Treatment Effect Estimates From Pilot Trials Are Unreliable

CONTEXT

The CONSORT guideline defines a pilot trial as a small-scale version of a desired future efficacy trial that is intended to answer the key questions of whether and how a larger study should be done. For example, a pilot trial might evaluate different approaches to data collection or outcome measurement. However, pilot trials are unreliable for assessing treatment efficacy due to the statistical phenomenon called sampling variability.

OBJECTIVES

In this tutorial we use computer simulation to demonstrate the influence of sampling variability on efficacy estimates from pilot trials, illustrating why pilot trial designs should not be used to evaluate whether a treatment is promising or not.

METHODS

We simulate a 2-arm parallel group trial (N=20 per group) with a survival outcome as an example. Simulations are done under two scenarios: 1) the treatment is efficacious at the level of a hypothetical minimum clinically important difference (hazard ratio [HR] = 0.75); and 2) the treatment is not efficacious (HR=1).

RESULTS

As expected, in both simulated scenarios the range of observed results is distributed around the true treatment effect, HR=0.75 or HR=1. Importantly, ∼20% of trials simulated under scenario 1 incorrectly suggest the treatment may be harmful (HR > 1). Under scenario 2, half of the simulated studies incorrectly suggest the treatment is beneficial.

CONCLUSION

Treatment effect estimates from pilot trials should not be used to make future development decisions regarding a novel therapy because of the high risk of misleading conclusions.

Evaluation of antibiotic-resistant bacteria in home kitchens and bathrooms: Is there a link between home disinfectant use and antibiotic resistance?

OBJECTIVE

To determine the relationship between home disinfectant use and the prevalence of antibiotic resistance among environmental isolates of human pathogens.

METHODS

Bacteria were cultured from 5 kitchen and 5 bathroom sites using quantitative methods. Antibiotic susceptibility was determined by standard methods. Home disinfectant use was assessed via a questionnaire.

RESULTS

The overall total mean log10 counts (total CFU) for the kitchen and bathroom were 4.31 and 4.88, respectively. Gram-positive bacteria were more common in the bathroom (4.05) than in the kitchen (3.60), while Gram-negative bacilli were more common in the kitchen (4.23) than in the bathroom (3.86). The sink and bath drains were the most contaminated sites with 6.16-log10 of total CFU and 6.6-log10 in the kitchen and bathroom, respectively. Households reported cleaning frequency with a variety of commercial products. Most respondents used antibacterial products (eg, soaps, surface disinfectants) in the home. Antibiotic-resistant pathogens were infrequently isolated in the homes evaluated.

CONCLUSIONS

Compared to pathogens causing community-acquired clinical infections in the ICARE study, pathogens isolated from households are less likely to demonstrate antibiotic resistance. In addition, no relationship between antibacterial use or frequency of cleaning or disinfection and antibiotic resistance was revealed.

Designing Psychosocial Intervention Pilot Studies: A Tutorial for Palliative Care Investigators

This is a tutorial on designing a persuasive pilot study of a psychosocial intervention (e.g., behavioral symptom management) in the palliative care setting. This tutorial is most relevant for early stages of intervention research that aims to progress toward a randomized controlled trial with a high degree of internal validity. Broadly, a pilot study aims to address multiple elements of feasibility and acceptability so that investigators are well positioned for the next study in their program of research. To assist investigators in writing compelling grant applications we designed this tutorial as an annotated checklist of goals that a pilot study within the palliative care domain should seek to accomplish. These goals include the following: 1) begin with the end in mind, 2) use a formal conceptual model, 3) use measures with strong psychometric properties, 4) justify the timing of study sessions and assessments, 5) test recruitment methods, 6) estimate retention, 7) assess interventionist fidelity, 8) assess acceptability of the intervention, 9) assess feasibility, and 10) identify barriers to the next study. We elaborate on these goals by describing an ongoing pilot study testing the feasibility and acceptability of a psychosocial pain management intervention for patients with advanced cancer. Pilot studies are crucial for building a successful program of research, but they are also limited in terms of their sample size and overall objectives. A persuasive pilot study is one that is limited yet useful rather than limited and trivial.

Institutional approaches to preventing questionable research practices

Questionable research practices (QRP) are actions taken by researchers that span a range of concern related to violation of research best practices, and ultimately expose institutions and research participants to risk. Numerous studies have shown that QRP are common. The continued prevalence of QRP indicates that existing approaches for dealing with QRP are falling short. In this editorial we discuss the risks associated with QRP and propose mitigation strategies at the institutional level using a common QRP as an example, questionable treatment of subgroup analyses. We argue that the need for institutional intervention in cases such as this are particularly motivating when both the investigator and the institution have a substantial financial conflict of interest related to intellectual property that requires the investigator's expertise to continue developing. To address this, we propose an expansion of the traditional conflict of interest management process.

Aerobic Versus Resistance Training Effects on Ventricular-Arterial Coupling and Vascular Function in the STRRIDE-AT/RT Trial

Background: The goal was studying the differential effects of aerobic training (AT) vs. resistance training (RT) on cardiac and peripheral arterial capacity on cardiopulmonary (CP) and peripheral vascular (PV) function in sedentary and obese adults.

Methods: In a prospective randomized controlled trial, we studied the effects of 6 months of AT vs. RT in 21 subjects. Testing included cardiac and vascular ultrasoundography and serial CP for ventricular-arterial coupling (Ees/Ea), strain-based variables, brachial artery flow-mediated dilation (BAFMD), and peak VO₂ (pVO_2; mL/kg/min) and peak O₂-pulse (O₂p; mL/beat).

Results: Within the AT group (n = 11), there were significant increases in rVO₂ of 4.2 mL/kg/min (SD 0.93) (p = 0.001); O₂p of 1.9 mL/beat (SD 1.3) (p = 0.008) and the brachial artery post-hyperemia peak diameter 0.18 mm (SD 0.08) (p = 0.05). Within the RT group (n = 10) there was a significant increase in left ventricular end diastolic volume 7.0 mL (SD 9.8; p = 0.05) and percent flow-mediated dilation (1.8%) (SD 0.47) (p = 0.004). Comparing the AT and RT groups, post exercise, rVO₂ 2.97, (SD 1.22), (p = 0.03), O₂p 0.01 (SD 1.3), (p = 0.01), peak hyperemic blood flow volume (1.77 mL) (SD 140.69) (p = 0.009), were higher in AT, but LVEDP 115 mL (SD 7.0) (p = 0.05) and Ees/Ea 0.68 mmHg/ml (SD 0.60) p = 0.03 were higher in RT.

Discussion: The differential effects of AT and RT in this hypothesis generating study have important implications for exercise modality and clinical endpoints.

Two Questions About the Design of Cluster Randomized Trials: A Tutorial

This is a short tutorial on two key questions that pertain to cluster randomized trials (CRTs): 1) Should I perform a CRT? and 2) If so, how do I derive the sample size? In summary, a CRT is the best option when you "must" (e.g., the intervention can only be administered to a group) or you "should" (e.g., because of issues such as feasibility and contamination). CRTs are less statistically efficient and usually more logistically complex than individually randomized trials, and so reviewing the rationale for their use is critical. The most straightforward approach to the sample size calculation is to first perform the calculation as if the design were randomized at the level of the patient and then to inflate this sample size by multiplying by the "design effect", which quantifies the degree to which responses within a cluster are similar to one another. Although trials with large numbers of small clusters are more statistically efficient than those with a few large clusters, trials with large clusters can be more feasible. Also, if results are to be compared across individual sites, then sufficient sample size will be required to attain adequate precision within each site. Sample size calculations should include sensitivity analyses, as inputs from the literature can lack precision. Collaborating with a statistician is essential. To illustrate these points, we describe an ongoing CRT testing a mobile-based app to systematically engage families of intensive care unit patients and help intensive care unit clinicians deliver needs-targeted palliative care.

Behavioral cancer pain intervention using videoconferencing and a mobile application for medically underserved patients: Rationale, design, and methods of a prospective multisite randomized controlled trial

BACKGROUND

Women with breast cancer in medically underserved areas are particularly vulnerable to persistent pain and disability. Behavioral pain interventions reduce pain and improve outcomes. Cancer patients in medically underserved areas receive limited adjunctive cancer care, as many lack access to pain therapists trained in behavioral interventions, face travel barriers to regional medical centers, and may have low literacy and limited resources. mHealth technologies have the potential to decrease barriers but must be carefully adapted for, and efficacy-tested with, medically underserved patients. We developed an mHealth behavioral pain coping skills training intervention (mPCST-Community). We now utilize a multisite randomized controlled trial to: 1) test the extent mPCST-Community reduces breast cancer patients' pain severity (primary outcome), pain interference, fatigue, physical disability, and psychological distress; 2) examine potential mediators of intervention effects; and 3) evaluate the intervention's cost and cost-effectiveness.

