Measure of Caregiver Attention-Deficit/Hyperactivity Disorder Knowledge Is Responsive to Decision Aid on Treatment for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Adapt and test a measure of knowledge for caregivers of children with attention-deficit/hyperactivity disorder (ADHD) and evaluate the impact of the information component of a decision aid (DA) on participant knowledge.

METHODS

A set of seven knowledge items were created based on prior knowledge measures and clinical guidelines. As part of a larger cross-sectional survey study of caregivers of children diagnosed with ADHD, caregivers were randomized to one of two arms: 1) a DA arm, where participants reviewed the information component of the Cincinnati Children's Hospital's DA, and 2) a control arm, where participants were not shown a DA. All participants completed the seven knowledge items. Knowledge items were assessed for difficulty, quality of distractors, acceptability, and redundancy. Total knowledge scores (0-100) for the DA and control arm were compared.

RESULTS

Caregivers were assigned to the DA arm (n = 243) or the control arm (n = 260). All 7 knowledge items were retained as no items were too difficult or too easy, all response options were used, there were little missing data, and no items were redundant. The overall knowledge score was normally distributed, and almost covered the full range of scores (5-100). Those who received the DA component had higher knowledge scores (M=68, SD=23) than those who did not receive the DA component (M=60, SD=19, P < .01, d=0.4).

CONCLUSIONS

The Caregiver ADHD Knowledge (CAKe) measure was acceptable and demonstrated construct validity as those who were assigned to review the DA component demonstrated greater knowledge than those who were not assigned to review the DA component.

Changes in Antidementia Medications upon Admission to the Nursing Home: Who Decides and Why? Results From a National Survey of Nursing Home Administrators

OBJECTIVE

Little is known about who is involved and what factors influence changes in antidementia medications for older adults living in nursing homes. The study sought to describe factors associated with initiation and discontinuation of antidementia medications in nursing home residents with dementia.

DESIGN

National survey of nursing homes with ≥30 beds; homes with dementia units were oversampled.

SETTINGS AND PARTICIPANTS

Nursing home administrators [eg, Directors of Nursing (DoNs)].

METHODS

In 2022, 1293 homes were surveyed (response rate: 26.6%, n = 340). Weighted analyses provided nationally representative results corrected for nonresponse (n = 14,455).

RESULTS

DoNs reported that people always/almost always involved in antidementia medication decisions included nursing home prescriber (84.4%), nursing staff (33.2%), family (23.4%), resident (13.8%), community primary care provider (12.1%), and dementia specialist (5.8%). DoNs reported that antidementia medications were much more likely to be initiated if residents (55.8%) and family members (53.2%) wanted antidementia medications, a dementia specialist was involved (51.9%), resident had aggressive behaviors (44.8%), resisted care (31.6%), or had severe physical/cognitive impairment (22.3%). DoNs reported that antidementia medications were much more likely to be discontinued with dementia specialist involvement (46.5%), progression to severe impairment (39.2%), hospice involvement (31.5%), <6 months' prognosis (28.5%), emergence of aggressive behaviors (25.2%), or resisting care (19.0%) and much less likely to be discontinued if residents (30.2%) and family (27.3%) were reluctant to discontinue. One in 6 homes reported that residents had no immediate family/caregivers usually or almost always/always.

CONCLUSIONS AND IMPLICATIONS

DoNs report that family/caregivers and dementia specialists have significant influence on antidementia medication decisions in nursing homes, but many residents lack their involvement. Real-world evidence on the risks and benefits of antidementia medications in nursing homes is needed to inform clinical guidance about appropriate use of antidementia medications in nursing homes.

U.S. nursing home leadership experiences with COVID-19 and its impact on residents and staff: A qualitative analysis

OBJECTIVES

To explore experiences of U.S. (United States) nursing home leadership during the COVID-19 pandemic in their efforts to address resident loneliness and social isolation and to elicit stories about personal and professional impacts on themselves and staff.

DESIGN

Qualitative inquiry via three optional open-ended questions appended to a national self-administered survey of American nursing home leaders was employed. Textual data was analyzed using an iterative reflexive thematic approach.

SETTING AND PARTICIPANTS

A stratified sample frame defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5) was employed. Web survey links and paper surveys were sent to 1,676 nursing home directors of nursing between February and May 2022.

RESULTS

Open text responses were collected from 271 nursing homes. Broad themes included: 1) Addressing needs of residents & families; 2) Challenges; and 3) Personal experiences of nursing home leadership/staff. Respondents described trauma to residents, staff, and leadership. Resident loneliness was addressed using existing and newer technologies and innovative indoor and outdoor activities. Residents experienced fear, illness, loss, and sometimes death. Isolation from family and lack of touch were particularly difficult. Regulations were seen as punitive while ignoring emotional needs of residents. Staffing challenges and pressures to do more with less created additional stress. Leadership and staff made significant sacrifices resulting in physical, social, and emotional consequences. Beneficial outcomes included staff bonding, professional growth, and permanent implementation of new interventions.

CONCLUSIONS AND IMPLICATIONS

New and creative interventions were successfully implemented to address social isolation and loneliness. Improved Wi-Fi and other nursing home infrastructure upgrades are needed to maintain them. Reimagining often conflicting overlapping federal, state, and local regulations, grounding them in good clinical judgement, and incentivizing performance improvement should be considered. Trauma experienced by staff needs to be addressed to deal with current and future workforce needs.

Rising to the Occasion: A National Nursing Home Study Documenting Attempts to Address Social Isolation During the COVID-19 Pandemic

OBJECTIVES

COVID-19-related policies introduced extraordinary social disruption in nursing homes. In response, nursing facilities implemented strategies to alleviate their residents' loneliness. This study sought to describe interventions nursing homes used, document the perceived effectiveness of efforts, and determine barriers to implementing strategies to mitigate social isolation and loneliness.

DESIGN

National survey of nursing homes sampled in strata defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5).

SETTINGS AND PARTICIPANTS

US Nursing Home Directors of Nursing/Administrators (n = 1676).

