Heather Stieglitz

Impact of Social Factors on Risk of Readmission or Mortality in Pneumonia and Heart Failure: Systematic Review

ABSTRACTBACKGROUNDReadmission and mortality after hospitalization for community-acquired pneumonia (CAP) and heart failure (HF) are publically reported. This systematic review assessed the impact of social factors on risk of readmission or mortality after hospitalization for CAP and HF—variables outside a hospital’s control.METHODSWe searched OVID, PubMed and PSYCHINFO for studies from 1980 to 2012. Eligible articles examined the association between social factors and readmission or mortality in patients hospitalized with CAP or HF. We abstracted data on study characteristics, domains of social factors examined, and presence and magnitude of associations.RESULTSSeventy-two articles met inclusion criteria (20 CAP, 52 HF). Most CAP studies evaluated age, gender, and race and found older age and non-White race were associated with worse outcomes. The results for gender were mixed. Few studies assessed higher level social factors, but those examined were often, but inconsistently, significantly associated with readmissions after CAP, including lower education, low income, and unemployment, and with mortality after CAP, including low income. For HF, older age was associated with worse outcomes and results for gender were mixed. Non-Whites had more readmissions after HF but decreased mortality. Again, higher level social factors were less frequently studied, but those examined were often, but inconsistently, significantly associated with readmissions, including low socioeconomic status (Medicaid insurance, low income), living situation (home stability rural address), lack of social support, being unmarried and risk behaviors (smoking, cocaine use and medical/visit non-adherence). Similar findings were observed for factors associated with mortality after HF, along with psychiatric comorbidities, lack of home resources and greater distance to hospital.CONCLUSIONSA broad range of social factors affect the risk of post-discharge readmission and mortality in CAP and HF. Future research on adverse events after discharge should study social determinants of health.

Racial Differences in Predictors of Intensive End-of-Life Care in Patients With Advanced Cancer

PURPOSE Black patients are more likely than white patients to receive life-prolonging care near death. This study examined predictors of intensive end-of-life (EOL) care for black and white advanced cancer patients. PATIENTS AND METHODS Three hundred two self-reported black (n = 68) and white (n = 234) patients with stage IV cancer and caregivers participated in a US multisite, prospective, interview-based cohort study from September 2002 to August 2008. Participants were observed until death, a median of 116 days from baseline. Patient-reported baseline predictors included EOL care preference, physician trust, EOL discussion, completion of a Do Not Resuscitate (DNR) order, and religious coping. Caregiver postmortem interviews provided information regarding EOL care received. Intensive EOL care was defined as resuscitation and/or ventilation followed by death in an intensive care unit. RESULTS Although black patients were three times more likely than white patients to receive intensive EOL care (adjusted odds ratio [aOR] = 3.04, P = .037), white patients with a preference for this care were approximately three times more likely to receive it (aOR = 13.20, P = .008) than black patients with the same preference (aOR = 4.46, P = .058). White patients who reported an EOL discussion or DNR order did not receive intensive EOL care; similar reports were not protective for black patients (aOR = 0.53, P = .460; and aOR = 0.65, P = .618, respectively). CONCLUSION White patients with advanced cancer are more likely than black patients with advanced cancer to receive the EOL care they initially prefer. EOL discussions and DNR orders are not associated with care for black patients, highlighting a need to improve communication between black patients and their clinicians.

