Aanand D. Naik

The Neglected Purpose of Comparative-Effectiveness Research

Drs. Aanand Naik and Laura Petersen write that surprisingly little attention has been paid to what they believe is the most critical question facing CER: Will its results significantly improve the quality and safety of the health care received by the average patient?

Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults.

Colorectal cancer (CRC) is common among older adults and surgical resection with curative intent is the primary treatment of CRC. Despite the changing demographics of CRC patients and increasing prevalence of multiple comorbidities, surgery is increasingly performed in this complex aging population. Clinically important short-term outcomes have improved for this population, but little is known about long-term outcomes. We review the literature to evaluate trends in CRC surgery in the geriatric population and the outcomes of surgical treatment. We explore the specific gaps in understanding longitudinal patient-centered outcomes of CRC treatment. We then propose adaptations from the geriatrics literature to better predict both short and long-term outcomes after CRC surgery. Interventions, such as prehabilitation, coupled with comprehensive geriatric assessment may be important future strategies for identifying vulnerable older patients, ameliorating the modifiable causes of vulnerability, and improving patient-centered longitudinal outcomes. Further research is needed to determine relevant aspects of geriatric assessments, identify effective intervention strategies, and demonstrate their validity in improving outcomes for at-risk older adults.

Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter–Associated Asymptomatic Bacteriuria

IMPORTANCE Overtreatment of asymptomatic bacteriuria (ASB) in patients with urinary catheters remains high. Health care professionals have difficulty differentiating cases of ASB from catheter-associated urinary tract infections. OBJECTIVES To evaluate the effectiveness and sustainability of an intervention to reduce urine culture ordering and antimicrobial prescribing for catheter-associated ASB compared with standard quality improvement methods. DESIGN, SETTING, AND PARTICIPANTS A preintervention and postintervention comparison with a contemporaneous control group from July 2010 to June 2013 at 2 Veterans Affairs health care systems. Study populations were patients with urinary catheters on acute medicine wards and long-term care units and health care professionals who order urine cultures and prescribe antimicrobials. INTERVENTION A multifaceted guidelines implementation intervention. MAIN OUTCOMES AND MEASURES The primary outcomes were urine cultures ordered per 1000 bed-days and cases of ASB receiving antibiotics (overtreatment) during intervention and maintenance periods compared with baseline at both sites. Patient-level analysis of inappropriate antimicrobial use adjusted for individual covariates. RESULTS Study surveillance included 289,754 total bed-days. The overall rate of urine culture ordering decreased significantly during the intervention period (from 41.2 to 23.3 per 1000 bed-days; incidence rate ration [IRR], 0.57; 95% CI, 0.53-0.61) and further during the maintenance period (to 12.0 per 1000 bed-days; IRR, 0.29; 95% CI, 0.26-0.32) (P < .001 for both). At the comparison site, urine cultures ordered did not change significantly across all 3 periods. There was a significant difference in the number of urine cultures ordered per month over time when comparing the 2 sites using longitudinal linear regression (P < .001). Overtreatment of ASB at the intervention site fell significantly during the intervention period (from 1.6 to 0.6 per 1000 bed-days; IRR, 0.35; 95% CI, 0.22-0.55), and these reductions persisted during the maintenance period (to 0.4 per 1000 bed-days; IRR, 0.24; 95% CI, 0.13-0.42) (P < .001 for both). Overtreatment of ASB at the comparison site was similar across all periods (odds ratio, 1.32; 95% CI, 0.69-2.52). When analyzed by type of ward, the decrease in ASB overtreatment was significant in long-term care. CONCLUSIONS AND RELEVANCE A multifaceted intervention targeting health care professionals who diagnose and treat patients with urinary catheters reduced overtreatment of ASB compared with standard quality improvement methods. These improvements persisted during a low-intensity maintenance period. The impact was more pronounced in long-term care, an emerging domain for antimicrobial stewardship.

Bathing Disability in Community-Living Older Persons: Common, Consequential, and Complex

Objectives: To identify the specific bathing subtasks that are affected in community‐living‐older persons with bathing disability and to determine the self‐reported reasons for bathing disability.