METHODS

The survey was conducted between February and May 2022 (response rate: 30%; n = 504, weighted n = 14,506). Weighted analyses provided nationally representative results.

RESULTS

One-third were extremely concerned about their home's ability to meet residents' medical and social needs during COVID-19 before vaccines were available and 13% after vaccines. Nearly all reported trying to mitigate residents' social isolation during the pandemic. Efforts tried, and perceived as most useful, included using technology (tablets, phones, emails), assigning staff as a family contact, and more staff time with residents. Most frequently cited barriers to implementation were related to staffing issues.

CONCLUSIONS AND IMPLICATIONS

Despite multiple challenges, nearly all nursing homes tried to implement many different approaches to address residents' social needs, with some (eg, having an assigned family contact, use of tablets and phones) perceived as more useful than others. Staffing issues presented barriers for addressing the social needs of nursing home residents. Many strategies for addressing social isolation placed more demands on a workforce already stretched to the limit. While concerns about resident social isolation reduced after vaccine availability, administrators remained extremely concerned about staff burnout and mental health.

ADDRESSING SOCIAL ISOLATION IN NURSING HOMES DURING COVID-19: A NATIONAL SURVEY

COVID-19 related policies introduced extraordinary social disruption in nursing homes. In response to the unprecedented COVID-19 pandemic, congregated long term care living facilities attempted and/or implemented innovative intervention strategies to alleviate loneliness in residents. We surveyed Directors of Nursing/Administrators of 1,669 homes sampled in strata defined by size (number of beds 30–99, 100+) and quality ratings (1, 2–4, 5) between February-May 2022. The response rate was 30%. Almost 2/3rds of respondents completed it online and the rest via paper. Analyses included nonresponse survey weights to provide nationally representative results. Among a list of 17 situations that occurred, staff shortages was identified as extremely stressful by the majority. Staff were extremely stressed about doing more to meet resident needs and keeping up with rapidly changing regulations which often lacked clinical sense. One third of respondents were extremely concerned about their home’s ability to meet residents’ social needs before vaccines, dropping to 13% after vaccines. Nursing homes tried and perceived as most useful using technology (tablets, phones, emails), assigning staff as a family contact, and staff spending more time with residents. Nearly 60% were extremely concerned about staff burnout/mental health before vaccines and 40% remained extremely concerned after vaccines. Many nursing homes attempted to mitigate the harmful effects of social isolation during the pandemic, despite the stressful circumstances in which staff worked. The extent to which various approaches were implemented varied. While concerns about social isolation reduced after vaccines were available, administrators remain extremely concerned about staff burnout and mental health.

ADDRESSING SOCIAL ISOLATION IN NURSING HOMES DURING COVID-19 – QUALITATIVE DATA FROM A NATIONAL SURVEY

The COVID-19 pandemic had dramatic, sometimes devastating impacts on nursing homes, residents, and staff. Rapid deployment of innovative approaches to resident care was required even while under sustained distress. We collected textual responses to open-ended questions about COVID-19 experiences through a national nursing home survey of Directors of Nursing/Administrators in February-May 2022. We employed a stratified (by size and quality ratings) sample of 1,669 nursing homes. Response rate was 30%, and 51% of responders answered > 1 open-ended question. We conducted an iterative thematic qualitative analysis yielding 10 themes. Respondents described addressing social isolation using new technology; enlisting staff from across the nursing home [beyond-the-call effort, gifting of voluntary time], and new ways for residents to safely connect with family. Respondents felt severely limited by COVID regulations that seemed to ignore residents’ mental health needs. The majority of respondents felt significant professional and personal impact of the pandemic experience: “The pandemic was the most stressful situation I have encountered in 26 years of nursing” – “What a toll it took on all us emotionally, physically, and mentality” – “Every day was a challenge and I felt hopeless” – Some respondents plan to quit: “I am now seeking other employment. It has been too much for too long and has directly affected my mental health.” Nursing homes reported extraordinary efforts put forth by administration and staff to meet the needs of residents. Efforts to retain nursing staff are needed given profound impacts of the pandemic on their personal and professional lives.

Pediatric Caregiver Version of the Shared Decision Making Process Scale: Validity and Reliability for ADHD Treatment Decisions

OBJECTIVE

Shared decision making (SDM) is recommended for common pediatric conditions; however, there are limited data on measures of SDM in pediatrics. This study adapted the SDM Process scale and examined validity and reliability of the scale for attention-deficit/hyperactivity disorder (ADHD) treatment decisions.

METHODS

Cross-sectional survey of caregivers (n = 498) of children (aged 5-13) diagnosed with ADHD, who had made a decision about ADHD medication in the last 2 years. Surveys included the adapted SDM Process scale (scores range 0-4, higher scores indicate more SDM), decisional conflict, decision regret, and decision involvement. Validity was assessed by testing hypothesized relationships between these constructs. A subset of participants was surveyed a week later to assess retest reliability.

RESULTS

Pediatric Caregiver version of the SDM Process scale (M = 2.8, SD = 1.05) showed no evidence of floor or ceiling effects. The scale was found to be acceptable (<1% missing data) and reliable (intraclass correlation coefficient = 0.74). Scores demonstrated convergent validity, as they were higher for those without decisional conflict than those with decisional conflict (2.93 vs 2.46, P < .001, d = 0.46), and higher for caregivers who stated they made the decision with the provider than those who made the decision themselves (3.0 vs 2.7; P = .003). Higher scores were related to less regret (r = -0.15, P < .001), though the magnitude of the relationship was small.

CONCLUSIONS

The adapted Pediatric Caregiver version of the SDM Process scale demonstrated acceptability, validity and reliability in the context of ADHD medication decisions made by caregivers of children 5-13. Scores indicate pediatricians generally involve caregivers in decision making about ADHD medication.

Measuring shared decision-making in younger and older adults with depression

BACKGROUND

This study examined the performance of the shared decision-making (SDM) Process scale in patients with depression, compared alternative wording of two items in the scale and explored performance in younger adults.

