Research

Mortality study reinforces safety of COVID-19 vaccinations

Kaiser Permanente researchers reported that people who were vaccinated for COVID-19 had lower non-COVID-19 death rates than did people who were not vaccinated. The study, which was conducted at 7 Vaccine Safety Datalink (VSD) sites, covered the period from December 2020 through July 2021 and examined the electronic health records of more than 11 million persons. Few studies to date have evaluated mortality from causes other than COVID-19. The study findings provide reassurance that vaccines are safe and can help to allay concerns about vaccine safety, which contribute to vaccine hesitancy.
Xu et al. MMWR Morb Mortal Wkly Rep. 2021 Oct;70(43):1520–1524.
Funding: The VSD is a collaborative project between CDC’s Immunization Safety Office and 9 health care organizations.

COVID-19 Delta variant associated with increased risk for severe disease

Researchers from the CDC and KPSC found that COVID-19 cases caused by the Delta variant increased rapidly from 0% to 95% of all infections from April 15 to July 21, 2021. Infections attributed to the Delta variant were particularly common among persons ages 18 to 44. The study was published in the CDC’s Morbidity and Mortality Weekly Report. The findings reinforce the importance of continued monitoring of new variants of SARS-CoV-2, in conjunction with effective preventive measures, to control the COVID-19 pandemic.
Malden et al. MMWR Morb Mortal Wkly Rep. 2012 Oct;70(40):1415–1419.

COVID-19 severity associated with air pollution from nonfreeway traffic

A study of KPSC members diagnosed with COVID-19 found that patients who had recently lived in areas with high levels of air pollution from roadways other than freeways had a higher risk for severe outcomes. Using a patient’s residential address history in the electronic health record, the researchers found that patients exposed to more air pollution were more likely to have received intensive respiratory support, been admitted to an intensive care unit, or died of COVID-19. The study findings bring new attention to the importance of air pollution from neighborhood streets and major roads with many stoplights.
Chen et al. Environ Int. 2021 Dec;157:106862.
Funding: National Institute of Environmental Health Science

Risk of severe COVID-19 higher for patients who recently needed asthma care

A study of KPSC members diagnosed with COVID-19 found that patients with active asthma, that is, those who had visited a health care provider for asthma care in the previous 12 months, had a higher risk for severe COVID-19 outcomes than patients without asthma. Among patients with active asthma, using asthma medications lowered the risk for severe outcomes. Earlier studies of associations between asthma and COVID-19 severity had not considered whether patients had active disease. The findings suggest that patients with asthma, especially those who require clinical care, should continue taking their control medications during the COVID-19 pandemic.
Huang BZ et al. J Allergy Clin Immunol Pract. 2021 Oct;9(10):3621-3628.e2.
Funding: National Institute of Environmental Health Science

Pfizer-BioNTech COVID vaccine effectiveness wanes over time

In a study published in The Lancet, KPSC researchers reported that the Pfizer-BioNTech COVID-19 vaccine is highly effective against hospitalization for 6 months after full vaccination, even in the midst of widespread transmission of the delta variant. However, vaccine effectiveness against infection started very high and declined over time. If the delta variant had escaped protection from the vaccine, researchers would have seen low vaccine effectiveness at all time points. The findings suggest that reductions in vaccine effectiveness against SARS-CoV-2 infections over time is primarily due to waning immunity rather than the delta variant escaping vaccine protection.
Tartof SY et al. Lancet. 2021 Oct;398(10309):1407-1416.
Funding: Pfizer, Inc.

Pneumonia vaccine may affect course of COVID-19

In a study published in The Journal of Infectious Diseases, researchers found that one type of pneumonia vaccine, the PCV13 vaccine, may affect the course of COVID-19 for some older adults. Bacteria like Streptococcus pneumoniae, called pneumococci, are known to interact with influenza, RSV, and several other viruses in the airway, but their contribution to SARS-CoV-2 infection and pathogenesis has not been widely investigated. In this study, researchers found that the PCV13 vaccine, which protects against 13 types of pneumococci, lowered the incidence of COVID-19 diagnoses along with hospitalizations and death in older adults.
Lewnard JA et al. J Infect Dis. 2021;jiab128.
Funding: Pfizer, Inc.

