The Permanente Journal

Background Previous studies have demonstrated racial and ethnic disparities in the treatment and outcomes of patients with colorectal cancer. However, none of these studies has examined whether these disparities exist in a closed health care delivery system. The aim of this study was to identify racial and ethnic disparities in rates of diagnosis, treatment, and outcomes for patients with colorectal cancer with liver metastasis (CRLM) within the Kaiser Permanente Southern California system. Methods The authors performed a retrospective review of 110 adult patients with CRLM who underwent surgery on both sites with curative intent at any Kaiser Permanente Southern California facility between 2010 and 2020. The authors stratified patients by race and ethnicity as Asian/Asian American, Black, Hispanic, or White individuals. Results There was a statistically significant difference in race and ethnicity breakdown between all Kaiser Permanente members and the patients diagnosed with CRLM (P < .01), with a lower proportion of Hispanic patients diagnosed (P < .01). Between the surgical and nonsurgical cohorts, the statistically significant difference between race and ethnicity breakdown (P = .03) was due to Hispanic patients being more likely to undergo surgery (P = .01). Between racial and ethnic groups within the surgical cohort there was no significant difference in mean age at diagnosis (P = .63), time from diagnosis to surgical resection (P = .64), proportion of synchronous vs metachronous resections (P = .53), complication rate (P = .91), recurrence rate (P = .40), or 5- and 10-year survival (P = .5 and P = .9). Conclusion Within a closed health care delivery system, racial and ethnic disparities in treatment and outcomes were not observed for surgical patients with CRLM. However, disparities in diagnosis for the Hispanic population persist and should be addressed.

Background Posttraumatic stress disorder (PTSD) is often underdiagnosed based on medical records. This study aimed to estimate the prevalence and health care utilization of individuals with PTSD and other trauma-related disorders in a large, integrated health care system. Methods Adults (between the ages of 18 and 65) with Kaiser Permanente Northern California membership and ≥ 1 outpatient visit in 2022 were eligible. Unspecified/other specified trauma and stressor-related disorder, acute stress disorder, and PTSD were based on diagnosis codes from the International Classification of Diseases, 10th Revision, Clinical Modification. The Primary Care PTSD (PC-PTSD) Scale was used as a screening tool. Prevalence was assessed overall and among the subset of patients seen in primary care, psychiatry, and addiction medicine. To contextualize health care utilization, the authors compared patients with trauma-related disorders to those with major depressive disorder. Results Of the 2,128,670 eligible adults, the overall prevalence of trauma-related diagnoses and positive screening on PC-PTSD was 4.9% (103,947); 1.3% (n = 27,670) had PTSD, 1.9% (n = 41,205) had unspecified/other specified trauma and stressor-related disorder, 0.1% (n = 1818) had acute stress disorder, and 1.6% (n = 33,254) screened positive on PC-PTSD without a trauma-related International Classification of Diseases code. Prevalence of trauma-related diagnoses by department was 18.3% (n = 47,516) in psychiatry, 16.5% (n = 3816) in addiction medicine, and 3.4% (n = 67,469) in primary care. There were no clinically meaningful differences in health care utilization between those with trauma-related diagnoses compared with major depressive disorder. Conclusion Broadly defining trauma-related disorders and substantial symptoms may provide a more accurate representation of the actual prevalence of PTSD in a health care system. These data may help health care leaders plan treatment options for this diverse group of individuals.

