Hawaii Permanente Medical Group

PurposeTo study the association between clinicopathologic characteristics of ductal carcinoma in situ (DCIS) and risk of subsequent invasive breast cancer (IBC).MethodsWe conducted a case–control study nested in a multicenter, population-based cohort of 8175 women aged ≥ 18 years with DCIS diagnosed between 1987 and 2016 and followed for a median duration of 83 months. Cases (n = 497) were women with a first diagnosis of DCIS who developed a subsequent IBC ≥ 6 months later; controls (2/case; n = 959) were matched to cases on age at and calendar year of DCIS diagnosis. Univariable and multivariable conditional logistic regression models were used to examine the associations between the DCIS characteristics of interest (non-screen detection of DCIS, tumor size, positive margins, grade of DCIS, necrosis, architectural pattern, microcalcification, and estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status) and risk of IBC.ResultsIn the total study population, the associations were largely null. In subgroup analyses, there were strong position associations with punctate necrosis (pre/perimenopausal women), detection by physical exam (postmenopausal women), architectural patterns other than the main types (breast-conserving surgery [BCS]), and DCIS margins (ipsilateral cases), and inverse associations with HER2 positivity (BCS) and microcalcification (mastectomy); however, the associated confidence intervals were mostly very wide.ConclusionThe results of this study provide limited support for associations of the DCIS clinicopathologic characteristics studied here and risk of IBC.

Background: Quality-of-life (OQL) is recognized as a proven benefit of atrial fibrillation (AF) ablation. The DEEP trial (NCT02393885) showed safety (6.7%) and efficacy (71.8%) of an epicardial-endocardial hybrid ablation (HA) approach with left atrial appendage exclusion (LAAE) for non-paroxysmal AF; results were consistent with two randomized trials comparing HA+LAAE to catheter ablation (CA). Limited data exist on QOL after HA+LAAE. Goal: To evaluate QOL changes from baseline to 12-months post-HA+LAAE in the DEEP trial. Methods: DEEP is a 17-site prospective, international, single arm trial. Key eligibility: adults with non-paroxysmal AF, left atrial diameter ≤5.5cm, failed class I/III anti-arrhythmic drugs, and ≤2 prior failed CA. Stage 1 was thoracoscopic radiofrequency epicardial ablation to isolate the pulmonary veins and left atrial posterior wall, and LAAE. Stage 2 was endocardial mapping and touchup ablation. QOL was measured via the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire at baseline and 12-months post-HA+LAAE. AFEQT yields scores from 0 to 100 (0 as complete disability and 100 as no disability) and includes an overall and four subscale scores. A 5-point AFEQT change is clinically important. Mean differences with 95% CIs were calculated; p-values are from paired t-tests. Results: Of 85 patients, 82 completed both baseline and 12-month AFEQT. The mean change in overall score was 30.1 ± 19.8 (95% CI: 25.8-34.5; median 29.5, min, max: -15.4, 78.2; p<0.0001) (Figure). The greatest improvement was in the Treatment Satisfaction subscale with a mean score of 53.2 ± 29.9 (95% CI: 46.6-59.7; median 58.3, min, max: 0.0, 100.0; p<0.0001), followed by Treatment Concern, Daily Activities, and Symptoms subscale scores. All mean improvements from baseline exceeded a clinically meaningful 5-point change. Conclusion: In the DEEP trial, HA+LAAE resulted in patient-reported QOL improvements at 12-months post-procedure.

229 Background: Anticipating and getting "the call" communicating a cancer diagnosis is reportedly one of the most stressful times in a person’s life. If not pre-scheduled patients are often in unfortunate locations, doing distractive activities and are with unsympathetic companions. Additionally, patients ask for a single point of contact, impactful resources, and immediate next steps and appointments scheduling. Methods: Pilot/Study: 120 breast cancer patients: Control group: 30 positive, 30 negative DX Test group: 30 positive, 30 negative DX Test approach: co-designed with 10 patients, 5 physicians and 5 staff. Interviews: 7 care team roles. Data collection: customized patient interview assessment tool. Steady State: sustaining work done. Conducted: January 2019 through December 2022. Evaluation Methods -11 tests: t-Tests, One-Way ANOVA, and Capability. Changes Made: call be at a pre-scheduled time delivered by ongoing point of contact offering immediate next steps and appointment scheduling offering meaningful support and resources delivered with deep empathy/compassion. Results: The project was highly successful based on the results it achieved. Results: Improved by 64% (original goal of 30%) the composite measure of care satisfaction of patients receiving a breast cancer diagnosis call in Kaiser Permanente Maui, Hawaii. Composite: 1) 61% improvement in “satisfaction with your circumstance”, 2) 63% improvement in “satisfaction with the conversation”, and 3) 70% improvement in “feeling supported” using a local measurement tool. Conclusions: The 64% improvement in the patients' experience for cancer diagnosis communication was accomplished by understanding the needs of the patients and care team, establishing new communication protocols and resources, and ensuring the process empowered patients. The study showed that both patients and care teams want a communication process that included the elements in the test approach. This project was deemed a Kaiser Permanente best practice and is in consideration for spread. Improved by 64% (goal was 30%) the composite measure of care satisfaction of patients receiving a breast cancer diagnosis call in Kaiser Permanente Maui, Hawaii. Breast Cancer Diagnosis Communication - Key Improvement Metrics: Control Group Test Group Outcome Measure: the composite measure improvement 64% of care satisfaction of patients receiving a DX Results Call 2.39 3.93 Composite Measure 1: 61% improvement in “satisfaction with your circumstance” 2.35 3.78 Composite Measure 2: 63% improvement in “satisfaction with the conversation” 2.50 4.07 Composite Measure 3: 70% improvement in “feeling supported” 2.33 3.95 Process Measure: the error rate over time had a statistically significant difference between the Control and Test groups 30.3 8.90 Balancing Measure: Negative result patients have a similar experience as the Positive result patients No significant difference No significant difference