Vulnerable populations sought virtual care during pandemic

In a study that spanned age, race/ethnicity, and income groups, researchers found that Hispanic patients and low-income patients had the largest increase in telehealth visits in response to the COVID-19 pandemic. Telehealth visits increased in these patient groups by about 300% compared with the prepandemic period. Although it was known that outpatient visits decreased dramatically and telehealth visits increased during the pandemic, it was unclear whether these changes differed according to patient demographics and socioeconomic status. The findings on the use of telehealth visits during the pandemic suggest that virtual care may be a way to reduce health care disparities.
Qian et al. J Med Internet Res. 2021;23(9):e29959.

Young children gained weight during the pandemic

Children, especially those ages 5 to 11 years, gained excess weight during the COVID-19 pandemic. In a study of nearly 200,000 children published in JAMA, researchers also reported that the number of the youngest children who fell into the categories of being overweight and obese increased by almost 9%. Few studies had previously focused on the weight of U.S. children and adolescents during the pandemic. If generalizable to all children in the United States, the findings suggest that intervention efforts to address weight gain related to COVID-19 may be needed.
Woolford SJ et al. JAMA. 2021;326(14):1434-1436.
Funding: Kaiser Permanente Direct Community Benefit funds

COVID-19 outcomes are more severe for people of color

A study published in Annals of Internal Medicine found that Hispanic patients were more likely to test positive or be diagnosed with COVID-19 than White patients and Asian, Black, and Pacific Islander patients were more likely to have severe outcomes than White patients. These disparities remained even after adjustment for known health risk factors. Prior research was limited by small, nondiverse samples, a shortcoming that researchers addressed in this study by using electronic health record data from the diverse KPSC membership. The findings underscore health inequities during the COVID-19 pandemic and the need for culturally appropriate pandemic responses and vaccination strategies.
Nau C. Ann Intern Med. 2021 Aug;174(8):1183-1186.
Funding: Roche–Genentech

Child vaccination rates recovering since pandemic’s early days

A study of trends in vaccination of children compared 3 timepoints during the pandemic in 2020—before the declaration of a national state of emergency, during the stay-at-home order, and during reopening—with similar timepoints in 2019. Even though the number of children being vaccinated recovered in younger children during reopening, vaccination coverage did not return to prepandemic levels in most age groups and continued to decline in some. The findings imply that additional strategies like immunization tracking and reminders for needed vaccinations, particularly during virtual visits, will be required during a pandemic to reduce the risk for outbreaks of vaccine-preventable diseases.
Ackerson BK. Pediatrics. 2021;148(1):e2020047092.

Physical activity may reduce risk of poor COVID-19 outcomes

Using data on physical activity collected during outpatient visits, researchers found that regular physical activity provided strong protection from hospitalization, intensive care unit admission, and death from COVID-19. The study of nearly 50,000 people with COVID-19 found that even exercising inconsistently lowered the odds for severe COVID-19 outcomes compared with people who were not active at all. Other than being over the age of 60 or having a history of organ transplantation, being consistently inactive conferred the highest risk for death from COVID-19. Physical activity can be an important component of recommendations to reduce severe COVID-19 outcomes.
Sallis R et al. Br J Sports Med. 2021;55:1099-1105.

Impact of COVID-19 on cervical cancer screening rates

During California’s stay-at-home order in 2020, cervical cancer screening rates in about 1.5 million women in the KPSC network decreased by about 80% and then returned to near normal after reopening. The COVID-19 pandemic has highlighted a critical need for effective cancer screening methods for patients who cannot or prefer not to have in-person appointments. Health care systems can take steps such as enhancing efforts to reach overdue patients, evaluating women at high risk first, and using telemedicine or other innovative technologies to reach women.
Miller MJ et al. MMWR Morb Mortal Wkly Rep. 2021;70:109-113.

Effectiveness of the Moderna COVID-19 vaccine against emerging variants of SARS-CoV-2

Two doses of the Moderna COVID-19 vaccine were highly effective against all SARS-CoV-2 variants tested. In the study, vaccine effectiveness against hospital admission was 97.5%. Of cases admitted to the hospital with the Delta variant, only 3.5% had received 2 doses of the vaccine, and no hospital deaths occurred among people who had received 2 doses. Vaccine effectiveness against infection with the Delta variant moderately declined with time since vaccination. These findings add to the literature specific to the Moderna COVID-19 vaccine and support recommendations for a booster dose.
Bruxvoort KJ et al. BMJ. 2021;375:e068848.
Funding: Moderna Inc.

