Jennifer Corbelli

Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis

Importance The use of palliative care programs and the number of trials assessing their effectiveness have increased. Objective To determine the association of palliative care with quality of life (QOL), symptom burden, survival, and other outcomes for people with life-limiting illness and for their caregivers. Data Sources MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL to July 2016. Study Selection Randomized clinical trials of palliative care interventions in adults with life-limiting illness. Data Extraction and Synthesis Two reviewers independently extracted data. Narrative synthesis was conducted for all trials. Quality of life, symptom burden, and survival were analyzed using random-effects meta-analysis, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-palliative care scale (FACIT-Pal) instrument (range, 0-184 [worst-best]; minimal clinically important difference [MCID], 9 points); and symptom burden translated to the Edmonton Symptom Assessment Scale (ESAS) (range, 0-90 [best-worst]; MCID, 5.7 points). Main Outcomes and Measures Quality of life, symptom burden, survival, mood, advance care planning, site of death, health care satisfaction, resource utilization, and health care expenditures. Results Forty-three RCTs provided data on 12 731 patients (mean age, 67 years) and 2479 caregivers. Thirty-five trials used usual care as the control, and 14 took place in the ambulatory setting. In the meta-analysis, palliative care was associated with statistically and clinically significant improvements in patient QOL at the 1- to 3-month follow-up (standardized mean difference, 0.46; 95% CI, 0.08 to 0.83; FACIT-Pal mean difference, 11.36] and symptom burden at the 1- to 3-month follow-up (standardized mean difference, -0.66; 95% CI, -1.25 to -0.07; ESAS mean difference, -10.30). When analyses were limited to trials at low risk of bias (n = 5), the association between palliative care and QOL was attenuated but remained statistically significant (standardized mean difference, 0.20; 95% CI, 0.06 to 0.34; FACIT-Pal mean difference, 4.94), whereas the association with symptom burden was not statistically significant (standardized mean difference, -0.21; 95% CI, -0.42 to 0.00; ESAS mean difference, -3.28). There was no association between palliative care and survival (hazard ratio, 0.90; 95% CI, 0.69 to 1.17). Palliative care was associated consistently with improvements in advance care planning, patient and caregiver satisfaction, and lower health care utilization. Evidence of associations with other outcomes was mixed. Conclusions and Relevance In this meta-analysis, palliative care interventions were associated with improvements in patient QOL and symptom burden. Findings for caregiver outcomes were inconsistent. However, many associations were no longer significant when limited to trials at low risk of bias, and there was no significant association between palliative care and survival.

Low-dose transdermal estradiol for vasomotor symptoms: A systematic review

ObjectiveThis review aims to determine the effectiveness of low-dose transdermal estrogen versus placebo in postmenopausal women with moderate to severe hot flashes. MethodsWe conducted a systematic review of studies by searching Medline and EMBASE using the following inclusion criteria: double-blind, placebo-controlled, randomized controlled trials conducted in postmenopausal women with at least 7 hot flashes per day and/or at least 50 hot flashes per week. All included studies used estrogen formulations below the equivalent dose of 0.05 mg of 17&bgr;-estradiol. ResultsNine studies met all inclusion criteria. Seven of nine studies had low risk of bias, whereas two studies had high risk of bias. Low-dose transdermal estrogen in all dose ranges was more likely than placebo to decrease the daily number of hot flashes. Meta-analysis was not performed as only three of the nine studies included measures of variance; weighted means were used to summarize the data. Results were divided into three groups by decreasing estrogen dose range (0.037-0.045, 0.020-0.029, and 0.003-0.125 mg). The mean daily decrease in the number of hot flashes from baseline was 9.36, 7.91, and 7.07, respectively. The mean daily decrease in the placebo groups was 5.07. Eight of the nine studies reported P values comparing each estrogen dose to placebo; all were significant at P < 0.05. ConclusionsAlthough publication bias cannot be excluded, risk of bias and heterogeneity among studies are low. There is strong evidence to conclude that low-dose transdermal estrogen at any dose is more effective than placebo in decreasing the daily number of moderate to severe hot flashes.