Introduction The COVID-19 pandemic has highlighted olfactory dysfunction (OD) as a major and often persistent symptom in affected individuals. Thus, it is important to identify demographic and clinical factors contributing to OD among patients with COVID-19. Methods A case-control (1:3) study was performed in adult patients with COVID-19 diagnosis between July 2020 and June 2021. Cases had OD; controls did not have OD. OD was subclassified as acute smell loss (< 3 months), chronic smell loss (> 3 months), or altered sense of smell (eg, parosmia, phantosmia). Bivariate tests and multivariable logistic regression were performed for analysis. Results Of the 4220 patients that met criteria, 1055 (25%) had OD. Of those with OD, 650 (61.6%) had acute smell reduction, 350 (33.2%) had chronic smell reduction, and 245 (23.2%) had altered sense of smell. Older (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.79–0.89), male (OR, 0.62; 95% CI, 0.54–0.72), and Asian (OR 0.75; 95% CI, 0.59–0.95) patients were less likely to experience OD. Having seasonal allergies (OR, 1.44; 95% CI, 1.11–1.86) and being hospitalized (OR, 1.52; 95% CI, 1.14–2.02) increased the likelihood of OD development. Compared with acute loss, chronic smell loss was likelier in older, female, non-White, hospitalized, and cerebrovascular disease patients (P < .05). Discussion Understanding the course of post–COVID-19 OD is becoming increasingly important and may broaden these insights. Conclusion Being younger, female, and atopic conferred highest likelihood of OD development after COVID-19.

Introduction Trigger finger is one of the most common conditions treated by hand surgeons. Although corticosteroid injection is a common first-line treatment, there is no consensus regarding the most effective type of steroid. Methods The authors performed a retrospective cohort study of patients with a diagnosis of trigger finger within Kaiser Permanente Northern California, a large, community-based, integrated health system with a comprehensive electronic medical record. Patients were potentially exposed to 4 different steroid regimens: betamethasone, dexamethasone, methylprednisolone, and triamcinolone. The primary outcome was the possibility of subsequent trigger finger surgery following initial corticosteroid treatment. Results Among 20,141 patients with an injection for trigger finger diagnosis, 1668 (8.3%) had a trigger finger release procedure following injection. Compared with patients injected with triamcinolone, dexamethasone patients had a hazard ratio of 4.12 for surgery (95% confidence interval [CI], 3.06–5.54), betamethasone patients had a hazard ratio of 2.40 (95% CI, 1.86–3.10), and methylprednisolone had a hazard ratio of 1.77 (95% CI, 1.32–2.37). Discussion This large, retrospective observational study suggests that the type of corticosteroid used for trigger finger may influence the possibility of subsequent surgery. Conclusions This information may inform corticosteroid choice for treating trigger finger, but findings should be confirmed in a prospective study.

This case report and technical note details the successful surgical repair of a latissimus dorsi (LD) tendon rupture in a high-demand athlete using a single-incision axillary approach with an all-suture anchor tension slide technique. The patient, a 38-year-old competitive athlete, sustained the injury during a Spartan Race, presenting with substantial functional limitations, including shoulder weakness and impaired performance in athletic and professional activities. Clinical and imaging findings confirmed a complete LD tendon rupture with 6 cm of retraction and associated teres major partial tearing. Surgical repair involved tendon mobilization, preparation of the humeral footprint, and fixation with all-suture anchors in a tension slide configuration. Postoperatively, the patient underwent a tailored rehabilitation protocol, achieving near-complete return to preinjury function by 7 months. This innovative technique offered advantages, including cosmetic incision, minimized surgical morbidity, and familiarity with sports surgeons' techniques. The all-suture anchors avoid metal implants, reduce bone loss, and simplify the procedure compared to cortical buttons. Although effective, the approach requires technical expertise, particularly in mitigating neurovascular risks. This report underscores the efficacy and reproducibility of this method in treating LD tendon ruptures in high-demand athletes. Further biomechanical and clinical comparisons are warranted to refine surgical indications and optimize outcomes.

Gulf War illness (GWI) is a chronic condition affecting nearly a third of Gulf War veterans and is characterized by persistent symptoms across a number of physical and neuropsychiatric domains. This case study examined a 52-year-old veteran admitted on a psychiatric hold for danger to others. The patient’s symptoms, including chronic migraine, widespread musculoskeletal pain, skin sensitivities, environmental allergies, and mood and cognitive disturbances, met criteria for GWI according to 2 accepted case definitions. Initial misdiagnosis of psychosis was corrected upon evaluation, which identified severe anxiety consistent with generalized anxiety disorder. Treatment focused on providing validation of the patient’s chronic symptoms and managing his anxiety through pharmacologic intervention. This case underscored the importance of recognizing GWI to ensure accurate diagnoses and targeted care for veterans.

