Treatment Effect Estimates From Pilot Trials Are Unreliable

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Experiential Learning Methods for Biostatistics Students: A Model for Embedding Student Interns in Academic Health Centers

This manuscript describes an experiential learning program for future collaborative biostatisticians (CBs) developed within an academic medical center. The program is a collaborative effort between the Biostatistics, Epidemiology, and Research Design (BERD) Methods Core and the Master of Biostatistics (MB) program, both housed in the Department of Biostatistics and Bioinformatics at Duke University School of Medicine and supported in partnership with the Duke Clinical and Translational Science Institute. To date, the BERD Core Training and Internship Program (BCTIP) has formally trained over 80 students to work on collaborative teams that are integrated throughout the Duke School of Medicine. This manuscript focuses on the setting for the training program, the experiential learning model on which it is based, the structure of the program, and lessons learned to date.

Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management

OBJECTIVE

We evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI.

METHODS

Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009-2013.

RESULTS

Participants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was - 3.97 and - 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, -10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%).

CONCLUSIONS

The main effects were not statistically significant.

PRACTICAL IMPLICATIONS

Completing the full dose of the intervention may be essential to experience the intervention effect.

CLINICAL TRIAL REGISTRATION

The unique identifier is NCT00901277 (http://www.

CLINICALTRIALS

gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).

Methods for training collaborative biostatisticians

The emphasis on team science in clinical and translational research increases the importance of collaborative biostatisticians (CBs) in healthcare. Adequate training and development of CBs ensure appropriate conduct of robust and meaningful research and, therefore, should be considered as a high-priority focus for biostatistics groups. Comprehensive training enhances clinical and translational research by facilitating more productive and efficient collaborations. While many graduate programs in Biostatistics and Epidemiology include training in research collaboration, it is often limited in scope and duration. Therefore, additional training is often required once a CB is hired into a full-time position. This article presents a comprehensive CB training strategy that can be adapted to any collaborative biostatistics group. This strategy follows a roadmap of the biostatistics collaboration process, which is also presented. A TIE approach (Teach the necessary skills, monitor the Implementation of these skills, and Evaluate the proficiency of these skills) was developed to support the adoption of key principles. The training strategy also incorporates a "train the trainer" approach to enable CBs who have successfully completed training to train new staff or faculty.

Epidemiologic Trends in Clostridioides difficile Infections in a Regional Community Hospital Network

IMPORTANCE

Clostridioides difficile infection (CDI) remains a leading cause of health care facility-associated infection. A greater understanding of the regional epidemiologic profile of CDI could inform targeted prevention strategies.

OBJECTIVES

To assess trends in incidence of health care facility-associated and community-acquired CDI among hospitalized patients over time and to conduct a subanalysis of trends in the NAP1 strain of CDI over time.

DESIGN, SETTING, AND PARTICIPANTS

This long-term multicenter cohort study reviewed records of patients (N = 2 025 678) admitted to a network of 43 regional community hospitals primarily in the southeastern United States from January 1, 2013, through December 31, 2017. Generalized linear mixed-effects models were used to adjust for potential clustering within facilities and changing test method (nucleic acid amplification testing or toxin enzyme immunoassay) over time.

MAIN OUTCOMES AND MEASURES

Clostridioides difficile infection incidence rates were counted as cases per 1000 admissions for community-acquired and total CDI cases or cases per 10 000 patient-days for health care facility-associated CDI. Long-term trends in the proportion of cases acquired in the community and in NAP1 strain incidence were also evaluated.

RESULTS

A total of 2 025 678 admissions and 21 254 CDI cases were included (12 678 [59.6%] female; median [interquartile range] age, 69 [55-80] years). Median (interquartile range) total CDI incidence increased slightly from 7.9 (3.5-12.4) cases per 1000 admissions in 2013 to 9.3 (4.9-13.7) cases per 1000 admissions in 2017. After adjustment, the overall incidence of health care facility-associated CDI declined (incidence rate ratio [IRR], 0.995; 95% CI, 0.990-0.999; P = .03), whereas insufficient evidence was found for either an increase or a decrease in community-acquired CDI (IRR, 1.004; 95% CI, 0.999-1.009; P = .14). The proportion of cases classified as community acquired increased over time from a mean (SD) of 0.49 (0.28) in 2013 to 0.61 (0.26) in 2017 (odds ratio, 1.010 per month; 95% CI, 1.006-1.015; P < .001). Rates of the NAP1 strain of CDI varied widely between facilities, with no statistically significant change in NAP1 strain incidence over time in the community setting (IRR, 1.007; 95% CI, 0.994-1.021) or health care facility setting (IRR, 1.011; 95% CI, 0.990-1.032).

CONCLUSIONS AND RELEVANCE

The findings suggest that, despite the modest improvement in health care facility-associated CDI rates, a better understanding of community-acquired CDI incidence is needed for future infection prevention efforts.

A New Stress Test for Knee Joint Cartilage

Cartilage metabolism—both the synthesis and breakdown of cartilage constituents and architecture—is influenced by its mechanical loading. Therefore, physical activity is often recommended to maintain cartilage health and to treat or slow the progression of osteoarthritis, a debilitating joint disease causing cartilage degeneration. However, the appropriate exercise frequency, intensity, and duration cannot be prescribed because direct in vivo evaluation of cartilage following exercise has not yet been performed. To address this gap in knowledge, we developed a cartilage stress test to measure the in vivo strain response of healthy human subjects’ tibial cartilage to walking exercise. We varied both walk duration and speed in a dose-dependent manner to quantify how these variables affect cartilage strain. We found a nonlinear relationship between walk duration and in vivo compressive strain, with compressive strain initially increasing with increasing duration, then leveling off with longer durations. This work provides innovative measurements of cartilage creep behavior (which has been well-documented in vitro but not in vivo) during walking. This study showed that compressive strain increased with increasing walking speed for the speeds tested in this study (0.9–2.0 m/s). Furthermore, our data provide novel measurements of the in vivo strain response of tibial cartilage to various doses of walking as a mechanical stimulus, with maximal strains of 5.0% observed after 60 minutes of walking. These data describe physiological benchmarks for healthy articular cartilage behavior during walking and provide a much-needed baseline for studies investigating the effect of exercise on cartilage health.

Indications for and outcomes of therapeutic plasma exchange after cardiac transplantation: A single center retrospective study

INTRODUCTION

Limited data are available describing indications for and outcomes of therapeutic plasma exchange (TPE) in cardiac transplantation.

METHODS

In a retrospective study of patients who underwent cardiac transplantation at Duke University Medical Center from 2010 to 2014, we reviewed 3 TPE treatment patterns: a Single TPE procedure within 24 h of transplant; Multiple TPE procedures initiated within 24 h of transplant; and 1 or more TPE procedures beginning >24 h post-transplant. Primary and secondary outcomes were overall survival (OS) and TPE survival (TS), respectively.

RESULTS

Of 313 patients meeting study criteria, 109 (35%) underwent TPE. TPE was initiated in 82 patients within 24 h, 40 (37%) receiving a single procedure (Single TPE), and 42 (38%) multiple procedures (Multiple TPE). Twenty-seven (25%) began TPE >24 h after transplant (Delayed TPE). The most common TPE indication was elevated/positive panel reactive or human leukocyte antigen antibodies (32%). With a median follow-up of 49 months, the non-TPE treated and Single TPE cohorts had similar OS (HR 1.08 [CI, 0.54, 2.14], P = .84), while the Multiple and Delayed TPE cohorts had worse OS (HR 2.62 [CI, 1.53, 4.49] and HR 1.98 [CI, 1.02, 3.83], respectively). The Multiple and Delayed TPE cohorts also had worse TS (HR 2.59 [CI, 1.31, 5.14] and HR 3.18 [CI, 1.56, 6.50], respectively). Infection rates did not differ between groups but was independently associated with OS (HR 2.31 [CI, 1.50, 3.54]).

