual primary care in enhancing quality of depression care and in improving depressive outcomes for up to 2 to 5 years. Collaborative care is currently being disseminated in large health care organizations such as the Veterans Administration and Kaiser Permanente, as well as in fee-for-services systems and federally funded clinic systems of care in multiple states. New adaptations of collaborative care are being tested in pediatric and ob-gyn populations as well as in populations of patients with multiple comorbid medical illnesses. New NIMH-funded research is also testing community-based participatory research approaches to collaborative care to attempt to decrease disparities of care in underserved minority populations. Collaborative depression care has extensive research supporting the effectiveness of this model. New research and demonstration projects have focused on adapting this model to new populations and medical settings and on studying ways to optimally disseminate this approach to care, including developing financial models to incentivize dissemination and partnerships with community populations to enhance sustainability and to decrease disparities in quality of mental health care. Copyright © 2010 Elsevier Inc. All rights reserved.
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Immunohistochemical expression of ERG in the molecular epidemiology of fatal prostate cancer study.
Weinmann, Sheila; Van Den Eeden, Stephen K; Haque, Reina; Chen, Chuhe; Richert-Boe, Kathryn; Schwartzman, Jacob; Gao, Lina; Berry, Deborah L; Kallakury, Bhaskar V S; Alumkal, Joshi J
2013-09-01
Gene fusions between the ERG transcription factor and the androgen-regulated gene TMPRSS2 occur in a subset of prostate cancers and contribute to transformation of prostatic epithelial cells. Prior reports have used fluorescence in situ hybridization (FISH) or quantitative PCR (QPCR) to determine the presence of TMPRSS2-ERG fusions or ERG expression, respectively. Recently, several groups have reported on immunohistochemistry (IHC) to measure ERG expression, which is much more readily performed in clinical practice. However, the prior studies examining ERG expression by IHC had small sample sizes or they failed to clarify the association of ERG protein expression with important clinico-pathological features or prostate cancer-specific mortality. To address these deficits, we evaluated ERG expression by IHC in 208 radical prostatectomy samples from the Kaiser Permanente Molecular Epidemiology of Fatal Prostate Cancer (MEFPC) study, a case-control study of prostate cancer-specific mortality. Nuclear ERG expression was seen in neoplastic prostate epithelia in 49 of the samples (23.7%). ERG expression in tumor cells was associated with higher tumor stage (OR = 2.0, 95% confidence interval 1.0-4.0, P value = 0.04). ERG immunoreactivity was positively associated with prostate cancer-specific mortality, although the confidence interval was wide (OR = 1.9, 95% confidence interval 0.88-4.0, P value = 0.10). Our results demonstrate that ERG protein expression is readily quantifiable with an existing commercial antibody. Evaluating ERG protein expression may improve our ability to identify the subset of more aggressive, invasive prostate cancers. © 2013 Wiley Periodicals, Inc.
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Kubo, Ai; Ferrara, Assiamira; Laurent, Cecile A.; Windham, Gayle C.; Greenspan, Louise C.; Deardorff, Julianna; Hiatt, Robert A.; Quesenberry, Charles P.; Kushi, Lawrence H.
2016-01-01
Abstract We investigated whether in utero exposure to maternal pregravid obesity and/or gestational diabetes mellitus (GDM) was associated with early puberty in girls. We used data from a longitudinal study of 421 mother-daughter pairs enrolled in an integrated health services organization, Kaiser Permanente Northern California (2005–2012). Girls aged 6–8 years were followed annually through ages 12–14 years. Onset of puberty was assessed using study clinic-based Tanner staging. We examined associations of self-reported pregravid obesity and maternal GDM with timing of the daughter's transition to pubertal maturation stage 2 or above for development of breasts and pubic hair, using accelerated failure time regression models with interval censoring to estimate time ratios and hazard ratios and corresponding 95% confidence intervals. Maternal obesity (pregravid body mass index (BMI; weight (kg)/height (m)2) ≥30) was associated with a daughter's earlier transition to breast and pubic hair stage 2+ in comparison with girls whose mothers had pregravid BMI <25. These associations were attenuated and not statistically significant after adjustment for covariates. Girls whose mothers had both pregravid BMI ≥25 and GDM were at higher risk of an earlier transition to pubic hair stage 2+ than those whose mothers had neither condition (adjusted time ratio = 0.89, 95% confidence interval: 0.83, 0.96; hazard ratio = 2.97, 95% confidence interval: 1.52, 5.83). These findings suggest that exposure to maternal obesity and hyperglycemia places girls at higher risk of earlier pubarche. PMID:27268032
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Koebnick, Corinna; Langer-Gould, Annette M; Gould, Michael K; Chao, Chun R; Iyer, Rajan L; Smith, Ning; Chen, Wansu; Jacobsen, Steven J
2012-01-01
Data from the memberships of large, integrated health care systems can be valuable for clinical, epidemiologic, and health services research, but a potential selection bias may threaten the inference to the population of interest. We reviewed administrative records of members of Kaiser Permanente Southern California (KPSC) in 2000 and 2010, and we compared their sociodemographic characteristics with those of the underlying population in the coverage area on the basis of US Census Bureau data. We identified 3,328,579 KPSC members in 2000 and 3,357,959 KPSC members in 2010, representing approximately 16% of the population in the coverage area. The distribution of sex and age of KPSC members appeared to be similar to the census reference population in 2000 and 2010 except with a slightly higher proportion of 40 to 64 year olds. The proportion of Hispanics/Latinos was comparable between KPSC and the census reference population (37.5% vs 38.2%, respectively, in 2000 and 45.2% vs 43.3% in 2010). However, KPSC members included more blacks (14.9% vs 7.0% in 2000 and 10.8% vs 6.5% in 2010). Neighborhood educational levels and neighborhood household incomes were generally similar between KPSC members and the census reference population, but with a marginal underrepresentation of individuals with extremely low income and high education. The membership of KPSC reflects the socioeconomic diversity of the Southern California census population, suggesting that findings from this setting may provide valid inference for clinical, epidemiologic, and health services research.
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Mouchawar, Judy; Laurion, Suzanne; Ritzwoller, Debra P; Ellis, Jennifer; Kulchak-Rahm, Alanna; Hensley-Alford, Sharon
2005-10-01
To describe the impact on patients and physicians at a managed care organization (MCO) of a direct-to-consumer advertising (DTC-ad) campaign concerning testing for the BRCA1 and BRCA2 genes. Observational study. In 2003, we mailed a 30-item questionnaire to 750 randomly chosen female members of Kaiser Permanente Colorado (KPCO) aged 25 to 54 years, and 100 female KPCO members with a history of breast cancer genetic referral. We mailed a 7-item questionnaire to 180 randomly chosen KPCO primary care providers. Of 394 patient respondents, 245 (62%) reported exposure to the DTC-ad of whom 63% reported that the DTC-ad caused no anxiety at all. A high level of perceived breast cancer risk and being of Hispanic ethnicity each were independently associated with reported anxiety due to the DTC-ad (adjusted odds ratio [OR] = 3.23, 95% confidence interval [CI] = 1.35, 7.73, and adjusted OR = 4.19, 95% CI = 1.48, 11.83, respectively). Greater knowledge was seen among respondents exposed to the DTC-ad than among those reporting no exposure (P = .015). Of the physician respondents, 84% reported that the DTC-ad caused no strain on the doctor-patient relationship, and nearly 80% reported no effect on daily clinical practice. Genetic referrals soared more than 200% compared with the prior year, when there was no advertising. The DTC-ad had a marked impact on genetic services, but little apparent negative impact on patients or primary care providers at an MCO.
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Becker, Davida; Garth, Hanna; Hollander, Rachel; Klein, Felice; Klau, Marc
2017-01-01
Graduate medical education (GME) programs must develop curriculum to ensure scholarly activity among trainees and faculty to meet accreditation requirements and to support evidence-based medicine. Test whether research-related needs and interests varied across four groups: primary care trainees, specialty trainees, primary care faculty, and specialty faculty. We surveyed a random sample of trainees and faculty in Kaiser Permanente Southern California's GME programs. We investigated group differences in outcomes using Fisher exact and Kruskal-Wallis tests. Research experiences, skills, barriers, motivators, and interests in specific research skills development. Participants included 47 trainees and 26 faculty (response rate = 30%). Among primary care faculty, 12 (71%) reported little or no research experience vs 1 (11%) for specialty faculty, 14 (41%) for primary care trainees, and 1 (8%) for specialty trainees (p < 0.001). Submission of research to the institutional review board, an abstract to a conference, or a manuscript for publication in the previous year varied across groups (p = 0.001, p = 0.003, and p < 0.001, respectively). Overall self-reported research skills also differed across groups (p < 0.001). Primary care faculty reported the lowest skill level. Research barriers that differed across groups included other work roles taking priority; desire for work-life balance; and lack of managerial support, research equipment, administrative support, and funding. Faculty and trainees in primary care and specialties have differing research-related needs that GME programs should consider when designing curricula to support scholarly activity. Developing research skills of primary care faculty is a priority to support trainees' scholarly activity.
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Shariff-Marco, Salma; Von Behren, Julie; Reynolds, Peggy; Keegan, Theresa H. M.; Hertz, Andrew; Kwan, Marilyn L.; Roh, Janise M.; Thomsen, Catherine; Kroenke, Candyce H.; Ambrosone, Christine; Kushi, Lawrence H.; Gomez, Scarlett Lin
2017-01-01
Background As social and built environment factors have been shown to be associated with physical activity, dietary patterns, and obesity in the general population, they likely also influence these health behaviors among cancer survivors, and thereby impact survivorship outcomes. Methods Enhancing the rich, individual-level survey and medical record data from 4,505 breast cancer survivors in the Pathways Study, a prospective cohort drawn from Kaiser Permanente Northern California, we geocoded baseline residential addresses and appended social and built environment data. With multinomial logistic models, we examined associations between neighborhood characteristics and body mass index and whether neighborhood factors explained racial/ethnic/nativity disparities in overweight/obesity. Results Low neighborhood socioeconomic status, high minority composition, high traffic density, high prevalence of commuting by car, and a higher number of fast food restaurants were independently associated with higher odds of overweight or obesity. The higher odds of overweight among African Americans, US-born Asian Americans/Pacific Islanders and foreign-born Hispanics and the higher odds of obesity among African Americans and US-born Hispanics, compared to non-Hispanic Whites, remained significant though somewhat attenuated when accounting for social and built environment features. Conclusions Addressing aspects of neighborhood environments may help breast cancer survivors maintain a healthy body weight. Impact Further research in this area, such as incorporating data on individuals’ perceptions and use of their neighborhood environments, is needed to ultimately inform multilevel interventions that would ameliorate such disparities and improve outcomes for breast cancer survivors, regardless of their social status (e.g., race/ethnicity, socioeconomic status, nativity). PMID:28154107
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Unpacking the impact of adverse childhood experiences on adult mental health.
Merrick, Melissa T; Ports, Katie A; Ford, Derek C; Afifi, Tracie O; Gershoff, Elizabeth T; Grogan-Kaylor, Andrew
2017-07-01
Exposure to childhood adversity has an impact on adult mental health, increasing the risk for depression and suicide. Associations between Adverse Childhood Experiences (ACEs) and several adult mental and behavioral health outcomes are well documented in the literature, establishing the need for prevention. The current study analyzes the relationship between an expanded ACE score that includes being spanked as a child and adult mental health outcomes by examining each ACE separately to determine the contribution of each ACE. Data were drawn from Wave II of the CDC-Kaiser ACE Study, consisting of 7465 adult members of Kaiser Permanente in southern California. Dichotomous variables corresponding to each of the 11 ACE categories were created, with ACE score ranging from 0 to 11 corresponding to the total number of ACEs experienced. Multiple logistic regression modeling was used to examine the relationship between ACEs and adult mental health outcomes adjusting for sociodemographic covariates. Results indicated a graded dose-response relationship between the expanded ACE score and the likelihood of moderate to heavy drinking, drug use, depressed affect, and suicide attempts in adulthood. In the adjusted models, being spanked as a child was significantly associated with all self-reported mental health outcomes. Over 80% of the sample reported exposure to at least one ACE, signifying the potential to capture experiences not previously considered by traditional ACE indices. The findings highlight the importance of examining both cumulative ACE scores and individual ACEs on adult health outcomes to better understand key risk and protective factors for future prevention efforts. Copyright © 2017. Published by Elsevier Ltd.
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Escobar, Gabriel J; Baker, Jennifer M; Turk, Benjamin J; Draper, David; Liu, Vincent; Kipnis, Patricia
2017-01-01
Introduction This article is not a traditional research report. It describes how conducting a specific set of benchmarking analyses led us to broader reflections on hospital benchmarking. We reexamined an issue that has received far less attention from researchers than in the past: How variations in the hospital admission threshold might affect hospital rankings. Considering this threshold made us reconsider what benchmarking is and what future benchmarking studies might be like. Although we recognize that some of our assertions are speculative, they are based on our reading of the literature and previous and ongoing data analyses being conducted in our research unit. We describe the benchmarking analyses that led to these reflections. Objectives The Centers for Medicare and Medicaid Services’ Hospital Compare Web site includes data on fee-for-service Medicare beneficiaries but does not control for severity of illness, which requires physiologic data now available in most electronic medical records. To address this limitation, we compared hospital processes and outcomes among Kaiser Permanente Northern California’s (KPNC) Medicare Advantage beneficiaries and non-KPNC California Medicare beneficiaries between 2009 and 2010. Methods We assigned a simulated severity of illness measure to each record and explored the effect of having the additional information on outcomes. Results We found that if the admission severity of illness in non-KPNC hospitals increased, KPNC hospitals’ mortality performance would appear worse; conversely, if admission severity at non-KPNC hospitals’ decreased, KPNC hospitals’ performance would appear better. Conclusion Future hospital benchmarking should consider the impact of variation in admission thresholds. PMID:29035176
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Al-Temimi, Mohammed; Kidon, Michael; Johna, Samir
2016-01-01
Reports evaluating faculty knowledge of the Accreditation Council for Graduate Medical Education (ACGME) core competencies in community hospitals without a dedicated residency program are uncommon. Faculty evaluation regarding knowledge of ACGME core competencies before a residency program is started. Physicians at the Kaiser Permanente Fontana Medical Center (N = 480) were surveyed for their knowledge of ACGME core competencies before starting new residency programs. Knowledge of ACGME core competencies. Fifty percent of physicians responded to the survey, and 172 (71%) of respondents were involved in teaching residents. Of physicians who taught residents and had complete responses (N = 164), 65 (39.7%) were unsure of their knowledge of the core competencies. However, most stated that they provided direct teaching to residents related to the knowledge, skills, and attitudes stated in each of the 6 competencies as follows: medical knowledge (96.3%), patient care (95.7%), professionalism (90.7%), interpersonal and communication skills (86.3%), practice-based learning (85.9%), and system-based practice (79.6%). Physician specialty, years in practice (1-10 vs > 10), and number of rotations taught per year (1-6 vs 7-12) were not associated with knowledge of the competencies (p > 0.05); however, full-time faculty (teaching 10-12 rotations per year) were more likely to provide competency-based teaching. Objective assessment of faculty awareness of ACGME core competencies is essential when starting a residency program. Discrepancy between knowledge of the competencies and acclaimed provision of competency-based teaching emphasizes the need for standardized teaching methods that incorporate the values of these competencies.
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Menopausal hormone therapy and breast cancer phenotype: does dose matter?
Garwood, Elisabeth R; Kumar, Anjali S; Shim, Veronica
2008-09-01
Duration and type of menopausal hormone therapy (HT) has been associated with increased breast cancer risk and the development of estrogen receptor (ER)-positive tumors. The effect of HT dose on breast cancer tumor characteristics remains undefined. We sought to determine if HT dosing regimens influence breast cancer phenotype. We conducted a retrospective review of incident female breast cancers occurring in the year 2003 listed in the Kaiser Permanente Northern California Cancer Registry. Type of HT, dose, number of tablets dispensed, tumor phenotype, stage, grade, and histology were obtained from electronic records for women aged >/=50 years who had more than 1 year of uninterrupted pharmacy data (n = 1701). A dose index of HT exposure was created and odds ratios were used to determine if tumor phenotype varied between exposure groups. These results were compared with a previously published analysis of HT duration on tumor phenotype conducted with the same dataset. The cumulative effect of estrogen and progesterone hormone therapy as calculated by factoring both dose and duration of HT use prior to breast cancer diagnosis did not reveal any new associations that were not previously identified by analysis of HT duration of exposure alone. Low-dose-index combination-HT users were less likely to have tumors with an ER-positive phenotype. An overall trend developed in which low- and high-dose-index exposed women had the lowest rates of ER- and progesterone receptor (PR) -positive tumors. Duration of use is an adequate surrogate for determining overall exposure to HT when considering the effect of HT on breast cancer phenotype.
