Ellen P. McCarthy

Declining Mortality in Patients with Acute Renal Failure, 1988 to 2002

Despite improvements in intensive care and dialysis, some experts have concluded that outcomes associated with acute renal failure (ARF) have not improved significantly over time. ARF was studied in hospitalized patients between 1988 and 2002 using the Nationwide Inpatient Sample, a nationally representative sample of discharges from acute-care, nonfederal hospitals. During a 15-yr period, 5,563,381 discharges with ARF and 598,768 with ARF that required dialysis (ARF-D) were identified. Between 1988 and 2002, the incidence of ARF rose from 61 to 288 per 100,000 population; the incidence of ARF-D increased from 4 to 27 per 100,000 population. Between 1988 and 2002, in-hospital mortality declined steadily in patients with ARF (40.4 to 20.3%; P < 0.001) and in those with ARF-D (41.3 to 28.1%; P < 0.001). Compared with 1988 to 1992, the multivariable-adjusted odds ratio (OR) of death was lower in 1993 to 1997 (ARF: OR 0.62, 95% confidence interval [CI] 0.61 to 0.64; ARF-D: OR 0.63, 95% CI 0.59 to 0.66) and 1998 to 2002 (ARF: OR 0.40, 95% CI 0.39 to 0.41; ARF-D: OR 0.47, 95% CI 0.45 to 0.50). The percentage of patients who had ARF with a Deyo-Charlson comorbidity index of 3 or more increased from 16.4% in 1988 to 26.6% in 2002 (P < 0.001). This study provides evidence from an administrative database that the incidence of ARF and ARF-D is rising. Despite an increase in the degree of comorbidity, in-hospital mortality has declined.

The Last Six Months of Life for Patients with Congestive Heart Failure

OBJECTIVE: To characterize the experiences of patients with congestive heart failure (CHF) during their last 6 months of life.

Racial and Ethnic Disparities in Cancer Screening: The Importance of Foreign Birth as a Barrier to Care

CONTEXT: Racial/ethnic groups comprised largely of foreign-born individuals have lower rates of cancer screening than white Americans. Little is known about whether these disparities are related primarily to their race/ethnicity or birthplace.OBJECTIVE: To determine whether foreign birthplace explains some racial/ethnic disparities in cancer screening.DESIGN, SETTING, AND SUBJECTS: Cross-sectional study using 1998 data from the National Health Interview Survey.MAIN OUTCOME MEASURES: Completion of cervical, breast, or colorectal cancer screening.RESULTS: Of respondents, 15% were foreign born. In analyses adjusted for sociodemographic characteristics and illness burden, black respondents were as or more likely to report cancer screening than white respondents; however, Hispanic and Asian-American and Pacific Islander (AAPI) respondents were significantly less likely to report screening for most cancers. When race/ethnicity and birthplace were considered together, U.S.-born Hispanic and AAPI respondents were as likely to report cancer screening as U.S.-born whites; however, foreign-born white (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.41 to 0.82), Hispanic (AOR, 0.65; 95% CI, 0.53 to 0.79), and AAPI respondents (AOR, 0.28; 95% CI, 0.19 to 0.39) were less likely than U.S.-born whites to report Pap smears. Foreign-born Hispanic and AAPI respondents were also less likely to report fecal occult blood testing (FOBT); AORs, 0.72; 95% CI, 0.53 to 0.98; and 0.61; 95% CI, 0.39 to 0.96, respectively); and sigmoidoscopy (AORs, 0.70; 95% CI, 0.51 to 0.97; and 0.63; 95% CI, 0.40 to 0.99, respectively). Furthermore, foreign-born AAPI respondents were less likely to report mammography (AOR, 0.49; 95% CI, 0.28 to 0.86). Adjusting for access to care partially attenuated disparities among foreign-born respondents.CONCLUSION: Foreign birthplace may explain some disparities previously attributed to race or ethnicity, and is an important barrier to cancer screening, even after adjustment for other factors. Increasing access to health care may improve disparities among foreign-born persons to some degree, but further study is needed to understand other barriers to screening among the foreign-born.