CONCLUSIONS

TPE is an important therapeutic modality in cardiac transplant patients. Prospective studies are needed to better define TPE's different roles in this patient population.

Outcome by Gender in the Veterans Health Administration Motivating Overweight/Obese Veterans Everywhere Weight Management Program

BACKGROUND

Few evaluations of the Veterans Health Administration Motivating Overweight/Obese Veterans Everywhere (MOVE!) weight management program have assessed 6-month weight change or factors associated with weight change by gender.

MATERIALS AND METHODS

Analysis of administrative data from a national sample of veterans in the VA MOVE!

PROGRAM

RESULTS

A total of 62,882 participants were included, 14.6% were women. Compared with men, women were younger (49.6 years [standard deviation, SD, 10.8] vs. 59.3 years [SD, 9.8], p < 0.0001), less likely to be married (34.1% vs. 56.0%, p < 0.0001), and had higher rates of post-traumatic stress disorder (26.0% vs. 22.4%, p < 0.0001) and depression (49.3% vs. 32.9%, p < 0.001). The mean number of MOVE! visits attended by women was lower than men (5.6 [SD, 5.3] vs. 6.0 [SD, 5.9], p < 0.0001). Women, compared with men, reported lower rates of being able to rely on family or friends (35.7% vs. 40.8%, p < 0.0001). Observed mean percent change in weight for women was -1.5% (SD, 5.2) and for men was -1.9% (SD, 4.8, p < 0.0001). The odds of ≥5% weight loss were no different for women (body-mass index [BMI] >25 kg/m²) compared with men (BMI >25 kg/m²; odds ratio, 1.05 [95% confidence interval, 0.99-1.11; p = 0.13]).

CONCLUSIONS

Women veterans lost less weight overall compared with men. There was no difference in the odds of achieving clinically significant weight loss by gender. The majority of women and men enrolled lost <5% weight despite being enrolled in a lifestyle intervention. Future studies should focus on identifying program- and participant-level barriers to weight loss.

The Symptom Experience in Rectal Cancer Survivors

CONTEXT

As the number of rectal cancer survivors grows, it is important to understand the symptom experience after treatment. Although data show that rectal cancer survivors experience a variety of symptoms after diagnosis, little has been done to study the way these symptoms are grouped and associated.

OBJECTIVES

To determine symptom prevalence and intensity in rectal cancer survivors and if clusters of survivors exist, who share similar symptom-defined survivor subgroups that may vary based on antecedent variables.

METHODS

A secondary analysis of the Cancer Care and Outcomes Research and Surveillance database was undertaken. Cluster analysis was performed on 15-month postdiagnosis data to form post-treatment survivor subgroups, and these were examined for differences in demographic and clinical characteristics. Data were analyzed using cluster analysis, chi-square, and analysis of variance.

RESULTS

A total of 275 rectal cancer survivors were included who had undergone chemotherapy, radiation therapy, and surgery. Most frequently reported symptoms included feeling "worn out" (87%), feeling "tired" (85%), and "trouble sleeping" (66%). Four symptom-defined survivor subgroups (minimally symptomatic n = 40, tired and trouble sleeping n = 138, moderate symptoms n = 42, and highly symptomatic n = 55) were identified with symptom differences existing among each subgroup. Age and being married/partnered were the only two antecedents found to differ across subgroups.

CONCLUSION

This study documents differences in the symptom experience after treatment. The identification of survivor subgroups allows researchers to further investigate tailored, supportive care strategies to minimize ongoing symptoms in those with the greatest symptom burden.

Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care

We compared the clinical outcomes after store-and-forward teledermatology with those following conventional clinic-based consultation. Subjects were randomized to either usual care (a conventional clinic-based dermatology appointment) or a store-and-forward teledermatology consultation. All subjects received baseline digital imaging and re-imaging was performed four months later. A total of 776 subjects were approached for inclusion, and a total of 508 image sets were reviewed, 236 in usual care and 272 in teledermatology. The image sets from both study arms were used to make clinical outcome assessments between baseline and four months. A dermatologist who was blinded to the randomization rated the clinical outcomes using a three-point clinical course rating scale (1 = improved, 2 = no change, 3 = worse). In the usual care group, 65% were rated as 'improved', 32% were rated as 'no change' and 3% were rated as 'worse'. For teledermatology, 64% were rated as 'improved', 33% as 'no change' and 4% as 'worse'. The results of the study indicate that store-and-forward teledermatology consultations produce similar clinical outcomes when compared with conventional clinic-based consultations.

Mobile health devices: will patients actually use them?

Although mobile health (mHealth) devices offer a unique opportunity to capture patient health data remotely, it is unclear whether patients will consistently use multiple devices simultaneously and/or if chronic disease affects adherence. Three healthy and three chronically ill participants were recruited to provide data on 11 health indicators via four devices and a diet app. The healthy participants averaged overall weekly use of 76%, compared to 16% for those with chronic illnesses. Device adherence declined across all participants during the study. Patients with chronic illnesses, with arguably the most to benefit from advanced (or increased) monitoring, may be less likely to adopt and use these devices compared to healthy individuals. Results suggest device fatigue may be a significant problem. Use of mobile technologies may have the potential to transform care delivery across populations and within individuals over time. However, devices may need to be tailored to meet the specific patient needs.

Impact of Smoking Cessation on Subsequent Pain Intensity Among Chronically Ill Veterans Enrolled in a Smoking Cessation Trial

CONTEXT

Prior cross-sectional studies have reported greater pain intensity among persistent smokers compared with nonsmokers or former smokers; yet, few prospective studies have examined how smoking abstinence affects pain intensity.

OBJECTIVES

To determine the impact of smoking cessation on subsequent pain intensity in smokers with chronic illness enrolled in a smoking cessation trial.

METHODS

We recruited veteran smokers with chronic illness (heart disease, cancer, chronic obstructive pulmonary disease, diabetes, or hypertension) for a randomized controlled smoking cessation trial and prospectively examined pain intensity and smoking status. Participants (n = 380) were asked to rate their pain in the past week from 0 to 10 at baseline and the five-month follow-up. The primary outcome measure was self-reported pain intensity at the five-month follow-up survey. Self-reported smoking status was categorized as an abstainer if patients reported no cigarettes in the seven days before the follow-up survey.

RESULTS

In unadjusted analyses, abstainers reported significantly lower pain levels at the five-month follow-up compared with patients who continued to smoke (parameter estimate = -1.07; 95% CI = -1.77, -0.36). In multivariable modeling, abstaining from cigarettes was not associated with subsequent pain intensity at five-month follow-up (parameter estimate = -0.27; 95% CI = -0.79, 0.25).

CONCLUSION

Participants who were classified as abstainers did not report significantly different levels of pain intensity than patients who continued to smoke. Future studies should expand on our findings and monitor pain intensity in smoking cessation trials.

TRIAL REGISTRATION

ClinicalTrials.govNCT00448344.

Cell phone intervention for you (CITY): A randomized, controlled trial of behavioral weight loss intervention for young adults using mobile technology

OBJECTIVE

To determine the effect on weight of two mobile technology-based (mHealth) behavioral weight loss interventions in young adults.

