Publications

RATIONALE: Inpatient consultation by specialists is one of the most common medical interventions in the modern intensive care unit (ICU), but few data exist on components of high-quality consultation.

OBJECTIVES: Our objective was to use qualitative methods to develop a conceptual framework of consultative quality in critically ill patients.

METHODS: We conducted a qualitative study of medical ICU physicians at a single institution using a novel, semistructured interview guide. We elicited physicians' attitudes toward processes of obtaining specialty consultation, identified perceived elements of high-quality consults, and identified barriers to obtaining high-quality consults. We used grounded theory to identify themes.

MEASUREMENTS AND MAIN RESULTS: ICU physicians described four common reasons for involving a consulting physician: the need for clinical or procedural expertise, an explicit or implicit protocol of the institution mandating the consult, an opportunity to provide education to the primary or consulting team, and/or at the family's request. Participants identified seven components of a high-quality consult, including the consulting teams' (1) decisiveness, (2) thoroughness, (3) level of interest, (4) professionalism, (5) expertise, (6) timeliness, and (7) involvement with the family of the patient. The intensive care team, the consult team, the health system, and the temporal context in which the consultation takes place may influence the quality of the consultation.

CONCLUSIONS: Several key factors are necessary for a consult to be judged high quality. An opportunity exists to develop an instrument to assess and to improve specialty consultations in the ICU based on these findings.

CONTEXT: To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions.

OBJECTIVE: To assess the quality and limitations of prognostic indices for mortality in older adults through systematic review.

DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from their inception through November 2011.

STUDY SELECTION: We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was 60 years or older. We excluded indices that estimated intensive care unit, disease-specific, or in-hospital mortality.

DATA EXTRACTION: For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy.

RESULTS: We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6 months to 5 years for older adults in a variety of clinical settings: the community (6 indices), nursing home (2 indices), and hospital (8 indices). At least 1 measure of transportability (the index is accurate in more than 1 population) was tested for all but 3 indices. By our measures, no study was free from potential bias. Although 13 indices had C statistics of 0.70 or greater, none of the indices had C statistics of 0.90 or greater. Only 2 indices were independently validated by investigators who were not involved in the index's development.

CONCLUSION: We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.

BACKGROUND: Data are needed on how life expectancy affects treatment decisions among women ≥80 years with early stage breast cancer. METHODS: We used the linked Surveillance Epidemiology and End Results-Medicare claims dataset from 1992-2005 to identify women aged ≥80 newly diagnosed with lymph node negative, estrogen receptor positive tumors, ≤5 centimeters. To estimate life expectancy, we matched these women to women of similar age, region, and insurance, not diagnosed with breast cancer. We examined 5-year mortality of matched controls by illness burden (measured with the Charlson Comorbidity Index [CCI]) using Kaplan-Meier statistics. We examined treatments received by estimated life expectancy within CCI levels. We further examined factors associated with receipt of radiotherapy after breast conserving surgery (BCS). RESULTS: Of 9,932 women, 39.6% underwent mastectomy, 30.4% received BCS plus radiotherapy, and 30.0% received BCS alone. Estimated 5-year mortality was 72% for women with CCIs of 3+, yet 38.0% of these women underwent mastectomy and 22.9% received radiotherapy after BCS. Conversely, estimated 5-year mortality was 36% for women with CCIs of 0 and 26.6% received BCS alone. Age 80-84, urban residence, higher grade, recent diagnosis, mammography use, and low comorbidity, were factors associated with receiving radiotherapy after BCS. Among women with CCIs of 3+ treated with BCS, 36.9% underwent radiotherapy. CONCLUSIONS: Many women aged ≥80 with limited life expectancies receive radiotherapy after BCS for treatment of early stage breast cancers while many in excellent health do not. More consideration needs to be given to patient life expectancy when considering breast cancer treatments. KEY WORDS: Breast cancer, older women, treatment, life expectancy, radiation.

OBJECTIVES: To identify factors that influence the breast cancer treatment decisions of women aged 80 and older.

DESIGN: Medical record review.

SETTING: One academic primary care clinic and two community health centers in Boston.

PARTICIPANTS: Sixty-five women aged 80 and older diagnosed with breast cancer between 1994 and 2004 and followed through June 30, 2010.

MEASUREMENTS: Data were abstracted on breast cancer characteristics, comorbidities, treatments received, and outcomes. Notes from primary care physicians, oncologists, and breast surgeons were reviewed to determine factors involved in treatment decision-making.