Despite increased recognition that structural racism contributes to poorer health outcomes for racial and ethnic minorities, there are knowledge gaps about how current patterns of racial residential segregation are associated with cancer screening uptake. The authors examined associations between Black residential segregation and screening for colorectal cancer (CRC) and cervical cancer among non-Hispanic Black and non-Hispanic White adults. This was a retrospective study of CRC and cervical cancer screening-eligible adults from five health care systems within the Population-Based Research to Optimize the Screening Process (PROSPR II) Consortium (cohort entry, 2010-2012). Residential segregation was measured using site-specific quartiles of the Black local isolation score (LIS). The outcome was receipt of CRC or cervical cancer screening within 3 years of cohort entry (2010-2015). Logistic regression was used to calculate associations between the LIS and screening completion, adjusting for patient-level covariates. Among CRC (n=642,661) and cervical cancer (n=163,340) screening-eligible patients, 456,526 (71.0%) and 106,124 (65.0%), respectively, received screening. Across PROSPR sites, living in neighborhoods with higher LIS tended to be associated with lower odds of CRC screening (Kaiser Permanente Northern California: adjusted odds ratio [aOR] LIS trend in Black patients, 0.95 [p<.001]; aOR LIS trend in White patients, 0.98 [p<.001]; Kaiser Permanente Southern California: aOR LIS trend in Black patients, 0.98 [p=.026]; aOR LIS trend in White patients, 1.01 [p=.023]; Kaiser Permanente Washington: aOR LIS trend in White patients, 0.97 [p=.002]. However, for cervical cancer screening, associations with the LIS varied by site and race (Kaiser Permanente Washington: aOR LIS trend in White patients, 0.95 [p<.001]; Mass General Brigham: aOR LIS trend in Black patients, 1.12 [p<.001]; aOR LIS trend in White patients, 1.03 [p<.001]). Across five diverse health care systems, the direction of the association between Black residential segregation and screening varied by PROSPR site, race, and screening type. Additional research, including studies that examine multiple dimensions of segregation and structural racism using intersectional approaches, are needed to further disentangle these relationships.

Introduction: Computed tomography (CT) measurements of bone mineral attenuation may be a useful means to identify older women who should be prioritized for bone mineral density screening. Methods: We compared bone mineral attenuation as measured in the L1 vertebra of CT studies to the results of dual-energy x-ray absorptiometry (DEXA) studies to determine what CT attenuation thresholds might yield a reasonable combination of sensitivity and specificity for the detection of osteoporosis. The study was limited to women between the ages of 65 and 75 years who had a DEXA study and a CT that included the L1 or adjacent vertebra performed within 3 years of the DEXA study. Results: There were 1226 women in this study, of whom 452 (38%) had osteoporosis based on a T-score ≤ −2.5 by DEXA. There were 830 CT studies performed with contrast and 396 studies which were performed without contrast. There was a statistically significant difference in the mean HU of those studies performed without contrast compared to those with contrast (unenhanced mean 103 HU versus 125 HU, p < 0.001). Different CT attenuation thresholds provided the most appropriate combination of sensitivity and specificity for the detection of osteoporosis when comparing CT studies performed without or with IV contrast and when all the CT data were used in aggregate. Conclusion: Different thresholds appear necessary when using the mean CT vertebral attenuation to identify older women for preferential referral for DEXA studies.