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Hudson, Darrell L; Karter, Andrew J; Fernandez, Alicia; Parker, Melissa; Adams, Alyce S; Schillinger, Dean; Moffet, Howard H; Zhou, Jufen; Adler, Nancy E
2013-05-01
It is unknown to what extent the gap between need and care for depression among patients with diabetes differs across racial/ethnic groups. We compared, by race/ethnicity, the likelihood of clinical recognition of depression (diagnosis or treatment) of patients who reported depressive symptoms in a well-characterized community-based population with diabetes. We used a survey follow-up study of 20,188 patients with diabetes from Kaiser Permanente Northern California. Analyses were limited to 910 patients who scored 10 or higher on the Patient Health Questionnaire (PHQ-8) which was included in the survey and who had no clinical recognition of depression in the 12 months prior to survey. Clinical recognition of depression was defined by a depression diagnosis, referral to mental health services, or antidepressant medication prescription. Among the 910 patients reporting moderate to severe depressive symptoms on the survey and who had no clinical recognition in the prior year, 12%, 8%, 8%, 14%, and 15% of African American, Asian, Filipino, Latino, and white patients, respectively, were clinically recognized for depression in the subsequent 12 months. After adjusting for sociodemographics, limited English proficiency, and depressive symptom severity, racial/ethnic minorities were less likely to be clinically recognized for depression compared with whites (relative risk: Filipino: 0.30, African American: 0.62). More work is needed to understand the modifiable patient and provider factors that influence clinical recognition of depression among diabetes patients from different racial/ethnic groups, and the potential impact of low rates of clinical recognition on quality of care.
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Association of Proteinuria with Central Venous Catheter Use at Initial Hemodialysis
Park, Ken J; Johnson, Eric S; Smith, Ning; Mosen, David M; Thorp, Micah L
2018-01-01
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. PMID:29236655
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Wilkes, T C R; Guyn, Lindsay; Li, Bing; Lu, Mingshan; Cawthorpe, David
2012-01-01
Few population-based studies have examined the relationship between psychiatric and somatic or biomedical disorders. We examined the effect of the presence or absence of any psychiatric disorder on somatic or biomedical diagnosis disorder costs. Guided by the Kaiser Permanente and Centers for Disease Control and Prevention Adverse Childhood Experiences (ACE) Study, we examined our administrative data to test if psychiatric disorder is associated with a higher level of somatic disorder. A dataset containing registration data for 205,281 patients younger than age 18 years was randomly selected from administrative data based on these patients never having received any specialized, publicly funded ambulatory, emergency or inpatient admission for treatment of a psychiatric disorder. All physician billing records (8,724,714) from the 16 fiscal years April 1993 to March 2009 were collected and grouped on the basis of presence or absence of any International Classification of Diseases (ICD) psychiatric disorder. We compared 2 groups (with or without any psychiatric disorder: dependent variable) on the cumulative 16-year mean cost for somatic (biomedical, nonpsychiatric) ICD diagnoses (independent variable). Billing costs related to somatic and biomedical disorders (nonpsychiatric costs) were 1.8 times greater for those with psychiatric disorders than for those without psychiatric disorders. Somatic costs peaked before the age of 6 years and remained higher than the groupings without psychiatric disorders in each age range. In support of the ACE study, ICD psychiatric disorders (as an index of developmental adversity) are associated with substantially greater ICD somatic disorders. The findings have implications for health care practice.
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Albright, Karen; Richardson, Terri; Kempe, Karin L; Wallace, Kristin
2014-01-01
Introduction: Colorectal cancer screening rates are lower among African-American members of Kaiser Permanente Colorado (KPCO) than among members of other races and ethnicities. This study evaluated use of a linguistically congruent voice in interactive voice response outreach calls about colorectal cancer screening as a strategy to increase call completion and response. Methods: After an initial discussion group to assess cultural acceptability of the project, 6 focus groups were conducted with 33 KPCO African-American members. Participants heard and discussed recordings of 5 female voices reading the same segment of the standard-practice colorectal cancer message using interactive voice response. The linguistic palette included the voices of a white woman, a lightly accented Latina, and 3 African-American women. Results: Participants strongly preferred the African-American voices, particularly two voices. Participants considered these voices the most trustworthy and reported that they would be the most effective at increasing motivation to complete an automated call. Participants supported the use of African-American voices when designing outgoing automated calls for African Americans because the sense of familiarity engendered trust among listeners. Participants also indicated that effective automated messages should provide immediate clarity of purpose; explain why the issue is relevant to African Americans; avoid sounding scripted; emphasize that the call is for the listener’s benefit only; sound personable, warm, and positive; and not create fear among listeners. Discussion: Establishing linguistic congruence between African Americans and the voices used in automated calls designed to reach them may increase the effectiveness of outreach efforts. PMID:24867548
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Langer-Gould, Annette; Lucas, Robyn; Xiang, Anny H; Chen, Lie H; Wu, Jun; Gonzalez, Edlin; Haraszti, Samantha; Smith, Jessica B; Quach, Hong; Barcellos, Lisa F
2018-02-27
Multiple sclerosis (MS) incidence and serum 25-hydroxyvitamin D (25OHD) levels vary by race/ethnicity. We examined the consistency of beneficial effects of 25OHD and/or sun exposure for MS risk across multiple racial/ethnic groups. We recruited incident MS cases and controls (blacks 116 cases/131 controls; Hispanics 183/197; whites 247/267) from the membership of Kaiser Permanente Southern California into the MS Sunshine Study to simultaneously examine sun exposure and 25OHD, accounting for genetic ancestry and other factors. Higher lifetime ultraviolet radiation exposure (a rigorous measure of sun exposure) was associated with a lower risk of MS independent of serum 25OHD levels in blacks (adjusted OR = 0.53, 95% CI = 0.31-0.83; p = 0.007) and whites (OR = 0.68, 95% CI = 0.48-0.94; p = 0.020) with a similar magnitude of effect that did not reach statistical significance in Hispanics (OR = 0.66, 95% CI = 0.42-1.04; p = 0.071). Higher serum 25OHD levels were associated with a lower risk of MS only in whites. No association was found in Hispanics or blacks regardless of how 25OHD was modeled. Lifetime sun exposure appears to reduce the risk of MS regardless of race/ethnicity. In contrast, serum 25OHD levels are not associated with MS risk in blacks or Hispanics. Our findings challenge the biological plausibility of vitamin D deficiency as causal for MS and call into question the targeting of specific serum 25OHD levels to achieve health benefits, particularly in blacks and Hispanics.
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Thorp, M L; Ditmer, D G; Nash, M K; Wise, R; Jaderholm, P L; Smith, J D; Chan, W
2005-05-01
Angiontension-converting enzyme inhibitors (ACEIs) are beneficial in the treatment of diabetic and nondiabetic kidney disease, coronary artery disease and congestive heart failure. One adverse effect of ACEIs use is a rise in serum creatinine and potential renal failure. This paper attempts to quantify this risk and assess the need for pre- and post-ACEI serum creatinine measurements. A computerized search of Kaiser Permanente Northwest's electronic medical record was conducted to find patients over the age of 40 years taking lisinopril between July 1, 2000 and June 30, 2002. Patient demographic information and presence in diabetes and coronary artery disease registries was collected. A subsequent search for pre- and postlisinopril serum creatinine levels within 6 months of initial lisinopril prescription was conducted. Patients with prelisinopril creatinine < or = 1.2 mg/dl and postlisinopril creatinine > 2.5 mg/dl underwent chart review to discern adverse events associated with the rise in serum creatinine. A total of 18,977 patients were prescribed lisinopril between July 1, 2000 and June 30, 2002. In all 13 166 patients had a pre- and postlisinopril creatinine checked. In all, 31 patients had a rise in creatinine from < or = 1.2 mg/dl to > 2.5 mg/dl (0.2%). Possible contributors to rise in creatinine included congestive heart failure, dehydration and infection. No patients developed end-stage renal disease, although three died. In conclusion, end-stage renal disease is an unlikely outcome among patients prescribed lisinopril and is most likely associated with other events.
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Outcomes of patients discharged from pharmacy-managed cardiovascular disease management.
Olson, Kari L; Delate, Thomas; Rasmussen, Jon; Humphries, Tammy L; Merenich, John A
2009-08-01
To evaluate whether patients with coronary artery disease (CAD) discharged from the Clinical Pharmacy Cardiac Risk Service (CPCRS) would maintain their lipid goals with use of an electronic laboratory reminder system. A 2-year, randomized study at Kaiser Permanente Colorado. Patients with prior CAD (acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention) who had been enrolled in the CPCRS for at least 1 year and who had 2 consecutive low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol, and blood pressure readings at goal within 6 months before enrollment were randomized to remain in the CPCRS (CPCRS care) or to receive usual care from primary care physicians plus laboratory reminder letters (usual care). The primary outcome was maintenance of LDL-C goal at study end. The t test and chi(2) test of association were used to assess differences in mean and categorical values, respectively. A total of 421 patients (214 CPCRS care, 207 usual care) were randomized. Their mean age was 72 years; 74% were male. After 1.7 years of follow-up, the proportions of patients maintaining their LDL-C goal of <100 mg/dL were 91% and 93.1% in the CPCRS care and usual care groups, respectively (P = .46). The proportions maintaining their LDL-C goal of <70 mg/dL were 68.6% and 56.8% in the CPCRS care and usual care groups, respectively (P = .23). This study demonstrated that LDL-C measures can remain controlled in most patients discharged from a cardiac disease management program.
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Urgent Need for Improved Mental Health Care and a More Collaborative Model of Care
Lake, James; Turner, Mason Spain
2017-01-01
Current treatments and the dominant model of mental health care do not adequately address the complex challenges of mental illness, which accounts for roughly one-third of adult disability globally. These circumstances call for radical change in the paradigm and practices of mental health care, including improving standards of clinician training, developing new research methods, and re-envisioning current models of mental health care delivery. Because of its dominant position in the US health care marketplace and its commitment to research and innovation, Kaiser Permanente (KP) is strategically positioned to make important contributions that will shape the future of mental health care nationally and globally. This article reviews challenges facing mental health care and proposes an agenda for developing a collaborative care model in primary care settings that incorporates conventional biomedical therapies and complementary and alternative medicine approaches. By moving beyond treatment delivery via telephone and secure video and providing earlier interventions through primary care clinics, KP is shifting the paradigm of mental health care to a collaborative care model focusing on prevention. Recommendations are to expand current practices to include integrative treatment strategies incorporating evidence-based biomedical and complementary and alternative medicine modalities that can be provided to patients using a collaborative care model. Recommendations also are made for an internal research program aimed at investigating the efficacy and cost-effectiveness of promising complementary and alternative medicine and integrative treatments addressing the complex needs of patients with severe psychiatric disorders, many of whom respond poorly to treatments available in KP mental health clinics. PMID:28898197
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Janisse, Tom; Tallman, Karen
2017-01-01
The top predictors of patient satisfaction with clinical visits are the quality of the physician-patient relationship and the communications contributing to their relationship. How do physicians improve their communication, and what effect does it have on them? This article presents the verbatim stories of seven high-performing physicians describing their transformative change in the areas of communication, connection, and well-being. Data for this study are based on interviews from a previous study in which a 6-question set was posed, in semistructured 60-minute interviews, to 77 of the highest-performing Permanente Medical Group physicians in 4 Regions on the "Art of Medicine" patient survey. Transformation stories emerged spontaneously during the interviews, and so it was an incidental finding when some physicians identified that they were not always high performing in their communication with patients. Seven different modes of transformation in communication were described by these physicians: a listening tool, an awareness course, finding new meaning in clinical practice, a technologic tool, a sudden insight, a mentor observation, and a physician-as-patient experience. These stories illustrate how communication skills can be learned through various activities and experiences that transform physicians into those who are highly successful communicators. All modes result in a change of state-a new way of seeing, of being-and are not just a new tool or a new practice, but a change in state of mind. This state resulted in a marked change of behavior, and a substantial improvement of communication and relationship.
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Tumor markers and rectal cancer: support for an inflammation-related pathway
Slattery, Martha L.; Wolff, Roger K.; Herrick, Jennifer; Caan, Bette J.; Samowitz, Wade
2009-01-01
Inflammation may be a key element in the etiology of colorectal cancer (CRC). In this study we examine associations between factors related to inflammation and specific rectal cancer mutations. A population-based study of 750 rectal cancer cases with interview and tumor DNA were compared to 1205 population-based controls. Study participants were from Utah and the Northern California Kaiser Permanente Medical Care Program. Tumor DNA was analyzed for TP53 and KRAS2 mutations and CpG Island methylator phenotype (CIMP). We assessed how these tumor markers were associated with use of anti-inflammatory drugs, polymorphisms in the IL6 genes (rs1800795 and rs1800796), and dietary antioxidants. Ibuprofen-type drugs, IL6 polymorphisms (rs1800796), and dietary alpha tocopherol and lycopene significantly altered likelihood of having a TP53 mutation. This was especially true for TP53 transversion mutations and dietary antioxidants (OR for beta carotene 0.51 95% CI 0.27,0.97, p trend 0.03; alpha tocopherol 0.41 95% CI 0.20,0.84, p trend 0.02) Beta carotene and ibuprofen significantly altered risk of KRAS2 tumors. The associations between lutein and tocopherol and TP53 and KRAS2 mutations were modified by IL6 genotype. These results suggest that inflammation-related factors may have unique associations with various rectal tumor markers. Many factors involved in an inflammation related pathway were associated with TP53 mutations and some dietary factors appeared to be modified by IL6 genotype. PMID:19452524
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Evaluation of Patient and Proxy Responses on the Activity Measure for Post Acute Care
Jette, Alan M.; Ni, Pengsheng; Rasch, Elizabeth K.; Appelman, Jed; Sandel, M. Elizabeth; Terdiman, Joseph; Chan, Leighton
2012-01-01
Background and Purpose Our objective was to examine the agreement between adult patients with stroke and family member or clinician proxies in Activity Measure for Post Acute Care (AM-PAC) summary scores for daily activity, basic mobility, and applied cognitive function. Methods This study involved 67 patients with stroke admitted to a hospital within the Kaiser Permanente of Northern California system and were participants in a parent study on stroke outcomes. Each participant and proxy respondent completed the AM-PAC by personal or telephone interview at the point of hospital discharge and/or during one or more transitions to different post-acute care settings. Results The results suggest that for patients with a stroke proxy AM-PAC data are robust for family or clinician proxy assessment of basic mobility function, clinician proxy assessment of daily activity function, but less robust for family proxy assessment of daily activity function and for all proxy groups’ assessment of applied cognitive function. The pattern of disagreement between patient and proxy was, on average, relatively small and random. There was little evidence of systematic bias between proxy and patient reports of their functional status. The degree of concordance between patient and proxy was similar for those with moderate to severe strokes compared with mild strokes. Conclusions Patient and proxy ratings on the AM-PAC achieved adequate agreement for use in stroke research where using proxy respondents could reduce sample selection bias. The AM-PAC data can be implemented across institutional as well as community care settings while achieving precision and reducing respondent burden. PMID:22343646
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Chi, Felicia W; Kaskutas, Lee A; Sterling, Stacy; Campbell, Cynthia I; Weisner, Constance
2009-06-01
Twelve-Step affiliation among adolescents is little understood. We examined 12-Step affiliation and its association with substance use outcomes 3 years post-treatment intake among adolescents seeking chemical dependency (CD) treatment in a private, managed-care health plan. We also examined the effects of social support and religious service attendance on the relationship. We analyzed data for 357 adolescents, aged 13-18, who entered treatment at four Kaiser Permanente Northern California CD programs between March 2000 and May 2002 and completed both baseline and 3-year follow-up interviews. Measures at follow-up included alcohol and drug use, 12-Step affiliation, social support and frequency of religious service attendance. At 3 years, 68 adolescents (19%) reported attending any 12-Step meetings, and 49 (14%) reported involvement in at least one of seven 12-Step activities, in the previous 6 months. Multivariate logistic regression analyses indicated that after controlling individual and treatment factors, 12-Step attendance at 1 year was marginally significant, while 12-Step attendance at 3 years was associated with both alcohol and drug abstinence at 3 years [odds ratio (OR) 2.58, P < 0.05 and OR 2.53, P < 0.05, respectively]. Similarly, 12-Step activity involvement was associated significantly with 30-day alcohol and drug abstinence. There are possible mediating effects of social support and religious service attendance on the relationship between post-treatment 12-Step affiliation and 3-year outcomes. The findings suggest the importance of 12-Step affiliation in maintaining long-term recovery, and help to understand the mechanism through which it works among adolescents.