METHODS

Randomized, controlled comparative effectiveness trial in 18- to 35-year-olds with BMI ≥ 25 kg/m(2) (overweight/obese), with participants randomized to 24 months of mHealth intervention delivered by interactive smartphone application on a cell phone (CP); personal coaching enhanced by smartphone self-monitoring (PC); or Control.

RESULTS

The 365 randomized participants had mean baseline BMI of 35 kg/m(2) . Final weight was measured in 86% of participants. CP was not superior to Control at any measurement point. PC participants lost significantly more weight than Controls at 6 months (net effect -1.92 kg [CI -3.17, -0.67], P = 0.003), but not at 12 and 24 months.

CONCLUSIONS

Despite high intervention engagement and study retention, the inclusion of behavioral principles and tools in both interventions, and weight loss in all treatment groups, CP did not lead to weight loss, and PC did not lead to sustained weight loss relative to Control. Although mHealth solutions offer broad dissemination and scalability, the CITY results sound a cautionary note concerning intervention delivery by mobile applications. Effective intervention may require the efficiency of mobile technology, the social support and human interaction of personal coaching, and an adaptive approach to intervention design.

Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System

BACKGROUND & AIMS

Colonoscopy can decrease colorectal cancer (CRC) mortality, although performing this procedure more frequently than recommended could increase costs and risks to patients. We aimed to determine rates and correlates of physician non-adherence to guidelines for repeat colonoscopy screening and polyp surveillance intervals.

METHODS

We performed a multi-center, retrospective, observational study using administrative claims, physician databases, and electronic medical records (EMR) from 1455 patients (50-64 y old) who underwent colonoscopy in the Veterans Affairs healthcare system in fiscal year 2008. Patients had no prior diagnosis of CRC or inflammatory bowel disease, and had not undergone colonoscopy examinations in the previous 10 years. We compared EMR-documented, endoscopist-recommended intervals for colonoscopies with intervals recommended by the 2008 Multi-Society Task Force guidelines.

RESULTS

The overall rate of non-adherence to guideline recommendations was 36% and ranged from 3% to 80% among facilities. Non-adherence was 28% for patients who underwent normal colonoscopies, but 45%-52% after colonoscopies that identified hyperplastic or adenomatous polyps. Most of all recommendations that were not followed recommended a shorter surveillance interval. In adjusted analyses, non-adherence was significantly higher for patients whose colonoscopies identified hyperplastic (odds ratio [OR] = 3.1; 95% CI, 1.7-5.5) or high-risk adenomatous polyps (OR = 3.0; 95% CI, 1.2-8.0), compared to patients with normal colonoscopy examinations, but not for patients with low-risk adenomatous polyps (OR = 1.8; 95% CI, 0.9-3.7). Nonadherence was also associated with bowel preparation quality, geographic region, Charlson comorbidity score, and colonoscopy indication.

CONCLUSIONS

In a managed care setting with salaried physicians, endoscopists recommend repeat colonoscopy sooner than guidelines for more than one third of patients. Factors associated with non-adherence to guideline recommendations were colonoscopy findings, quality of bowel preparation, and geographic region. Targeting endoscopist about non-adherence to colonoscopy guidelines could reduce overuse of colonoscopy and associated healthcare costs.

Patient-provider communication, self-reported medication adherence, and race in a postmyocardial infarction population

OBJECTIVES

Our objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients' race.

METHODS

We conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors.

RESULTS

Overall, 298 patients (74%) reported never leaving their doctor's office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor's office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19-3.92) and those of minority race (OR: 1.19; 95% CI: 0.54-2.66), the overall interaction effect was not statistically significant (P=0.24).

CONCLUSION

The quality of patient-provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients' race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.

Association between perceived life chaos and medication adherence in a postmyocardial infarction population

BACKGROUND

The benefits of medication adherence to control cardiovascular disease (CVD) are well defined, yet multiple studies have identified poor adherence. The influence of life chaos on medication adherence is unknown. Because this is a novel application of an instrument, our preliminary objective was to understand patient factors associated with chaos. The main objective was to evaluate the extent to which an instrument designed to measure life chaos is associated with CVD-medication nonadherence.

METHODS AND RESULTS

Using baseline data from an ongoing randomized trial to improve postmyocardial infarction (MI) management, multivariable logistic regression identified the association between life chaos and CVD-medication nonadherence. Patients had hypertension and a myocardial infarction in the past 3 years (n=406). Nearly 43% reported CVD-medication nonadherence in the past month. In simple linear regression, the following were associated with higher life chaos: medication nonadherence (β=1.86; 95% confidence interval [CI], 0.96-2.76), female sex (β=1.22; 95% CI [0.22-2.24]), minority race (β=1.72; 95% CI [0.78-2.66]), having less than high school education (β=2.05; 95% CI [0.71-3.39]), low health literacy (β=2.06; 95% CI [0.86-3.26]), and inadequate financial status (β=1.93; 95% CI [0.87-3.00]). Being married (β=-2.09, 95% CI [-3.03 to -1.15]) was associated with lower life chaos. As chaos quartile increased, patients exhibited more nonadherence. In logistic regression, adjusting for sex, race, marital status, employment, education, health literacy, and financial status, a 1-unit life chaos increase was associated with a 7% increase (odds ratio, 1.07; 95% CI [1.02-1.12]) in odds of reporting medication nonadherence.

CONCLUSIONS

Our results suggest that life chaos may be an important determinant of medication adherence. Life chaos screenings could identify those at risk for nonadherence.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT000901277.

Recruiting young adults into a weight loss trial: report of protocol development and recruitment results

Obesity has spread to all segments of the U.S. population. Young adults, aged 18-35 years, are rarely represented in clinical weight loss trials. We conducted a qualitative study to identify factors that may facilitate recruitment of young adults into a weight loss intervention trial. Participants were 33 adults aged 18-35 years with BMI ≥25 kg/m(2). Six group discussions were conducted using the nominal group technique. Health, social image, and "self" factors such as emotions, self-esteem, and confidence were reported as reasons to pursue weight loss. Physical activity, dietary intake, social support, medical intervention, and taking control (e.g. being motivated) were perceived as the best weight loss strategies. Incentives, positive outcomes, education, convenience, and social support were endorsed as reasons young adults would consider participating in a weight loss study. Incentives, advertisement, emphasizing benefits, and convenience were endorsed as ways to recruit young adults. These results informed the Cellphone Intervention for You (CITY) marketing and advertising, including message framing and advertising avenues. Implications for recruitment methods are discussed.

Variability in resource use: diagnosing colorectal cancer

OBJECTIVES

Efficient resource use is relevant in all healthcare systems. Although colorectal cancer is common, little has been published regarding the utilization of clinical resources in diagnosis.

STUDY DESIGN

The primary aim was to evaluate the patterns and factors associated with clinical services used to diagnose colorectal cancer at 14 US Department of Veterans Affairs facilities. The secondary aim was to investigate whether using more clinical services was associated with time to diagnosis.

METHODS

We reviewed medical records for 449 patients with colorectal cancer in an observational study. Study end points were the use of clinical diagnostic services grouped as laboratory tests, imaging studies, and subspecialty consultations. Cumulative logistic regression models were used to explore factors associated with each outcome.

