Preferences for cardiopulmonary resuscitation

PURPOSE

To examine nurse-patient communication about preferences for cardiopulmonary resuscitation (CPR).

DESIGN

Prospective cohort. Sampled were patients and nurses caring for patients enrolled in SUPPORT (1989-91), a multicenter study of seriously-ill hospitalized adults at four U.S. hospitals.

METHODS

Information about patient preferences was obtained by interviews with patients and their designated surrogates. For selected patients, nurses were interviewed prospectively about their understanding of patients' preferences and whether they discussed these preferences with their patients. Nurse demographic information was obtained by questionnaire. Additional patient data were obtained by interview and chart review. Logistic regression was used to identify independent correlates of nurse-patient communication and nurses' understanding of patients' preferences.

FINDINGS

For 1,763 study patients, 1,427 nurse interviews (response rate 81%) were obtained. The median age of interviewed nurses was 29 years; 96% were women, 68% had a bachelor's or master's degree, and 62% had worked for 5 years or more as a nurse. Nurses reported discussions about CPR with 13% of their patients, and these discussions were more likely if the nurse thought the patient did not want CPR (adjusted odds ratio [AOR] 2.68; 95% CI 1.84 to 3.90), if the nurse had spent more time with the patient (AOR 1.05; 95% CI 1.02 to 1.08) per 5 additional days, if the patient had metastatic cancer (AOR 3.56; 95% CI 1.86 to 6.78), or if the patient was in an intensive care unit at the time of study entry (AOR 2.08; 95% CI 1.26 to 3.42). Diagnosis and study site were also associated with nurses' reports of discussions with patients. Of 551 patients with available data, 58% (n = 317) wanted CPR and 30% (n = 164) did not. Nurses understood patients' CPR preferences correctly for 74% of the patients. Nurses were more likely to understand patients' preferences to forego CPR if the patient was 75 years of age or older (AOR 6.6; 95% CI 2.0 to 22.0) or if the nurse and patient had discussed the patient's preferences (AOR 25.3; 95% CI 6.5 to 98.6) or if the patient had cancer (AOR 10.9; 95% CI 2.3 to 50.1). Nurses' understanding of patients' preferences for CPR was no better than that of physicians or patients' surrogate decision-makers.

CONCLUSIONS

In this sample of seriously ill hospitalized adults, discussions between patients and nurses about CPR were infrequent. Nurses' understanding of patients' preferences for care was similar to that of physicians and patients' surrogate decision-makers. Educational interventions should focus on increasing the frequency of nurse-patient discussions about end-of-life care and improving nurses' understanding of patients' preferences for care.

Brief communication: detecting depression: providing high quality primary care for HIV-infected patients

Depression is common among HIV-infected patients, but little is known about risk factors for depression in this population. Several studies before protease inhibitors became available have reported inconsistent associations between depression and disease severity. Delivering high quality HIV care includes adequate detection and treatment of depression. The objective of this study was to describe the prevalence and correlates of depression among a contemporary group of HIV-infected patients. The setting and design for the study was a chart abstraction for HIV-infected patients in a primary care practice in Boston, Mass, in June 1997. Among 275 HIV-infected patients, depression was documented in 147 patient charts (53%), half of whom (n = 73, 27%) also received antidepressant medications. We used multivariable logistic regression to identify risk factors for depression among patients with both a chart diagnosis of depression and current antidepressant medication use. We observed increased risk of depression among patients with a history of substance use (odds ratio 2.7, 95% confidence interval 1.5-4.7), recent medical hospitalization (2.6, 1.4-5.0), and homosexual risk behavior (2.1, 1.1-4.2). Depression remains a common problem for HIV-infected patients, particularly among those with history of substance abuse, medical hospitalization, or homosexual risk behavior. Routine screening for depression in this population with special attention to those at higher risk may offer opportunities for earlier diagnosis and treatment.

Relationship between smoking and weight control efforts among adults in the united states

BACKGROUND

The effect of weight control concerns on smoking among adults is unclear. We examined the association between smoking behavior and weight control efforts among US adults.