Marital Status and Survival in Patients With Cancer

PURPOSE To examine the impact of marital status on stage at diagnosis, use of definitive therapy, and cancer-specific mortality among each of the 10 leading causes of cancer-related death in the United States. METHODS We used the Surveillance, Epidemiology and End Results program to identify 1,260,898 patients diagnosed in 2004 through 2008 with lung, colorectal, breast, pancreatic, prostate, liver/intrahepatic bile duct, non-Hodgkin lymphoma, head/neck, ovarian, or esophageal cancer. We used multivariable logistic and Cox regression to analyze the 734,889 patients who had clinical and follow-up information available. RESULTS Married patients were less likely to present with metastatic disease (adjusted odds ratio [OR], 0.83; 95% CI, 0.82 to 0.84; P < .001), more likely to receive definitive therapy (adjusted OR, 1.53; 95% CI, 1.51 to 1.56; P < .001), and less likely to die as a result of their cancer after adjusting for demographics, stage, and treatment (adjusted hazard ratio, 0.80; 95% CI, 0.79 to 0.81; P < .001) than unmarried patients. These associations remained significant when each individual cancer was analyzed (P < .05 for all end points for each malignancy). The benefit associated with marriage was greater in males than females for all outcome measures analyzed (P < .001 in all cases). For prostate, breast, colorectal, esophageal, and head/neck cancers, the survival benefit associated with marriage was larger than the published survival benefit of chemotherapy. CONCLUSION Even after adjusting for known confounders, unmarried patients are at significantly higher risk of presentation with metastatic cancer, undertreatment, and death resulting from their cancer. This study highlights the potentially significant impact that social support can have on cancer detection, treatment, and survival.

Breast Cancer Among the Oldest Old: Tumor Characteristics, Treatment Choices, and Survival

PURPOSE Few data are available on breast cancer characteristics, treatment, and survival for women age 80 years or older. PATIENTS AND METHODS We used the linked Surveillance, Epidemiology and End Results-Medicare data set from 1992 to 2003 to examine tumor characteristics, treatments (mastectomy, breast-conserving surgery [BCS] with radiation therapy or alone, or no surgery), and outcomes of women age 80 years or older (80 to 84, 85 to 89, > or = 90 years) with stage I/II breast cancer compared with younger women (age 67 to 79 years). We used Cox proportional hazard models to examine the impact of age on breast cancer-related and other causes of death. Analyses were performed within stage, adjusted for tumor and sociodemographic characteristics, treatments received, and comorbidities. Results In total, 49,616 women age 67 years or older with stage I/II disease were included. Tumor characteristics (grade, hormone receptivity) were similar across age groups. Treatment with BCS alone increased with age, especially after age 80. The risk of dying from breast cancer increased with age, significantly after age 80. For stage I disease, the adjusted hazard ratio of dying from breast cancer for women age > or = 90 years compared with women age 67 to 69 years was 2.6 (range, 2.0 to 3.4). Types of treatments received were significantly associated with age and comorbidity, with age as the stronger predictor (26% of women age > or = 80 years without comorbidity received BCS alone or no surgery compared with 6% of women age 67 to 79 years). CONCLUSION Women age > or = 80 years have breast cancer characteristics similar to those of younger women yet receive less aggressive treatment and experience higher mortality from early-stage breast cancer. Future studies should focus on identifying tumor and patient characteristics to help target treatments to the oldest women most likely to benefit.

Impact of Hospital Volume on Postoperative Morbidity and Mortality Following a Colectomy for Ulcerative Colitis

BACKGROUND & AIMS Postoperative morbidity and mortality following a colectomy for ulcerative colitis (UC) has been primarily reported from tertiary care referral centers that perform a high volume of operations; however, the postoperative outcomes among nonselected hospitals are not known. We set out to evaluate postoperative morbidity and mortality using a nationally representative database and to determine the factors that influenced outcomes. METHODS We analyzed the 1995-2005 Nationwide Inpatient Sample to identify 7108 discharges for UC patients who underwent a total abdominal colectomy. The effects of hospital volume on postoperative morbidity and mortality were evaluated in logistic regression models adjusting for demographic and clinical factors. RESULTS Postoperative mortality and morbidity rates were 2.3% and 30.8%, respectively. Most operations were performed in low-volume hospitals that had an increased risk of death (adjusted odds ratio [aOR], 2.42; 95% confidence interval [CI]: 1.26-4.63). In-hospital mortality was increased in patients who were admitted emergently (aOR, 5.40; 95% CI: 3.48-8.40), aged 60-80 years (aOR, 8.70; 95% CI: 3.30-22.92), and those with Medicaid (aOR, 4.29; 95% CI: 2.13-8.66). Emergently admitted UC patients whose surgery was performed 6 days after their admission had significantly increased likelihood of in-hospital death (aOR, 2.12; 95% CI: 1.13-3.97). CONCLUSIONS Postoperative mortality was lowest in hospitals that performed the highest volume of operations. Increasing the proportion of total colectomies performed in high-volume hospitals may improve clinical outcomes for patients with UC.