Patient Autonomy for the Management of Chronic Conditions: A Two-Component Re-Conceptualization

The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic care. The purpose of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy.

Risk of Lower and Upper Gastrointestinal Bleeding, Transfusions, and Hospitalizations with Complex Antithrombotic Therapy in Elderly Patients

Background— Complex antithrombotic therapy (CAT) prescribed to elderly patients increases the risk of gastrointestinal bleeding. We quantified upper (UGIE) and lower gastrointestinal (LGIE) events, transfusions, and hospitalizations in a national cohort of elderly veterans prescribed CAT. Methods and Results— Veterans ≥60 years of age prescribed anticoagulant-antiplatelet, aspirin (ASA)-antiplatelet, ASA-anticoagulant, or triple therapy (ie, TRIP, anticoagulant-antiplatelet-ASA) were identified from the national pharmacy database (October 1, 2002 to September 30, 2008). Prescription-fill data were linked to Veteran Affairs and Medicare encounter files, each person-day of follow-up was assessed for CAT exposure, and outcomes were defined by using diagnostic code algorithms derived following chart abstraction. Incidence density ratios (compared with the reference category of no CAT) and survival analysis was conducted. Among 78 133 veterans (98.6% white; mean age, 72.3 [standard deviation 7.7]), 64% were prescribed ASA-antiplatelet and anticoagulant-antiplatelet and 6% were prescribed TRIP. The incidence of UGIE was 20.1/1000 patient-years, and the incidence of LGIE was 70.1/1000 patient-years. ASA-anticoagulant and TRIP were associated with the highest incidence of transfusion and hospitalization. A 40% to 60% increased risk of UGIE was observed with all strategies. LGIE was 30% higher with anticoagulant-antiplatelet, and transfusion increased with ASA-anticoagulant (hazard ratio, 6.1; 95% confidence interval, 5.2–7.1) and TRIP (hazard ratio, 5.0; 95% confidence interval, 4.2–5.8). Increased risk of hospitalization was noted with all strategies. The number needed to harm for UGIE or LGIE ranged from 52 to 65 and 15 to 23, respectively. The number needed to harm for hospitalization was 39 (anticoagulant-antiplatelet), 34 (ASA-anticoagulant), 67 (ASA-antiplatelet), and 45 (TRIP) patients. Conclusions— Among elderly patients, CAT-related LGIE and UGIE are clinically relevant risks resulting in increased hospitalizations and transfusions.

The utility of the Kohlman Evaluation of Living Skills test is associated with substantiated cases of elder self-neglect.

Purpose: Self‐neglect is the most prevalent finding among cases reported to Adult Protective Services (APS) and is characterized by an inability to meet one’s own basic needs. The Kohlman evaluation of living skills (KELS) has been validated in geriatric populations to assess performance with both instrumental and basic activities of daily living and as an assessment tool for the capacity to live independently; therefore, the purpose of this analysis was to compare the scores of the KELS between substantiated cases of self‐neglect and matched community‐dwelling elders. Data sources: This is a cross‐sectional pilot study of 50 adults aged 65 years and older who were recruited from APS as documented cases of self‐neglect and 50 control participants recruited from Harris County Hospital District outpatient clinics. Control participants were matched for age, race, gender, and ZIP code. A geriatric nurse practitioner (NP)–led team administered a comprehensive geriatric assessment in homes of all study participants. The assessment included the KELS and mini‐mental state examination (MMSE) tests. Chi‐square analyses were used to determine if cases of self‐neglect were significantly more likely to fail the KELS test than matched controls. Conclusions: The analyses revealed that self‐neglectors were significantly more likely to fail the KELS than non‐self‐neglectors (50% vs. 30%, p = .025). When stratified by MMSE scores, self‐neglectors with intact cognitive function remained significantly more likely to fail the KELS compared to matched, cognitively intact controls (45% vs. 17%, p = .013). Abnormal results using an in‐home KELS test were significantly associated with substantiated cases of self‐neglect. Implications for practice: There is currently no gold‐standard measure for identifying capacity with self‐care behaviors among cases of self‐neglect. As a result, self‐neglect may remain unidentified in many clinical settings. The KELS provides clinicians with an objective measure of an individual’s capacity and performance with everyday life–supporting tasks and thus, provides information that can help NPs identify elders at risk for self‐neglect. These findings suggest that the KELS test has significant utility as part of a comprehensive geriatric assessment to aid clinicians in suspected cases of self‐neglect.