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Ghai, Nirupa R; Jacobsen, Steven J; Van Den Eeden, Stephen K; Ahmed, Ameena T; Haque, Reina; Rhoads, George G; Quinn, Virginia P
2012-01-01
We compared lifestyle CVD risk factors between Asian Indian and White non-Hispanic men within categories of BMI. Participants included 51,901 White non-Hispanic men and 602 Asian Indian men enrolled in the California Men's Health Study cohort. Men were aged 45-69 years and members of Kaiser Permanente Southern or Northern California at baseline (2001-2002). Lifestyle characteristics including diet, physical activity, alcohol intake and smoking were collected from a survey. Multivariable logistic regression, adjusting for demographics, was performed. Asian Indians more often reported a healthy BMI (18.5-24.9), and consumed < 30% calories from fat within each BMI category (healthy weight and overweight/obese). Among healthy weight men, Asian Indians were less likely to eat -5 fruit and vegetables a day. Overall, Asian Indians were more likely to have never smoked and to abstain from alcohol. Asian Indians were less likely to report moderate/vigorous physical activity > or = 3.5 hours/week. No differences were found in sedentary activity. We identified health behaviors that were protective (lower fat intake, lower levels of smoking and alcohol) and harmful (lower levels of physical activity and fruit and vegetable intake) for cardiovascular health among the Asian Indians in comparison to White non-Hispanics. Results stratified by BMI were similar to those overall. However, the likelihood of consuming a low fat diet was lower among healthy weight men, while fruit and vegetable consumption, physical activity and alcohol intake was greater. These results suggest risk factors other than lifestyle behaviors may be important contributors to CVD in the Asian Indian population.
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Schmittdiel, Julie A; Karter, Andrew J; Dyer, Wendy; Parker, Melissa; Uratsu, Connie; Chan, James; Duru, O Kenrik
2011-12-01
Mail order pharmacies are commonly used to deliver CVD risk factor medications. Previous studies have shown that mail order pharmacy use is associated with greater medication adherence; however, no studies have examined whether mail order pharmacy use is related to improved CVD risk factor outcomes. To examine the comparative effectiveness of mail order pharmacy vs. local pharmacy use on LDL-C control in new statin users. Observational cohort study. 100,298 adult Kaiser Permanente Northern California (KPNC) members who were new users of statins between January 1, 2005 and December 31, 2007. The main outcome measure was LDL-C control in the 3-15 month period after statin therapy was initiated. After adjustment for patient, clinical, and census-block characteristics, and for potential unmeasured differences between mail order and local KPNC pharmacy users with instrumental variables analysis, 85.0% of patients who used the mail order pharmacy to deliver their statin at any time achieved target LDL-C levels compared with 74.2% of patients who only used the local KPNC pharmacy to dispense the statin (p < 0.001). Greater adjusted rates of LDL-C control in mail order pharmacy users were seen across all gender and race/ethnicity subgroups. Mail order pharmacy use was positively associated with LDL-C control in new statin users. Future research should continue to explore the relationship between mail order pharmacy use and outcomes, and address how to appropriately target mail order services to patients most likely to benefit without compromising patient choice, care, and safety.
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Brown, Susan D.; Unger Hu, Kirsten A.; Mevi, Ashley A.; Hedderson, Monique M.; Shan, Jun; Quesenberry, Charles P.; Ferrara, Assiamira
2014-01-01
The Multigroup Ethnic Identity Measure-Revised (MEIM-R), a brief instrument assessing affiliation with one’s ethnic group, is a promising advance in the ethnic identity literature. However, equivalency of its measurement properties across specific racial and ethnic groups should be confirmed before using it in diverse samples. We examined a) the psychometric properties of the MEIM-R including factor structure, measurement invariance, and internal consistency reliability, and b) levels of and differences in ethnic identity across multiple racial and ethnic groups and subgroups. Asian (n = 630), Black/African American (n = 58), Hispanic (n = 240), multiethnic (n = 160), and White (n = 375) women completed the MEIM-R as part of the “Gestational diabetes’ Effect on Moms” diabetes prevention trial in the Kaiser Permanente Northern California health care setting (N = 1,463; M age 32.5 years, SD = 4.9). Multiple-groups confirmatory factor analyses provided provisional evidence of measurement invariance, i.e., an equal, correlated two-factor structure, equal factor loadings, and equal item intercepts across racial and ethnic groups. Latent factor means for the two MEIM-R subscales, exploration and commitment, differed across groups; effect sizes ranging from small to large generally supported the notion of ethnic identity as more salient among people of color. Pending replication, good psychometric properties in this large and diverse sample of women support the future use of the MEIM-R. Preliminary evidence of measurement invariance suggests that the MEIM-R could be used to measure and compare ethnic identity across multiple racial and ethnic groups. PMID:24188656
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Serious infections among a large cohort of subjects with systemically treated psoriasis.
Dobry, Allison S; Quesenberry, Charles P; Ray, G Thomas; Geier, Jamie L; Asgari, Maryam M
2017-11-01
Biologic therapy is effective for treatment of moderate-to-severe psoriasis but may be associated with an increased risk for serious infection. To estimate the serious infection rate among patients with psoriasis treated with biologic as compared with nonbiologic systemic agents within a community-based health care delivery setting. We identified 5889 adult Kaiser Permanente Northern California health plan members with psoriasis who had ever been treated with systemic therapies and calculated the incidence rates and 95% confidence intervals (CIs) for serious infections over 29,717 person-years of follow-up. Adjusted hazard ratios (aHRs) were calculated using Cox regression. Adjusting for age, sex, race or ethnicity, and comorbidities revealed a significantly increased risk for overall serious infection among patients treated with biologics as compared with those treated with nonbiologics (aHR, 1.31; 95% CI, 1.02-1.68). More specifically, there was a significantly elevated risk for skin and soft tissue infection (aHR, 1.75; 95% CI, 1.19-2.56) and meningitis (aHR, 9.22; 95% CI, 1.77-48.10) during periods of active biologic use. Risk associated with individual drugs was not examined. We found an increased rate of skin and soft tissue infections among patients with psoriasis treated with biologic agents. There also was a signal suggesting increased risk for meningitis. Clinicians should be aware of these potential adverse events when prescribing biologic agents. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.
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Musunuru, Kiran; Arora, Pankaj; Cooke, John P; Ferguson, Jane F; Hershberger, Ray E; Hickey, Kathleen T; Lee, Jin-Moo; Lima, João A C; Loscalzo, Joseph; Pereira, Naveen L; Russell, Mark W; Shah, Svati H; Sheikh, Farah; Wang, Thomas J; MacRae, Calum A
2018-06-01
The completion of the Human Genome Project has unleashed a wealth of human genomics information, but it remains unclear how best to implement this information for the benefit of patients. The standard approach of biomedical research, with researchers pursuing advances in knowledge in the laboratory and, separately, clinicians translating research findings into the clinic as much as decades later, will need to give way to new interdisciplinary models for research in genomic medicine. These models should include scientists and clinicians actively working as teams to study patients and populations recruited in clinical settings and communities to make genomics discoveries-through the combined efforts of data scientists, clinical researchers, epidemiologists, and basic scientists-and to rapidly apply these discoveries in the clinic for the prediction, prevention, diagnosis, prognosis, and treatment of cardiovascular diseases and stroke. The highly publicized US Precision Medicine Initiative, also known as All of Us, is a large-scale program funded by the US National Institutes of Health that will energize these efforts, but several ongoing studies such as the UK Biobank Initiative; the Million Veteran Program; the Electronic Medical Records and Genomics Network; the Kaiser Permanente Research Program on Genes, Environment and Health; and the DiscovEHR collaboration are already providing exemplary models of this kind of interdisciplinary work. In this statement, we outline the opportunities and challenges in broadly implementing new interdisciplinary models in academic medical centers and community settings and bringing the promise of genomics to fruition. © 2018 American Heart Association, Inc.
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Mundt, Marlon P; Parthasarathy, Sujaya; Chi, Felicia W; Sterling, Stacy; Campbell, Cynthia I
2012-11-01
Adolescents who attend 12-step groups following alcohol and other drug (AOD) treatment are more likely to remain abstinent and to avoid relapse post-treatment. We examined whether 12-step attendance is also associated with a corresponding reduction in health care use and costs. We used difference-in-difference analysis to compare changes in seven-year follow-up health care use and costs by changes in 12-step participation. Four Kaiser Permanente Northern California AOD treatment programs enrolled 403 adolescents, 13-18-years old, into a longitudinal cohort study upon AOD treatment entry. Participants self-reported 12-step meeting attendance at six-month, one-year, three-year, and five-year follow-up. Outcomes included counts of hospital inpatient days, emergency room (ER) visits, primary care visits, psychiatric visits, AOD treatment costs and total medical care costs. Each additional 12-step meeting attended was associated with an incremental medical cost reduction of 4.7% during seven-year follow-up. The medical cost offset was largely due to reductions in hospital inpatient days, psychiatric visits, and AOD treatment costs. We estimate total medical use cost savings at $145 per year (in 2010 U.S. dollars) per additional 12-step meeting attended. The findings suggest that 12-step participation conveys medical cost offsets for youth who undergo AOD treatment. Reduced costs may be related to improved AOD outcomes due to 12-step participation, improved general health due to changes in social network following 12-step participation, or better compliance to both AOD treatment and 12-step meetings. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
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2011-01-01
Objective Many healthcare organizations (HCOs) including Kaiser Permanente, Johns Hopkins, Cleveland Medical Center, and MD Anderson Cancer Center, provide access to online health communities as part of their overall patient support services. The key objective in establishing and running these online health communities is to offer empathic support to patients. Patients' perceived empathy is considered to be critical in patient recovery, specifically, by enhancing patient's compliance with treatment protocols and the pace of healing. Most online health communities are characterized by two main functions: informational support and social support. This study examines the relative impact of these two distinct functions—that is, as an information seeking forum and as a social support forum—on patients' perceived empathy in online health communities. Design This study tests the impact of two variables that reflect the above functions of online health communities—information seeking effectiveness and perceived social support—on perceived empathy. The model also incorporates the potential moderating effect of homophily on these relationships. Measurements A web-based survey was used to collect data from members of the online health communities provided by three major healthcare centers. A regression technique was used to analyze the data to test the hypotheses. Results The study finds that it is the information seeking effectiveness rather than the social support which affects patient's perceived empathy in online health communities run by HCOs. The results indicate that HCOs that provide online health communities for their patients need to focus more on developing tools that will make information seeking more effective and efficient. PMID:21486888
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Long-term effectiveness of varicella vaccine: a 14-Year, prospective cohort study.
Baxter, Roger; Ray, Paula; Tran, Trung N; Black, Steve; Shinefield, Henry R; Coplan, Paul M; Lewis, Edwin; Fireman, Bruce; Saddier, Patricia
2013-05-01
Varicella vaccine was licensed in the United States in 1995 for individuals ≥12 months of age. A second dose was recommended in the United States in June 2006. Varicella incidence and vaccine effectiveness were assessed in a 14-year prospective study conducted at Kaiser Permanente Northern California. A total of 7585 children vaccinated with varicella vaccine in their second year of life in 1995 were followed up prospectively for breakthrough varicella and herpes zoster (HZ) through 2009. A total of 2826 of these children received a second dose in 2006-2009. Incidences of varicella and HZ were estimated and compared with prevaccine era rates. In this cohort of vaccinated children, the average incidence of varicella was 15.9 per 1000 person-years, nine- to tenfold lower than in the prevaccine era. Vaccine effectiveness at the end of the study period was 90%, with no indication of waning over time. Most cases of varicella were mild and occurred early after vaccination. No child developed varicella after a second dose. HZ cases were mild, and rates were lower in the cohort of vaccinated children than in unvaccinated children during the prevaccine era (relative risk: 0.61 [95% confidence interval: 0.43-0.89]). This study confirmed that varicella vaccine is effective at preventing chicken pox, with no waning noted over a 14-year period. One dose provided excellent protection against moderate to severe disease, and most cases occurred shortly after the cohort was vaccinated. The study data also suggest that varicella vaccination may reduce the risks of HZ in vaccinated children.
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McCulloch, Michael; Broffman, Michael; van der Laan, Mark; Hubbard, Alan; Kushi, Lawrence; Abrams, Donald I.; Gao, Jin; Colford, John M.
2014-01-01
Although localized colon cancer is often successfully treated with surgery, advanced disease requires aggressive systemic therapy that has lower effectiveness. Approximately 30% to 75% of patients with colon cancer use complementary and alternative medicine (CAM), but there is limited formal evidence of survival efficacy. In a consecutive case series with 10-year follow-up of all colon cancer patients (n = 193) presenting at a San Francisco Bay-Area center for Chinese medicine (Pine Street Clinic, San Anselmo, CA), the authors compared survival in patients choosing short-term treatment lasting the duration of chemotherapy/radiotherapy with those continuing long-term. To put these data into the context of treatment responses seen in conventional medical practice, they also compared survival with Pan-Asian medicine + vitamins (PAM+V) with that of concurrent external controls from Kaiser Permanente Northern California and California Cancer Registries. Kaplan-Meier, traditional Cox regression, and more modern methods were used for causal inference—namely, propensity score and marginal structural models (MSMs), which have not been used before in studies of cancer survival and Chinese herbal medicine. PAM+V combined with conventional therapy, compared with conventional therapy alone, reduced the risk of death in stage I by 95%, stage II by 64%, stage III by 29%, and stage IV by 75%. There was no significant difference between short-term and long-term PAM+V. Combining PAM+V with conventional therapy improved survival, compared with conventional therapy alone, suggesting that prospective trials combining PAM+V with conventional therapy are justified. PMID:21964510
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Kong, Chung Yin; Sigel, Keith; Criss, Steven D; Sheehan, Deirdre F; Triplette, Matthew; Silverberg, Michael J; Henschke, Claudia I; Justice, Amy; Braithwaite, R Scott; Wisnivesky, Juan; Crothers, Kristina
2018-04-19
Lung cancer is the leading cause of non-AIDS-defining cancer deaths among HIV-infected individuals. Although lung cancer screening with low-dose computed tomography (LDCT) is endorsed by multiple national organizations, whether HIV-infected individuals would have similar benefit as uninfected individuals from lung cancer screening is unknown. Our objective was to determine the benefits and harms of lung cancer screening among HIV-infected individuals. We modified an existing simulation model, the Lung Cancer Policy Model, for HIV-infected patients. Veterans Aging Cohort Study, Kaiser Permanente Northern California HIV Cohort, and medical literature. Target population: HIV-infected current and former smokers. Lifetime. Population. Annual LDCT screening from ages 45, 50, or 55 until ages 72 or 77 years. Benefits assessed included lung cancer mortality reduction and life-years gained; harms assessed included numbers of LDCT examinations, false-positive results, and overdiagnosed cases. For HIV-infected patients with CD4 at least 500 and 100% antiretroviral therapy adherence, screening using the Centers for Medicare & Medicaid Services criteria (age 55-77, 30 pack-years of smoking, current smoker or quit within 15 years of screening) would reduce lung cancer mortality by 18.9%, similar to the mortality reduction of uninfected individuals. Alternative screening strategies utilizing lower screening age and/or pack-years criteria increase mortality reduction, but require more LDCT examinations. Strategies assumed 100% screening adherence. Lung cancer screening reduces mortality in HIV-infected patients with CD4 at least l500, with a number of efficient strategies for eligibility, including the current Centers for Medicare & Medicaid Services criteria.
