Donald H. Taylor

Benefits of Smoking Cessation for Longevity

OBJECTIVES This study determined the life extension obtained from stopping smoking at various ages. METHODS We estimated the relation between smoking and mortality among 877,243 respondents to the Cancer Prevention Study II. These estimates were applied to the 1990 US census population to examine the longevity benefits of smoking cessation. RESULTS Life expectancy among smokers who quit at age 35 exceeded that of continuing smokers by 6.9 to 8.5 years for men and 6.1 to 7.7 years for women. Smokers who quit at younger ages realized greater life extensions. However, even those who quit much later in life gained some benefits: among smokers who quit at age 65 years, men gained 1.4 to 2.0 years of life, and women gained 2.7 to 3.7 years. CONCLUSIONS Stopping smoking as early as possible is important, but cessation at any age provides meaningful life extensions.

Hospital Ownership and Cost and Quality of Care: is There a Dime's Worth of Difference?

Nonprofit organizations may predominate when output quality is difficult to monitor. Hospital care has this characteristic. This study compared program cost and quality of care for Medicare patients hospitalized following onset of four common conditions by hospital ownership. Payments on behalf of Medicare patients admitted to for-profit hospitals during the first 6 months following a health shock were higher than for those admitted to other hospitals. With quality measured in terms of survival, changes in functional and cognitive status, and living arrangements, we found no differences in outcomes by hospital ownership.

A randomized, placebo-controlled study of fentanyl buccal tablet for breakthrough pain in opioid-treated patients with cancer.

ObjectivesCancer-related breakthrough pain (BTP) is typically managed with a short-acting oral opioid, taken as needed during a fixed-schedule opioid regimen. The conventional approach may not provide the onset of analgesia required for BTP for many patients, because the onset of analgesia with short-acting opioids lags behind the time course of the majority of episodes of BTP. The fentanyl buccal tablet (FBT) employs a novel delivery system that enhances the rate and extent of absorption of fentanyl through the buccal mucosa. This double-blind, randomized, placebo-controlled study evaluated the efficacy, safety, and tolerability of FBT in opioid-treated patients with cancer-related BTP. MethodsAfter an open-label titration (N=123) to identify an effective FBT dose to treat BTP episodes, 77 patients were randomly assigned to 1 of 18 prespecified dose sequences of 10 tablets (7 FBT and 3 placebo). Pain intensity, pain relief (PR), and global performance of the medication were recorded at regular time intervals between 15 and 60 minutes. Pain intensity differences (PID), the summed PID (SPID), and summed total PR were calculated. The SPID at 30 minutes (SPID30) was the primary efficacy variable. Adverse events were reported. ResultsSixty-five percent (80/123) of patients were titrated to an effective dose. The mean (SE) SPID30 for FBT was 3.0±0.12 versus 1.8±0.18 for placebo (P<0.0001). Measures of PR, PID, SPID, summed total PR, and patient ratings of global performance of medication significantly favored FBT over placebo at all time points. Adverse events were typical of opioid drugs. Poor oral tolerability was noted in 2 patients. ConclusionsFBT is efficacious and safe in the treatment of cancer-related BTP.

Longevity Expectations and Death: Can People Predict Their Own Demise?

Using four waves of the Health and Retirement Survey (HRS) this paper tests whether longevity expectations predict actual mortality at the individual level. The results suggest longevity expectations do predict mortality reasonably well. Serious health shocks and new activity limitations do reduce longevity expectations. Given one is prepared to accept that other unobserved causal factors have the same means for those who die and those who survive in each wave it is possible to test whether longevity expectations can serve as a sufficient statistic. The test findings imply that they do not appear to reflect all that individuals know about their personal odds of living to seventy-five.

Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial.

IMPORTANCE For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were

Does Assistive Technology Substitute for Personal Assistance Among the Disabled Elderly

3.37 per day and

A multicenter, placebo-controlled, double-blind, multiple-crossover study of Fentanyl Pectin Nasal Spray (FPNS) in the treatment of breakthrough cancer pain.

716 per patient. CONCLUSIONS AND RELEVANCE This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01415934.

Effects of Risk and Time Preference and Expected Longevity on Demand for Medical Tests

OBJECTIVES This study examined whether use of equipment (technological assistance) to cope with disability was associated with use of fewer hours of help from another person (personal assistance). METHODS In a cross-sectional study of 2368 community dwellers older than 65 years with 1 or more limitations in basic activities of daily living (ADLs) from the 1994 National Long Term Care Survey, the relation between technological assistance and personal assistance was examined. RESULTS Among people with ADL limitations, multivariate models showed a strong and consistent relation between technological assistance and personal assistance, whereby use of equipment was associated with fewer hours of help. CONCLUSIONS Among people with disability, use of assistive technology was associated with use of fewer hours of personal assistance.

Associations Between Obesity and Receipt of Screening Mammography, Papanicolaou Tests, and Influenza Vaccination: Results from the Health and Retirement Study (HRS) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study

&NA; This randomized, double‐blind, crossover study assessed the efficacy and tolerability of a new rapid onset nasal fentanyl formulation (Fentanyl Pectin Nasal Spray; FPNS) for breakthrough cancer pain (BTCP). Eighty‐three of 114 patients experiencing one to four BTCP episodes/day while taking ≥60 mg/day of oral morphine or equivalent successfully identified an effective dose of FPNS during a titration phase and entered a double‐blind phase in which 10 BTCP episodes were treated with this effective dose (7) or placebo (3). Compared with placebo, FPNS significantly improved mean summed pain intensity difference (SPID) from 10 min (P < 0.05) until 60 min (P < 0.0001), including the primary endpoint at 30 min (P < 0.0001). FPNS significantly improved pain intensity (PI) scores as early as 5 min (P < 0.05); pain intensity difference (PID) from 10 min (P < 0.01); and pain relief (PR) scores from 10 min (P < 0.001). More patients showed a clinically meaningful (≥2‐point reduction in PI) pain reduction from 10 min onward (P ≤ 0.01) and 90.6% of the FPNS‐treated versus 80.0% of placebo‐treated BTCP episodes did not require rescue medication (P < 0.001). Approximately 70% of patients were satisfied or very satisfied with the convenience and ease of use of FPNS. Only 5.3% of patients withdrew from treatment due to adverse events, no significant nasal effects were reported, and 87% of patients elected to continue open‐label treatment post‐study. In this short‐term study, FPNS was safe, well tolerated, and rapidly efficacious for BTCP.

The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited.

Despite their conceptual importance, the effects of time preference, expected longevity, uncertainty, and risk aversion on behavior have not been analyzed empirically. We use data from the Health and Retirement Study (HRS) to assess the role of risk and time preference, expected longevity, and education on demand for three measures used for early detection of breast and cervical cancer—regular breast self-exams, mammograms, and Pap smears. We find that individuals with a higher life expectancy and lower time preference are more likely to undergo cancer screening. Less risk averse individuals tend to be more likely to undergo testing.