METHODS

A total of 17 317 adults responded to the Year 2000 Supplement of the 1995 National Health Interview Survey (83% combined response rate). Respondents provided sociodemographic and health information, including their smoking history and whether they were trying to lose weight, maintain weight, or gain weight.

RESULTS

Rates of smoking were lower among adults who were trying to lose or maintain weight than among those not trying to control weight (25% vs 31%; P<.001). After adjustment for sex, race, education, income, marital status, region of the country, and body mass index, the relationship between trying to lose weight and current smoking varied according to age. Among adults younger than 30 years, those trying to lose weight were more likely to smoke currently (odds ratio, 1.36 [95% confidence interval, 1.09-1.70]), whereas older adults trying to lose weight were as likely or less likely to smoke compared with adults not trying to control weight. After adjustment, smokers of all ages who were trying to lose weight were more likely to express a desire to quit smoking. Results were similar after stratification by sex and body mass index.

CONCLUSIONS

Adults younger than 30 years are more likely to smoke if they are trying to lose weight. However, smokers of all ages who are trying to lose weight are more likely to want to stop smoking. Patients' weight control efforts should not discourage clinicians from counseling about smoking cessation. Education about smoking and healthy weight control methods should target young adults.

Influence of financial productivity incentives on the use of preventive care

PURPOSE

We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care.

SUBJECTS AND METHODS

We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates.

RESULTS

After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%).

CONCLUSIONS

Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.

Physician views on caring for hospitalized patients and the hospitalist model of inpatient care

We surveyed 241 board-certified internists affiliated with a large teaching hospital (Boston, Mass) before implementing a hospitalist service to determine attitudes towards providing inpatient care and the hospitalist model. Of physicians surveyed, 66% responded. Most disagreed that inpatient care is "an inefficient use of my time," only 10% felt a hospitalist service would improve patient satisfaction, and 54% felt it would hurt patient-doctor relationships. Multivariable analyses suggest that physicians physically furthest from their inpatient site were had more favorable attitudes toward the hospitalist model; more experienced and busier physicians were more negative. Future investigations should determine strategies for implementing the hospitalist model which address physicians' concerns.

Current status of malaria and potential for control

Malaria remains one of the world's worst health problems with 1.5 to 2.7 million deaths annually; these deaths are primarily among children under 5 years of age and pregnant women in sub-Saharan Africa. Of significance, more people are dying from malaria today than 30 years ago. This review considers the factors which have contributed to this gloomy picture, including those which relate to the vector, the female anopheline mosquito; to human activity such as creating new mosquito breeding sites, the impact of increased numbers of people, and how their migratory behavior can increase the incidence and spread of malaria; and the problems of drug resistance by the parasites to almost all currently available antimalarial drugs. In a selective manner, this review describes what is being done to ameliorate this situation both in terms of applying existing methods in a useful or even crucial role in control and prevention and in terms of new additions to the antimalarial armory that are being developed. Topics covered include biological control of mosquitoes, the use of insecticide-impregnated bed nets, transgenic mosquitoes manipulated for resistance to malaria parasites, old and new antimalarial drugs, drug resistance and how best to maintain the useful life of antimalarials, immunity to malaria and the search for antimalarial vaccines, and the malaria genome project and the potential benefits to accrue from it.

Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

OBJECTIVES

The goal of this study was to determine factors associated with receiving cardiologist care among patients with an acute exacerbation of congestive heart failure.

BACKGROUND

Because cardiologist care for acute cardiovascular illness may improve care, barriers to specialty care could impact patient outcomes.

METHODS

We studied 1,298 patients hospitalized with acute exacerbation of congestive heart failure who were cared for by cardiologists or generalist physicians. Using multivariable logistic models we determined factors independently associated with attending cardiologist care.

RESULTS

Patients were less likely to receive care from a cardiologist if they were black (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.35, 0.80), had an income of less than $11,000 (AOR 0.65, 95% CI 0.45, 0.93) or were older than 80 years of age (AOR 0.23, 95% CI 0.12, 0.46). Patients were more likely to receive cardiologist care if they had college level education (AOR 1.89, 95% CI 1.02, 3.51), a history of myocardial infarction (AOR 1.59, 95% CI 1.17, 2.16), a serum sodium less than 133 on admission (AOR 1.96, 95% CI 1.30, 2.95) or a systolic blood pressure less than 90 on admission (AOR 1.97, 95% CI 1.20, 3.24). Patients who stated a desire for life extending care were also more likely to receive care from a cardiologist (AOR 1.40, 95% CI 1.04, 1.90).