Real-world effectiveness of the Moderna COVID-19 vaccine against COVID-19

The interim results of a study conducted by KPSC researchers confirmed high Moderna COVID-19 vaccine effectiveness up to 5 months after the second dose. The study findings, from a large, diverse population with a broad range of underlying conditions, add to the evidence for the real-world effectiveness of the Moderna COVID-19 vaccine. Effectiveness was 87% against COVID-19 infection, 96% against COVID-19 hospitalization, and 98% against COVID-19 death. Vaccine effectiveness remained high across age, sex, and racial/ethnic subgroups.
Bruxvoort KJ et al. Lancet Regional Health Americas. 2021;100134. doi:10.1016/j.lana.2021.100134
Funding: Moderna Inc.

Rates of acute myocardial infarction during the COVID-19 pandemic

Among KPSC patients, rates of hospital admissions or emergency department visits for heart attacks dropped significantly after the implementation of stay-at-home orders during the COVID-19 pandemic. Researchers compared rates of heart attacks in adults before and during the COVID-19 pandemic in 2020 and during the same period in 2019. The findings suggest that public health messaging encouraging people to seek emergency care for life-threatening conditions, even during stay-at-home orders, is necessary and important.
Mefford MT et al. Perm J. 2021;25:21.074.
Funding: Southern California Permanente Medical Group

Associations of physical activity, time spent outdoors in nature, and symptoms of depression and anxiety during COVID-19 quarantine

During the lockdown period of the COVID-19 pandemic, people who reported no mild, moderate, or vigorous exercise had higher depression and anxiety scores than people who exercised more. Less time spent outdoors was also associated with higher depression and anxiety scores compared with no change in time outdoors. More than 20,000 people without COVID-19 symptoms from 6 regions served by Kaiser Permanente participated in the study. The findings suggest that even during an active pandemic or other public health crisis, people should be encouraged to be physically active to help maintain their physical and mental health.
Young DR et al. Prev Med. 2022;154:106863.
Funding: Kaiser Permanente Research Bank

Sleep aids increase fracture risk in breast cancer survivors

About 40% of breast cancer survivors use prescription medications to alleviate sleep problems, but these medications can increase their risk for bone fractures, according to research from KPSC published in Breast Cancer Research and Treatment. Breast cancer survivors are more likely to have insomnia than the general population, and they may be vulnerable to bone fractures because certain cancer treatments like aromatase inhibitors can weaken bones. Sleep problems among women who have survived breast cancer might be better resolved by nonmedical approaches, such as cognitive behavioral therapy, increasing daytime physical activity, and limiting caffeine and alcohol use.
Haque R et al. Breast Cancer Res Treat. 2021;190:541–548.
Funding: Kaiser Permanente Southern California, Research & Evaluation

Kaiser Permanente members have higher survival rate after cancer diagnosis

Among insured cancer patients in Southern California, those who were diagnosed and treated at Kaiser Permanente had better survival rates, especially Black and Latinx patients, a difference that held within each age category, racial/ethnic group, and stage at diagnosis. Inadequate health insurance coverage is a major contributor to disparities in cancer outcomes. The study findings, which were published in The American Journal of Managed Care, suggest that vertically integrated health care delivery systems like KPSC may be well positioned to help reduce disparity gaps in cancer outcomes.
Cooper RM et al. Am J Manage Care. 2021;27(5).
Funding: Kaiser Permanente Southern California

Infant lung disease rates drop dramatically over 10-year effort

Neonatologists at KPSC completed a quality improvement study of a new system of care for prematurely born infants that led to a drop in bronchopulmonary dysplasia (BPD), a chronic lung condition in preterm infants, from 31% to less than 2%. Rates of BPD have changed little in the United States in the last decade. The new system includes a comprehensive clinical decision roadmap and BPD prevention bundle. The adoption of a proactive care approach through a multidisciplinary team could have huge benefits for infants and their families within Kaiser Permanente neonatal intensive care units and throughout the country.
Villosis MFB et al. JAMA Netw Open. 2021;4(6):e2114140