METHODS/DESIGN

Breast cancer patients (N = 180) will be randomized to mPCST-Community or an attention control. mPCST-Community's four-session protocol will be delivered via videoconferencing at an underserved community clinic by a remote pain therapist at a major medical center. Videoconference sessions will be supplemented with a mobile application. Participants will complete self-report measures at baseline, post-intervention, and 3- and 6-month follow-ups.

CONCLUSIONS

mPCST-Community has the potential to reduce pain and disability, and decrease barriers for cancer patients in medically underserved areas. This is one of the first trials to test an mHealth behavioral cancer pain intervention developed specifically for medically underserved communities. If successful, it could lead to widespread implementation and decreased health disparities.

An analysis of missing items in real-world electronic patient reported outcomes data: implications for clinical care

PURPOSE

Utilization of electronic patient-reported outcomes (ePROs) in the clinic can improve quality of life and prolong survival in cancer care. However, there remain unanswered questions regarding trends in missing data and the potential effect on real-time patient care.

METHODS

This study utilized a prospectively collected dataset of ePROs from oncology clinics that administered the Patient Care Monitor 2.0 (PCM), a validated symptoms survey assessing 78 items for men, and 86 for women. We tabulated the frequency of missing items, by item and domain (emotional, functional and physical symptom-related), and examined these by age, gender, education, race and marital status.

RESULTS

Within 20,986 encounters, there were responses to at least 1 PCM item from 6933 unique patients. The highest frequency of missing answers occurred for: "attend a paid job" (10.7%), "reduced sexual enjoyment" (3.8%), and "run" (3.7%). By domain, 12.3% of functional, 8.4% of physical symptom-related, and 1.6% of emotional constructs contained at least one missing item. For functional and physical symptom-related items, missingness was most common in patients >60 years old.

CONCLUSION

The frequency of missingness was highest for functional items, like attending a paid job, suggesting that some respondents (e.g., retirees without a paid job) skipped questions that were less applicable to them. More universal issues for cancer patients, such as emotional well-being, had much lower frequencies of missingness. This suggests differential item completion that warrants further study to understand the inherent drivers. Identifying causes of missingness could improve the clinical utility of ePROs and highlight opportunities to personalize care.

Some statistical memes which sound correct but aren't quite: Application to the analysis of observational databases used in learning health systems

We consider four memes, correct within the context of randomized trials but requiring modification for the analysis of the observational databases typically associated with learning health systems: (a) the right answer always requires randomization; (b) a bigger database is always a better database; (c) statistical adjustment always works if based on a large enough database; and (d) always make a formal adjustment when testing multiple hypotheses. The rationale for these memes within the context of randomized trials is discussed, and the memes are restated in a fashion that is consistent with learning health systems.

Vascular Cellular Adhesion Molecule-1 (VCAM-1) and Memory Impairment in African-Americans after Small Vessel-Type Stroke

BACKGROUND

African-Americans (AA) are 3 times more likely to have small-vessel-type ischemic strokes (SVS) than Whites. Small vessel strokes are associated with cognitive impairment, a relationship incompletely explained by white matter hyperintensity (WMH) burden. We examined whether inflammatory/endothelial dysfunction biomarkers are associated with cognition after SVS in AAs.

METHODS

Biomarkers were obtained in 24 subjects (median age 56.5 years, 54% women, median 12 years education). Cognition was assessed more than 6 weeks poststroke using the memory composite score (MCS), which was generated using recall from the Hopkins Verbal Learning Test-II and Brief Visuospatial Memory Test-Revised. A semi-automated, volumetric protocol was used to quantify WMH volume (WMHv) on clinical MRI scans. Potential biomarkers including vascular cell adhesion molecule-1 (VCAM-1), interleukin-1 receptor antagonist, interleukin-6, interleukin-8, interleukin-10, interferon gamma, and thrombin-antithrombin (TAT) were log-transformed and correlated with MCS with adjustment for potential confounders.

RESULTS

Among serum biomarkers, only VCAM-1-correlated with poorer memory based on the MCS (r = -.659; P = .0006). VCAM-1 (r = .554; P = .005) and age (r = .479; P = .018) correlated with WMHv; VCAM-1 was independently associated with MCS after adjustment for WMHv, age, and education (P = .023).

CONCLUSIONS

The findings of this exploratory analysis suggest that endothelial dysfunction and inflammation as reflected by VCAM-1 levels may play a role in poststroke cognitive impairment. Additional studies are needed to validate this observation and to evaluate this relationship in non-AAs and with other stroke types and compare this finding to cognitive impairment in nonstroke populations.

Prognostic significance of primary tumor sidedness in patients undergoing liver resection for metastatic colorectal cancer

BACKGROUND

Approximately 38% of patients with colorectal cancer will develop isolated liver metastases. Sidedness of colon tumor is identified in non-metastatic and unresected metastatic cancers as predictive of survival, yet its dedicated analysis in resected liver metastases is minimal. Our primary aim was to assess whether left-sided primary tumors improve prognosis in stage IV cancer patients undergoing curative-intent liver metastasectomy; it was hypothesized that it would.

METHODS

This is a retrospective, observational cohort study from 1996 to 2016 in a single tertiary-care facility. Survival from diagnosis was calculated via Kaplan-Meier method and compared between the right and left sides via log-rank analysis.

RESULTS

Median survival differs significantly between colorectal tumors of the right and left origins after hepatic metastasectomy in 612 patients. In patients with right-sided tumors, median survival from diagnosis was 4.5 years (IQR 4.1-5.3), and 6.3 years (IQR 5.6-6.9) in those with left tumors (HR 1.5, 95% CI 1.38-1.60, p < 0.001).

CONCLUSION

As in studies on earlier-stage or unresected metastatic disease, tumor sidedness is an important prognostic factor in patient survival with liver metastasectomy. Clinical risk scores should include side of primary tumor. Further work is needed to determine the molecular basis for this difference.

Effect of Dextroamphetamine on Poststroke Motor Recovery: A Randomized Clinical Trial

Importance

Data from animal models show that the administration of dextroamphetamine combined with task-relevant training facilitates recovery after focal brain injury. Results of clinical trials in patients with stroke have been inconsistent.

Objectives

To collect data important for future studies evaluating the effect of dextroamphetamine combined with physiotherapy for improving poststroke motor recovery and to test the efficacy of the approach.

Design, Setting, Participants

This pilot, double-blind, block-randomized clinical trial included patients with cortical or subcortical ischemic stroke and moderate or severe motor deficits from 5 rehabilitation hospitals or units. Participants were screened and enrolled from March 2001 through March 2003. The primary outcome was assessed 3 months after stroke. Study analysis was completed December 31, 2015. A total of 1665 potential participants were screened and 64 were randomized. Participants had to begin treatment 10 to 30 days after ischemic stroke. Data analysis was based on intention to treat.

Interventions

Participants were allocated to a regimen of 10 mg of dextroamphetamine (n = 32) or placebo (n = 32) combined with a 1-hour physical therapy session beginning 1 hour after drug or placebo administration every 4 days for 6 sessions in addition to standard rehabilitation.

Main Outcomes and Measures

The primary outcome was the difference between groups in change in Fugl-Meyer motor scores from baseline to 3 months after stroke (intention to treat with dextroamphetamine). Secondary exploratory measures included the National Institutes of Health Stroke Scale, Canadian Neurological Scale, Action Research Arm Test, modified Rankin Scale score, Functional Independence Measure, Ambulation Speed and Distance, Mini-Mental State Examination, Beck Depression Inventory, and Stroke Impact Scale.

Results

Among the 64 patients randomized to dextroamphetamine vs placebo (55% men; median age, 66 years; age range, 27-91 years), no overall treatment-associated difference in the mean (SEM) change in Fugl-Meyer motor scores from baseline to 3 months after stroke was noted (-18.65 [2.27] points with dextroamphetamine vs -20.83 [2.94] points with placebo; P = .58). No overall treatment-associated differences in any of the study's secondary measures and no differences in subgroups based on stroke location or baseline severity were found. No adverse events were attributed to study treatments.

Conclusions and Relevance

Treatment with dextroamphetamine combined with physical therapy did not improve recovery of motor function compared with placebo combined with physical therapy as assessed 3 months after hemispheric ischemic stroke. The studied treatment regimen was safe.

Trial Registration

ClinicalTrials.gov identifier: NCT01905371.