Development of Geriatrics-Oriented Faculty in General Internal Medicine

The need for all medical students and primary care housestaff to acquire skills in the care of the elderly has been recognized for decades (1, 2). More recently, studies have shown that fellows training in general internal medicine and internal medicine subspecialties need to develop these skills as well (3). It was hoped that faculty with geriatrics training or expertise could meet the educational needs of trainees; however, we continue to have insufficient numbers of academic geriatricians, and this shortage will worsen in the future (46). Clinicianeducators in general internal medicine do much of the teaching of trainees in both ambulatory and inpatient settings, where many of the patients are elderly. Thus, academic general internists have the opportunity to help impart the basic knowledge and skills necessary to care for older adults (7). To incorporate geriatrics into their already busy teaching agendas, general internists must have the necessary motivation, knowledge, and skills. We describe what is being done to develop geriatrics-oriented general internal medicine faculty. We identify current practices, best practices, goals and targets, and barriers to achieving those goals and targets. We then offer potential solutions for overcoming barriers to faculty development in geriatrics among academic general internists. Methods Literature Review We searched the literature using several databases: MEDLINE (1966 to February 2001), ERIC (Educational Resources Information Center) (1966 to February 2001), AgeLine (1978 to February 2001), Best Evidence (1991 to February 2001), Current Contents (1995 to February 2001), the Cochrane Database of Systematic Reviews, and Pre-MEDLINE. Abstracts from national meetings of the American Geriatrics Society and the Society of General Internal Medicine were reviewed for the years 1999 to 2001. Program reports on geriatrics-oriented faculty-development activities were requested from the John A. Hartford Foundation, Inc., and the Health Resources and Services Administration. We also asked leaders in geriatric medicine about their knowledge of programs related to geriatrics-oriented faculty development in general internal medicine. We reviewed titles and available abstracts for a match to at least 1 of 6 areas: current practices, best practices, goals and targets for optimal development of geriatrics-oriented general internal medicine faculty, barriers to achieving those goals and targets, solutions to identified barriers, and institutions that have programs and have published in the area of geriatrics-oriented faculty development. Two authors reviewed articles for the following inclusion criteria: 1) inclusion of general internal medicine faculty, 2) description of the educational interventions, 3) evaluation of the outcomes, and 4) description of the outcomes. The literature review identified a total of 504 references. We reviewed all titles and available abstracts (64%) and read 138 articles in their entirety. Four published articles and 3 program project reports (814) (Appendix Table) met the inclusion criteria. Focus Group and Structured Interviews As a convenience sample, 40 division heads of general internal medicine units at 38 medical schools in the southern United States were asked to participate in an 80-minute focus-group session on training general internists in geriatrics. We used a random-numbers table to select 34 other medical schools for interviewing. We sent letters to the general internal medicine chiefs at those schools, requesting their participation in a structured 15-minute telephone interview. We also sent letters to the directors and the heads of general internal medicine of 21 Hartford Centers of Excellence. Results Literature Review The faculty-development projects described in the literature or project reports were all funded by 1 of 2 sources: the Health Resources and Services Administration, as part of its Geriatrics Education Centers in the 1980s, or the John A. Hartford Foundation, Inc., in the 1990s. All faculty-development activities included faculty from more than 1 discipline. The interventions ranged from 9 evening sessions held over 3 years (9) to 1 year of on-site training (10). They all included educational modules related to geriatrics content and training in educational methods. A few included experiential training at geriatric clinical sites or teaching, or both (Appendix Table) (10, 11; Silliman R. John A. Hartford Foundation Progress Report. Boston University Center of Excellence in Geriatrics: 1/1/98 to 12/31/00, 2001, Personal communication; Stratos G. Final Report: Stanford Education Resource and Dissemination Center for the John A. Hartford Geriatrics in Primary Care Residency Training Initiatives, 2001, Personal communication). All of the faculty-development projects measured outcomes by using surveys and evaluations of educational offerings at or after the conclusion of the projects. They