Dana Nickleach

Patterns of Interpreter Use for Hospitalized Patients with Limited English Proficiency

ABSTRACTBACKGROUNDProfessional interpreter use improves the quality of care for patients with limited English proficiency (LEP), but little is known about interpreter use in the hospital.OBJECTIVEEvaluate interpreter use for clinical encounters in the hospital.DESIGNCross-sectional.PARTICIPANTSHospitalized Spanish and Chinese-speaking LEP patients.MAIN MEASURESPatient reported use of interpreters during hospitalization.KEY RESULTSAmong 234 patients, 57% reported that any kind of interpreter was present with the physician at admission, 60% with physicians during hospitalization, and 37% with nurses since admission. The use of professional interpreters with physicians was infrequent overall (17% at admission and 14% since admission), but even less common for encounters with nurses (4%, p < 0.0001). Use of a family member, friend or other patient as interpreter was more common with physicians (28% at admission, 23% since admission) than with nurses (18%, p = 0.008). Few patients reported that physicians spoke their language well (19% at admission, 12% since admission) and even fewer reported that nurses spoke their language well (6%, p = 0.0001). Patients were more likely to report that they either “got by” without an interpreter or were barely spoken to at all with nurses (38%) than with physicians at admission (14%) or since admission (15%, p < 0.0001).CONCLUSIONSInterpreter use varied by type of clinical contact, but was overall more common with physicians than with nurses. Professional interpreters were rarely used. With physicians, use of ad hoc interpreters such as family or friends was most common; with nurses, patients often reported, “getting by” without an interpreter or barely speaking at all.

Language Barriers and Understanding of Hospital Discharge Instructions

Background:Effective communication at hospital discharge is necessary for an optimal transition and to avoid adverse events. We investigated the association of a language barrier with patient understanding of discharge instructions. Methods:Spanish-speaking, Chinese-speaking, and English-speaking patients admitted to 2 urban hospitals between 2005 and 2008, comparing patient understanding of follow-up appointment type, and medication category and purpose between limited English-proficient (LEP) and English-proficient patients. Results:Of the 308 patients, 203 were LEP. Rates of understanding were low overall for follow-up appointment type (56%) and the 3 medication outcomes (category 48%, purpose 55%, both 41%). In unadjusted analysis, LEP patients were less likely than English-proficient patients to know appointment type (50% vs. 66%; P=0.01), medication category (45% vs. 54%; P=0.05), and medication category and purpose combined (38% vs. 47%; P=0.04), but equally likely to know medication purpose alone. These results persisted in the adjusted models for medication outcomes: LEP patients had lower odds of understanding medication category (odds ratio 0.63; 95% confidence interval, 0.42–0.95); and category/purpose (odds ratio 0.59; 95% confidence interval, 0.39–0.89). Conclusions:Understanding of appointment type and medications after discharge was low, with LEP patients demonstrating worse understanding of medications. System interventions to improve communication at hospital discharge for all patients, and especially those with LEP, are needed.

Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base

Introduction: Questions remain regarding differences in nodal evaluation and upstaging between thoracotomy (open) and video‐assisted thoracic surgery (VATS) approaches to lobectomy for early‐stage lung cancer. Potential differences in nodal staging based on operative approach remain the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy. Methods: The National Cancer Data Base was queried for patients with clinical stage T2N0M0 or lower lung cancer who underwent lobectomy in 2010–2011. Propensity score matching was performed to compare the rate of nodal upstaging in VATS with that in open approaches. Additional subgroup analysis was performed to assess whether rates of upstaging differed by specific clinical setting. Results: A total of 16,983 lobectomies were analyzed; 4935 (29.1%) were performed using VATS. Nodal upstaging was more frequent in the open group (12.8% versus 10.3%; p < 0.001). In 4437 matched pairs, nodal upstaging remained more common for open approaches. For a subgroup of patients who had seven lymph or more nodes examined, propensity matching revealed that nodal upstaging remained more common after an open approach than after VATS (14.0% versus 12.1%; p = 0.03). For patients who were treated in an academic/research facility, however, the difference in nodal upstaging between an open and VATS approach was no longer significant (12.2% versus 10.5%, p = 0.08). Conclusions: For early‐stage lung cancer, nodal upstaging was observed more frequently with thoracotomy than with VATS. However, nodal upstaging appears to be affected by facility type, which may be a surrogate for expertise in minimally invasive surgical procedures.

Chemoradiation therapy sequencing for resected pancreatic adenocarcinoma in the National Cancer Data Base.

Pancreatic adenocarcinoma (PAC) has low overall survival (OS) rates and high recurrence rates following surgical resection. The role for preoperative radiation therapy (prRT) for PAC versus postoperative RT (poRT) remains uncertain. The authors used the National Cancer Data Base (NCDB) to report prRT outcomes for the largest multi‐institutional patient cohort to date.