Background Little is known about how comprehensively the Agency for Healthcare Research and Quality’s patient safety indicators (PSIs) capture true complications. Therefore, the authors sought to assess the PSIs' sensitivity using a novel sampling and analytic strategy tailored for unusual events to ensure adequate capture of false negative cases. Methods The authors retrospectively reviewed hospitalization records not flagged by 7 selected PSIs, oversampling those with specific diagnosis or procedure codes suggesting an unreported complication, with a special interest in PSI 09 (Postoperative Hemorrhage or Hematoma) and PSI 10 (Postoperative Physiologic and Metabolic Derangement). The authors evaluated data from 27 hospitals in 11 states between 2006 and 2009. For each PSI, the authors determined the negative predictive value (NPV), accounting for sampling weights, and used previous estimates of positive predictive value (PPV) and incidence to estimate sensitivity. Results For PSI 09, 32 of 281 abstracted records (including 30 of 116 high-risk records) were falsely negative (NPV 99.73%; 97.5%, confidence interval [CI], 98.96–99.94); the estimated sensitivity was 40% (95% CI, 12–76). For PSI 10, 3 of 230 records (including 3 of 108 high-risk records) were falsely negative (NPV 99.92%; 97.5% CI, 99.28–99.99); the sensitivity was 53% (95% CI, 9–92). The estimated sensitivity of other PSIs varied (19%–100%). Conclusions The sensitivity of several Agency for Healthcare Research and Quality PSIs, estimated from a sample of hospitalizations enriched with records suggesting an unreported complication, varied widely. Although the 2-stage complex stratified sampling design (using weights based on sampling probabilities) allows estimation of the sensitivity of hospital outcome measures, large sample sizes are still required for unusual events.

Background Multiple sclerosis (MS) is a costly, chronic, complex condition, which requires customization of care at the system level to achieve better outcomes. The authors describe a cluster-randomized, coach-supported quality improvement (QI) intervention in the MS continuous QI (MS-CQI) Collaborative, which was a multicenter learning health system (LHS) study to improve MS outcomes (2018–2022). Methods The authors developed a coach-supported QI intervention within the MS-CQI LHS, which included aspects of standard QI approaches utilized in health care. This included a 12-step standardized QI Toolkit; team coaching twice monthly; team capability assessments; and patient-reported and clinical feedback data provided by the MS-CQI data registry. Assessments helped the coach understand clinic culture, readiness for change, QI skills and knowledge, and progress over time. The coach monitored and guided team activity and assured general adherence to the 12-step improvement process. Teams selected local QI activities within those constraints. Results A total of 3 out of the 4 MS-CQI centers were cluster randomized to the intervention and completed the study. Initial QI assessments revealed that teams perceived QI as important but had low initial skill and knowledge levels. Improved QI skills, knowledge, and engagement in the intervention improved, as teams realized ownership and perceived benefits. Conclusions The coach-supported QI intervention demonstrated basic feasibility, acceptability, QI skill advancement, and utility in the MS-CQI study. It is an example of an LHS-enabled humanistic (QI team–focused) intervention, which invests in developing capability of people involved in QI work.