also measured either 1) the intent of participating faculty to change geriatrics practice or teaching or 2) self-reported change in the activities of participating faculty at some point after the training. Only 1 project (Stratos G. Personal communication) measured and reported change in knowledge, skills, and attitude by learners. None of the projects measured change in behavior by learners that might have resulted from the educational intervention. Focus Group and Structured Interviews Eleven of the 40 division heads, representing 10 schools, participated in the focus-group session. We completed interviews with 13 Hartford Center directors (62%), 21 general internal medicine unit chiefs at medical schools that are not Centers of Excellence (62%), and 9 general internal medicine unit chiefs at schools with a Hartford Center (43%). Between the focus group and the individual interviews, 49 medical schools were represented. According to general internal medicine unit chiefs, geriatrics was taught exclusively by geriatrics faculty at 24% of schools that are not Centers of Excellence and 67% of schools with Hartford Centers. It was taught by both general internal medicine and geriatrics faculty at 38% of schools that are not Centers of Excellence and 33% of schools with Hartford Centers. It was taught exclusively by general internal medicine faculty at 33% of schools that are not Centers of Excellence and none of the schools with Hartford Centers. At 1 school, internists did not teach geriatrics. At 3 of the 5 schools with Hartford Centers where both the Center director and the general internal medicine unit chief were interviewed, the director and the chief disagreed about who taught geriatrics. When asked whether geriatrics should be taught by general internal medicine faculty, general internal medicine unit chiefs said yes at 86% of schools that are not Centers of Excellence and at 56% of schools with Hartford Centers. When Center directors were asked the same question, 85% said yes. General internal medicine unit chiefs were asked whether their faculty perceived that they should teach geriatrics. At schools that are not Centers of Excellence, 57% said yes and 52% said that their faculty currently had the knowledge and skills to teach geriatrics (81% concordance). At schools with Hartford Centers, 22% said yes and 33% said that their faculty currently had the knowledge and skills to teach geriatrics (87.5% concordance). When Hartford Center directors were asked whether their general internal medicine faculty had the knowledge and skills to teach geriatrics, 46% said yes. Activities to increase clinical or teaching skills in geriatrics for general internal medicine faculty were reported by 5 (24%) of the general internal medicine unit chiefs at schools that are not Centers of Excellence, 5 (56%) of the general internal medicine unit chiefs at schools with Hartford Centers, and 4 (31%) of the Hartford Center directors. Some Center directors noted that although geriatrics-oriented faculty-development activities were offered to general internal medicine faculty, few or no faculty participated. The rest of the reported activities were done as part of ongoing general internal medicine unit activities, such as journal clubs, grand rounds, and conferences. Outcomes have not been measured or published for most of these activities, many of which were not sustained over time. At Hartford Centers, we identified 2 additional faculty-development programs for which outcomes have not been published. At 1 site, faculty members received a small stipend, participated in didactic work, and were paired with geriatricians who helped them develop a scholarly project. The intervention does not seem to have had a measurable effect on the teaching of geriatrics by general internal medicine faculty at this institution. Another program offered support to assist general internal medicine faculty with the development of core geriatrics content areas for teaching. As a result, general internal medicine faculty and geriatrics faculty provide didactic lectures during resident and student geriatrics rotations. The general internal medicine chiefs were asked in an open-ended manner to identify existing barriers that hinder their faculty from teaching geriatrics and participating in geriatrics-oriented faculty development. Nineteen (70%) specified lack of time, both for teaching and for participation in faculty development. Ten (37%) suggested that their faculty did not perceive a need to teach geriatrics or were not motivated to teach geriatrics. Some identified a lack of resources as a barrierspecifically, materials for geriatrics-oriented faculty development and clinical resources to enable interdisciplinary teams to teach geriatrics. Although the focus-group participants were a subset of a regional group of general internal medicine unit chiefs, their responses yielded information similar to that offered in the structured interviews. Discussion Our findings suggest a great