CONCLUSIONS

After adjusting for severity of illness and patient preferences for care, patient sociodemographic factors were strongly associated with receiving care from a cardiologist. Future investigations are required to determine whether these associations represent unmeasured preferences for care or inequities in our health care system.

Alternative medicine use in older Americans

OBJECTIVES

Because there are few data describing alternative medicine use in older populations, we analyzed a nationally representative survey to quantify and characterize the use of alternative medicine in people aged 65 and older.

DESIGN

We utilized data collected in a nationally representative, random, telephone survey of adults, measuring use of conventional medical services and use of 20 alternative medicine therapies in the last 12 months.

PARTICIPANTS

A total of 2,055 adults, 311 of whom were aged 65 and older and who constituted our sample of older Americans.

RESULTS

Overall, 30% of people aged 65 and older used at least one alternative medicine modality in the last year compared with 46% of those less than age 65 (P < .001), and 19% of older people saw a provider of alternative medicine within the past year compared with 26% of those less than age 65. The alternative medicine modalities used most commonly by those aged 65 and older were chiropractic (11%), herbal remedies (8%), relaxation techniques (5%), high dose or mega-vitamins (5%), and religious or spiritual healing by others (4%). Older persons with a primary care provider used alternative medicine more frequently (34% vs 7% P < .05) than those with no primary care provider. Patients who saw their physician more frequently were more likely to use alternative medicine (0 visits 7%, 1-2 visits 22%, 3-6 visits 35%, 7 or more visits 44% P < .05). Six percent of older patients were taking both herbs and prescription drugs. Of older patients who used alternative medicine, 57% made no mention of their use of any alternative modality to their doctor.

CONCLUSIONS

Thirty percent of Americans aged 65 and older reported using alternative medicine (amounting to 10 million Americans based on extrapolations to census data) and 19% visited an alternative medicine provider (making 63 million visits based on extrapolations to census data) within the past year. The two modalities used most commonly were chiropractic and herbs, both of which may be problematic in older patients. Physicians should ask all patients, including those aged 65 and older, about their use of alternative medicine, and in those aged 65 and older, physicians should ask specific questions about the user of chiropractic and herbal medicine.

Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome

PURPOSE

Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

SUBJECTS AND METHODS

We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support. We estimated life expectancy based on long-term follow-up of SUPPORT patients. Utilities were estimated using time-tradeoff questions. Costs (in 1998 dollars) were based on hospital fiscal data and Medicare data.

RESULTS

Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 dependence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator support was withheld, the median survival was 3 days. Among patients whose estimated probability of surviving at least 2 months from the time of ventilator support ("prognostic estimate") was 70% or more, the incremental cost per quality-adjusted life-year (QALY) saved by providing rather than withholding ventilator support and aggressive care was $29,000. For medium-risk patients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate < or =50%), it was $110,000 per QALY. When assumptions were varied from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76, 000 for medium-risk patients, and from $67,000 to $200,000 for high-risk patients.

CONCLUSIONS

Ventilator support and intensive care for acute respiratory failure due to pneumonia or acute respiratory distress syndrome are relatively cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival < or =50%, the cost per QALY is more than threefold greater at >$100,000.

Protective immunity to erythrocytic Plasmodium chabaudi AS infection involves IFNgamma-mediated responses and a cellular infiltrate to the liver

IFNgamma receptor (IFNgammaR) deficient mice and IL-4 deficient mice were infected with blood-stage Plasmodium chabaudi AS in order to analyse the role of Th1 (IFNgamma) and Th2 (IL-4)-associated cytokines in the development of protective immunity to the parasite. A high mortality rate and failure to reduce the primary parasitaemia to subpatent levels was observed in the IFNgammaR deficient mice. IL-4 deficient mice controlled a primary P. chabaudi AS infection in a similar manner to control mice and no mortality was observed. IFNyR deficient mice had a reduction in parasite-specific IgG and a significantly increased level of total IgE compared to control mice. There was no reduction in the level of parasite-specific IgG in IL-4 deficient mice. Cytological analysis of the cells present in the spleen and liver during the primary parasitaemia revealed a reduction in the numbers of lymphocytes, monocytes and polymorphonuclear (PMN) cells in the liver at the peak of parasitaemia in both IFNgammaR deficient mice and IL-4 deficient mice compared to control mice. Adoptive transfer studies demonstrated that cells isolated from the liver at day 11 post-infection could confer some protective immunity to P. chabaudi AS infection.