Pruritus in patients with solid tumors: an overlooked supportive care need

PURPOSE

Pruritus is a common symptom in cutaneous malignancies, but its impact on patients with solid tumors is unclear. We explored the impact and management of pruritus in patients with solid tumors, using patient-reported outcomes (PRO) data from a real-world registry.

METHODS

From 2006 to 2011, patients seen in the Duke Cancer Institute reported their symptoms via the Patient Care Monitor v2.0, a validated PRO tool that includes a 0-10-point question about pruritus severity. From > 25,000 encounters, 203 patients reported severe pruritus (> 6/10) on at least one visit and 506 total visits were abstracted where patients reported either moderate or severe pruritus (> 3/10). From this cohort, we abstracted demographics, diagnosis, stage, cancer therapy, anti-pruritic therapy, and clinicians' responses.

RESULTS

Mean age was 59.8 (SD 13.3), 134 (66%) were female, 125 (62%) were Caucasian, and 65 (32%) were African American. Breast cancer was the most common tumor (36.5%), followed by lung cancer (23.2%). Mean pruritus severity score was 6.8 (SD 1.8) for patients on chemotherapy, 6.9 (SD 1.8) for patients on targeted therapy alone or in combination, and 7.1(SD 1.8) for patients off treatment. Overall, 67% of patients reported at least two episodes of moderate-severe pruritus (mean # of visits 4.2 (SD 2.7)). Despite frequent report of severe and persistent pruritus, this was mentioned in just 28% of clinician notes and an intervention was recommended/prescribed in only 7% of visits.

CONCLUSIONS

Pruritus is an under-addressed symptom in patients with solid tumors. Additional research is needed to understand the burden of pruritus in affected populations.

Public Awareness of HIV Pre-Exposure Prophylaxis in Durham, North Carolina: Results of a Community Survey

BACKGROUND Adoption of HIV pre-exposure prophylaxis (PrEP) remains limited among populations at greatest risk for HIV acquisition. This study aims to assess awareness of PrEP among individuals in Durham, North Carolina, which has one of the highest rates of HIV diagnoses in the state.METHOD In 2015-2016, we administered a survey including questions to assess PrEP awareness to individuals at multiple venues throughout Durham, North Carolina.RESULTS A total of 139 respondents were surveyed. The majority were male (66%) and black/African American (75%); 21% were Hispanic/Latino. There were an estimated 53 men who have sex with men (MSM), of which 18 (33%) were black MSM M 24 years of age. Overall, only 53/138 (38%) respondents were aware of PrEP. Awareness was reported among 33/52 (63%) MSM respondents, 29/46 (63%) black MSM, and 10/17 (59%) black MSM M 24 years of age. In multivariate analysis, non-heterosexual orientation, health-insured status, and prior HIV testing were significantly associated with PrEP awareness. Ninety-four (69%) of 137 respondents reported prior HIV testing.LIMITATIONS Limitations include non-random sampling and limited sample size. Further research needs to be done in other areas of North Carolina, and assessment of PrEP acceptability and uptake needs to be performed.CONCLUSION This study reveals low overall awareness of PrEP in Durham, North Carolina, indicating that expanded outreach is necessary to increase public awareness and encourage adoption of PrEP among all demographics at risk for HIV.

The impact of remission status on patients' experiences with acute myeloid leukemia (AML): an exploratory analysis of longitudinal patient-reported outcomes data

PURPOSE

Shared decision-making in acute myeloid leukemia (AML) requires understanding patients' longitudinal experiences of illness, but little is known about the impact of remission status on patient-reported outcomes (PROs). We aimed to explore the association between remission status and PROs 6-12 months following induction chemotherapy.

METHODS

Forty-two patients completed three validated instruments characterizing symptom burden (Patient Care Monitor v2.0), distress (NCCN Distress Thermometer), and QOL (FACT-Leu), as part of a longitudinal observational study. We used regression models to explore the relationship between remission status and PROs, and explore differences by initial disease type (de novo versus secondary/relapsed AML).

RESULTS

Those with secondary or relapsed AML at study onset had marked impairments in all measures compared to de novo AML patients. After 6 months, their mean distress score was 4.8 (> 4.0 warrants intervention), they reported a mean of 14.1 moderate/severe symptoms and had a mean QOL score of 113.6, compared to 1.0, 1.7, and 155.2, respectively, for those with de novo AML (p < .0001). Similarly, patients in relapse had a mean distress score of 5.3, a mean of 12.8 moderate/severe symptoms, and a mean QOL score of 113.4, compared to 1.8, 5.7, and 143.8, respectively, among those in remission (p < .005). These patterns persisted after adjusting for baseline differences (p < .0001).

CONCLUSION

Remission is associated with markedly better patient well-being in AML. Patients with secondary or relapsed AML face more severe symptom burden, distress, and QOL issues after induction. Interventions are needed to improve AML patients' experiences of illness.

An mHealth Pain Coping Skills Training Intervention for Hematopoietic Stem Cell Transplantation Patients: Development and Pilot Randomized Controlled Trial

BACKGROUND

Pain is a challenge for patients following hematopoietic stem cell transplantation (HCT).

OBJECTIVE

This study aimed to develop and test the feasibility, acceptability, and initial efficacy of a Web-based mobile pain coping skills training (mPCST) protocol designed to address the needs of HCT patients.

METHODS

Participants had undergone HCT and reported pain following transplant (N=68). To guide intervention development, qualitative data were collected from focus group participants (n=25) and participants who completed user testing (n=7). After their input was integrated into the mPCST intervention, a pilot randomized controlled trial (RCT, n=36) was conducted to examine the feasibility, acceptability, and initial efficacy of the intervention. Measures of acceptability, pain severity, pain disability, pain self-efficacy, fatigue, and physical disability (self-report and 2-min walk test [2MWT]) were collected.

RESULTS

Participants in the focus groups and user testing provided qualitative data that were used to iteratively refine the mPCST protocol. Focus group qualitative data included participants' experiences with pain following transplant, perspectives on ways to cope with pain, and suggestions for pain management for other HCT patients. User testing participants provided feedback on the HCT protocol and information on the use of videoconferencing. The final version of the mPCST intervention was designed to bridge the intensive outpatient (1 in-person session) and home settings (5 videoconferencing sessions). A key component of the intervention was a website that provided personalized messages based on daily assessments of pain and activity. The website also provided intervention materials (ie, electronic handouts, short videos, and audio files). The intervention content included pain coping advice from other transplant patients and instructions on how to apply pain coping skills while engaging in meaningful and leisure activities. In the RCT phase of this research, HCT patients (n=36) were randomized to receive the mPCST intervention or to proceed with the treatment as usual. Results revealed that the mPCST participants completed an average of 5 out of 6 sessions. The participants reported that the intervention was highly acceptable (mean 3/4), and they found the sessions to be helpful (mean 8/10) and easy to understand (mean 7/7). The mPCST participants demonstrated significant improvements in pre- to post-treatment pain, self-efficacy (P=.03, d=0.61), and on the 2MWT (P=.03, d=0.66), whereas the patients in the treatment-as-usual group did not report any such improvements. Significant changes in pain disability and fatigue were found in both groups (multiple P<.02); the magnitudes of the effect sizes were larger for the mPCST group than for the control group (pain disability: d=0.79 vs 0.69; fatigue: d=0.94 vs 0.81). There were no significant changes in pain severity in either group.

CONCLUSIONS

Using focus groups and user testing, we developed an mPCST protocol that was feasible, acceptable, and beneficial for HCT patients with pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01984671; https://clinicaltrials.gov/ct2/show/NCT01984671 (Archived by WebCite at http://www.webcitation.org/6xbpx3clZ).

The Surprise Question and Identification of Palliative Care Needs among Hospitalized Patients with Advanced Hematologic or Solid Malignancies

BACKGROUND

Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer.

OBJECTIVE

To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs.

DESIGN

Prospective cohort study and long-term follow-up.

SETTING/SUBJECTS

From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year.

MEASUREMENTS

We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes.

RESULTS

Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p < 0.0001), controlling for tumor type, education, and spiritual well-being. Physicians correctly estimated death within one year in 101 (69%) cases, yet only 37 patients (25%) used hospice, and 4 (2.7%) received a palliative care consult; 89 (60.5%) had a do-not-resuscitate order, and 63 (43%) died in the hospital.

CONCLUSIONS

The surprise question identifies inpatients with advanced solid or hematologic cancers having poor QOL and frequent depressive symptoms. Although physicians expected death within a year, EOL quality outcomes were poor. Hospitalized patients with advanced cancer may benefit from palliative care interventions to improve mood, QOL, and EOL care, and the surprise question is a practical method to identify those with unmet needs.

