Summer 2014 - Volume 18 Number 3

Original Research and Contributions

An Adaptation of Family-Based Behavioral Pediatric Obesity
Treatment for a Primary Care Setting: Group Health Family
Wellness Program Pilot
Karin R Riggs, MSW; Paula Lozano, MD, MPH; Amy Mohelnitzky, MEd; Sarah Rudnick, MD;
Julie Richards, MPH

Thirty-eight parent-child pairs enrolled (28% of 134 pairs invited) in an evidence-based intervention to a group format and completed six 12- to 16-week groups over 3 years. Twenty-four (63%) completed the program and achieved a significant mean change in BMI Z-scores and significant improvement in parent-reported child quality of life, and a significant mean BMI of parents changed. Parent experiences with lack of social support suggest possible ways to improve retention and adherence.

Temporal Trends in Mortality after Coronary Artery Revascularization in Patients with End-Stage Renal Disease
Ashok Krishnaswami, MD; Thomas K Leong, MPH; Mark A Hlatky, MD; Tara I Chang, MD, MS; Alan S Go, MD

In an observational longitudinal study among a high-risk cohort of 1015 patients with end-stage renal disease and coronary artery disease within Kaiser Permanente Northern California who were referred for coronary revascularization by either coronary artery bypass surgery or percutaneous coronary intervention, the relative risk of mortality in the 2004-2008 period decreased by 34% compared with the 1996-1999 period, with the benefit primarily in the decrease in late mortality.

Improving Care for Older Adults: A Model to Segment the Senior Population
Yi Yvonne Zhou, PhD; Warren Wong, MD; Hui Li, PhD

A tool identifies each member aged 65 years and older in 1 of 4 segments: without chronic conditions, with one or more chronic conditions, with advanced illness or end-organ failure, or with extreme frailty, or nearing the end of life. Concordance of the algorithm with physician-assessed segmentation of 1615 Medicare recipients was 85%. After 1 year, approximately 85% of 86,140 surviving seniors remained in the same segment; 3.9% moved to a lower need segment, and 11% moved to a higher need segment. Six-month and 12-month mortality rates varied substantially across segments. The Senior Segmentation Algorithm accurately identifies older adults in care groups with similar needs, trajectories, and utilization patterns.

Comparison of Paper and Electronic Surveys for Measuring Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction
Jamie L Bojcic, MPH; Valerie M Sue, PhD; Tomy S Huon; Gregory B Maletis, MD;Maria CS Inacio, PhD

The Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry listed 1486 patients between 2005 and 2010, who were included in this survey study. The overall response rate was 42%. The 36% rate in the electronic-survey group was significantly higher than the 22% in the paper-survey group. The electronic response rate was also significantly higher than the paper response rate at all follow-up times of 1, 2, and 3 years. Although the electronic survey produced higher response rates, it is not sufficient alone to replace the traditional paper version among this Kaiser Permanente population.

An Audit of Clinician Compliance with Best Practice Recommendations to Repair Severe Obstetric Anal Sphincter Injuries
Shamir O Cawich, MBBS, DM; Santosh Kulkarni, MBBS, FRCOG; Michael Ramdass, MBBS, FRCS; Dale Hassranah, MBBS, FRCS; Ian Bambury, MBBS, DM; Loxley R Christie, MBBS, DM; Vijay Naraynsingh, MBBS, FRCS

A retrospective review of the records of all consecutive obstetric patients with anal sphincter injuries between November 2007 and December 2012 found 26 women (mean age = 27), who had obstetric anal sphincter injuries. Nine cases earned clinician compliance scores above 6, and 17 had scores of 6 or below. Experienced clinicians repaired all the injuries in this study—the only task for which compliance was 100%. There is a serious barrier to success because 65% of senior clinicians are noncompliant.

Designed for Workarounds: A Qualitative Study of the Causes of Operational Failures in Hospitals
Anita L Tucker, DBA, MS; W Scott Heisler, MBA, RN; Laura D Janisse, MFA

Frontline care clinicians and staff in hospitals spend at least 10% of their time working around operational failures: situations in which information, supplies, or equipment needed for patient care are insufficient. The authors examined the internal supply chains at two hospitals, conducting in-depth qualitative research, including observations and interviews, of 80 individuals from 4 nursing units and the ancillary support departments. We found that a lack of interconnectedness among interdependent departments' routines was a major source of operational failures.

Home Diuretic Protocol for Heart Failure: Partnering with Home Health to Improve Outcomes and Reduce Readmissions
Richard P Veilleux, MPH, MBA; Joseph N Wight, MD; Ann Cannon, RN; Moira Whalen, RN; David Bachman, MD

In late 2011, the MaineHealth Home Diuretic Protocol was implemented in 2 hospitals and in the home health agency serving those hospitals. The patient population included recently hospitalized patients with a diagnosis of advanced heart failure, who were eligible for home health services and telemonitoring. Sixty patients were enrolled between November 2011 and January 2014. The protocol was initiated 84 times for 30 of these patients. Sixteen patients had multiple activations. The readmission rate was 10% and no adverse outcomes were observed. Clinician and patient satisfaction was 97% or greater.