METHODS

A web-based non-probability panel of respondents with depression aged 18-39 (younger) or 40-75 (older) who talked with a health-care provider about starting or stopping treatment for depression in the past year were surveyed. Respondents completed one of two versions of the SDM Process scale that differed in the wording of pros and cons items and completed measures of decisional conflict, decision regret and who made the decision (mainly the respondent, mainly the provider or together). A subset of respondents completed a retest survey by 1 week. We examined how version and age group impacted SDM Process scores and calculated construct validity and retest reliability. We hypothesized that patients with higher SDM Process scores would show less decisional conflict using the SURE scale (range = 0-4); top score = no conflict versus other and less regret (range 1-4; higher scores indicated more regret).

RESULTS

The sample (N = 494) was majority White, non-Hispanic (82%) and female (72%), 48% were younger and 23% had a high school education or less. SDM Process scores did not differ by version (P = 0.09). SDM Process scores were higher for younger respondents (M = 2.6, SD = 1.0) than older respondents (M = 2.3, SD = 1.1; P = 0.001). Higher SDM Process scores were also associated with no decisional conflict (M = 2.6, SD = 0.99 vs. M = 2.1, SD = 1.2; P < 0.001) and less decision regret (r = -0.18, P < 0.001). Retest reliability was intraclass correlation coefficient = 0.81.

CONCLUSIONS

The SDM Process scale demonstrated validity and retest reliability in younger adults, and changes to item wording did not impact scores. Although younger respondents reported more SDM, there is room for improvement in SDM for depression treatment decisions.

How responding in Spanish affects CAHPS results

BACKGROUND

The most widely used surveys for assessing patient health care experiences in the U.S. are the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Studies examining the associations of language and ethnicity with responses to CAHPS surveys have yielded inconsistent findings. More research is needed to assess the effect of responding to CAHPS surveys in Spanish.

METHODS

Subjects were patients who had received care at a study community health center in Connecticut within 6 or 12 months of being sent a CAHPS survey that asks about care experiences. The survey included four multi-item measures of care plus an overall rating of the provider. Sampled patients were mailed dual language (English and Spanish) cover letters and questionnaires. Those who did not respond after follow-up mailings were contacted by bilingual interviewers to complete the survey by telephone. We tested three hypotheses for any observed differences by ethnicity and language: 1. Spanish speakers are more likely than others to choose extreme response options. 2. The semantic meaning of the Spanish translation is not the same as the English version of the questions, resulting in Spanish speakers giving different answers because of meaning differences. 3. Spanish speakers have different expectations regarding their health care than those who answer in English. Analyses compared the answers on the survey measures for three groups: non-Hispanics answering in English, Hispanics answering in English, and Hispanics answering in Spanish.

RESULTS

The overall response rate was 45%. After adjusting for differences in demographic characteristics and self-rated health, those answering in Spanish gave significantly more positive reports than the other two groups on three of the five measures, and higher than the non-Hispanic respondents on a fourth.

CONCLUSIONS

Those answering in Spanish gave more positive reports of their medical experiences than Hispanics and non-Hispanics answering in English. Whether these results reflect different response tendencies, different standards for care, or better care experiences is a key issue in whether CAHPS responses in Spanish need adjustment to make them comparable to responses in English.

Using Standardized Videos to Examine the Validity of the Shared Decision Making Process Scale: Results of a Randomized Online Experiment

BACKGROUND

The Shared Decision Making (SDM) Process scale is a brief, patient-reported measure of SDM with demonstrated validity in surgical decision making studies. Herein we examine the validity of the scores in assessing SDM for cancer screening and medication decisions through standardized videos of good-quality and poor-quality SDM consultations.

METHOD

An online sample was randomized to a clinical decision-colon cancer screening or high cholesterol-and a viewing order-good-quality video first or poor-quality video first. Participants watched both videos, completing a survey after each video. Surveys included the SDM Process scale and the 9-item SDM Questionnaire (SDM-Q-9); higher scores indicated greater SDM. Multilevel linear regressions identified if video, order, or their interaction predicted SDM Process scores. To identify how the SDM Process score classified videos, area under the curve (AUC) was calculated. The correlation between SDM Process score and SDM-Q-9 assessed construct validity. Heterogeneity analyses were conducted.

RESULTS

In the sample of 388 participants (68% white, 70% female, average age 45 years) good-quality videos received higher SDM Process scores than poor-quality videos (Ps < 0.001), and those who viewed the good-quality high cholesterol video first tended to rate the videos higher. SDM Process scores were related to SDM-Q-9 scores (rs > 0.58; Ps < 0.001). AUC was poor (0.69) for the high cholesterol model and fair (0.79) for the colorectal cancer model. Heterogeneity analyses suggested individual differences were predictive of SDM Process scores.

CONCLUSION

SDM Process scores showed good evidence of validity in a hypothetical scenario but were lacking in ability to classify good-quality or poor-quality videos accurately. Considerable heterogeneity of scoring existed, suggesting that individual differences played a role in evaluating good- or poor-quality SDM conversations.

Cognitive testing of a survey instrument for self-assessed menstrual cycle characteristics and androgen excess

Background

In large population-based studies, there is a lack of existing survey instruments designed to ascertain menstrual cycle characteristics and androgen excess status including hirsutism, alopecia, and acne. Our objective was to cognitively test a survey instrument for self-assessed menstrual cycle characteristics androgen excess.

Methods

Questions to assess menstrual characteristics and health were designed using existing surveys and clinical experience. Pictorial self-assessment tools for androgen excess were also developed with an experienced medical illustrator to include the modified Ferrimen-Galway, acne and androgenic alopecia. These were combined into an online survey instrument using REDCap. Of the 219 questions, 120 were selected for cognitive testing to assess question comprehension in a population representative of the future study population.