Abstract Background: Racial and ethnic disparities in HCC risk have been documented, but disparities across detailed racial and ethnic groups and the relative contribution of these factors to HCC risk across those groups has not been assessed. We assembled a pooled, EHR-based cohort linked to cancer registry data to study disparities in HCC risk among detailed racial and ethnic groups and to examine the relative contribution of known and putative HCC risk factors to disparities in risk. Methods: Adults with at least one in-person encounter in 2000-2017 within three healthcare systems, San Francisco Health Network, Sutter Health Northern California, and Kaiser Permanente Hawai’i, were linked to their respective population-based state cancer registries for data on incident HCC. We used EHR data to define 17 detailed racial and ethnic groups and other sociodemographic and clinical factors. We used Cox proportional hazards regression with age as the timescale to examine racial/ethnic disparities in HCC risk with sex-specific models adjusted for length of active follow-up and with underlying stratification by site, birth cohort, baseline year and number of encounters. We calculated sex-specific hazards and population attributable fractions (PAFs) of HCC risk factors among racial/ethnic groups (e.g., smoking, hepatitis infections, metabolic syndrome). Results: The pooled cohort contained data on 4,249,671 adults followed a median of 6.8 years; 55% were female, and 2,916 had incident HCC. Compared to non-Hispanic White males, Vietnamese American males had greater risk of HCC (HR: 7.42; 95% CI: 4.25, 12.96) as did American Indian/Alaska Native, Black, Chinese American, Hispanic, Native Hawaiian, and Pacific Islander males, and those of multiple races or ethnicities. Among females, every group except for American Indian/Alaska Native, Asian Indian American, and Pacific Islander females had greater risk of HCC compared to the non-Hispanic White group; HRs ranged from 1.68 (1.01, 2.78) among Filipino to 6.38 (2.79, 14.55) among Vietnamese American females. Risk of HCC according to clinical risk factors was similar for males and females; however, the PAF of HCC for alcohol disorders was much higher for females (43%) than males (2%). Analyses by racial/ethnic group are ongoing, but variation in factor-specific risk of HCC was observed in preliminary analyses; for example, only non-Hispanic White and Asian American males had greater risk of HCC with metabolic-associated fatty liver disease and ever-smoking. Conclusions: Analysis of a large EHR-based cohort linked with cancer registry data yields additional information on cancer disparities across detailed racial and ethnic groups and may benefit efforts to identify targets for intervention. Our results indicate disparities in HCC risk across detailed racial and ethnic groups traditionally aggregated into larger groups (e.g., Asian American/Pacific Islander). Variation in the PAF of HCC for known risk factors suggest that the most impactful prevention efforts may require tailoring to the target populations. Citation Format: Mindy C. DeRouen, Alison J. Canchola, Janet Chu, Aly Cortella, Pushkar Inamdar, Sixiang Nie, Mai Vu, Ma Somsouk, Michele Tana, Caroline A. Thompson, Scarlett L. Gomez, Hashem El-Serag, Mi-Ok Kim, Mark Segal, Chanda Ho, Yihe G. Daida, Su-Ying Liang, Salma Shariff-Marco. Examining factors that contribute to racial and ethnic disparities in liver cancer within an EHR-based epidemiologic cohort linked to cancer registries [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B138.

Hepatic steatosis (HS) is common worldwide, but there is little data on the prevalence of HS in Pacific Islanders (PIs) and Asians within the United States. Our aim was to compare prevalence of HS in obese 18-50-year-olds of Asian and PI ethnicity who underwent computerized tomography (CT). We performed a retrospective analysis of all members of an integrated healthcare system who self-identified as Asian or PI, were between the ages of 18 and 50 years, had a body mass index (BMI) ≥ 30, and underwent a CT scan that included the liver during 2021, resulting in 748 subjects. Imaging was analyzed using a method sensitive and specific for moderate to severe HS. Additionally, multiple binary logistic regression was performed to explore the relationship between HS and HbA1c, BMI, and age. Of the 748 patients, 311 (41.6%) had HS. We found no significant difference in the prevalence of HS between Asians and PIs (χ2 1 = 1.3, P = 0.25), between Asian and PI men (χ2 1 = 2.8, P = 0.096), or between Asian and PI women (χ2 1 = 0.053, P = 0.82). Higher odds of HS was associated with increasing BMI (OR = 1.08; 95% CI: 1.06-1.11; P < 0.001) and HbA1c (OR = 1.15; 95% CI: 1.04-1.26; P = 0.00489), but HS was not associated with age in this age range (OR = 0.993; 95% CI: 0.973-1.01; P = 0.46). Moderate to severe HS is very common in obese Asian and PI adults, and occurs at similar rates in these ethnicities. Abdominal CT imaging presents an opportunity to diagnose HS and provides relevant information to patients and healthcare providers.

