Ana R. Quiñones

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey.

In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.

Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries

In the first of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues find low levels of surgical care provision suggesting unmet need for surgical services.

Screening for hepatocellular carcinoma in chronic liver disease: a systematic review.

Hepatocellular carcinoma (HCC) incidence and mortality have increased internationally over the past 4 decades (1, 2), with localized tumors accounting for most of the increase (3). The rationale for screening is that imaging tests, such as ultrasonography, may identify patients with early-stage HCC (4), and several potential options exist for treating patients with early-stage HCC, including liver transplantation, radiofrequency ablation, and liver resection (5). Several professional societies currently recommend HCC screening using imaging studies and tumor markers, primarily in patients at higher risk for HCC due to chronic hepatitis B or cirrhosis (57). However, recommendations for HCC screening remain controversial, in part because of concerns over the quality and paucity of existing evidence and because concerns about overdiagnosis and patient harms have been raised in other cancer screening programs (812). We conducted a systematic review of the published literature to better understand the incremental benefits and harms of routine HCC screening compared with clinical diagnosis. Methods This manuscript is part of a larger report commissioned by the Veterans Health Administration (13). A protocol describing the review plan was posted to a public Web site before the study was initiated (14). The analytic framework that guided this review was developed in collaboration with a panel of technical experts and is provided in Figure 1 of Supplement 1. Supplement 1. Figures Data Sources and Searches We searched MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from database inception to June 2013. We updated the MEDLINE, PsycINFO, and ClinicalTrials.gov searches in April 2014. The detailed search strategy is provided in Supplement 2. We obtained additional articles from systematic reviews, reference lists of pertinent studies, reviews, and editorials and by consulting technical advisors. Supplement 2. Search Strategy Study Selection Detailed inclusion and exclusion criteria are provided in Supplement 3. We included English-language, controlled clinical trials and observational studies that assessed the effects of screening on HCC-specific and all-cause mortality in adult populations. We used the term screening to include any surveillance or screening program in which specific tests (ultrasonography, computed tomography, magnetic resonance imaging, or -fetoprotein measurement) were performed explicitly to detect HCC in asymptomatic patients. Studies had to include a comparison group of patients who did not have routine screening. We excluded observational studies that did not consider important confounding factors, such as age, sex, and liver disease severity. Because we anticipated few clinical trials comparing screening versus no screening, we also included trials comparing frequencies of screening. We included studies of any population with chronic liver disease with or without cirrhosis but excluded studies of patients with prior HCC. We also searched for systematic reviews and primary studies that focused on potential harms of HCC screening. Supplement 3. Inclusion/Exclusion Criteria Seven investigators reviewed the titles and abstracts of citations identified from literature searches. If at least 1 reviewer indicated that a citation may be relevant, a second reviewer screened the citation for concordance. Two reviewers independently assessed the full-text articles for inclusion using the eligibility criteria in Supplement 3. Disagreements were resolved through consensus. Data Extraction and Quality Assessment From each study, we abstracted study design, objectives, setting, population characteristics (including sex, age, race or ethnicity, and liver disease cause and severity), patient eligibility and exclusion criteria, number of patients, years of enrollment, method and frequency of screening, adjusted and unadjusted mortality, and adverse events. A second author checked each entry for accuracy. Two reviewers independently assessed the quality of each trial by using a tool developed by the Cochrane Collaboration (15). We resolved disagreements through discussion. Each trial was given an overall summary assessment of low, high, or unclear risk of bias. Two reviewers graded the strength of evidence for outcomes by using published criteria that consider the consistency, coherence, directness, and applicability of a body of evidence as well as the internal validity of individual studies (16). We adapted existing tools to assess the quality of observational studies (1719). We do not report an overall summary assessment for observational studies because there are