Kaiser Permanente Walnut Creek Medical Center

This past June, Dr. Carlos Puig and I, your ISHRS representatives for the American Medical Association (AMA), attended the AMA Annual Meeting held in Chicago. Additionally, we were joined by Dr. Farhad Riyaz, who drove in from Michigan. Here is a “top three” synopsis from the AMA proceedings

e23232 Background: The 2015 ASCO Breast Cancer Survivorship Guidelines recommend needs assessment, although real-world implementation data are limited. To address this gap, as part of the ASCO Quality Training Program (QTP) 2024, we implemented an electronic breast cancer survivorship needs assessment tool. The goal of the project was to demonstrate feasibility of the tool and actionability of the findings. Methods: From April - November 2024, Stage I–III breast cancer patients at Kaiser Permanente San Francisco scheduled for a 1-year survivorship visit completed an electronic needs assessment tool. Process maps and Plan-Do-Study-Act (PDSA) methodology led to identification of patients active on the electronic portal, who then received survey links via electronic outreach, with a second outreach for nonrespondents. Respondents received tailored online resources from a community health worker through follow-up communication. Results: Out of 119 patients, 116 (97%) had access to the electronic portal. The cohort had a median age of 59.6 years and was 47.4% Asian/Pacific Islander, 36.2% White, 8.6% Hispanic, and 7.8% Multiracial/Other. Disease stages included 50% with Stage I, 30.2% with DCIS, 15.5% with Stage II, and 4.3% with Stage III. Survey response rates were 37%, with a median review time of 1 day and a response time of 4 days. Response rates were 28% with a single outreach and increased to 51% if received a second outreach. There were no differences between respondents and non-respondents in terms of age, race/ethnicity, socio-economic status, stage, receptor status or treatment (P > 0.05 for all categories). Table 1 summarizes main patient-reported needs across domains. All survey respondents received a follow-up communication with informational links related to their needs. Conclusions: Our ASCO QTP project demonstrated the feasibility and actionability of implementing a cancer survivorship needs assessment tool in a community oncology setting without significant differences seen in responders compared to non-responders. Using the PDSA methodology, we identified unmet needs across various domains, addressing key concerns at 1-year survivorship visits and developed a follow-up plan to provide informational resources for each identified need. Domain Total Responsesn=42 (%) Physical Well Being Fatigue 29 (69%)17 (40%) Emotional/Social Wellbeing Fear of cancer coming back 32 (76%)29 (69%) Staying Healthy Eating Healthy 26 (62%)20 (48%) Sexual Health/Fertility Interest /Ability in sexual activity 7 (17%)5 (12%) Practical Taking care of myself 23 (55%)19 (45%) Informational Needs Supplements / Herbs / Vitamins 31 (74%)18 (43%) Displaying the most reported category in each domain.

Hypertension is highly prevalent in primary care. Unhealthy alcohol use can impact its management and associated cardiovascular disease risks. Alcohol screening and brief intervention (ASBI) in primary care is effective for early intervention for unhealthy use, yet its effectiveness in heterogeneous populations in real-world settings remains unclear. Using electronic health records, we emulated a pragmatic clinical trial to evaluate the effects of receiving ASBI on drinking and blood pressure (BP) outcomes among primary care patients with hypertension and unhealthy alcohol use. This observational study identified 72,979 patients with hypertension who screened positive for unhealthy drinking between January 1, 2014, and December 31, 2017. We used a target trial framework to compare the effects of receiving ASBI (intervention) to not receiving brief intervention (comparison) on drinking (change in heavy drinking days and drinks/week) and BP outcomes (changes in diastolic and systolic BP) from baseline to 2- and 5-year follow-ups. Treatment effect estimates were obtained using inverse probability-weighted models. At 2 years, the intervention condition had about 0.2 fewer heavy drinking days and about 0.1 fewer drinks/week than the comparison condition. The intervention condition had an additional 0.5 mmHg and 0.7 mmHg decline in diastolic and systolic BP, and 8% and 6% higher odds of having a ≥3 mmHg reduction in diastolic and systolic BP, respectively, than the comparison condition. Between-group differences in both outcomes diminished at 5 years. The modest changes in drinking and BP we found contribute to the emerging evidence that brief intervention may benefit broader health outcomes at the population level.