Bariatric surgery associated with better health for mothers

Women with obesity who undergo bariatric surgery before pregnancy may have improved outcomes, such as a reduced risk for serious pregnancy-related blood pressure conditions and lower instances of a newborn needing care in the neonatal intensive care unit. However, these women may also be at increased risk of heavy bleeding and of delivering small infants. The study, published in the , fills a gap in research on the effects of bariatric surgery on perinatal outcomes. Women with severe obesity who undergo bariatric surgery may experience several benefits on pregnancy outcomes but should be monitored closely.
Getahun et al. Am J Obstet Gynecol. June 30, 2021.
Funding: Kaiser Permanente Direct Community Benefit funds

Where you live may affect your long-term survival after heart attack

A study of ≈31,000 KPSC members showed that Black patients from disadvantaged neighborhoods were significantly more likely to die within 5 years of surviving a heart attack than White patients. To explore sociodemographic factors outside the health system, investigators considered the effects of neighborhood resources on patient outcomes using a metric of neighborhood disadvantage called the Area Deprivation Index. Because all patients in the study were KPSC members, they had equal access to health care and were treated at the same medical facilities. The findings suggested that the neighborhood in which a patient lives may affect their long-term health outcomes.
Goitia JJ et al. J Am Coll Cardiol. 2021 Aug;78(6):632–633.

Researchers examine association of preterm birth and chemicals in flame-retardant fabrics

Chemical pollutants, such as polybrominated diphenyl ethers (PBDEs) that are widely used as flame retardants, may increase the risk for preterm birth. In this study, KPSC researchers found that pregnant women with high levels of PDBE-47 were at increased risk of giving birth early in the pregnancy. Nearly all plasma samples from the women had detectable levels of PBDE-47 in the first trimester. High levels of PBDEs had previously been associated with lower birth weight, but the effects on preterm birth had been less clear. One way to reduce exposure to PBDEs is to replace furniture containing flame-retardant material.
Peltier MR et al. J Perinat Med. 2021 Jan 4;49(4):439-447.
Funding: National Institutes of Health, National Institute of Environmental Health Sciences

Rates of heart failure deaths lower at Kaiser Permanente Southern California than U.S.

Age-adjusted rates of death from heart failure were lower among KPSC members ages 45 and older from 2001 to 2017 than in the general U.S. population. Although mortality due to cardiovascular disease has declined in past decades, death from heart failure has begun increasing. Researchers designed this study to compare mortality in KPSC members and the populations of California and the United States. Given the aging of the U.S. population and the increasing prevalence of heart failure, findings such as these can help to inform health care policy and practice.
Mefford MT et al. BMC Cardiovasc Disord. 2021;21:261.

Most patients’ end-of-life care wishes are met

To answer the question of how well patients’ end-of-life care wishes are met, researchers surveyed next of kin about their loved ones’ experiences in the last year of life. The findings suggest that most older adults (89%) are receiving care in line with their wishes. In addition, more than 80% of respondents in the study reported that their loved ones had participated in end-of-life discussions and had received the right amount of care. Clinician training on end-of-life care should continue to encourage physicians to start informed discussions with patients about their preferences at the appropriate time.
Glass DP et al. JAMA Netw Open. 2021;4(4):e213053.
Funding: Southern California Permanente Medical Group

Diabetic eye damage reflects future cardiovascular risks

In a study published in Ophthalmology, researchers reported that people with more severe diabetic retinopathy, an eye condition that can lead to vision loss, are at greater risk for heart attacks, strokes, congestive heart failure, and death, even after accounting for traditional diabetic and cardiovascular risk factors. The new study builds on earlier research showing an association between diabetic retinopathy and the risk of vascular events, demonstrating that higher risks of retinopathy may confer higher risk of future systemic disease. Incorporating retinal information into clinical risk prediction tools could help to predict which patients with diabetes are most at risk for future disease.
Modjtahedi BS et al. Ophthalmology. 2021 Aug;128(8):1169-1179.
Funding: Southern California Permanente Medical Group Clinician Investigator Program

