Katherine Thompson

How do I best manage the care of older patients with cancer with multimorbidity

The typical older patient with cancer presents with several other chronic conditions. The coexistence of multiple chronic conditions in one patient is best termed multimorbidity, and it affects a growing percentage of the population each year. In cancer care, as in much sub-specialty care, other diseases have been approached from a research and clinical standpoint as comorbidities--other age-associated diseases that are of secondary importance to cancer care. This is not the same as the newer concept of multimorbidity, a situation in which several overlapping chronic conditions are managed as equally-important to patient quality of life and outcomes. In the absence of a substantial evidence base or clinical practice guidelines that are tailored for multimorbid patients, clinicians need practical guidance for a rational approach to care for these complex patients. We adapt the American Geriatrics Societys Guiding Principles as an excellent starting point for clinical decision-making and management. These Guiding Principles include: 1) assessing patient preferences, 2) interpreting the available evidence, 3) estimating prognosis, 4) considering treatment feasibility, and 5) optimizing therapies and care plans. We apply them to older patients with cancer. As the population of older adults with cancer and multimorbidity grows, understanding the impact of multimorbidity on the care of patients with cancer and developing a management approach for these vulnerable patients will be vital for oncology care.

Screening for Frailty in Thoracic Surgical Patients

BACKGROUNDnThe presence of frailty or prefrailty in older adults is a risk factor for postsurgical complications. The frailty phenotype can be improved through long-term resistance and aerobic training. It is unknown whether short-term preoperative interventions targeting frailty will help to mitigate surgical risk. The purpose of this study was to determine the proportion of frail and prefrail patients presenting to a thoracic surgical clinic who could benefit from a frailty reduction intervention.nnnMETHODSnA prospective cohort study was performed at a single-site thoracic surgical clinic. Starting October 1, 2014, surgical candidates 60 years of age or older who consented to be screened were included. Patients were screened using an adapted version of Frieds phenotypic frailty criteria: weakness (grip strength), slow gait (15-foot walk), unintentional weight loss, self-reported exhaustion, and low self-reported physical activity (Physical Activity Scale for the Elderly). Prefrailty was identified when participants demonstrated one to two frailty characteristics; frailty was identified when participants demonstrated three to five frailty characteristics.nnnRESULTSnOf 180 eligible patients, 126 consented, and 125 completed screening. Thirty-nine participants (31%) were not frail, 71 (57%) were prefrail, and 15 (12%) were frail. Exhaustion was the most common frailty symptom (34%). Frailty prevalence did not significantly differ among men and women (men: 10%, women: 14%; pxa0= 0.75).nnnCONCLUSIONSnWe found a high proportion of prefrail and frail patients among patients deemed candidates for thoracic surgical procedures. This finding indicates that frailty may be underrecognized. Substantial numbers of patients may be considered for a presurgical frailty reduction intervention.

Thoracic surgeons' perception of frail behavior in videos of standardized patients.

Background Frailty is a predictor of poor outcomes following many types of operations. We measured thoracic surgeons accuracy in assessing patient frailty using videos of standarized patients demonstrating signs of physical frailty. We compared their performance to that of geriatrics specialists. Methods We developed an anchored scale for rating degree of frailty. Reference categories were assigned to 31 videos of standarized patients trained to exhibit five levels of activity ranging from “vigorous” to “frail.” Following an explanation of frailty, thoracic surgeons and geriatrics specialists rated the videos. We evaluated inter-rater agreement and tested differences between ratings and reference categories. The influences of clinical specialty, clinical experience, and self-rated expertise were examined. Results Inter-rater rank correlation among all participants was high (Kendalls W 0.85) whereas exact agreement (Fleiss kappa) was only moderate (0.47). Better inter-rater agreement was demonstrated for videos exhibiting extremes of behavior. Exact agreement was better for thoracic surgeons (nu200a=u200a32) than geriatrics specialists (nu200a=u200a9; pu200a=u200a0.045), whereas rank correlation was similar for both groups. More clinical years of experience and self-reported expertise were not associated with better inter-rater agreement. Conclusions Videos of standarized patients exhibiting varying degrees of frailty are rated with internal consistency by thoracic surgeons as accurately as geriatrics specialists when referenced to an anchored scale. Ratings were less consistent for moderate degrees of frailty, suggesting that physicians require training to recognize early frailty. Such videos may be useful in assessing and teaching frailty recognition.

The Influence of Physician and Patient Gender on Risk Assessment for Lung Cancer Resection

BACKGROUNDnWomen do not receive appropriate surgical therapy for lung cancer as often as men. Patient gender may influence treatment recommendations; less is known about the effect of physician gender on recommendations.nnnMETHODSnGender-neutral vignettes representing low-risk, average-risk, and high-risk candidates for lung resection were paired with concordant videos of standardized patients (SPs). Cardiothoracic trainees and practicing thoracic surgeons read a vignette, provided an initial estimate of the percentage risk of major adverse events after lung resection, viewed a video (randomized to male or female SP), provided a final estimate of risk, and ranked the importance of the video in the final risk estimate.nnnRESULTSnOverall, 107 surgeons participated, of whom 90 were men. Initial estimated risks mirrored actual vignette risks: 10.4% ± 9.9 for low risk, 17.6% ± 13.2 for average risk, and 21.0% ± 14.7 for high risk (p < 0.001). After SP videos were viewed and final risk estimates were rendered, there was a significant difference between male and female physicians in the absolute change in estimated risk (pxa0= 0.002), with male physicians having larger changes than female physicians. There was also an effect of SP gender that varied by vignette type (p < 0.001). Increasing video importance scores were directly associated with increasing change in risk scores for average-risk and high-risk vignette/video combinations (p < 0.001 for each).nnnCONCLUSIONSnDifferences in estimating complication risk for lung resection candidates are related to physician and patient gender. This may influence recommendations for surgical treatment. Understanding such differences may help reduce inequities in treatment recommendations.

