Importance:Contemporary data regarding the safety and quality of acute hospital care at home for heart failure (HF) are limited. Objective:To compare safety and quality outcomes of an advanced medical care at home (AMCAH) program to brick-and-mortar (BAM) hospitalization for HF. Design, Setting, and Participants:This retrospective cohort study was conducted at 11 service areas within Kaiser Permanente Southern California. Participants were adult patients hospitalized with a principal diagnosis of HF between February 2023 and December 2024. Analysis included propensity score matching and both intra- and inter-service area comparisons. Data were analyzed from April 2025 through March 2026. Exposure:KPSC's AMCAH program vs continued BAM hospitalization. Main Outcomes and Measures:The primary outcome was a composite outcome of all-cause escalation, readmission, or mortality at 30 days. Secondary outcomes included individual components of the composite outcome at 30 days, the composite outcome and its individual components at 60 days, days alive and out of hospital (DAOH) at 30 and 60 days, and guideline-directed medical therapy (GDMT) score at 30 and 60 days. Results:In the intra-service area comparison, 307 pairs were matched (mean [SD] age, 75 [12.6] years; 374 [61%] male). By 30 days, there were 73 composite outcome events (24%) in the AMCAH group, including 18 (6%) escalations, compared with 80 events (26%) in the BAM group (odds ratio [OR], 0.89 [95% CI, 0.61 to 1.28]); individual components were directionally consistent. Participants in the AMCAH group had a mean (SD) of 28.2 (4.9) vs 28.3 (4.2) DAOH in the BAM group (β = -0.12 [95% CI, -0.85 to 0.60]). The mean (SD) GDMT score was 3.2 (2.2) in the AMCAH group vs 3.1 (2.5) in the BAM group (β = 0.13 [95% CI, -0.23 to 0.50]). In the inter-service area comparison, 239 pairs were matched. By 30 days, there were 53 composite outcome events (22%) in the AMCAH group, including 12 participants (5%) with escalations, vs 59 participants (25%) in the BAM group (OR, 0.87 [95% CI, 0.57 to 1.34]). Participants in the AMCAH group had a mean (SD) of 28.0 (5.6) DAOH vs 28.2 (4.5) DAOH in the BAM group (β = -0.21 [95% CI, -1.12 to 0.70]). The mean (SD) GDMT score was 3.0 (2.1) in the AMCAH group vs 2.9 (2.4) in the BAM group (β = 0.11 [95% CI, -0.29 to 0.51]). No significant differences were observed at 60 days in either comparison. Conclusions and Relevance:In this cohort study among patients hospitalized with HF, no differences in all-cause readmissions, mortality, DAOH, or GDMT scores were seen at 30 or 60 days after discharge among individuals who received AMCAH vs those who underwent continued BAM hospitalization, highlighting the safety and quality of an AMCAH program with clinician-determined eligibility.
In recent years, treatment options for opioid use disorder have expanded significantly with the availability of a wide range of medication formulations. Extended-release buprenorphine is a long-acting, injectable medication used to treat moderate-to-severe opioid use disorder by providing a steady, continuous dose of buprenorphine over several weeks. Needle-related anxiety and injection-site pain are frequent adverse events that can significantly impede patient adherence to extended-release buprenorphine therapy. Topical and injectable anesthetics can enhance patient comfort and support greater adherence to the treatment protocol. This report presents two cases detailing a protocol to minimize pain from extended-release buprenorphine injections. This protocol utilizes a combination of topical anesthetic skin refrigerant (vapocoolant spray), local anesthetic, and an alkalizing agent, using specific techniques to minimize discomfort. After achieving adequate local anesthesia, extended-release buprenorphine therapy was well-tolerated, with participants reporting an essentially painless procedure. Topical and injectable anesthetics can improve patient comfort during extended buprenorphine administration, boosting adherence to opioid maintenance therapy.