Introduction Physicians are facing a constant shortage, with market estimates of shortfalls only projected to increase as the population of the United States ages and health care employment needs increase. A lack of physicians has led to a steady increase in the number and scope of advanced practice practitioners (APPs) in the United States. Nurse practitioners and physician assistants have increased, in terms of percentage of the practitioner workforce, with varying degrees of autonomy. The authors describe a model of APPs to determine whether indirect supervision vs direct supervision is fiscally optimum in hospital medicine departments. Methods The authors utilized R software in R Studio to simulate, via Monte Carlo methods, APP-independent and supervised models of care. Publicly available salary data were used as the foundation to generate the models. The data were then used to simulate typical care teams of APPs and physicians in hospital medicine, while utilizing typical billing practices. Discussion Analysis of the models of care generated demonstrated that APPs, given the current payer reimbursements, are an integral part of the hospital medicine care team. A range of scenarios are accounted for. This research demonstrates that direct supervision has a lower cost per work relative value unit cost to the employer, as opposed to indirect supervision. Conclusion APPs will only continue to increase their share of billed visits. In the setting of a hospital medicine workflow, given current payer and salary constraints, direct supervision is recommended to optimize the care team from a fiduciary perspective.

Introduction Addressing health inequity should involve improving access and quality of care for individuals with low income. In the United States, programs that involve accountable care incentives and broader risk adjustment are poised to help address these issues. However, there is limited understanding of perspectives among physicians as key stakeholders in determining access and quality. Methods The authors surveyed physicians about how they perceived accountable care incentives and broader risk adjustment (greater inclusion of clinical, social, and behavioral risk factors) would impact access and quality for patients with low income insured through Medicaid. Results Low Medicaid reimbursement rates and inadequate adjustment for patients’ clinical, social, and behavioral risk factors were major factors why physicians reported not seeing Medicaid patients in their clinical practices. Many physicians believed that accountable care incentives and changes in risk adjustment would help facilitate higher quality of care for Medicaid patients, while the minority of physicians believed that accountable care organizations could ultimately improve the value of care beyond managed care organizations. Discussion Policymakers could incorporate behavioral, social, and equity-related factors into risk adjustment and consider ways to incorporate accountable care incentives into existing and new entities in Medicaid. Conclusion The majority of physicians believed that the care of Medicaid patients would improve under accountable care incentives and broader risk adjustment. Understanding physician perspectives is important for contextualizing policy about how payment reforms could affect access and quality of care for Medicaid patients.

Introduction Opportunities for otolaryngology residents to gain exposure and training in gender-affirming care (GAC) are not well-described. The authors examined the prevalence of US otolaryngology residency programs with GAC clinics, surgeons performing gender-affirming surgery (GAS), and faculty that published GAC research. Methods US otolaryngology residencies were identified with the AMA FREIDA, the AMA Residency & Fellowship Database®. Public program websites were used to identify facial plastic surgeons, laryngologists, and GAC clinics. Faculty were queried in PubMed for publications specific to GAC. Data were collected in January 2024. Results A total of 92 (70.0%) out of 131 programs had an institutional GAC clinic. Presence of GAC clinics varied between regions, and 42 (32.1%) programs encompassing 765 (41%) residents had ≥ 1 otolaryngology-trained specialist offering GAS. Within each region, programs with any faculty performing GAS were most prevalent in the midwest, with 47% of residencies (16/34 programs) publicly advertising ≥ 1 otolaryngology department faculty member working in the affiliated institutional gender clinic. The next highest region was the west (42%, 9/21 programs), followed by the northeast (29%, 10/34 programs), and lastly the south, with only 17% (7/42 programs) (P = .03). Nationally, 29.0% of programs (36/126), encompassing 652 residents (35.0% of all US trainees) had ≥ 1 otolaryngology faculty member with ≥ 1 GAC publication. Discussion Most otolaryngology residents in the United States train at institutions with a GAC clinic, but involvement of otolaryngology faculty is highly variable. A minority of residents have any department faculty who perform GAS or research in GAC. Conclusion Opportunities exist to improve otolaryngology resident exposure to both clinical and scholarly GAC, particularly in the southern region of the United States.