Self-order option boosts colorectal cancer screening rates

A study of KPSC members showed that allowing patients to self-order a colorectal cancer screening test online improves rates of testing completion. Members who ordered a testing kit directly from the Kaiser Permanente patient portal using an embedded order button were more likely to take the test and send it in than those mailed a test when they were due for screening. Despite significant investment in colorectal cancer screening, 40% of U.S. adults are not up to date. The ability to self-order screening kits may act as a “commitment device” that can complement existing colorectal cancer outreach strategies.
Hahn EE et al. J Gen Intern Med. 2021;36:952–960.
Funding: Kaiser Permanente Southern California Care Improvement Research Team

Gastric bypass vs vertical sleeve gastrectomy for hypertension remission and relapse

In a study of almost 5000 patients with high blood pressure who underwent either vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) surgery, researchers found that both operations were equally effective for hypertension remission (43% for VSG, 42% for RYGB) after 5 years. However, many patients experienced relapse of their high blood pressure, so that the durable remission rate was only 18% for VSG and 17% for RYGB. The research was part of the ENGAGE CVD cohort study. Future studies will examine why most bariatric patients did not experience durable remission of their high blood pressure.
Reynolds K et al. Hypertension. 2021 Sep;78(4):1116-1125.

Does hospital admission for chest pain improve patient outcomes?

Among patients presenting to 1 of 13 KPSC emergency departments (EDs) with chest pain who were not diagnosed as having a heart attack, patient outcomes did not differ according to whether the patients were admitted for observation or discharged for outpatient follow-up. The risk for major adverse cardiac events appears to be quite low in ED patients with chest pain who are not having a heart attack. These results question why chest pain is the top reason for hospitalization or observation in the United States, when it is unclear how hospitalization improves patient outcomes.
Sharp AL et al. J Gen Intern Med. 2021 May 14. doi: 10.1007/s11606-021-06841-2
Funding: National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R01HL134647

Environmental and social health determinants of pregnancy outcomes related to COVID-19 pandemic

Adverse pregnancy outcomes such as gestational diabetes, preeclampsia and eclampsia, preterm birth, antepartum depression, and postpartum depression are likely worsened by the COVID-19 pandemic, and ambient air pollution may increase this risk further. In an extension of a previous study, investigators will examine the link between air pollution and adverse pregnancy outcomes during the pandemic, taking into account maternal comorbidities and sociodemographic factors. The study results can help to inform public health practices to reduce adverse pregnancy outcomes, particularly while COVID-19 transmission remains widespread.
Principal investigators: Darios Getahun, MD, PhD, MPH, and Jun Wu, PhD (University of California, Irvine)
Funding agency: National Institute of Environmental Health Sciences

Evaluating influenza and COVID-19 vaccine effectiveness in preventing laboratory-confirmed illness in a Southern California population

The U.S. Flu VE (Vaccine Effectiveness) Network provides estimates of the vaccine effectiveness of licensed flu and COVID-19 vaccines by age group and by influenza type and subtype. As one of 7 study sites in the network, KPSC will evaluate vaccine effectiveness for influenza and COVID-19. These studies help to determine the effectiveness of the vaccines used in clinical practice and monitor health problems after vaccination.
Principal investigator: Sara Tartof, PhD, MPH
Funding agency: Centers for Disease Control and Prevention

Text and web-based data collection for adverse events after SARS-CoV-2 vaccination in the Vaccine Safety Datalink

The Vaccine Safety Datalink (VSD) is a collaborative project between the Immunization Safety Office of the CDC and 9 health care organizations to monitor the safety of vaccines and conduct studies about rare and serious adverse events after immunization. In this project, investigators from KPSC will design, test, and expand a vaccine safety monitoring system for COVID-19 vaccines that uses text messaging and web applications. Collecting data on adverse events by use of digital tools will allow the VSD to rapidly monitor and identify potential safety problems and provide timely information on COVID-19 vaccines.
Principal investigator: Sara Tartof, PhD, MPH
Funding agency: Centers for Disease Control and Prevention