Surveillance endoscopy is associated with improved outcomes of oesophageal adenocarcinoma detected in patients with Barrett's oesophagus

Background The effectiveness of surveillance endoscopy in patients with Barretts oesophagus (BE) for reducing oesophageal adenocarcinoma (EAC)-related mortality in patients with BE is unclear. Methods This is a cohort study of patients with BE diagnosed in the National Veterans Affairs hospitals during 2004–2009 excluding those with conditions that affect overall survival. We identified those diagnosed with EAC after BE diagnosis through 2011 and conducted chart reviews to identify BE surveillance programme, and indication for EAC diagnosis, verify diagnosis, stage, therapy and cause of death. We examined the association between surveillance indication for EAC diagnosis with or without surveillance programme and EAC stage and treatment receipt in logistic regression models, and with time to death or cancer-related death using a Cox proportional hazards regression model. Results Among 29 536 patients with BE, 424 patients developed EAC during a mean follow-up of 5.0 years. A total of 209 (49.3%) patients with EAC were in BE surveillance programme and were diagnosed as a result of surveillance endoscopy. These patients were more likely to be diagnosed at an early stage (stage 0 or 1: 74.7% vs 56.2, p<0.001), survived longer (median 3.2 vs 2.3 years; p<0.001) and have lower cancer-related mortality (34.0% vs 54.0%, p<0.0001) and had a trend to receive oesophagectomy (51.2% vs 42.3%; p=0.07) than 215 patients diagnosed by non-BE surveillance endoscopy (17.2% of whom were BE surveillance failure). BE surveillance endoscopy was associated with a decreased risk of cancer-related death (HR 0.47, 0.35 to 0.64), which was largely explained by the early stage of EAC at the time of diagnosis. Similarly, the adjusted mortality for patients with cancer in a prior surveillance programme for overall death was 0.63 (0.47 to 0.84) compared with patients with cancer not in a surveillance programme. Conclusions Surveillance endoscopy among patients with BE is associated with significantly better EAC outcomes including cancer-related mortality compared with other non-surveillance endoscopy.

Underutilization of Environmental Adaptations for Bathing in Community‐Living Older Persons

Objectives: To determine the prevalence and utilization of environmental adaptations (home modifications and assistive devices) for bathing in community‐living older persons with and without bathing disability.

Reconceptualizing the Experience of Surrogate Decision Making: Reports vs Genuine Decisions

BACKGROUND We propose a reconceptualization of surrogate decision making when patients lack an advance directive stating their preferences about life-sustaining treatment. This reconceptualization replaces the current 2-standard model of substituted judgment (based on the patient’s prior preferences and values) and best interests (an assessment of how best to protect and promote the patient’s health-related and other interests). METHODS We undertook a conceptual analysis based on the ethics of informed consent, a qualitative study of how surrogates of seriously ill patients experience the surrogate’s role, and descriptions of decision making. RESULTS When the surrogate can meet the substituted judgment standard, the experience of the surrogate should be understood as providing a report, not making a decision. Surrogate decisions based on the best interest standard are experienced as genuine decisions, and the label “surrogate decision making” should be reserved to characterize only these experiences. CONCLUSIONS Physicians should identify clinically reasonable options and elicit the surrogate’s sense of decision-making burden. Some surrogates will be able to make reports, and the physician should make a clear recommendation that implements the patient’s reported preference. Some surrogates will confront genuine decisions, which should be managed by negotiating treatment goals. Requests by the surrogate that everything be done may represent a psychosocially burdensome decision, and support should be provided to help the surrogate work through the decision-making process.