Attending physicians' annual service volume and use of virtual end-of-life care: A population-based cohort study in Ontario, Canada

IMPORTANCE

Physicians and their practice behaviors influence access to healthcare and may represent potentially modifiable targets for practice-changing interventions. Use of virtual care at the end-of-life significantly increased during the COVID-19 pandemic, but its association with physician practice behaviors, (e.g., annual service volume) is unknown.

OBJECTIVE

Measure the association of physicians' annual service volume with their use of virtual end-of-life care (EOLC) and the magnitude of physician-attributable variation in its use, before and during the pandemic.

DESIGN, SETTING AND PARTICIPANTS

Population-based cohort study using administrative data of all physicians in Ontario, Canada who cared for adults in the last 90 days of life between 01/25/2018-12/31/2021. Multivariable modified Poisson regression models measured the association between attending physicians' use of virtual EOLC and their annual service volume. We calculated the variance partition coefficients for each regression and stratified by time period before and during the pandemic.

EXPOSURE

Annual service volume of a person's attending physician in the preceding year.

MAIN OUTCOMES AND MEASURES

Delivery of ≥1 virtual EOLC visit by a person's attending physician and the proportion of variation in its use attributable to physicians.

RESULTS

Among the 35,825 unique attending physicians caring for 315,494 adults, use of virtual EOLC was associated with receiving care from a high compared to low service volume attending physician; the magnitude of this association diminished during the pandemic (adjusted RR 1.25 [95% CI 1.14, 1.37] pre-pandemic;1.10 (95% CI 1.08, 1.12) during the pandemic). Physicians accounted for 36% of the variation in virtual EOLC use pre-pandemic and 12% of this variation during the pandemic.

CONCLUSIONS AND RELEVANCE

Physicians' annual service volume was associated with use of virtual EOLC and physicians accounted for a substantial proportion of the variation in its use. Physicians may be appropriate and potentially modifiable targets for interventions to modulate use of EOLC delivery.

THE EFFECT OF DISRUPTIVE MEDICAL EVENTS ON MORTALITY IN PEOPLE WITH AND WITHOUT DEMENTIA

Disruptive medical events such as pneumonia and hip fracture occur more frequently among older adults with dementia than those without dementia. It is not well-understood whether these events increase the risk of mortality to a greater extent for people with dementia (PWD) compared to people without dementia (PWoD). Using data from the Health and Retirement Study linked to Medicare claims, we estimated the impact of hip fracture and pneumonia on risk of mortality among 700 PWD and 12,438 PWoD using a Cox proportional hazards model. PWD had a higher risk of mortality both in the case of hip fracture (HR 1.64, 95% CI 1.31, 1.96) and pneumonia (HR 1.21 95% CI 1.09, 1.34) compared to PWoD who experienced those events. This study provides evidence that dementia may increase mortality after a disruptive medical event and suggests that the clinical course of dementia may not always be slow and gradual.

THE WIDOWHOOD EFFECT IN COMPLEX SERIOUS ILLNESS: THE IMPACT OF SPOUSAL DEATH ON MORTALITY IN DEMENTIA

Numerous studies suggest that there is an association between widowhood and mortality. This “widowhood effect” may be heightened in patients with dementia, who have high support needs and for whom spouses typically provide extensive caregiving support. Yet there are limited data on widowhood and mortality that account for dementia status. To determine the relative mortality risk of widowhood among those with and without dementia, we conducted a retrospective cohort study among community-dwelling, married/partnered persons, ≥65 years, enrolled in the Health and Retirement Study, 2000-2018. Among the 12,308 persons (n=390 with dementia), widowhood was not associated with increased mortality, after adjusting for age and dementia status, in men or women (adjusted HR 1.04; 95%C.I.(0.95-1.13); HR 0.96; 95%C.I.(0.87-1.95), respectively). These findings suggest that dementia, age, or other unmeasured confounding variables may account for the previous finding of increased mortality following spousal death. Further research is needed to confirm these findings in diverse populations.

Impact of early palliative care according to baseline symptom severity: Secondary analysis of a cluster-randomized controlled trial in patients with advanced cancer

Background

Early palliative care (EPC) improves the quality of life but may not be feasible for all patients with advanced cancer. Symptom screening has been suggested to triage patients for EPC, but scant evidence exists for this practice.

Methods

We conducted a subgroup analysis of a cluster‐randomized controlled trial of EPC vs. standard oncology care according to patients' baseline symptom scores (high [>23] vs. low [≤23] Edmonton Symptom Assessment System Distress Score [ESAS SDS]). A linear mixed‐effects model was used to account for correlation within clusters, adjusting for the baseline outcome score and all covariates in the original trial.