Objective This study aimed to evaluate associations among pretreatment hearing deficit, corticosteroid intervention, and audiologic recovery among patients presenting with sudden sensorineural hearing loss within an integrated health system. Methods Electronic health records within a multicenter integrated health system were queried for clinical encounters with a diagnosis of sudden sensorineural hearing loss in 2021. Patient demographics, audiometric data, and therapeutic steroid intervention were recorded. Audiologic response was defined as a decrease of 15 dB in 4-frequency (500, 1000, 2000, 4000 Hz) pure tone average (PTA). Audiologic recovery, or complete response, was defined as a follow-up PTA (PTA2) of ≤ 25 dB or within 10 dB of 1) baseline or 2) contralateral ear. Logistic regressions were performed to evaluate for predictive factors. Results A total of 403 patients (mean age 59.27 ± 15.80 years, 57.32% male) met inclusion criteria, of which 355 underwent corticosteroid intervention. The nonsteroid group had a less severe hearing deficit (median PTA1 49.38 dB vs 58.75 dB with steroid group; P < .05). Median PTA improvement was 6.25 dB with steroid therapy and 3.63 dB without (P < .05), but median PTA2 between steroid and nonsteroid users was not significantly different (42.5 dB and 38.13 dB, respectively; P = .821). Steroid intervention within 14 days was predictive of an audiologic response (odds ratio [OR] = 2.33) and recovery (OR = 2.46; both P < .05) compared with patients who did not undergo steroid therapy, whereas delayed steroid intervention was not, regardless of steroid regimen. Severe hearing loss had worse odds of audiologic response (OR = 0.40) or recovery (OR = 0.10; both P < .05) compared with mild hearing loss. Conclusion Pretreatment hearing deficit and initiation of empiric steroid therapy within 14 days were associated with audiologic prognosis, independent of the corticosteroid regimen. These findings reinforce the benefit of prompt steroid intervention, while further highlighting a need for standardized measures of audiometric outcomes.

Introduction Optimal timing of anterior cruciate ligament reconstruction (ACLR) remains controversial. This study evaluated the impact of timing of ACLR on rates of revision, return to the operating room, and pre- and postoperative tibiofemoral laxity. Methods A retrospective review was performed from January 1, 2010, to December 31, 2015, and included patients ≥ 16 years of age with no history of prior ipsilateral or contralateral knee surgery who underwent primary arthroscopic ACLR. Patients were categorized as early ACLR (< 6 months postinjury) or delayed ACLR (≥ 6 months). Pre- and postoperative manual–maximum differences (MMDs) based on KT-1000 testing and postoperative pivot shift were examined. Results A total of 611 patients met inclusion criteria (n = 198 early ACLR and n = 413 delayed ACLR). Compared to the early ACLR group, patients receiving delayed ACLR had a lower preoperative MMD (mean 6.55 vs 7.27 mm). Postoperative MMD, as measured by a single physical therapist, was not significantly different for early vs delayed reconstruction. Logistic regression controlling for age, graft type, and postoperative laxity revealed that delayed ACLR was associated with lower odds of return to the operating room (odds ratio = 0.523, P = .045). Conclusion Delayed ACLR was associated with a lower return to the operating room and no difference in postoperative MMD.

Background Rapid initiation of antiretroviral therapy (Rapid ART) is a key strategy for the Ending the HIV Epidemic inititative. In Harris County, Texas, a priority Ending the HIV Epidemic jurisdiction, 57% of persons with HIV receive care at 1 of 5 public agencies that receive funding from the Ryan White HIV/AIDS Program. The Ryan White HIV/AIDS Program is administered by the US Department of Health and Human Services, Health Resources and Services Administration, and HIV/AIDS Bureau. This program administers grants to clinics and local/state programs to deliver medical and support services (Part A) for low-income persons with HIV. In 2019, 39% of recently diagnosed persons with HIV in Houston took > 1 month to start ART. Herein, the authors evaluate the acceptability of the Baylor College of Medicine ECHO Facilitating Antiretroviral StART Earlier (BE FASTER) program, a community of practice collaborative among 5 Ryan White Part A Clinics, to increase Rapid ART in Harris County, Texas. Methods Semistructured interviews across 4 time points were conducted among health care workers participating in the BE FASTER program. Interviews took place from November 2021 through February 2023 and were analyzed using rapid qualitative analysis. Results A total of 29 participants were interviewed. Analyses revealed 6 themes: 1) Rapid ART protocols varied between clinics; 2) participants were interested in getting to know Rapid ART staff at other Ryan White clinics; 3) participants enjoyed the active components of BE FASTER and asked for more opportunities to engage; 4) at the end of BE FASTER, participants reported that they had streamlined their processes for Rapid ART, but barriers to long-term retention remained an ongoing challenge; 5) participants reported an increased sense of community from participating in the BE FASTER program; and 6) overall, participants had a positive experience with BE FASTER. Conclusions Participants found BE FASTER valuable and reported a positive impact on their cross-agency interactions. The BE FASTER program using the ECHO model can augment the creation of cross-organizational networks for Rapid ART.

