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Fischer SM, Min SJ, Kline DM, Lester K, Gozansky W, Schifeling C, Himberger J, Lopez J, Fink RM. Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:384-393. [PMID: 38345793 PMCID: PMC10862271 DOI: 10.1001/jamainternmed.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
Importance Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations. Objective To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients. Design, Setting, and Participants This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023. Interventions Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment. Main Outcomes and Measures Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life. Results Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046). Conclusion and Relevance In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness. Trial Registration ClinicalTrials.gov Identifier: NCT03181750.
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Affiliation(s)
- Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | | | | | | | | | | | | | - Joseph Lopez
- University of Colorado Health North, Fort Collins
| | - Regina M. Fink
- University of Colorado School of Medicine, Aurora
- University of Colorado College of Nursing, Aurora
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Zakrajsek JK, Min SJ, Ho PM, Kiser TH, Kannappan A, Sottile PD, Allen RR, Althoff MD, Reynolds PM, Moss M, Burnham EL, Mikkelsen ME, Vandivier RW. Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure. Chest 2023; 163:38-51. [PMID: 36191634 PMCID: PMC10354700 DOI: 10.1016/j.chest.2022.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7% to 15%. Extracorporeal membrane oxygenation (ECMO) has been used as a salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed. RESEARCH QUESTION Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care? STUDY DESIGN AND METHODS This is a retrospective, epidemiologic, observational cohort study using a national, administrative data set from 2010 to 2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an asthma exacerbation, and were treated with short-acting bronchodilators, systemic corticosteroids, and invasive ventilation. People were excluded for age < 18 years, no ICU stay, nonasthma chronic lung disease, COVID-19, or multiple admissions. The main exposure was ECMO vs No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time receiving invasive ventilation, and total hospital costs. RESULTS The study analyzed 13,714 patients with AERF, including 127 with ECMO and 13,587 with No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR, 0.33; 95% CI, 0.17-0.64; P = .001), propensity score-adjusted (OR, 0.36; 95% CI, 0.16-0.81; P = .01), and propensity score-matched models (OR, 0.48; 95% CI, 0.24-0.98; P = .04) vs No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (P < .0001 for all) vs No ECMO, but not with decreased ICU LOS, hospital LOS, or time receiving invasive ventilation. INTERPRETATION ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.
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Affiliation(s)
- Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sung-Joon Min
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tyree H Kiser
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Arun Kannappan
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Meghan D Althoff
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mark E Mikkelsen
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
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Singh S, Molina E, Meyer E, Min SJ, Fischer S. Post-Acute Care Outcomes and Functional Status Changes of Adults with New Cancer Discharged to Skilled Nursing Facilities. J Am Med Dir Assoc 2022; 23:1854-1860. [PMID: 35337793 PMCID: PMC9912689 DOI: 10.1016/j.jamda.2022.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Older hospitalized adults with an existing diagnosis of cancer rarely receive cancer treatment after discharge to a skilled nursing facility (SNF). It is unclear to what degree these outcomes may be driven by cumulative effects of previous cancer treatment and their complications vs an absolute functional threshold from which it is not possible to return. We sought to understand post-acute care outcomes of adults newly diagnosed with cancer and explore functional improvement during their SNF stay. DESIGN Retrospective cohort study, 2011-2013. SETTING AND PARTICIPANTS Surveillance, Epidemiology, and End Results - Medicare database of patients with new stage II-IV colorectal, pancreatic, bladder, or lung cancer discharged to SNF. METHODS Primary outcome was time to death after hospital discharge. Covariates include cancer treatment receipt and hospice use. A Minimum Data Set (MDS)-Activities of Daily Living (ADL) score was calculated to measure changes in ADLs during SNF stay. Patient groups of interest were compared descriptively using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Logistic regression was used to compare patient groups. RESULTS A total of 6791 cases were identified. Forty-six percent of patients did not receive treatment or hospice, 25.0% received no treatment but received hospice, 20.8% received treatment but no hospice, and 8.5% received both treatment and hospice. Only 43% of decedents received hospice. Patients who received treatment but not hospice had the best survival. There were limited improvements in MDS-ADL scores in the subset of patients for whom we have complete data. Those with greater functional improvement had improved survival. CONCLUSIONS AND IMPLICATIONS The majority of patients did not receive future cancer treatment or hospice care prior to death. There was limited improvement in MDS-ADL scores raising concern this population might not benefit from the rehabilitative intent of SNFs.
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Affiliation(s)
- Sarguni Singh
- Division of Hospital Medicine, University of Colorado Denver, Aurora, CO, USA.
| | | | | | - Sung-Joon Min
- Division of Health Care Policy & Research, University of Colorado Denver, Aurora, Colorado
| | - Stacy Fischer
- Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado
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Diaz Del Valle F, Zakrajsek JK, Min SJ, Koff PB, Bell HW, Kincaid KA, Frank DN, Ramakrishnan V, Ghosh M, Vandivier RW. Impact of Airline Secondhand Tobacco Smoke Exposure on Respiratory Health and Lung Function Decades After Exposure Cessation. Chest 2022; 162:556-568. [PMID: 35271841 PMCID: PMC9470742 DOI: 10.1016/j.chest.2022.02.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Twenty-five percent to 45% of COPD is caused by exposures other than active smoking. Secondhand tobacco smoke (SHS) has been suggested as an independent cause of COPD, based on its association with increased respiratory symptoms and a small decrease in lung function, but its impact on respiratory health and lung function after exposure cessation has not been explored. RESEARCH QUESTION What are the consequences of airline SHS exposure on respiratory health and lung function decades after cessation? STUDY DESIGN AND METHODS We performed a cohort study involving flight attendants because of their exposure to SHS that stopped > 20 years ago. We included subjects ≥ 50 years of age with > 1 year vs ≤ 1 year of airline SHS exposure (ie, exposed vs unexposed). Respiratory quality of life, as determined by the St. George's Respiratory Questionnaire (SGRQ), was the primary outcome for respiratory health. Key secondary outcomes included general quality of life (the Rand Corporation modification of the 36-item Short Form Health Survey Questionnaire; RAND-36), respiratory symptoms (COPD Assessment Test; CAT), and spirometry. RESULTS The study enrolled 183 SHS-exposed and 59 unexposed subjects. Exposed subjects were 66.7 years of age, and 90.7% were female. They were hired at 23.8 years of age, were exposed to airline SHS for 16.1 years, and stopped exposure 27.5 years before enrollment. Prior SHS exposure was associated with worsened SGRQ (6.7 units; 95% CI, 2.7-10.7; P = .001), RAND-36 physical and social function, and CAT vs unexposed subjects. SHS exposure did not affect prebronchodilator spirometry or obstruction, but was associated with lower postbronchodilator FEV1 and FEV1/FVC, total lung capacity, and diffusing capacity of the lungs for carbon monoxide in a subset of subjects. Former smoking and SHS exposure synergistically worsened SGRQ (β = 8.4; 95% CI, 0.4-16.4; P = .04). SHS exposure in people who never smoked replicated primary results and was associated with worsened SGRQ vs unexposed people (4.7 units; 95% CI, 0.7-7.0; P = .006). INTERPRETATION Almost three decades after exposure ended, airline SHS exposure is strongly and dose-dependently associated with worsened respiratory health, but less robustly associated with airflow abnormalities used to diagnose COPD.
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Affiliation(s)
- Fernando Diaz Del Valle
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group (CPOR), Aurora, CO
| | - Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group (CPOR), Aurora, CO
| | - Sung-Joon Min
- Division of Healthcare Policy and Research, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
| | - Patricia B Koff
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group (CPOR), Aurora, CO
| | - Harold W Bell
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group (CPOR), Aurora, CO
| | - Keegan A Kincaid
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group (CPOR), Aurora, CO
| | - Daniel N Frank
- Division of Infectious Diseases, Department of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
| | - Vijay Ramakrishnan
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO
| | - Moumita Ghosh
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group (CPOR), Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group (CPOR), Aurora, CO.
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Diaz Del Valle F, Koff PB, Min SJ, Zakrajsek JK, Zittleman L, Fernald DH, Nederveld A, Nease DE, Hunter AR, Moody EJ, Miller Temple K, Niblock JL, Grund C, Oser TK, Greiner KA, Vandivier RW. Challenges Faced by Rural Primary Care Providers When Caring for COPD Patients in the Western United States. Chronic Obstr Pulm Dis 2021; 8:336-349. [PMID: 34048644 PMCID: PMC8428598 DOI: 10.15326/jcopdf.2021.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
RATIONALE Rural chronic obstructive pulmonary disease (COPD) patients have worse outcomes and higher mortality compared with urban patients. Reasons for these disparities likely include challenges to delivery of care that have not been explored. OBJECTIVE To determine challenges faced by rural primary care providers when caring for COPD patients. METHODS Rural primary care providers in 7 primarily western states were asked about barriers they experienced when caring for COPD patients. RESULTS A total of 71 rural primary care medical providers completed the survey, of which 51% were physicians and 49% were advanced practice providers (APPs). A total of 61% used Global Initiative for Chronic Obstructive Lung Disease or American Thoracic Society/European Respiratory Society guidelines as an assessment and treatment resource. The presence of multiple chronic conditions and patient failure to recognize and report symptoms were the greatest barriers to diagnose COPD. A total of 89% of providers used spirometry to diagnose COPD, but only 62% were satisfied with access to spirometry. Despite recommendations, 41% of providers never test for alpha-1 antitrypsin deficiency. A total of 87% were comfortable with their ability to assess symptoms, but only 11% used a guideline-recommended assessment tool. Although most providers were satisfied with their ability to treat symptoms and exacerbations, only 66% were content with their ability to prevent exacerbations. Fewer providers were happy with their access to pulmonologists (55%) or pulmonary rehabilitation (37%). Subgroup analyses revealed differences based on provider type (APP versus physician) and location (Colorado and Kansas versus other states), but not on population or practice size. CONCLUSIONS Rural providers face significant challenges when caring for COPD patients that should be targeted in future interventions to improve COPD outcomes.
