Cindy L. Bryce

Survival after liver transplantation in the United States: a disease-specific analysis of the UNOS database.

Our goal was to describe disease‐specific survival and the clinical variables that predict survival in a large national cohort of adult liver transplant recipients. Data on 17,044 adult patients who received an initial orthotopic liver transplant between 1990 and 1996 with follow‐up through 1999 was obtained from the United Network for Organ Sharing (UNOS). Disease‐specific Kaplan‐Meier survival plots and Cox Proportional Hazards models were estimated, and differences in the clinical characteristics of patients at the time of transplantation by disease were examined. Overall posttransplant survival currently exceeds 85% in the first year and is approaching 75% at 5 years. Unadjusted Kaplan‐Meier survival is improved for recipients who are younger, female, and in better clinical condition. Survival is a function of disease and level of illness: cancer, fulminant liver failure, alcoholic liver disease, and the hepatitidies have the poorest prognosis, while primary billiary cirrohsis and sclerosing cholangitis have the best. Recipients who were outpatients before transplantation have longer survival than those transplanted from the hospital or intensive care unit. Although the model for end‐stage liver disease (MELD) score was designed to predict pretransplant survival, patients with higher MELD scores have poorer posttransplant survival, but the MELD score is less predictive than the specific disease. Differences in disease‐specific survival are partially explained by differences in disease severity at the time of transplantation. In conclusion, Disease‐specific survival models indicate that there remains tremendous variability in survival as a function of underlying liver disease. However, a significant portion of the difference in survival between diseases arises from differences in clinical characteristics at the time of transplantation. (Liver Transpl 2004;10:886–897.)

Water-pipe tobacco smoking among middle and high school students in arizona

BACKGROUND. Using a water pipe to smoke tobacco is increasing in prevalence among US college students, and it may also be common among younger adolescents. The purpose of this study of Arizona middle and high school students was to examine the prevalence of water-pipe tobacco smoking, compare water-pipe tobacco smoking with other forms of tobacco use, and determine associations between sociodemographic variables and water-pipe tobacco smoking in this population. METHODS. We added items assessing water-pipe tobacco smoking to Arizonas 2005 Youth Tobacco Survey and used them to estimate statewide water-pipe tobacco smoking prevalence among various demographic groups by using survey weights. We also used multiple logistic regression to determine which demographic characteristics had independent relationships with each of 2 outcomes: ever use of water pipe to smoke tobacco and water-pipe tobacco smoking in the previous 30 days. RESULTS. Median age of the sample was 14. Accounting for survey weights, among middle school students, 2.1% had ever smoked water-pipe tobacco and 1.4% had done so within the previous 30 days. Among those in high school, 10.3% had ever smoked from a water pipe and 5.4% had done so in the previous 30 days, making water-pipe tobacco smoking more common than use of smokeless tobacco, pipes, bidis, and kreteks (clove cigarettes). In multivariate analyses that controlled for covariates, ever smoking of water-pipe tobacco was associated with older age, Asian race, white race, charter school attendance, and lack of plans to attend college. CONCLUSIONS. Among Arizona youth, water pipe is the third most common source of tobacco after cigarettes and cigars. Increased national surveillance and additional research will be important for addressing this threat to public health.

Using the Internet to translate an evidence-based lifestyle intervention into practice.