Generalists and oncologists show similar care practices and outcomes for hospitalized late-stage cancer patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks for Treatment

OBJECTIVE

The objective of this work was to identify similarities and differences in primary attending physicians' (generalists' versus oncologists') care practices and outcomes for seriously ill hospitalized patients with malignancy.

DESIGN

This was a prospective cohort study (SUPPORT project).

SETTING

Subjects were recruited from 5 US teaching hospitals; data were gathered from 1989 to 1994.

SUBJECTS

Included in the study was a matched sample of 642 hospitalized patients receiving care for non-small-cell lung cancer, colon cancer metastasized to the liver, or multiorgan system failure associated with malignancy with either a generalist or an oncologist as the primary attending physician.

MEASUREMENTS

Care practices and patient outcomes were determined from hospital records. Length of survival was identified with the National Death Index. Physicians' perceptions of patient's prognosis, preference for cardiopulmonary resuscitation (CPR), and length of relationship were assessed by interview. A propensity score for receiving care from an oncologist was constructed. After propensity-based matching of patients, practices and outcomes of oncologists' and generalists' patients were assessed through group comparison techniques.

RESULTS

Generalist and oncologist attendings showed comparable care practices, including the number of therapeutic interventions, eg, "rescue care" and chemotherapy, and the number of care topics discussed with patients/ families. Length of stay, discharge to supportive care, readmission, total hospital costs, and survival rates were similar. For both physician groups, perception of patients' wish for CPR was associated with rescue care (P < 0.03), and such care was related to higher hospital costs (P < 0.000). Poorer prognostic estimates predicted aggressiveness-of-care discussions by both types of physicians. Length of the patient-doctor relationship was associated with oncologists' care practices. More documented discussion about aggressiveness of care was related to higher hospital costs and shorter survival for patients in both physician groups (P < 0.001).

CONCLUSIONS

Generalists and oncologists showed similar care practices and outcomes for comparable hospitalized late-stage cancer patients. Physicians' perceptions about patients' preferences for CPR and prognosis influenced decision making and outcomes for patients in both physician groups. Length of relationship with patients was associated only with oncologists' care practices. Rescue care increased hospital costs but had no effect on patient survival. Future studies should compare physicians' palliative care as well as acute-care practices in both inpatient and ambulatory care settings. Patients' end-of-life quality and interchange between physician groups should also be documented and compared.

Does clinical evidence support ICD-9-CM diagnosis coding of complications?

BACKGROUND

Hospital discharge diagnoses, coded by use of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), increasingly determine reimbursement and support quality monitoring. Prior studies of coding validity have investigated whether coding guidelines were met, not whether the clinical condition was actually present.

OBJECTIVE

To determine whether clinical evidence in medical records confirms selected ICD-9-CM discharge diagnoses coded by hospitals.

RESEARCH DESIGN AND SUBJECTS

Retrospective record review of 485 randomly sampled 1994 hospitalizations of elderly Medicare beneficiaries in Califomia and Connecticut.

MAIN OUTCOME MEASURE

Proportion of patients with specified ICD-9-CM codes representing potential complications who had clinical evidence confirming the coded condition.

RESULTS

Clinical evidence supported most postoperative acute myocardial infarction diagnoses, but fewer than 60% of other diagnoses had confirmatory clinical evidence by explicit clinical criteria; 30% of medical and 19% of surgical patients lacked objective confirmatory evidence in the medical record. Across 11 surgical and 2 medical complications, objective clinical criteria or physicians' notes supported the coded diagnosis in >90% of patients for 2 complications, 80% to 90% of patients for 4 complications, 70% to <80% of patients for 5 complications, and <70% for 2 complications. For some complications (postoperative pneumonia, aspiration pneumonia, and hemorrhage or hematoma), a large fraction of patients had only a physician's note reporting the complication.