RESULTS

Facility variability contributed to the variability of resource use in all models. In adjusted analyses, older patients had higher use of laboratory tests (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.02-1.43) and incidentally discovered colorectal cancer was associated with increased use of consultations (OR, 1.97; 95% CI, 1.27-3.05), imaging studies (OR, 1.70; 95% CI, 1.12-2.58), and laboratory tests (OR, 3.14; 95% CI, 2.06-4.77) compared with screen-detected cancers. There was a strong direct correlation between thenumber of diagnostic services performed and the median time to diagnosis (Spearman correlation coefficient, 0.99; P < .001).

CONCLUSIONS

Variability in utilization of diagnostic clinical services was associated with patient age, patient presentation, and facility. Increased resource use was highly correlated with increased time to diagnosis.

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study

BACKGROUND

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.

METHODS

Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.

RESULTS

Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.

CONCLUSIONS

The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

Dietary saturated fat intake is negatively associated with weight maintenance among the PREMIER participants

Research finding on the composition of macronutrient intakes on body weight has not been consistent. Furthermore, little research has examined the impact of subcomponents of macronutrients such as saturated fat or plant protein on body weight. The purpose of this report was to examine the impact of saturated fat, animal and plant protein, and other macronutrient intakes at the end of an intensive intervention on subsequent follow-up body weight. This is a secondary, observational data analysis using data from PREMIER, an 18-month randomized clinical trial that enrolled a total of 810 participants. Participants completed group and individual sessions designed to help them improve blood pressure (BP) control by making lifestyle changes. Dietary intakes were assessed by two 24-h diet recalls at baseline, 6, and 18 months. Body weight and physical fitness were monitored regularly. Regression models were used to examine the impact of animal or plant protein and other macronutrient intakes on subsequent body weight. After controlling for potential confounders, none of the calorie-contributing nutrient intakes at baseline was associated with subsequent weight at 6 or 18 months. However, a greater intake of saturated fat at 6 months was associated with higher weight at 18 months (P = 0.002). A greater intake of plant protein at 6 month was marginally associated with lower absolute weight at 18 month (P = 0.069). We conclude that macronutrient intakes before the intervention were not associated with subsequent body weight at 6 or 18 months. However, a lower saturated fat intake achieved after 6-month intervention predicts a lower body weight at 18 months and thus greater weight-loss maintenance.

Correlates of expected positive and negative support for smoking cessation among a sample of chronically ill veterans

OBJECTIVE

To examine demographic, relationship, and smoking history factors related to expected positive and negative support for quitting smoking among chronically ill veterans.

METHODS

Data for this report comes from baseline data from a randomized controlled trial of a support-based smoking cessation intervention for veterans with chronic diseases (cancer, cardiovascular disease, hypertension, diabetes, and chronic obstructive pulmonary disease). We used separate multiple linear regression models to analyze relationships between positive and negative support and variables selected for model entry.

RESULTS

Veterans in our sample expected high positive and negative support for quitting. Veterans who were married/living as married, had some college education, were female, or named a female support person expected higher levels of positive support. Veterans who named a female or a nonsmoker as a support person expected higher levels of negative support. Males and non-Caucasians also reported higher levels of expected negative support.

CONCLUSIONS

Individual differences that influence perceptions of expected support are likely to influence intervention participation and engagement. Thus, understanding factors associated with expected positive and negative support is necessary to optimize future implementation of support-based cessation interventions through better treatment matching.

Early dissemination of bevacizumab for advanced colorectal cancer: a prospective cohort study

Background

We describe early dissemination patterns for first-line bevacizumab given for metastatic colorectal cancer treatment.

Methods

We analyzed patient surveys and medical records for a population-based cohort with metastatic colorectal cancer treated in multiple regions and health systems in the United States (US). Eligible patients were diagnosed with metastatic colorectal cancer and initiated first-line chemotherapy after US Food & Drug Administration (FDA) bevacizumab approval in February 2004. First-line bevacizumab therapy was defined as receiving bevacizumab within 8 weeks of starting chemotherapy for metastatic colorectal cancer. We evaluated factors associated with first-line bevacizumab treatment using logistic regression.

Results

Among 355 patients, 31% received first-line bevacizumab in the two years after FDA approval, including 26% of men, 41% of women, and 16% of those ≥ 75 years. Use rose sharply within 6 months after FDA approval, then plateaued. 20% of patients received bevacizumab in combination with irinotecan; 53% received it with oxaliplatin. Men were less likely than women to receive bevacizumab (adjusted OR 0.55; 95% CI 0.32-0.93; p = 0.026). Patients ≥ 75 years were less likely to receive bevacizumab than patients < 55 years (adjusted OR 0.13; 95% CI 0.04-0.46; p = 0.001).

Conclusions

One-third of eligible metastatic colorectal cancer patients received first-line bevacizumab shortly after FDA approval. Most patients did not receive bevacizumab as part of the regimen used in the pivotal study leading to FDA approval.

Secondary prevention risk interventions via telemedicine and tailored patient education (SPRITE): a randomized trial to improve postmyocardial infarction management

BACKGROUND

Secondary prevention by risk factor modification improves patient outcomes, yet it is often not achieved in clinical practice. Reasons for failure stem from challenges of prioritizing risk factor reduction and engaging patients in changing their behaviors. We hypothesize that a novel telemedicine intervention with tailored patient education could improve cardiovascular risk factors.

METHODS

To evaluate this intervention, we propose enrolling 450 patients with a recent myocardial infarction and hypertension into a 3-arm randomized, controlled trial. The first arm (n=150) will receive home blood pressure (BP) monitors plus a nurse-delivered, telephone-based tailored patient education intervention and will be enrolled into HealthVault, a Microsoft electronic health record platform. The second arm (n=150) will also receive BP monitors plus a tailored patient education intervention and be enrolled in HeartVault. However, the patient education intervention will be delivered by a Web-based program and will cover topics identical to those in the nurse-delivered intervention. Both arms will be compared with a control group receiving standard care (n=150). All participants will have an in-person assessment at baseline and at completion of the study, including standardized measurements of BP, LDL cholesterol, and glycosylated hemoglobin (in diabetic subjects). The study design will allow assessment of a telephone-based, nurse-administered disease management program versus standard care. The main outcome of interest is the reduction in systolic BP in each intervention group compared with the control group at 12 months. Secondary outcomes assessed will include reductions in LDL cholesterol, body weight, and glycosylated hemoglobin, as well as adherence to evidence-based therapies and improvement in health behaviors.

CONCLUSION

If successful in optimizing BP control, managing other coronary heart disease risk factors, and demonstrating a lower cost, the Web-based disease management tool has the potential to enhance coronary artery disease management, quality of care, and ultimately, patient outcomes. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00901277.

Cost minimization analysis of a store-and-forward teledermatology consult system

The aim of this study was to perform a cost minimization analysis of store-and-forward teledermatology compared to a conventional dermatology referral process (usual care). In a Department of Defense (DoD) setting, subjects were randomized to either a teledermatology consult or usual care. Accrued healthcare utilization recorded over a 4-month period included clinic visits, teledermatology visits, laboratories, preparations, procedures, radiological tests, and medications. Direct medical care costs were estimated by combining utilization data with Medicare reimbursement rates and wholesale drug prices. The indirect cost of productivity loss for seeking treatment was also included in the analysis using an average labor rate. Total and average costs were compared between groups. Teledermatology patients incurred $103,043 in total direct costs ($294 average), while usual-care patients incurred $98,365 ($283 average). However, teledermatology patients only incurred $16,359 ($47 average) in lost productivity cost while usual-care patients incurred $30,768 ($89 average). In total, teledermatology patients incurred $119,402 ($340 average) and usual-care patients incurred $129,133 ($372 average) in costs. From the economic perspective of the DoD, store-and-forward teledermatology was a cost-saving strategy for delivering dermatology care compared to conventional consultation methods when productivity loss cost is taken into consideration.

Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs

PURPOSE

The Veterans Affairs (VA) healthcare system treats approximately 3% of patients with cancer in the United States each year. We measured the quality of nonmetastatic colorectal cancer (CRC) care in VA as indicated by concordance with National Comprehensive Cancer Network practice guidelines (six indicators) and timeliness of care (three indicators).

PATIENTS AND METHODS

A retrospective medical record abstraction was done for 2,492 patients with incident stages I to III CRC diagnosed between October 1, 2003, and March 31, 2006, who underwent definitive CRC surgery. Patients were treated at one or more of 128 VA medical centers. The proportion of patients receiving guideline-concordant care and time intervals between care processes were calculated.

RESULTS

More than 80% of patients had preoperative carcinoembryonic antigen determination (ie, stages II to III disease) and documented clear surgical margins (ie, stages II to III disease). Between 72% and 80% of patients had appropriate referral to a medical oncologist (ie, stages II to III disease), preoperative computed tomography scan of the abdomen and pelvis (ie, stages II to III disease), and adjuvant fluorouracil-based chemotherapy (ie, stage III disease). Less than half of patients with stages I to III CRC (43.5%) had a follow-up colonoscopy 7 to 18 months after surgery. The mean number of days between major treatment events included the following: 26.6 days (standard deviation [SD], 38.2; median, 20 days) between diagnosis and initiation of treatment (in stages II to III disease); 64.8 [corrected] days (SD, 54.9; median, 50 days) between definitive surgery and start of adjuvant chemotherapy (in stages II to III disease); and 444.2 [corrected] days (SD, 182.1; median, 393 days) between definitive surgery and follow-up colonoscopies (in stages I to III disease).

CONCLUSION

Although there is opportunity for improvement in the area of cancer surveillance, the VA performs well in meeting established guidelines for diagnosis and treatment of CRC.

Determinants of medical system delay in the diagnosis of colorectal cancer within the Veteran Affairs Health System

BACKGROUND AND AIMS

The goals of this study are to evaluate determinants of the time in the medical system until a colorectal cancer diagnosis and to explore characteristics associated with stage at diagnosis.

METHODS

We examined medical records and survey data for 468 patients with colorectal cancer at 15 Veterans Affairs medical centers. Patients were classified as screen-detected, bleeding-detected, or other (resulting from the evaluation of another medical concern). Patients who presented emergently with obstruction or perforation were excluded. We used Cox proportional hazards models to determine predictors of time in the medical system until diagnosis. Logistic regression models were used to determine predictors of stage at diagnosis.

RESULTS

We excluded 21 subjects who presented emergently, leaving 447 subjects; the mean age was 67 years and 98% were male, 66% Caucasian, and 43% stage I or II. Diagnosis was by screening for 39%, bleeding symptoms for 27%, and other for 34%. The median times to diagnosis were 73-91 days and were not significantly different by diagnostic category. In the multivariable model for time to diagnosis, older age, having comorbidities, and Atlantic region were associated with a longer time to diagnosis. In the multivariable model for stage-at-diagnosis, only the diagnostic category was associated with stage; the screen-detected category was associated with decreased risk of late-stage cancer.

CONCLUSIONS

Our results point to several factors associated with a longer time from the initial clinical event until diagnosis. This increased time in the health care system did not clearly translate into more advanced disease at diagnosis.

A randomized trial of a low-carbohydrate diet vs orlistat plus a low-fat diet for weight loss

BACKGROUND

Two potent weight loss therapies, a low-carbohydrate, ketogenic diet (LCKD) and orlistat therapy combined with a low-fat diet (O + LFD), are available to the public but, to our knowledge, have never been compared.

METHODS

Overweight or obese outpatients (n = 146) from the Department of Veterans Affairs primary care clinics in Durham, North Carolina, were randomized to either LCKD instruction (initially, <20 g of carbohydrate daily) or orlistat therapy, 120 mg orally 3 times daily, plus low-fat diet instruction (<30% energy from fat, 500-1000 kcal/d deficit) delivered at group meetings over 48 weeks. Main outcome measures were body weight, blood pressure, fasting serum lipid, and glycemic parameters.

RESULTS

The mean age was 52 years and mean body mass index was 39.3 (calculated as weight in kilograms divided by height in meters squared); 72% were men, 55% were black, and 32% had type 2 diabetes mellitus. Of the study participants, 57 of the LCKD group (79%) and 65 of the O + LFD group (88%) completed measurements at 48 weeks. Weight loss was similar for the LCKD (expected mean change, -9.5%) and the O + LFD (-8.5%) (P = .60 for comparison) groups. The LCKD had a more beneficial impact than O + LFD on systolic (-5.9 vs 1.5 mm Hg) and diastolic (-4.5 vs 0.4 mm Hg) blood pressures (P < .001 for both comparisons). High-density lipoprotein cholesterol and triglyceride levels improved similarly within both groups. Low-density lipoprotein cholesterol levels improved within the O + LFD group only, whereas glucose, insulin, and hemoglobin A(1c) levels improved within the LCKD group only; comparisons between groups, however, were not statistically significant.

CONCLUSION

In a sample of medical outpatients, an LCKD led to similar improvements as O + LFD for weight, serum lipid, and glycemic parameters and was more effective for lowering blood pressure.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00108524.

Comparison of medicine resident diabetes care between Veterans Affairs and academic health care systems

BACKGROUND

Although others have reported national disparities in the quality of diabetes care between the Veterans Affairs (VA) and private health care delivery systems, it is not known whether these differences persist among internal medicine resident providers in academic settings.

OBJECTIVE

We compared the quality of diabetes primary care delivered by resident physicians in either a private academic health care system (AHS) or its affiliated VA health care system.

DESIGN

Cross-sectional observational study

PARTICIPANTS

We included patients who: had a diagnosis of diabetes, had >2 primary care visits with the same resident provider during 2005, and were not separately managed by an attending physician or endocrinologist. A total of 640 patients met our criteria and were included in the analysis.

MEASUREMENTS AND RESULTS

Compared to the VA, patients in the AHS were more likely to be younger, female, have fewer medications, and be treated with insulin, but had less comorbidity. Patients in the VA were more likely to be referred for an annual eye exam (94% vs. 78%), receive lipid screening (88% vs. 74%), receive proteinuria screening (63% vs. 34%), and receive a complete foot exam (85% vs. 32%) in analyses adjusted for patient demographics and comorbidities (p-value <0.001 for all comparisons). In adjusted analyses, there were no significant differences in HbA1(c), blood pressure, or LDL cholesterol control.

CONCLUSIONS

In spite of similar resident providers and practice models, there were substantial differences in the diabetes quality of care delivered in the VA and AHS. Understanding how these factors influence subsequent practice patterns is an important area for study.

Ghrelin concentrations in Prader-Willi syndrome (PWS) infants and children: changes during development

BACKGROUND

Prader-Willi syndrome (PWS) is associated with failure to thrive in infancy and progressive hyperphagia and obesity in childhood. This progressive weight gain is associated with hyperghrelinaemia and increased insulin sensitivity. The role of ghrelin excess in the pathogenesis of obesity is unclear.

OBJECTIVE

To determine if high ghrelin levels precede the onset of obesity in young PWS children.

DESIGN AND METHODS

A cross-sectional study of 33 infants with PWS and 28 healthy control subjects (C). Fasting ghrelin and other satiety hormones were measured.