Special Report
Successful Practices in the Use of Secure E-mail
Laura W Johnson, MPH; Terhilda Garrido, MPH; Kate Christensen, MD; Matt Handley, MD

The authors interviewed 27 "super user" physicians at Kaiser Permanente and Group Health Cooperative 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.

Special Report
Treatment Progress Indicator: Application of a New Assessment Tool to Objectively Monitor the Therapeutic Progress of Patients With Depression, Anxiety, or Behavioral Health Impairment
Phillip Tuso, MD, FACP, FASN

A new tool called the Treatment Progress Indicator appears to offer clinicians an objective approach to assess patients with depression, anxiety, and chemical dependency, and to objectively measure a patient's response to therapy over time. This allows clinicians to compare their patients' responses to therapy with those of a cohort of patients with a similar diagnosis and severity, and allows for objective population-level management of disease. Implementation of the tool has the potential to improve behavioral health access and affordability.

Review Articles

Thoracic Endometriosis Syndrome: Case Report and Review of the Literature
Parisa Azizad-Pinto, MD; David Clarke, MD, FCCP

Thoracic endometriosis syndrome is the presence of endometrial tissue in or around the lung in 4 distinct clinical entities: catamenial pneumothorax, catamenial hemothorax, hemoptysis, and pulmonary nodules. The diagnosis is often delayed or missed by clinicians. The authors report the case of a 48-year-old woman with endometriosis causing bowel obstruction and concurrent catemenial pneumothorax.

Comparative Health Systems Research among Kaiser Permanente and Other Integrated Delivery Systems: A Systematic Literature Review
Jared Lane K Maeda, PhD, MPH; Karen M Lee; Michael Horberg, MD, MAS

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. The authors conducted a literature search of 1605 articles from PubMed and the Kaiser Permanente (KP) Publications Library. Studies that compared KP as a system or organization with other health care systems or across KP facilities internally were included. Only a small proportion of articles (4%) was identified as being comparative health systems research.

Case Studies

Special Medical Conditions Associated with Catatonia in the Internal Medicine Setting: Hyponatremia-Inducing Psychosis and Subsequent Catatonia
Andrei A Novac, MD; Daniela Bota, MD, PhD; Joanne Witkowski, MD; Jorge Lipiz, MD; Robert G Bota, MD, MSG

There are only 6 reports of hyponatremia-induced catatonia and psychosis in the literature. The authors present the case of a 30-year-old woman with catatonia and psychosis induced by hyponatremia, and use this report to exemplify the multitude of biologic causes of catatonia, and to propose a new way to look at the neuroananatomical basis of processing, particularly the vertical processing systems the authors believe are involved in catatonia.

A Novel Use of Foley Catheters to Prevent Injury to the Pelvic Viscera During Stereotactic Radiosurgery for Undifferentiated Pleomorphic Sarcoma of the Sacrum
John Maa, MD; Stephen Waterford, MD; Thierry Jahan, MD; David A Larson, MD; Dean Chou, MD

The use of a Foley catheter to protect the small and large bowel from radiation injury during stereotactive radiosurgery to the spine has not previously been described in the surgical literature. The proximity of visceral organs may preclude adequate target delivery of radiation. The authors describe the novel use of Foley catheters placed intraoperatively to displace the bowel during stereotactive radiosurgery, allowing for a full radiation dose to be safely delivered to the tumor.


Best Clinical Practices for Male Adult Survivors of Childhood Sexual Abuse: "Do No Harm."
Les Gallo-Silver, MSW, LCSW-R; Christopher M Anderson; Jaime Romo, EdD

Currently, there are no recommendations for best clinical practices for male survivors of childhood sexual abuse or other adverse clinical experiences. Physicians can address the needs of adult male survivors of childhood sexual abuse by changes in communication, locus of control, and consent/permission before and during physical examinations and procedures.

Prediabetes and Lifestyle Modification: Time to Prevent a Preventable Disease
Phillip Tuso, MD, FACP, FASN

More than 100 million Americans have prediabetes or diabetes; of the 34% of adults with prediabetes 37% may have diabetes in 4 years, if untreated. Lifestyle invervention may decrease the percentage of patients with prediabetes who develop diabetes by 20% and may decrease the risk of prediabetes progressing to diabetes for as long as 10 years. Indirect and direct costs to care for an individual with diabetes vs prediabetes may be as much as $7000 more per year.


A Commentary on "Comparative Health Systems Research among Kaiser Permanente and Other Integrated Delivery Systems: A Systematic Literature Review."
Thomas E Kottke, MD, MSPH; Patrick T Courneya, MD

"Knowing is not enough, we must apply. Willing is not enough, we must do." This quote attributed to von Goethe underscores the fact that biomedical research and health care are social investments that are expected to create value for the public. Friedson recognized that an effective care delivery system is the substrate that creates value from knowledge. It is now time for the health care research and practice communities to collaborate, increase comparative health systems research activity, and give Americans the value in health care that they deserve.

Narrative Medicine

"Walking with My Mother"
Cecilia Runkle, PhD

Damien Webb

Soul of the Healer

"Agave Americana"
Michael S Nelson, MD

Samuel Glassner, MD

"Great White in Flight"
Bridget Bourgon, PA-C

Sally J Cullen, MD

On the Cover

"Aurora with Reflection"
Stephen Henry, MD


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