Sexual orientation differences in HIV testing motivation among college men

OBJECTIVE

To investigate sexual orientation differences in college men's motivations for HIV testing.

PARTICIPANTS

665 male college students in the Southeastern United States from 2006 to 2014.

METHODS

Students completed a survey on HIV risk factors and testing motivations. Logistic regressions were conducted to determine the differences between heterosexual men (HM) and sexual minority men (SMM).

RESULTS

SMM were more motivated to get tested by concern over past condomless sex, while HM were more often cited supporting the testing program "on principle" and wanting a free t-shirt. SMM and HM differed in behaviors that impact HIV risk and other demographics. However, differences in testing motivation by concern over past condomless sex or wanting a free t-shirt persisted when controlling for these demographic and behavioral differences.

CONCLUSIONS

Appropriately designed HIV prevention interventions on college campuses should target SMM's distinct concern over past condomless sex as a testing motivation.

Development and Refinement of a Learning Health Systems Training Program

CONTEXT

In the emerging Learning Health System (LHS), the application and generation of medical knowledge are a natural outgrowth of patient care. Achieving this ideal requires a physician workforce adept in information systems, quality improvement methods, and systems-based practice to be able to use existing data to inform future care. These skills are not currently taught in medical school or graduate medical education.

CASE DESCRIPTION

We initiated a first-ever Learning Health Systems Training Program (LHSTP) for resident physicians. The curriculum builds analytical, informatics and systems engineering skills through an active-learning project utilizing health system data that culminates in a final presentation to health system leadership.

FINDINGS

LHSTP has been in place for two years, with 14 participants from multiple medical disciplines. Challenges included scheduling, mentoring, data standardization, and iterative optimization of the curriculum for real-time instruction. Satisfaction surveys and feedback were solicited mid-year in year 2. Most respondents were satisfied with the program, and several participants wished to continue in the program in various capacities after their official completion.

MAJOR THEMES

We adapted our curriculum to successes and challenges encountered in the first two years. Modifications include a revised approach to teaching statistics, smaller cohorts, and more intensive mentorship. We continue to explore ways for our graduates to remain involved in the LHSTP and to disseminate this program to other institutions.

CONCLUSION

The LHSTP is a novel curriculum that trains physicians to lead towards the LHS. Successful methods have included diverse multidisciplinary educators, just in time instruction, tailored content, and mentored projects with local health system impact.

Effects of exercise training alone vs a combined exercise and nutritional lifestyle intervention on glucose homeostasis in prediabetic individuals: a randomised controlled trial

AIMS/HYPOTHESIS

Although the Diabetes Prevention Program (DPP) established lifestyle changes (diet, exercise and weight loss) as the 'gold standard' preventive therapy for diabetes, the relative contribution of exercise alone to the overall utility of the combined diet and exercise effect of DPP is unknown; furthermore, the optimal intensity of exercise for preventing progression to diabetes remains very controversial. To establish clinical efficacy, we undertook a study (2009 to 2013) to determine: how much of the effect on measures of glucose homeostasis of a 6 month programme modelled after the first 6 months of the DPP is due to exercise alone; whether moderate- or vigorous-intensity exercise is better for improving glucose homeostasis; and to what extent amount of exercise is a contributor to improving glucose control. The primary outcome was improvement in fasting plasma glucose, with improvement in plasma glucose AUC response to an OGTT as the major secondary outcome.

METHODS

The trial was a parallel clinical trial. Sedentary, non-smokers who were 45-75 year old adults (n = 237) with elevated fasting glucose (5.28-6.94 mmol/l) but without cardiovascular disease, uncontrolled hypertension, or diabetes, from the Durham area, were studied at Duke University. They were randomised into one of four 6 month interventions: (1) low amount (42 kJ kg body weight(-1) week(-1) [KKW])/moderate intensity: equivalent of expending 42 KKW (e.g. walking ∼16 km [8.6 miles] per week) with moderate-intensity (50% [Formula: see text]) exercise; (2) high amount (67 KKW)/moderate intensity: equivalent of expending 67 KKW (∼22.3 km [13.8 miles] per week) with moderate-intensity exercise; (3) high amount (67 KKW)/vigorous intensity: equivalent to group 2, but with vigorous-intensity exercise (75% [Formula: see text]); and (4) diet + 42 KKW moderate intensity: same as group 1 but with diet and weight loss (7%) to mimic the first 6 months of the DPP. Computer-generated randomisation lists were provided by our statistician (G. P. Samsa). The randomisation list was maintained by L. H. Willis and C. A. Slentz with no knowledge of or input into the scheduling, whereas all scheduling was done by L. A. Bateman, with no knowledge of the randomisation list. Subjects were automatically assigned to the next group listed on the randomisation sheet (with no ability to manipulate the list order) on the day that they came in for the OGTT, by L. H. Willis. All plasma analysis was done blinded by the individuals doing the measurements (i.e. lipids, glucose, insulin). Subjects and research staff (other than individuals analysing the blood) were not blinded to the group assignments.

RESULTS

Number randomised, completers and number analysed with complete OGTT data for each group were: low-amount/moderate-intensity (61, 43, 35); high-amount/moderate-intensity (61, 44, 40); high-amount/vigorous-intensity (61, 43, 38); diet/exercise (54, 45, 37), respectively. Only the diet and exercise group experienced a decrease in fasting glucose (p < 0.001). The means and 95% CIs for changes in fasting glucose (mmol/l) for each group were: high-amount/moderate-intensity -0.07 (-0.20, 0.06); high-amount/vigorous 0.06 (-0.07, 0.19); low-amount/moderate 0.05 (-0.05, 0.15); and diet/exercise -0.32 (-0.46, -0.18). The effects sizes for each group (in the same order) were: 0.17, 0.15, 0.18 and 0.71, respecively. For glucose tolerance (glucose AUC of OGTT), similar improvements were observed for the diet and exercise (8.2% improvement, effect size 0.73) and the 67 KKW moderate-intensity exercise (6.4% improvement, effect size 0.60) groups; moderate-intensity exercise was significantly more effective than the same amount of vigorous-intensity exercise (p < 0.0207). The equivalent amount of vigorous-intensity exercise alone did not significantly improve glucose tolerance (1.2% improvement, effect size 0.21). Changes in insulin AUC, fasting plasma glucose and insulin did not differ among the exercise groups and were numerically inferior to the diet and exercise group.

CONCLUSIONS/INTERPRETATION

In the present clinical efficacy trial we found that a high amount of moderate-intensity exercise alone was very effective at improving oral glucose tolerance despite a relatively modest 2 kg change in body fat mass. These data, combined with numerous published observations of the strong independent relation between postprandial glucose concentrations and prediction of future diabetes, suggest that walking ∼18.2 km (22.3 km prescribed with 81.6% adherence in the 67 KKW moderate-intensity group) per week may be nearly as effective as a more intensive multicomponent approach involving diet, exercise and weight loss for preventing the progression to diabetes in prediabetic individuals. These findings have important implications for the choice of clinical intervention to prevent progression to type 2 diabetes for those at high risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00962962 FUNDING: The study was funded by National Institutes for Health National Institute of Diabetes and Digestive and Kidney Diseases (NIH-NDDK) (R01DK081559).

Cost of multiple sclerosis by level of disability: a review of literature

We performed a review of the economic literature to identify what is known about the relationship between Expanded Disability Status Scale (EDSS) categories and cost of multiple sclerosis (MS). We sought cohort studies of patients with multiple sclerosis that described the costs attributed to each EDSS score and utilized specific inclusion criteria for the selection of 10 studies. We found that both direct and indirect costs rise continuously with increasing EDSS category, and this rise is qualitatively exponential. The rise in indirect costs appears at lower EDSS scores. The cost of a relapse occurring in any given EDSS category exceeds that associated with that particular EDSS category. Few studies comprehensively assessed the entire spectrum of the costs, and much of the literature is based on EDSS categories in coarse groupings. In spite of several variations between studies, one important conclusion that we can draw is that rise in cost is positively correlated to scores on the EDSS categories, and therefore agents with a capacity to prevent or arrest the rate of MS progression may affect the overall cost of MS.