RESULTS

Median total serum ghrelin in young children with PWS trended higher, but did not differ significantly from those in C of similar age, weight-for-age z-score and sex. However, there was more variability in ghrelin concentrations of young PWS. Eleven of 33 PWS subjects had ghrelin levels greater than the 95th percentile for ghrelin values in the C subjects (> 2871 pg/ml). Six of the PWS subjects with high ghrelin levels had weight-for-age z-scores < 0. Ghrelin concentrations in PWS and C infants exceeded those in older children. In youngsters with PWS, leptin was higher, suggesting a relative excess of fat to lean body mass and plasma adiponectin was increased.

CONCLUSIONS

Young infants with PWS who have not yet developed hyperphagia or obesity have median fasting ghrelin levels similar to controls. However, a subset (33%) of young PWS is hyperghrelinaemic; approximately one-half of those with hyperghrelinaemia have BMI z-score < 0. The age-related decline in ghrelin is blunted in PWS.

Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems

BACKGROUND

Stage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis.

METHODS

Two distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-2007. We assessed metastatic CRC patients treated from 2003-2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression.

RESULTS

342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58-1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82-1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race.

CONCLUSION

Higher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.

Amyotrophic lateral sclerosis among 1991 Gulf War veterans: evidence for a time-limited outbreak

BACKGROUND

In follow-up to recent reports of an elevated risk of amyotrophic lateral sclerosis (ALS) among 1991 Gulf War veterans, we analyzed the distribution of disease onset times to determine whether the excess risk was time limited.

METHODS

This secondary analysis used data from a population-based series of ALS cases identified between 1991 and 2001 among the 2.5 million military personnel who were on active duty during the 1991 Gulf War. Annual standardized incidence ratios (SIR) were calculated for all cases and for those with disease onset before age 45 years.

RESULTS

Forty-eight of 124 cases occurred among those deployed to the Persian Gulf region during the war. The annual SIR for deployed military personnel did not demonstrate a monotonically increasing trend for either all cases (chi(2) = 0.11, d.f. = 1, p = 0.74) or for cases under 45 years of age at onset (chi(2) = 2.41, d.f. = 1, p = 0.12). The highest risk was observed in 1996, declining thereafter. Among military personnel who were not deployed to the Gulf region, the level of risk remained fairly constant during the 11-year period.

CONCLUSIONS

The excess risk of ALS among 1991 Gulf War veterans was limited to the decade following the war.

Altered distribution of adiponectin isoforms in children with Prader-Willi syndrome (PWS): association with insulin sensitivity and circulating satiety peptide hormones

OBJECTIVE

Prader-Willi syndrome (PWS) is a genetic syndrome characterized by relative hypoinsulinaemia and normal or increased insulin sensitivity despite profound obesity. We hypothesized that this increased insulin sensitivity is mediated by increased levels of total and high molecular weight adiponectin and associated with changes in levels of satiety hormones.

DESIGN, PATIENTS AND MEASUREMENTS

We measured total adiponectin and its isoforms [high molecular weight (HMW), middle molecular weight (MMW) and low molecular weight (LMW) adiponectin] and satiety hormones in 14 children with PWS [median age 11.35 years, body mass index (BMI) Z-score 2.15] and 14 BMI-matched controls (median age 11.97 years, BMI Z-score 2.34).

RESULTS

Despite comparable BMI Z-scores and leptin levels, the PWS children exhibited lower fasting insulin and HOMA-IR (homeostasis model assessment of insulin resistance) scores compared to obese controls. For any given BMI Z-score, the PWS children showed higher concentrations of fasting total and HMW adiponectin and higher HMW/total adiponectin ratios. The HMW/total adioponectin ratio was preserved in children with PWS at high degrees of obesity. In PWS children, fasting plasma total adiponectin, HMW adiponectin and HMW/total adiponectin ratio correlated negatively with age (P < 0.05), HOMA-IR (P < 0.01), BMI Z-score (P < 0.05), insulin (P < 0.01) and leptin (P < 0.05). In addition to higher fasting ghrelin concentrations, the PWS children showed significantly higher fasting levels of total peptide YY (PYY) and gastric inhibitory polypeptide (GIP) compared to obese controls.

CONCLUSIONS

Relative to controls of similar age and BMI Z-score, the PWS children had significantly higher levels of total and HMW adiponectin, and increased ratios of HMW/total adiponectin. These findings may explain in part the heightened insulin sensitivity of PWS children relative to BMI-matched controls.

Contracting, prompting, and reinforcing substance use disorder continuing care: a randomized clinical trial

Although continuing care is strongly related to positive treatment outcomes for substance use disorder (SUD), participation rates are low and few effective interventions are available. In a randomized clinical trial with 150 participants (97% men), 75 graduates of a residential Veterans Affairs Medical Center SUD program who received an aftercare contract, attendance prompts, and reinforcers (CPR) were compared to 75 graduates who received standard treatment (STX). Among CPR participants, 55% completed at least 3 months of aftercare, compared to 36% in STX. Similarly, CPR participants remained in treatment longer than those in STX (5.5 vs. 4.4 months). Additionally, CPR participants were more likely to be abstinent compared to STX (57% vs. 37%) after 1 year. The CPR intervention offers a practical means to improve adherence among individuals in SUD treatment.

Convergent validity of the Timeline Followback for persons with comorbid psychiatric disorders engaged in residential substance use treatment

This study examined the convergent validity of the Timeline Followback (TLFB) for individuals with comorbid (Axis I and/or Axis II) psychiatric disorders in a sample of persons (N=150) engaged in residential treatment for substance use disorders (SUDs). Approximately one-half of the sample was diagnosed with at least one comorbid psychiatric disorder. Validity was assessed comparing data from the TLFB with data from the Addiction Severity Index (ASI) and collateral reports. For the entire sample, data from the TLFB was significantly correlated with data from the ASI and collateral reports of substance use. No significant differences were found between those with and those without a comorbid psychiatric disorder, suggesting that the TLFB was equally valid for both groups.

Grade-specific prostate cancer associations of IGF1 (CA)19 repeats and IGFBP3-202A/C in blacks and whites

Carrying the cytosine-adenosine (CA)19 repeat polymorphism in insulin-like growth factor-1 (IGF1) is associated with lower serum proteins and decreased prostate cancer risk. Carrying the -202A/C genotype in insulin-like growth factor binding protein-3 (IGFBP3) also has been associated with lower serum levels of the binding protein. However, the association between this variant and prostate cancer is inconsistent. To test the hypothesis that inconsistencies are partly due to cancer grade-specific differences in strength and direction of associations, we reanalyzed data from our previous Durham Veterans Administration Hospital study of blacks and whites comprising 47 cases (19 African Americans) with Gleason sum > or = 7, 50 cases (30 African Americans) with Gleason sum < 7 and 93 controls (49 African Americans). Compared to controls, the association between carrying the IGFBP3 C allele and prostate cancer risk was in OR(Low-Gleason) = 4.0; 95% CI: 1.4-12.3 compared to OR(High-Gleason) = 1.0; 95% CI: 0.4-2.2. Association patterns were similar in African Americans (OR(Low-Gleason) = 3.6; 95% CI: 1.0-13.2 vs. OR(High-Gleason) = 1.4; 95% CI: 0.4-2.3) and whites (OR(Low-Gleason) = 5.6; 95% CI: 0.6-49.0 vs. OR(High-Gleason) = 0.6; 95% CI: 0.2-2.2). The inverse association between carrying the IGF1 (CA)19 repeat variant did not vary by grade or ethnicity. If confirmed in larger studies, these findings support the hypothesis that the association between IGFBP3 C allele and prostate cancer is grade specific in both ethnic groups.