Postoperative Radiotherapy is Associated with Better Survival in Non–Small Cell Lung Cancer with Involved N2 Lymph Nodes: Results of an Analysis of the National Cancer Data Base

Introduction: Use of postoperative radiotherapy (PORT) in non–small-cell lung cancer remains controversial. Limited data indicate that PORT may benefit patients with involved N2 nodes. This study evaluates this hypothesis in a large retrospective cohort treated with chemotherapy and contemporary radiation techniques. Methods: The National Cancer Data Base was queried for patients diagnosed 2004–2006 with resected non–small-cell lung cancer and pathologically involved N2 (pN2) nodes also treated with chemotherapy. Multivariable Cox proportional hazards model was used to assess factors associated with overall survival (OS). Inverse probability of treatment weighting (IPTW) using the propensity score was used to reduce selection bias. OS was compared between patients treated with versus without PORT using the adjusted Kaplan–Meier estimator and weighted log-rank test based on IPTW. Results: Two thousand and one hundred and fifteen patients were eligible for analysis. 918 (43.4%) received PORT, 1197 (56.6%) did not. PORT was associated with better OS (median survival time 42 months with PORT versus 38 months without, p = 0.048). This effect was significant in multivariable and IPTW Cox models (hazard ratio: 0.87, 95% confidence interval: 0.78–0.98, p = 0.026, and hazard ratio: 0.89, 95% confidence interval: 0.79–1.00, p = 0.046, respectively). No interaction was seen between the effects of PORT and number of involved lymph nodes (p = 0.615). Conclusions: PORT was associated with better survival for patients with pN2 nodes also treated with chemotherapy. No interaction was seen between benefit of PORT and number of involved nodes. These findings reinforce the benefit of PORT for N2 disease in modern practice using the largest, most recent cohort of chemotherapy-treated pN2 patients to date.

Breast reconstruction and post-mastectomy radiation practice

PurposeThe goal of this study was to explore the perspectives and practice of radiation oncologists who treat breast cancer patients who have had breast reconstruction.MethodsIn 2010, an original electronic survey was sent to all physician members of the American Society of Radiation Oncology, National Cancer Research Institute-Breast Cancer Studies Group in the United Kingdom, Thai Society of Therapeutic Radiology and Oncology, Swiss Society of Radiation Oncology, and Turkish Radiation Oncology Society. We identified factors associated with radiation oncologists who treat breast cancer patients with reconstruction performed prior to radiation and obtained information regarding radiation management of the breast reconstruction.Results358 radiation oncologists responded, and 60% of the physicians were from the United States. While 64% of participants agree or strongly agree that breast image affects a woman’s quality of life during radiation, 57% feel that reconstruction challenges their ability to deliver effective breast radiation. Compared with other countries, treatment within the United States was associated with a high reconstruction rate (>/= 50% of mastectomy patients) prior to radiation (p < 0.05). Delayed-immediate reconstruction with a temporary tissue expander was more common in the United States than in other countries (52% vs. 23%, p = 0.01). Among physicians who treat patients with tissue expanders, the majority (60%) prefer a moderately inflated implant with 150-250 cc of fluid rather than a completely deflated (13%) or inflated expander (28%) during radiation. Among radiation oncologists who treat reconstructions, 49% never use bolus and 40% never boost a breast reconstruction. United States physicians were more likely than physicians from other countries to boost or bolus the reconstruction irrespective of the type of reconstruction seen in their clinic patients (p < 0.01).ConclusionsGreat variation in practice is evident from our study of radiation treatment for breast cancer patients with reconstruction. Further research on the impact and delivery of radiation to a reconstructed breast may validate some of the observed practices, highlight the variability in treatment practice, and help create a treatment consensus.

Socioeconomic Risk Factors for Long-Term Mortality after Pulmonary Resection for Lung Cancer: An Analysis of More than 90,000 Patients from the National Cancer Data Base

BACKGROUND Several clinical variables, such as tumor stage and age, are well established factors associated with long-term survival after surgical resection of lung cancer. Our aim was to examine the impact of other clinical and demographic variables, controlling for known predictors of long-term survival, in order to investigate how outcomes varied according to important nonclinical factors. STUDY DESIGN The National Cancer Data Base, jointly supported by the Commission on Cancer of the American College of Surgeons and the American Cancer Society, was used to identify patients undergoing pulmonary resection for lung cancer and perform a retrospective cohort study. The cohort consisted of patients diagnosed with nonsmall cell lung cancer from 2003 to 2006, who underwent resection; overall survival data are available only for patients diagnosed through 2006. A Cox proportional hazards survival model was used to examine factors associated with risk of mortality. RESULTS A total of 92,929 patients were identified as diagnosed during the study period and undergoing surgical resection for lung cancer. On multivariable analysis, several socioeconomic factors such as lack of insurance, lower income, less education, and treatment at community centers vs academic or research programs predicted worse overall survival after controlling for disease characteristics known to be predictors of worse survival, such as tumor stage, histology, age, and extent of resection. CONCLUSIONS Diminished long-term survival after pulmonary resection was associated with a number of socioeconomic factors. To date, this represents the largest database analysis of long-term mortality in patients undergoing surgical resection for lung cancer. The disparities in survival outcomes reported here require further detailed investigation.

Factors influencing time to diagnosis after abnormal mammography in diverse women.

BACKGROUND Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram. METHODS Women aged 40-80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation. RESULTS In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < 

The association between C-reactive protein (CRP) level and biochemical failure-free survival in patients after radiation therapy for nonmetastatic adenocarcinoma of the prostate.

10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis. CONCLUSIONS Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.

Tumor size on abdominal MRI versus pathologic specimen in resected pancreatic adenocarcinoma: implications for radiation treatment planning.

C‐reactive protein (CRP) has been associated with outcomes in patients with metastatic adenocarcinoma of the prostate. Associations between prostate adenocarcinoma‐specific endpoints and CRP in patients who are treated for localized disease remain unknown.