RESULTS: Median age at diagnosis was 84.0 (interquartile range 82.0-86.3), 55 (84.6%) were non-Hispanic white, and 40 (61.5%) had at least one comorbidity. Nine women were diagnosed with ductal carcinoma in situ, 42 with a new primary invasive breast cancer, eight with a second primary, and six with a breast cancer recurrence. Sixty-three (96.9%) received some type of treatment. Fifty-six (86.2%) had at least one detailed physician note on treatment decision-making in their charts. The main categories found to influence participant, family, and physician treatment decision-making were tumor characteristics, ratio of treatment benefits to risks, logistics (e.g., transportation, finances), and participant age, health (including a concurrent diagnosis), and psychosocial characteristics. Family was involved in treatment discussions for 46 (70.8%) participants.

CONCLUSION: The quality of physician documentation about decision-making in these women was high. A great amount of thoughtful and complex decision-making involving patients, family, and physicians occurs after a woman aged 80 and older is diagnosed with breast cancer.

OBJECTIVES: To further validate an index predicting mortality in community-dwelling older adults.

DESIGN: A comparison of the performance of the index in predicting mortality among new respondents to the National Health Interview Survey (NHIS, 2001-2004) with that of respondents from the original development and validation cohorts (1997-2000) and a test of its performance over extended follow-up (up to 9 years) using the original cohorts. Follow-up mortality data were available through 2006.

SETTING: NHIS.

PARTICIPANTS: Twenty-two thousand fifty-seven new respondents to the NHIS (2001-2004) and 24,139 respondents from the original development and validation cohorts (1997-2000).

MEASUREMENTS: A risk score was calculated for each respondent based on the presence or absence of 11 factors (function, illnesses, behaviors, demographics) that make up the index. Using the Kaplan-Meier method, 5-year mortality estimates were computed for the new and original cohort respondents and 9-year mortality estimates for the original cohorts.

RESULTS: New respondents were similar to original cohort respondents but were slightly more likely to be aged 85 and older, report diabetes mellitus, and have a body mass index of 25.0 kg/m² or greater. The model performed as well in the new cohort as it had in the original cohort. New respondents with risk scores of 0 to 1 had a 2% risk of 5-year mortality, whereas respondents who scored 18 or higher had a 69% risk of 5-year mortality (range 3-71% risk of 5-year mortality in the development cohort). The index also demonstrated excellent calibration and discrimination in predicting 9-year mortality (range 7% risk for scores of 0-1 to 92% risk for scores of ≥ 18, original validation cohort extended).

CONCLUSION: These results further justify use of this index to estimate life expectancy in clinical decision-making.

PURPOSE: For patients who elect to have prostate cancer screening, the optimal time to discontinue screening is unknown. Our objective was to describe rates and predictors of prostate-specific antigen (PSA) screening among older men in the United States.

METHODS: Data were extracted from the population-based 2000 and 2005 National Health Interview Survey (NHIS). PSA screening was defined as a PSA test as part of a routine exam within the past year. Demographic, socioeconomic, and functional characteristics were collected, and a validated 5-year estimated life expectancy was calculated. Age-specific rates of PSA screening were determined, and sampling weight-adjusted multivariate regressions were fitted to determine predictors of screening among men age 70 years or older.

RESULTS: The PSA screening rate was 24.0% in men age 50 to 54 years, and it increased steadily with age until a peak of 45.5% among age 70 to 74 years. Screening rates then gradually declined by age, and 24.6% of men age 85 years or older reported being screened. Among men age 70 years or older, screening rates varied by estimated 5-year life expectancy: rates were 47.3% in men with high life expectancies (≤ 15% probability of 5-year mortality), 39.2% in men with intermediate life expectancies (16% to 48% probability), and 30.7% in men with low life expectancies (> 48% probability; P < .001). In multivariate analysis, estimated life expectancy and age remained independently associated with PSA screening (P < .001 for each).

CONCLUSION: Rates of PSA screening in the United States are associated with age and estimated life expectancy, but excessive PSA screening in elderly men with limited life expectancies remains a significant problem. The merits and limitations of PSA should be discussed with all patients considering prostate cancer screening.

PURPOSE: To understand the impact of breast cancer on older women's survival, we compared survival of older women diagnosed with breast cancer with matched controls. METHODS Using the linked 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER) -Medicare data set, we identified women age 67 years or older who were newly diagnosed with ductal carcinoma in situ (DCIS) or breast cancer. We identified women not diagnosed with breast cancer from the 5% random sample of Medicare beneficiaries residing in SEER areas.We matched patient cases to controls by birth year and registry (99% or 66,039 [corrected] patient cases matched successfully). We assigned the start of follow-up for controls as the patient cases' date of diagnosis. Mortality data were available through 2006. We compared survival of women with breast cancer by stage with survival of controls using multivariable proportional hazards models adjusting for age at diagnosis, comorbidity, prior mammography use, and sociodemographics. We repeated these analyses stratifying by age.