Behind closed doors: management of patient expectations in primary care practices

BACKGROUND

Managed care restrictions on resource use may affect communication between patients and health care professionals.

METHODS

To characterize negotiations between primary care physicians and patients with expectations for new medications, tests, or referrals, this observational study combined survey data with audiotape recordings of clinical encounters. Fifty-five physicians from 20 randomly selected primary care practices in a managed care network and 211 patients who voiced specific expectations in a previsit survey were included. From the recorded clinic visits we determined modes of negotiation of patient expectations and requests. From the surveys we determined patient previsit expectations, postvisit fulfillment of expectations, satisfaction, and trust.

RESULTS

Two-hundred fifty-six self-reported expectations were captured in 200 audiotape-recorded encounters. Of the previsit expectations, 97.3% were discussed during the encounter. Expectations were expressed by direct patient request (40.6%), mentioning of symptoms related to request (29.7%), or physician-initiated discussion (27.0%). Most expectations were met (66.8%); physicians suggested an alternative 21.6% of the time. Expectations for medications and tests were met more frequently than expectations for referrals (75.6% and 71.4% vs 40.8%). Patient satisfaction and trust remained high regardless of whether expectations were met. Physicians reported that they would not have ordered 62 (44.9%) of 138 requests had the patients not directly asked, and they were uncomfortable filling 8 requests (12.9%).

CONCLUSIONS

Previsit expectations for medications, tests, or referrals were discussed at the visit, and physicians met or offered alternatives for nearly 90%. Patients generally received what they asked for and altered physician behavior nearly half of the time.

Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis

BACKGROUND

Hospital admissions consume a large proportion of costs for the end-stage renal disease (ESRD) program in the United States. We investigated whether a physician diagnosis of depression increases the risk for hospitalization or death in patients with ESRD receiving long-term hemodialysis (HD), independent of medical comorbidities.

METHODS

Centralized Veterans Affairs (VA) databases were used to identify a population-based prevalence cohort of 1,588 male patients with ESRD receiving long-term HD in VA facilities between September 1, 2000, and September 30, 2000. International Classification of Diseases, Ninth Revision, codes were used to identify comorbidities and depression diagnosis. Negative binomial regression models were used to examine the association between depression diagnosis and number of hospitalizations and cumulative hospital days in a 2-year observation period. Logistic regression models were used to investigate the association between depression diagnosis and hospitalization, death, and death or hospitalization.

RESULTS

The prevalence of physician-diagnosed depression was 14.7%. Patients with a depression diagnosis were more likely to be white and have more comorbidities. Depression diagnosis was associated with increased hospital days (rate ratio for adjusted model, 1.31; 95% confidence interval, 1.04 to 1.66) and increased number of hospitalizations (rate ratio for adjusted model, 1.30; 95% confidence interval, 1.11 to 1.52). Depression diagnosis was not statistically associated with death or the composite of death or hospitalization in adjusted models.

CONCLUSION

Physician-diagnosed depression was associated significantly with both increased hospitalization rate and length of stay in patients with ESRD receiving outpatient HD in VA facilities, independent of demographics and comorbidities. Prospective studies should be conducted to assess whether treatment of depression will decrease hospitalization in these patients.

Seasonal variations in air pollution particle-induced inflammatory mediator release and oxidative stress

Health effects associated with particulate matter (PM) show seasonal variations. We hypothesized that these heterogeneous effects may be attributed partly to the differences in the elemental composition of PM. Normal human bronchial epithelial (NHBE) cells and alveolar macrophages (AMs) were exposed to equal mass of coarse [PM with aerodynamic diameter of 2.5-10 microm (PM(2.5-10)], fine (PM(2.5)), and ultrafine (PM(<0.1)) ambient PM from Chapel Hill, North Carolina, during October 2001 (fall) and January (winter), April (spring), and July (summer) 2002. Production of interleukin (IL)-8, IL-6, and reactive oxygen species (ROS) was measured. Coarse PM was more potent in inducing cytokines, but not ROSs, than was fine or ultrafine PM. In AMs, the October coarse PM was the most potent stimulator for IL-6 release, whereas the July PM consistently stimulated the highest ROS production measured by dichlorofluorescein acetate and dihydrorhodamine 123 (DHR). In NHBE cells, the January and the October PM were consistently the strongest stimulators for IL-8 and ROS, respectively. The July PM increased only ROS measured by DHR. PM had minimal effects on chemiluminescence. Principal-component analysis on elemental constituents of PM of all size fractions identified two factors, Cr/Al/Si/Ti/Fe/Cu and Zn/As/V/Ni/Pb/Se, with only the first factor correlating with IL-6/IL-8 release. Among the elements in the first factor, Fe and Si correlated with IL-6 release, whereas Cr correlated with IL-8 release. These positive correlations were confirmed in additional experiments with PM from all 12 months. These results indicate that elemental constituents of PM may in part account for the seasonal variations in PM-induced adverse health effects related to lung inflammation.

Estimating the Occurrence of Amyotrophic Lateral Sclerosis among Gulf War (1990–1991) Veterans Using Capture-Recapture Methods

OBJECTIVE

Using data from a recent report that indicated a 2-fold higher risk of amyotrophic lateral sclerosis (ALS) among veterans of the 1991 Gulf War, we applied capture-recapture methodology to estimate possible under-ascertainment of ALS cases among deployed and non-deployed military personnel who were on active duty during that war.

STUDY DESIGN AND SETTING

One of the most serious concerns facing field epidemiological investigations is that of case ascertainment bias, particularly when it is differential among the study groups. Capture-recapture methods, however, have promise as an approach to assessing the impact of case ascertainment bias in such studies. To overcome potential limitations of any one approach, three different estimation methods were used: log-linear models, sample coverage, and ecological models, to obtain a comprehensive view of under-ascertainment bias in these populations.

RESULTS

All three approaches indicated differential undercount of ALS cases with modest under-ascertainment likely to have occurred among non-deployed military personnel, but little under-ascertainment among the deployed. After correcting the rates for under-ascertainment, the age-adjusted risk of ALS remained elevated among military personnel who had been deployed to S.W. Asia during the 1991 Gulf War, confirming the earlier report.

CONCLUSIONS

Capture-recapture methods are a useful approach to assessing the magnitude of case ascertainment bias in epidemiological studies from which ascertainment-adjusted estimates of rates and relative risks can be calculated.

Prostate cancer: a significant risk factor for late-life suicide

OBJECTIVE

The authors sought to determine the incidence of suicide and its relevant correlates among men with prostate cancer.

METHODS

This was a population-based, retrospective cohort review of men age 65 and older, residing in South Florida between 1983 and 1993. Average annual suicide rate was calculated for prostate cancer-related suicides and contrasted with age and gender-specific rates in the same geographic area.

RESULTS

Of 667 completed suicides, 20 were prostate cancer-related (3% of the total male suicide sample). The average annual incidence of suicide for men was 55.32 per 100,000 persons, but for men with prostate cancer, the rate was 274.7 per 100,000. The risk of suicide in men with prostate cancer was 4.24 times that of an age- and gender-specific cohort. The clinical correlates included depression (70%), cancer diagnosis within 6 months of suicide (80%), physician visit within 1 month of suicide (60%), and being foreign-born (70%).