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Affiliation(s)
- Fernando Diaz Del Valle
- Division of Pulmonary Sciences and Critical Care Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Patricia B Koff
- Division of Pulmonary Sciences and Critical Care Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Sung-Joon Min
- Department of Medicine, Division of Healthcare Policy and Research, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Linda Zittleman
- Department of Family Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Douglas H Fernald
- Department of Family Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Andrea Nederveld
- Department of Family Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Donald E Nease
- Department of Family Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Alexis R Hunter
- High Plains Research Council Community Advisory Council, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - Eric J Moody
- Wyoming Institute for Disabilities, University of Wyoming, Laramie, Wyoming, United States
| | - Kay Miller Temple
- Center for Rural Health, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, United States
| | - Jenny L Niblock
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Chrysanne Grund
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Tamara K Oser
- Department of Family Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
| | - K Allen Greiner
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Denver Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States
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Koff PB, Min SJ, Freitag TJ, Diaz DLP, James SS, Voelkel NF, Linderman DJ, Diaz Del Valle F, Zakrajsek JK, Albert RK, Bull TM, Beck A, Stelzner TJ, Ritzwoller DP, Kveton CM, Carwin S, Ghosh M, Keith RL, Westfall JM, Vandivier RW. Impact of Proactive Integrated Care on Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis 2021; 8. [PMID: 33238087 DOI: 10.15326/jcopdf.2020.0139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Up to 50% of chronic obstructive pulmonary disease (COPD) patients do not receive recommended care for COPD. To address this issue, we developed Proactive Integrated Care (Proactive iCare), a health care delivery model that couples integrated care with remote monitoring. Methods We conducted a prospective, quasi-randomized clinical trial in 511 patients with advanced COPD or a recent COPD exacerbation, to test whether Proactive iCare impacts patient-centered outcomes and health care utilization. Patients were allocated to Proactive iCare (n=352) or Usual Care ( =159) and were examined for changes in quality of life using the St George's Respiratory Questionnaire (SGRQ), symptoms, guideline-based care, and health care utilization. Findings Proactive iCare improved total SGRQ by 7-9 units (p < 0.0001), symptom SGRQ by 9 units (p<0.0001), activity SGRQ by 6-7 units (p<0.001) and impact SGRQ by 7-11 units (p<0.0001) at 3, 6 and 9 months compared with Usual Care. Proactive iCare increased the 6-minute walk distance by 40 m (p<0.001), reduced annual COPD-related urgent office visits by 76 visits per 100 participants (p<0.0001), identified unreported exacerbations, and decreased smoking (p=0.01). Proactive iCare also improved symptoms, the body mass index-airway obstruction-dyspnea-exercise tolerance (BODE) index and oxygen titration (p<0.05). Mortality in the Proactive iCare group (1.1%) was not significantly different than mortality in the Usual Care group (3.8%; p=0.08). Interpretation Linking integrated care with remote monitoring improves the lives of people with advanced COPD, findings that may have been made more relevant by the coronavirus 2019 (COVID-19) pandemic.
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Affiliation(s)
- Patricia B Koff
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Sung-Joon Min
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Tammie J Freitag
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Debora L P Diaz
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Shannon S James
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Norbert F Voelkel
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Derek J Linderman
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Fernando Diaz Del Valle
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Richard K Albert
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
| | - Arne Beck
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Thomas J Stelzner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Christine M Kveton
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Stephanie Carwin
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, United States
| | - Moumita Ghosh
- National Jewish Health, Denver, Colorado, United States
| | - Robert L Keith
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States.,Denver Veterans Administration Medical Center, Denver, Colorado, United States
| | - John M Westfall
- Department of Family Medicine, High Plains Research Network, University of Colorado Denver, Anschutz Medical Campus, United States
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Colorado Pulmonary Outcomes Research Group, Aurora, Colorado, United States
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Singh S, Eguchi M, Min SJ, Fischer S. Outcomes of Patients With Cancer Discharged to a Skilled Nursing Facility After Acute Care Hospitalization. J Natl Compr Canc Netw 2020; 18:856-865. [PMID: 32634778 PMCID: PMC8370039 DOI: 10.6004/jnccn.2020.7534] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/10/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND After discharge from an acute care hospitalization, patients with cancer may choose to pursue rehabilitative care in a skilled nursing facility (SNF). The objective of this study was to examine receipt of anticancer therapy, death, readmission, and hospice use among patients with cancer who discharge to an SNF compared with those who are functionally able to discharge to home or home with home healthcare in the 6 months after an acute care hospitalization. METHODS A population-based cohort study was conducted using the SEER-Medicare database of patients with stage II-IV colorectal, pancreatic, bladder, or lung cancer who had an acute care hospitalization between 2010 and 2013. A total of 58,770 cases were identified and patient groups of interest were compared descriptively using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Logistic regression was used to compare patient groups, adjusting for covariates. RESULTS Of patients discharged to an SNF, 21%, 17%, and 2% went on to receive chemotherapy, radiotherapy, and targeted chemotherapy, respectively, compared with 54%, 28%, and 6%, respectively, among patients discharged home. Fifty-six percent of patients discharged to an SNF died within 6 months of their hospitalization compared with 36% discharged home. Thirty-day readmission rates were 29% and 28% for patients discharged to an SNF and home, respectively, and 12% of patients in hospice received <3 days of hospice care before death regardless of their discharge location. CONCLUSIONS Patients with cancer who discharge to an SNF are significantly less likely to receive subsequent oncologic treatment of any kind and have higher mortality compared with patients who discharge to home after an acute care hospitalization. Further research is needed to understand and address patient goals of care before discharge to an SNF.
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Affiliation(s)
- Sarguni Singh
- 1Division of Hospital Medicine, University of Colorado Denver
| | | | | | - Stacy Fischer
- 4Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado
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Fischer SM, Kline DM, Min SJ, Okuyama-Sasaki S, Fink RM. Effect of Apoyo con Cariño (Support With Caring) Trial of a Patient Navigator Intervention to Improve Palliative Care Outcomes for Latino Adults With Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol 2019; 4:1736-1741. [PMID: 30326035 DOI: 10.1001/jamaoncol.2018.4014] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Strategies to increase access to palliative care, particularly for racial/ethnic minorities, must maximize primary palliative care and community-based models to meet the ever-growing need in a culturally sensitive and congruent manner. Objective To investigate if a culturally tailored patient navigator intervention can improve palliative care outcomes for Latino adults with advanced cancer. Design, Setting, and Participants The Apoyo con Cariño (Support With Caring) randomized clinical trial was conducted from July 2012 to March 2016. The setting was clinics across the state of Colorado, including an academic National Cancer Institute-designated cancer center, community cancer clinics (urban and rural), and a safety-net cancer center. Participants were adults who self-identified as Latino and were being treated for advanced cancer. Intervention Culturally tailored patient navigator intervention. Main Outcomes and Measures Primary outcome measures were advance care planning in the medical record, the Brief Pain Inventory, and hospice use. Secondary outcome measures included the McGill Quality of Life Questionnaire (MQOL), hospice length of stay, and aggressiveness of care at the end of life. This study used an intent-to-treat design. Results In total, 223 Latino adults enrolled (mean [SD] age, 58.1 [13.6] years; 55.6% female) and were randomized to control (n = 111) or intervention (n = 112) groups. Intervention group patients were more likely to have a documented advance directive compared with control group patients (73 of 112 [65.2%] vs 40 of 111 [36.0%], P < .001). Both groups reported mild pain intensity (mean pain rating of 3 on a scale of 0-10). Intervention group patients had a mean (SD) reported change from baseline in the Brief Pain Inventory pain severity subscale score (range, 0-10) of 0.1 (2.6) vs 0.2 (2.7) in control group patients (P = .88) and a mean (SD) reported change from baseline in the Brief Pain Inventory pain interference subscale score of 0.1 (3.2) vs -0.2 (3.0) in control group patients (P = .66). Hospice use was similar in both groups. Secondary outcomes of overall MQOL score and aggressiveness of care at the end of life showed no significant differences between groups. The MQOL physical subscale showed a mean (SD) significant change from baseline of 1.4 (3.1) in the intervention group vs 0.1 (3.0) in the control group (P = .004). Conclusions and Relevance The intervention had mixed results. The intervention increased advance care planning and improved physical symptoms; however, it had no effect on pain management and hospice use or overall quality of life. Further research is needed to determine the role and scope of lay navigators in palliative care. Trial Registration ClinicalTrials.gov identifier: NCT01695382.
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Affiliation(s)
- Stacy M Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | - Danielle M Kline
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | - Sung-Joon Min
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora
| | | | - Regina M Fink
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora.,CU College of Nursing, University of Colorado, Aurora
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Fischer SM, Min SJ, Atherly A, Kline DM, Gozansky WS, Himberger J, Lopez J, Lester K, Fink RM. Apoyo con Cariño (support with caring): RCT protocol to improve palliative care outcomes for Latinos with advanced medical illness. Res Nurs Health 2018; 41:501-510. [PMID: 30302769 DOI: 10.1002/nur.21915] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/09/2018] [Indexed: 11/07/2022]
Abstract
Latinos are more likely to experience uncontrolled pain, and institutional death, and are less likely to engage in advance care planning. Efforts to increase access to palliative care must maximize primary palliative care and community based models to meet the ever-growing need in a culturally sensitive and congruent manner. Patient navigator interventions are community-based, culturally tailored models of care that have been successfully implemented to improve disease prevention, early diagnosis, and treatment. We have developed a patient navigation intervention to improve palliative care outcomes for seriously ill Latinos. We describe the protocol for a National Institute of Nursing Research-funded randomized controlled trial designed to determine the effectiveness of the manualized patient navigator intervention. We aim to enroll 240 Latino adults with non-cancer, advanced medical illness from both urban and rural clinical sites. Participants will be randomized to the intervention group (five palliative care patient navigator visits plus bilingual educational materials) or control group (usual care plus bilingual educational materials). Outcomes include quality of life (Functional Assessment of Chronic Illness Therapy), advance care planning (Advance Care Planning Engagement survey), pain (Brief Pain Inventory), symptom management (Edmonton Symptom Assessment Scale-revised), hospice utilization, and cost and utilization of healthcare resources. This culturally tailored, evidence-based, theory-driven, innovative patient navigation intervention has significant potential to improve palliative care for Latinos, and facilitate health equity in palliative and end-of-life care.