Bacterial epitopes involved in the induction of reactive arthritis

A panel of documented arthritogenic Shigella flexneri strains as well as an epidemic-associated non-arthritogenic Shigella sonnei control was used to identify a 2-megadalton plasmid specific to the arthritogenic strains. The plasmid, pHS-2, contains a DNA sequence that encodes a 22-amino acid polypeptide encompassing a pentapeptide homologous to part of the polymorphic region of the alpha-1 domain of HLA-B27. These results suggest that molecular mimicry between arthritogenic bacterial-encoded epitopes and the HLA-B27 molecule may play a role in the development of reactive arthritis.

Envisioning a Social-Health Information Exchange as a Platform to Support a Patient-Centered Medical Neighborhood: A Feasibility Study

ABSTRACTBACKGROUNDSocial determinants directly contribute to poorer health, and coordination between healthcare and community-based resources is pivotal to addressing these needs. However, our healthcare system remains poorly equipped to address social determinants of health. The potential of health information technology to bridge this gap across the delivery of healthcare and social services remains unrealized.OBJECTIVE, DESIGN, AND PARTICIPANTSWe conducted in-depth, in-person interviews with 50 healthcare and social service providers to determine the feasibility of a social-health information exchange (S-HIE) in an urban safety-net setting in Dallas County, Texas. After completion of interviews, we conducted a town hall meeting to identify desired functionalities for a S-HIE.APPROACHWe conducted thematic analysis of interview responses using the constant comparative method to explore perceptions about current communication and coordination across sectors, and barriers and enablers to S-HIE implementation. We sought participant confirmation of findings and conducted a forced-rank vote during the town hall to prioritize potential S-HIE functionalities.KEY RESULTSWe found that healthcare and social service providers perceived a need for improved information sharing, communication, and care coordination across sectors and were enthusiastic about the potential of a S-HIE, but shared many technical, legal, and ethical concerns around cross-sector information sharing. Desired technical S-HIE functionalities encompassed fairly simple transactional operations such as the ability to view basic demographic information, visit and referral data, and medical history from both healthcare and social service settings.CONCLUSIONSA S-HIE is an innovative and feasible approach to enabling better linkages between healthcare and social service providers. However, to develop S-HIEs in communities across the country, policy interventions are needed to standardize regulatory requirements, to foster increased IT capability and uptake among social service agencies, and to align healthcare and social service priorities to enable dissemination and broader adoption of this and similar IT initiatives.

Associations between United States Acculturation and the End-of-Life Experience of Caregivers of Patients with Advanced Cancer

BACKGROUND Cultural beliefs and values influence treatment preferences for and experiences with end-of-life (EOL) care among racial and ethnic groups. Within-group variations, however, may exist based on level of acculturation. OBJECTIVES To examine the extent to which EOL treatment factors (EOL treatment preferences and physician-caregiver communication) and select psychosocial factors (mental health, complementary therapies, and internal and external social support) differ based on the level of acculturation of caregivers of patients with advanced cancer. METHODS One hundred sixty-seven primary caregivers of patients with advanced cancer were interviewed as part of the multisite, prospective Coping with Cancer Study. RESULTS Caregivers who were less acculturated were more positively predisposed to use of a feeding tube at EOL (odds ratio [OR] 0.99 [p = 0.05]), were more likely to perceive that they received too much information from their doctors (OR 0.95 [p = 0.05]), were less likely to use mental health services (OR 1.03 [p = 0.003] and OR 1.02 [p = 0.02]), and desire additional services (OR 1.03 [p = 0.10] to 1.05 [p = 0.009]) than their more acculturated counterparts. Additionally, caregivers who were less acculturated cared for patients who were less likely to report having a living will (OR 1.03 [p = 0.0003]) or durable power of attorney for health care (OR 1.02 [p = 0.007]) than more acculturated caregivers. Caregivers who were less acculturated felt their religious and spiritual needs were supported by both the community (beta -0.28 [p = 0.0003]) and medical system (beta -0.38 [p < 0.0001]), had higher degrees of self-efficacy (beta -0.22 [p = 0.005]), and had stronger family relationships and support (beta -0.27 [p = 0.0004]). CONCLUSIONS The level of acculturation of caregivers of patients with advanced cancer does contribute to differences in EOL preferences and EOL medical decision-making.

An Examination of End-of-Life Care in a Safety Net Hospital System: A Decade in Review

Objectives. To examine patterns of use of end-of-life care in patients receiving treatment at a large, urban safety-net hospital from 2000 to 2010. Methods. Data from the Parkland Hospital palliative care database, which tracked all consults for this period, were analyzed. Logistic regression was used to identify predictors of hospice use, and Cox proportional hazards modeling to examine survival. Results. There were 5,083 palliative care consults over the study period. More patients were Black (41%) or White (31%), and younger than 65 years old (75%). Cancer patients or those who received palliative care services longer were more likely to receive hospice; those who had no form of health care assistance were less likely. There were no racial/ethnic differences in hospice use. Conclusion. In this cohort, there were no racial/ethnic disparities in hospice use. Those who had no form of health care assistance were less likely to receive hospice.