Results

Cognitive testing identified questions and concepts not easily comprehended, recalled, or had problematic response choices. Comprehension examples included simplifying the definition for polycystic ovary syndrome and revising questions on historic menstrual regularity and bleeding duration. Recall and answer formation examples include issues with recalling waist size, beverage consumption, and interpretation of questions using symbols (> or <). The survey was revised based on feedback and subsequently used in the Ovulation and Menstruation (OM) Health Pilot study.

Conclusion

We present a cognitively tested, novel survey instrument to assess menstrual cycle characteristics and androgen excess.

Assessing the Quality of Published Surveys in Ophthalmology

PURPOSE

Surveys are an important research modality in ophthalmology, but their quality has not been rigorously assessed. This study evaluated the quality of published ophthalmic surveys.

METHODS

Three survey methodologists, three senior ophthalmologists, and two research assistants developed a survey evaluation instrument focused on survey development and testing; sampling frame; response bias; results reporting; and ethics. Two investigators used the instrument to assess the quality of all ophthalmic surveys that were published between January 1, 2018 and December 31, 2018; indexed in MEDLINE/PubMed, Embase, and/or Web of Science; contained the search terms "ophthalmology" and "survey" or "questionnaire" in the title and/or abstract; and were available in English.

RESULTS

The search identified 626 articles; 60 met the eligibility criteria and were assessed with the survey evaluation instrument. Most surveys (93%; 56/60) defined the study population; 48% (29/60) described how question items were chosen; 30% (18/60) provided the survey for review or described the questions in sufficient detail; 30% (18/60) were pre-tested or piloted; 25% (15/60) reported validity/clinical sensibility testing; 15% (9/60) described techniques used to assess non-response bias; and 63% (38/60) documented review by an institutional review board (IRB).

CONCLUSION

The quality of published ophthalmic surveys can be improved by focusing on survey development, pilot testing, non-response bias and institutional review board review. The survey evaluation instrument can help guide researchers in conducting quality ophthalmic surveys and assist journal editors in evaluating surveys submitted for publication.

Examining Physician Interactions with Disease Advocacy Organizations

Disease advocacy organizations (DAOs) have traditionally focused on raising awareness of rare diseases, providing educational resources to patients, and supporting patients and families. Previous research has described how scientists collaborate with DAOs, but few empirical data are available regarding the extent to which physicians interact with DAOs and how those interactions impact patient care. We conducted a national survey of 230 board-certified pediatric neurologists to assess their engagement with DAOs and their beliefs about the impact of DAOs on patient care. In that context, we evaluated a set of 24 items describing interactions between physicians and DAOs. Exploratory factor analysis produced a 19-item model capturing four types of physician-DAO engagement: (1) accessing or distributing DAO-produced materials (6 items, alpha = 0.80); (2) consulting on DAO activities (5 items, alpha = 0.81); (3) collaborating with DAOs on research activities (6 items, alpha = 0.80); and (4) co-producing scholarly materials with DAOs (2 items, alpha = 0.80). Our data indicate that physicians engage with DAOs in more frequent and diverse ways than has been previously reported. Almost all physicians in our sample had interacted directly with a DAO in some way, from low-effort activities such as visiting a DAO's website to deeper forms of engagement including coauthoring journal articles. These findings may provide a framework for bioethicists to characterize the nature and extent of physician interactions with advocacy organizations, which is critical for evaluating the ethical implications of physician-DAO relationships.

The effect of different sampling and recall periods in the CAHPS Clinician & Group (CG-CAHPS) survey

OBJECTIVE

To examine the effect of changing the sampling and reference periods for the CAHPS^® Clinician & Group Survey from 12 to 6 months.

DATA SOURCES/STUDY SETTING

Adult patients with a visit in the last 12 months to New England community health centers.

STUDY DESIGN

We randomly assigned patients to receive a survey with either a 12- or 6-month recall period.

DATA COLLECTION/EXTRACTION METHODS

Questionnaires were mailed to patients, with a second questionnaire mailed to nonrespondents, followed by six attempts to complete a telephone interview.

PRINCIPAL FINDINGS

If the sampling criterion was a visit in the last 6 months, 9 percent of those with a visit in the last 12 months would not have been surveyed. A total of 1837 patients completed 6-month surveys (44.9 percent response rate); 588 completed 12-month surveys (46.0 percent response rate). Shortening the reference from 12 to 6 months reduced the proportion of respondents reporting a blood test, X-ray, or other tests. Adjusting for respondent characteristics, the most positive response was selected more often on the 6-month survey for 12 out of 13 questions, and three of these differences were statistically significant (P < 0.05).

CONCLUSIONS

Surveys using a 6-month recall period may yield slightly higher scores than surveys with a 12-month recall period.

A survey of risk tolerance to multiple sclerosis therapies

OBJECTIVE

To determine tolerance to various risk scenarios associated with current multiple sclerosis (MS) therapies.

METHODS

People with MS from the North American Research Committee on Multiple Sclerosis Registry's online cohort and the National Multiple Sclerosis Society were invited to complete a questionnaire on tolerance to real-world risks associated with a hypothetical therapy. Multiple risks levels were presented, including skin rash, infection, kidney injury, thyroid injury, liver injury, and progressive multifocal leukoencephalopathy (PML).

RESULTS

Both PML and kidney injury had the lowest risk tolerance (RT) at 1:1,000,000, and thyroid and infection risks had the highest tolerance at 1:1,000. Men, younger individuals, and participants with greater disability reported a higher tolerance to all risk scenarios. Those who were currently taking an MS therapy reported higher tolerance than those not taking any therapy. Participants taking infusion therapies reported high tolerance to all risks, and those taking injectables reported a lower tolerance.

CONCLUSION

People with MS displayed a wide range of RT for MS therapies. Our study identified sex, age, disability, and current disease-modifying therapy use to be associated with RT.

The effect of administration mode on CAHPS survey response rates and results: A comparison of mail and web-based approaches

OBJECTIVE

The objective of this study was to compare response rates, respondents' characteristics, and substantive results for CAHPS surveys administered using web and mail protocols.

