Joshua Hemmerich

Source Evaluation, Comprehension, and Learning in Internet Science Inquiry Tasks

In two experiments, undergraduates’ evaluation and use of multiple Internet sources during a science inquiry task were examined. In Experiment 1, undergraduates had the task of explaining what caused the eruption of Mt. St. Helens using the results of an Internet search. Multiple regression analyses indicated that source evaluation significantly predicted learning outcomes, with more successful learners better able to discriminate scientifically reliable from unreliable information. In Experiment 2, an instructional unit (SEEK) taught undergraduates how to evaluate the reliability of information sources. Undergraduates who used SEEK while working on an inquiry task about the Atkins low-carbohydrate diet displayed greater differentiation in their reliability judgments of information sources than a comparison group. Both groups then participated in the Mt. St. Helens task. Undergraduates in the SEEK conditions demonstrated better learning from the volcano task. The current studies indicate that the evaluation of information sources is critical to successful learning from Internet-based inquiry and amenable to improvement through instruction.

Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006

OBJECTIVE This study used a large national administrative in-hospital database to compare utilization and age-specific outcomes between open repair (OAR) and endovascular (EVAR) repair for the treatment of abdominal aortic aneurysm (AAA). METHODS Discharges with the principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for EVAR and OAR and principal diagnosis code of intact AAAs were selected from the 2001 to 2006 Nationwide Inpatient Sample (NIS). Weighted least-square regression was used to test the trend of utilization by age. Multiple linear and logistic regression analyses were used to assess the risk-adjusted outcomes. RESULTS Nationally, the estimated number of elective AAAs treated with EVAR increased from 11,171 in 2001 to 21,725 in 2006 (P = .003). The number of elective AAAs treated with OAR declined from 17,784 to 8451 during the same period (P < .001). By 2006, EVAR was more frequently used than OAR for patients of all ages. Compared with the younger age groups, patients aged >or=85 years had a significant increase in the total number of asymptomatic AAA repairs, driven almost entirely by an increase in the use of EVAR. Compared with open patients, EVAR patients had a significantly shorter length of hospitalization (adjusted mean, 2.99 days [95% confidence interval (CI), 2.97-3.01] vs 8.78 days [95% CI, 8.53-8.57]), less in-hospital mortality (odds ratio [OR], 0.23; 95% CI, 0.19-0.28), fewer in-hospital complications (OR, 0.27; 95% CI, 0.25-0.28), and a higher likelihood of being discharged to home (OR, 3.95; 95% CI, 3.62-4.31). The reduction of complications from the use of EVAR versus OAR was most dramatic for the oldest patients. CONCLUSIONS As short-term surgical outcomes are consistently improving for patients undergoing AAA repair, elective EVAR has replaced OAR as the more common method of repair in the United States. The introduction of this technology has been rapidly adopted, particularly for the oldest-old surgical patients, aged >or=85 years, who previously may not have been offered surgical intervention for asymptomatic AAA. Further investigation is necessary to examine whether this trend improves the long-term survival and quality of life for this elderly population.

Geriatric assessment improves prediction of surgical outcomes in older adults undergoing pancreaticoduodenectomy: a prospective cohort study.