RESULTS: Median follow-up time was 7.7 years. Differences between patient cases and controls in sociodemographics and comorbidities were small (< 4%). Women diagnosed with DCIS (adjusted hazard ratio [aHR], 0.7; 95% CI, 0.7 to 0.7) or stage I disease (aHR, 0.8; 95% CI, 0.8 to 0.8) had slightly lower mortality than controls.Women diagnosed with stage II disease or higher had greater mortality than controls (stage II disease:aHR, 1.2; 95% CI, 1.2 to 1.2). The association of a breast cancer diagnosis with mortality declined with age among women with advanced disease [corrected].

CONCLUSION: Compared with matched controls, a diagnosis of DCIS or stage I breast cancer in older women is associated with better [corrected] survival, whereas a diagnosis of stage II or higher breast cancer is associated with worse survival.

PURPOSE Few data are available on breast cancer characteristics, treatment, and survival for women age 80 years or older. PATIENTS AND METHODS We used the linked Surveillance, Epidemiology and End Results-Medicare data set from 1992 to 2003 to examine tumor characteristics, treatments (mastectomy, breast-conserving surgery [BCS] with radiation therapy or alone, or no surgery), and outcomes of women age 80 years or older (80 to 84, 85 to 89, > or = 90 years) with stage I/II breast cancer compared with younger women (age 67 to 79 years). We used Cox proportional hazard models to examine the impact of age on breast cancer-related and other causes of death. Analyses were performed within stage, adjusted for tumor and sociodemographic characteristics, treatments received, and comorbidities. Results In total, 49,616 women age 67 years or older with stage I/II disease were included. Tumor characteristics (grade, hormone receptivity) were similar across age groups. Treatment with BCS alone increased with age, especially after age 80. The risk of dying from breast cancer increased with age, significantly after age 80. For stage I disease, the adjusted hazard ratio of dying from breast cancer for women age > or = 90 years compared with women age 67 to 69 years was 2.6 (range, 2.0 to 3.4). Types of treatments received were significantly associated with age and comorbidity, with age as the stronger predictor (26% of women age > or = 80 years without comorbidity received BCS alone or no surgery compared with 6% of women age 67 to 79 years). CONCLUSION Women age > or = 80 years have breast cancer characteristics similar to those of younger women yet receive less aggressive treatment and experience higher mortality from early-stage breast cancer. Future studies should focus on identifying tumor and patient characteristics to help target treatments to the oldest women most likely to benefit.

CONTEXT: Despite increased focus on improving palliative care in the emergency department (ED), there is little research on how to best address the specific needs of this patient population.

OBJECTIVES: To better understand the experiences of acutely symptomatic patients seen in the ED.

METHODS: Using in-person semi-structured interviews, we explored the attitudes, experiences, and beliefs of 14 patients and seven family caregivers on the inpatient palliative care consult service, who had been admitted through the ED at two academic medical centers. We used a grounded theory approach to code responses. Transcripts were coded by a palliative medicine physician, an emergency medicine physician, and a general internist. Discrepancies were resolved by consensus. Coded sections were iteratively reviewed for interpretation, and concepts were collapsed into themes.

RESULTS: Five distinct themes emerged: 1) unprepared for managing symptoms at home; 2) uncertainty and anxiety; 3) communication is essential; 4) mixed experiences with symptom management; and 5) conflicting perspectives about the purpose of palliative care clinicians in the ED.

CONCLUSION: Patients and caregivers identified systems, communication, and clinical issues in ED care that should be a focus for future research.

OBJECTIVES: To exfamine patient perceptions of physician discussions and recommendations about total joint arthroplasty (TJA).

DESIGN: Prospective cohort study.

SETTING: One large academic medical center and four community affiliates in Boston.

PARTICIPANTS: One hundred seventy-four patients aged 65 and older with severe osteoarthritis of the hip or knee for at least 6 months not controlled with medications.

MEASUREMENTS: Patient perceptions of primary care physicians' (PCPs) and orthopedists' communication about TJA were assessed at baseline for all patients and at 12 months for those who did not undergo surgery.

RESULTS: Of the 174 patients, 49 were aged 80 and older, 82% were non-Hispanic white, and 69% had knee osteoarthritis. Eighty-seven percent of individuals with baseline interviews and a PCP (142/163) reported that they had discussed their hip or knee arthritis with their PCP at baseline, and 26% (42/163) reported that their PCP discussed TJA as a treatment option. Of the 128 patients who saw an orthopedist, 65% reported that their orthopedist recommended TJA. Only 29% (51/174) of patients underwent TJA. Those who reported discussing TJA with their PCP at baseline were more likely to undergo TJA (P<.01). Thirty-six percent (44/123) of the patients who did not undergo TJA reported that their PCP discussed surgery as a treatment option at baseline or at 12month follow-up.

CONCLUSION: Patients with severe osteoarthritis of their hip or knee who report discussing TJA as a treatment option with their PCP are more likely to undergo TJA within the next year, but few older adults report having these discussions. Improvement is needed in communication between PCPs and patients about TJA.