no validated criteria for doing so. Data Synthesis and Analysis We qualitatively synthesized the evidence on the benefits and harms of HCC screening. Clinical heterogeneity and the small number of trials precluded a meta-analysis of the findings. Role of the Funding Source The U.S. Department of Veterans Affairs Quality Enhancement Research Initiative supported this review but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Results The electronic and manual searches yielded 13801 total citations, from which we identified 286 potentially relevant full-text articles. Twenty-two primary studies contained primary data relevant to the efficacy of HCC screening and met our inclusion criteria (Figure). Figure. Summary of evidence search and selection. RCT = randomized, controlled trial. Effects of Screening on Mortality Two trials and 18 observational studies provided very-low-strength evidence from which to draw conclusions about the mortality effects of HCC screening compared with no screening. The trials had substantial methodological flaws that threatened their internal validity, and their findings have limited applicability beyond the patient population with hepatitis B. The observational studies, most of which included patients with cirrhosis and hepatitis B, hepatitis C, or alcoholic liver disease, showed that screening detects patients with earlier-stage disease, who more frequently receive curative therapy. However, it is impossible to say whether the longer survival in patients with screen-detected disease was a true effect of screening or reflects lead- and length-time biases inherent to all observational studies, as well as selection biases that were common in many of the studies. Randomized, Controlled Trials Two community-based trials compared the effects on mortality of screening versus no screening (20, 21). Both were conducted in China in areas with high prevalence of HCC, and most participants had hepatitis B with or without cirrhosis (Table 1 of Supplement 4). One cluster randomized trial recruited screening group participants (n= 9757) from 1993 to 1995 and offered them serum -fetoprotein testing and ultrasonography every 6 months. Participants in the control group (n= 9443) were not made aware of the study nor actively followed. Death from HCC occurred less frequently in the screening group (83.2 vs. 131.5 per 100000 person-years; rate ratio, 0.63 [95% CI, 0.41 to 0.98]). Supplement 4. Tables However, the trial had several serious methodological limitations that gave it a high risk of bias (Table 2 of Supplement 4). One major concern is whether patients in both groups had the same risk for HCC. There is no information about randomization technique or allocation concealment and very little information about the baseline characteristics of the 2 groups, which is especially important in cluster randomized trials. Another concern is that weak methods used to ascertain the outcome measuredeath from HCCcould have introduced bias. If deaths were underreported in the control group, results could have been biased toward the null. On the other hand, if outcome adjudicators were not blinded, more deaths in the control group could have been misclassified as HCC-related, especially because the symptoms that define stage III HCC (cachexia, jaundice, and ascites) overlap substantially with symptoms of end-stage liver disease and no data were provided about liver disease severity in either group. Selective reporting and analysis of favorable outcomes were other concerns. Although the authors reported that vital status was available for all patients, overall mortality was not reported and there was no statistical adjustment for the effects of clustering. Finally, the study is less applicable to patients in the United States, in whom cirrhosis and thus HCC are usually secondary to hepatitis C, and the results probably have limited applicability to contemporary practice, in which the threshold for imaging for symptoms may be lower and the number of patients with incidentally discovered HCC on imaging is higher. The second trial used patient-level randomization stratified by township to assign patients with hepatitis B from 1989 to 1992 to the screening intervention (n= 3712), which consisted of serial -fetoprotein tests followed by ultrasonography for high -fetoprotein values, or the usual care group (n= 1869) (21). The population-based cancer registry used active case-finding techniques, and mortality was ascertained through the cancer registry and a population-based vital status registry. Cancer staging and cause of death were assessed by personnel blinded to intervention status. Only 28.8% of screening group participants completed all scheduled testing, but all participants completed at least 1 screening test. Fewer patients had stage III HCC in the screening group (19.8% vs. 41.0%; P value not reported). Hepatocellular carcinoma mortality was similar in both groups (1138 vs. 1114 per 100000 person-years; P= 0.86), as was all-cause mortality (1843 vs. 1788 per 100000 person-years; P value not s