CONCLUSIONS

Our findings raise questions about whether the clinical conditions represented by ICD-9-CM codes used by the Complications Screening Program were in fact always present. These findings highlight concerns about the clinical validity of using ICD-9-CM codes for quality monitoring.

Use of administrative data to find substandard care: validation of the complications screening program

OBJECTIVE

The use of administrative data to identify inpatient complications is technically feasible and inexpensive but unproven as a quality measure. Our objective was to validate whether a screening method that uses data from standard hospital discharge abstracts identifies complications of care and potential quality problems.

DESIGN

This was a case-control study with structured implicit physician reviews.

SETTING

Acute-care hospitals in California and Connecticut in 1994.

PATIENTS

The study included 1,025 Medicare beneficiaries greater than 265 years of age.

METHODS

Using administrative data, we stratified acute-care hospitals by observed-to-expected complication rates and randomly selected hospitals within each state. We randomly selected cases flagged with 1 of 17 surgical complications and 6 medical complications. We randomly selected controls from unflagged cases.

MAIN OUTCOME MEASURE

Peer-review organization physicians' judgments about the presence of the flagged complication and potential quality-of-care problems.

RESULTS

Physicians confirmed flagged complications in 68.4% of surgical and 27.2% of medical cases. They identified potential quality problems in 29.5% of flagged surgical and 15.7% of medical cases but in only 2.1% of surgical and medical controls. The rate of physician-identified potential quality problems among flagged cases exceeded 25% in 9 surgical screens and 1 medical screen. Reviewers noted several potentially mitigating circumstances that affected their judgments about quality, including factors related to the patients' illness, the complexity of the case, and technical difficulties that clinicians encountered.

CONCLUSIONS

For some types of complications, screening administrative data may offer an efficient approach for identifying potentially problematic cases for physician review. Understanding the basis for physicians' judgments about quality requires more investigation.

The role of glutamic acid-69 in the activation of Citrobacter freundii tyrosine phenol-lyase by monovalent cations

Tyrosine phenol-lyase (TPL) from Citrobacter freundii is activated about 30-fold by monovalent cations, the most effective being K(+), NH(4)(+), and Rb(+). Previous X-ray crystal structure analysis has demonstrated that the monovalent cation binding site is located at the interface between subunits, with ligands contributed by the carbonyl oxygens of Gly52 and Asn262 from one chain and monodentate ligation by one of the epsilon-oxygens of Glu69 from another chain [Antson, A. A., Demidkina, T. V., Gollnick, P., Dauter, Z., Von Tersch, R. L., Long, J., Berezhnoy, S. N., Phillips, R. S., Harutyunyan, E. H., and Wilson, K. S. (1993) Biochemistry 32, 4195]. We have studied the effect of mutation of Glu69 to glutamine (E69Q) and aspartate (E69D) to determine the role of Glu69 in the activation of TPL. E69Q TPL is activated by K(+), NH(4)(+), and Rb(+), with K(D) values similar to wild-type TPL, indicating that the negative charge on Glu69 is not necessary for cation binding and activation. In contrast, E69D TPL exhibits very low basal activity and only weak activation by monovalent cations, even though monovalent cations are capable of binding, indicating that the geometry of the monovalent cation binding site is critical for activation. Rapid-scanning stopped-flow kinetic studies of wild-type TPL show that the activating effect of the cation is seen in an acceleration of rates of quinonoid intermediate formation (30-50-fold) and of phenol elimination. Similar rapid-scanning stopped-flow results were obtained with E69Q TPL; however, E69D TPL shows only a 4-fold increase in the rate of quinonoid intermediate formation with K(+). Preincubation of TPL with monovalent cations is necessary to observe the rate acceleration in stopped flow kinetic experiments, suggesting that the activation of TPL by monovalent cations is a slow process. In agreement with this conclusion, a slow increase (k < 0.5 s(-)(1)) in fluorescence intensity (lambda(ex) = 420 nm, lambda(em) = 505 nm) is observed when wild-type and E69Q TPL are mixed with K(+), Rb(+), and NH(4)(+) but not Li(+) or Na(+). E69D TPL shows no change in fluorescence under these conditions. High concentrations (>100 mM) of all monovalent cations result in inhibition of wild-type TPL. This inhibition is probably due to cation binding to the ES complex to form a complex that releases pyruvate slowly.