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Affiliation(s)
- Stacy M Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Sung-Joon Min
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, Colorado
| | - Adam Atherly
- University of Vermont, College of Medicine, Burlington, Vermont
| | - Danielle M Kline
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Wendolyn S Gozansky
- Kaiser Permanente, Institute for Health Research, Colorado Permanente Medical Group, Denver, Colorado
| | - John Himberger
- University of Colorado, South, Colorado Springs, Colorado
| | - Joseph Lopez
- University of Colorado, North, Colorado Springs, Colorado
| | | | - Regina M Fink
- Division of General Internal Medicine, University of Colorado School of Medicine, College of Nursing, Aurora, Colorado
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Fischer SM, Kline DM, Min SJ, Okuyama S, Fink RM. Apoyo con Cariño: Strategies to Promote Recruiting, Enrolling, and Retaining Latinos in a Cancer Clinical Trial. J Natl Compr Canc Netw 2018; 15:1392-1399. [PMID: 29118231 DOI: 10.6004/jnccn.2017.7005] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 07/05/2017] [Indexed: 12/21/2022]
Abstract
Background: We present and describe tailored strategies to address known barriers to minority participation in clinical trial research. The strategies used allowed our team to engage communities and successfully recruit, enroll, and retain a diverse underserved population of Latinos with advanced cancer for this clinical trial. Methods: Participants were recruited from 3 urban and 7 rural sites. We identified 4 critical barriers to recruitment for this underserved population: (1) mistrust; (2) language and communication barriers; (3) lack of access to academic cancer center; and (4) inability to participate due to transportation, childcare, or work responsibilities. We developed tailored strategies to engage referring sites and patients to participate in the clinical trial. Results: We identified 318 potentially eligible participants; 34 were found to be ineligible, and 223 consented to participate in the study, representing a 79.0% enrollment rate. All patients (100%) self-identified as Latino, and 47.5% spoke Spanish as their primary language. Patients were socioeconomically disadvantaged: 53.6% had an annual income <$15,000 USD, and 50.2% had less than a high school education. A total of 177 participants completed the 3-month follow-up; 26 died before the 3-month follow interview, and 20 did not complete the follow-up evaluation (9% withdrawal rate). Conclusions: Our community-informed strategies were highly effective for recruiting, enrolling, and retaining an underserved diverse population of Latinos. The barriers we identified and the strategies we used have the potential to inform research to increase minority participation in cancer clinical trials. ClinicalTrials.gov identifier: NCT01695382.
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Affiliation(s)
| | | | | | - Sonia Okuyama
- University of Colorado School of Medicine,Denver Health and Hospital Authority, Denver, Colorado
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Abstract
BACKGROUND Prognostication of survival in patients with advanced cancer has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even among providers and is a less studied phenomenon. OBJECTIVE We introduced the surprise question (SQ), "Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?," at multidisciplinary rounds to increase palliative care referrals through the introduction of this prognostic prompt. DESIGN, SETTING, PATIENTS This quality improvement project took place from March 2016 to May 2016 on the medical oncology service at a tertiary academic medical center. The question was asked 3 times a week at multidisciplinary rounds which are attended by the hospital medicine provider, palliative care provider, and consulting oncologist. Primary oncologists and bedside nurses were also asked the SQ. MEASUREMENTS Referral rates to outpatient palliative care clinic, community-based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 5 months postintervention. RESULTS Regular discussion of prognosis of patients with cancer in an inpatient medical setting did not increase referrals to inpatient or outpatient palliative care or hospice. Increased clinical experience impacted hospital medicine providers and bedside nurses' estimation of prognosis differently than oncology providers. Medical oncologists were significantly more optimistic than hospital medicine providers.
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Affiliation(s)
- Sarguni Singh
- 1 Division of Hospital Medicine, University of Colorado Denver, Aurora, CO, USA
| | - Adrian Rodriguez
- 2 College of Nursing, University of Colorado Denver, Aurora, CO, USA
| | - Darrell Lee
- 2 College of Nursing, University of Colorado Denver, Aurora, CO, USA
| | - Sung-Joon Min
- 3 Division of Health Care Policy and Research, University of Colorado Denver, Aurora, CO, USA
| | - Stacy Fischer
- 4 Division of General Internal Medicine, University of Colorado Denver, Aurora, CO, USA
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LeNoue SR, Salomonsen-Sautel S, Min SJ, Thurstone C. Marijuana commercialization and adolescent substance treatment outcomes in Colorado. Am J Addict 2017; 26:802-806. [PMID: 29064160 DOI: 10.1111/ajad.12634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/06/2017] [Accepted: 09/17/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In Colorado, marijuana was legalized for medical use in 2000, commercialized in 2009, and approved for recreational purposes in 2012. Little is known about the association between recent policy changes and adolescent substance treatment outcomes measured by urine drug screens (UDS). This study addressed this research gap. METHODS Participants were youth (N = 523) aged 11-19 years who were enrolled in an outpatient motivational interviewing (MI)/cognitive behavioral therapy (CBT) plus contingency management (CM) in Denver, Colorado from October 2007 to June 2014. The measures included UDS collected during weekly treatment sessions and sent to a commercial laboratory for quantitative analysis of tetrahydrocannabinol (THC)/Creatinine (Cr). Linear regression models and logistic regression models using a Generalized Estimating Equations (GEE) approach for repeated measures were completed to answer the study aims. RESULTS Males, but not females, had a marginally significant increasing trend over time in monthly average THC/Cr (β = 1.99, p = 0.046). There was a significant increasing trend over time (per 30 days) in the odds of having a negative UDS within 6 sessions (OR = 1.02, 95%CI = 1.003-1.04, p = 0.006). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Based on these data, substance treatment outcomes from MI and CBT are mixed, but overall treatment appears to remain effective in a state with legalized marijuana. (Am J Addict 2017;26:802-806).
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Affiliation(s)
- Sean R LeNoue
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado.,Department of Psychiatry, Denver Health and Hospital Authority, Denver, Colorado
| | - Stacy Salomonsen-Sautel
- Department of Psychiatry, Drug Policy Institute, University of Florida College of Medicine, Gainesville, Florida
| | - Sung-Joon Min
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, Colorado
| | - Christian Thurstone
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado.,Department of Psychiatry, Denver Health and Hospital Authority, Denver, Colorado
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Abstract
The aims of this study were to (a) describe the nature of patients' goals upon discharge from hospital, family caregivers' goals for their loved ones, and family caregivers' goals for themselves; (b) determine the degree of concordance with respect to the three elicited goals; (c) ascertain goal attainment across the three elicited goals; and (d) examine factors predictive of goal attainment. Our findings support the position that eliciting patient and family caregiver goals and promoting goal attainment may represent an important step toward promoting greater patient and family caregiver engagement in their care.
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Affiliation(s)
- Eric A Coleman
- a Division of Health Care Policy and Research , University of Colorado Denver Anschutz Medical Campus , Aurora , Colorado , USA
| | - Sung-Joon Min
- a Division of Health Care Policy and Research , University of Colorado Denver Anschutz Medical Campus , Aurora , Colorado , USA
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Bandle B, Ward K, Min SJ, Drake C, McIlvennan CK, Kao D, Wald HL. Can Braden Score Predict Outcomes for Hospitalized Heart Failure Patients? J Am Geriatr Soc 2017; 65:1328-1332. [DOI: 10.1111/jgs.14801] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Brian Bandle
- New York Department of Public Health; Albany New York
| | - Kelsey Ward
- University of Colorado School of Medicine; Aurora Colorado
| | - Sung-Joon Min
- University of Colorado School of Medicine; Aurora Colorado
| | - Cynthia Drake
- University of Colorado School of Medicine; Aurora Colorado
| | | | - David Kao
- University of Colorado School of Medicine; Aurora Colorado
| | - Heidi L. Wald
- University of Colorado School of Medicine; Aurora Colorado
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Battaglia C, Peterson J, Whitfield E, Min SJ, Benson SL, Maddox TM, Prochazka AV. Integrating Motivational Interviewing Into a Home Telehealth Program for Veterans With Posttraumatic Stress Disorder Who Smoke: A Randomized Controlled Trial. J Clin Psychol 2016; 72:194-206. [DOI: 10.1002/jclp.22252] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
| | | | | | | | | | - Thomas M. Maddox
- Eastern Colorado Health Care System
- University of Colorado Denver
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Ground K, Jones W, Drake C, Gahm G, Min SJ, Trautner B, Wald H. Antibiotic Treatment for Urinary Tract Infections in Nursing Homes: Identifying Opportunities for Antimicrobial Stewardship. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv131.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hutt E, Whitfield E, Min SJ, Jones J, Weber M, Albright K, Levy C, O'Toole T. Challenges of Providing End-of-Life Care for Homeless Veterans. Am J Hosp Palliat Care 2015; 33:381-9. [PMID: 25701660 DOI: 10.1177/1049909115572992] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To describe challenges of caring for homeless veterans at end of life (EOL) as perceived by Veterans Affairs Medical Center (VAMC) homeless and EOL care staff. DESIGN E-mail survey. SETTING/PARTICIPANTS Homelessness and EOL programs at VAMCs. MEASUREMENTS Programs and their ratings of personal, structural, and clinical care challenges were described statistically. Homelessness and EOL program responses were compared in unadjusted analyses and using multivariable models. RESULTS Of 152 VAMCs, 50 (33%) completed the survey. The VAMCs treated an average of 6.5 homeless veterans at EOL annually. Lack of appropriate housing was the most critical challenge. The EOL programs expressed somewhat more concern about lack of appropriate care site and care coordination than did homelessness programs. CONCLUSIONS Personal, clinical, and structural challenges face care providers for veterans who are homeless at EOL. Deeper understanding of these challenges will require qualitative study of homeless veterans and care providers.