Evolving Self-Rated Health in Middle and Old Age: How Does it Differ Across Black, Hispanic, and White Americans?

Objective:This research focuses on ethnic variations in the intraindividual changes in self-rated health. Method: Data came from the Health and Retirement Study involving up to 6 repeated observations between 1995 and 2006 of a national sample of 18,486 Americans above 50 years of age. Hierarchical linear models were employed in depicting variations in self-rated health across White, Black, and Hispanic Americans. Results: Subjective health worsened over time albeit moderately. Relative to younger persons, older individuals rated their health poorer with a greater rate of deteriorating health. With reference to ethnic variations in the intercept and slope of perceived health, White Americans rated their health most positively, followed by Black Americans, with Hispanics rating their health least positively. This pattern held even when socioeconomic status, social networks, and prior health were adjusted. Discussion: Significant ethnic differences exist in the evolvement of self-rated health in middle and late life. Further inquiries may include analyzing ethnic heterogeneities from a person-centered perspective, health disparities across subgroups of Hispanics, effects of neighborhood attributes, and implications of left truncation.

Ethnicity and Changing Functional Health in Middle and Late Life: A Person-Centered Approach

OBJECTIVES Following a person-centered approach, this research aims to depict distinct courses of disability and to ascertain how the probabilities of experiencing these trajectories vary across Black, Hispanic, and White middle-aged and older Americans. METHODS Data came from the 1995-2006 Health and Retirement Study, which involved a national sample of 18,486 Americans older than 50 years of age. Group-based semiparametric mixture models (Proc Traj) were used for data analysis. RESULTS Five trajectories were identified: (a) excellent functional health (61%), (b) good functional health with small increasing disability (25%), (c) accelerated increase in disability (7%), (d) high but stable disability (4%), and (e) persistent severe impairment (3%). However, when time-varying covariates (e.g., martial status and health conditions) were controlled, only 3 trajectories emerged: (a) healthy functioning (53%), moderate functional decrement (40%), and (c) large functional decrement (8%). Black and Hispanic Americans had significantly higher probabilities than White Americans in experiencing poor functional health trajectories, with Blacks at greater risks than Hispanics. CONCLUSIONS Parallel to the concepts of successful aging, usual aging, and pathological aging, there exist distinct courses of changing functional health over time. The mechanisms underlying changes in disability may vary between Black and Hispanic Americans.

Early Warning System Scores for Clinical Deterioration in Hospitalized Patients: A Systematic Review

RATIONALE Early warning system (EWS) scores are used by hospital care teams to recognize early signs of clinical deterioration and trigger more intensive care. OBJECTIVE To systematically review the evidence on the ability of early warning system scores to predict a patients risk of clinical deterioration and the impact of early warning system implementation on health outcomes and resource utilization. METHODS We searched the MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials databases through May 2014. We included English-language studies of early warning system scores used with adults admitted to medical or surgical wards. We abstracted study characteristics, including population, setting, sample size, duration, and criteria used for early warning system scoring. For predictive ability, the primary outcomes were modeled for discrimination on 48-hour mortality, cardiac arrest, or pulmonary arrest. Outcomes for the impact of early warning system implementation included 30-day mortality, cardiovascular events, use of vasopressors, respiratory failure, days on ventilator, and resource utilization. We assessed study quality using a modified Quality in Prognosis Studies assessment tool where applicable. MEASUREMENTS AND MAIN RESULTS Of 11,183 citations studies reviewed, one controlled trial and 20 observational studies of 13 unique models met our inclusion criteria. In eight studies, researchers addressed the predictive ability of early warning system tools and found a strong predictive value for death (area under the receiver operating characteristic curve [AUROC], 0.88-0.93) and cardiac arrest (AUROC, 0.74-0.86) within 48 hours. In 13 studies (one controlled trial and 12 pre-post observational studies), researchers addressed the impact on health outcomes and resource utilization and had mixed results. The one controlled trial was of good quality, and the researchers found no difference in mortality, transfers to the ICU, or length of hospital stay. The pre-post designs of the remaining studies have significant methodological limitations, resulting in insufficient evidence to draw conclusions. CONCLUSIONS Early warning system scores perform well for prediction of cardiac arrest and death within 48 hours, although the impact on health outcomes and resource utilization remains uncertain, owing to methodological limitations. Efforts to assess performance and effectiveness more rigorously will be needed as early warning system use becomes more widespread.

Multiple trajectories of depressive symptoms in middle and late life: racial/ethnic variations.

This research aims to identify distinct courses of depressive symptoms among middle-aged and older Americans and to ascertain how these courses vary by race/ethnicity. Data came from the 1995-2006 Health and Retirement Study which involved a national sample of 17,196 Americans over 50 years of age with up to six repeated observations. Depressive symptoms were measured by an abbreviated version of the Center for Epidemiologic Studies Depression scale. Semiparametric group based mixture models (Proc Traj) were used for data analysis. Six major trajectories were identified: (a) minimal depressive symptoms (15.9%), (b) low depressive symptoms (36.3%), (c) moderate and stable depressive symptoms (29.2%), (d) high but decreasing depressive symptoms (6.6%), (e) moderate but increasing depressive symptoms (8.3%), and (f) persistently high depressive symptoms (3.6%). Adjustment of time-varying covariates (e.g., income and health conditions) resulted in a similar set of distinct trajectories. Relative to White Americans, Black and Hispanic Americans were significantly more likely to be in trajectories of more elevated depressive symptoms. In addition, they were more likely to experience increasing and decreasing depressive symptoms. Racial and ethnic variations in trajectory groups were partially mediated by SES, marital status, and health conditions, particularly when both interpersonal and intrapersonal differences in these variables were taken into account.

How Does the Trajectory of Multimorbidity Vary Across Black, White, and Mexican Americans in Middle and Old Age?