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Gharibian, Derenik; Polzin, Jennifer K; Rho, Jay P
2013-05-01
Neuropathic pain (NP) is a chronic condition that has human, social, and economic consequences. A variety of agents can be used for treatment; however, antidepressants and anticonvulsants are the 2 classes most widely studied and represent first-line agents in the management of NP. Little information is known about the adherence patterns of these medications during the first year of therapy in patients with NP. To examine the compliance and persistence of antidepressants versus anticonvulsants in patients with NP during the first year of therapy. Using electronic medical and pharmacy data for the Kaiser Permanente Southern California region, the adherence patterns for patients with a NP diagnosis prescribed an antidepressant or an anticonvulsant were studied. Compliance and persistence were measured using the medication possession ratio and the Refill-Sequence model, respectively. The study included 1817 patients with NP diagnosis taking either an antidepressant or an anticonvulsant. Within the antidepressant group, 42.9% were considered compliant, compared with 43.7% in the anticonvulsant group. Subanalysis of the 2 cohorts revealed that patients on venlafaxine were the most compliant (69.4%) compared with patients taking gabapentin (44.4%) and tricyclic antidepressants (41.8%) (P<0.01). Only 21.2% of patients in the antidepressant group and 21.4% in the anticonvulsant group were considered persistent with their medication refills. Compliance and persistence rates were similar for patients with NP diagnosis taking antidepressants and anticonvulsants. Higher compliance was observed among patients taking venlafaxine; however, this population did have a small sample size.
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Laraia, Barbara A; Downing, Janelle M; Zhang, Y Tara; Dow, William H; Kelly, Maggi; Blanchard, Samuel D; Adler, Nancy; Schillinger, Dean; Moffet, Howard; Warton, E Margaret; Karter, Andrew J
2017-05-01
Associations between neighborhood food environment and adult body mass index (BMI; weight (kg)/height (m)2) derived using cross-sectional or longitudinal random-effects models may be biased due to unmeasured confounding and measurement and methodological limitations. In this study, we assessed the within-individual association between change in food environment from 2006 to 2011 and change in BMI among adults with type 2 diabetes using clinical data from the Kaiser Permanente Diabetes Registry collected from 2007 to 2011. Healthy food environment was measured using the kernel density of healthful food venues. Fixed-effects models with a 1-year-lagged BMI were estimated. Separate models were fitted for persons who moved and those who did not. Sensitivity analysis using different lag times and kernel density bandwidths were tested to establish the consistency of findings. On average, patients lost 1 pound (0.45 kg) for each standard-deviation improvement in their food environment. This relationship held for persons who remained in the same location throughout the 5-year study period but not among persons who moved. Proximity to food venues that promote nutritious foods alone may not translate into clinically meaningful diet-related health changes. Community-level policies for improving the food environment need multifaceted strategies to invoke clinically meaningful change in BMI among adult patients with diabetes. © The Author 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Low Back Imaging When Not Indicated: A Descriptive Cross-System Analysis
Gold, Rachel; Esterberg, Elizabeth; Hollombe, Celine; Arkind, Jill; Vakarcs, Patricia A; Tran, Huong; Burdick, Tim; DeVoe, Jennifer E; Horberg, Michael A
2016-01-01
Context: Guideline-discordant imaging to evaluate incident low back pain is common. Objective: We compared rates of guideline-discordant imaging in patients with low back pain in two care delivery systems with differing abilities to track care through an electronic health record (EHR), and in their patients’ insurance status, to measure the association between these factors and rates of ordered low back imaging. Design: We used data from two Kaiser Permanente (KP) Regions and from OCHIN, a community health center network. We extracted data on imaging performed after index visits for low back pain from June 1, 2011, to May 31, 2012, in these systems. Adjusted logistic regression measured associations between system-level factors and imaging rates. Main Outcome Measures: Imaging rates for incident low back pain using 2 national quality metrics: Clinical Quality Measure 0052, a measure for assessing Meaningful Use of EHRs, and the Healthcare Effectiveness Data and Information Set measure “Use of Imaging Studies for Low Back Pain.” Results: Among 19,503 KP patients and 2694 OCHIN patients with incident low back pain, ordered imaging was higher among men and whites but did not differ across health care systems. OCHIN’s publicly insured patients had higher rates of imaging compared with those with private or no insurance. Conclusion: Rates of ordered imaging to evaluate incident low back pain among uninsured OCHIN patients were lower than in KP overall; among insured OCHIN patients, rates were higher than in KP overall. Research is needed to establish causality and develop interventions. PMID:26934626
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Physical activity, bowel function, and quality of life among rectal cancer survivors.
Krouse, Robert S; Wendel, Christopher S; Garcia, David O; Grant, Marcia; Temple, Larissa K F; Going, Scott B; Hornbrook, Mark C; Bulkley, Joanna E; McMullen, Carmit K; Herrinton, Lisa J
2017-11-01
Physical activity (PA) is positively associated with numerous health benefits among cancer survivors. This study examined insufficiently investigated relationships among PA, health-related quality of life (HRQOL), and bowel function (BF) in rectal cancer survivors. RC survivors (n = 1063) ≥5 years from diagnosis in two Kaiser permanente regions were mailed a multidimensional survey to assess HRQOL and BF. PA was assessed by a modified Godin Leisure-Time Exercise Questionnaire. PA minutes were categorized into weighted categories based on guidelines: (1) not active (zero PA minutes); (2) insufficiently active (1-149 PA minutes); (3) meeting guidelines (150-299 PA minutes); and (4) above guidelines (≥300 PA minutes). Relationships of PA with HRQOL and BF were evaluated using multiple linear regression, stratified by sex and ostomy status for BF. Types of PA identified as helpful for BF and symptoms addressed were summarized. Response rate was 60.5%. Of 557 participants, 40% met or exceeded PA guidelines, 34% were not active, and 26% were insufficiently active. Aerobic activities, specifically walking and cycling, were most commonly reported to help BF. Higher PA was associated with better psychological wellbeing and multiple SF12 scales, worse BF scores in men with ostomies, and better BF scores in women. Meeting or exceeding PA guidelines was associated with higher HRQOL. Although the BF findings are exploratory, they suggest women may benefit from increased PA, whereas men with ostomies may face challenges that require more study. Identifying PA strategies that will lead to improved patient compliance and benefit are needed.
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Desai, Shilpa H; Kaplan, Michael S; Chen, Qiaoling; Macy, Eric M
2017-01-01
The morbidity potentially associated with unverified penicillin allergy in pregnant women, with and without group B streptococcus (GBS) infections, is unknown. Penicillin allergy testing is safe during pregnancy but is done infrequently. To determine morbidity associated with antibiotic use in a large cohort of pregnant women, with and without an unverified history of penicillin allergy, and with and without GBS. Retrospective. All pregnant women who delivered live infants in Kaiser Permanente Southern California between January 1, 2009, and December 31, 2014, were identified. Penicillin allergy status at delivery, delivery method, maternal and infant hospital utilization, peripartum antibiotic exposures, new antibiotic-associated adverse drug reactions, and new Clostridium difficile infections. There were 170,379 unique women who had 201,316 pregnancies during the study period. There were 16,084 pregnancies in women with an active, but unverified, penicillin allergy at delivery. There were 42,524 pregnancies in GBS-positive women, and 3500 also had a penicillin allergy. Women with a penicillin allergy, with or without GBS, had significantly (about 10%) higher cesarean section rates and spent significantly more (about 0.1) days in the hospital after delivery. Among GBS-positive women, those with an unverified penicillin allergy were exposed to significantly more cefazolin, clindamycin, vancomycin, and gentamicin and had significantly higher rates of adverse drug reactions associated with all antibiotic use. Unverified penicillin allergy is associated with more hospital utilization and additional morbidity. Penicillin allergy testing of pregnant women with a history of penicillin allergy may help reduce these unwanted outcomes.
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Escobar, Gabriel J; Baker, Jennifer M; Turk, Benjamin J; Draper, David; Liu, Vincent; Kipnis, Patricia
2017-01-01
This article is not a traditional research report. It describes how conducting a specific set of benchmarking analyses led us to broader reflections on hospital benchmarking. We reexamined an issue that has received far less attention from researchers than in the past: How variations in the hospital admission threshold might affect hospital rankings. Considering this threshold made us reconsider what benchmarking is and what future benchmarking studies might be like. Although we recognize that some of our assertions are speculative, they are based on our reading of the literature and previous and ongoing data analyses being conducted in our research unit. We describe the benchmarking analyses that led to these reflections. The Centers for Medicare and Medicaid Services' Hospital Compare Web site includes data on fee-for-service Medicare beneficiaries but does not control for severity of illness, which requires physiologic data now available in most electronic medical records.To address this limitation, we compared hospital processes and outcomes among Kaiser Permanente Northern California's (KPNC) Medicare Advantage beneficiaries and non-KPNC California Medicare beneficiaries between 2009 and 2010. We assigned a simulated severity of illness measure to each record and explored the effect of having the additional information on outcomes. We found that if the admission severity of illness in non-KPNC hospitals increased, KPNC hospitals' mortality performance would appear worse; conversely, if admission severity at non-KPNC hospitals' decreased, KPNC hospitals' performance would appear better. Future hospital benchmarking should consider the impact of variation in admission thresholds.
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Iribarren, Carlos; Round, Alfred D; Lu, Meng; Okin, Peter M; McNulty, Edward J
2017-10-05
ECG left ventricular hypertrophy (LVH) is a well-known predictor of cardiovascular disease. However, no prior study has characterized patterns of presence/absence of ECG LVH ("ECG LVH trajectories") across the adult lifespan in both sexes and across ethnicities. We examined: (1) correlates of ECG LVH trajectories; (2) the association of ECG LVH trajectories with incident coronary heart disease, transient ischemic attack, ischemic stroke, hemorrhagic stroke, and heart failure; and (3) reclassification of cardiovascular disease risk using ECG LVH trajectories. We performed a cohort study among 75 412 men and 107 954 women in the Northern California Kaiser Permanente Medical Care Program who had available longitudinal exposures of ECG LVH and covariates, followed for a median of 4.8 (range <1-9.3) years. ECG LVH was measured by Cornell voltage-duration product. Adverse trajectories of ECG LVH (persistent, new development, or variable pattern) were more common among blacks and Native American men and were independently related to incident cardiovascular disease with hazard ratios ranging from 1.2 for ECG LVH variable pattern and transient ischemic attack in women to 2.8 for persistent ECG LVH and heart failure in men. ECG LVH trajectories reclassified 4% and 7% of men and women with intermediate coronary heart disease risk, respectively. ECG LVH trajectories were significant indicators of coronary heart disease, stroke, and heart failure risk, independently of level and change in cardiovascular disease risk factors, and may have clinical utility. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
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Effect of non-steroidal anti-inflammatory medications on the risk of amyotrophic lateral sclerosis.
Popat, Rita A; Tanner, Caroline M; van den Eeden, Stephen K; Bernstein, Allan L; Bloch, Daniel A; Leimpeter, Amethyst; McGuire, Valerie; Nelson, Lorene M
2007-06-01
Inflammatory processes may be involved in the pathogenesis of amyotrophic lateral sclerosis (ALS). We examined the association of non-steroidal anti-inflammatory drugs (NSAIDs) with the risk of ALS in case-control study of incident cases (n = 111) conducted within the Kaiser Permanente Medical Care Program of Northern California during the years 1996-2000. Controls (n = 258) randomly selected from the same population were frequency matched by age and gender to the ALS cases. Information regarding use of NSAIDs (non-aspirin and aspirin) and three classes of 'control' medications was collected by in-person structured interview. Subjects who used medication at least twice a week for at least a month were classified as 'ever users'. Multivariable logistic regression models were adjusted for age, gender, history of osteoarthritis/rheumatoid arthritis and pain, and other medication use. Overall, there was no association between NSAID use and ALS; however, some sex differences were noted for non-aspirin NSAID use. Among men, non-aspirin NSAID use was associated with a two-fold increased risk of ALS (adjusted odds ratio (OR) 2.0, 95% confidence interval (CI) 1.0-3.9), whereas among women, non-aspirin NSAID use was not associated with increased ALS risk (adjusted OR 0.5, 95% CI 0.2-1.2). ALS risk was not associated with aspirin use or with 'control' medications. This study did not find any evidence to suggest that NSAID use reduces the risk of ALS. The observed sex differences with non-aspirin NSAID use could be due to chance or an unmeasured confounder.
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Failure Modes and Effects Analysis of bilateral same-day cataract surgery
Shorstein, Neal H.; Lucido, Carol; Carolan, James; Liu, Liyan; Slean, Geraldine; Herrinton, Lisa J.
2017-01-01
PURPOSE To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN Retrospective cohort study. METHODS Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry. Potential failures in human factors and communication (modes) were identified. Rates of endophthalmitis, toxic anterior segment syndrome (TASS), and unintended intraocular lens (IOL) implantation were assessed in eyes having bilateral same-day surgery from 2010 through 2014. RESULTS The study comprised 4754 eyes. The analysis identified 15 significant potential failure modes. These included lapses in instrument processing and compounding error of intracameral antibiotic that could lead to endophthalmitis or TASS and ambiguous documentation of IOL selection by surgeons, which could lead to unintended IOL implantation. Of the study sample, 1 eye developed endophthalmitis, 1 eye had unintended IOL implantation (rates, 2 per 10 000; 95% confidence intervals [CI] 0.1–12.0 per 10 000), and no eyes developed TASS (upper 95% CI, 8 per 10 000). Recommendations included improving oversight of cleaning and sterilization practices, separating lots of compounded drugs for each eye, and enhancing IOL verification procedures. CONCLUSIONS Potential failure modes and recommended actions in bilateral same-day cataract surgery were determined using a FMEA. These findings might help improve the reliability and safety of bilateral same-day cataract surgery based on current evidence and standards. PMID:28410711
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Soper, Margaret S; Hastings, Joseph R; Cosmatos, Harry A; Slezak, Jeffrey M; Wang, Ricardo; Lodin, Kenneth
2014-08-01
The management of stage I seminoma has evolved over the past 20 years. Contemporary management options after orchiectomy include adjuvant radiation, adjuvant chemotherapy, and observation. This analysis defines the experience at Kaiser Permanente Southern California from 1990 to 2010. We examined outcomes for stage I seminoma patients and reviewed prognostic factors for recurrence in those managed with observation. This is a retrospective study of 502 stage I seminoma patients who underwent orchiectomy from 1990 to 2010. Outcomes examined were relapse-free survival (RFS), overall survival (OS), and cause-specific survival (CSS). Risk factors for recurrence evaluated were age, preoperative hCG elevation, preoperative LDH elevation, tumor size, lymphovascular invasion, rete testis invasion, epididymis invasion, and invasion through the tunica albuginea. Among radiation patients, 5-year RFS was 97.2%, OS was 98.0%, and CSS was 99.3%. Among chemotherapy patients, 2-year RFS was 98.3% and OS and CSS were 100%. Among observation patients, 5-year RFS was 89.2%, OS was 98.8%, and CSS was 100%. There was no difference in OS or CSS among the groups. RFS was significantly lower for observation patients. Among observation patients, univariate analysis identified tumor size, lymphovascular invasion, and rete testis invasion as risk factors for relapse. No factors were significant on multivariate analysis. Our data show that adjuvant radiation and chemotherapy yield similar outcomes in the management of stage I seminoma. Observation results in a lower RFS, but patients who relapse can be salvaged; OS and CSS are not affected.
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Low Risk of Cervical Cancer/Precancer Among Most Women Under Surveillance Postcolposcopy.