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Affiliation(s)
- Evelyn Hutt
- Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA Department of Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Emily Whitfield
- Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA Department of Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Sung-Joon Min
- Department of Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Mary Weber
- University of Colorado College of Nursing, Denver, CO, USA
| | - Karen Albright
- Department of Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Cari Levy
- Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA Department of Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Thomas O'Toole
- Providence Veterans Affairs Medical Center, Providence, RI, USA Department of Medicine, Alpert Medical School, Brown University, Providence, RI, USA
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Silbermann M, Fink RM, Min SJ, Mancuso MP, Brant J, Hajjar R, Al-Alfi N, Baider L, Turker I, ElShamy K, Ghrayeb I, Al-Jadiry M, Khader K, Kav S, Charalambous H, Uslu R, Kebudi R, Barsela G, Kuruku N, Mutafoglu K, Ozalp-Senel G, Oberman A, Kislev L, Khleif M, Keoppi N, Nestoros S, Abdalla RF, Rassouli M, Morag A, Sabar R, Nimri O, Al-Qadire M, Al-Khalaileh M, Tayyem M, Doumit M, Punjwani R, Rasheed O, Fallatah F, Can G, Ahmed J, Strode D. Evaluating Palliative Care Needs in Middle Eastern Countries. J Palliat Med 2015; 18:18-25. [DOI: 10.1089/jpm.2014.0194] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael Silbermann
- Middle East Cancer Consortium, Technion–Israel Institute of Technology, Haifa, Israel
| | | | - Sung-Joon Min
- University of Colorado, School of Medicine, Aurora, Colorado
| | | | | | | | - Nesreen Al-Alfi
- Fatima College for Health Care/Sciences, Abu Dhabi, United Arab Emirates
| | | | - Ibrahim Turker
- Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Karima ElShamy
- Faculty of Nursing, Mansoura University, Mansoura, Egypt
| | | | - Mazin Al-Jadiry
- Children Welfare Teaching Hospital University of Baghdad, Baghdad, Iraq
| | | | | | | | - Ruchan Uslu
- Ege University School of Medicine, Tulay Aktas Oncology Hospital, Izmir, Turkey
| | - Rejin Kebudi
- Cerrahpaşa Medical Faculty Istanbul University, Istanbul, Turkey
| | - Gil Barsela
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Nilgün Kuruku
- Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | | | | | | | | | - Mohammad Khleif
- Al-Sadeel Society for Palliative Care, Bethlehem, West Bank, Palestinian Authority
| | | | | | | | - Maryam Rassouli
- School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Teheran, Islamic Republic of Iran
| | - Amira Morag
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | - Ron Sabar
- Sabar Clinics for Community Health Services, Israel
| | - Omar Nimri
- Jordan Cancer Registry, Ministry of Health, Amman, The Hashemite Kingdom of Jordan
| | | | - Murad Al-Khalaileh
- Al-Bayt University Faculty of Nursing, Mafraq, The Hashemite Kingdom of Jordan
| | - Mona Tayyem
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, The Hashemite Kingdom of Jordan
| | - Myrna Doumit
- Alice Ramez Chagoury School of Nursing, Lebanese American University, Beirut, Lebanon
| | | | - Osaid Rasheed
- Al Quds University, Abu Dies and Al-Ahli Hospital, Hebron, West Bank, Palestine
| | | | - Gulbeyaz Can
- Istanbul University Florence Nightingale Hemsirelik Fakultesi, Istanbul, Turkey
| | - Jamila Ahmed
- Faculty of Medicine, University of Aden, Aden, Yemen
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Norton WE, Hosokawa PW, Henderson WG, Volckmann ET, Pell J, Tomeh MG, Glasgow RE, Min SJ, Neumayer LA, Hawn MT. Acceptability of the decision support for safer surgery tool. Am J Surg 2014; 209:977-84. [PMID: 25457241 DOI: 10.1016/j.amjsurg.2014.06.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/04/2014] [Accepted: 06/09/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events. METHODS The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests. RESULTS During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably. CONCLUSION The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.
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Affiliation(s)
- Wynne E Norton
- Department of Health Behavior, University of Alabama at Birmingham School of Public Health, 1665 University Boulevard, Birmingham, AL 35294, USA.
| | - Patrick W Hosokawa
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Health Outcomes Program, University of Colorado Denver, Denver, CO, USA
| | - William G Henderson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Health Outcomes Program, University of Colorado Denver, Denver, CO, USA
| | - Eric T Volckmann
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Joyce Pell
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Robert E Glasgow
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Sung-Joon Min
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Health Outcomes Program, University of Colorado Denver, Denver, CO, USA
| | - Leigh A Neumayer
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Mary T Hawn
- Department of Surgery, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294, USA
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Wald HL, Bandle B, Richard AA, Min SJ, Capezuti E. Implementation of electronic surveillance of catheter use and catheter-associated urinary tract infection at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Am J Infect Control 2014; 42:S242-9. [PMID: 25239717 DOI: 10.1016/j.ajic.2014.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/21/2014] [Accepted: 04/22/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Manual surveillance of indwelling urinary catheters (IUCs) and catheter-associated urinary tract infections (CAUTIs) is resource intense. METHODS We implemented electronic surveillance in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Capacity was created centrally to analyze data collected electronically or manually at each site. We measured the average IUC duration and proportion of patients with IUC duration <3 days. CAUTIs were identified using a validated algorithm based on the Centers for Disease Control and Prevention definition and used to calculate rates and standardized incidence ratios (SIRs). RESULTS Electronic surveillance was implemented in 25 units at 20 NICHE hospitals. Full automation was achieved at 15 of 16 sites with electronic health records (EHRs). Electronic surveillance challenges included EHR data element formats and IUC documentation. Study units reported on 4,574 patients for 16,105 IUC days over a 6-month period. The mean of the unit-level average IUC duration was 3.2 ± 2.6 days, mean proportion of patients with IUC duration <3 days was 52.4% ± 50%, and mean CAUTI SIR was 0.14 ± 0.31. CONCLUSION A centralized electronic surveillance strategy for CAUTI is feasible and sustainable. Baseline performance of participating sites was exemplary, with very low SIRs at baseline.
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Affiliation(s)
- Heidi L Wald
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO.
| | - Brian Bandle
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO
| | - Angela A Richard
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO
| | - Sung-Joon Min
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth Capezuti
- Hunter-Bellevue School of Nursing, Hunter College of the City University of New York, New York, NY
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Salomonsen-Sautel S, Min SJ, Sakai JT, Thurstone C, Hopfer C. Trends in fatal motor vehicle crashes before and after marijuana commercialization in Colorado. Drug Alcohol Depend 2014; 140:137-44. [PMID: 24831752 PMCID: PMC4068732 DOI: 10.1016/j.drugalcdep.2014.04.008] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 04/09/2014] [Accepted: 04/10/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Legal medical marijuana has been commercially available on a widespread basis in Colorado since mid-2009; however, there is a dearth of information about the impact of marijuana commercialization on impaired driving. This study examined if the proportions of drivers in a fatal motor vehicle crash who were marijuana-positive and alcohol-impaired, respectively, have changed in Colorado before and after mid-2009 and then compared changes in Colorado with 34 non-medical marijuana states (NMMS). METHODS Thirty-six 6-month intervals (1994-2011) from the Fatality Analysis Reporting System were used to examine temporal changes in the proportions of drivers in a fatal motor vehicle crash who were alcohol-impaired (≥0.08 g/dl) and marijuana-positive, respectively. The pre-commercial marijuana time period in Colorado was defined as 1994-June 2009 while July 2009-2011 represented the post-commercialization period. RESULTS In Colorado, since mid-2009 when medical marijuana became commercially available and prevalent, the trend became positive in the proportion of drivers in a fatal motor vehicle crash who were marijuana-positive (change in trend, 2.16 (0.45), p<0.0001); in contrast, no significant changes were seen in NMMS. For both Colorado and NMMS, no significant changes were seen in the proportion of drivers in a fatal motor vehicle crash who were alcohol-impaired. CONCLUSIONS Prevention efforts and policy changes in Colorado are needed to address this concerning trend in marijuana-positive drivers. In addition, education on the risks of marijuana-positive driving needs to be implemented.
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Affiliation(s)
- Stacy Salomonsen-Sautel
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States.
| | - Sung-Joon Min
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Joseph T. Sakai
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Christian Thurstone
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045,Denver Health and Hospital Authority, Denver, CO, 80204
| | - Christian Hopfer
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
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Schuermeyer J, Salomonsen-Sautel S, Price RK, Balan S, Thurstone C, Min SJ, Sakai JT. Temporal trends in marijuana attitudes, availability and use in Colorado compared to non-medical marijuana states: 2003-11. Drug Alcohol Depend 2014; 140:145-55. [PMID: 24837585 PMCID: PMC4161452 DOI: 10.1016/j.drugalcdep.2014.04.016] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 04/13/2014] [Accepted: 04/13/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2009, policy changes were accompanied by a rapid increase in the number of medical marijuana cardholders in Colorado. Little published epidemiological work has tracked changes in the state around this time. METHODS Using the National Survey on Drug Use and Health, we tested for temporal changes in marijuana attitudes and marijuana-use-related outcomes in Colorado (2003-11) and differences within-year between Colorado and thirty-four non-medical-marijuana states (NMMS). Using regression analyses, we further tested whether patterns seen in Colorado prior to (2006-8) and during (2009-11) marijuana commercialization differed from patterns in NMMS while controlling for demographics. RESULTS Within Colorado those reporting "great-risk" to using marijuana 1-2 times/week dropped significantly in all age groups studied between 2007-8 and 2010-11 (e.g. from 45% to 31% among those 26 years and older; p=0.0006). By 2010-11 past-year marijuana abuse/dependence had become more prevalent in Colorado for 12-17 year olds (5% in Colorado, 3% in NMMS; p=0.03) and 18-25 year olds (9% vs. 5%; p=0.02). Regressions demonstrated significantly greater reductions in perceived risk (12-17 year olds, p=0.005; those 26 years and older, p=0.01), and trend for difference in changes in availability among those 26 years and older and marijuana abuse/dependence among 12-17 year olds in Colorado compared to NMMS in more recent years (2009-11 vs. 2006-8). CONCLUSIONS Our results show that commercialization of marijuana in Colorado has been associated with lower risk perception. Evidence is suggestive for marijuana abuse/dependence. Analyses including subsequent years 2012+ once available, will help determine whether such changes represent momentary vs. sustained effects.