Compliance With Recommendations From an Outpatient Geriatric Consultation Team

For outpatient geriatric consultation to be effective, it is necessary, although not sufficient, that recommendations made to patients are followed. This prospective cohort study describes the nature of, types of, and compliance with, recommendations made to patients by clinicians at a university-based outpatient geriatric clinic. All patients seen by an internal medicine physician or family practitioner were contacted 1 year following their initial visit to determine compliance with recommendations. Clinicians identified 4.6 problems per patient; more than one half had never been documented previously. The most common problems were medical (53.1%) and neuropsychiatric (26.7%). Pahents had substantial limitations in both instrumental (X = 2.3) and physical (X = 1.3) activities of daily living. Clinicians made 5.9 recommendations per patient, 67.1% of which were followed. Compliance was similar for medical and social recommendations. No predictors of compliance were identified. Practitioners need to be aware that one third of their recommendations are not followed, and characterizing patients at increased risk for noncompliance is difficult.

An Exploratory Factor Analysis of the Scale Structure of the Patient Care Monitor Version 2.0

CONTEXT

The Patient Care Monitor (PCM), version 2.0, is an electronic patient-reported outcomes instrument designed to be embedded into oncology practices. One key psychometric component of an instrument is its factor structure.

OBJECTIVES

To validate the factor structure of the PCM.

METHODS

The PCM was administered within various oncology clinics at our institution from 2006 to 2011 as part of standard of care, yielding a large (n = 5624) and diverse data set. An exploratory factor analysis was performed.

RESULTS

The PCM performed well in terms of missing values and floor and ceiling effects. The three scales postulated by the PCM developers exhibited high internal consistency (Cronbach alpha 0.94-0.95); the six subscales exhibited good internal consistency (Cronbach alpha 0.80-0.95). A three-factor model approximated simple structure and was consistent with the constructs of emotional function, physical function, and physical symptoms suggested by the PCM developers. However, a six-factor model did not support the division of these three constructs into subscales of despair, distress, ambulation, impaired performance, treatment side effects, and general physical symptoms. Instead, we observed an emotional factor, a physical functioning factor, a factor including many of the treatment side effects, and three factors consisting of various clusters of physical symptoms.

CONCLUSION

Although six subscales postulated by its developers perform reasonably, allocation of the PCM items to three constructs is more accurate and likely more consistent with how symptoms and concerns are conceptualized by patients.

Characterizing the Hospice and Palliative Care Workforce in the U.S.: Clinician Demographics and Professional Responsibilities

CONTEXT

Palliative care services are growing at an unprecedented pace. Yet, the characteristics of the clinician population who deliver these services are not known. Information on the roles, motivations, and future plans of the clinician workforce would allow for planning to sustain and grow the field.

OBJECTIVES

To better understand the characteristics of clinicians within the field of hospice and palliative care.

METHODS

From June through December 2013, we conducted an electronic survey of American Academy of Hospice and Palliative Medicine members. We queried information on demographics, professional roles and responsibilities, motivations for entering the field, and future plans. We compared palliative care and hospice populations alongside clinician roles using chi-square analyses. Multivariable logistic regression was used to identify predictors of leaving the field early.

RESULTS

A total of 1365 persons, representing a 30% response rate, participated. Our survey findings revealed a current palliative care clinician workforce that is older, predominantly female, and generally with less than 10 years clinical experience in the field. Most clinicians have both clinical hospice and palliative care responsibilities. Many cite personal or professional growth or influential experiences during training or practice as motivations to enter the field.

CONCLUSION

Palliative care clinicians are a heterogeneous group. We identified motivations for entering the field that can be leveraged to sustain and grow the workforce.

Practical Dyspnea Assessment: Relationship Between the 0-10 Numerical Rating Scale and the Four-Level Categorical Verbal Descriptor Scale of Dyspnea Intensity

CONTEXT

Measurement of dyspnea is important for clinical care and research.

OBJECTIVES

To characterize the relationship between the 0-10 Numerical Rating Scale (NRS) and four-level categorical Verbal Descriptor Scale (VDS) for dyspnea assessment.

METHODS

This was a substudy of a double-blind randomized controlled trial comparing palliative oxygen to room air for relief of refractory breathlessness in patients with life-limiting illness. Dyspnea was assessed with both a 0-10 NRS and a four-level categorical VDS over the one-week trial. NRS and VDS responses were analyzed in cross section and longitudinally. Relationships between NRS and VDS responses were portrayed using descriptive statistics and visual representations.

RESULTS

Two hundred twenty-six participants contributed responses. At baseline, mild and moderate levels of breathlessness were reported by 41.9% and 44.6% of participants, respectively. NRS scores demonstrated increasing mean and median levels for increasing VDS intensity, from a mean (SD) of 0.6 (±1.04) for VDS none category to 8.2 (1.4) for VDS severe category. The Spearman correlation coefficient was strong at 0.78 (P < 0.0001). Based on the distribution of NRS scores within VDS categories, we calculated test characteristics of two different cutpoint models. Both models yielded 75% correct translations from NRS to VDS; however, Model A was more sensitive for moderate or greater dyspnea, with fewer misses downcoded.

CONCLUSION

There is strong correlation between VDS and NRS measures for dyspnea. Proposed practical cutpoints for the relationship between the dyspnea VDS and NRS are 0 for none, 1-4 for mild, 5-8 for moderate, and 9-10 for severe.

Chronic Systemic Immune Dysfunction in African-Americans with Small Vessel-Type Ischemic Stroke

The incidence of small vessel-type (lacunar) ischemic strokes is greater in African-Americans compared to whites. The chronic inflammatory changes that result from lacunar stroke are poorly understood. To elucidate these changes, we measured serum inflammatory and thrombotic biomarkers in African-Americans at least 6 weeks post-stroke compared to control individuals. Cases were African-Americans with lacunar stroke (n = 30), and controls were age-matched African-Americans with no history of stroke or other major neurologic disease (n = 37). Blood was obtained >6 weeks post-stroke and was analyzed for inflammatory biomarkers. Freshly isolated peripheral blood mononuclear cells were stimulated with lipopolysaccharide (LPS) to assess immune responsiveness in a subset of cases (n = 5) and controls (n = 4). After adjustment for covariates, the pro-inflammatory biomarkers, soluble vascular cadherin adhesion molecule-1 (sVCAM-1) and thrombin anti-thrombin (TAT), were independently associated with lacunar stroke. Immune responsiveness to LPS challenge was abnormal in cases compared to controls. African-Americans with lacunar stroke had elevated blood levels of VCAM-1 and TAT and an abnormal response to acute immune challenge >6 weeks post-stroke, suggesting a chronically compromised systemic inflammatory response.

Evaluation of Pillars4life: a virtual coping skills program for cancer survivors

OBJECTIVE

Pillars4Life is an educational program that teaches coping skills to cancer patients in a virtual group setting; it was recently implemented at 17 hospitals across the USA. The cost-effective, scalable, and assessable Pillars4Life curriculum targets psychosocial resources (e.g., self-efficacy and coping skills) as a means to reduce symptoms (e.g., depression, anxiety, and posttraumatic stress) and enhance quality of life.

METHODS

Cancer patients were recruited from hospitals that received the LIVESTRONG Community Impact Project Award to enroll in a pilot study of Pillars4Life. Consenting participants met with a certified instructor weekly for 10 weeks in a virtual environment; the manualized intervention trained participants in personal coping skills. Longitudinal assessments over 6 months were assessed using validated instruments to determine changes in Pillars4Life targeted resources and outcomes. Multiple linear regression models examined the relationship between changes in targeted resources and changes in outcome from baseline to 3 months post-intervention.

RESULTS

Participants (n = 130) had the following characteristics: mean age of 56 ± 11 years, 87% women, 11% non-Caucasian, and 77% with college degree. At 3- and 6-month follow-up, mean scores improved on all key outcome measures such as depression (Patient Health Questionnaire), anxiety (Generalized Anxiety Disorder), posttraumatic stress (Posttraumatic Stress Disorder Checklist), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), and well-being (Functional Assessment of Cancer Therapy-General) from baseline (all p < 0.01); results were most pronounced among participants who reported ≥4/10 on the Distress Thermometer at baseline (all p < 0.001). Changes in each targeted resource were associated with 3-month improvements in at least one outcome.

CONCLUSIONS

Participation in the Pillars4Life program was associated with statistically and clinically significant improvements in scores on pre-specified outcomes and targeted resources.

Microbiology of Ventilator–Associated Pneumonia Compared With That of Hospital-Acquired Pneumonia

Objective.

Nosocomial pneumonia is the leading cause of mortality attributed to nosocomial infection. Appropriate empirical therapy has been associated with improved survival, but data are limited regarding the etiologic agents of hospital-acquired pneumonia in non-ventilated patients (HAP). This evaluation assessed whether the currently recommended empirical therapy is appropriate for both ventilator-associated pneumonia (VAP) and HAP by evaluating the infecting flora.

Design.

Prospectively collected hospitalwide surveillance data was obtained by infection control professionals using standard Centers for Disease Control and Prevention definitions.