Introduction Restricted in-person interaction throughout the pandemic coincided with increased reliance on telehealth for patient evaluation and treatment. However, few studies have investigated telehealth efficacy and accuracy compared with in-person musculoskeletal physical examination. Importantly, this virtual platform can be challenging for practitioners whose care relies on physical examination measurements. This study evaluated the validity and accuracy of measuring hip and shoulder strength and range of motion (ROM) via telehealth examination. Methods In this cross-sectional study, 45 participants without hip or shoulder pain underwent an in-person physical examination and a telehealth examination. Hip and shoulder ROM were measured from in-person and telehealth examinations, using Halo goniometers (Halo Medical Devices) and virtual goniometers, respectively. Hip and shoulder strength were also assessed. Measures obtained from in-person and telehealth examinations were compared, and percent agreements were calculated. Results The mean age of participants was 32.0 ± 7.2 years; 67% (n = 30) were female. Hip flexion strength, right hip abduction, and right shoulder strength had the strongest percent agreement (91.1%–100.0%) across in-person and telehealth modalities. Left hip abduction, left shoulder active abduction, shoulder internal ROM, and shoulder external ROM showed moderate-to-high agreement (26.7%–77.8%). Left (2.2%) and right hip (8.9%) external ROM showed poor agreement. Discussion Measurements with the greatest agreement between telehealth and in-person examinations included hip flexion, shoulder strength, hip abduction, and shoulder active abduction. Conclusion Certain strength and ROM tests can be accurately assessed via telehealth examination. Future research is needed to expand upon these findings and to develop a reliable, standardized protocol for the telehealth musculoskeletal physical examination.

Introduction The authors evaluated factors associated with neonatal hepatitis B vaccination (HepB), including prenatal vaccinations, race, ethnicity, neonatal disposition, parity, and maternal age to identify potential areas of engagement to improve maternal and child health. Methods The authors conducted a retrospective cohort study of patients who received prenatal care and delivered at an academic tertiary care hospital in central Pennsylvania from 2015–2020. A multiple logistic regression model was used to assess factors associated with newborn receipt of HepB. Results Prenatal vaccination was significantly (P < .0001) associated with subsequent neonatal HepB vaccination in the hospital following birth. Race, Hispanic ethnicity, age at delivery, neonatal disposition, and parity were not shown to be associated with HepB vaccine uptake. Conclusion Prenatal vaccination was significantly associated with neonatal in-hospital HepB vaccine uptake.

Background The volume and complexity of administrative regulations, standards, and associated tasks contribute to administrative burden in health care. Misinterpretation and misapplication of regulations impede efficiency and contribute to professional dissatisfaction. Objectives The authors aimed to 1) understand the compliance professional role, training, and background; 2) uncover their perspectives toward documentation and administrative burden; and 3) identify common regulatory misconceptions by compliance professionals. Methods In June 2023, the authors surveyed a sample of professionals serving in compliance roles listed within the directory of a national network of federally qualified health centers. Data were collected through REDCap. Follow-up interviews were completed with 4 participants between September and November of 2023. Descriptive statistics were calculated for all quantitative variables; interview transcripts were analyzed using rapid qualitative analysis. Methodological triangulation was employed to identify themes across survey and interview responses. Results About one-third (5/16, 31%) of compliance professionals had formal training. The majority (15/16, 94%) agreed or strongly agreed that “If a clinician’s action is not documented it is not ‘done.’” Compliance professionals’ perceptions of regulatory adherence in clinical scenarios showed high variability, with some participants noting noncompliance in situations where there were no regulatory infractions. Participants perceived administrative burden and waste in health care but diverged in their views of whether they have a role in protecting clinicians from administrative burden. Conclusions This study reveals inaccuracies in compliance professionals’ interpretations of regulations and standards and suggests a gap between written regulations and interpretation at the organizational level. This overinterpretation may create unnecessary work for physicians and their teams.