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Affiliation(s)
- Joseph Schuermeyer
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Rumi Kato Price
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Sundari Balan
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Christian Thurstone
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, Denver Health and Hospital Authority, Denver, Colorado
| | - Sung-Joon Min
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Joseph T. Sakai
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Abstract
BACKGROUND Former prison inmates experience high rates of hospitalizations and death during the transition from prison to the community, particularly from drug-related causes and early after release. The authors designed a randomized controlled trial (RCT) of patient navigation to reduce barriers to health care and hospitalizations for former prison inmates. METHODS Forty former prison inmates with a history of drug involvement were recruited and randomized within 15 days after prison release. Participants were randomized to receive 3 months of patient navigation (PN) with facilitated enrollment into an indigent care discount program (intervention) or facilitated enrollment into an indigent care discount program alone (control). Structured interviews were conducted at baseline, 3 months, and 6 months. Outcomes were measured as a change in self-reported barriers to care and as the rate of health service use per 100 person-days. RESULTS The mean number of reported barriers to care was reduced at 3 and 6 months in both groups. At 6 months, the rate of emergency department/urgent care visits per 100 person-days since baseline was 1.1 among intervention participants and 0.5 among control participants (P = .04), whereas the rate of hospitalizations per 100 person-days was 0.2 in intervention participants and 0.6 in control participants (P = .04). CONCLUSIONS Recruitment of former inmates into an RCT of patient navigation was highly feasible, but follow-up was limited by rearrests. Results suggest a significantly lower rate of hospitalizations among navigation participants, although the rate of emergency department/urgent care visits was not improved. Patient navigation is a promising, pragmatic intervention that may be effective at reducing high-cost health care utilization in former prison inmates.
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Affiliation(s)
- Ingrid A Binswanger
- a Division of General Internal Medicine , University of Colorado School of Medicine , Aurora , Colorado , USA
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Calcaterra SL, Beaty B, Mueller SR, Min SJ, Binswanger IA. The association between social stressors and drug use/hazardous drinking among former prison inmates. J Subst Abuse Treat 2014; 47:41-9. [PMID: 24642070 DOI: 10.1016/j.jsat.2014.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 02/11/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
Social stressors are associated with relapse to substance use among people receiving addiction treatment and people with substance use risk behaviors. The relationship between social stressors and drug use/hazardous drinking in former prisoners has not been studied. We interviewed former prisoners at baseline, 1 to 3 weeks post prison release, and follow up, between 2 and 9 months following the baseline interview. Social stressors were characterized by unemployment, homelessness, unstable housing, problems with family, friends, and/or significant others, being single, or major symptoms of depression. Associations between baseline social stressors and follow-up drug use and hazardous drinking were analyzed using multivariable logistic regression. Problems with family, friends, and/or significant others were associated with reported drug use (AOR 3.01, 95% CI 1.18-7.67) and hazardous drinking (AOR 2.69, 95% CI 1.05-6.87) post release. Further research may determine whether interventions and policies targeting social stressors can reduce relapse among former inmates.
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Affiliation(s)
- Susan L Calcaterra
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO; Denver Health Medical Center, Denver, CO.
| | - Brenda Beaty
- Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Children's Outcomes Research Program, Children's Hospital Colorado, Aurora, Colorado
| | - Shane R Mueller
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Sung-Joon Min
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO
| | - Ingrid A Binswanger
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO; Denver Health Medical Center, Denver, CO; Children's Outcomes Research Program, Children's Hospital Colorado, Aurora, Colorado; Division of Substance Dependence, University of Colorado School of Medicine, Aurora, CO
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Tanaka T, Doe JM, Horstmann SA, Ahmad S, Ahmad A, Min SJ, Reynolds PR, Suram S, Gaydos J, Burnham EL, Vandivier RW. Neuroendocrine signaling via the serotonin transporter regulates clearance of apoptotic cells. J Biol Chem 2014; 289:10466-10475. [PMID: 24570000 DOI: 10.1074/jbc.m113.482299] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Serotonin (5-hydroxytryptamine; 5-HT) is a CNS neurotransmitter increasingly recognized to exert immunomodulatory effects outside the CNS that contribute to the pathogenesis of autoimmune and chronic inflammatory diseases. 5-HT signals to activate the RhoA/Rho kinase (ROCK) pathway, a pathway known for its ability to regulate phagocytosis. The clearance of apoptotic cells (i.e. efferocytosis) is a key modulator of the immune response that is inhibited by the RhoA/ROCK pathway. Because efferocytosis is defective in many of the same illnesses where 5-HT has been implicated in disease pathogenesis, we hypothesized that 5-HT would suppress efferocytosis via activation of RhoA/ROCK. The effect of 5-HT on efferocytosis was examined in murine peritoneal and human alveolar macrophages, and its mechanisms were investigated using pharmacologic blockade and genetic deletion. 5-HT impaired efferocytosis by murine peritoneal macrophages and human alveolar macrophages. 5-HT increased phosphorylation of myosin phosphatase subunit 1 (Mypt-1), a known ROCK target, and inhibitors of RhoA and ROCK reversed the suppressive effect of 5-HT on efferocytosis. Peritoneal macrophages expressed the 5-HT transporter and 5-HT receptors (R) 2a, 2b, but not 2c. Inhibition of 5-HTR2a and 5-HTR2b had no effect on efferocytosis, but blockade of the 5-HT transporter prevented 5-HT-impaired efferocytosis. Genetic deletion of the 5-HT transporter inhibited 5-HT uptake into peritoneal macrophages, prevented 5-HT-induced phosphorylation of Mypt-1, reversed the inhibitory effect of 5-HT on efferocytosis, and decreased cellular peritoneal inflammation. These results suggest a novel mechanism by which 5-HT might disrupt efferocytosis and contribute to the pathogenesis of autoimmune and chronic inflammatory diseases.
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Affiliation(s)
- Takeshi Tanaka
- COPD Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Jenna M Doe
- COPD Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Sarah A Horstmann
- COPD Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Shama Ahmad
- Pediatric Airway Research Center, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Aftab Ahmad
- Pediatric Airway Research Center, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Sung-Joon Min
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Paul R Reynolds
- Department of Pediatrics, Division of Cell Biology, National Jewish Health, Denver, Colorado 80206
| | - Saritha Suram
- COPD Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Jeanette Gaydos
- COPD Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - Ellen L Burnham
- COPD Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045
| | - R William Vandivier
- COPD Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045.
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Glasgow RE, Hawn MT, Hosokawa PW, Henderson WG, Min SJ, Richman JS, Tomeh MG, Campbell D, Neumayer LA. Comparison of prospective risk estimates for postoperative complications: human vs computer model. J Am Coll Surg 2013; 218:237-45.e1-4. [PMID: 24440066 DOI: 10.1016/j.jamcollsurg.2013.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 10/23/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk. STUDY DESIGN This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes. RESULTS The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity. CONCLUSIONS Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications.
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Affiliation(s)
| | - Mary T Hawn
- Department of Surgery, University of Alabama, Birmingham, AL
| | | | | | - Sung-Joon Min
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Majed G Tomeh
- University of Colorado Health Outcomes Program, Aurora, CO
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Thurstone C, Salomonsen-Sautel S, Mikulich-Gilbertson SK, Hartman CA, Sakai JT, Hoffenberg AS, McQueen MB, Min SJ, Crowley TJ, Corley RP, Hewitt JK, Hopfer CJ. Prevalence and predictors of injection drug use and risky sexual behaviors among adolescents in substance treatment. Am J Addict 2013; 22:558-65. [PMID: 24131163 DOI: 10.1111/j.1521-0391.2013.12064.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 09/26/2012] [Accepted: 10/08/2012] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The longitudinal risk for human immunodeficiency virus (HIV) infection following adolescent substance treatment is not known. Therefore, it is not known if adolescent substance treatment should include HIV prevention interventions. To address this important research gap, this study evaluates the longitudinal prevalence and predictors of injection drug use (IDU) and sex risk behaviors among adolescents in substance treatment. METHODS Participants were 260 adolescents (13-18 years) in substance treatment and 201 community control adolescents (11-19 years). Participants were assessed at baseline and follow-up (mean time between assessments = 6.9 years for the clinical sample and 5.6 years for the community control sample). Outcomes included self-report lifetime history of IDU, number of lifetime sex partners and frequency of unprotected sexual intercourse. RESULTS At baseline, 7.5% of the clinical sample, compared to 1.0% of the community control sample had a lifetime history of IDU (χ12=10.53, p = .001). At follow-up, 17.4% of the clinical sample compared to 0% of the community control sample had a lifetime history of IDU (χ12=26.61, p = .0005). The number of baseline substance use disorders and onset age of marijuana use significantly predicted the presence of lifetime IDU at follow-up, after adjusting for baseline age, race, and sex. The clinical sample reported more lifetime sex partners and more frequent unprotected sex than the community control sample at baseline and follow-up. CONCLUSIONS Many adolescents in substance treatment develop IDU and report persistent risky sex. Effective risk reduction interventions for adolescents in substance treatment are needed that address both IDU and risky sex.
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Affiliation(s)
- Christian Thurstone
- Denver Health and Hospital Authority, Denver, Colorado; University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Hopfer C, Salomonsen-Sautel S, Mikulich-Gilbertson S, Min SJ, McQueen M, Crowley T, Young S, Corley R, Sakai J, Thurstone C, Hoffenberg A, Hartman C, Hewitt J. Conduct disorder and initiation of substance use: a prospective longitudinal study. J Am Acad Child Adolesc Psychiatry 2013; 52:511-518.e4. [PMID: 23622852 PMCID: PMC3813459 DOI: 10.1016/j.jaac.2013.02.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 02/22/2013] [Accepted: 02/28/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine the influence of conduct disorder (CD) on substance use initiation. METHOD Community adolescents without CD (n = 1,165, mean baseline age = 14.6 years), with CD (n = 194, mean baseline age = 15.3 years), and youth with CD recruited from treatment (n = 268, mean baseline age = 15.7 years) were prospectively followed and re-interviewed during young adulthood (mean ages at follow-up respectively: 20, 20.8, and 24). Young adult retrospective reports of age of substance initiation for 10 substance classes were analyzed using Cox regression analyses. Hazard ratios of initiation for the CD cohorts (community without CD as the reference) at ages 15, 18, and 21 were calculated, adjusting for baseline age, gender, and race/ethnicity. RESULTS Among community subjects, CD was associated with elevated adjusted hazards for initiation of all substances, with comparatively greater hazard ratios of initiating illicit substances at age 15 years. By age 18, the adjusted hazard ratios remained significant except for alcohol. At age 21, the adjusted hazard ratios were significant only for cocaine, amphetamines, inhalants, and club drugs. A substantial portion of community subjects without CD never initiated illicit substance use. Clinical youth with CD demonstrated similar patterns, with comparatively larger adjusted hazard ratios. CONCLUSIONS CD confers increased risk for substance use initiation across all substance classes at age 15 years, with greater relative risk for illicit substances compared to licit substances. This effect continues until age 18 years, with the weakest effect for alcohol. It further diminishes for other substances by age 21, However, the likelihood of initiating cocaine, amphetamines, inhalants and club drug use among those who have not initiated yet continues to be highly elevated by age 21.