Setting.

A tertiary care academic hospital.

Patients.

All patients admitted from 2000 through 2003.

Results.

A total of 588 episodes of pneumonia were reported in 556 patients: 327 episodes of VAP in 309 patients, and 261 episodes of HAP in 247 Patients. The infecting flora in ventilated patients included gram-positive cocci (32.0% [oxacillin-susceptible Staphylococcus aureus {OSSA}, 9.25%; oxacillin-resistant Staphylococcus aureus {ORSA}, 17.75%]), gram-negative bacilli (59.0% {Pseudomonas aeruginosa, 17.50%; Stenotrophomonas maltophilia, 6.75%; Acinetobacter species, 7.75%), and miscellaneous pathogens (9.0%). The infecting flora in nonventilated patients included gram-positive cocci (42.59% [OSSA, 13.33%; ORSA, 20.37%]), gram-negative bacilli (39.63% [P. aeruginosa, 9.26%; S. maltophilia, 1.11%; Acinetobacter species, 3.33%), and miscellaneous pathogens (17.78%).

Conclusions.

Our data demonstrated that patients with HAP, compared with those with VAP, had a similar frequency of infection with ORSA but less commonly had infections due to P. aeruginosa, Acinetobacter species, and S. maltophilia. However, the overall frequency of infection with these pathogens was sufficiently high to warrant the use of empirical therapy likely to be active against them. Our data supports using the currently recommended empirical therapy for both HAP and VAP.

There is a mismatch between the medicare benefit package and the preferences of patients with cancer and their caregivers

PURPOSE

To identify insured services that are most important to Medicare beneficiaries with cancer and their family caregivers when coverage is limited.

METHODS

A total of 440 participants (patients, n = 246; caregivers, n = 194) were enrolled onto the CHAT (Choosing Health Plans All Together) study from August 2010 to March 2013. The exercise elicited preferences about what benefits Medicare should cover for patients with cancer in their last 6 months of life. Facilitated sessions lasted 2.5 hours, included 8 to 10 participants, and focused on choices about Medicare health benefits within the context of a resource-constrained environment.

RESULTS

Six of 15 benefit categories were selected by > 80% of participants: cancer care, prescription drugs, primary care, home care, palliative care, and nursing home coverage. Only 12% of participants chose the maximum level of cancer benefits, a level of care commonly financed in the Medicare program. Between 40% and 50% of participants chose benefits not currently covered by Medicare: unrestricted cash, concurrent palliative care, and home-based long-term care. Nearly one in five participants picked some level of each of these three benefit categories and allocated on average 30% of their resources toward them.

CONCLUSION

The mismatch between covered benefits and participant preferences shows that addressing quality of life and the financial burden of care is a priority for a substantial subset of patients with cancer in the Medicare program. Patient and caregiver preferences can be elicited, and the choices they express could suggest potential for Medicare benefit package reform and flexibility.

A decision exercise to engage cancer patients and families in deliberation about Medicare coverage for advanced cancer care

Background

Concerns about unsustainable costs in the US Medicare program loom as the number of retirees increase and experiences serious and costly illnesses like cancer. Engagement of stakeholders, particularly cancer patients and their families, in prioritizing insured services offers a valuable strategy for informing Medicare coverage policy. We designed and evaluated a decision exercise that allowed cancer patients and family members to choose Medicare benefits for advanced cancer patients.

Methods

The decision tool, Choosing Health plans All Together (CHAT) was modified to select services for advanced cancer patients. Patients with a cancer history (N = 246) and their family members (N = 194) from North Carolina participated in 70 CHAT sessions. Variables including participants’ socio-demographic characteristics, health status, assessments of the exercise and results of group benefit selections were collected. Routine descriptive statistics summarized participant characteristics and Fisher’s exact test compared group differences. Qualitative analysis of group discussions were used to ascertain reasons for or against selecting benefits.

Results

Patients and family members (N = 440) participated in 70 CHAT exercises. Many groups opted for such services as palliative care, nursing facilities, and services not currently covered by the Medicare program. In choosing among four levels of cancer treatment coverage, no groups chose basic coverage, 27 groups (39%) selected intermediate coverage, 39 groups (56%) selected high coverage, and 4 groups (6%) chose the most comprehensive cancer coverage. Reasons for or against benefit selection included fairness, necessity, need for prioritizing, personal experience, attention to family needs, holistic health outlook, preference for comfort, freedom of choice, and beliefs about the proper role of government. Participants found the exercise very easy (59%) or fairly easy (39%) to understand and very informative (66%) or fairly informative (31%). The majority agreed that the CHAT exercise led to fair decisions about priorities for coverage by which they could abide.

Conclusions

It is possible to involve cancer patients and families in explicit discussions of their priorities for affordable advanced cancer care through the use of decision tools designed for this purpose. A key question is whether such a conversation is possible on a broader, national level.

Patient-oncologist cost communication, financial distress, and medication adherence

BACKGROUND

Little is known about the association between patient-oncologist discussion of cancer treatment out-of-pocket (OOP) cost and medication adherence, a critical component of quality cancer care.

METHODS

We surveyed insured adults receiving anticancer therapy. Patients were asked if they had discussed OOP cost with their oncologist. Medication nonadherence was defined as skipping doses or taking less medication than prescribed to make prescriptions last longer, or not filling prescriptions because of cost. Multivariable analysis assessed the association between nonadherence and cost discussions.

RESULTS

Among 300 respondents (86% response), 16% (n = 49) reported high or overwhelming financial distress. Nineteen percent (n = 56) reported talking to their oncologist about cost. Twenty-seven percent (n = 77) reported medication nonadherence. To make a prescription last longer, 14% (n = 42) skipped medication doses, and 11% (n = 33) took less medication than prescribed; 22% (n = 66) did not fill a prescription because of cost. Five percent (n = 14) reported chemotherapy nonadherence. To make a prescription last longer, 1% (n = 3) skipped chemotherapy doses, and 2% (n = 5) took less chemotherapy; 3% (n = 10) did not fill a chemotherapy prescription because of cost. In adjusted analyses, cost discussion (odds ratio [OR] = 2.58; 95% CI, 1.14 to 5.85; P = .02), financial distress (OR = 1.64, 95% CI, 1.38 to 1.96; P < .001) and higher financial burden than expected (OR = 2.89; 95% CI, 1.41 to 5.89; P < .01) were associated with increased odds of nonadherence.

CONCLUSION

Patient-oncologist cost communication and financial distress were associated with medication nonadherence, suggesting that cost discussions are important for patients forced to make cost-related behavior alterations. Future research should examine the timing, content, and quality of cost-discussions.

The influence of a physician and patient intervention program on dietary intake

BACKGROUND

Efficient dietary interventions for patients with hypertension in clinical settings are needed.

OBJECTIVE

To assess the separate and combined influence of a physician intervention (MD-I) and a patient intervention (PT-I) on dietary intakes of patients with hypertension.

DESIGN

A nested 2×2 design, randomized controlled trial conducted over 18 months.

PARTICIPANTS

A total of 32 physicians and 574 outpatients with hypertension.

INTERVENTION

MD-I included training modules addressing the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure hypertension management guidelines and lifestyle modification. PT-I included lifestyle coaching to adopt the Dietary Approaches to Stop Hypertension (DASH) eating pattern, reduce sodium intake, manage weight, increase exercise, and moderate alcohol intake.

MAIN OUTCOME MEASURES

Dietary intakes were measured by the Block Food Frequency Questionnaire. Concordance with the DASH dietary pattern was estimated by a DASH score.

STATISTICAL ANALYSES

The main effects of MD-I and PT-I, and their interaction, were evaluated using analysis of covariance.

RESULTS

After 6 months of intervention, MD-I participants significantly increased intakes of potassium, fruits, juices, and carbohydrate; decreased intake of fat; and improved overall dietary quality as measured by the Healthy Eating Index. PT-I intervention resulted in increased intakes of carbohydrate, protein, fiber, calcium, potassium, fruits and fruit juices, vegetables, dairy and Healthy Eating Index score, and decreased intakes in fat, saturated fat, cholesterol, sodium, sweets, and added fats/oils/sweets. In addition, PT-I improved overall DASH concordance score. The change in DASH score was significantly associated with the changes in blood pressure and weight at 6 months. At 18 months, most changes reversed back toward baseline levels, including the DASH score.