DATA SOURCES

Patients who had one or more primary care visits in the preceding 6 months.

STUDY DESIGN/DATA COLLECTION METHODS

Patients for whom primary care practices had email addresses were randomized to one of four survey administration protocols: web via a portal invitation; web via an email invitation; combination of web and mail; and mail only. Another sample of patients without known email addresses was surveyed by mail. Samples of nonrespondents to the Internet and mail protocols were surveyed by telephone.

PRINCIPAL FINDINGS

Response rates to surveys administered using the Internet protocols were lower than for the surveys administered by mail (20 percent vs over 40 percent). However, characteristics of respondents and survey answers were very similar across protocols. Respondents without email addresses were older, less educated, and more likely to be male than those with email addresses, and there were a few differences in their responses. There was little evidence of nonresponse bias in either the mail or web protocols.

CONCLUSION

In this well-educated patient population, web protocols had lower response rates, but substantive results very similar to those from mail protocols.

Making Cuts to Medicare: The Views of Patients, Physicians, and the Public

Purpose

Cancer-related expenditures are increasing health care costs. Determining how patients with cancer, oncologists, and the general public view Medicare spending and whether they would support cost-containment measures is important to identifying acceptable approaches to reducing health care expenditures.

Methods

Patients with cancer treated at an academic medical center, a random national sample of oncologists, and the general public were surveyed between July 2012 and March 2013 about causes of high health care costs and proposed cost-control measures.

Results

Three hundred twenty-six patients (response rate, 72%), 250 oncologists (response rate, 55%), and 891 members of the general public (response rate, 50%) completed surveys. The majority thought Medicare spending was a moderate or big problem (75.8% of patients; 97.2% of oncologists; 75.3% of the general public) and thought Medicare could spend less without causing harm (65.6% of patients; 74.0% of oncologists; 69.7% of the general public). There was broad consensus that drug and insurance companies' profits added to costs, although physicians, hospitals, and patients were also perceived as sharing responsibility. More than 75% of respondents supported enabling Medicare to refuse reimbursement for more expensive treatment if less costly, equally effective treatment was available. Respondents generally favored means testing Medicare cost sharing but, except for oncologists, resisted the idea of an independent oversight panel. All groups opposed annual ceilings on Medicare spending per patient.

Conclusion

The majority of respondents view Medicare costs as a substantial problem and that all players in the system, including providers, contribute to high costs. Most thought Medicare could spend less without causing harm. Overall, respondents strongly favored not paying for more expensive treatments when cheaper ones are equally effective.

Development and evaluation of a new survey instrument to measure the quality of colorectal cancer screening decisions

Background

Guidelines for colorectal cancer screening recommend that patients be informed about options and be able to select preferred method of screening; however, there are no existing measures available to assess whether this happens.

Methods

Colorectal Cancer Screening Decision Quality Instrument (CRC-DQI) includes knowledge items and patients' goals and concerns. Items were generated through literature review and qualitative work with patients and providers. Hypotheses relating to the acceptability, feasibility, discriminant validity and retest reliability of the survey were examined using data from three studies: (1) 2X2 randomized study of participants recruited online, (2) cross-sectional sample of patients recruited in community health clinics, and (3) cross-sectional sample of providers recruited from American Medical Association Master file.

Results

338 participants were recruited online, 94 participants were recruited from community health centers, and 115 physicians were recruited. The CRC-DQI was feasible and acceptable with low missing data and high response rates for both online and paper-based administrations. The knowledge score was able to discriminate between those who had seen a decision aid or not (84% vs. 64%, p < 0.001) and between providers, online patients and clinic patients (89% vs. 74% vs. 41%, p < 0.001 for all comparisons). The knowledge score and most of the goals had adequate retest reliability. About half of the participants received a test that matched their goals (47% and 51% in online and clinic samples respectively). Many respondents who had never been screened had goals that indicated a preference for colonoscopy. A minority of respondents in the online (21%) and in clinic (2%) samples were both well informed and received a test that matched their goals.

Conclusions

The CRC-DQI demonstrated good psychometric properties in diverse samples, and across different modes of administration. Few respondents made high quality decisions about colon cancer screening.

An innovative model of culturally tailored health promotion groups for Cambodian survivors of torture

Cambodians living in the U.S.A. suffer from depression, posttraumatic stress disorder (PTSD), and chronic medical disease at rates far in excess of national averages. The Harvard Program in Refugee Trauma's Cambodian Health Promotion Program seeks to address this burden of disease by offering them culturally tailored health education in a group setting. A health professional and a bicultural health educator co-facilitated a five-session health promotion group for Cambodian survivors of torture from 2007 to 2011. The program covered five major topics from Western and Cambodian worldviews. They included the meaning of health promotion, nutrition, exercise, stress management and sleep hygiene, and health practitioner-patient communication. The bicultural worker administered Pre and Post semi-structured Health Promotion Questionnaires. The data presented here are the results from 126 participants. Changes between the Pre and Post health promotion groups demonstrated significant improvements in health status, lifestyle activities, sleep, and depression. Participants revealed greater confidence in communicating with their primary health care practitioner. Culturally tailored Cambodian health promotion education administered in a small group setting may improve health and mental health behaviors. Culturally tailored health promotion education in a small group setting may promote healing in survivors of torture. It is an intervention worthy of further research and development.