Demarco, Maria; Cheung, Li C; Kinney, Walter K; Wentzensen, Nicolas; Lorey, Thomas S; Fetterman, Barbara; Poitras, Nancy E; Befano, Brian; Castle, Philip E; Schiffman, Mark
2018-04-01
To inform impending postcolposcopy guidelines, this analysis examined the subsequent risk of CIN 3+ among women with a grade lower than CIN 2 (< CIN 2) colposcopy results, taking into account the referring results that brought them to colposcopy and cotest results postcolposcopy. We analyzed 107,005 women from 25 to 65 years old, recommended for colposcopy at Kaiser Permanente Northern California. We estimated absolute risks of CIN 3+ among women: (1) recommended for colposcopy (precolposcopy), (2) following colposcopy and with histology results < CIN 2 (postcolposcopy), and (3) with cotest results 12 months after a < CIN 2 colposcopy (return cotest). After colposcopy showing < CIN 2 (n = 69,790; 87% of the women at colposcopy), the 1-year risk of CIN 3+ was 1.2%, compared with 6.3% at the time of colposcopy recommendation. Negative cotest results 1 year after colposcopy identified a large group (37.1%) of women whose risk of CIN 3+ (i.e., <0.2% at 3 years after postcolposcopy cotest) was comparable with women with normal cytology in the screening population. These risks are consistent with current guidelines recommending repeat cotesting 12 months after colposcopy < CIN 2 and a 3-year return for women with a negative postcolposcopy cotest. Most women are at low risk of subsequent CIN 3+ after a colposcopy showing < CIN 2, especially those who are human papillomavirus-negative postcolposcopy, consistent with current management guidelines for repeat testing intervals. Before the finalizing the upcoming guidelines, we will consider additional rounds of postcolposcopy cotesting.
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Low Risk of Cervical Cancer/Precancer Among Most Women Under Surveillance Postcolposcopy
Demarco, Maria; Cheung, Li C.; Kinney, Walter K.; Wentzensen, Nicolas; Lorey, Thomas S.; Fetterman, Barbara; Poitras, Nancy E.; Befano, Brian; Castle, Philip E.; Schiffman, Mark
2018-01-01
Objective To inform impending postcolposcopy guidelines, this analysis examined the subsequent risk of CIN 3+ among women with a grade lower than CIN 2 (< CIN 2) colposcopy results, taking into account the referring results that brought them to colposcopy and cotest results postcolposcopy. Methods We analyzed 107,005 women from 25 to 65 years old, recommended for colposcopy at Kaiser Permanente Northern California. We estimated absolute risks of CIN 3+ among women: (1) recommended for colposcopy (precolposcopy), (2) following colposcopy and with histology results < CIN 2 (postcolposcopy), and (3) with cotest results 12 months after a < CIN 2 colposcopy (return cotest). Results After colposcopy showing < CIN 2 (n = 69,790; 87% of the women at colposcopy), the 1-year risk of CIN 3+ was 1.2%, compared with 6.3% at the time of colposcopy recommendation. Negative cotest results 1 year after colposcopy identified a large group (37.1%) of women whose risk of CIN 3+ (i.e., <0.2% at 3 years after postcolposcopy cotest) was comparable with women with normal cytology in the screening population. These risks are consistent with current guidelines recommending repeat cotesting 12 months after colposcopy < CIN 2 and a 3-year return for women with a negative postcolposcopy cotest. Conclusions Most women are at low risk of subsequent CIN 3+ after a colposcopy showing < CIN 2, especially those who are human papillomavirus–negative postcolposcopy, consistent with current management guidelines for repeat testing intervals. Before the finalizing the upcoming guidelines, we will consider additional rounds of postcolposcopy cotesting. PMID:29570564
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Arthur, Rhonda; Wang, Yihong; Ye, Kenny; Glass, Andrew G; Ginsberg, Mindy; Loudig, Olivier; Rohan, Thomas
2017-10-01
Women with benign breast disease (BBD) have an increased risk of subsequent breast cancer. However, whether conventional breast cancer risk factors influence risk of breast cancer among women with BBD is unclear. In this study, we investigated the associations of lifestyle, menstrual/reproductive, and histological factors with risk of breast cancer among women biopsied for BBD. We conducted a case-control study, nested within a cohort of 15,395 women biopsied for BBD at Kaiser Permanente Northwest between 1971 and 2006. Cases were women who developed a subsequent invasive breast cancer during follow-up; controls were individually matched to cases on age at BBD diagnosis. A total of 526 case-control pairs were included in the study. We calculated crude and multivariable OR and 95% CI for the associations between lifestyle, menstrual/reproductive, and histological factors and breast cancer risk using conditional logistic regression. Compared to premenopausal women, postmenopausal women had reduced risk of subsequent breast cancer (OR 0.60; 95% CI 0.39-0.94), whereas women who ever used hormone replacement therapy (HRT) had increased risk (OR 3.61; 95% CI 1.68-7.75), as did women whose BBD lesion showed atypical hyperplasia (OR 5.56; 95% CI 2.05-15.06). Smoking, BMI, early menarche, multiparity (≥4), history of oophorectomy, and extent of lobular involution were not associated with risk of breast cancer. This study suggests that use of HRT and having atypical hyperplasia are associated with increased risk of breast cancer among women with BBD, while postmenopausal women with BBD have a reduced risk.
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Food Insecurity in Older Adults in an Integrated Health Care System.
Steiner, John F; Stenmark, Sandra H; Sterrett, Andrew T; Paolino, Andrea R; Stiefel, Matthew; Gozansky, Wendolyn S; Zeng, Chan
2018-05-01
To estimate food insecurity prevalence and develop a statistical prediction model for food insecurity. Retrospective cohort study. Kaiser Permanente Colorado. Adult members who completed a pre-Medicare Annual Wellness Visit survey. Food insecurity was assessed using a single screening question. Sociodemographic and clinical characteristics from electronic health records and self-reported characteristics from the survey were used to develop the prediction model. Of 130,208 older adult members between January 2012 and December 2015, 50,097 (38.5%) completed food insecurity screening, 2,859 of whom (5.7% of respondents) reported food insecurity. The prevalence of food insecurity was 10.0% or greater among individuals who were black or Hispanic, had less than high school education, had Medicaid insurance, were extremely obese, had poor health status or quality of life, had depression or anxiety, had impairments in specific activities of daily living, had other nutritional risk factors, or were socially isolated (all p<.001). A multivariable model based on these and other characteristics showed moderate discrimination (c-statistic = 0.74) between individuals with food insecurity and those without and 14.3% of individuals in the highest quintile of risk reported food insecurity. Food insecurity is prevalent even in older adults with private-sector healthcare coverage. Specific individual characteristics, and a model based on those characteristics, can identify older adults at higher risk of food insecurity. System-level interventions will be necessary to connect older adults with community-based food resources. © 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.
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NASA Astrophysics Data System (ADS)
Rosado Olivieri, Wilda Y.
Gran parte de la investigacion acerca de la ensenanza de las ciencias se dedica a estudiar la forma o manera en que los estudiantes visualizan los conceptos cientificos. Para Driver (1983) esas ideas o concepciones se conocen como concepciones alternativas; las cuales pueden ocasionar dificultad para comprender los conceptos de las diferentes areas del conocimiento. El proposito de este estudio fue: (a) indagar como las distintas etapas del ABP permiten explorar las concepciones alternativas que poseen los estudiantes de nivel elemental acerca de los estados de agregacion de la materia y, (b) explorar en que medida el ABP permite identificar e incorporar las concepciones alternativas que poseen los estudiantes de nivel elemental con relacion al concepto de estados de agregacion de la materia para facilitar su aprendizaje. Con el fin de explorar las concepciones alternativas en el tema de los estados agregados de la materia se implanto la estrategia de Aprendizaje Basado en Problemas (ABP) con estudiantes de quinto grado de nivel elemental. Se utilizo la metodologia mixta con varias estrategias de recopilacion de datos, como una pre y pos prueba para elucidar el conocimiento previo y al mismo tiempo las concepciones alternativas sobre el tema bajo estudio y luego verificar el aprendizaje en los estudiantes. Asimismo, el uso de mapas conceptuales para determinar la profundidad del tema estudiado y el entrelazamiento de los conceptos Una tercera estrategia fue el grupo focal para tomar en cuenta la impresion de los estudiantes acerca del proyecto ABP. El aspecto colaborativo y cooperativo fue un factor fundamental, ya que el aprendizaje ocurrio en ese contexto educativo. Para los hallazgos de esta investigacion fue tan importante el conocimiento previo como los procesos que se generaban para que la adquisicion del mismo fuera de forma significativa y funcional (Escribano & Del Valle, 2010). La estrategia de ABP constituyo en este estudio una forma para indagar las
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NASA Astrophysics Data System (ADS)
Delgado, Isabel C.
Los modelos de eensenanza y aprendizaje constructivistas conceptualizan el aprendizaje como un proceso activo. El modelo de Aprendizaje Basado en Proyectos (ABPr) se distingue por una serie de componentes, entre los cuales se destaca el aspecto colaborativo y cooperativo como un reto al momento de su implantacion. Son pocas las investigaciones que se concentran en este aspecto del modelo. En este estudio, se analizaron las diversas interacciones que surgen durante la implantacion de una unidad curricular sobre el tema de Geologia de Puerto Rico, la cual se diseno con el modelo ABPr cuyo enfoque es orientacion a proyectos. Particularmente, se examinaron las interacciones sociales que surgen entre los pares y entre pares y docente durante el proceso de planificacion y desarrollo de los productos finales, al igual que las interacciones entre los estudiantes y el material didactico en estas etapas del modelo. La investigacion es de tipo cualitativo e incorpora como diseno el estudio de caso. Las diversas interacciones constituyen la unidad de analisis. En el estudio participaron 19 estudiantes de 9no grado, a quienes se organizaron en 5 grupos colaborativos por temas de interes (Pangea, Placas tectonicas, Volcanes, Tsunamis y Terremotos). Las tecnicas que se utilizaron para recopilar los datos fueron: observaciones participativas, grupos focales y analisis de documentos (cuadernos reflexivos y respuestas de los estudiantes a la pregunta central del proyecto). Para el analisis de los datos se aplico la teoria de actividad (CHAT) que concentra la unidad de analisis en la actividad humana en un contexto particular. Los resultados del estudio senalan que las interacciones entre pares, entre pares y docente, asi como entre estudiantes y material didactico son fundamentales en el proceso de aprendizaje. Una mayor interaccion entre pares durante las etapas de planificar y desarrollar los productos finales de la unidad, promueve una mejor comprension de los conceptos de la
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NASA Astrophysics Data System (ADS)
Ballesteros Benavides, Maria Elvira
Para este trabajo utilizamos el estudio de casos cualitativo que se llevo a cabo en una universidad privada de Puerto Rico. Empleamos como unidad de analisis el concepto de enlace quimico, ionico y covalente. Los participantes fueron los estudiantes de la seccion nocturna del curso de Quimica General I. La investigacion se desarrollo por medio de dos entrevistas de persona a persona, observaciones de las expresiones no verbales y la hoja de identificacion de conceptos. Para la triangulacion tomamos en consideracion las preconcepciones erroneas, las concepciones alternativas y el mapa de conceptos de cada participante. Preparamos un mapa de conceptos para el enlace quimico validado por un comite de expertos. Tambien, elaboramos los mapas de conceptos de los participantes que sirvieron para varios propositos: conocer la estructura conceptual, expresar los logros, hacer comparaciones e identificar la presencia de concepciones alternativas. Entre los hallazgos encontramos que todos los participantes poseen conocimiento previo de los enlaces quimicos ionico y covalente y dentro de ese conocimiento existen preconcepciones erroneas mas numerosas para el enlace ionico. Al principio del semestre el 50% de los participantes demostraron tener "carencia fuerte de conceptos" tanto para el enlace ionico como para el covalente. Al finalizar el semestre encontramos en el 40% de los participantes concepciones alternativas tanto para el enlace ionico como para el covalente y el 90% no lograron distinguir un enlace del otro. Nuestras conclusiones fueron que los participantes sin distincion del aprovechamiento academico demostraron tener la tendencia de "carencia fuerte de conceptos" tanto para el enlace ionico como para el covalente, presentaron dificultad al integrar los conceptos de los enlaces quimicos ionico y covalente que se pusieron de manifiesto al dar los ejemplos. Las preconcepciones erroneas contribuyen en el desarrollo de las concepciones alternativas. Ademas, los
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Determinação de regiões de órbitas diretas estáveis ao redor da Lua
NASA Astrophysics Data System (ADS)
de Melo, C. F.; Winter, O. C.; Vieira Neto, E.
2003-08-01
Neste Trabalho estamos investigando regiões do sistema Terra-Lua que contêm órbitas diretas estáveis ao redor da Lua visando a utilização destas órbitas em futuras missões de veículos espaciais como alternativas de trajetórias com baixo custo de manutenção. Adotando-se o problema restrito de três corpos, Terra-Lua-partícula, a localização e a extensão destas regiões de estabilidade foram investigadas numericamente considerando como estável toda órbita que permanece ao redor a Lua por, no mínimo, 1000 dias com energia de dois corpos da partícula em relação à Lua negativa. A estabilidade de tais regiões está associada a duas famílias de órbitas periódicas simples H1 e H2 e a órbitas quase-periódicas associadas a elas. Uma vez identificadas as regiões de estabilidade passamos a analisá-las introduzindo, paulatinamente, outras interações relevantes ao sistema como as perturbações do Sol (via problema restrito de quatro corpos), das marés, da pressão de radiação e do achatamento terrestre. Os resultados encontrados até o momento mostram que a perturbação do Sol é a única que reduz significativamente o tamanho das regiões de estabilidade. Também estamos investigando o comportamento de tais regiões quando características intrínsecas do sistema como as excentricidades das órbitas da Terra e da Lua e a inclinação da órbita Lua são consideradas. Com este estudo estamos reunindo informações que nos permitirão compreender a evolução das regiões de estabilidade no sistema Terra-Lua, bem como estabelecer parâmetros adequados para a utilização das trajetórias estáveis em futuras missões espaciais. Agradecimentos: Este projeto conta com o apoio do CNPq, da Capes e da Fapesp.
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Camporro, Fernando Astur; Gutierrez Magaldi, Ignacio; Bulacio, Exequiel
2017-09-08
Introducción: El tabaquismo es la primera causa evitable de muerte en el mundo. El cigarrillo electrónico (CE), es un dispositivo que simula a los cigarrillos convencionales y permite inhalar nicotina y otras sustancias de forma vaporizada, sin combustión de tabaco. Su conocimiento por parte de la población general, así como su comercialización y consumo viene en constante aumento. Es utilizado en todo el mundo con el objetivo de disminuir el consumo de tabaco, lograr su abandono o poder utilizarlo en lugares públicos donde el consumo de cigarrillos convencionales está prohibido. Efectos nocivos sobre la salud: Su utilización se ha asociado a neumonía lipoidea e irritación de la vía aérea superior y toxicidad por nicotina. Presenta sustancias cancerígenas como nitrosaminas, formaldeido y metales como el niquel, cromo y plomo. Aumenta la resistencia de la vía aérea, efecto que es similar al que se produce después de la inhalación del humo del tabaco. Eficacia para dejar de fumar: No hay hasta el momento trabajos que demuestren con poder estadístico y buena metodología que este producto sea eficaz para dejar de fumar. Conclusiones: De acuerdo a la evidencia disponible, no podemos descartar que el uso del cigarrillo electrónico no tenga riesgos para la salud. La seguridad y eficacia de los cigarrillos electrónicos como ayuda para el abandono del hábito tabáquico no han sido demostradas.
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Zea-Vera, Alonso; Turin, Christie G.; Ochoa, Theresa J.
2015-01-01
Las infecciones constituyen una de las principales causas de muerte en el periodo neonatal. El diagnóstico de sepsis neonatal representa un gran desafío ya que los recién nacidos presentan signos clínicos muy inespecíficos y los exámenes auxiliares tienen una baja sensibilidad. Con el objetivo de mejorar el diagnóstico correcto de esta patología proponemos un algoritmo de vigilancia diagnóstica para sepsis neonatal tardía en el Perú y países de la región. El algoritmo permite clasificar a los episodios como sepsis confirmada, probable o posible, y sobretodo busca identificar aquellos episodios que no corresponden a sepsis, evitando calificar otras patologías como “sepsis”. Un mejor diagnóstico permitiría tener tasas más reales de sepsis neonatal, mejorar el uso de antibióticos y evitar sus efectos negativos en el recién nacido, así como una visión más exacta de su impacto en la salud pública. PMID:25123879
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Del sujeto que ha intentado suicidarse y el Otro: la Institución Psiquiátrica
Liliana, Mondragón B.; Miguel Ángel, Caballero G.
