Carmen E. Guerra

Three-Year Outcomes for Medicare Beneficiaries Who Survive Intensive Care

CONTEXT Although hospital mortality has decreased over time in the United States for patients who receive intensive care, little is known about subsequent outcomes for those discharged alive. OBJECTIVE To assess 3-year outcomes for Medicare beneficiaries who survive intensive care. DESIGN, SETTING, AND PATIENTS A matched, retrospective cohort study was conducted using a 5% sample of Medicare beneficiaries older than 65 years. A random half of all patients were selected who received intensive care and survived to hospital discharge in 2003 with 3-year follow-up through 2006. From the other half of the sample, 2 matched control groups were generated: hospitalized patients who survived to discharge (hospital controls) and the general population (general controls), individually matched on age, sex, race, and whether they had surgery (for hospital controls). MAIN OUTCOME MEASURE Three-year mortality after hospital discharge. RESULTS There were 35,308 intensive care unit (ICU) patients who survived to hospital discharge. The ICU survivors had a higher 3-year mortality (39.5%; n = 13,950) than hospital controls (34.5%; n = 12,173) (adjusted hazard ratio [AHR], 1.07 [95% confidence interval {CI}, 1.04-1.10]; P < .001) and general controls (14.9%; n = 5266) (AHR, 2.39 [95% CI, 2.31-2.48]; P < .001). The ICU survivors who did not receive mechanical ventilation had minimal increased risk compared with hospital controls (3-year mortality, 38.3% [n = 12,716] vs 34.6% [n=11,470], respectively; AHR, 1.04 [95% CI, 1.02-1.07]). Those receiving mechanical ventilation had substantially increased mortality (57.6% [1234 ICU survivors] vs 32.8% [703 hospital controls]; AHR, 1.56 [95% CI, 1.40-1.73]), with risk concentrated in the 6 months after the quarter of hospital discharge (6-month mortality, 30.1% (n = 645) for those receiving mechanical ventilation vs 9.6% (n = 206) for hospital controls; AHR, 2.26 [95% CI, 1.90-2.69]). Discharge to a skilled care facility for ICU survivors (33.0%; n = 11,634) and hospital controls (26.4%; n = 9328) also was associated with high 6-month mortality (24.1% for ICU survivors and hospital controls discharged to a skilled care facility vs 7.5% for ICU survivors and hospital controls discharged home; AHR, 2.62 [95% CI, 2.50-2.74]; P < .001 for ICU survivors and hospital controls combined). CONCLUSIONS There is a large US population of elderly individuals who survived the ICU stay to hospital discharge but who have a high mortality over the subsequent years in excess of that seen in comparable controls. The risk is concentrated early after hospital discharge among those who require mechanical ventilation.

Barriers of and Facilitators to Physician Recommendation of Colorectal Cancer Screening

BACKGROUNDColorectal cancer screening (CRCS) has been demonstrated to be effective and is consistently recommended by clinical practice guidelines. However, only slightly over half of all Americans have ever been screened. Patients cite physician recommendation as the most important motivator of screening. This study explored the barriers of and facilitators to physician recommendation of CRCS.METHODSA 3-component qualitative study to explore the barriers of and facilitators to physician recommendation of CRCS: in-depth, semistructured interviews with 29 purposively sampled, community- and academic-based primary care physicians; chart-stimulated recall, a technique that utilizes patient charts to probe physician recall and provide context about the barriers of and facilitators to physician recommendation of CRCS during actual clinic encounters; and focus groups with 18 academic primary care physicians. Grounded theory techniques of analysis were used.RESULTSAll the participating physicians were aware of and recommended CRCS. The overwhelmingly preferred test was colonoscopy. Barriers of physician recommendation of CRCS included patient comorbidities, prior patient refusal of screening, physician forgetfulness, acute care visits, lack of time, and lack of reminder systems and test tracking systems. Facilitators to physician recommendation of CRCS included patient request, patient age 50–59, physician positive attitudes about CRCS, physician prioritization of screening, visits devoted to preventive health, reminders, and incentives.CONCLUSIONThere are multiple physician, patient, and system barriers to recommending CRCS. Thus, interventions may need to target barriers at multiple levels to successfully increase physician recommendation of CRCS.