Implementation strategies for improving HPV vaccination

Millions of US teens remain at risk of developing human papillomavirus (HPV)-related cancers because they do not complete the recommended series of HPV vaccination. Researchers at KPSC will study whether tailoring an intervention to a specific location and context can better remove barriers to HPV vaccination and improve recommendations made by health care providers. The study findings can provide much needed guidance on strategies for optimizing HPV vaccination.
Principal investigators: Chun Chao, PhD, MS, and Erin Hahn, PhD, MPH
Funding agency: National Cancer Institute

Evaluating broad-spectrum antibiotic use and high birth weight as potential risk factors for early-onset colorectal cancer

The incidence of colorectal cancer in adults younger than 50 (called early-onset colorectal cancer) has been rising but it is unknown why. By studying >1,000 people diagnosed with this disease, researchers will test whether risk factors like greater exposure to broad-spectrum antibiotics and high birth weight increase risk. The insights gained can help to explain the increase in cases of early-onset colorectal cancer and improve early screening and prevention.|
Principal investigator: Chun Chao, PhD, MS
Funding agency: National Cancer Institute

Reducing childhood obesity through motivational interviewing

Rates of childhood obesity in the United States remain at historic highs, and although successful treatment approaches that rely on engaging and motivating parents exist, duplicating these approaches in real-world settings remains a challenge. In 18 randomly chosen pediatric clinics in KPSC, researchers will use motivational interviewing of parents by primary care practitioners and trained wellness coaches. If successful, the intervention will be shared with other providers and translated for use in other settings to reduce obesity in children.
Principal investigator: Corinna Koebnick, PhD, MSc
Funding agency: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Improving blood pressure screening and treatment strategies in young adults

About 20% of US young adults have high blood pressure (BP), but the best ways to screen and treat high BP in young adults are unknown. To address this lack of evidence, researchers will study optimal screening intervals and identify subgroups of young adults at high risk for heart disease who may benefit the most from BP-lowering medications. The study findings can help to inform future guidelines, reduce health inequities by directing screening and treatment to high-risk subgroups, and improve the heart health of US young adults.
Principal investigators: Jaejin An, PhD, and Yiyi Zhang, PhD, MS (Columbia University)
Funding agency: National Heart, Lung, and Blood Institute

Optimizing risk assessment for incident and recurrent atherosclerotic cardiovascular disease

Current cholesterol treatment guidelines rely on risk assessment to guide decisions about lipid-lowering therapies, but the tools used for risk prediction lack data on social determinants of health and important US ethnic groups. Using large, contemporary sources of data that are racially and ethnically diverse, researchers will develop more refined approaches to risk assessment. By improving the precision of cholesterol treatment guidelines, the study findings can help to direct lipid-lowering therapies to high-risk groups, ultimately improving health outcomes and narrowing health inequities.
Principal investigators: Jaejin An, PhD, and Yiyi Zhang, PhD, MS (Columbia University)
Funding agency: National Heart, Lung, and Blood Institute

Air pollution and pregnancy complications in complex urban environments

Pregnancy complications like gestational diabetes, gestational hypertension, and preeclampsia and eclampsia are major causes of morbidity and mortality in pregnant women. Previous studies that examined how air pollution affects pregnancy had limitations. To address these limitations, KPSC researchers will use state-of-the-art modeling and statistical methods, such as measuring individual pollutants instead of mixtures and considering the effects of the weather, the built environment (like the greenness or walkability of a neighborhood), and socioeconomic status. The data can help to identify pregnant women at risk and inform decisions about how to protect these women from the adverse effects of environmental pollution.
Principal investigators: Darios Getahun, MD, PhD, MPH, and Jun Wu, PhD (University of California, Irvine)
Funding agency: National Institute of Environmental Health Sciences

Food prescriptions to promote affordable healthy diets in multi-generational Latino households

Latino families are unequally affected by obesity, type 2 diabetes, nonalcoholic fatty liver disease, and dyslipidemia, and diet is a major contributing factor to these disparities in chronic disease risk. In this trial, multi-generational Latino households will be provided with culturally sensitive meal planning, including information on portion sizes, and grocery delivery. The study researchers will assess whether such “food prescriptions” can improve diet quality, weight control, and chronic disease risk. Food prescriptions could provide a scalable and sustainable model to improve diet, health, and well-being in Latino families.
Principal investigator: Deborah Cohen, MD, MPH
Funding agency: National Institute on Minority Health and Health Disparities