2009-01-01
El hospital psiquiátrico se ha constituido como un lugar donde se posibilita legitimar la exclusión y la radicalidad de ese otro “que no es igual”, como es el caso del sujeto que atenta contra su propia vida. En consecuencia, el intento de suicidio desde el pensamiento foucaultiano, es una resistencia que desmantela la estructura de dominación a través de un acto de poder, el cual se ejerce sobre el propio cuerpo. Así, la intención de este texto es mostrar que la relación Otro-otro es un lugar en la estructura subjetiva, que se deposita en la institución psiquiátrica, la cual representa el poder, la ley, y es aquello a lo que se le quiere agredir, resistir, abatir con un intento de suicidio. Para demostrar como se materializan estos hechos, se exponen los testimonios de tres adolescentes atendidas en un hospital psiquiátrico por intentos suicidas, en los cuales se señalan los diferentes significados que le atribuyen a la institución psiquiátrica en tanto que representa un Otro en sus actos autoinfligidos. PMID:25400324
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Nota sobre el "Se" como Sujeto Indefinido (A Note on "Se" as an Indefinite Subject)
ERIC Educational Resources Information Center
Lujan, Marta
1975-01-01
Contradicts Pablo Jordan's theory that certain "se" constructions in Spanish are neither passive nor reflexive. It is claimed that syntactic evidence reveals two types of impersonal structures, the impersonal active and the passive reflexive. (Text is in Spanish.) (CK)
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Como ayudar a sus hijos a usar la biblioteca (Helping Your Child Use the Library).
ERIC Educational Resources Information Center
Perkinson, Kathryn
Focusing on the cooperative role of parents and public libraries in stimulating reading interests in children of all ages, this booklet addresses the following issues: (1) getting children interested in reading (reading aloud to children; encouraging children to read to you; starting a home library; showing children that you enjoy reading;…
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ERIC Educational Resources Information Center
Office of Federal Student Aid (ED), Washington, DC.
This guide, written in Spanish, discusses reasons for going to college, how to pay for college, and how to apply for federal student aid in a series of brief, clear illustrations. Following outlines of financial benefits of college, college costs, and space to note costs for the student's area, the guide outlines these steps in the application…
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ERIC Educational Resources Information Center
Rockefeller Foundation, New York, NY.
This volume presents nine papers read at a conference on affirmative action, sponsored by the Rockefeller Foundation and held at Columbia University in August 1982; a preface, summary paper, and list of participants are also included. Each paper addresses the issue of affirmative action within a different country and describes: (1) the policies…
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Distribución del continuo ultravioleta e infrarrojo en estrellas Be
NASA Astrophysics Data System (ADS)
Cruzado, A.; Ringuelet, A.; di Rocco, H.
Estamos interesados en interpretar los excesos de flujo infrarrojo y/o ultravioleta observados en estrellas Be con respecto al de estrellas B normales, así como su posible correlación. Una envoltura rodeando la estrella distingue una estrella Be de una B normal; para explicar las observaciones es necesario entonces tener en cuenta todos los posibles procesos físicos que en ella tienen lugar. Adoptando un modelo atmosférico específico, hemos estudiado el proceso de recombinación dielectrónica de metales como MgII y FeII, teniendo en cuenta la posible influencia de la opacidad del medio en el flujo emitido.
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Cálculos ab initio con correlación electrónica
NASA Astrophysics Data System (ADS)
Merchán Bonete, M.
Estamos entrando en una era donde la ortogonalidad entre las investigaciones de carácter experimental y de naturaleza teórica se irá difuminando progresivamente y la problemática a resolver quedará en escena como el único actor principal de la obra. Como premisa para una cooperación teórico-experimental de igual a igual, la metodología químico-cuántica utilizada debe ser capaz de ofrecer resultados de carácter predictivo. Sin duda, esta madurez en la metodología químico-cuántica ya la hemos alcanzado hace algunos años, tal y como muestra entre otras muchas, la labor que nuestro grupo ha realizado en el transcurso de la última década, dentro del campo de la Espectroscopía Teórica. Los estudios realizados comprenden una amplia gama de sistemas, variando tanto en tamaño como en complejidad, abordando problemáticas espectroscópicas consideradas tradicionalmente como especialmente controvertidas. Nuestra contribución científica más relevante reside en el carácter cuantitativo de las asignaciones espectroscópicas que hemos propuesto en base a resultados ab initio. Recordemos que en los años noventa los resultados ab initio solían presentar para las energías de excitación de sistemas de tamaño molecular moderado, como el benceno, errores de más de 1 eV. En comparación con el éxito relativo de los métodos semiempíricos, la frustración de la metodología ab initio quedaba todavía más patente. Los estudios que hemos presentado representan una comprensión profunda de los espectros electrónicos en sistemas orgánicos claves, mostrando el camino a seguir para obtener asignaciones espectroscópicas precisas (entre 0.1-0.2 eV). La naturaleza del método CASPT2 junto al diseño de estrategias computacionales nos ha permitido alcanzar el carácter cuantitativo con el que se caracterizan nuestras contribuciones[1,2]. Por todo ello, algunos de los trabajos publicados se consideran clásicos dentro del campo, pues en cierto modo definen el
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NASA Astrophysics Data System (ADS)
Leite, Cristina; Hosoume, Yassuko
2007-12-01
The research presented in this article is about the way science teachers from Elementary School think about astronomical elements. Its methodology is based on semi-structured interviews, which were video recorded. The research is centered in a three-dimensional perspective of astronomical Earth, the Sun, the Moon, the planets and the stars, and also the conceptions about sky and Universe. The esults indicate a Universe that contains: Sun, stars, planets and Moon; where the Solar System is a little part of the whole. Sometimes they think that the Solar System is the Universe. The objects are in the sky or in the Universe, which, for many of them, is only the space above the Earth. The flat shape of astronomical objects and the spatial structure of the Universe are striking features. Many of them think that Sun and stars are different: the Sun is a hot object and the stars are cold ones. These results worry us and they certainly indicate how urgent it is to plan Professional Development in Astronomy for teachers, after all the PCN's emphasize that this subject is important to be taught. El objeto de investigación de este artículo es la manera de pensar sobre los elementos de la Astronomía de los profesores de Ciencias en la enseñanza fundamental. La metodología consiste en entrevistas semi-estructuradas, filmadas en video y centradas en la tridimensionalidad de los elementos astronómicos, para posibilitar un mapeamiento de las concepciones sobre las formas y dimensiones de la Tierra, del Sol, de la Luna, de los planetas y de las estrellas, como también de la concepción de cielo y de Universo en su totalidad. Los resultados indican un Universo conteniendo: Sol, estrellas, planetas y Luna, donde el Sistema Solar se ubica como parte. Algunas veces, el Universo es concebido como el propio Sistema Solar. Los objetos están en el cielo o en el Universo, que, para muchos, se restringe al espacio que está arriba de la Tierra. La forma plana de los objetos astron
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SURGERY AND CARDIOVASCULAR SURGERY JOURNALS ANALYSIS.
Schanaider, Alberto
2015-01-01
com estes conteúdos. Utilizaram-se as bases de dados Thomson Reuters/ISI (JCR), Elsevier/Scopus (SJR), além do Scielo. Somente nos programas 7, os docentes têm média de artigos Qualis A1 maior ou igual que os demais estratos. Apenas 11 periódicos da área de Cirurgia estão no estrato A1 (5%) e na Cirurgia Cardiovascular são 25%. Dos seis periódicos com o maior número de publicações na área Medicina III, Qualis A1, cinco não são específicos da área. A Acta Cirúrgica Brasileira representou 58% das publicações no estrato A2. Há alguns óbices na classificação Qualis com pouca uniformidade entre as Medicinas I, II e III. Se impõe a criação de um comitê permanente para atualização do Qualis, composto pelas três áreas da Medicina. Deve-se ponderar a utilização de outras bases de indexação e a unificação dos critérios Qualis para as revistas das áreas de medicina. Critérios de classificação dos periódicos multi e transdisciplinares precisam ser revistos. É imprescindível suporte financeiro institucional aos periódicos nacionais escolhidos pelos pares visando informatização completa e prover revisão profissional da língua inglesa, tendo como meta a elevação do fator de impacto.
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Patient safety and nursing: interface with stress and Burnout Syndrome.
Rodrigues, Cláudia Cristiane Filgueira Martins; Santos, Viviane Euzébia Pereira; Sousa, Paulo
2017-01-01
To analyze studies on stress, Burnout Syndrome, and patient safety in the scope of nursing care in the hospital environment. This was an integrative literature review. Data collection was performed in February 2016 in the following databases: Medical Literature Analysis and Retrieval System Online - PubMed/MEDLINE, Latin American and Caribbean Literature in Health Sciences - LILACS. Ten scientific productions were selected, which listed that factors contributing to stress and Burnout Syndrome of nursing professionals are the work environment as a source of stress, and excessive workload as a source of failures. The analysis found that the stress and Burnout Syndrome experienced by these professionals lead to greater vulnerability and development of unsafe care, and factors such as lack of organizational support can contribute to prevent these failures. Analisar estudos que versam sobre o estresse e Síndrome de Burnout, bem como a segurança do paciente no âmbito da assistência de enfermagem no ambiente hospitalar. Tratou-se de uma revisão integrativa de literatura. O levantamento dos dados foi efetuado nas bases de dados Medical Literature Analysis and Retrieval System Online - PubMed / MEDLINE, Literatura Latino-Americana e do Caribe em Ciências da Saúde -LILACS em fevereiro de 2016. Foram selecionadas10 produções científicas que apontaram que os fatores que contribuem para o estresse e a Síndrome de Burnout dos profissionais de enfermagem são o ambiente de trabalho como fonte de estresse e a carga de trabalho excessiva como geradora de falhas. A análise apontou que o estresse e a Síndrome de Burnout vivenciada por esses profissionais acarretam maior vulnerabilidade ao desenvolvimento de uma assistência insegura e que fatores como a falta de apoio organizacional podem contribuir para dirimir essas falhas.
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Bravo-Oro, Antonio; Abud-Mendoza, Carlos; Quezada-Corona, Arturo; Dalmau, Josep; Campos-Guevara, Verónica
2016-01-01
Introducción La encefalitis por anticuerpos contra el receptor de N-metil-D-aspartato (NMDA) es una entidad cada vez más diagnosticada en edad pediátrica. A diferencia de los adultos, en muchos casos no se asocia a tumores y las manifestaciones iniciales en niños más frecuentes son crisis convulsivas y trastornos del movimiento, mientras que en los adultos predominan las alteraciones psiquiátricas. Casos clínicos Presentamos seis casos pediátricos confirmados con anticuerpos contra la subunidad NR1 del receptor de NMDA en suero y líquido cefalorraquídeo. Cinco de los casos comenzaron con crisis convulsivas como manifestación clínica inicial antes de desarrollar el cuadro clásico de esta entidad. En todos los casos se utilizaron esteroides como primera línea de tratamiento, con los que sólo se observó control de las manifestaciones en uno, por lo que el resto de los pacientes requirió inmunomoduladores de segunda línea. Todos los pacientes recibieron metotrexato como tratamiento inmunomodulador para evitar recaídas y la evolución fue a la mejoría en todos ellos. Conclusiones En nuestra serie de pacientes con encefalitis por anticuerpos contra el receptor de NMDA, ninguno se asoció a tumores. Todos los casos recibieron metotrexato por lo menos durante un año, no observamos eventos adversos clínicos ni por laboratorio, ni hubo secuelas neurológicas ni recaídas durante el tratamiento. Aunque es una serie pequeña y es deseable incrementar el número y tiempo de evolución, consideramos el metotrexato una excelente alternativa como tratamiento inmunomodulador para esta patología. PMID:24150952
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NASA Astrophysics Data System (ADS)
Balan, Catalin
Na ultima decada, foram feitos grandes progressos no desenvolvimento dos detetores de detecao direta das particulas que constituem a materia negra. Com estrategias do aumento gradual do volume do alvo e, simultaneamente, de reducao dos niveis de fundo, a experiencia XENON obteve resultados muito bons e perspetivas promissoras para a detecao de materia negra. Tarefas relativas a analise de dados experimentais adquiridos com o detetor de dupla fase em uso, assim como as simulacoes do campo eletrico, desenvolvimento, montagem e testes para o proximo detetor XENON1T, assim como a participacao regular na manutencao geral e monitorizacao do prototipo atual XENON100 no LNGS, constituiram o plano de trabalhos para as atividades de investigacao do presente doutoramento e a minha contribuicao para a otimizacao da detecao de cintilacao nos detetores da experiencia XENON. A necessidade de alcancar niveis elevados de sensibilidade, requer inovacao em todos os aspetos fisicos do detetor, assim como a reducao de todas as fontes de radioatividade que contribuem para o fundo. O modo mais indicado de operacao para os detetores com enchimento a Xe no estado liquido e gasoso envolve a medicao da cintilacao primaria e da secundaria provenientes da interacao das particulas no Xe liquido. A razao entre estes dois sinais permite diferenciar claramente a maior parte dos eventos correspondentes as fundo dos eventos correspondentes a WIMPs. Deste modo, a leitura dos sinais correspondentes a cintilacao e de extrema importancia. A amplitude do sinal de cintilacao antes dos fotossensores e maximizada atraves da otimizacao de varios parametros, tais como a geometria do alvo do detetor, a transparencia das grelhas dos eletrodos, a uniformidade do ganho em cintilacao secundaria e a utilizacao de material reflectivo para cobrir as superficies que nao sao fotossensiveis.