Are Physicians Discussing Prostate Cancer Screening with Their Patients and Why or Why Not? A Pilot Study

BACKGROUNDProstate cancer screening (PCS) is controversial. Ideally, patients should understand the risks and benefits of screening before undergoing PSA testing. This study assessed whether primary care physicians routinely discuss PCS and explored the barriers to and facilitators of these discussions.METHODSQualitative pilot study involving in-depth, semistructured interviews with 18 purposively sampled, academic and community-based primary care physicians. Barriers and facilitators of PCS discussions were ascertained using both interviews and chart-stimulated recall—a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinic encounters. Analysis was performed using consensus conferences based on grounded theory techniques.RESULTSAll 18 participating physicians reported that they generally discussed PCS with patients, though 6 reported sometimes ordering PSA tests without discussion. A PCS discussion occurred in only 16 (36%) of the 44 patient–physician encounters when patients were due for PCS that also met criteria for chart-stimulated recall. Barriers to PCS discussion were patient comorbidity, limited education/health literacy, prior refusal of care, physician forgetfulness, acute-care visits, and lack of time. Facilitators of PCS discussion included patient-requested screening, highly educated patients, family history of prostate cancer, African-American race, visits for routine physicals, review of previous PSA results, extra time during encounters, and reminder systems.CONCLUSIONSPCS discussions sometimes do not occur. Important barriers to discussion are inadequate time for health maintenance, physician forgetfulness, and patient characteristics. Future research should explore using educational and decision support interventions to involve more patients in PCS decisions.

Literacy and Knowledge, Attitudes, and Behavior About Colorectal Cancer Screening

ABSTRACT This cross-sectional survey explored the association between functional health literacy and knowledge of, beliefs and attitudes about, and reported usage of colorectal cancer screening tests. The results indicate that functional health literacy, as assessed by the Short Test of Functional Health Literacy in Adults (STOFHLA), is not an independent predictor of colorectal cancer screening knowledge, beliefs, attitudes, or behavior. Latino ethnicity and education, however, often predicted screening responses, suggesting that efforts to improve communication about colorectal cancer screening with Latino patients and patients with low education clearly are needed to reduce the disparities in awareness and utilization of colorectal cancer screening tests. This study also explored influences on intended screening behavior. Physician recommendation was found to be a powerful motivator of intention to undergo colorectal cancer screening regardless of literacy level, indicating that interventions aimed at increasing physician recommendation of colorectal cancer screening may be an effective way of increasing screening rates.

Literacy and Knowledge, Attitudes and Behavior About Mammography in Latinas

This cross-sectional study explored the association between functional health literacy and the knowledge, beliefs, attitudes, and behavior about mammography and self-breast examination in a sample of Latinas attending community health clinics in Philadelphia. The results show that 70% of Latinas had inadequate or marginal functional health literacy. In Latinas, functional health literacy is only weakly associated with knowledge and not associated with beliefs and attitudes about screening mammography, but is significantly associated with having ever had a mammogram. After adjusting for demographic characteristics, functional health literacy was significantly associated with having ever had a mammogram (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.02-1.27). These findings suggest that Latinas with poor functional health literacy are less likely to undergo mammography. Future research should target increasing the knowledge about and rates of screening mammography in patients with low functional health literacy.

Determinants of Coronary Artery Calcification Progression in Renal Transplant Recipients

Coronary artery calcification (CAC) is associated with increased atherosclerotic burden and cardiovascular events. The objective of this study was to determine the natural history and risk factors associated with CAC progression in a cohort of incident asymptomatic renal transplant recipients with no history of coronary revascularization. Electron‐beam computed tomography was performed in 82 subjects at time of transplantation and at least 1 year later. Mean (SD) and median CAC score increased for all subjects from 392.4 (747.9) and 75.8 at time of transplant to 475.3 (873.5), (p = 0.002[log]) and 98.9 (p < 0.001), respectively. Most subjects (89%) with no calcifications remained without calcification. Mean annualized rate (SD) of CAC score change was 52.5 (150) with a median of 0.5. Average yearly percent change was 67.3 (409.6) with a median of 1.4. In multivariate analysis, diastolic blood pressure at 3 months post‐transplant, Caucasian race, glomerular filtration rate at 3.0, months post‐transplant, body mass index and baseline CAC score were independent predictors of annualized rate of CAC change. There is significant progression of CAC post‐renal transplantation in most subjects. Progression is most likely to occur in white patients and is associated with clinical factors such as blood pressure, body mass index, renal function and baseline CAC score.

Diffusion of breast cancer risk assessment in primary care.

Background: Physicians who provide primary care to women have the opportunity to identify patients at high risk for breast cancer who are candidates for risk reduction strategies. Our objective was to determine the prevalence and determinants of the adoption of breast cancer risk assessment by primary care physicians. Methods: A cross-sectional survey of a nationally representative random sample of 351 internists, family practitioners, and obstetricians-gynecologists. We used a questionnaire that assessed knowledge, attitudes, discussion of breast cancer risk, use of software to calculate breast cancer risk, and ordering of BRCA1/2 testing. Results: Eighty-eight percent of physicians reported discussing breast cancer risk at least once during the previous 12 months; 48% had ordered or referred a patient for BRCA1/2 testing; and 18% had used a software program to calculate breast cancer risk. Physicians who had used BRCA1/2 testing or discussed breast cancer risk factors were more likely to be obstetrician-gynecologists and not in a solo practice; the use of risk software was also more common among obstetrician-gynecologists but was also associated with having a family member with breast cancer and a greater knowledge about breast cancer risk. Having patients ask for risk information was associated with the discussion of risk factors but not with the other risk assessment strategies. Conclusions: Diffusion of breast cancer risk assessment is occurring in primary care practices, with a greater adoption of BRCA1/2 testing than of the use of risk assessment software. Adoption of these strategies seems to be related to the salience of breast cancer personally (for the physician) and within the practice, as well as the size of the practice, rather than attitudes about the risk assessment methods.