Objective:To prospectively evaluate the additional value of geriatric assessment (GA) for predicting surgical outcomes in a cohort of older patients undergoing a pancreaticoduodenectomy (PD) for pancreatic tumors. Background:Older patients are less often referred for possible PD. Standard preoperative assessments may underestimate the likelihood of significant adverse outcomes. The prospective utility of validated GA has not been studied in this group. Methods:PD-eligible patients were enrolled in a prospective outcome study. Standard preoperative assessments were recorded. Elements of validated GA were also measured, including components of Frieds model of frailty, the Vulnerable Elders Survey (VES-13), and the Short Physical Performance Battery (SPPB). All postoperative adverse events were recorded, systematically reviewed, and graded using the Clavien-Dindo system by a surgeon blinded to the GA results. Multivariate regression analyses were conducted. Results:Seventy-six older patients underwent a PD. Significant unrecognized vulnerability was identified at the baseline: Frieds “exhaustion” (37.3%), SPPB <10 (28.5%), and VES-13 >3 (15.4%). Within 30 days of PD, 46% experienced a severe complication (Clavien-Dindo grade ≥III). In regression analyses controlling for age, the body mass index, the American Society of Anesthesiologists score, and comorbidity burden, Frieds “exhaustion” predicted major complications [odds ratio (OR) = 4.06; P = 0.01], longer hospital stays (&bgr; = 0.27; P = 0.02), and surgical intensive care unit admissions (OR = 4.30; P = 0.01). Both SPPB (OR = 0.61; P = 0.04) and older age predicted discharge to a rehabilitation facility (OR = 1.1; P < 0.05) and age correlated with a lower likelihood of hospital readmission (OR = 0.94; P = 0.02). Conclusions:Controlling for standard preoperative assessments, worse scores on GA prospectively and independently predicted important adverse outcomes. Geriatric assessment may help identify older patients at high risk for complications from PD.

Patient Anxiety About Prostate Cancer Independently Predicts Early Initiation of Androgen Deprivation Therapy for Biochemical Cancer Recurrence in Older Men: A Prospective Cohort Study

PURPOSE Androgen deprivation therapy (ADT) is first-line therapy for patients with prostate cancer (PCA) who experience biochemical recurrence (BCR). However, the optimal timing of ADT initiation is uncertain, and earlier ADT initiation can cause toxicities that lower quality of life (QOL). We tested the hypothesis that elevated cancer anxiety leads to earlier ADT initiation for BCR in older men. PATIENTS AND METHODS We conducted a prospective cohort study of older patients with BCR of PCA (n = 67). Patients completed questionnaires at presentation and each follow-up visit until initiation of ADT. PCA-specific anxiety was measured with the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Other collected data included demographics, clinical information, and general anxiety information. Treating oncologists were surveyed about their recommendations for ADT initiation. The primary outcome was the time to ADT initiation. Univariate, multivariate logistic regression, and time-to-event analyses were conducted to evaluate whether cancer anxiety was a predictor of earlier initiation of ADT. RESULTS Thirty-three percent of patients initiated ADT at the first or second clinic visit. Elevated PCA anxiety (MAX-PC > 16) was the most robust predictor in multivariate analyses of early initiation (odds ratio [OR], 9.19; P = .01). PSA also independently correlated with early initiation (OR, 1.31; P = .01). PSA did not correlate with MAX-PC. CONCLUSION Cancer anxiety independently and robustly predicts earlier ADT initiation in older men with BCR. For older patients with PCA, earlier ADT initiation may not change life expectancy and can negatively impact QOL. PCA-specific anxiety is a potential target for a decision-making intervention in this setting.

Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making.

BackgroundAlthough chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD.MethodsWe administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision.ResultsMore than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24).ConclusionsIn this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.

Palliative Access Through Care at Home: experiences with an urban, geriatric home palliative care program.

The aging of the U.S. population has resulted in a large number of persons with multiple, chronic illnesses and gradual functional decline. Many older adults with these conditions are homebound and have great difficulty accessing medical care. They are also more likely to suffer from unaddressed symptoms and end‐of‐life care needs. Certain groups, such as African‐American patients and patients with dementia, are even less likely to access palliative care and hospice services. Although the informal caregivers attending to such persons may become overwhelmed without adequate support, palliative care, which covers a broad population, is an optimal way to address many of these needs. This article describes a unique, urban, home‐based geriatrics palliative care program (Palliative Access Through Care at Home (PATCH)) designed to address some of these unmet needs. After 1 year of providing service, a mixed‐methods study consisting of chart review, telephone interviews, and face‐to‐face interviews was conducted to assess caregiver expectations of and satisfaction with the program. Caregivers for the elderly, mostly African‐American patients, more than half of whom had dementia, were overall very satisfied with their experience, despite the large amount of time necessary to provide the care that patients required. Themes extracted during qualitative analysis were the desire to remain at home, the need for easy access to a practitioner specializing in geriatrics and palliative medicine, and the challenges of transitions of care. PATCH was able to address many of these needs and provide high levels of caregiver satisfaction.