OBJECTIVES This research examines intra- and interpersonal differences in multiple chronic conditions reported by Americans aged 51 and older for a period up to 11 years. It focuses on how changes in multimorbidity vary across White, Black, and Mexican Americans. METHODS Data came from 17,517 respondents of the Health and Retirement Study (1995-2006) with up to 5 repeated observations. Hierarchical linear models were employed to analyze ethnic variations in temporal changes of reported comorbidities. FINDINGS Middle-aged and older Americans have on average nearly 2 chronic diseases at the baseline, which increased to almost 3 conditions in 11 years. White Americans differ from Black and Mexican Americans in terms of level and rate of change of multimorbidity. Mexican Americans demonstrate lower initial levels and slower accumulation of comorbidities relative to Whites. In contrast, Blacks showed an elevated level of multimorbidity throughout the 11-year period of observation, although their rate of change slowed relative to Whites. DISCUSSION These results suggest that health differences between Black Americans and other ethnic groups including White and Mexican Americans persist in the trajectory of multimorbidity even when population heterogeneity is adjusted. Further research is needed concerning the impact of health disadvantages and differential mortality that may have occurred before middle age as well as exploring the role of nativity, the nature of self-reported diseases, and heterogeneity underlying the average trajectory of multimorbidity for ethnic elders.

Multimorbidity Combinations and Disability in Older Adults

BACKGROUND Multimorbidity (multiple co-occurring chronic diseases) is associated with greater likelihood of disability and mortality, above and beyond the risk attributable to individual diseases. This study identifies prevalent multimorbidity patterns and evaluates their association with disability among U.S. older adults. METHODS Prospective cohort study using longitudinal Health and Retirement Study data (2010-2012). We included 8,782 participants aged 65 years and older and used negative binomial models to examine prospective disability, measured by the combined activities of daily living-instrumental activities of daily living index. Multimorbidity was defined as the co-occurring combination of at least two of the following chronic diseases: hypertension, cardiovascular disease, lung disease, diabetes, cancer, arthritis, stroke, cognitive impairment, or high depressive symptoms (CES-D score ≥ 4). RESULTS We found 291 unique disease combinations with 1 to 1,167 older adults per disease combination. The three most prevalent combinations were: (a) hypertension and arthritis (n = 1,167); (b) hypertension, arthritis, and cardiovascular disease (n = 510); and (c) hypertension, arthritis, and diabetes (n = 430). Only one of the prevalent combinations included depressive symptoms (in combination with arthritis, hypertension; n = 129). This group showed the highest level of activities of daily living-instrumental activities of daily living disability compared to healthy participants or participants with a single disease (either included in the combination or different from diseases in the combination) even after adjusting for age, gender, education, race/ethnicity, and body mass index. CONCLUSIONS Clinicians stand to gain from a better understanding of which disease combinations are more and less disabling among older adults. Understanding how multimorbidity combinations relate to functional status is an important step towards reducing disability and sustaining independent living among older adults.

Racial and Ethnic Differences in Receipt of Antidepressants and Psychotherapy by Veterans With Chronic Depression

OBJECTIVE This study characterized racial-ethnic differences in treatment of veterans with chronic depression by examining antidepressant and psychotherapy use among non-Hispanic black, non-Hispanic white, Hispanic, Asian, and American Indian-Alaska Native (AI/AN) veterans. METHODS Logistic regression models were estimated with data from the U.S. Department of Veterans Affairs (VA) medical records for a sample of 62,095 chronically depressed patients. Data (2009-2010) were from the VA External Peer Review Program. Three primary outcome measures were used: receipt of adequate antidepressant therapy (≥80% medications on hand), receipt of adequate psychotherapy (at least six sessions in six months), and receipt of guideline-concordant treatment (either of these treatments). RESULTS Compared with whites, nearly all minority groups had lower odds of adequate antidepressant use and guideline-concordant care in unadjusted and adjusted models (antidepressant adjusted odds ratio [AOR] range=.53-.82, p<.05; guideline-concordant AOR range=.59-.83, p<.05). Although receipt of adequate psychotherapy was more common among veterans from minority groups in unadjusted analyses, differences between Hispanic, AI/AN, and white veterans were no longer significant after covariate adjustment. After adjustment for distance to the VA facility, the difference between black and white veterans was no longer significant. CONCLUSIONS A better understanding of how patient preferences and provider and system factors interact to generate differences in depression care is needed to improve care for patients from racial-ethnic minority groups. It will become increasingly important to differentiate between health service use patterns that stem from genuine differences in patient preferences and those that signify inequitable quality of depression care.