Psychedelic and empathogenic compounds show promise for a variety of conditions. However, studying these compounds can be highly complex, be very expensive, and have substantial patient safety concerns. Here, the authors will review 8 late-phase medicinal psychedelic studies in the Food and Drug Adminisration (FDA) approval pipeline. The authors will include a review of the FDA’s recent denial of the New Drug Application for 3-4-methylenedioxymethamphetamine with adjuvant psychotherapy for posttraumatic stress disorder from Lykos Therapeutics of San Jose, California (formerly the Multidisciplinary Association for Psychedelic Studies Public Benefit Corporation). Additionally, the authors will discuss the parallel legislative proposals in California to legalize psychedelic compounds for adult use. These legislative efforts reflect an alternative and less expensive pathway, but they do not make as thorough of an evaluation for drug safety. The authors will propose that the FDA remains the appropriate agency to evaluate and approve the use of this class of proposed therapeutics.

Introduction Patient portals are increasingly becoming the primary channel for communicating health information, raising concerns about the potential worsening of health care access disparities among limited English proficient (LEP) patients. The authors studied the use of a health plan patient portal and potential barriers to use by comparing LEP Latino and Chinese Health Plan members to those with English language preference (non-LEP). Methods The authors used health record data for 480,833 Latino (31.8% LEP) and 137,904 Chinese (31.6% LEP) adult Kaiser Permanente Northern California members 25–85 years of age to study portal use during 2019. Clinic-collected survey data for 489 Latino and 1037 Chinese LEP patients was compared with data for 849 Latino and 426 Chinese non-LEP Kaiser Permanente Northern California 2020 Member Health Survey respondents to identify factors potentially inhibiting portal use. The authors used chi-square tests to assess differences in portal use and potential influencing factors across ethnic, language, and age subgroups. Results During 2019, LEP Latino and Chinese adults were less likely than non-LEP adults to have a portal account and, among those with a portal account, to have sent secure messages and viewed laboratory results online. Portal use was lower among LEP Latino than LEP Chinese adults. Patient surveys identified lower educational attainment, health literacy, and access to and use of digital tools among LEP vs non-LEP Latino and Chinese adults. Conclusions Patient portal use is lower among LEP than non-LEP Latino and Chinese patients. Health care systems should take action to decrease barriers to use, but they also should consider patient communication preferences.

Introduction Lymphoma is the most common neck mass malignancy in adults but can present diagnostic challenges due to controversy surrounding the best initial biopsy approach. In this study, the authors characterize the diagnostic pathway in adults with lymphoma (or leukemia) presenting initially as a neck mass and examine the biopsy procedures required for diagnosis in a large community-based practice setting. Methods Using data from a retrospective cohort of 4103 adults referred to otolaryngology with a neck mass (5% found to be malignant), the authors identified the subset with lymphoma (or leukemia) and examined the time to diagnosis and the number and type of biopsies required for diagnosis. Results Among 73 adults with lymphoma or leukemia that initially presented with a neck mass (25% diffuse large B-cell lymphoma, 32% Hodgkin lymphoma, 18% follicular lymphoma, and 25% other lymphoma/leukemia), 70% required repeated biopsies for diagnosis. Overall, 93% required a core-needle biopsy (CNB) or an excisional biopsy for diagnosis, although 64% of patients underwent fine-needle aspiration (FNA) for their first biopsy. Patients undergoing initial FNA were diagnosed a median of 19 days after presentation (95% required additional biopsy), whereas those undergoing initial CNB were diagnosed a median of 5 days after presentation (only 25% required additional biopsy). Discussion These data highlight the limited diagnostic utility of FNA for lymphoma presenting as a neck mass and support consideration of CNB when lymphoma is suspected in a neck mass to minimize repeat biopsy and time to diagnosis. Conclusion Lymphoma represents a diagnostic challenge. CNB represents an opportunity to improve diagnostic efficiency, although additional research is needed to ascertain impacts on cost and side effects in various health care environments.

