Can physicians refuse treatment to patients who smoke?

Postsurgical morbidity and mortality favorably informs deep brain stimulation for new indications including schizophrenia and schizoaffective disorder

Background

Deep brain stimulation (DBS) shows promise for new indications like treatment-refractory schizophrenia in early clinical trials. In the first DBS clinical trial for treatment refractory schizophrenia, despite promising results in treating psychosis, one of the eight subjects experienced both a symptomatic hemorrhage and an infection requiring device removal. Now, ethical concerns about higher surgical risk in schizophrenia/schizoaffective disorder (SZ/SAD) are impacting clinical trial progress. However, insufficient cases preclude conclusions regarding DBS risk in SZ/SAD. Therefore, we directly compare adverse surgical outcomes for all surgical procedures between SZ/SAD and Parkinson's disease (PD) cases to infer relative surgical risk relevant to gauging DBS risks in subjects with SZ/SAD.

Design

In the primary analysis, we used browser-based statistical analysis software, TriNetX Live (trinetx.com TriNetX LLC, Cambridge, MA), for Measures of Association using the Z-test. Postsurgical morbidity and mortality after matching for ethnicity, over 39 risk factors, and 19 CPT 1003143 coded surgical procedures from over 35,000 electronic medical records, over 19 years, from 48 United States health care organizations (HCOs) through the TriNetX Research Network™. TriNetXis a global, federated, web-based health research network providing access and statistical analysis of aggregate counts of deidentified EMR data. Diagnoses were based on ICD-10 codes. In the final analysis, logistic regression was used to determine relative frequencies of outcomes among 21 diagnostic groups/cohorts being treated with or considered for DBS and 3 control cohorts.

Results

Postsurgical mortality was 1.01-4.11% lower in SZ/SAD compared to the matched PD cohort at 1 month and 1 year after any surgery, while morbidity was 1.91-2.73% higher and associated with postsurgical noncompliance with medical treatment. Hemorrhages and infections were not increased. Across the 21 cohorts compared, PD and SZ/SAD were among eight cohorts with fewer surgeries, nine cohorts with higher postsurgical morbidity, and fifteen cohorts within the control-group range for 1-month postsurgical mortality.

Conclusions

Given that the subjects with SZ or SAD, along with most other diagnostic groups examined, had lower postsurgical mortality than PD subjects, it is reasonable to apply existing ethical and clinical guidelines to identify appropriate surgical candidates for inclusion of these patient populations in DBS clinical trials.

Disparities in Systemic Treatment Use in Advanced-stage Non-Small Cell Lung Cancer by Source of Health Insurance

BACKGROUND

Management of advanced-stage non-small cell lung cancer (NSCLC) has changed significantly over the past two decades with the development of numerous systemic treatments, including targeted therapies. However, a high proportion of advanced-stage patients are untreated. The role that health insurance plays in receipt of systemic treatments is unclear.

METHODS

Using California Cancer Registry data (2012-2014), we developed multivariable Poisson regression models to assess the independent effect of health insurance type on systemic treatment utilization among patients with stage IV NSCLC. Systemic treatment information was manually abstracted from treatment text fields.

RESULTS

A total of 17,310 patients were evaluated. Patients with Medicaid/other public insurance were significantly less likely to receive any systemic treatments [risk ratio (RR), 0.78; 95% confidence interval (CI), 0.75-0.82], bevacizumab combinations (RR, 0.57; 95% CI, 0.45-0.71), or tyrosine kinase inhibitors (RR, 0.70; 95% CI, 0.60-0.82) compared with the privately insured. Patients with Medicare or dual Medicare-Medicaid insurance were not significantly different from the privately insured in their likelihood of receiving systemic treatments.

CONCLUSIONS

Substantial disparities in the use of systemic treatments for stage IV NSCLC exist by source of health insurance in California. Patients with Medicaid/other public insurance were significantly less likely to receive systemic treatments compared with their privately insured counterparts.

IMPACT

Source of health insurance influences care received. Further research is warranted to better understand barriers to treatment that patients with Medicaid face.

Moral Economy and Moral Capital in the Community of Clinical Practice

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

How Can We Balance Ethics and Law When Treating Smokers?

A physician is a valued member of society on whom many individuals rely for both professional advice and support during times when they may feel to be at a disadvantage, whether it be physically or mentally. An issue on the rise today concerns the population of smokers in our society. Many are coming to share the opinion that physicians should not provide treatments for smokers. Some of the opinions are based on the claim that smokers are morally responsible for their medical conditions. But, providing care in a fair manner includes not treating differently those who suffer from addiction. Moreover, it is important to recognize that allocating medical resources based on moral responsibility will undermine the physician-patient relationship which is necessary for the practice of medicine. Many countries have codes and policies that physicians must legally follow in terms of providing treatments. With acceptance of the fact that the patient may be unable to execute the decisions made by the physician, it is the legal duty of the physician to provide care and not abandon the patient. An analysis of the many policies around the world brings forward certain changes that must be made in order to make sure that physicians fulfil their legal duty, which is to provide care. As such, this article looks into the existing ethical dilemma in treating smokers around the world, with a review of some policies that will guide our approach in this matter.