CONCLUSIONS

Both MD-I and PT-I improved eating patterns at 6 months with some sustained effects at 18 months. Even though all dietary changes observed were consistent with the DASH nutrient targets or food group guidelines, only the PT-I intervention was effective in improving the overall DASH concordance score. This finding affirms the role of medical nutrition therapy in long-term intensive interventions for hypertension risk reduction and weight management and underlines the need for development of maintenance strategies. Furthermore, this study emphasizes the importance of collaborations among physicians, registered dietitians and other dietetics practitioners, and lay health advisors while assisting patients to make healthy behavior changes.

Longitudinal patient-reported performance status assessment in the cancer clinic is feasible and prognostic

PURPOSE

Performance status is prognostic in oncology and palliative care settings. Traditionally clinician rated, it is often inconsistently collected, recorded, and measured, thereby limiting its utility. Patient-reported strategies are increasingly used for routine symptom and quality of life assessment in the clinic, and may be useful for tracking performance status.

METHODS

Tablet personal computers were used to collect patient-reported reviews of systems via the Patient Care Monitor (PCM) v2.0 for 86 patients with advanced lung cancer. Relevant subscales included the PCM Impaired Performance and Impaired Ambulation scales. Trained nurse clinicians measured performance status using traditional Karnofsky and Eastern Cooperative Oncology Group (ECOG) instruments. Correlation coefficients were used to compare performance status scales, and survival analysis was performed by Cox proportional hazards modeling.

RESULTS

All four performance status scales demonstrated excellent internal consistency and convergent validity. Initial KPS and ECOG scores were statistically correlated with survival, whereas PCM scores showed a nonsignificant trend in this direction. Change in PCM Impaired Performance over time was statistically correlated with survival (hazard ratio = 1.62, P = .046), whereas the other three performance status measures were not statistically prognostic.

CONCLUSION

Patient-reported performance status as measured by PCM v2.0 is at least as reliable as KPS or ECOG. The enhanced resolution provided by this patient-reported method allows for the detection of clinically meaningful changes in trajectory over time, potentially serving as an early-warning system to trigger clinical interventions. Further study is needed to test these findings on a larger scale.

Delivery strategies to optimize resource utilization and performance status for patients with advanced life-limiting illness: results from the "palliative care trial" [ISRCTN 81117481]

CONTEXT

Evidence-based approaches are needed to improve the delivery of specialized palliative care.

OBJECTIVES

The aim of this trial was to improve on current models of service provision.

METHODS

This 2×2×2 factorial cluster randomized controlled trial was conducted at an Australian community-based palliative care service, allowing three simultaneous comparative effectiveness studies. Participating patients were newly referred adults, experiencing pain, and who were expected to live >48 hours. Patients enrolled with their general practitioners (GPs) and were randomized three times: 1) individualized interdisciplinary case conference including their GP vs. control, 2) educational outreach visiting for GPs about pain management vs. control, and 3) structured educational visiting for patients/caregivers about pain management vs. control. The control condition was current palliative care. Outcomes included Australia-modified Karnofsky Performance Status (AKPS) and pain from 60 days after randomization and hospitalizations.

RESULTS

There were 461 participants: mean age 71 years, 50% male, 91% with cancer, median survival 179 days, and median baseline AKPS 60. Only 47% of individuals randomized to the case conferencing intervention received it; based on a priori-defined analyses, 32% of participants were included in final analyses. Case conferencing reduced hospitalizations by 26% (least squares means hospitalizations per patient: case conference 1.26 [SE 0.10] vs. control 1.70 [SE 0.13], P=0.0069) and better maintained performance status (AKPS case conferences 57.3 [SE 1.5] vs. control 51.7 [SE 2.3], P=0.0368). Among patients with declining function (AKPS <70), case conferencing and patient/caregiver education better maintained performance status (AKPS case conferences 55.0 [SE 2.1] vs. control 46.5 [SE 2.9], P=0.0143; patient/caregiver education 54.7 [SE 2.8] vs. control 46.8 [SE 2.1], P=0.0206). Pain was unchanged. GP education did not change outcomes.

CONCLUSION

A single case conference added to current specialized community-based palliative care reduced hospitalizations and better maintained performance status. Comparatively, patient/caregiver education was less effective; GP education was not effective.

In-hospital resource use and medical costs in the last year of life by mode of death (from the HF-ACTION randomized controlled trial)

Patterns of medical resource use near the end of life may differ across modes of death. The aim of this study was to characterize patterns of inpatient resource use and direct costs for patients with heart failure (HF) who died of sudden cardiac death (SCD), HF, other cardiovascular causes, or noncardiovascular causes during the last year of life. Data were from a randomized trial of exercise training in patients with HF. Mode of death was adjudicated by an end point committee. Generalized estimating equations were used to compare hospitalizations, inpatient days, and inpatient costs incurred during the final year of life in patients who died of different causes, adjusting for clinical and treatment characteristics. Of 2,331 patients enrolled in the trial, 231 died after ≥1 year of follow-up with an adjudicated mode of death, including 72 of SCD, 80 of HF, 34 of other cardiovascular causes, and 45 of noncardiovascular causes. Patients who died of SCD were younger, had less severe HF, and incurred fewer hospitalizations, fewer inpatient days, and lower inpatient costs than patients who died of other causes. After adjustment for patient characteristics, inpatient resource use varied by 2 to 4 times across modes of death, suggesting that cost-effectiveness analyses of interventions that reduce mortality from SCD compared to other causes should incorporate mode-specific end-of-life costs. In conclusion, resource use and associated medical costs in the last year of life differed markedly in patients with HF who experienced SCD and patients who died of other causes.

Exercise effects on lipids in persons with varying dietary patterns-does diet matter if they exercise? Responses in Studies of a Targeted Risk Reduction Intervention through Defined Exercise I

BACKGROUND

The standard clinical approach for reducing cardiovascular disease risk due to dyslipidemia is to prescribe changes in diet and physical activity. The purpose of the current study was to determine if, across a range of dietary patterns, there were variable lipoprotein responses to an aerobic exercise training intervention.

METHODS

Subjects were participants in the STRRIDE I, a supervised exercise program in sedentary, overweight subjects randomized to 6 months of inactivity or 1 of 3 aerobic exercise programs. To characterize diet patterns observed during the study, we calculated a modified z-score that included intakes of total fat, saturated fat, trans fatty acids, cholesterol, omega-3 fatty acids, and fiber as compared with the 2006 American Heart Association diet recommendations. Linear models were used to evaluate relationships between diet patterns and exercise effects on lipoproteins/lipids.

RESULTS

Independent of diet, exercise had beneficial effects on low-density lipoprotein cholesterol particle number, low-density lipoprotein cholesterol size, high-density lipoprotein cholesterol, high-density lipoprotein cholesterol size, and triglycerides (P < .05 for all). However, having a diet pattern that closely adhered to American Heart Association recommendations was not related to changes in these or any other serum lipids or lipoproteins in any of the exercise groups.

CONCLUSIONS

We found that even in sedentary individuals whose habitual diets vary in the extent of adherence to AHA dietary recommendations, a rigorous, supervised exercise intervention can achieve significant beneficial lipid effects.

Conflict of interest disclosure in off-label oncology clinical trials

PURPOSE

We sought to determine the prevalence, reliability, and predictors of conflict of interest (COI) and funding disclosure statements for studies of anticancer targeted therapies conducted in the off-label prescribing setting.

METHODS

As a part of a federally funded systematic review, manuscripts were included in the analysis if they were used to support one of 19 indications for cancer targeted therapies that were off-label but reimbursable according to compendia published in 2006 or before. Studies were categorized according to trial design, trial results, average impact factor of journals, and presence of COI and funding disclosure statements.

RESULTS

Among the 69 included studies, prevalence of COI and funding disclosures was low, at 33% and 58% respectively; time trends showed some improvement between 2002 to 2007, but only 60% of studies had disclosures by 2007. Predictors of COI disclosure were publication in high-impact-factor journals (P < .001), large study sample size (P = .001), enrollment exclusively in the United States (P = .04), and study of the targeted therapy in combination with other agents as opposed to the study drug alone (P = .03).

CONCLUSION

Disclosure of potential sources of bias in COI and funding statements in studies of off-label indications for anticancer targeted therapies was low and did not increase substantially over time.

Introduction of the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Costing Tool: a user-friendly spreadsheet program to estimate costs of providing patient-centered interventions

BACKGROUND

Patient-centered health care interventions, such as heart failure disease management programs, are under increasing pressure to demonstrate good value. Variability in costing methods and assumptions in economic evaluations of such interventions limit the comparability of cost estimates across studies. Valid cost estimation is critical to conducting economic evaluations and for program budgeting and reimbursement negotiations.