Results

Among the 461 participants, baseline symptom scores were high in 229 patients (127 intervention, 102 control) and low in 232 (101 intervention and 131 control). Among those with high baseline symptoms, there was improved quality of life in the EPC arm compared to controls at 4 months (adjusted difference in primary outcome of FACIT‐Sp change score [95% CI], 8.7 [2.8 to 14.5], p = 0.01; adjusted difference in QUAL‐E, 4.2 [0.9–7.5], p = 0.02); there was also improved satisfaction with care (6.9 [3.8–9.9], p = 0.001) and clinician‐patient interactions (−1.7 [−3.4 to −0.1], p = 0.04), but no significant difference in ESAS SDS (−5.6 [−12.7 to 1.4], p = 0.11). In the low baseline symptom group, there were no significant differences between arms for any outcomes.

Conclusion

EPC improved quality of life, satisfaction with care, and clinician‐patient interactions only in those with high baseline symptoms. Symptom severity may be an appropriate criterion to trigger early referrals to palliative care.

The Oral Case Presentation: Time for a "Refresh"

Despite enormous changes in medicine over the last 50 years, the oral presentation of newly admitted patients remains a core activity in academic teaching hospitals. With increased pace and complexity of care, it is time to refresh this tradition, as its efficiency and utility in contemporary practice are open to question. In this paper, we suggest a revised structure to help presenters organize their thoughts before the oral presentation and provide an online tool for doing so. We then offer tips on how to present the facts and inferences to the team in a compelling and memorable fashion; how to tell a story. Organizing information and oral presentation are advanced skills that require repeated practice to learn.

Expressive flexibility in combat veterans with posttraumatic stress disorder and depression

BACKGROUND

A growing body of evidence suggests that the ability to flexibly express and suppress emotions ("expressive flexibility") supports successful adaptation to trauma and loss. However, studies have yet to examine whether individuals that meet criteria for posttraumatic stress disorder (PTSD) or depression exhibit alterations in expressive flexibility. The present study aims to test whether lower levels of expressive flexibility are associated with PTSD and depression in combat-exposed veterans.

METHODS

Fifty-nine combat veterans with and without PTSD completed self-report measures assessing symptoms of depression, PTSD, and combat exposure. Participants also completed an expressive flexibility task in which they were asked to either enhance or suppress their expressions of emotion while viewing affective images on a computer screen. Expressive flexibility was assessed by both expressive enhancement ability and expressive suppression ability.

RESULTS

Repeated measures ANOVA's showed that both PTSD and depression were associated with lower levels of emotional enhancement ability. In addition, a series of linear regressions demonstrated that lower levels of emotional enhancement ability were associated with greater symptom severity of PTSD and depression. The ability to suppress emotional responses did not differ among individuals with and without PTSD or depression.

LIMITATIONS

of the study include a cross-sectional design, precluding causality; the lack of a non-trauma exposed group and predominantly male participants limit the generalizability to other populations.

CONCLUSIONS

Alterations in expressive flexibility is a previously unrecognized affective mechanism associated with PTSD and depression. Clinical strategies aimed at enhancing emotional expression may aid in the treatment of these disorders.

Somatic Complaints and Attachment in Former Prisoners of War: A Longitudinal Study

OBJECTIVE

War captivity includes a unique constellation of simultaneous somatic and interpersonal assaults. This raises questions about the link between attachment and somatic complaints among ex-prisoners of war (ex-POWs). Although the attachment literature assumes that attachment affects somatic complaints and not vice versa, to date no empirical studies assess the association between the two variables over time. In this article we prospectively examine the association between attachment and somatic complaints over time among ex-POWs and comparable veterans.

METHOD

The current study included two groups of male Israeli veterans of the 1973 Yom Kippur War: ex-POWs and comparable veterans who were not taken captive. Both groups were assessed via self-report measures at three times: T1 (1991), T2 (2003), and T3 (2008)--18, 30, and 35 years after the war, respectively.

RESULTS

Ex-POWs reported higher levels of somatic complaints and attachment insecurities. These levels increased over time compared to combatant veterans. Moreover, while there was a unidirectional influence of somatic complaints on attachment security over time among combatant veterans, this relationship was bidirectional among ex-POWs.

CONCLUSIONS

The present study suggests that the combined physical and interpersonal assaults experienced during captivity have adverse effects on combatants and on attachment security, even three decades later. More important, in ex-POWs the relationship between these domains appears to be interactive and mutual, with one reinforcing the other, and vice versa.