Rethinking How to Measure the Appropriateness of Cervical Cancer Screening

Background: Health care systems use performance measures based on guidelines from such organizations as the American College of Obstetricians and Gynecologists to monitor the appropriateness of cervical cancer screening. According to the performance measure currently in the Healthcare Effectiveness Data and Information Set, satisfactory cervical cancer screening involves at least 1 Papanicolaou (Pap) test every 3 years for average-risk women aged 21 to 64 years or at least 1 Pap and human papillomavirus test every 5 years for average-risk women aged 30 to 64 years (1). These performance measures have notable flaws. They do not allow for brief and clinically nonsignificant delays in screening. For example, a 29-year-old woman 3 years and 1 day after her last screening is considered nonadherent. These measures also fail to recognize overscreening. For example, an average-risk woman screened 3 times in 3 years is considered adherent despite evidence showing no benefit and potential harms of overscreening due to unnecessary follow-up procedures and other treatments (2). Objective: To show how changes in the performance measures for cervical cancer screening can address these 2 flaws. Methods and Findings: We determined how frequently screening practices were adherent to traditional performance measures and to alternative measures that incorporated 2 changes. We accepted existing categories of underscreening and appropriate screening and added a new category for overscreening that applied when intervals between screenings were shorter than guideline-recommended ones. We also replaced the single interval for adherence with ranges (3 months and6 months). To calculate actual frequencies, we used Pennsylvania Medicaid administrative data for women aged 18 to 64 years between 2007 and 2013. We used 2009 American College of Obstetricians and Gynecologists guidelines, because our data did not provide enough follow-up information to use more recent guidelines. The 2009 guidelines recommended beginning Pap testing at age 21 years and screening at 2-year intervals for women younger than 30 years and at 3-year intervals for women aged 30 years or older (3). To ensure adequate follow-up information, we required continuous enrollment of at least 3 years among women younger than 30 years and at least 4 years among women aged 30 years or older and included only women who had an initial Pap test during the 6 months after November 2009, the month that the guidelines were released. We excluded women who did not have at least 1 office visit; were dually enrolled in Medicare; and had preexisting conditions requiring different screening frequencies, such as cervical cancer, abnormal findings on cervical cytologic evaluation, total hysterectomy, HIV, and immunosuppression. We classified 27076 screening intervals among 14786 women using traditional and alternative measures. According to traditional measures, 29% of intervals among women younger than 30 years and 35% of intervals among women aged 30 years or older represented underscreening (Table). Most intervals that were appropriate under traditional measures were classified as overscreening under alternative ones. After we incorporated ranges of3 months and6 months, underscreening declined slightly; however, most intervals still represented overscreening. Table. Percentage of Intervals, by Category of Adherence and Type of Performance Measure* Discussion: We observed an up to 11% increase in appropriate cervical cancer screening when including 6-month ranges instead of a single interval in the definition of performance measures. We believe that incorporating this flexibility is reasonable and unlikely to negatively affect health. Most important, we found that most Pap screening classified as appropriate actually represented overscreening, even when adding ranges to the adherence intervals. Current performance measures that classify overscreening as appropriate may incentivize providers to overscreen, to the detriment of patients and the health care system. We believe that changing cervical cancer screening performance measures to align better with clinical guidelines will help reduce the frequency of unnecessary procedures (4, 5) and more accurately measure the quality of womens health care.

Hormone therapy prescribing trends in the decade after the Women's Health Initiative: how patients and providers have found a way to sleep better at night.