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Arístegui, Inés; Dorigo, Analía; Bofill, Lina; Bordatto, Alejandra; Lucas, Mar; Cabanillas, Graciela Fernández; Sued, Omar; Cahn, Pedro; Cassetti, Isabel; Weiss, Stephen; Jones., Deborah
2016-01-01
Resumen Introducción el Programa Nacional de Sida garantiza el acceso universal a los antirretrovirales, aun así las personas que reciben medicamentos a través del sistema público no logran obtener una carga viral indetectable en la misma proporción que los pacientes del sistema privado. Este estudio cualitativo tiene como objeto identificar los factores asociados a la adherencia y retención en la cascada de atención de VIH de los sistemas de salud público y privado de Buenos Aires, según las percepciones de pacientes y del personal de salud. Métodos se registraron datos cualitativos de 12 entrevistas semi-estructuradas a informantes clave y 4 grupos focales de pacientes y personal de salud tanto del sistema público como privado. Se codificaron y analizaron temas predeterminados sobre adherencia, utilizando el software QRS Nvivo9® de análisis de datos cualitativos. Resultados pacientes y personal de salud de ambos sistemas coinciden en la importancia del estigma asociado al VIH, la relación médicopaciente, la comunicación entre ambos y la división de responsabilidades en relación al tratamiento como aspectos fundamentales para la adherencia y retención en la cascada de atención. Se observan diferencias entre los sistemas en la forma en que algunos de estos aspectos actúan. Las barreras estructurales se presentan como principales obstáculos del sistema público. Discusión se resalta la necesidad de intervenciones focalizadas en la díada médico-paciente que considere las particularidades de cada sistema de atención para facilitar el compromiso del paciente en la adherencia. PMID:26878024
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Jiménez-Castro, Lorena; Raventós-Vorst, Henriette; Escamilla, Michael
2012-01-01
El interés por comprender la co-morbilidad de la esquizofrenia y el trastorno en el uso de sustancias, ha aumentado debido al incremento de este diagnóstico, a los efectos negativos observados en el sujeto y a los costos en los servicios de salud. Este trastorno dual puede tener efectos dramáticos en el curso clínico del trastorno psicótico tales como: mayores recaídas, re-hospitalizaciones, síntomas más severos, no adherencia al tratamiento antipsicótico, cambios marcados del humor, aumento en el grado de hostilidad e ideación suicida, así como alteraciones en otras áreas del funcionamiento incluyendo violencia, victimización, indigencia y problemas legales. La literatura proveniente en particular de Estados Unidos y Europa sugiere que el rango de prevalencia para este diagnóstico puede oscilar entre el 10% hasta el 70%. En este estudio, revisamos la prevalencia del diagnóstico dual de esquizofrenia y trastorno en el uso sustancias, así como sus características sociodemográficas, con base en la literatura disponible alrededor del mundo dando énfasis en la poblacion latina. A pesar de que este diagnóstico es ampliamente aceptado, se conoce poco sobre su prevalencia en la población latina, sobre los factores ambientales, demográficos, clínicos y otras características de estos individuos. Un mejor conocimiento sobre este diagnóstico permitiría mejorar los métodos para la detección y adecuada valoración del trastorno en el uso de sustancias en personas con trastornos metales severos como la esquizofrenia. PMID:21404151
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The Douro estuarine plume: Detection, processes and dynamics =
NASA Astrophysics Data System (ADS)
Mendes, Renato Paulo dos Santos
O Douro e um dos maiores rios da Peninsula Iberica, constituindo a maior descarga de agua doce para o Oceano Atlântico na costa noroeste portuguesa. A sua pluma estuarina tem particular relevância na dinâmica costeira e na modulacao de fenomenos biogeoquimicos. Sao objetivos desta dissertacao contribuir para a compreensao dos processos fisicos associados a geracao e propagacao da pluma estuarina do Rio Douro no oceano, assim como para o conhecimento dos seus padroes de dispersao e da forma como estes alteram a hidrologia e a circulacao costeira, considerando os agentes forcadores tipicos deste fenomeno (caudal fluvial, vento e mare) e indices climaticos relevantes. Para concretizacao destes objetivos foram desenvolvidas e aplicadas metodologias inovadoras de processamento de dados de detecao remota, assim como novas implementacoes estuarinas e costeiras de modelos numericos. Atraves de imagens MODIS, otimizadas para o estudo de fenomenos costeiros, efetuou-se uma detecao rigorosa da pluma. Identificou-se uma relacao entre o sinal turbido nLw555 e o caudal, demonstrando-se este produto como um bom proxy para a observacao da pluma no oceano. As escalas temporais e espaciais da pluma foram caraterizadas atraves destas imagens, combinadas com dados de caudal fluvial, mare, vento e precipitacao, e tambem com indices climaticos relevantes. Para compreender a propagacao da pluma e caracterizar a sua dinâmica e impacto na circulacao costeira, foi desenvolvida uma aplicacao 3D de modelos estuarinos e costeiros com malhas aninhadas de resolucao variavel. Definiramse e analisaram-se diferentes cenarios de vento e descarga fluvial. A interacao da pluma do Rio Douro e do Minho foi ainda analisada atraves dos resultados de simulacoes baseadas num evento de inverno. Os compositos turbidos mostraram que a pluma e facilmente detetada quando o caudal e maior que 500 m3 s??1. A descarga fluvial e o vento sao os principais forcadores da sua propagacao, enquanto a mare e apenas
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Perspectivas Futuras para o Observatório do Pico dos Dias
NASA Astrophysics Data System (ADS)
Bruch, Albert
2004-02-01
Com o Observatório Gemini plenamente operacional e o telescópio SOAR iniciando suas operações em breve, a astronomia observacional brasileira encontra-se no auge de uma transformação profunda que terá um impacto grave no Observatório do Pico dos Dias - OPD. Refletimos aqui sobre a natureza desse impacto e estratégias para manter a competitividade do OPD. Não queremos apresentar receitas prontas, mas idéias que poderão servir como base de discussão sobre o uso inteligente dos telescópios do OPD como parte do conjunto de instrumentos disponíveis à comunidade astronômica brasileira.
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Conceptos Basicos Sobre el Gas Natural (in Spanish)
DOE Office of Scientific and Technical Information (OSTI.GOV)
El gas natural abastece cerca de 150.000 vehiculos en los Estados Unidos y aproximadamente 22 millones de vehiculos en todo el mundo. Los vehiculos de gas natural (NGV, por sus siglas en ingles) son una buena opcion para las flotas de vehiculos de alto kilometraje, tales como autobuses, taxis, vehiculos de recoleccion de basura, los cuales son alimentados centralmente u operan dentro de un area limitada o a lo largo de una ruta con estaciones de servicio de gas natural. Las ventajas del gas natural como combustible alternativo incluyen su disponibilidad interna, la red de distribucion establecida, un costo relativamentemore » bajo, y los beneficios de las emisiones.« less
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Measurement and evaluation of national family planning programs.
Mauldin, W P
1967-03-01
presentadas en formularios estandarizados, en las siguienies formas: 1. Informes nensuales por áreas administrativas, sobre los actuales servicios de planeamiento familiar proporcionados en la actualidad, de carácter permanente o de larga duración (al presente, esterilización y IUD de acuerdo a las siguientes características del receptor: residencia, edad, paridad (número de hijos vivos por sexo), y donde se enteró del programa, si es posible "clase";(probablemente educación de la madre, pero posiblemente ocupación del esposo, ingreso, o equivalente); prácticas anticonceptivas anteriores; intervalo; y deseo de tener más hijos. En un programa grande estos datos pueden obtenerse en base a una muestra. 2. Informes mensuales sobre la distribución de suministros anticonceptivos (condones, píldoras, sustancias efervescentes, etc.), los primeros suministros deben ir acompañados de un registro de las características del recipiente, como anteriormente; los suministros subsecuentes se regietrarán sólo en volumen bruto. Esto también se aplicará al ritmo, donde éste método se enseñe a un número considerable de mujeres. 3. Informes regulares sobre las actividades de planeamiento familiar de médicos privados, como una estimación del efecto catalítico del programa del gobierno sobre ci sector privado. 4. Datos generates mensuales, ppr áreas admirtistrativas importantes, sabre: visitas domiciliarias, reuniones, cuñas radiates y televisadas, avisos en los periódicos y personal que trabaja. 5. Para propósitos de seguimiento una entrevi eta de campo cada 6 a 12 meses a cada N mujer de las listas para (1) y (2) arriba, en un total de 300 o 400, para conocer las tasas de continuación y las razones de abandono (ej: desea otro hijo, insatisfecha can ci método, otras). Las mue.stras podrían ser de 300 cada una, con una supuesta experiencia de 6, 12, 18 y 24 meses. B. Un buen conjunto de datos sobre costa (datos sobre cotos actulaes atribuíbles directamente al
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Lana, Francisco C. F.; Malvárez, Silvina
2012-01-01
Resumen La BVS Enfermeria constituye un nuevo paradigma en enfermería una vez que o modelo representa una expansión de la cooperación técnica y ha como objetivos centrales promover la ampliación del acceso la información sobre enfermería la través del acceso universal equitativo y construir un patrimonio informacional en enfermería, ayudando la mejorar la formación y práctica de enfermería a actuar con compromiso ético-social en el área de educación, investigación y atención a la salud. Como resultado del proceso de sensibilización, verifica-se la construcción de Bibliotecas Virtuales de Enfermería en varios países (Brasil, Argentina, Bolívia y Uruguay). La expectativa es que las BVS’s nacionais convergen a un gran portal que se está construyendo en una colaboración con BIREME/OPS/OMS, de la Asesoría Regional de Enfermería de la OPS-Washington y de Ministerio de Salud del Brasil, así como instituciones líderes en la producción del conocimiento en enfermería Iberoamérica. PMID:24199093
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Neurobiología de la impulsividad y los trastornos de la conducta alimentaria*
Orozco-Cabal, Luis Felipe; Herin, David
2009-01-01
Resumen Introducción La impulsividad es un rasgo de personalidad multidimensional relacionado con el control del comportamiento y las emociones. Está presente de manera diversa en los trastornos de la conducta alimentaria, particularmente, en la bulimia nerviosa (BN). Aunque la relación entre la impulsividad y BN ha sido objeto de numerosas investigaciones, en la actualidad se desconocen los sustratos neurobiológicos de esta relación. Objetivos Discutir críticamente la evidencia que sugiere que las alteraciones en los sistemas neuronales relacio-nados con las funciones ejecutivas, con la formación de preferencias y con la regulación de los estados emocionales sirven como base para el rasgo de personalidad impulsiva, así como su estado en subgrupos de pacientes con BN. Métodos Búsqueda selectiva de la literatura relevante. Resultados y conclusiones Esta discusión ilustra la complejidad de la relación entre la impulsividad y BN, donde la impulsividad actúa como un factor de vulnerabilidad que puede sensibilizar al sujeto con BN a estados emocionales negativos, durante los cuales modifica el impacto de estímulos internos y externos sobre el comportamiento y su regulación, favoreciendo así patrones de comportamiento maladaptativos e inflexibles. PMID:19838321
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Torres Díaz, Cristina V; Martín Peña, Gonzalo; Ezquiaga, Elena; Navas García, Marta; García de Sola, Rafael
2016-07-19
Gracias a los avances técnicos en técnicas neuroquirúrgicas, y debido a que el diagnóstico y la clasificación de las enfermedades psiquiátricas han evolucionado significativamente a lo largo de las últimas décadas, se están desarrollando tratamientos a nivel experimental para aquellos pacientes resistentes al manejo conservador.La anorexia nerviosa es una enfermedad de prevalencia creciente, con la tasa de mortalidad más elevada dentro de los trastornos psiquiátricos, y con aproximadamente un 20% de pacientes que presentan una evolución tórpida. Para estos pacientes que no responden a manejo conservador, la estimulación cerebral profunda ha surgido como una alternativa terapéutica, si bien la literatura especializada al respecto es escasa.A continuación presentamos una revisión de la fisiopatología de la anorexia nerviosa, así como de los distintos tratamientos neuroquirúrgicos realizados a lo largo de la historia. Se detalla la perspectiva de tratamiento quirúrgico actual, así como los aspectos éticos que se han de considerar en relación con el surgimiento de estas nuevas terapias.
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Omachi, Theodore A; Gregorich, Steven E; Eisner, Mark D; Penaloza, Renee A; Tolstykh, Irina V; Yelin, Edward H; Iribarren, Carlos; Dudley, R Adams; Blanc, Paul D
2013-08-01
Adjustment for differing risks among patients is usually incorporated into newer payment approaches, and current risk models rely on age, sex, and diagnosis codes. It is unknown the extent to which controlling additionally for disease severity improves cost prediction. Failure to adjust for within-disease variation may create incentives to avoid sicker patients. We address this issue among patients with chronic obstructive pulmonary disease (COPD). Cost and clinical data were collected prospectively from 1202 COPD patients at Kaiser Permanente. Baseline analysis included age, sex, and diagnosis codes (using the Diagnostic Cost Group Relative Risk Score) in a general linear model predicting total medical costs in the following year. We determined whether adding COPD severity measures-forced expiratory volume in 1 second, 6-Minute Walk Test, dyspnea score, body mass index, and BODE Index (composite of the other 4 measures)-improved predictions. Separately, we examined household income as a cost predictor. Mean costs were $12,334/y. Controlling for Relative Risk Score, each ½ SD worsening in COPD severity factor was associated with $629 to $1135 in increased annual costs (all P<0.01). The lowest stratum of forced expiratory volume in 1 second (<30% normal) predicted $4098 (95% confidence interval, $576-$8773) additional costs. Household income predicted excess costs when added to the baseline model (P=0.038), but this became nonsignificant when also incorporating the BODE Index. Disease severity measures explain significant cost variations beyond current risk models, and adding them to such models appears important to fairly compensate organizations that accept responsibility for sicker COPD patients. Appropriately controlling for disease severity also accounts for costs otherwise associated with lower socioeconomic status.
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Longitudinal Study of New and Prevalent Use of Self-Monitoring of Blood Glucose
Karter, Andrew J.; Parker, Melissa M.; Moffet, Howard H.; Spence, Michele M.; Chan, James; Ettner, Susan L.; Selby, Joe V.
2008-01-01
OBJECTIVE We sought to assess longitudinal association between self-monitoring of blood glucose (SMBG) and glycemic control in diabetic patients from an integrated health plan (Kaiser Permanente Northern California). RESEARCH DESIGN AND METHODS Longitudinal analyses of glycemic control among 1) 16,091 patients initiating SMBG (new-user cohort) and 2) 15,347 ongoing users of SMBG (prevalent-user cohort). SMBG frequency was based on pharmacy use (number of blood glucose test strips dispensed), and glycemic control was based on HbA1c (A1C). In the new-user cohort, ANCOVA models (pre- and posttest design) were used to assess the effect of initiating SMBG. In the prevalent-user cohort, repeated-measure, mixed-effects models with random-intercept and time-dependent covariates were used to assess changes in SMBG and A1C. All models were stratified by therapy (no medications, oral agents only, or insulin) and adjusted for baseline A1C, sociodemographics, insulin injection frequency, comorbidity index, medication adherence, smoking status, health care use, and provider specialty. RESULTS Greater SMBG practice frequency among new users was associated with a graded decrease in A1C (relative to nonusers) regardless of diabetes therapy (P < 0.0001). Changes in SMBG frequency among prevalent users were associated with an inverse graded change in A1C only among pharmacologically treated patients (P < 0.0001). CONCLUSIONS These observational findings are consistent with short-term benefits of initiating SMBG practice for all patients but continuing benefits only for pharmacologically treated patients. Differences in effectiveness between new versus prevalent users of SMBG have implications for guideline development and interpretation of observational outcomes data. PMID:16873776
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Chiu, Vicki; Mueller, Lisa A.; Cooper, Robert
2013-01-01
Purpose To determine the feasibility of conducting survivorship research for long-term health outcomes with survivors of cancer diagnosed as an adolescent or young adult (AYA) and enrolled in Kaiser Permanente Southern California (KPSC), an integrated managed care organization. Methods Survivors diagnosed at ages 15–39 during 1990 and 2000 at KPSC were included. A 1:5 age-, gender-, and calendar-year-matched non-cancer KPSC comparison group was also identified. Date of cancer diagnosis was defined as the study baseline. KPSC insurance retention rate was calculated at 5 and 10 years post-baseline among survivors. Multivariable logistic regression was used to examine demographic and cancer characteristics associated with KPSC insurance retention at ≥5 years after baseline. Results A total of 6170 AYA cancer patients were identified: 4745 (77%) and 4471 (72%) survived at 5 and 10 years after diagnosis respectively. Of these survivors, 3654 (77%) and 2817 (63%) remained insured at KPSC at 5 and 10 years post-cancer diagnosis respectively. Those aged 20–29 years when diagnosed and those with stage 4 cancer were less likely to retain KPSC insurance than other survivors. For non-cancer comparison subjects, the KPSC insurance retention rate was lower: 66% at 5 years and 51% at 10 years post-baseline. Younger age, female gender, white race, and later calendar years of study baseline were associated with a lower likelihood of KPSC insurance retention. Conclusion These results demonstrate the feasibility and potential limitations of conducting survivorship research to characterize long-term health outcomes for survivors of AYA cancer in a large, integrated managed care organization. PMID:23781402
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Correlates of Quality of Life in Older Adults With Diabetes
Laiteerapong, Neda; Karter, Andrew J.; Liu, Jennifer Y.; Moffet, Howard H.; Sudore, Rebecca; Schillinger, Dean; John, Priya M.; Huang, Elbert S.