The O(2) binding pocket of myohemerythrin: role of a conserved leucine

A conserved O(2) binding pocket residue in Phascolopsis gouldii myohemerythrin (myoHr), namely, L104, was mutated to several other residues, and the effects on O(2) association and dissociation rates, O(2) affinity, and autoxidation were examined. The L104V, -F, and -Y myoHrs formed stable O(2) adducts whose UV-vis and resonance Raman spectra closely matched those of wild-type oxymyoHr. The L104V mutation produced only minimal effects on either O(2) association or dissociation, whereas the L104F and -Y mutations resulted in 100-300-fold decreases in both O(2) association and dissociation rates. These decreases are attributed to introduction of steric restrictions into the O(2) binding pocket, which are not present in either wild-type or L104V myoHrs. The failure to observe increased O(2) association or dissociation rates for L104V indicates that the side chain of leucine at position 104 does not sterically "gate" O(2) entry into or exit from the binding pocket in the rate-determining step(s). L104V myoHr autoxidized approximately 3 times faster than did wild type, whereas L104T autoxidized >10(6) times faster than did wild type. The latter large increase is attributed to increased side chain polarity, thereby increasing water occupancy in the oxymyoHr binding pocket. These results indicate that L104 contributes a hydrophobic barrier that restricts water entry into the oxymyoHr binding pocket. Thus, a leucine at position 104 in myoHr appears to have the optimal combination of size and hydrophobicity to facilitate O(2) binding while simultaneously inhibiting autoxidation.

Patient-centered quality measures for Asian Americans: research in progress

We aim to develop and validate a questionnaire that examines quality of care from the patient's perspective for limited-English-proficient Asian Americans (AA) of Chinese and Vietnamese descent. We will conduct focus groups of patients to identify issues important to them, with an emphasis on communication and access to care. We will then draft a questionnaire and test its validity using standard survey research methods and direct observation of patient-provider encounters. Subsequent field testing will involve face-to-face patient interviews 1 month after an outpatient visit. We will evaluate alternate modes of administration to test feasibility and to maximize response. The result of our study will be a validated, culturally sensitive, patient-centered instrument that measures health care quality for limited-English-proficient AA patients. Our research will provide a template for developing future quality measures for other vulnerable populations.

Discussion of hormone replacement therapy between physicians and their patients

We determined the relationship between patients' socioeconomic status and discussions with their primary care physicians about hormone replacement therapy (HRT) among women facing a decision about HRT within the prior year. The study included telephone interviews and medical record reviews. The setting was a general medicine practice of an urban teaching hospital in Boston, Mass. Women ages 50-65 visiting an academic teaching practice over a 3-month period were selected randomly. Of the 198 potential subjects, 118 (60%) agreed to participate in the survey. We examined discussions of HRT by women who had faced the decision to initiate HRT within the previous year. Women who were not on HRT or had been on therapy for less than 1 year were asked if they had discussed HRT with their physician in the past year. Socioeconomic factors and comorbidities were elicited during the survey and abstracted by chart review. The mean age of the 118 participants was 57; 36% were black, 54% were white, 10% were other race, 17% had less than a high school education, 14% had diabetes, 31% had had a hysterectomy, and 7% had a history of breast cancer. Of the 80 women who did not use HRT or had used it for less than 1 year, 49 (61%) reported a discussion of HRT. In bivariable analysis, patients of white race were more likely to report a discussion than black patients (72% versus 43%, odds ratio [OR] 3.6, 95% confidence interval [CI] 1.3-9.7). After adjustment for history of osteoporosis and age, white patients were more likely to report a discussion (adjusted OR 3.3, 95% CI 1.1-9.8). Further adjustment for the presence of 2 or more cardiac risk factors did not change the result. Neither level of education nor family income were significantly associated with HRT discussion. Compared with white women, the African-American women we studied were less likely to discuss HRT with their physicians. Further study is needed to determine whether the failure to discuss HRT is due to failure to initiate a discussion on the part of patients, physicians, or both.