In the current era of evidence-based medicine, scientific publications play a crucial role in guiding patient care. While the lack of diversity among orthopaedic surgeons has been well documented, little is known about the diversity of orthopaedic journal editorial boards. The purpose of this study was to assess the racial/ethnic and gender diversity of U.S. orthopaedic journal editorial boards. The editorial boards of 13 orthopaedic journals were examined, including 10 subspecialty and 3 general orthopaedic journals. Race/ethnicity and gender were determined for each editorial board member. The representation observed on orthopaedic journal editorial boards was compared with representation at other phases of the orthopaedic pipeline, as well as within the various subspecialty fields of orthopaedics. Logistic regression and t tests were used to evaluate these comparisons. We identified 876 editorial board members of the 13 journals; 14.0% were Asian, 1.9% were Black, 1.9% were Hispanic, 2.4% were multiracial/other, and 79.7% were White. Racial/ethnic representation was similar across the subspecialty fields of orthopaedics (p > 0.05). The representation of women on orthopaedic editorial boards was 7.9%, with differences in gender diversity observed across subspecialty fields (p < 0.05). Among journals in the subspecialty fields of spine and trauma, female editorial board representation was lower than expected, even after taking into account the representation of women in these subspecialty fields (2.0% versus 9.0% [p = 0.002] and 3.8% versus 10.0% [p = 0.03], respectively). In this study of 13 subspecialty and general orthopaedic journals, the representation of racial/ethnic minorities and women on editorial boards was similar to their representation in academic orthopaedics. However, these values remain low in comparison with the population of patients treated by orthopaedic surgeons. Given the importance of scientific publications in the current era of evidence-based medicine, orthopaedic journals should continue working to diversify the membership of their editorial boards.

Long-term outcomes of vein morphologies in the endoscopic vein harvesting setting are lacking. We analyzed 15-year follow-up for endoscopic versus open vein harvesting and associated vein morphology outcomes in coronary artery bypass grafting at a single center. This single-center, prospectively collected, retrospective, observational study evaluated 15-year major adverse cardiovascular events (MACE) of endoscopic versus open vein harvesting and associated vein morphologies. Among 729 patients, no differences were found between endoscopic and open vein harvesting in MACE hazard ratios despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Asian and Filipino patients had more thin-walled veins and Asian and multirace patients had more vasovasoral branches than White patients. Bifid veins were associated with increased risk of cardiac catheterization. Varicose veins were associated with myocardial infarction, congestive heart failure, and death. Thick-walled veins were associated with revascularization and dense adhesions with cardiac catheterization and revascularization. Fifteen-year adjusted MACE was similar between endoscopic and open vein harvesting in small coronary targets despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Bifid, varicose, thick-walled veins, and dense adhesions had worse MACE.

Background:Hemiarthroplasty is currently the most common treatment for displaced femoral neck fractures in the elderly. While bipolar hemiarthroplasty was developed to reduce the risk of acetabular erosion that is associated with traditional unipolar hemiarthroplasty, meta-analyses have reported similar outcomes for bipolar and unipolar hemiarthroplasty devices. The primary objective of this study was to evaluate the risks of aseptic revision and periprosthetic fracture following bipolar versus unipolar hemiarthroplasty in a large integrated health-care system in the United States.Methods:We conducted a retrospective cohort study using data from the hip fracture registry of an integrated health-care system. Patients aged ≥60 years who underwent hemiarthroplasty for hip fracture between 2009 and 2019 were included. The primary outcome measure was aseptic revision, and the secondary outcome measure was revision for periprosthetic fracture. Cause-specific Cox proportional hazards regression was performed, with mortality considered as a competing event. In the multivariable analysis, estimates were adjusted for potential confounders such as age, sex, race/ethnicity, body mass index, American Society of Anesthesiologists classification, femoral fixation, surgeon volume, type of anesthesia, and discharge disposition.Results:The study sample included 13,939 patients who had been treated with hemiarthroplasty by 498 surgeons at 35 hospitals. The mean follow-up time was 3.7 ± 2.9 years. The overall incidence of aseptic revision at 5 years following hemiarthroplasty was 2.8% (386). In the multivariable analysis controlling for potential confounders, bipolar hemiarthroplasty was associated with a lower risk of aseptic revision than unipolar hemiarthroplasty (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59 to 0.94; p = 0.012). Rates of revision for periprosthetic fracture were similar between the bipolar and unipolar devices (HR, 0.79; 95% CI, 0.58 to 1.10; p = 0.16).Conclusions:In this study of hemiarthroplasty for hip fracture in elderly patients, bipolar designs were associated with a lower risk of aseptic revision than unipolar designs. In contrast to prior research, we did not find any difference in the risk of periprosthetic fracture between the 2 designs.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.