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Affiliation(s)
- Christian Hopfer
- Division of Substance Dependence, Department of Psychiatry, University of Colorado Denver, Building 400, 12469 East 17th Place, Aurora, CO 80045, USA.
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Fischer S, Min SJ, Cervantes L, Kutner J. Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults. J Hosp Med 2013; 8:178-83. [PMID: 23440934 PMCID: PMC4705849 DOI: 10.1002/jhm.2018] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 11/29/2012] [Accepted: 01/03/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Death in the U.S. frequently occurs in institutions despite the overwhelming majority of persons who state that they prefer to die at home. Little research to date has examined how well individual preferences compare to actual site of death. OBJECTIVES Determine the concordance between preferred and actual place of death and examine independent predictors for concordance. DESIGN Observational cohort study. SETTING Three area hospitals including a safety net hospital, veterans' hospital, and academic tertiary referral center. PATIENTS 458 adult patients admitted to the general medical service from 2003-2005. MEASUREMENTS Patients were asked where they preferred to spend their last days of life. Data on date and actual site of death from 2005-2009 was collected from hospital records and death certificates. RESULTS The majority of patients preferred to die at home (75% n = 343). Low income and being married were significantly associated with a preference to die at home compared to nursing home or inpatient hospice (OR 2.71 95% CI 1.30-5.67 and OR 2.44 95% CI 1.14-5.21 respectively). Of the 123 patients who died during the follow up period, most (66% n = 80) died in an institutional setting. Overall concordance between preferred and actual site of death was only 37% (n = 41). Female gender was significantly associated with concordance between preferred and actual site of death (OR 3.30 95% CI 1.25-8.72). CONCLUSIONS Concordance between preferred and actual site of death is low and female gender was the sole patient level variable associated with concordance.
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Affiliation(s)
- Stacy Fischer
- Division of General Internal Medicine, University of Colorado Denver School of Medicine, Denver, Colorado 80045, USA.
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Coleman EA, Chugh A, Williams MV, Grigsby J, Glasheen JJ, McKenzie M, Min SJ. Understanding and Execution of Discharge Instructions. Am J Med Qual 2013; 28:383-91. [DOI: 10.1177/1062860612472931] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Amita Chugh
- University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Jim Grigsby
- University of Colorado Anschutz Medical Campus, Aurora, CO
- University of Colorado Denver, Denver, CO
| | | | | | - Sung-Joon Min
- University of Colorado Anschutz Medical Campus, Aurora, CO
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Borucinska JD, Obasa OA, Haffey NM, Scott JP, Williams LN, Baker SM, Min SJ, Kaplan A, Mudimala R. Morphological features of coronary arteries and lesions in hearts from five species of sharks collected from the northwestern Atlantic Ocean. J Fish Dis 2012; 35:741-753. [PMID: 22882583 DOI: 10.1111/j.1365-2761.2012.01405.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 06/25/2012] [Accepted: 04/30/2012] [Indexed: 06/01/2023]
Abstract
Morphological features of coronary arteries and incidental lesions are reported from hearts in five species of sharks, the shortfin mako shark, Isurus oxyrhinchus Rafinesque, thresher shark Alopias vulpinus (Bonaterre), blue shark, Prionace glauca L., the smooth dogfish, Mustelus canis (Mitchill), and spiny dogfish, Squalus acanthias L. Sharks were collected from the northwestern Atlantic between June and August from 1996 to 2010. They were necropsied dockside and the hearts were preserved in buffered formalin. Routine sections including ventricle/conus arteriosus and the atrio-ventricular junctions were embedded in paraffin, stained with common histological and immunohistochemical methods and examined by brightfield microscopy. Myointimal hyperplasia, medial myo-myxomatous hyperplasia and bifurcation pads were observed commonly, and medial muscle reorientation and epicardial myeloid tissues were rare. All the above features differed in severity, prevalence and distribution depending on anatomical site and shark species/size. Morphometric analysis indicated that myomyxomatous hyperplasia is associated with luminal narrowing of blood vessels. As suggested previously, the described morphological features are most likely physiological responses to blood flow characteristics. Vascular and cardiac lesions were uncommon and included, granulomatous proliferative epicarditis with fibroepitheliomas, myxomatous epicardial expansions, medial arterial vacuolation, myocardial fibrosis, acute ventricular emboli and parasitic granulomas. The lesions of embolism, proliferative and granulomatous epicarditis and myocardial fibrosis were in all sharks associated with capture events including retained fishing hooks. The significance and aetiopathogenesis of medial vacuolation and epicardial myxomatous expansions remains unclear.
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Affiliation(s)
- J D Borucinska
- Department of Biology, University of Hartford, West Hartford, CT 06117-1559, USA.
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Richman JS, Hosokawa PW, Min SJ, Tomeh MG, Neumayer L, Campbell DA, Henderson WG, Hawn MT. Toward prospective identification of high-risk surgical patients. Am Surg 2012; 78:755-760. [PMID: 22748533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: "low" risk corresponding to the bottom quartile, "average" to the middle two quartiles, and "high" to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of "high-risk" patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.
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Affiliation(s)
- Joshua S Richman
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama 35222, USA.
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Richman JS, Hosokawa PW, Min SJ, Tomeh MG, Neumayer L, Campbell DA, Henderson WG, Hawn MT. Toward Prospective Identification of High-Risk Surgical Patients. Am Surg 2012. [DOI: 10.1177/000313481207800713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: “low” risk corresponding to the bottom quartile, “average” to the middle two quartiles, and “high” to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of “high-risk” patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.
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Affiliation(s)
- Joshua S. Richman
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
- Division of General Surgery, Gastrointestinal Section, University of Alabama School of Medicine, Birmingham, Alabama
| | - Patrick W. Hosokawa
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
| | - Sung-Joon Min
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
| | | | | | | | - William G. Henderson
- Colorado Health Outcomes Program, School of Medicine, University of Colorado Denver, Denver, Colorado
- Department of Biostatistics & Informatics, School of Public Health, University of Colorado Denver, Denver, Colorado
| | - Mary T. Hawn
- C-SMART, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
- Division of General Surgery, Gastrointestinal Section, University of Alabama School of Medicine, Birmingham, Alabama
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Linderman DJ, Koff PB, Freitag TJ, Min SJ, Vandivier RW. Effect of integrated care on advanced chronic obstructive pulmonary disease in high-mortality rural areas. ACTA ACUST UNITED AC 2012; 171:2059-61. [PMID: 22158579 DOI: 10.1001/archinternmed.2011.576] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
BACKGROUND Previous studies have shown that minority populations have low rates of documented advance directives and express preferences for more life-prolonging interventions at the end of life. We sought to determine the impact of Latino ethnicity on patients' self-report of having an advance directive discussion and having a completed advance directive in the medical record at an index hospitalization for serious medical illness. METHODS This was a prospective observational cohort study of 458 adults admitted to the general medical services of a safety net hospital, an academic medical center, and a Veterans' Affairs (VA) hospital. Patients were asked if they had discussed advance directives, and we reviewed medical records for documented advance directives. RESULTS Overall, 45% of patients reported having had a discussion about advance directives (29% of Latinos compared with 54% of Caucasians, p=0.0002) and 24% of patients had a completed advance directive in their medical record (25% Latinos and 26% of Caucasians, p=not significant [ns]). Using logistic regression modeling and adjusting for socioeconomic status (SES), education level, and language spoken, Latinos (odds ratio [OR] 0.42, confidence interval [CI] 0.24-0.75) were less likely to report having advance directive discussions compared with Caucasians (referent). However, modeling of a completed advance directive in the medical record showed no significant difference between Latinos (OR 1.44, CI 0.73-2.85) and Caucasians (referent). CONCLUSIONS The unexpected discrepancy we found highlights the need for more effective communication in advance care planning that includes education that is culturally sensitive and accessible to persons with low health literacy.
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Affiliation(s)
- Stacy M Fischer
- Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Aurora, Colorado 80045-7201, USA.
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Corsi KF, Lehman WE, Min SJ, Lance SP, Speer N, Booth RE, Shoptaw S. The Feasibility of Interventions to Reduce HIV Risk and Drug Use among Heterosexual Methamphetamine Users. ACTA ACUST UNITED AC 2012; S1. [PMID: 23493796 DOI: 10.4172/2155-6113.s1-010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This paper reports on a feasibility study that examined contingency management among out-of-treatment, heterosexual methamphetamine users and the reduction of drug use and HIV risk. Fifty-eight meth users were recruited through street outreach in Denver from November 2006 through March 2007. The low sample size reflects that this was a pilot study to see if CM is feasible in an out-of-treatment, street-recruited population of meth users. Secondary aims were to examine if reductions and drug use and risk behavior could be found. Subjects were randomly assigned to contingency management (CM) or CM plus strengths-based case management (CM/SBCM), with follow-up at 4 and 8 months. Participants were primarily White (90%), 52% male and averaged 38 years old. Eighty-three percent attended at least one CM session, with 29% attending at least fifteen. All participants reduced meth use significantly at follow-up. Those who attended more sessions submitted more stimulant-free urines than those who attended fewer sessions. Participants assigned to CM/SBCM attended more sessions and earned more vouchers than clients in CM. Similarly, participants reported reduced needle-sharing and sex risk. Findings demonstrate that CM and SBCM may help meth users reduce drug use and HIV risk.