PHYSICIAN REFERRAL DECISIONS FOR OLDER CHRONIC KIDNEY DISEASE PATIENTS: A PILOT STUDY OF GERIATRICIANS, INTERNISTS, AND NEPHROLOGISTS

disorders. In an inner-city hospital study of patients aged 60 and older, 2% were positive for cocaine. This was a much higher prevalence than the NHSDA survey of 0.6% in patients aged 65 and older. Understanding the patterns of illegal drug use in older individuals is important from several standpoints. Cocaine users are more likely also to smoke tobacco and drink alcohol than those who do not use cocaine; the combination of cocaine, tobacco, and alcohol can further and synergistically exacerbate underlying medical conditions. Causes of illegal drug use in older adults has been attributed to stressful late-life events, loss of productive social roles, loneliness, drinking habits acquired in early life, and the absence of supportive social relationships. Because cocaine has been clearly implicated in cardiovascular disease, older patients should also be queried about such usage. Different geographic areas, ethnicities, and socioeconomic groups all require further study. It is apparent from reviewing the literature that cocaine abuse in older adults is underscreened. Proper counseling and treatment for substance dependence will not be provided if the problem is not identified. Many physicians do not focus on drug use history in a geriatric population. This is a dangerous trend that may stem from prejudices that this population ‘‘ages out’’ of abusing illicit substances. There is a high prevalence of psychiatric disorders, particularly depression, in older adults and a known link with drug abuse. The overall trend is for a rise in the prevalence of cocaine use, and thus an expected similar rise in the older population is likely. It is also likely that this problem is much less recognized in older adults because of its relative infrequency. Moreover, the statistics seem to underestimate the number of patients affected. Until there is greater appreciation of this problem and the underreporting bias is eliminated, it is likely that the abuse of cocaine by older adults will continue to be an ‘‘invisible epidemic.’’

The Vulnerable Elders Survey-13 Predicts Mortality in Older Adults with Later-Stage Colorectal Cancer Receiving Chemotherapy: A Prospective Pilot Study