Background: Levonorgestrel-releasing intrauterine systems (LNG-IUS) are considered off-label and investigational in the United States for treating non-atypical endometrial hyperplasia (NAEH), atypical endometrial hyperplasia (AEH), and early-stage endometrial cancer (EC), though evidence suggests potential benefit. Objectives: To summarize the available evidence regarding the use of LNG-IUS, with or without other therapies, for the treatment of NAEH, AEH, and early-stage (FIGO I/IA) EC. Design: Systematic literature review and meta-analyses. Data sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) were searched from database inception through May 2022. Methods: Data from studies reporting complete outcome definitions and study populations that were aligned with the 2014 World Health Organization (WHO) endometrial hyperplasia classification criteria or were defined as FIGO grade 1 stage I/IA EC were extracted and assessed in random-effects meta-analyses. A risk of bias assessment was completed using recommended study-design-specific tools. Results: 1085 unique records were reviewed; 80 publications were included, with data from 30 assessed in meta-analyses: NAEH, n = 14; AEH, n = 21; EC, n = 5. Complete response (CR) rates at 12 months were high: 86.3% (95% confidence interval (CI): 78.50%–91.55%; n = 342) of patients with NAEH, 83.9% (95% CI: 71.95%–91.34%; n = 196) of patients with AEH, and 51.1% (95% CI: 16.30%–84.90%; n = 20) of patients with EC. LNG-IUS was associated with significantly greater odds of CR at 12 months compared to oral progestins in NAEH and AEH populations, with odds ratios ranging from 2.16 (95% CI: 1.38–3.36) to 4.56 (95% CI: 2.57–8.09). No comparative data were available for EC. Safety information was consistent with that of approved LNG-IUS indications. Risk of bias varied across study designs. Conclusion: The findings suggest that NAEH, AEH, and early-stage (FIGO I/IA) EC can be effectively treated with LNG-IUS, with the evidence being strongest for NAEH and weakest for EC. Greater availability of LNG-IUS treatment could provide meaningful benefit to these patients. Trial registration: Not applicable.
Objective:This study aimed to examine adverse perinatal outcomes by gestational surrogacy status among in vitro fertilization (IVF) pregnancies. Study Design:This was a retrospective cohort study of IVF pregnant women (2008-2023) who received obstetrical care at Kaiser Permanente Southern California, a large integrated health care system. Unstructured clinical notes abstracted from electronic health records were analyzed using natural language processing and chart reviews to identify IVF and surrogate pregnancy status. This study analyzed 997 (6.3%) surrogate pregnancies among 15,822 IVF pregnancies. Births at <20 weeks of gestation were excluded. Adjusted risk ratios (aRRs) derived from robust Poisson regression models were used to describe the magnitude of associations between surrogacy status and adverse perinatal outcomes among IVF pregnancies. Results:Compared with non-surrogate pregnancies, women with gestational surrogacy were younger (<35 years, 46.7% vs. 66.6%), non-Hispanic White (29.8% vs. 39.8%), Hispanic (38.3% vs. 45.8%), privately insured (11.3% vs. 21.4%), and had multiple gestations (10.9% vs. 16.5%), respectively. They were less likely to smoke (0.8% vs. 0.4%) or drink alcohol (31.0% vs. 18.9%) during pregnancy. IVF gestational surrogacy was not associated with an increased risk of placenta previa (aRR: 1.20; 95% confidence interval [CI]: 0.98-1.47), placental abruption (aRR: 1.07; 95% CI: 0.63-1.81), or preterm birth (PTB; aRR: 1.03, 95% CI: 0.91-1.16) but was significantly associated with decreased risk of gestational diabetes (aRR: 0.82; 95% CI: 0.69-0.97), small for gestational age/intrauterine growth restriction (SGA/IUGR; aRR: 0.72; 95% CI: 0.61-0.84), preeclampsia/eclampsia (aRR: 0.70; 95% CI: 0.56-0.87), preterm premature rupture of membranes (PPROM; aRR: 0.56; 95% CI: 0.40-0.77), and chorioamnionitis (aRR: 0.42; 95% CI: 0.22-0.79). Conclusion:Gestational surrogacy had lower odds of selected adverse perinatal outcomes that were not previously reported. This information may be helpful to patients considering gestational surrogacy as a reproductive option. Key Points:· Surrogate pregnancy was not associated with placental abruption, placenta previa, or PTB.. · Surrogate pregnancy was inversely linked to gestational diabetes mellitus, SGA, preeclampsia, PROM, and chorioamnionitis.. · Gestational surrogacy had lower odds of certain adverse perinatal outcomes not previously reported..