A leucine residue "Gates" solvent but not O2 access to the binding pocket of phascolopsis gouldii hemerythrin

A leucine residue, Leu-98, lines the O(2)-binding pocket in all known hemerythrins. Leu-98 in recombinant Phascolopsis gouldii hemerythrin, was mutated to several other residues of varying sizes (Ala, Val), polarities (Thr, Asp, Asn), and aromaticities (Phe, Tyr, Trp). UV-visible and resonance Raman spectra showed that the di-iron sites in these L98X Hrs are very similar to those in the wild type protein, and several of the L98X hemerythrins formed stable oxy adducts. Despite the apparently tight packing in the pocket, all of the L98X Hrs except for L98W, had second order O(2) association rate constants within a factor of 3 of the wild type value. Similarly, the O(2) dissociation rate constant was essentially unaffected by substitutions of larger (Phe) or smaller (Val, Thr) residues for Leu-98. L98Y Hr showed a 170-fold decrease in the O(2) dissociation rate constant and a large D(2)O effect on this rate, which are attributed to a hydrogen-bonding interaction between the Tyr-98 hydroxyl and the bound O(2). Significant increases in autoxidation rates were observed for all of the L98X Hrs other than X = Tyr. These increases in autoxidation rates are attributed to increased solvent access to the binding pocket caused by inefficient packing (Phe), smaller size (Val, Ala), or increased polarity (Thr, Asp, Asn) of the residue 98 side chain. A leucine at position 98 appears to have the optimal size, shape, and hydrophobicity for inhibition of solvent access. Thus, "gating" of small molecule access to the binding pocket of Hr by Leu-98 is not evident for O(2), but is evident for solvent.

Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care?

BACKGROUND

Compared with thinner women, obese women have higher mortality rates for breast and cervical cancer. In addition, obesity leads to adverse social and psychological consequences. Whether obesity limits access to screening for breast and cervical cancer is unclear.

OBJECTIVE

To examine the relation between obesity and screening with Papanicolaou (Pap) smears and mammography.

DESIGN

Population-based survey.

SETTING

United States.

PARTICIPANTS

11 435 women who responded to the "Year 2000 Supplement" of the 1994 National Health Interview Survey.

MEASUREMENTS

Screening with Pap smears and mammography was assessed by questionnaire.

RESULTS

In women 18 to 75 years of age who had not previously undergone hysterectomy (n = 8394), fewer overweight women (78%) and obese women (78%) than normal-weight women (84%) had had Pap smears in the previous 3 years (P < 0.001). After adjustment for sociodemographic information, insurance and access to care, illness burden, and provider specialty, rate differences for screening with Pap smears were still seen among overweight (-3.5% [95% CI, -5.9% to -1.1%]) and obese women (-5.3% [CI, -8.0% to -2.6%]). In women 50 to 75 years of age (n = 3502), fewer overweight women (64%) and obese women (62%) than normal-weight women (68%) had had mammography in the previous 2 years (P < 0.002). After adjustment, rate differences were -2.8% (CI, -6.7% to 0.9%) for overweight women and -5.4% (CI, -10.8% to -0.1%) for obese women.

CONCLUSIONS

Overweight and obese women were less likely to be screened for cervical and breast cancer with Pap smears and mammography, even after adjustment for other known barriers to care. Because overweight and obese women have higher mortality rates for cervical and breast cancer, they should be targeted for increased screening.

Family satisfaction with end-of-life care in seriously ill hospitalized adults

OBJECTIVE

To examine factors associated with family satisfaction with end-of-life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN

A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision-making.

SETTING

Five teaching hospitals in the United States.

PARTICIPANTS

Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died.

MEASUREMENTS

Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision-making.

RESULTS

Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision-making. Factors found to be significantly associated with satisfaction with communication and decision-making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3-3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0, 1.2-3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4-1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1-0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2-0.8).

CONCLUSIONS

Satisfaction scores suggest the need for improvement in end-of-life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end-of-life care. An intervention like that used in SUPPORT may help family members.

Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT

OBJECTIVES

To review previously published findings about how patient age influenced patterns of care for seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN

An observational prospective study.

SETTING

Five acute care hospitals.

PARTICIPANTS

A total of 9105 seriously ill patients enrolled in SUPPORT.

MEASUREMENTS

The outcomes examined included patients' preferences for aggressive care, decision making regarding cardiopulmonary resuscitation and use of other life-sustaining treatments, hospital costs, intensity of resource use, and survival.

RESULTS

Although older patients preferred less aggressive care than younger patients, many older patients wanted cardiopulmonary resuscitation and care focused on life extension. Patients' families and healthcare providers underestimated older patients' desire for aggressive care. After adjustment for illness severity, comorbidity, baseline function, and patients' preferences for aggressive care, older age was associated with lower hospital costs and resource intensity and higher rates of decisions to withhold life-sustaining treatments. In adjusted analyses, older age was associated with a slight survival disadvantage. This survival disadvantage persisted, even after adjustment for aggressiveness of care, suggesting that the relation between age and survival is not accounted for by less aggressive treatment of older patients.

CONCLUSIONS

Even after adjustment for patients' prognoses and care preferences, seriously ill hospitalized older patients were treated less aggressively than younger patients. SUPPORT cannot fully identify whether the relationship between older age and less aggressive treatment is better explained by the withholding of potentially beneficial treatments from older patients, or by the excessive provision of ineffective treatment to younger patients. However, the latter explanation is favored by the SUPPORT finding that less aggressive treatment for older patients does not contribute to the modest survival disadvantage associated with older age.

The last six months of life for patients with congestive heart failure

OBJECTIVE

To characterize the experiences of patients with congestive heart failure (CHF) during their last 6 months of life.

DESIGN

A retrospective analysis of data from a prospective cohort study.

SETTING

Five geographically diverse tertiary care academic medical centers.

PARTICIPANTS

A total of 1404 patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) with a diagnosis of an acute exacerbation of CHF, of whom 539 patients died within 1 year of their index hospitalization.

METHODS

Data from interviews with patients or their surrogates were collected and chart abstractions performed at several time points in SUPPORT. To describe progression to death, we constructed four observational windows backward in time, beginning with patients' dates of death and ending with their date of entry into the SUPPORT project or 6 months before death, whichever came first. For each outcome, patients contributed information to all windows for which they had data collected. We describe frequency distributions for each outcome over time and report tests for trend.

OUTCOME MEASURES

Outcomes examined over time included: percentage of days spent in a hospital; model-based prognostic estimates of 6-month survival; functional status; occurrence of severe physical and emotional symptoms, including pain, depression and anxiety; patients' preferences for care; and the financial impact of patients' illnesses on their families.

RESULTS

As death approached, patients' prognoses became poorer and illnesses more severe. Median Acute Physiology Scores for hospitalized patients rose from 33 in the interval 6 months to 3 months before death, to 44 within 3 days of death. However, the median model-based estimate of 6-month survival was 54% even within 3 days of death. Number of functional impairments, median depression scores and percent of patients reporting severe pain or dyspnea increased as death approached, with 41% of patient surrogates reporting that the patient was in severe pain and 63% reporting that the patient was severely short of breath during the 3 days before death. Perceived quality of life did not change appreciably, with 29 to 58 % of patients reporting good to excellent quality of life in all intervals before death. As death approached, patients were more likely to prefer Do Not Resuscitate (DNR) status, with the percent of patients preferring DNR rising from 33% at 6 months to 3 months before death to 47% at 1 month to 3 days before death (P < .05). The frequency with which DNR orders were written for hospitalized patients also increased as death approached. The patients' illnesses had marked financial impact on their families, with 23 % of patients' families reporting the loss of most or all of family savings at the time of the patient's death.

CONCLUSIONS

As death approaches during the last 6 months of life in CHF, illness becomes more severe, disability and the experience of certain symptoms more frequent, and patient preference not to be resuscitated more common. However, there is no significant decrement in quality of life as death approaches. Reflecting the unpredictable course of CHF during the last month of life, many patients have good median model-based 6-month prognoses and enjoy good to excellent quality of life.