Despite evidence-based recommendations for addressing obesity in the clinical setting, lifestyle interventions are lacking in practice. The objective of this study was to translate an evidence-based lifestyle program into the clinical setting by adapting it for delivery via the Internet. We adapted the Diabetes Prevention Programs lifestyle curriculum to an online format, comprising 16 weekly and 8 monthly lessons, and conducted a before-and-after pilot study of program implementation and feasibility. The program incorporates behavioral tools such as e-mail prompts for online self-monitoring of diet, physical activity, and weight, and automated weekly progress reports. Electronic counseling provides further support. Physician referral, automated progress reports, and as-needed communication with lifestyle coaches integrate the intervention with clinical care. We enrolled 50 patients from a large academic general internal practice into a pilot program between November 16, 2006 and February 11, 2007. Patients with a body mass index (BMI) =25 kg/m2, at least one weight-related cardiovascular risk factor, and Internet access were eligible if referring physicians felt the lifestyle goals were safe and medically appropriate. Participants were primarily female (76%), with an average age of 51.94 (standard deviation [SD] 10.82), and BMI of 36.43 (SD 6.78). At 12 months of enrollment, 50% of participants had logged in within 30 days. On average, completers (n = 45) lost 4.79 (SD 8.55) kg. Systolic blood pressure dropped 7.33 (SD 11.36) mm Hg, and diastolic blood pressure changed minimally (+0.44 mm Hg; SD 9.27). An Internet-based lifestyle intervention may overcome significant barriers to preventive counseling and facilitate the incorporation of evidence-based lifestyle interventions into primary care.

A Clinically Based Discrete-Event Simulation of End-Stage Liver Disease and the Organ Allocation Process

Background . The optimal allocation of scarce donor livers is a contentious health care issue requiring careful analysis. The objective of this article was to design a biologically based discrete-event simulation to test proposed changes in allocation policies. Methods . The authors used data from multiple sources to simulate end-stage liver disease and the complex allocation system. To validate the model, they compared simulation output with historical data. Results . Simulation outcomes were within 1% to 2% of actual results for measures such as new candidates, donated livers, and transplants by year. The model overestimated the yearly size of the waiting list by 5% in the last year of the simulation and the total number of pretransplant deaths by 10%. Conclusion . The authors created a discrete-event simulation model that represents the biology of end-stage liver disease and the health care organization of transplantation in the United States.

Living With Diabetes Normalizing the Process of Managing Diabetes

Purpose The purpose of this qualitative study was to explore perceptions of people with diabetes about their experience of living with and managing their diabetes. Methods This study was part of a larger study of patients with diabetes who used a novel computer portal system for access to information about diabetes and to their health care providers for enhanced communication. The research method used for this portion of the study was grounded theory methodology, a particular kind of qualitative research method. Results A central theme generated from the data was “normalizing an identity as a person with diabetes.” The participants described themselves as diabetic; they took on an identity in which having diabetes was central. They struggled with how to become “a person with diabetes” rather than a “diabetic person.” Conclusions For people who are diagnosed with diabetes, there is a struggle to become a person with diabetes rather than a diabetic person and to manage the lifestyle changes that are mandated by this role/identity. One way of dealing or coping with this new identity is to begin to “normalize” these lifestyle changes—to view them as healthy living for all people, those with and without diabetes. This will then have implications for interventions—encouraging healthy lifestyles among people with diabetes rather than emphasizing that people with diabetes are “different from” the general population.

Interest in the Use of Computerized Patient Portals: Role of the Provider–Patient Relationship

BackgroundBioinformatics experts are developing interactive patient portals to help those living with diabetes and other chronic diseases to better manage their conditions. However, little is known about what influences patients’ desires to use this technology.ObjectiveTo discern the impact of the provider–patient relationship on interest in using a web-based patient portal.DesignQualitative analysis of focus groups.ParticipantsTen focus groups involving 39 patients (range 2–7) recruited from four primary care practices.ApproachA qualitative approach was used, which involved reading transcribed texts until a consensus was reached on data interpretation. An intercoder reliability kappa score (0.89) was determined by comparing the provider–patient relationship talk selected by the two coders. A conceptual framework was developed, which involved the development and refinement of a codebook and the application of it to the transcripts.ResultsInterest in the portal was linked to dissatisfaction with the provider–patient relationship, including dissatisfaction with provider communication/responsiveness, the inability to obtain medical information, and logistical problems with the office. Disinterest in the portal was linked to satisfaction with the provider–patient relationship, including provider communication/responsiveness, difficulty in using the portal, and fear of losing relationships and e-mail contact with the provider. No patient identified encrypted e-mail communication through the portal as an advantage.ConclusionsPromoting the use of computerized portals requires patient-based adaptations. These should include ease of use, direct provider e-mail, and reassurances that access and interpersonal relationships will not be lost. Education is needed about privacy concerns regarding traditional e-mail communication.

Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer : A pilot feasibility study

Objective:To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer. Design:Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview. Setting:Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh. Subjects:Twenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists. Measurements and Main Results:Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient’s code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043). Conclusions:Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.

The patient is in: patient involvement strategies for diagnostic error mitigation

Although healthcare quality and patient safety have longstanding international attention, the target of reducing diagnostic errors has only recently gained prominence, even though numerous patients, families and professional caregivers have suffered from diagnostic mishaps for a long time. Similarly, patients have always been involved in their own care to some extent, but only recently have patients sought more opportunities for engagement and participation in healthcare improvements. This paper brings these two promising trends together, analysing strategies for patient involvement in reducing diagnostic errors in an individuals own care, in improving the healthcare delivery systems diagnostic safety, and in contributing to research and policy development on diagnosis-related issues.

Quality of death: assessing the importance placed on end-of-life treatment in the intensive-care unit.

Context:The value of good end-of-life (EOL) care could be underestimated if its effects are assessed using the standard metric of quality-adjusted survival, especially if the time horizon is limited to the duration of the EOL care. This issue is particularly problematic in the intensive-care unit (ICU) where death is frequent, care is difficult, and costs are high. Objectives:The objectives of this study were to test whether people would trade healthy life expectancy for better EOL care, to understand how much life expectancy they would trade relative to domains of good care, and to determine the association of respondent characteristics to time traded. Design and Subjects:We used a computerized survey instrument describing hypothetical patient experiences in the ICU used to assess attitudes of a general population sample (n = 104) recruited in Pittsburgh, Pennsylvania. Measures:We used life expectancy traded (from a baseline of 80 healthy years followed by a 1-month fatal ICU stay) for improving ICU care in 4 domains: pain and discomfort, daily surroundings, treatment decisions, and family support. Results:Three fourths of respondents (n = 78) were prepared to shorten healthy life for better EOL care. Median time traded in individual domains ranged from 7.2 to 7.7 months overall and 9.6 to 11.4 months when restricted to those willing to trade. Median time traded for improvement in all domains was 8.3 months overall and 24.0 months by those willing to trade. In multivariable analyses, respondents who were older, nonwhite, or had children traded significantly less time, whereas those who did not perceive the ICU to be a caring environment traded more time. Conclusions:Good EOL care is highly valued, both in terms of medical and nonmedical domains, as suggested by previous work and confirmed by our data showing respondents trading quantities of healthy life several times longer than the duration of the EOL period itself. The considerable interperson variation highlights the importance of soliciting individual preferences about EOL care.

Sociodemographic Differences in Early Access to Liver Transplantation Services

The question of whether health care inequities occur before patients with end‐stage liver disease (ESLD) are waitlisted for transplantation has not previously been assessed. To determine the impact of gender, race and insurance on access to transplantation, we linked Pennsylvania sources of data regarding adult patients discharged from nongovernmental hospitals from 1994 to 2001. We followed the patients through 2003 and linked information to records from five centers responsible for 95% of liver transplants in Pennsylvania during this period. Using multinomial logistic regressions, we estimated probabilities that patients would undergo transplant evaluation, transplant waitlisting and transplantation itself. Of the 144 507 patients in the study, 4361 (3.0%) underwent transplant evaluation. Of those evaluated, 3071 (70.4%) were waitlisted. Of those waitlisted, 1537 (50.0%) received a transplant. Overall, 57 020 (39.5%) died during the study period. Patients were less likely to undergo evaluation, waitlisting and transplantation if they were women, black and lacked commercial insurance (p < 0.001 each). Differences were more pronounced for early stages (evaluation and listing) than for the transplantation stage (in which national oversight and review occur). For early management and treatment decisions of patients with ESLD to be better understood, more comprehensive data concerning referral and listing practices are needed.