Adapting a patient satisfaction instrument for low literate and Spanish-speaking populations: Comparison of three formats

OBJECTIVE To compare responses to print versions of the Consumer Assessment of Healthcare Providers and Systems 2.0 survey (CAHPS) to those for an illustration enhanced format and a telephone based interactive voice response format. METHODS First, 2015 adult patients awaiting primary care visits completed: demographic information, Test of Functional Health Literacy (S-TOFHLA), CAHPS in one of three formats: print, illustrated, or interactive voice. A second sample of 4800 active patients was randomized to receive alternative formats. RESULTS Response rates for the illustrated (31.3%) and print (30.4%) formats were significantly higher than for the interactive voice format (18.1%). The results of the illustrated format were comparable to the traditional text version, but required about 2 min more to complete by both low and high literacy groups. There were almost no invalid responses for the interactive voice format, but the format was associated with lower CAHPS satisfaction scores. CONCLUSION Despite extensive efforts to produce formats tailored to individuals with limited literacy, surprisingly we found no consistent advantages to either alternative format. In fact, the interactive voice format yielded lower satisfaction scores and lower response rates. PRACTICE IMPLICATIONS Practitioners need to ensure the health instruments they use are aligned with literacy skills and delivery preferences of their consumers. The lack of benefit of the illustrated form does not support investment of resources in these formats to measure satisfaction. The interactive voice response deserves more study--do lower scores register limited access to or use of telephones, irritation or true signal?

Cultural, Economic, and Psychological Predictors of Colonoscopy in a National Sample

BackgroundAlthough colorectal cancer (CRC) is the second leading cause of cancer death among adults in the US and colonoscopy is efficacious in reducing morbidity and mortality from CRC, screening rates are sub-optimal. Understanding the socioeconomic, cultural, and health care context within which decisions about colonoscopy are made allows physicians to address patients’ most salient beliefs and values and other constraints when making screening recommendations.ObjectiveTo evaluate the direct and interactive effects of socioeconomics, health care variables, psychological characteristics, and cultural values on colonoscopy use.Design, Setting, ParticipantsNational survey completed between January-August 2009 in a random sample of African American, white, and Hispanic adults ages 50–75 without cancer (n = 582).Main MeasureSelf-reported colonoscopy use.Key ResultsOnly 59% of respondents reported having a colonoscopy. The likelihood of colonoscopy increased with having health insurance (OR = 2.82, 95% CI = 1.24, 6.43, p = 0.004), and increasing age (OR = 1.40, 95% CI = 1.11, 1.77, p = 0.001). In addition, respondents with greater self-efficacy were more likely to have a colonoscopy (OR = 2.41, 95% CI = 1.35, 4.29, p = 0.003).ConclusionsPrograms that help patients to overcome access and psychological barriers to screening are needed.

Relationship Between ICU Length of Stay and Long-Term Mortality for Elderly ICU Survivors.

Objectives:To evaluate the association between length of ICU stay and 1-year mortality for elderly patients who survived to hospital discharge in the United States. Design:Retrospective cohort study of a random sample of Medicare beneficiaries who survived to hospital discharge, with 1- and 3-year follow-up, stratified by the number of days of intensive care and with additional stratification based on receipt of mechanical ventilation. Interventions:None. Patients:The cohort included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to hospital discharge in 2005. Measurements and Main Results:Among 34,696 patients who survived to hospital discharge, the mean ICU length of stay was 3.4 days (± 4.5 d). Patients (88.9%) were in the ICU for 1–6 days, representing 58.6% of ICU bed-days. Patients (1.3%) were in the ICU for 21 or more days, but these patients used 11.6% of bed-days. The percentage of mechanically ventilated patients increased with increasing length of stay (6.3% for 1–6 d in the ICU and 71.3% for ≥ 21 d). One-year mortality was 26.6%, ranging from 19.4% for patients in the ICU for 1 day, up to 57.8% for patients in the ICU for 21 or more days. For each day beyond 7 days in the ICU, there was an increased odds of death by 1 year of 1.04 (95% CI, 1.03–1.05) irrespective of the need for mechanical ventilation. Conclusions:Increasing ICU length of stay is associated with higher 1-year mortality for both mechanically ventilated and non–mechanically ventilated patients. No specific cutoff was associated with a clear plateau or sharp increase in long-term risk.