Predictors of intensive end-of-life and hospice care in Latino and white advanced cancer patients.

BACKGROUND The role of end-of-life (EOL) care preferences and conversations in receipt of care near death for Latinos is unclear. OBJECTIVE This study examines rates and predictors of intensive EOL and hospice care among Latino and white advanced cancer patients. DESIGN Two-hundred-and-ninety-two self-reported Latino (n=58) and white (n=234) Stage IV cancer patients participated in a U.S. multisite, prospective, cohort study from September 2002 to August 2008. The Latino and white, non-Hispanic participants were interviewed and followed until death, a median of 118.5 days from baseline. MEASUREMENTS Patient-reported, baseline predictors of EOL care included EOL care preference; terminal illness acknowledgement; EOL discussion; completion of a DNR order; and religious coping. Caregiver postmortem interviews provided information regarding EOL care received. Intensive EOL care was defined as resuscitation and/or ventilation followed by death in an intensive care unit. Hospice was either in- or outpatient. RESULTS Latino and white patients received intensive EOL and hospice care at similar rates (5.2% and 3.4% for intensive care, p=0.88; 70.7% versus 73.4% for hospice, p=0.33). No white or Latino patient who reported a DNR order or EOL discussion at baseline received intensive EOL care. Religious coping and a preference for life-extending care predicted intensive EOL care for white patients (adjusted odds ratio [aOR] 6.69 [p=0.02] and aOR 6.63 [p=0.01], respectively), but not for Latinos. No predictors were associated with Latino hospice care. CONCLUSIONS EOL discussions and DNR orders may prevent intensive EOL care among Latino cancer patients. Efforts should continue to engage Latino patients and caregivers in these activities.

United States Acculturation and Cancer Patients’ End-of-Life Care

Background Culture shapes how people understand illness and death, but few studies examine whether acculturation influences patients’ end-of-life treatment preferences and medical care. Methods and Findings In this multi-site, prospective, longitudinal cohort study of terminally-ill cancer patients and their caregivers (n = 171 dyads), trained interviewers administered the United States Acculturation Scale (USAS). The USAS is a 19-item scale developed to assess the degree of “Americanization” in first generation or non-US born caregivers of terminally-ill cancer patients. We evaluated the internal consistency, concurrent, criterion, and content validity of the USAS. We also examined whether caregivers’ USAS scores predicted patients’ communication, treatment preferences, and end-of-life medical care in multivariable models that corrected for significant confounding influences (e.g. education, country of origin, English proficiency). The USAS measure was internally consistent (Cronbach α = 0.98); and significantly associated with US birthplace (r = 0.66, P<0.0001). USAS scores were predictive of patients’ preferences for prognostic information (AOR = 1.31, 95% CI:1.00–1.72), but not comfort asking physicians’ questions about care (AOR 1.23, 95% CI:0.87–1.73). They predicted patients’ preferences for feeding tubes (AOR = 0.68, 95% CI:0.49–0.99) and wish to avoid dying in an intensive care unit (AOR = 1.36, 95% CI:1.05–1.76). Scores indicating greater acculturation were also associated with increased odds of patient participation in clinical trials (AOR = 2.20, 95% CI:1.28–3.78), compared with lower USAS scores, and greater odds of patients receiving chemotherapy (AOR = 1.59, 95% CI:1.20–2.12). Conclusion The USAS is a reliable and valid measure of “Americanization” associated with advanced cancer patients’ end-of-life preferences and care. USAS scores indicating greater caregiver acculturation were associated with increased odds of patient participation in cancer treatment (chemotherapy, clinical trials) compared with lower scores. Future studies should examine the effects of acculturation on end-of-life care to identify patient and provider factors that explain these effects and targets for future interventions to improve care (e.g., by designing more culturally-competent health education materials).