To the Editor: Colorectal cancer (CRC) is the second most common cause of cancer death in the Western world. Almost half of all CRC cases occur in individuals aged 70 and older, but the data regarding treatment are largely focused on individuals younger than 65, even though studies suggest that older adults with CRC derive benefit from adjuvant chemotherapy equivalent or nearly equivalent to that of younger individuals. Older adults form a heterogeneous group, and physiological fitness is weakly correlated with chronological age; criteria other than age should help form the basis for treatment decisions. One solution is to derive these criteria using the tools of a comprehensive geriatric assessment (CGA). A prospective cohort study was conducted to evaluate baseline CGA for older adults with Stage III and IV CRC undergoing first-line chemotherapy. It was hypothesized that the presence of impairments on the CGA would be associated with poorer survival. Eligible individuals were recruited from the University of Chicago Gastrointestinal Medical Oncology Clinic between February 2006 and February 2009. Protocol approval was obtained from the institutional review board, and all participants provided written informed consent. Participants underwent assessments just before their first dose of chemotherapy. Survival data were obtained from chart review and the Social Security Death Index. The comprehensive evaluation included the Vulnerable Elders Survey (VES-13), a 13-item self-administered survey designed to screen for overall functional status, and assessments of cognition, emotional affect, social functioning, nutritional status, activities of daily living (ADLs), comorbidities, and physical performance. Bivariate analysis for overall survival used Cox proportional hazards models and Kaplan-Meier curves, and multivariate survival analysis was performed using logistic regression. The initial model was obtained by including Eastern Co-operative Oncology Group Performance Status (ECOG-PS), ADL, and VES-13 scores, all of which were significant (P ≤ .05) in the bivariate analysis, plus age. The models were limited to four variables to avoid overfitting, given the small data set. All statistical calculations were performed using Stata SE, version 11 (StataCorp LP, College Station, TX). Thirty-eight patients were enrolled (median age 72, range 65–89; 63% male). Seventy-nine percent had metastatic disease at presentation. Of the 33 for whom baseline ECOG-PS was assessed, 30 (91%) had a PS of 0 or 1 as assessed according to the treating physician. Bivariate analysis revealed several measures that were associated with poorer overall survival in this cohort. For the entire cohort, VES-13 of 3 or greater (hazard ratio (HR) = 5.34, P = .002), ECOG PS of 1 or greater (HR = 2.4, P = .05), ADL dependence (HR = 5.62, P = .005), and Geriatric Depression Scale (GDS) score of 5 or greater (HR = 3.95, P = .04) were correlated with poorer survival. For individuals with metastatic disease, only VES-13 of 3 of greater (HR = 4.71, P = .005) and ADL dependence (HR = 6.19, P = .01) were prognostic. Using a multivariate regression model, only abnormal VES-13 score remained significant (HR = 15.61, P = .02, Figure 1). Age was not prognostic in the bivariate (HR = 1.02, P = .56 for ≥75 vs <75) or multivariate model. Relative dose intensity of chemotherapy of greater than 85% was also not predictive of overall survival (HR = 0.61, 95% confidence interval = 0.25–1.41). Oncologists are increasingly faced with treatment decisions for older adults, who are much less likely to receive even well-established therapies. This may derive from lack of knowledge about trials that included older adults or concern about the generalizability of trial results from younger cohorts being applied to older adults. Tools such as the VES-13 that formally and prospectively assess vulnerability may help provide important prognostic information. In the current study, baseline VES-13 scores emerged as the best prognostic tool. Competing causes of death are important to consider in this age group, and VES-13 should be incorporated into risk assessments. It adds prognostic information to ECOG-PS, a commonly used assessment of performance status in oncology practice typically used to determine fitness for chemotherapy. The cohort was small and incorporated individuals receiving chemotherapy in addition to surgery and those with metastatic disease, reducing the generalizability of the

The prevalence, correlates, and impact of logically inconsistent preferences in utility assessments for joint health states in prostate cancer

Background:Variations in health state utilities can impact cost-effectiveness analyses. One potential source of error is when joint health state (JS) utilities are rated higher than the embedded single state (SS) utilities. Knowing when and in whom this occurs can improve cost-effectiveness analyses. Methods:Men (n = 323) were surveyed at the time of prostate biopsy. Time tradeoff SS and JS utilities for prevalent prostate cancer (PCa) health states were collected. JS utilities assessed included those most prevalent for PCa. “Inconsistency” was defined in the following 3 ways: (1) any size rank order violation; (2) total number of violations; and (3) differences greater than 1 standard deviation (SD). Regression analysis assessed independent patient characteristics associated with inconsistent responses. Results:Aggregate JS utilities were consistent. At the individual level, 36% to 41% of responses violated rank order and 12% to 14% were larger than 1 SD. In all, 69% of respondents had at least 1 JS inconsistency, and 24% had >1 SD inconsistencies. Being married and feeling anxious were independently correlated with giving all types of inconsistent ratings, and lower education correlated with making >SD errors. SS utilities, and not JS utilities, were significantly lower for the inconsistent group. “Correcting” JS inconsistencies decreased aggregate utilities 1 to 9 units. Conclusions:Inconsistent JS utilities for PCa are prevalent in men at biopsy. Being married, more anxious, and having less education are correlated with inconsistencies. It is the SS utilities, rather than the JS utilities, that differ between consistent and inconsistent raters. Better understanding of the source of these inconsistencies is needed.

Effect of Specialty and Recent Experience on Perioperative Decision-Making for Abdominal Aortic Aneurysm Repair

To determine whether recent experience and specialty choice would affect physician adherence to evidence‐based guidelines.