METHODS AND RESULTS

Using sound economic principles, we developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure (TEAM-HF) Costing Tool, a spreadsheet program that can be used by researchers and health care managers to systematically generate cost estimates for economic evaluations and to inform budgetary decisions. The tool guides users on data collection and cost assignment for associated personnel, facilities, equipment, supplies, patient incentives, miscellaneous items, and start-up activities. The tool generates estimates of total program costs, cost per patient, and cost per week and presents results using both standardized and customized unit costs for side-by-side comparisons. Results from pilot testing indicated that the tool was well-formatted, easy to use, and followed a logical order. Cost estimates of a 12-week exercise training program in patients with heart failure were generated with the costing tool and were found to be consistent with estimates published in a recent study.

CONCLUSIONS

The TEAM-HF Costing Tool could prove to be a valuable resource for researchers and health care managers to generate comprehensive cost estimates of patient-centered interventions in heart failure or other conditions for conducting high-quality economic evaluations and making well-informed health care management decisions.

Abstract P220: Interim Results of the Registry to Evaluate Anticoagulation in Atrial Fibrillation (REAL-AF)

BACKGROUND: Warfarin reduces the risk of ischemic stroke in patients (pts) with atrial fibrillation (AF) by >50% compared to aspirin in clinical trials, but is underutilized and can be difficult to manage.

METHODS: REAL-AF is an observational registry that consists of retrospective and prospectively-enrolled pts with newly-diagnosed nonvalvular AF from 250 community-based US practices. This interim analysis focuses only on the retrospective arm, with six months of follow-up data. For all pts, baseline demographics were collected. Healthcare utilization, time to reach and time within target therapeutic range (TTR) were analyzed in pts on warfarin. For those not on warfarin, reasons for not prescribing were collected by selecting from a list of commonly-cited reasons. Multivariate models were used to assess factors associated with use of anticoagulation.

RESULTS: Of 961pts observed to date, the mean age was 71.2±12.5 years; 51.5% male; 71.8% (654/911) white. Of the 68.4% (657/961) that received warfarin, 71% (3810/5356) of INR tests were conducted in the physician's office with about half (2501/5356) requiring further action such as a dose adjustment, more frequent monitoring, or physician or hospital visit. On average, pts had 13 INR tests (5070/390) and 4.5 dose adjustments (972/216) over a 6-month period. Mean TTR was 52.1% (N=348 pts). Median time to reach stable therapeutic range (3 consecutive INRs between 2.0 and 3.0) was 17.9 weeks (N=339 pts). High variability of INR values was associated with higher healthcare utilization (r=0.25, p=0.004). Physician-perceived “low stroke risk” (45%; 136/304) and “high bleed risk” (22%; 68/304) were the most common reasons for no anticoagulation. Excessive fall risk (OR 0.069, 95% CI 0.036-0.133) and full-time employment (OR 0.61, 95% CI 0.40-0.94) were significant predictors for warfarin non-use, based upon multivariate analysis.

CONCLUSIONS: Non-therapeutic INR values and warfarin dose adjustments are common among newly diagnosed AF pts who have little or no previous exposure to anticoagulation therapy. From this retrospective analysis it appears that the current use of anticoagulation therapy in pts with AF is not optimal.

Physician characteristics as predictors of blood pressure control in patients enrolled in the hypertension improvement project (HIP)

The authors sought to examine the relationship between physician characteristics and patient blood pressure (BP) in participants enrolled in the Hypertension Improvement Project (HIP). In this cross-sectional study using baseline data of HIP participants, the authors used multiple linear regression to examine how patient BP was related to physician characteristics, including experience, practice patterns, and clinic load. Patients had significantly lower systolic BP (SBP) (-0.2 mm Hg for every 1% increase, P=.008) and diastolic BP (DBP) (-0.1 mm Hg for every 1% increase, P=.0007) when seen by physicians with a higher percentage of patients with hypertension. Patients had significantly higher SBP (0.8 mm Hg for every 1% increase, P=.002) when seen by physicians with a higher number of total clinic visits per day. Patients had significantly lower DBP (-4.4 mm Hg decrease, P=.0002) when seen by physicians with inpatient duties. Physician's volume of patients with hypertension was related to better BP control. However, two indicators of a busy practice had conflicting relationships with BP control. Given the increasing time demands on physicians, future research should examine how physicians with a busy practice are able to successfully address BP in their patients.

Differential patterns of cognitive decline in anterior and posterior white matter hyperintensity progression

BACKGROUND AND PURPOSE

White matter hyperintensities (WMHs) found on brain MRI in elderly individuals are largely thought to be due to microvascular disease, and its progression has been associated with cognitive decline. The present study sought to determine patterns of cognitive decline associated with anterior and posterior WMH progression.

METHODS

Subjects included 110 normal controls, aged >or=60 years, who were participants in the Duke Neurocognitive Outcomes of Depression in the Elderly study. All subjects had comprehensive cognitive evaluations and MRI scans at baseline and after 2 years. Cognitive composites were created in 5 domains: complex processing speed, working memory, general memory, visual-constructional skills, and language. Change in cognition was calculated using standard regression-based models accounting for variables known to impact serial testing. A semiautomated segmentation method was used to measure WMH extent in anterior and posterior brain regions. Hierarchical multiple linear regression models were used to evaluate which of the 5 measured cognitive domains was most strongly associated with regional (anterior and posterior) and total WMH progression after adjusting for demographics (age, sex, and education).

RESULTS

Decline in complex processing speed was independently associated with both anterior (r(2)=0.06, P=0.02) and total WMH progression (r(2)=0.05, P=0.04). In contrast, decline in visual-constructional skills was uniquely associated with posterior progression (r(2)=0.05, P<0.05).

CONCLUSIONS

Distinct cognitive profiles are associated with anterior and posterior WMH progression among normal elders. These differing profiles need to be considered when evaluating the cognitive correlates of WMHs.

Hypertension Improvement Project (HIP): study protocol and implementation challenges

BACKGROUND

Hypertension affects 29% of the adult U.S. population and is a leading cause of heart disease, stroke, and kidney failure. Despite numerous effective treatments, only 53% of people with hypertension are at goal blood pressure. The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care.

METHODS AND DESIGN

This paper describes the protocol of a nested 2 x 2 randomized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients and a quality improvement-type intervention for physicians. Primary care practices were randomly assigned to the physician intervention or to the physician control condition. Physician randomization occurred at the clinic level. The physician intervention included training and performance monitoring. The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension. Performance data were collected for 18 months, and feedback was provided to physicians every 3 months. Patient participants in both intervention and control clinics were individually randomized to the patient intervention or to usual care. The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions, followed by 12 monthly phone contacts by community health advisors. Follow-up measurements were performed at 6 and 18 months. The primary outcome was the mean change in systolic blood pressure at 6 months. Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months.

DISCUSSION

Overall, 8 practices (4 per treatment group), 32 physicians (4 per practice; 16 per treatment group), and 574 patients (289 control and 285 intervention) were enrolled. Baseline characteristics of patients and providers and the challenges faced during study implementation are presented. The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model. The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately, so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local resources.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT00201136.

Impact of hormone replacement therapy on exercise training-induced improvements in insulin action in sedentary overweight adults

Exercise training (ET) and hormone replacement therapy (HRT) are both recognized influences on insulin action, but the influence of HRT on responses to ET has not been examined. To determine if HRT use provided additive benefits for the response of insulin action to ET, we evaluated the impact of HRT use on changes in insulin during the course of a randomized, controlled, aerobic ET intervention. Subjects at baseline were sedentary, dyslipidemic, and overweight. These individuals were randomized to 6 months of one of 3 aerobic ET interventions or continued physical inactivity. In 206 subjects, an insulin sensitivity index (S(I)) was obtained with a frequently sampled intravenous glucose tolerance test pre- and post-ET. Baseline and postintervention fitness, regional adiposity, general adiposity, skeletal muscle biochemistry and histology, and serum lipoproteins were measured as other putative mediators influencing insulin action. Two-way analyses of variance were used to determine if sex or HRT use influenced responses to exercise training. Linear modeling was used to determine if predictors for response in S(I) differed by sex or HRT use(.) Women who used HRT (HRT+) demonstrated significantly greater improvements in S(I) with ET than women not using HRT (HRT-). In those HRT+ women, plasma triglyceride change best correlated with change in S(I). For HRT- women, capillary density change and, for men, subcutaneous adiposity change best correlated with change in S(I). In summary, in an ET intervention, HRT use appears to be associated with more robust responses in insulin action. Furthermore, relationships between ET-induced changes in insulin action and potential mediators of change in insulin action are different for men, and for women on or off HRT. These findings have implications for the relative utility of ET for improving insulin action in middle-aged men and women, particularly in the setting of differences in HRT use.