Jane Paik Kim

Validation of Reported Predialysis Nephrology Care of Older Patients Initiating Dialysis

The Centers for Medicare and Medicaid Services (CMS) Medical Evidence Report (form CMS-2728) queries providers about the timing of the patients first nephrologist consultation before initiation of dialysis. The monitoring of disease-specific goals in the Healthy People 2020 initiative will use information from this question, but the accuracy of the reported information is unknown. We defined a cohort of 80,509 patients aged ≥67 years who initiated dialysis between July 2005 and December 2008 with ≥2 years of uninterrupted Medicare coverage as their primary payer. The primary referent, determined from claims data, was the first observed outpatient nephrologist consultation; secondary analyses used the earliest nephrology consultation, whether inpatient or outpatient. We used linear regression models to assess the associations among the magnitude of discrepant reporting and patient characteristics and we tested for any temporal trends. When using the earliest recorded outpatient nephrology encounter, agreement between the two sources of ascertainment was 48.2%, and the κ statistic was 0.29 when we categorized the timing of the visit into four periods (never, <6, 6-12, and >12 months). When we dichotomized the timing of first predialysis nephrology care at >12 or ≤12 months, accuracy was 70% (κ=0.36), but it differed by patient characteristics and declined over time. In conclusion, we found substantial disagreement between information from the CMS Medical Evidence Report and Medicare physician claims on the timing of first predialysis nephrologist care. More-specific instructions may improve reporting and increase the utility of form CMS-2728 for research and public health surveillance.

A Unified Approach to Semiparametric Transformation Models Under General Biased Sampling Schemes

We propose a unified estimation method for semiparametric linear transformation models under general biased sampling schemes. The new estimator is obtained from a set of counting process-based unbiased estimating equations, developed through introducing a general weighting scheme that offsets the sampling bias. The usual asymptotic properties, including consistency and asymptotic normality, are established under suitable regularity conditions. A closed-form formula is derived for the limiting variance and the plug-in estimator is shown to be consistent. We demonstrate the unified approach through the special cases of left truncation, length bias, the case-cohort design, and variants thereof. Simulation studies and applications to real datasets are presented.

Donor-Recipient Sex Mismatch in Kidney Transplantation

BACKGROUND The lack of reliable human proxies for minor (ie, non-HLA) histocompatibility loci hampers the ability to leverage these factors toward improving transplant outcomes. Despite conflicting reports of the effect of donor-recipient sex mismatch on renal allografts, the association between acute rejection of renal allografts and the development of human alloantibodies to the male H-Y antigen suggested to us that donor-recipient sex mismatch deserved re-evaluation. OBJECTIVE To evaluate whether the relationships between donor sex and allograft failure differed by recipient sex. METHODS We studied recipients of deceased-donor (n = 125,369) and living-donor (n = 63,139) transplants in the United States Renal Data System. Using Cox proportional hazards models stratified by donor type, we estimated the association between donor-recipient sex mismatch and death-censored allograft failure with adjustment for known risk factors, with and without the use of multiple imputation methods to account for potential bias and/or loss of efficiency due to missing data. RESULTS The advantage afforded by male donor kidneys was more pronounced among male than among female recipients (8% vs 2% relative risk reduction; interaction P < 0.01). This difference is of the order of magnitude of several other risk factors affecting donor selection decisions. CONCLUSIONS Donor-recipient sex mismatch affects renal allograft survival in a direction consistent with immune responses to sexually determined minor histocompatibility antigens. Our study provides a paradigm for clinical detection of markers for minor histocompatibility loci.

Moving beyond community mental health: public mental health as an emerging focus for psychiatry residency training.