Patient, public, and oncologists’ attitudes toward rationing medical care

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Background: Lowering health care costs is critical. Patients with cancer (PT) and oncologists (MD) regularly make decisions regarding interventions with potentially marginal benefit but substantial expense. What are the attitudes of PT, the public (GP), and MD on ways to control costs? Methods: In 2012, surveys were completed by 326 adult PT (Response Rate (RR)=72%), a random sample of 891 U.S. adults (RR=50%) and 245 MD (RR=55%). Results: A majority thought Medicare spending was a big or moderate problem (76% PT; 75% GP; 97% MD) and that Medicare could spend less without causing harm (66% PT; 70% GP; 74% MD). Respondents attributed rising costs to multiple factors including drug companies charging too much (94% PT; 90% GP; 94% MD) and insurance company profits (88% PT; 88% GP; 83% MD). Many also thought physicians and hospitals provided unnecessary tests and treatments (RX) (69% PT; 81% GP; 70% MD). Regarding solutions, most supported refusing to pay for expensive care if an equally effective, less expensive alternative was available or if therapy did not improve survival or quality of life (QOL). Few respondents were willing to refuse payment for RX that extend life by 4 months. Conclusions: The majority of those sampled view Medicare costs as a substantial problem and pharmaceutical and insurance companies as significant contributors. The GP in particular believe physicians and hospitals add considerably to the cost problem. A majority favor not paying for more expensive RX when cheaper ones are equally effective or if RX do not improve survival or QOL. MD were accepting of an independent oversight panel however this was met with resistance by PT and the GP. Currently, Medicare and other payers do not consistently follow such practices. [Table: see text]

Preparing to Measure Health Coverage in Federal Surveys Post-Reform

In preparation for health reform in 2014, qualitative research was conducted with Massachusetts residents to explore how to adapt surveys to accommodate reporting information about health exchanges. Questions about exchange participation were effective when state-specific exchange program names were offered, but generic terms such as “marketplace” and “exchange” did not resonate with respondents. However, respondents were able to understand new questions about premiums and subsidies and to answer with a high degree of accuracy. These questions, taken in tandem with answers on plan type, were sufficient to distinguish among Medicaid, subsidized exchange coverage, and unsubsidized coverage, even without the benefit of state-specific exchange program names.

Measuring decision quality: psychometric evaluation of a new instrument for breast cancer surgery

BACKGROUND

The purpose of this paper is to examine the acceptability, feasibility, reliability and validity of a new decision quality instrument that assesses the extent to which patients are informed and receive treatments that match their goals.

METHODS

Cross-sectional mail survey of recent breast cancer survivors, providers and healthy controls and a retest survey of survivors. The decision quality instrument includes knowledge questions and a set of goals, and results in two scores: a breast cancer surgery knowledge score and a concordance score, which reflects the percentage of patients who received treatments that match their goals. Hypotheses related to acceptability, feasibility, discriminant validity, content validity, predictive validity and retest reliability of the survey instrument were examined.

RESULTS

We had responses from 440 eligible patients, 88 providers and 35 healthy controls. The decision quality instrument was feasible to implement in this study, with low missing data. The knowledge score had good retest reliability (intraclass correlation coefficient=0.70) and discriminated between providers and patients (mean difference 35%, p<0.001). The majority of providers felt that the knowledge items covered content that was essential for the decision. Five of the 6 treatment goals met targets for content validity. The five goals had moderate to strong retest reliability (0.64 to 0.87). The concordance score was 89%, indicating that a majority had treatments concordant with that predicted by their goals. Patients who had concordant treatment had similar levels of confidence and regret as those who did not.

CONCLUSIONS

The decision quality instrument met the criteria of feasibility, reliability, discriminant and content validity in this sample. Additional research to examine performance of the instrument in prospective studies and more diverse populations is needed.

Abstract 86: What Do Patients Remember? The Knowledge Gap in Patients Undergoing Elective Percutaneous Coronary Interventions

Background: There is increasing scrutiny of the use of elective percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD), due to the lack of mortality benefit compared with optimal medical therapy. Because of the clinical equipoise involved, decisions for elective PCI should include the preferences and involvement (to the extent desired) of a well-informed patient. However, there have been no large, national studies directly assessing knowledge and decision-making in patients with stable CAD undergoing elective procedures, so the overall state of knowledge in such patients is not clear. Our objective was to assess whether patients who have undergone elective PCI recalled critical facts and key decision-making processes regarding their treatment.

Methods: National cross-sectional survey of 461 randomly sampled Medicare beneficiaries aged ≥ 65 who underwent elective PCI in 2008. Survey questions assessed patient demographics, cardiac history, decision-making processes, and knowledge. Knowledge was measured as the percentage of correct responses to 7 questions about the risks and benefits of elective PCI, bypass surgery and medical therapy for CAD. Questions about the decision-making process included assessment of physician-patient communication about the procedure and the patient's perception of their participation in the decision-making process. Association between knowledge and various predictors was determined using multivariate linear regression.

Results: Patients answered a mean of 31.1% of questions correctly, and no patients answered all the questions correctly. Patients having undergone prior coronary artery bypass surgery had slightly more knowledge than those having their first PCI (mean correct score 36.7% vs. 29.4%, p<0.01). In a multivariate model, younger patients and patients who had previous bypass surgery were more knowledgeable. Neither educational level nor the patients’ subjective feeling of being informed was associated with knowledge level. Very few patients reported that their physicians talked about alternate treatment options (4.3%) or asked their preferences about the procedure (14.3%), two critical elements of shared decision-making; however, 67.3% of patients felt that decision-making was equally shared between the physician and patient.

Conclusions: Medicare patients who underwent elective PCI had poor recollection about the benefits and risks of PCI, making it difficult to assess whether or not the patients made informed decisions. In addition, patients reported incomplete discussions about treatment alternatives and limited discussion of treatment preferences, despite reporting a high level of perceived shared decision-making. Although it is not clear whether the gaps in knowledge are a result of poor recall by the patient, poor knowledge transfer, or both, greater focus on improving patient knowledge and the physician-patient conversation about treatment alternatives and preferences is needed to ensure that elective PCIs are reflective of the preferences of well-informed patients.

Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation

BACKGROUND

A high quality decision requires that patients who meet clinical criteria for surgery are informed about the options (including non-surgical alternatives) and receive treatments that match their goals. The aim of this study was to evaluate the psychometric properties and clinical sensibility of a patient self report instrument, to measure the quality of decisions about total joint replacement for knee or hip osteoarthritis.