Eosinophilic fasciitis (EF) is a rare dermatologic disease with clinical similarities to localized scleroderma and systemic sclerosis (SSc). Diagnosing EF is challenging due to overlapping clinical features among these conditions. Differentiating EF from localized scleroderma and SSc can be aided by laboratory tests, histopathological examination, and imaging studies. The diagnosis of EF specifically requires the exclusion of SSc and typically requires magnetic resonance imaging or en bloc fascial biopsy of affected areas. Here, the authors present a 75-year-old woman with a painful, violaceous rash on the legs and abdomen, leg swelling, and tightness around her upper abdomen. Review of systems revealed decreased appetite, unintentional weight loss, and shortness of breath on exertion. Physical examination showed a faint violaceous rash on the abdomen and legs as well as abdominal distention. The patient’s clinical picture was complicated by worsening of the rash, development of chronic cough, continued unintentional weight loss, decreased appetite, early satiety, dry eyes, and dry mouth. An autoimmune process was considered, and the patient was seen by rheumatology, where an appropriate workup excluded localized scleroderma and SSc. EF was suspected and supported by magnetic resonance imaging findings showing fascial edema. En bloc fascial biopsy of the right thigh did not reveal classic EF findings.

Introduction Transgender and gender-diverse (TGD) individuals frequently encounter discrimination in health care settings. The Veterans Health Administration (VA) is committed to addressing the health disparities experienced by TGD veterans. The purpose of this study was to explore the experiences of TGD veterans with LGBTQ+ veteran care coordinators. Methods The authors conducted semi-structured interviews with TGD veterans with depression between January and March 2022. Participants were recruited with assistance from the VA’s network of LGBTQ+ veteran care coordinators. Interviews were recorded, transcribed, and analyzed. Results Twenty-six TGD veterans participated in the study, with a range of experiences, both positive and negative, with LGBTQ+ veteran care coordinators. Veterans spoke of the role of coordinators in educating both patients and clinicians about TGD health care needs. Participants who expressed dissatisfaction with their coordinators highlighted the need for a clearer definition and communication of coordinator duties. Conclusions This study highlights the important roles played by the VA LGBTQ+ care coordinators in addressing the needs of TGD veterans. The study also points to an immense need for clinician education in TGD care. Further training and education are recommended to improve equitable care for TGD veterans.

Background Multiple studies have demonstrated associations between psychiatric conditions and Parkinson’s disease (PD) development; fewer have examined psychotic-spectrum disorders and PD development. Objective The objective was to assess the prevalence of psychotic-spectrum disorders with and without depression and anxiety preceding a PD diagnosis. Methods In this retrospective, case–control study of adults > 60 years of age, cases were identified by PD diagnosis and controls were identified in a 3:1 ratio by ambulatory encounter from 2015 to 2020. Psychiatric conditions were identified by diagnosis code up to 5 years prior to the index date. Conditional logistic regression was conducted to assess associations. Results Among 13,998 patients, the odds of PD were 76% (95% confidence interval = 1.39–2.22) higher among those with psychotic-spectrum diagnoses. An additional anxiety diagnosis was associated with 166% (95% confidence interval = 1.35–5.25) higher odds of PD. Conclusions Awareness of psychiatric conditions, including psychotic-spectrum disorders with comorbid anxiety, can stratify individuals at higher risk of developing PD.