Dying with cancer: patients' function, symptoms, and care preferences as death approaches.

OBJECTIVE: To characterize the dying experience of patients with cancer over the last 6 months of life.

Use of Screening and Preventive Services Among Women With Disabilities

Roughly 54 million Americans have some disability; at older ages, women are more likely to be disabled than men. Many people with disabilities today live virtually normal life spans, and therefore routine screening and preventive services are essential to their overall quality of care. We used the 1994-1995 National Health Interview Survey (NHIS), with Disability, Family Resources, and Healthy People 2000 supplements, to examine screening and preventive service use for adult women with disabilities living in the community-about 18.4% of women (estimated 18.28 million). Disability was associated with higher age-adjusted rates of: poverty; living alone; low education; inability to work; obesity; and being frequently depressed or anxious. Disabled women generally reported screening and preventive services at rates comparable to all women. Women with major lower extremity mobility difficulties had much lower adjusted odds of Papanicolaou smears (odds ratio, 0.6; 95% confidence interval, 0.4-0.9), mammograms (odds ratio, 0.7; 95% confidence interval, 0.5-0.9), and smoking queries (odds ratio, 0.6; 95% confidence interval, 0.5-0.8). Various approaches exist to improve access for disabled women to health care services.

Am I Doing the Right Thing? Provider Perspectives on Improving Palliative Care in the Emergency Department

STUDY OBJECTIVE Although the focus of emergency care is on the diagnosis and treatment of acute illnesses and injuries or the stabilization of patients for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED, using structured qualitative methods. METHODS We studied 3 focus groups with 26 providers, including 14 physicians (10 residents, 4 attending physicians), 6 nurses, 2 social workers, and 4 technicians, working in 2 academic EDs in Boston. We used a grounded theory approach to code responses, resolving discrepancies by consensus. RESULTS Six distinct themes emerged: (1) participants equated palliative care with end-of-life care; (2) participants disagreed about the feasibility and desirability of providing palliative care in the ED; (3) patients for whom a palliative approach has been established often visit the ED because family members are distressed by end-of-life symptoms; (4) lack of communication between outpatient and ED providers leads to undesirable outcomes (eg, resuscitation of patients with a do-not-resuscitate order); (5) conflict around withholding life-prolonging treatment is common (eg, between patients family and written advance directives); and (6) training in pain management is inadequate. CONCLUSION Providers ranked improved communication and documentation from outpatient providers as their highest priority for improvement. Attitudinal and structural barriers may need to be overcome to improve palliative care in the ED. Despite targeted recruitment, attending physician participation was low.

Psychological Distress in Long-term Survivors of Adult-Onset Cancer: Results From a National Survey

BACKGROUND As advances in cancer screening and treatment increase the number of long-term cancer survivors, it is important to understand the long-term psychological sequelae of the cancer experience. METHODS The 4636 respondents who identified themselves as survivors of adult-onset cancer of 5 years or more and 122 220 respondents who were never diagnosed as having cancer were identified in the 2002 to 2006 National Health Interview Survey. The primary outcome in this population-based study was serious psychological distress (SPD) defined as a K6 scale (a validated screening tool for mental illness) score of 13 or more. RESULTS Among survivors, the median age at diagnosis was 50 years, the age at interview was 66 years, and the time since diagnosis was 12 years. The prevalence of SPD was significantly higher among long-term cancer survivors than among respondents who were never diagnosed as having cancer (5.6% vs 3.0%; P < .001). After adjustment for clinical and sociodemographic variables (age, sex, race, relationship status, educational attainment, insurance status, comorbidities, smoking history, and ability to perform instrumental activities of daily living), survivors remained significantly more likely to experience SPD (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.7). After adjustment for other clinical and sociodemographic variables, long-term survivors who were younger, were unmarried, had less than a high school education, were uninsured, had more comorbidities, or had difficulty performing instrumental activities of daily living were more likely to experience SPD. CONCLUSIONS Long-term survivors of adult-onset cancer are at increased risk for psychological distress. This study identifies several clinical and sociodemographic factors associated with SPD that may help target high-risk survivors for psychological screening and support.