METHODS

The performance of the Hip/Knee Osteoarthritis Decision Quality Instrument (HK-DQI) was evaluated in two samples: (1) a cross-sectional mail survey with 489 patients and 77 providers (study 1); and (2) a randomized controlled trial of a patient decision aid with 138 osteoarthritis patients considering total joint replacement (study 2). The HK-DQI results in two scores. Knowledge items are summed to create a total knowledge score, and a set of goals and concerns are used in a logistic regression model to develop a concordance score. The concordance score measures the proportion of patients whose treatment matched their goals. Hypotheses related to acceptability, feasibility, reliability and validity of the knowledge and concordance scores were examined.

RESULTS

In study 1, the HK-DQI was completed by 382 patients (79%) and 45 providers (58%), and in study 2 by 127 patients (92%), with low rates of missing data. The DQI-knowledge score was reproducible (ICC = 0.81) and demonstrated discriminant validity (68% decision aid vs. 54% control, and 78% providers vs. 61% patients) and content validity. The concordance score demonstrated predictive validity, as patients whose treatments were concordant with their goals had more confidence and less regret with their decision compared to those who did not.

CONCLUSIONS

The HK-DQI is feasible and acceptable to patients. It can be used to assess whether patients with osteoarthritis are making informed decisions about surgery that are concordant with their goals.

Development of instruments to measure the quality of breast cancer treatment decisions

BACKGROUND

Women with early-stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients' knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality.

OBJECTIVE

To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them.

METHODS

Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross-sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined.

RESULTS

Thirty-eight facts (11-14 per decision) and 27 goals (8-10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals.

CONCLUSIONS

Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients' and providers' perspectives are different, it is vital that instrument development should include items reflecting both views.

Decisions about Breast Reconstruction after Mastectomy: Patient Involvement, Knowledge, and Preferences

Background:Most breast cancer patients who have a mastectomy do not have breast reconstruction, and rates of reconstruction vary by race, education, and geographic location, suggesting problems with decision making. We sought to assess the quality of decisions about breast reconstruction by measuring patient involvement in decision making, patient knowledge, and the degree to which decisions reflected patients' goals.Methods: Breast cancer survivors from four sites who were treated with mastectomy in the past 3 years completed a mailed survey, as part of a larger study to validate decision quality instruments. The survey contained questions about the decision making process, factual questions, and questions about personal goals and concerns. Characteristics associated with knowledge were identified with linear regression. Goals/concerns associated with reconstruction were identified using logistic regression. The percent match between treatment preference and treatment received was calculated.Results: The larger study recruited 456 patients (overall response rate 59%). 91 patients completed the reconstruction module. Average age was 56.9 years, 82.6% were white, 63.7% had a college degree, and 64% had Stage I disease. 45.8% had reconstruction.Decision making: 78% of patients reported that their doctor mentioned reconstruction. Most reported a discussion of the pros of reconstruction (63.8%), whereas the minority reported a discussion of the cons (20.9%). 76% reported being asked for their preference about reconstruction. 3% said the doctor mainly made the decision, 74% said they made the decision, and 15% said both made the decision. Most (81%) felt their level of involvement was about right.Knowledge:The mean knowledge score was 32.9% (SD=19). 41% knew that reconstruction has little effect on cancer surveillance. 54% knew that recovery after implant surgery is easier than after flap surgery. 3.3% knew that about 1/3 of patients have a major complication. On bivariate analysis, reconstruction (43.3 vs. 32.6, p=0.053), higher income (43.4 vs. 26.3, p=0.008), a college degree (43.4 vs. 26.2, p&lt;0.01), and being married (40.9 vs. 29, p=0.04) were associated with higher knowledge. On multivariate analysis, higher income was associated with higher knowledge (p=0.0013).Preferences:The following goals were associated with reconstruction: “use your own tissue to make a breast” (OR 1.309, CI 1.028, 1.605), “avoid using a prosthesis” (OR 1.254, CI 1.039, 1.512), and “wake up after mastectomy with reconstruction underway” (OR 1.254, CI 1.057, 1.487). Patients who felt it was important to “avoid putting foreign material in your body” were less likely to have reconstruction (OR 0.682, CI 0.518, 0.899).The majority of patients (81%) had treatment that was concordant with preference.Conclusions: Despite reporting high involvement in decisions about reconstruction, breast cancer patients undergoing mastectomy had major knowledge deficits, and many reported having treatment they did not prefer. In addition to involving patients in decisions about reconstruction, surgeons should discuss both the pros and the cons and should explicitly ask patients for their preference about reconstruction.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3103.

The development of a CAHPS instrument for Nursing Home Residents (NHCAHPS)

We report on a federal initiative to develop a CAHPS (The Consumer Assessment of Healthcare Providers and Systems) survey to measure residents' experiences with quality-of-care and quality-of-life in nursing homes (known as NHCAHPS). We focus on how we created and tested questions for inclusion in the instrument and tested a possible cognitive screener to determine which residents could participate in a NHCAHPS interview. The major lessons learned were: (1) In contrast to other CAHPS surveys, ratings were more useful than reports because of the difficulty that residents had with summarizing over time and people; (2) consistent with other CAHPS surveys, the 0 to 10 response scale appeared to work well with nursing home residents for many of the quality-of-care questions; however, a different response scale was needed for many of the quality-of-life items; and (3) in contrast with typical survey methodology and other CAHPS surveys where explicit time reference periods are used, a non-specific present reference period in questions seemed to work best.

Renal cell carcinoma metastatic to the pancreas: a single-institution series and review of the literature

OBJECTIVES

To present a series of 5 patients with solitary metastatic renal cell carcinoma (RCC) to the pancreas after radical nephrectomy at our institution and review the published reports of this rare event.