T he impact of the Women’s Health Initiative (WHI) was both immediate and widespread, and its influence has been sustained. Through the late 1990s, hormone therapy (HT) was commonly used not only for the management of menopausal symptoms but also for both primary and, before the Heart Estrogen Progestin Replacement Study (HERS), secondary prevention of cardiovascular disease. With the publication of the WHI results in 2002 and the intense media frenzy that ensued, women and providers abruptly changed course. Millions of women stopped taking HT, essentially overnight. And for the first time, women and physicians initiated HT with the notion that they were incurring significant health risks to improve quality of life. In this issue of Menopause, Steinkellner et al and Ettinger et al report the results of their retrospective analyses of pharmacy databases to track patterns of HT prescriptions. Previous work has examined HT prescription in the immediate aftermath of the WHI: in the year after the publication of WHI results in 2002, HT use sharply decreased by 25% to 72%. The current two studies demonstrate that this trend extended well past 2003 and that much of the decline in prevalent HT use was attributable to decreased prescriptions of standard and high doses of oral estrogens. Steinkellner et al found a 75% decrease in oral HT claims, an 80% decrease in high-dose HT claims, and an 85% drop in standard-dose HT claims from 2000 to 2009. Ettinger et al similarly found a 77% decrease in oral HT claims in the seven years after WHI, and an 80% overall decline in high-dose/standard-dose HT over the same time period. Similar patterns were not observed for other HT doses and formulations. Both Steinkellner et al and Ettinger et al showed that the number of women with claims for lowdose HT preparations remained constant from 2000 to 2009. Steinkellner et al also found that claims for transdermal HT remained essentially unchanged. Ettinger et al reported an approximately 20% decrease in claims for transdermal HT overall, and claims for low-dose transdermal formulations increased more than 10-fold. Overall, these findings point to a clear phenomenon: the concern caused by WHI catalyzed a sharp decrease in the number of women using high-dose/ standard-dose oral estrogen. However, HT did not become a thing of the past, as patients and providers sought seemingly safer methods to continue to use it. After the initial post-WHI decline in HT claims, both Steinkellner et al and Ettinger et al observed a plateau in claims for HT between 2004 and 2005. Reasons for the plateau are primarily speculative but warrant consideration. By 2004, women who used HT only for cardioprotection had discontinued use, and women who initiated or continued HT did so for relief of menopausal symptoms. In fact, Steinkellner et al found that new claims for HT were essentially unaffected by WHI, suggesting that the initiation of HT, probably for relief of menopausal symptoms, remained even as the risks of HT were so prominently highlighted. In addition, data also emerged from the WHI tempering the initial study conclusions. Finally, position statements from organizations that support the care of postmenopausal women, such as The North American Menopause Society (NAMS), also likely played a role. The 2003 NAMS position statement on HT use was crafted in the immediate aftermath of WHI and HERS and advocated the use of HT only for menopausal symptoms and for the shortest duration possible and called for increased research regarding the impact of alternative delivery strategies (eg, transdermal, transvaginal). By 2008, the NAMS position statement included caveats such as the role of HT in the prevention and treatment of osteoporosis and specifically discussed a favorable risk-to-benefit ratio of HT in women closer to menopause. The finding that claims for transdermal, vaginal, and lowdose estrogen either remained stable or increased begs the question of what evidence base exists for this approach to HT. Are these options effective compared with the formulations tested by both HERS and WHI? The data to address this question are limited. We know that lower HT doses and vaginal estradiol improve vasomotor symptoms, although less effectively than higher dose oral HT. Lower dose vaginal estrogen (equivalent to conjugated equine estrogens 0.3 mg) is effective at relieving symptoms of vaginal dryness and at one year showed no association with endometrial hyperplasia or carcinoma. Few studies to date of alternative formulations have been of sufficient scope or duration to address the safety concerns raised by WHI and HERS. Indeed, thromboembolic risk is the only life-threatening outcome for which we can draw evidencebased conclusions. Specifically, a series of retrospective studies have found that risk of venous thromboembolism is lower with transdermal than with oral estrogen. And although it is commonly recommended to use HT for the shortest duration possible, it is unclear what this shortest duration is. WHI showed that the risk of breast cancer significantly increases

Contraception Use in Women with Hypertension

Hypertension is among the most common conditions that affect women of reproductive age. It is also a common complication of pregnancy, and should be treated in pregnant women with blood pressures ≥160/110. For blood pressures 140–159/90–109, no clear data exist to demonstrate benefits of treatment. When treatment is indicated, labetalol and methyldopa are first-line agents.

Different story, different day: medical errors on a teaching service.

The only thing worse than making a medical error is making one when you are in charge of a resident team.