![Figure][1]</img> The questions presented by the author are not taken from the ABHRS item pool and accordingly will not be found on the ABHRS Certifying Examination . When it comes to health, “nutrition” is not the same as “supplements”—but of course, each affects the other. So outside

Background: Few studies have compared the risk of reoperation by timing in breast reconstruction surgery after mastectomy. We evaluated the first and total number of reoperations by reconstruction timing in women with breast cancer undergoing primary mastectomy. Methods: A cohort study of 23,301 primary mastectomies in women with breast cancer undergoing either immediate breast reconstruction (IBR) or delayed reconstruction was carried out within Kaiser Permanente between 2010 and 2022. The first reoperation rate was calculated using cause-specific Cox Proportional Hazards Models, while Multiplicative Cox Proportional Hazards Models were used to account for mortality and timing in reoperation. Patients were continuously monitored for death, outcome of interest, loss to follow-up through healthcare membership termination, or study end date (31 December 2022). Results: In total, 78.4% (n = 18,276) of the cohort underwent IBR. The average follow-up time was 5.9 years (±3.8). The following covariates were imbalanced (standardized mean difference [SMD] ≥ 0.20) between IBR and delayed groups: BMI, smoking status, year of mastectomy, bilateral procedures, and reconstruction type. The crude incidence of first reoperation was 33.04% vs. 31.72% in IBR vs. delayed patients and the risk of reoperation was 18% higher in IBR patients (HR = 1.18, 95% CI = 1.12–1.25). There was no difference in the risk of reoperation by timing (p &gt; 0.05) when assessing multiple reoperations. The reoperation risk was the highest for IBR patients who did not complete reconstruction or single-stage reconstruction. In addition, the first reoperation rate of IBR patients was higher in those who underwent expander–implant-based reconstruction. Conclusions: The first reoperation rate was higher in IBR patients compared to those who delayed reconstruction, although we failed to detect a difference for multiple returns to surgery, except in certain subgroups. Assessing reoperation risk by timing among different reconstruction modalities can aid patients in making informed decisions about the type of breast reconstruction to undergo.

Paresthesia-based spinal cord stimulation (SCS) depends upon dorsal column (DC) fiber activation to engage pain-relieving neural mechanisms. However, the mechanisms for 10-kHz paresthesia-free SCS have not been fully elucidated. Preclinical work has shown selective drive of inhibitory dorsal horn neurons, while other hypotheses suggest that DC fibers may be activated. To provide clinical data for guiding mechanism work, we analyzed paresthesia perception thresholds (PPT) over a range of low to high kHz frequency and compared those values to the stimulation parameters from the therapeutic 10-kHz SCS programs used by patients. The goal of this study was to provide clinically relevant stimulation parameters for translational mechanism work. Retrospective chart review of technical data collected during baseline evaluation from two prospective clinical studies. Acute outpatient follow-up. Data were extracted from study files of enrolled patients who had used fully implanted SCS for at least 3 months with leads positioned in the epidural space at the T8-T11 vertebral levels to treat their chronic intractable back and/or leg pain. PPTs had been measured using a bipole program at 10 kHz at pulse width (PW) = 30 µs, and at 50 Hz, 500 Hz, 1 kHz, and 5 kHz at PW = 80 µs. Therapeutic stimulation amplitudes for 10 kHz at 30 µs were obtained from patients' IPG log files at the time of study enrollment. PPTs were obtained from 23 patients with failed back surgery syndrome (11 M/ 12 F; 60 ± 15 years old). PPTs at PW = 80 µs were PPT (50 Hz) = 7.9 (5.7 - 9.7) mA, PPT (500 Hz) = 7.0 (5.2 - 9.1) mA, PPT(1 kHz) = 7.0 (5.5 --8.5) mA, and PPT (5 kHz) = 6.1 (4.1- 7.9) mA; all higher frequencies had statistically significantly lower PPTs than PPT(50 Hz at 80 µs). For 10 kHz at 30 µs, the PPT was higher than 15 mA for 13 (56%) of the subjects; for the remaining 44%, the PPT = 8.3 ± 4.0 mA was statistically significantly larger than the therapeutic stimulation pulse amplitudes = 2.4 ± 0.4 mA. Retrospective chart review, small number of patients. Therapeutic 10-kHz SCS uses stimulation amplitudes far lower than the PPT, providing evidence that therapeutic 10-kHz SCS does not activate dorsal column axons. Additionally, the PPT decreases with increasing kHz frequency, suggesting that a presumed asynchronous pattern of activation from kHz stimulation does not raise the threshold at which sensation occurs.