Mental disorders and behavioral conditions represent a challenge to the well-being of communities throughout the world. This statement is bold, certainly, but not without basis. One in four adults in the USAmeets criteria for a mental disorder, and estimates from the World Health Organization indicate that mental disorders represent nearly 23 % of years lived with disability for all people globally [1, 2]. This level of disease burden is greater than that associated with HIV/AIDS, cancer, and diabetes combined.Moreover, the most common causes of death, including ischemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes, HIV, andmultiple forms of cancer, are linked with at-risk behaviors and behavioral conditions. The number of completed suicides each year— nearly 900,000 worldwide and 37,000 in the USA—in rough terms represents more than twice the number of people who die annually from war or from interpersonal violence. By 2030, depression will be the top cause of disease burden globally, 1.01 million people will die from self-inflicted injury each year, and 1.85 million people will die from traffic accidents frequently associated with substance-related disorders, sleep deprivation, and co-occurring physical and mental health conditions [2]. The burden associated with mental illness and behavioral disorders will continue to be the greatest among certain vulnerable subpopulations, including socioeconomically disadvantaged children, certain underrepresented minorities, the homeless, rural and immigrant populations, and individuals with co-occurring, stigmatized, and severe physical illnesses. For these reasons, the impact of mental disorders and behavioral conditions can be characterized as one of the greatest concerns of our world. Mental disorders are the largest diagnostic category for those in the USA receiving disability, at a cost of

Ethical Issues in Biomedical Research and Clinical Training

25 billion a year [3]. Even with decades of research, antipsychotic medication, and deinstitutionalization, evidence of improved prospects for recovery remains scarce. Of those with schizophrenia, 80% are unemployed; 60 % of individuals with bipolar disorder experience co-occurring substance abuse dependency; posttraumatic stress disorder is not less prevalent today than it was 50 years ago [3]. Together, these outcomes data demonstrate a concerning, sobering unmet need in public mental health. Are we doing enough in residency training to prepare future psychiatrists to address these grave realities? Do residency curricula offer sufficient exposure to the range of issues faced by the diverse communities and distinctly vulnerable subpopulations hardest hit by mental illness and related health conditions? Further, are we providing physicians-in-training—those who will be established in their careers by 2030—with the means to improve population mental health, as well as to enhance the well-being and resilience of their individual patients? Are we giving the field of psychiatry and our patients, as well as our physicians-in-training, a reason to be hopeful in light of the sobering facts on state of mental health?

Caring for Patients Takes Time: Dr. Peabody Says So!

The authors outline the key ethical principles, safeguards, and practices that exist to fulfill the ethical conduct of research involving human subjects. They also outline ethical challenges and issues encountered by medical trainees on their path to becoming independent physicians: authorship and professional misconduct in research. As the physician-in-training strives to fulfill the standards of the profession, his or her aim to attain competence is balanced against the reality that the trainee begins without sufficient knowledge and skill and must learn “with” and “through” patients. With this in mind, goals and objectives for ethics training in medicine are outlined in the context of the natural progression of the identity of the physician.

Subgrouping the users of a specialized app for eating disorders

The emotional exhaustion of present-day physicians and physicians-in-training is well described and of genuine concern. It is assumed, however, that the origin of exhaustion, cynicism, compassion fatigue, and burnout is patient care or “service” burden. The Accreditation Council for Graduate Medical Education cautions program directors to limit the number of hours in which resident physicians engage in patient care responsibilities. The guidelines imply that caring for patients is intrinsically burdensome—the notion of service is represented as onerous—as mere labor, not as an act of professionalism in which our efforts are dedicated to the wellbeing of others and a greater good. The guidelines were introduced, quite correctly, when tragic mistakes in patient care and the exploitative practices of some residency programs were recognized. Nevertheless, Dr. Peabody’s remarks in 1927 [1], nearly a century ago, remind us that our aim should not be to limit contact with patients but to provide excellent patient care and to foster great clinical skills in our trainees. Moreover, what if, as Dr. Peabody suggests, by limiting the contact that we have with our patients, we have damaged the deepest source of satisfaction in our work as physicians? Taken one step further, what if the ever-expanding administrative responsibilities associated with clinical care are diminishing time spent with patients as well as contributing to the emotional exhaustion, depersonalization, and lack of sense of personal achievement of physicians? The time allocated to maintenance of documentation in the electronic medical record, interactions with insurers, and fulfillment of regulatory requirements, among other activities, has grown dramatically over the past decades. A recent RAND study [2] found that physicians experienced many obstacles to providing high-quality care and that these barriers were a major source of dissatisfaction as a professional. Physicians in that study described how the pressure to provide greater quantity of service for a greater number of patients and to engage in extensive administrative activities effectively decreased the time and attention they could spend with each patient, which in turn detracted from the quality of care in some cases. Moreover, limiting hours and contact with patients can set up problems—more mistakes may be precipitated by, for example, multiple hand offs that occur with “shift work” and not really knowing and caring for patients longitudinally, even through a critical episode of illness. A personal sense of fulfillment and integrity is likely compromised when a E. V. Beresin Harvard Medical School, Boston, MA, USA