CONCLUSION

The incidence of suicide among older men with prostate cancer is higher than previously recognized. Depression, recent diagnosis, pain, and being foreign-born are important clinical correlates. Screens for depression and suicide in older men with prostate cancer should be done after diagnosis and redone during the first 6 months regularly, particularly in the primary-care setting. Public education is needed to decrease the stigma associated with having a cancer diagnosis.

IGF1 (CA)19 Repeat and IGFBP3 -202 A/C Genotypes and the Risk of Prostate Cancer in Black and White Men

We investigated the relationship between the insulin-like growth factor-1 (IGF1) cytosine-adenine repeat (CA)(19) polymorphism located upstream of the gene's transcription start site, the insulin-like growth factor binding protein-3 (IGFBP3) -202 A/C promoter region polymorphism, and prostate cancer risk in Black and White men. Study subjects were U.S. veterans ages 41 to 75 years identified at the Durham Veterans Administration Medical Center over a 2.5-year period. Controls (n = 93) were frequency matched to cases (n = 100) based on race (Black or White) and age. Multivariable unconditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for the associations between the polymorphisms and prostate cancer risk. For Blacks and Whites combined, an inverse association between prostate cancer and being homozygous for the most common IGF1 repeat allele, (CA)(19), (adjusted OR, 0.3; 95% CI, 0.1-0.7) was observed. Similar associations were noted for both Blacks (OR, 0.2; 95% CI, 0.0-0.8) and Whites (OR, 0.4; 95% CI, 0.1-1.6) separately. No statistically significant associations between the IGFBP3 C allele and prostate cancer were noted for Blacks (adjusted OR, 2.3; 95% CI, 0.8-6.2) or Whites (OR, 1.0; 95% CI, 0.3-3.1). The prevalence of the homozygous IGF1 (CA)(19) genotype was much lower in Black controls (21%) than White controls (46%), which may, in part, explain the increased prostate cancer incidence in Black versus White men. Further research is needed to confirm these findings.

Initiation and Discontinuation of Hormone Therapy for Menopausal Symptoms: Results From a Community Sample

Factors related to initiation and discontinuation of hormonal therapy (HT) for treatment of menopausal symptoms were examined in a community sample of 533 peri/postmenopausal women aged 45-54 by telephone three times. Over 40 variables including: sociodemographic characteristics, clinical reasons to start HT use, HT contraindications, HT attitudes/knowledge, and health behaviors were examined in logistic regression models comparing women who discontinued HT to women who continued using HT over 9 months (discontinuers) and women who initiated HT versus women who never used HT over 9 months (initiators). Increased understanding of HT, confidence, mental health symptoms, perception that menopause is natural, and having gynecological surgery were related to decreased likelihood of HT discontinuation. Increased understanding about risks of HT, vasomotor symptoms, mood symptoms, and having gynecological surgery were related to increased likelihood of HT Initiation. These findings highlight the importance of physicians discussing HT with their patients, particularly because of recent clinical trial developments.

Patient and Clinician Satisfaction with a Store-and-Forward Teledermatology Consult System

The aim of this study was to assess satisfaction with and acceptance of a store and forward teledermatology consult system among patients, referring primary-care clinicians, and consultant dermatologists. As part of a randomized clinical trial that compared the clinical and economic outcomes of store and forward teledermatology to a conventional referral process, we conducted satisfaction assessments among participating patients, referring primary-care clinicians, and consultant dermatologists. Survey questions included issues related to the timeliness of each consult process, the confidence participants displayed in each consult modality, and assessments of overall satisfaction and preferences. A majority of referring clinicians (92%) and dermatologist consultants (75%) reported overall satisfaction with the teledermatology consult process. Ninety-five percent of referring clinicians reported that teledermatology resulted in more timely referrals for their patients. This finding was validated by the observation that teledermatology patients reached a point of initial intervention significantly sooner than did patients in usual care (41 days versus 127 days, p = 0.0001). Teledermatology patients reported satisfaction with the outcome of their teledermatology consultation 82% of the time. However, patients did not express a clear preference for a consult method. A total of 41.5% of patients preferred teledermatology, 36.5% preferred usual care, and 22% were neutral. Our study showed a high level of satisfaction among all users of a store-and-forward teledermatology consult system, and, in some cases, our survey results could be validated with observed clinical outcomes.

Do unmet expectations for specific tests, referrals, and new medications reduce patients' satisfaction?

BACKGROUND

Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit.

OBJECTIVE

To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction.

DESIGN

Prospective cohort study.

SETTING

VA general medicine clinic.

PATIENTS/PARTICIPANTS

Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit.

MEASUREMENTS AND MAIN RESULTS

Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing "excellent"). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction.

CONCLUSIONS

Patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.

Racial/ethnic variations in non-steroidal anti-inflammatory drug(NSAID) use among patients with osteoarthritis

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed drugs for the treatment of osteoarthritis (OA). While there are documented racial differences in the use of opioid analgesics, little is known about racial differences in the use of NSAIDs.

METHODS

This was a retrospective cohort study among a national sample of 6038 veterans with OA. Patients were new NSAID users, followed for approximately 6 months. Primary outcomes included: type of NSAID prescribed (COX-2 selective or preferentially COX-2 selective NSAIDs vs other NSAIDs), days' supply of initial prescription and time to discontinuation of the index NSAID.

RESULTS

In an analysis adjusted for demographic and gastrointestinal (GI) bleeding risk factors (age, sex, geographic region, history of GI bleeding, comorbid illnesses, use of anti-coagulants and glucocorticoids), Hispanics were less likely than whites to be prescribed an NSAID with some degree of COX-2 selectivity (odds ratio (OR): 0.47, p < 0.01). The days' supply of the initial prescription was lower for both blacks and Hispanics compared to whites (mean: 38, 31 and 43 days respectively, p < 0.01). In an analysis adjusted for demographics, GI bleeding risk factors and type of NSAID prescribed, blacks discontinued use of the index NSAID earlier than whites (hazard ratio = 1.19, p < 0.001) and there was a similar trend for Hispanics.

CONCLUSION

Minorities with OA were prescribed NSAIDs with less COX-2 selectivity and lower days' supply than whites. Further research should address underlying reasons and whether these differences impact outcomes such as pain control, side effects and cost-effectiveness of care.

Patient risk perceptions for carotid endarterectomy: which patients are strongly averse to surgery?

BACKGROUND AND PURPOSE

Patient risk perception for surgery may be central to their willingness to undergo surgery. This study examined potential factors associated with patient aversion of surgery.

METHODS

This is a secondary data analysis of a prospective cohort study that examined patients referred for evaluation of carotid artery stenosis at five Veterans Affairs Medical Centers. The study collected demographic, clinical, and psychosocial information related to surgery. This analysis focused on patient response to a question assessing their aversion to surgery.

RESULTS

Among the 1065 individuals, at the time of evaluation for carotid endarterectomy (CEA), 66% of patients had no symptoms, 16% had a transient ischemic attack, and 18% had stroke. Twelve percent of patients referred for CEA evaluation were averse to surgery. In adjusted analyses, increased age, black race, no previous surgery, lower level of chance locus of control, less trust of physicians, and less social support were significantly related to greater likelihood of surgery aversion among individuals referred for CEA evaluation. Patient degree of medical comorbidity and a validated measure of preoperative risk score were not associated with increased aversion to surgery.

CONCLUSIONS

In previous work, aversion to CEA was associated with lack of receipt of CEA even after accounting for patient clinical appropriateness for surgery. We identified important patient characteristics associated with aversion to CEA. Interventions designed to assist patient decision making should focus on these more complex factors related to CEA aversion rather than the simple explanation of clinical usefulness.