2011-01-01
OBJECTIVE To evaluate associations between health-related quality of life (HRQL) and geriatric syndromes, diabetes complications, and hypoglycemia in older adults with diabetes. RESEARCH DESIGN AND METHODS A race-stratified random sample of 6,317 adults with type 2 or type 1 diabetes, aged 60 to 75 years, enrolled in Kaiser Permanente Northern California, who completed a survey that included a HRQL instrument based on the Short Form 8-item health survey. Administrative records were used to ascertain diagnoses of geriatric syndromes, diabetes complications, and hypoglycemia. Associations were estimated between HRQL and exposures in exposure-specific and combined exposure models (any syndrome, any complication, or hypoglycemia). Conservatively, differences of ≥3 points were considered the minimally important difference in HRQL scores. RESULTS HRQL was lower with nearly all exposures of interest. The lowest physical HRQL was associated with amputation. In combined exposure models, geriatric syndromes (−5.3 [95% CI −5.8 to −4.8], P < 0.001) and diabetes complications (−3.5 [−4.0 to −2.9], P < 0.001) were associated with lower physical HRQL. The lowest mental HRQL was associated with depression, underweight (BMI <18 kg/m2), amputation, and hypoglycemia. In combined exposure models, only hypoglycemia was associated with lower mental HRQL (−4.0 [−7.0 to −1.1], P = 0.008). CONCLUSIONS Geriatric syndromes and hypoglycemia are associated with lower HRQL to a comparable degree as diabetes complications. Addressing geriatric syndromes and avoiding hypoglycemia should be given as high a priority as preventing diabetes complications in older adults with diabetes. PMID:21636795
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Dohrenwend, Paul B; Le, Minh V; Bush, Jeff A; Thomas, Cyril F
2013-03-01
In 2007 wildfires ravaged Southern California resulting in the largest evacuation due to a wildfire in American history. We report how these wildfires affected emergency department (ED) visits for respiratory illness. We extracted data from a Kaiser Permanente database for a single metropolitan community ED. We compared the number of visits due to respiratory illness at time intervals of 2 weeks before and during the time when the fires were burning. We counted the total number of patients with chief complaint of dyspnea, cough, and asthma and final international classification of disease 9 coding diagnosis of asthma, bronchitis, chronic obstructive pulmonary disease and respiratory syndrome, and analyzed data for both total number and proportion of ED visits. We evaluated the data using Early Aberration Reporting System software to determine significant single-visit increases compared to expected counts. We also analyzed the average length of ED stay. Data on air quality were extracted from the http://www.airnow.gov site. There were significant differences between pre-fire and fire period average visit counts for the chief complaints of dyspnea and asthma. Dypnea complaints increased by 3.2 visits per day. During the fire the diagnoses of asthma increased significantly by 2.6 patients per day. Air quality reached air quality index values of 300, indicating very unhealthy conditions. Average ED length of stay times remained unchanged during the fire period compared to the pre-fire period. The 2007 Southern California wildfires caused significant surges in the volume of ED patients seeking treatment for respiratory illness. Disaster plans should prepare for these surges when future wildfires occur.
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Dohrenwend, Paul B.; Le, Minh V.; Bush, Jeff A.; Thomas, Cyril F.
2013-01-01
Introduction: In 2007 wildfires ravaged Southern California resulting in the largest evacuation due to a wildfire in American history. We report how these wildfires affected emergency department (ED) visits for respiratory illness. Methods: We extracted data from a Kaiser Permanente database for a single metropolitan community ED. We compared the number of visits due to respiratory illness at time intervals of 2 weeks before and during the time when the fires were burning. We counted the total number of patients with chief complaint of dyspnea, cough, and asthma and final international classification of disease 9 coding diagnosis of asthma, bronchitis, chronic obstructive pulmonary disease and respiratory syndrome, and analyzed data for both total number and proportion of ED visits. We evaluated the data using Early Aberration Reporting System software to determine significant single-visit increases compared to expected counts. We also analyzed the average length of ED stay. Data on air quality were extracted from the http://www.airnow.gov site. Results: There were significant differences between pre-fire and fire period average visit counts for the chief complaints of dyspnea and asthma. Dypnea complaints increased by 3.2 visits per day. During the fire the diagnoses of asthma increased significantly by 2.6 patients per day. Air quality reached air quality index values of 300, indicating very unhealthy conditions. Average ED length of stay times remained unchanged during the fire period compared to the pre-fire period. Conclusion: The 2007 Southern California wildfires caused significant surges in the volume of ED patients seeking treatment for respiratory illness. Disaster plans should prepare for these surges when future wildfires occur. PMID:23599837
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Scarborough, Ashley P; Slome, Sally; Hurley, Leo B; Park, Ina U
2015-10-01
Screening for gonorrhea (GC) and chlamydia (CT) and syphilis among HIV-positive (HIV+) men who have sex with men (MSM) is recommended at least annually. However, significant gaps in screening coverage exist. We conducted a quality improvement intervention to determine whether informing providers of preintervention screening rates and routinizing sexual risk assessment would improve sexually transmitted disease (STD) screening in a large HIV care clinic. In partnership with Kaiser Permanente Northern California, we developed and implemented a 10-item assessment addressing sexual and other behavioral risk factors among HIV+ MSM. We analyzed the proportion of patients screened for GC/CT and syphilis in a preintervention period (June 25-September 26, 2012) and during the intervention period (June 25-September 26, 2013). Of 364 HIV+ MSM seen for care during the intervention period, 47.3% completed the sexual risk assessment. Improvements in GC/CT screening and syphilis screening were observed; when comparing the preintervention period with the intervention period, the proportion of HIV+ MSM receiving GC/CT screening increased by 26.8% (31.6%-40.1%, P = 0.01) at any anatomical site and by 45% (19.5%-28.3%, P = 0.003) at the pharyngeal site. Syphilis screening significantly increased by 18.8% (48.7%-58.0%, P = 0.009). Overall STD screening increases were observed after this intervention that included didactic training on the urgency of STD screening needs for HIV+ MSM, a presentation of preintervention clinic STD screening data, and the implementation of self-reported sexual risk assessment. Additional efforts are needed to determine feasible ways to accurately assess the appropriateness of STD screening and success of interventions to improve STD screening.
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Ratchford, Andria M; Hamman, Richard F; Regensteiner, Judith G; Magid, David J; Gallagher, Stacy Brennan; Merenich, John A
2004-01-01
Poor rates of participation in cardiac rehabilitation programs are well documented, especially among women and older patients. The Colorado Kaiser Permanente Cardiac Rehabilitation (KPCR) program is a home-based, case-managed, goal-oriented program with an active recruitment process and unlimited program length. This study evaluated the participation rates for the program and the predictors of attendance and graduation. Patients hospitalized with acute myocardial infarction, coronary artery bypass graft, and percutaneous coronary intervention from June 1999 to May 2000 (n = 1030) were identified from the administrative database, and the proportion captured by the KPCR staff was determined. Subsequent attendance and graduation patterns were evaluated. Nearly 94% of patients with one of the three aforementioned conditions were identified by the rehabilitation staff, and 41% of all patients attended the KPCR program. More than 75% of the patients who participated went on to graduate from the program. Gender comparisons showed no difference in participation between men (66.8%) and women (59.7%) (P =.07). Participation rates were inversely associated with age, yet age was not associated with graduation from the program. Surgical interventions and two or more events experienced within the first 4 weeks of the index event were the strongest predictors of attendance and graduation from the KPCR program. Innovative approaches for the capture and retention of patients in cardiac rehabilitation programs are urgently needed. The alternative program evaluated in this study showed little difference in participation between men and women, yet participation among older patients remained poor. Overall, patients who underwent surgical interventions or multiple events were more likely to attend and graduate from the program.
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Dietary guideline adherence for gastroesophageal reflux disease
2014-01-01
Background Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disease, and the cost of health care and lost productivity due to GERD is extremely high. Recently described side effects of long-term acid suppression have increased the interest in nonpharmacologic methods for alleviating GERD symptoms. We aimed to examine whether GERD patients follow recommended dietary guidelines, and if adherence is associated with the severity and frequency of reflux symptoms. Methods We conducted a population-based cross-sectional study within the Kaiser Permanente Northern California population, comparing 317 GERD patients to 182 asymptomatic population controls. All analyses adjusted for smoking and education. Results GERD patients, even those with moderate to severe symptoms or frequent symptoms, were as likely to consume tomato products and large portion meals as GERD-free controls and were even more likely to consume soft drinks and tea [odds ratio (OR) = 2.01 95% confidence interval (CI) 1.12-3.61; OR = 2.63 95% CI 1.24-5.59, respectively] and eat fried foods and high fat diet. The only reflux-triggering foods GERD patients were less likely to consume were citrus and alcohol [OR = 0.59; 95% CI: 0.35-0.97 for citrus; OR = 0.41 95% CI 0.19-0.87 for 1 + drink/day of alcohol]. The associations were similar when we excluded users of proton pump inhibitors. Conclusions GERD patients consume many putative GERD causing foods as frequently or even more frequently than asymptomatic patients despite reporting symptoms. These findings suggest that, if dietary modification is effective in reducing GERD, substantial opportunities for nonpharmacologic interventions exist for many GERD patients. PMID:25125219
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PRESCRIPTION LONG-TERM OPIOID USE IN HIV-INFECTED PATIENTS
Silverberg, Michael J.; Ray, G. Thomas; Saunders, Kathleen; Rutter, Carolyn M.; Campbell, Cynthia I.; Merrill, Joseph O.; Sullivan, Mark D.; Banta-Green, Caleb; Von Korff, Michael; Weisner, Constance
2011-01-01
Objectives To examine changes in use of prescription opioids for the management of chronic non-cancer pain in HIV-infected patients and to identify patient characteristics associated with long-term use. Methods Long-term prescription opioid use (i.e. 120+ days supply or 10+ prescriptions during a year) was assessed between 1997 and 2005 among 6,939 HIV-infected Kaiser Permanente members and HIV-uninfected persons in the general health plan memberships. Results In 2005, 8% of HIV+ individuals had prevalent long-term opioid use, more than double the prevalence among HIV-uninfected individuals. However, the large increases in use from 1997 to 2005 in the general population were not observed for HIV-infected individuals. The strongest associations with prevalent use among HIV-infected individuals were female gender with a prevalence ratio [PR] of 1.8 (95% CI=1.3, 2.5); Charlson comorbidity score of 2 or more (compared with a score of 0) with a PR of 1.9 (95% CI=1.4, 2.8); injection drug use history with a PR of 1.8 (95% CI=1.3, 2.6); substance use disorders with a PR of 1.8 (95% CI=1.3, 2.5). CD4, HIV RNA, and AIDS diagnoses were associated with prevalent opioid use early in the antiretroviral therapy era (1997), but not in 2005. Conclusions Long-term opioid use for chronic pain has remained stable over time for HIV patients, while use increased in the general population. The prevalence of prescribed opioids in HIV patients was highest for certain subgroups, including women, and those with a comorbidity and substance abuse history. PMID:21677568
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Zhang, Y Tara; Mujahid, Mahasin S; Laraia, Barbara A; Warton, E Margaret; Blanchard, Samuel D; Moffet, Howard H; Downing, Janelle; Karter, Andrew J
2017-06-15
We estimated associations between neighborhood supermarket gain or loss and glycemic control (assessed by glycated hemoglobin (HbA1c) values) in patients from the Kaiser Permanente Northern California Diabetes Registry (n = 434,806 person-years; 2007-2010). Annual clinical measures were linked to metrics from a geographic information system for each patient's address of longest residence. We estimated the association between change in supermarket presence (gain, loss, or no change) and change in HbA1c value, adjusting for individual- and area-level attributes and according to baseline glycemic control (near normal, <6.5%; good, 6.5%-7.9%; moderate, 8.0%-8.9%; and poor, ≥9.0%). Supermarket loss was associated with worse HbA1c trajectories for those with good, moderate, and poor glycemic control at baseline, while supermarket gain was associated with marginally better HbA1c outcomes only among patients with near normal HbA1c values at baseline. Patients with the poorest baseline HbA1c values (≥9.0%) had the worst associated changes in glycemic control following either supermarket loss or gain. Differences were not clinically meaningful relative to no change in supermarket presence. For patients with type 2 diabetes mellitus, gaining neighborhood supermarket presence did not benefit glycemic control in a substantive way. The significance of supermarket changes on health depends on a complex interaction of resident, neighborhood, and store characteristics. © The Author 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Geographic clusters in underimmunization and vaccine refusal.
Lieu, Tracy A; Ray, G Thomas; Klein, Nicola P; Chung, Cindy; Kulldorff, Martin
2015-02-01
Parental refusal and delay of childhood vaccines has increased in recent years and is believed to cluster in some communities. Such clusters could pose public health risks and barriers to achieving immunization quality benchmarks. Our aims were to (1) describe geographic clusters of underimmunization and vaccine refusal, (2) compare clusters of underimmunization with different vaccines, and (3) evaluate whether vaccine refusal clusters may pose barriers to achieving high immunization rates. We analyzed electronic health records among children born between 2000 and 2011 with membership in Kaiser Permanente Northern California. The study population included 154,424 children in 13 counties with continuous membership from birth to 36 months of age. We used spatial scan statistics to identify clusters of underimmunization (having missed 1 or more vaccines by 36 months of age) and vaccine refusal (based on International Classification of Diseases, Ninth Revision, Clinical Modification codes). We identified 5 statistically significant clusters of underimmunization among children who turned 36 months old during 2010-2012. The underimmunization rate within clusters ranged from 18% to 23%, and the rate outside them was 11%. Children in the most statistically significant cluster had 1.58 (P < .001) times the rate of underimmunization as others. Underimmunization with measles, mumps, rubella vaccine and varicella vaccines clustered in similar geographic areas. Vaccine refusal also clustered, with rates of 5.5% to 13.5% within clusters, compared with 2.6% outside them. Underimmunization and vaccine refusal cluster geographically. Spatial scan statistics may be a useful tool to identify locations with challenges to achieving high immunization rates, which deserve focused intervention. Copyright © 2015 by the American Academy of Pediatrics.
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Assessment of algorithms to identify patients with thrombophilia following venous thromboembolism.
Delate, Thomas; Hsiao, Wendy; Kim, Benjamin; Witt, Daniel M; Meyer, Melissa R; Go, Alan S; Fang, Margaret C
2016-01-01
Routine testing for thrombophilia following venous thromboembolism (VTE) is controversial. The use of large datasets to study the clinical impact of thrombophilia testing on patterns of care and patient outcomes may enable more efficient analysis of this practice in a wide range of settings. We set out to examine how accurately algorithms using International Classification of Diseases 9th Revision (ICD-9) codes and/or pharmacy data reflect laboratory-confirmed thrombophilia diagnoses. A random sample of adult Kaiser Permanente Colorado patients diagnosed with unprovoked VTE between 1/2004 and 12/2010 underwent medical record abstraction of thrombophilia test results. Algorithms using "ICD-9" (positive if a thrombophilia ICD-9 code was present), "Extended anticoagulation (AC)" (positive if AC therapy duration was >6 months), and "ICD-9 & Extended AC" (positive for both) criteria to identify possible thrombophilia cases were tested. Using positive thrombophilia laboratory results as the gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value of each algorithm were calculated, along with 95% confidence intervals (CIs). In our cohort of 636 patients, sensitivities were low (<50%) for each algorithm. "ICD-9" yielded the highest PPV (41.5%, 95% CI 26.3-57.9%) and a high specificity (95.9%, 95% CI 94.0-97.4%). "Extended AC" had the highest sensitivity but lowest specificity, and "ICD-9 & Extended AC" had the highest specificity but lowest sensitivity. ICD-9 codes for thrombophilia are highly specific for laboratory-confirmed cases, but all algorithms had low sensitivities. Further development of methods to identify thrombophilia patients in large datasets is warranted. Copyright © 2015 Elsevier Ltd. All rights reserved.
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Greene, Sharon K; Kulldorff, Martin; Huang, Jie; Brand, Richard J; Kleinman, Kenneth P; Hsu, John; Platt, Richard
2011-02-28
Timely detection of clusters of localized influenza activity in excess of background seasonal levels could improve situational awareness for public health officials and health systems. However, no single data type may capture influenza activity with optimal sensitivity, specificity, and timeliness, and it is unknown which data types could be most useful for surveillance. We compared the performance of 10 types of electronic clinical data for timely detection of influenza clusters throughout the 2007/08 influenza season in northern California. Kaiser Permanente Northern California generated zip code-specific daily episode counts for: influenza-like illness (ILI) diagnoses in ambulatory care (AC) and emergency departments (ED), both with and without regard to fever; hospital admissions and discharges for pneumonia and influenza; antiviral drugs dispensed (Rx); influenza laboratory tests ordered (Tests); and tests positive for influenza type A (FluA) and type B (FluB). Four credible events of localized excess illness were identified. Prospective surveillance was mimicked within each data stream using a space-time permutation scan statistic, analyzing only data available as of each day, to evaluate the ability and timeliness to detect the credible events. AC without fever and Tests signaled during all four events and, along with Rx, had the most timely signals. FluA had less timely signals. ED, hospitalizations, and FluB did not signal reliably. When fever was included in the ILI definition, signals were either delayed or missed. Although limited to one health plan, location, and year, these results can inform the choice of data streams for public health surveillance of influenza. Copyright © 2010 John Wiley & Sons, Ltd.