Lifetime anxiety disorder and current anxiety symptoms associated with hastened depressive recurrence in bipolar disorder

ABSTRACT Although mobile technologies for eating disorders (EDs) are burgeoning, there is limited data about the clinical characteristics of individuals using specialized smartphone applications (apps) without accompanying traditional forms of treatment. This study evaluated whether the users of an ED app cluster in clinically meaningful groups. Participants were 1,280 app users (91.3% female; mean age 27) who reported not being in a weekly treatment for their ED. A hierarchical cluster analysis distinguished five groups of participants, all approximating DSM-5 ED categories. One cluster comprised of non-female, ethnically diverse users with Bulimia Nervosa features. Findings suggest that app users resemble known patient classifications.

Accelerated failure time model under general biased sampling scheme

AIMS To assess differential relationships between lifetime anxiety disorder/current anxiety symptoms and longitudinal depressive severity in bipolar disorder (BD). METHODS Stanford BD Clinic outpatients enrolled during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation and followed with the STEP-BD Clinical Monitoring Form while receiving naturalistic treatment for up to two years. Baseline unfavorable illness characteristics/current mood symptoms and times to depressive recurrence/recovery were compared in patients with versus without lifetime anxiety disorder/current anxiety symptoms. RESULTS Among 105 currently recovered patients, lifetime anxiety disorder was significantly associated with 10/27 (37.0%) demographic/other unfavorable illness characteristics/current mood symptoms/current psychotropics, hastened depressive recurrence (driven by earlier onset age), and a significantly (> two-fold) higher Kaplan-Meier estimated depressive recurrence rate, whereas current anxiety symptoms were significantly associated with 10/27 (37.0%) demographic/other unfavorable illness characteristics/current mood symptoms/current psychotropics and hastened depressive recurrence (driven by lifetime anxiety disorder), but only a numerically higher Kaplan-Meier estimated depressive recurrence rate. In contrast, among 153 currently depressed patients, lifetime anxiety disorder/current anxiety symptoms were not significantly associated with time to depressive recovery or depressive recovery rate. LIMITATIONS American tertiary BD clinic referral sample, open naturalistic treatment. CONCLUSIONS Research is needed regarding differential relationships between lifetime anxiety disorder and current anxiety symptoms and hastened/delayed depressive recurrence/recovery - specifically whether lifetime anxiety disorder versus current anxiety symptoms has marginally more robust association with hastened depressive recurrence, and whether both have marginally more robust associations with hastened depressive recurrence versus delayed depressive recovery, and related clinical implications.

Perspectives of psychiatric investigators and IRB chairs regarding benefits of psychiatric genetics research

Right-censored time-to-event data are sometimes observed from a (sub)cohort of patients whose survival times can be subject to outcome-dependent sampling schemes. In this paper, we propose a unified estimation method for semiparametric accelerated failure time models under general biased estimating schemes. The proposed estimator of the regression covariates is developed upon a bias-offsetting weighting scheme and is proved to be consistent and asymptotically normally distributed. Large sample properties for the estimator are also derived. Using rank-based monotone estimating functions for the regression parameters, we find that the estimating equations can be easily solved via convex optimization. The methods are confirmed through simulations and illustrated by application to real datasets on various sampling schemes including length-bias sampling, the case-cohort design and its variants.