METHODS

A retrospective review of the records of 5 patients with histologically confirmed RCC metastatic to the pancreas after radical nephrectomy was performed. A total of 5 patients (4 men, 1 woman) with a median age of 56 years (range 54 to 68) underwent radical nephrectomy for primary RCC. The pathologic stage was Robson I (n = 3) or Robson III (n = 2), with a left-sided tumor occurring in 3 patients and a right-sided tumor in 2 patients. The median interval from nephrectomy to the diagnosis of the pancreatic metastasis was 12 years (range 4 to 15). All patients were symptomatic at presentation, including weight loss (n = 3), abdominal pain (n = 3), early satiety (n = 1), steatorrhea (n = 1), and/or hemosuccus pancreaticus (n = 1).

RESULTS

All pancreatic metastases were hypervascular on imaging studies, and surgical removal was accomplished by pancreaticoduodenectomy (n = 3), partial pancreatectomy (n = 1), or subtotal pancreatectomy (n = 1). One patient died of disseminated disease 12 months after pancreatic resection. Two other patients had recurrences in the lung (n = 1) at 5 months or the pancreas/liver (n = 1) at 48 months. Both of these patients underwent a second resection and were disease free at 2 and 12 months afterward. The two remaining patients were disease free at 7 and 24 months after pancreatic resection.

CONCLUSIONS

RCC is an unpredictable tumor that may demonstrate very late metastases even from early-stage lesions. Aggressive surgical management of isolated pancreatic lesions offers a chance of long-term survival.

Brequinar sodium: monitoring immunosuppressive activity

There has been remarkable consistency in our laboratory for the experimental results derived from a variety of allogeneic and xenogeneic models of organ transplantation using BQR, a primary immunosuppressive agent, to prevent graft rejection. Considerable knowledge exists in a number of species with respect to the dose-response immunosuppressive efficacy, organ specificity, peripheral drug measurements, toxic side-effects, species sensitivity, and synergistic drug interactions. Despite the complexity of transferring experimental results to the clinical setting, the cumulative experience with this new immunosuppressive compound suggests that it may be highly effective when used for clinical transplantation. The identification of a predictive monitoring technique(s) would provide clinicians with a highly sensitive marker to effectively regulate BQR posttransplantation immunosuppressive therapies. Although the maintenance of a "therapeutic window" of immunosuppressive efficacy did not necessarily prevent the rejection of allografts or xenografts in the rat models tested, there was an important correlation between elevated BQR levels and the onset of recipient toxicity. Increased morbidity and mortality was noted when BQR blood levels were elevated above 16 micrograms/mL. The measurement of pyrimidine biosynthetic pathway metabolites provided a direct correlation between graft viability, global depletion of nucleotides (UTP, CTP, ATP, GTP), and suppression of PHA-mitogenic lymphocyte proliferative responses when different doses of BQR were tested. The analysis of these parameters were less informative following combination therapy with CsA. As with other immunosuppressive agents, the difficulty in relying exclusively on plasma trough drug levels as an accurate means to project graft viability may be influenced by individual differences in absorption, metabolism, and excretion of the compound. Additional parameters that may provide valuable information for the posttransplant therapeutic course include drug bioavailability, peak levels, drug clearance, or inhibition of immune response. It is anticipated that these studies will provide important baseline information for further refinement of these monitoring techniques to aid in posttransplant patient management.

Fetal antigens as tumor growth enhancing factors in Yoshida's tumor rats

Malignant neoplastic cells have been shown to have some antigenic features identical to those of embryonic cells. Since several antigens are likely to be shared by both embryonic cells and neoplastic tissue, we tried to understand the meaning of the appearance of such antigens and the type of effect that the immunization with embryonic antigens would have on the survival of Yoshida's tumor rats. Wistar rats were immunized with fetal antigens by fetal cells (1.5 x 10(6)) suspended in 0.5 ml of Hanks solution plus an equal volume of Freund adjuvant, were injected in hind footpads, i.p. and i.m., respectively, for active immunization. Rabbit antigen sera were used for passive immunization. All animals presented ascites and tumor growth. Animals immunized by means of fetal cell antigens showed a mean survival rate after neoplastic transplant of 14 days. Animals that received rabbit immune serum showed a mean survival rate after neoplastic transplant of 17 days. The immunization by means of fetal antigens elicited a scanty effect on the survival of Yoshida's tumor transplanted rats. It can be concluded that antibodies, which are able to cross react with neoplastic cells, do not have cytotoxic effect and do not interfere with the survival of the neoplastic transplanted animals. Therefore, fetal antigens are likely able to carry out an immunosuppressive action. The fact that they appear on neoplastic cells could be seen as a metabolic modification effect or as a growth enhancing factor.

Expression of cell cycle-dependent genes and proliferative state of lymphocytes in aging

The authors analyzed the expression of some genes involved in the control of T lymphocyte proliferation in a group of healthy elderly subjects. They focused their attention on genes involved in the G(0)/G(1) transition (TK, PCNA, H3, IL2-R) and showed decreased expression in the TK, H3 and IL2-R genes. Using flow cytofluorimetry, delayed transition from the G(0)/G(1) to the S stage was observed.

Pathophysiology of the immune system in elderly subjects with or without diabetes and variations after recombinant interleukin-2

This study reports two groups of elderly diabetic patients and normal subjects, with or without hypercholesterolemia and hypertriglyceridemia, who presented a decrease of the T lymphocyte-mediated function, proliferative capacity, phagocytosis, cytotoxicity and surface markers. This fall was more evident in hypercholesterolemic and hypertriglyceridemic subjects. The humoral responses and other parameters studied did not reveal significant variations. The authors also observed that recombinant interleukin-2 (rIL-2) stimulation determined a satisfactory response in healthy and diabetic subjects, while it did not normalize values in patients with altered lipid balance.

[Immunologic characteristics of a polyvalent vaccine]

A lot of bacterial vaccines show a very interesting immunostimulating profile. The AA. studied the effects of a polyvalent vaccine on the phagocytosis, on the cellular immunity and on the IgA production. They also investigated its capacity to reactivate the response to the C tetani toxin (Booster effect), both "in vitro" and in human volunteers. The results show a significant improvement in the immunity response to specific and aspecific stimuli.