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Affiliation(s)
- Karen F Corsi
- University of Colorado Denver School of Medicine, Denver, CO 80206, USA
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Fischer SM, Min SJ, Sauaia A, Kutner JS. "They're going to unplug grandma": advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death. J Hosp Med 2012; 7:3-7. [PMID: 21960524 DOI: 10.1002/jhm.930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 03/23/2011] [Accepted: 03/28/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the effect of having advance directive (AD) discussions or having an AD in the medical record on patient survival. DESIGN Prospective observational cohort study. SETTING Three Colorado area hospitals: a large academic tertiary referral center, a Veteran's Affairs medical center, and an urban safety net hospital. PARTICIPANTS Four hundred fifty-eight adults admitted to the general internal medicine service interviewed about AD discussions. A concurrent chart review documented the presence of an AD in the medical record. Participants were stratified into low, medium, and high risk of death within 1 year based on validated prognostic criteria. MEASURES Kaplan-Meier survival plots were estimated for those at low and medium risk of death. RESULTS No significant differences in survival for participants at low and medium risk of death who reported having had an AD discussion and those who had not (Wilcoxon low risk, P = 0.97; medium risk, P = 0.28; and log-rank low risk, P = 0.82; medium risk, P = 0.45), and for those who had an AD in the medical record vs those who did not (Wilcoxon low risk, P = 0.84; medium risk, P = 0.78; and log-rank low risk, P = 0.86; medium risk, P = 0.69). CONCLUSIONS There is no evidence that AD discussions or documentation result in increased mortality. In regards to the current national debate about the merits of advance care planning, this study suggests that honoring patients' wishes to engage in AD discussions and documentation does not lead to harm.
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Affiliation(s)
- Stacy M Fischer
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.
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Warden D, Riggs PD, Min SJ, Mikulich-Gilbertson SK, Tamm L, Trello-Rishel K, Winhusen T. Major depression and treatment response in adolescents with ADHD and substance use disorder. Drug Alcohol Depend 2012; 120:214-9. [PMID: 21885210 PMCID: PMC3245790 DOI: 10.1016/j.drugalcdep.2011.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 07/28/2011] [Accepted: 08/02/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) frequently co-occurs in adolescents with substance use disorders (SUDs) and attention deficit hyperactivity disorder (ADHD), but the impact of MDD on substance treatment and ADHD outcomes and implications for clinical practice are unclear. METHODS Adolescents (n=303; ages 13-18) meeting DSM-IV criteria for ADHD and SUD were randomized to osmotic release methylphenidate (OROS-MPH) or placebo and 16 weeks of cognitive behavioral therapy (CBT). Adolescents with (n=38) and without (n=265) MDD were compared on baseline demographic and clinical characteristics as well as non-nicotine substance use and ADHD treatment outcomes. RESULTS Adolescents with MDD reported more non-nicotine substance use days at baseline and continued using more throughout treatment compared to those without MDD (p<0.0001 based on timeline followback; p<0.001 based on urine drug screens). There was no difference between adolescents with and without MDD in retention or CBT sessions attended. ADHD symptom severity (based on DSM-IV ADHD rating scale) followed a slightly different course of improvement although with no difference between groups in baseline or 16-week symptom severity or 16-week symptom reduction. There was no difference in days of substance use or ADHD symptom outcomes over time in adolescents with MDD or those without MDD treated with OROS-MPH or placebo. Depressed adolescents were more often female, older, and not court ordered. CONCLUSIONS These preliminary findings suggest that compared to non-depressed adolescents with ADHD and SUD, those with co-occurring MDD have more severe substance use at baseline and throughout treatment. Such youth may require interventions targeting depression.
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Affiliation(s)
- Diane Warden
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390-9119, United States.
| | | | - Sung-Joon Min
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | | | - Leanne Tamm
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center
| | | | - Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine
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Ciemins E, Coon P, Peck R, Holloway B, Min SJ. Using telehealth to provide diabetes care to patients in rural Montana: findings from the promoting realistic individual self-management program. Telemed J E Health 2011; 17:596-602. [PMID: 21859347 PMCID: PMC3208251 DOI: 10.1089/tmj.2011.0028] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 03/23/2011] [Accepted: 03/25/2011] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE The objectives of this study were to demonstrate the feasibility of telehealth technology to provide a team approach to diabetes care for rural patients and determine its effect on patient outcomes when compared with face-to-face diabetes visits. MATERIALS AND METHODS An evaluation of a patient-centered interdisciplinary team approach to diabetes management compared telehealth with face-to-face visits on receipt of recommended preventive guidelines, vascular risk factor control, patient satisfaction, and diabetes self-management at baseline and 1, 2, and 3 years postintervention. RESULTS One-year postintervention the receipt of recommended dilated eye exams increased 31% and 43% among telehealth and face-to-face patients, respectively (p=0.28). Control of two or more risk factors increased 37% and 69% (p=0.21). Patient diabetes care satisfaction rates increased 191% and 131% among telehealth and face-to-face patients, respectively (p=0.51). A comparison of telehealth with face-to-face patients resulted in increased self-reported blood glucose monitoring as instructed (97% vs. 89%; p=0.63) and increased dietary adherence (244% vs. 159%; p=0.86), respectively. Receipt of a monofilament foot test showed a significantly greater improvement among face-to-face patients (17% vs. 35%; p=0.01) at 1 year postintervention, but this difference disappeared in years 2 and 3. CONCLUSIONS Telehealth proved to be an effective mode for the provision of diabetes care to rural patients. Few differences were detected in the delivery of a team approach to diabetes management via telehealth compared with face-to-face visits on receipt of preventive care services, vascular risk factor control, patient satisfaction, and patient self-management. A team approach using telehealth may be a viable strategy for addressing the unique challenges faced by patients living in rural communities.
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Affiliation(s)
- Elizabeth Ciemins
- Billings Clinic Center for Clinical Translational Research, Billings, Montana 59107, USA.
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Gray KM, Riggs PD, Min SJ, Mikulich-Gilbertson SK, Bandyopadhyay D, Winhusen T. Cigarette and cannabis use trajectories among adolescents in treatment for attention-deficit/hyperactivity disorder and substance use disorders. Drug Alcohol Depend 2011; 117:242-7. [PMID: 21411243 PMCID: PMC3128687 DOI: 10.1016/j.drugalcdep.2011.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/10/2011] [Accepted: 02/10/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cigarette smoking is common in adolescents with attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUD). However, little is known about the relationship between cigarette and cannabis use trajectories in the context of treatment for both ADHD and SUD. To address this research gap, we report collateral analyses from a 16-week randomized, controlled trial (n=303) of osmotic-release methylphenidate (OROS-MPH) in adolescents with ADHD concurrently receiving cognitive behavioral therapy (CBT) targeting non-nicotine SUD. METHODS Participants completed cigarette and cannabis use self-report at baseline and throughout treatment. Analyses were performed to explore the relationships between cigarette smoking, cannabis use, and other factors, such as medication treatment assignment (OROS-MPH versus placebo). RESULTS Baseline (pre-treatment) cigarette smoking was positively correlated with cannabis use. Negligible decline in cigarette smoking during treatment for non-nicotine SUD was observed in both medication groups. Regular cigarette and cannabis users at baseline who reduced their cannabis use by >50% also reduced cigarette smoking (from 10.8±1.1 to 6.2±1.1 cigarettes per day). CONCLUSIONS Findings highlight the challenging nature of concurrent cannabis and cigarette use in adolescents with ADHD, but demonstrate that changes in use of these substances during treatment may occur in parallel.
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Affiliation(s)
- Kevin M. Gray
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,Corresponding Author: Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, MSC861, Charleston, South Carolina 29425, Telephone: (843) 792-6330, Facsimile: (843) 792-8206,
| | - Paula D. Riggs
- Department of Psychiatry, University of Colorado Anschutz Medical Campus
| | - Sung-Joon Min
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | | | | | - Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine
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Parry C, Min SJ, Chugh A, Chalmers S, Coleman EA. Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-For-Service Setting. Home Health Care Serv Q 2009; 28:84-99. [DOI: 10.1080/01621420903155924] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ciemins EL, Holloway B, Coon PJ, McClosky-Armstrong T, Min SJ. Telemedicine and the mini-mental state examination: assessment from a distance. Telemed J E Health 2009; 15:476-8. [PMID: 19548827 DOI: 10.1089/tmj.2008.0144] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The objective of this study was to determine the reliability of the Mini-Mental State Examination (MMSE) administration via telehealth with a focus on the auditory and visual test components. Reliability was assessed through use of an in-person collaborator and by assessment of faxed test copies. The MMSE was administered via telehealth with the assistance of a face-to-face collaborator. Patient responses were recorded by both the remote and in-person nurse and compared item by item; total scores for each subject were also compared. Visual items were assessed through a blinded separate scoring of a faxed copy. Percent agreement per item and total score were calculated and correlations between scores were determined by Pearson correlation coefficients. Mean score differences and associated 95% confidence intervals were calculated. Eighty percent of individual items demonstrated remote to in-person agreement of >95% and all items were >85.5% in agreement. Pearson correlation coefficients demonstrated high correlations (>0.86) between 80% of the items examined. Mean differences in scored test items were not significantly different from zero. This study demonstrates the utility of using telehealth for cognitive assessment by MMSE. It supports the use of telehealth to improve healthcare access among patients for whom distance, cost, and mobility are potential barriers to attending face-to-face clinical visits. Continued validation and reliability testing is warranted to ensure that all healthcare provided via telehealth maintains an equal quality level to that of in-person care.
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Affiliation(s)
- Elizabeth L Ciemins
- Billings Clinic-Center for Clinical Translational Research, Billings, MT 59107, USA.
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Denberg TD, Myers BA, Lin CT, Libby AM, Min SJ, McDermott MT, Steiner JF. An outreach intervention increases bone densitometry testing in older women. J Am Geriatr Soc 2009; 57:341-7. [PMID: 19207149 DOI: 10.1111/j.1532-5415.2008.02111.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the performance of a patient recall intervention that relies on an outreach coordinator with a bachelor's degree to prompt women by mail and telephone about their eligibility for bone densitometry (dual-energy X-ray absorptiometry (DXA)) screening and allow them to schedule an examination without a medical provider visit ahead of time. DESIGN Observational. SETTING Academic general internal medicine practice. INTERVENTION Mail- and telephone-based patient recall for DXA. PARTICIPANTS Five hundred sixty-four women aged 65 to 79 at average risk for osteoporosis without a history of DXA. MEASUREMENTS Rates of DXA completion and the change in proportion of screened women during a 7-month intervention period, case finding for clinically significant bone loss, frequency of appropriate clinical follow-up, DXA no-show rates compared with usual care, and clinician satisfaction. RESULTS Through patient recall, rates of DXA screening rose significantly (P<.001), and the proportion of the eligible clinic population screened increased 13%. Thirty percent of patients had clinically significant bone loss, with almost all of these receiving follow-up. DXA no-show rates were comparable with usual care, and provider acceptance was high. CONCLUSION A patient recall intervention substantially increased DXA screening, allowing pharmacological therapy to be started much earlier in some women with significant bone loss. It imposed minimal burden on providers and enhanced patient convenience. This type of program may have utility for additional preventive services.
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Affiliation(s)
- Thomas D Denberg
- Department of Medicine, University of Colorado Denver Anschutz Medical Campus, Auora, USA.
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Leehey MA, Berry-Kravis E, Min SJ, Hall DA, Rice CD, Zhang L, Grigsby J, Greco CM, Reynolds A, Lara R, Cogswell J, Jacquemont S, Hessl DR, Tassone F, Hagerman R, Hagerman PJ. Progression of tremor and ataxia in male carriers of the FMR1 premutation. Mov Disord 2007; 22:203-6. [PMID: 17133502 DOI: 10.1002/mds.21252] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Premutation alleles of the fragile X mental retardation 1 (FMR1) gene give rise to a late-onset movement disorder, fragile X-associated tremor/ataxia syndrome (FXTAS), characterized by progressive intention tremor and gait ataxia, with associated dementia and global brain atrophy. The natural history of FXTAS is largely unknown. To address this issue, a family-based, retrospective, longitudinal study was conducted with a cohort of 55 male premutation carriers. Analysis of the progression of the major motor signs of FXTAS, tremor and ataxia, shows that tremor usually occurs first, with median onset at approximately 60 years of age. From the onset of the initial motor sign, median delay of onset of ataxia was 2 years; onset of falls, 6 years; dependence on a walking aid, 15 years; and death, 21 years. Preliminary data on life expectancy are variable, with a range from 5 to 25 years.
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Affiliation(s)
- Maureen A Leehey
- Department of Neurology, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80262, USA.
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Abstract
BACKGROUND Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates. METHODS Randomized controlled trial. Between September 1, 2002, and August 31, 2003, patients were identified at the time of hospitalization and were randomized to receive the intervention or usual care. The setting was a large integrated delivery system located in Colorado. Subjects (N = 750) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions. Intervention patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care and to assert their preferences, and (3) continuity across settings and guidance from a "transition coach." Rates of rehospitalization were measured at 30, 90, and 180 days. RESULTS Intervention patients had lower rehospitalization rates at 30 days (8.3 vs 11.9, P = .048) and at 90 days (16.7 vs 22.5, P = .04) than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days (5.3 vs 9.8, P = .04) and at 180 days (8.6 vs 13.9, P = .046) than controls. The mean hospital costs were lower for intervention patients ($2058) vs controls ($2546) at 180 days (log-transformed P = .049). CONCLUSION Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.
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Affiliation(s)
- Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver, USA.
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Fischer SM, Gozansky WS, Sauaia A, Min SJ, Kutner JS, Kramer A. A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria. J Pain Symptom Manage 2006; 31:285-92. [PMID: 16632076 DOI: 10.1016/j.jpainsymman.2005.08.012] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2005] [Indexed: 11/19/2022]
Abstract
Palliative care is often offered only late in the course of disease after curative measures have been exhausted. To provide timelier symptom management, advance care planning, and spiritual support, we propose a simple set of prognostic criteria that identifies persons near the end of life. In this retrospective cohort study of five prognostic indicators, the CARING criteria (Cancer, Admissions > or = 2, Residence in a nursing home, Intensive care unit admit with multiorgan failure, > or = 2 Noncancer hospice Guidelines), logistic regression modeling demonstrated high sensitivity and specificity for mortality at 1 year (c statistic > 0.8). A simple set of clinically relevant criteria applied at the time of hospital admission can identify seriously ill persons who have a high likelihood of death in 1 year and, therefore, may benefit the most from incorporating palliative measures into the plan of care.
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Affiliation(s)
- Stacy M Fischer
- Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver, Colorado 80206, USA.
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Luke B, Hediger M, Min SJ, Brown MB, Misiunas RB, Gonzalez-Quintero VH, Nugent C, Witter FR, Newman RB, Hankins GDV, Grainger DA, Macones GA. Gender mix in twins and fetal growth, length of gestation and adult cancer risk. Paediatr Perinat Epidemiol 2005; 19 Suppl 1:41-7. [PMID: 15670121 DOI: 10.1111/j.1365-3016.2005.00616.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study evaluated the effect of gender mix (the gender combinations of twin pairs) on fetal growth and length of gestation, and reviewed the literature on the long-term effects of this altered fetal milieu on cancer risk. In singletons, it is well established that females weigh less than males at all gestations, averaging 125-135 g less at full term. This gender difference is generally believed to be the result of the effect of androgens on fetal growth. The gender difference in fetal growth is greater before the third trimester and less towards term, with males growing not only more, but also earlier than females. Plurality is a known risk factor for reduced fetal growth and birthweight. Compared with singletons, the mean birthweight percentiles of twins fall substantially (by 10% or more) below the singleton 10th percentile by 28 weeks, below the singleton 50th percentile by 30 weeks, and below the singleton 90th percentile by 34 weeks. In unlike-gender twin pairs, it has been reported that the female prolongs gestation for her brother, resulting in a higher birthweight for the male twin than that of like-gender male twins. Other researchers have demonstrated that females in unlike-gender pairs had higher birthweights than females in like-gender pairs. Analyses from our consortium on 2491 twin pregnancies with known chorionicity showed longer gestations and faster rates of fetal growth in both males and females in unlike-gender pairs compared with like-gender male or female pairs, although these differences were not statistically significant. The post-natal effects for females growing in an androgenic-anabolic environment include increased sensation-seeking behaviour and aggression, lowered visual acuity, more masculine attitudes and masculinising effects of the auditory system and craniofacial growth. In contrast, there is no evidence to suggest that there might be a similar feminising effect on males from unlike-gender pairs. This hormonal exposure in utero may influence adult body size and susceptability to breast cancer.
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Affiliation(s)
- Barbara Luke
- Department of Epidemiology and Public Health, University of Miami School of Medicine, Miami, FL, USA.
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Smith JD, Coleman EA, Min SJ. A new tool for identifying discrepancies in postacute medications for community-dwelling older adults. ACTA ACUST UNITED AC 2004; 2:141-7. [PMID: 15555490 DOI: 10.1016/s1543-5946(04)90019-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite a national focus on the problem of medication safety, few studies have examined the frequency, causes, and factors contributing to discrepancies between the medications prescribed in acute care settings and what elderly patients (age>or=65 years) actually take after their discharge. OBJECTIVE The aims of this study were to develop a new instrument, the Medication Discrepancy Tool (MDT), for use by multiple practitioners across the continuum of care and to assess the MDT's reliability among nurses, pharmacists, and physicians, all of whom play a part in the formulation and administration of medication regimens for patients in transition. METHODS The study was conducted in a vertically integrated health care system and at a geriatric clinic in an academic health center. We applied the MDT to a series of 20 clinical vignettes based on actual cases involving older patients discharged from a community hospital to home. The interrater reliability of the MDT was assessed by asking clinicians (2 home health care nurses, 2 doctoral-trained geriatric pharmacists, and 2 physicians) to use this tool to rate the clinical vignettes. Reliability comparisons were then made within and across clinical disciplines. Intrarater reliability was also determined. RESULTS Across all 3 clinical disciplines, the mean interrater reliability (kappa) for the 20 vignettes was 0.56 (15% low agreement, 80% good agreement, and 5% excellent agreement). Within disciplines, the kappa statistic was as follows: nurses, 0.68; pharmacists, 0.50; and physicians, 0.64. Intrarater reliability ranged from 0.58 to 0.69. CONCLUSIONS By capturing transition-related medication discrepancies, the MDT fills an important gap in national efforts to promote patient safety. MDT items are actionable at both the patient and system level, suggesting that this tool could be used to foster continuous quality improvement efforts.
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Affiliation(s)
- Jodi D Smith
- Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver, CO, USA.
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Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc 2004; 52:1817-25. [PMID: 15507057 DOI: 10.1111/j.1532-5415.2004.52504.x] [Citation(s) in RCA: 408] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates. DESIGN Quasi-experimental design whereby subjects receiving the intervention (n=158) were compared with control subjects derived from administrative data (n=1,235). SETTING A large integrated delivery system in Colorado. PARTICIPANTS Community-dwelling adults aged 65 and older admitted to the study hospital with one of nine selected conditions. INTERVENTION Intervention subjects received tools to promote cross-site communication, encouragement to take a more active role in their care and assert their preferences, and continuity across settings and guidance from a transition coach. MEASUREMENTS Rates of postdischarge hospital use at 30, 60, and 90 days. Intervention subjects' care experience was assessed using the care transitions measure. RESULTS The adjusted odds ratio comparing rehospitalization of intervention subjects with that of controls was 0.52 (95% confidence interval (CI)=0.28-0.96) at 30 days, 0.43 (95% CI=0.25-0.72) at 90 days, and 0.57 (95% CI=0.36-0.92) at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen. CONCLUSION Supporting patients and caregivers to take a more active role during care transitions appears promising for reducing rates of subsequent hospitalization. Further testing may include more diverse populations and patients at risk for transitions who are not acutely ill.
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Affiliation(s)
- Eric A Coleman
- Division of Health Care Policy and Research, and Geriatric Medicine, University of Colorado Health Sciences Center, 13611 East Colfax Avenue, Aurora, CO 80011, USA.
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