The Impact of a Frailty Education Module on Surgical Resident Estimates of Lobectomy Risk

BACKGROUNDnFrailty is a risk factor for adverse events after surgery. Residents ability to recognize frailty is underdeveloped. We assessed the influence of a frailty education module on surgical residents estimates of lobectomy risk.nnnMETHODSnTraditional track cardiothoracic surgery residents were randomly allocated to take an online short course on frailty (experimental group) or to receive no training (control group). Residents read a clinical vignette, made an initial risk estimate of major complications for lobectomy, and rated clinical factors on their importance to their estimates. They viewed a video of a standardized patient portraying the patient in the vignette, randomly selected to exhibit either vigorous or frail behavior, and provided a final risk estimate. After rating five vignettes, they completed a test on their frailty knowledge.nnnRESULTSnForty-one residents participated (20 in the experimental group). Initial risk estimates were similar between the groups. The experimental group rated clinical factors as very important in their initial risk estimates more often than did the control group (47.6% versus 38.5%; p < 0.001). Viewing videos resulted in a significant change from initial to final risk estimates (frail 50% ± 75% increase, p = 0.008; vigorous 14% ± 32% decrease, p = 0.043). The magnitude of change in risk estimates was greater for the experimental group (10.0 ± 8.1 versus 5.1 ± 7.7; p < 0.001). The experimental group answered more frailty test questions correctly (93.7% versus 75.2%; p < 0.001).nnnCONCLUSIONSnA frailty education module improved resident knowledge of frailty and influenced surgical risk estimates. Training in frailty may help educate residents in frailty recognition and surgical risk assessment.

Does Race Influence Risk Assessment and Recommendations for Lung Resection? A Randomized Trial

BACKGROUNDnRacial disparities in use of surgical therapy for lung cancer exist in the United States. Videos of standardized patients (SPs) can help identify factors that influence physicians surgical risk estimation. We hypothesized that physician race and SP race in videos influence surgeon decision making.nnnMETHODSnFour race-neutral clinical vignettes representing lung resection candidates were paired with risk-level concordant short silent videos of SPs. Vignette/video combinations were classified as low or high risk. Trainees and practicing thoracic surgeons read a race-neutral vignette, provided an initial estimate of the percentage risk of major surgical complications, viewed a video randomized to a black or white SP, provided a final estimate of risk, and scored the likelihood that they would recommend operative therapy. Changes in risk estimates were assessed.nnnRESULTSnParticipants included 113 surgeons (38 practicing surgeons, 75 trainees); of these, 76 were white non-Hispanic (67%), and 37 were other self-identified racial categories. Percentage changes between initial and final risk estimates were not significantly related to patient race (pxa0= 0.11) or surgeon race (white versus other; pxa0= 0.52). Videos of black SPs were associated with a similar likelihood of recommending an operation compared with that of videos of white SPs (pxa0= 0.90). Physician race (white versus other) was not related to the likelihood of recommending surgical intervention (pxa0= 0.79).nnnCONCLUSIONSnNeither patient nor physician race was significantly associated with risk estimation or surgical recommendations. These findings do not provide an explanation for documented racial disparities in lung cancer therapy. Further investigation is needed to identify the mechanism underlying these disparities.

Do Estimates of Treatment Risk Based on Clinical Vignettes Differ by Physician Gender

BACKGROUNDnClinical vignettes are frequently used as instructional and evaluative instruments for physicians. Physicians gender is a source of unconscious bias in treatment recommendations. This study assessed whether interpretation of information in clinical vignettes differed by physicians gender as a possible source of unconscious bias.nnnMETHODSnThoracic surgeons and physicians in cardiothoracic surgical training were asked to provide estimates of major complication rates for lung resection on the basis of anonymized clinical vignettes of patients undergoing lung resection. Vignettes were categorized as low, average, and high risk by using a sum of Charlson Comorbidity Index (possible range, 0 to 37) and a combined physiologic score, EVAD (forced expiratory volume in 1 second, diffusing capacity of lung for carbon monoxide, age; possible range, 0 to 12); participants were not aware of the risk scores or vignette categories. Generalized estimating equation linear regression models were fit with risk scores treated as a continuous independent variable.nnnRESULTSnA total of 247 physicians (105 practicing surgeons, 142 trainees; 203 men, 44 women) participated in one or more of the studies. Nearly all (103; 98%) of the practicing surgeons rated themselves as competent or expert in lung resection compared with 77 (54%) of the trainees (p < 0.001). Participants complication estimates mirrored both vignette risk category and combined risk score. There was no significant difference between men and women physicians in their estimates of complication rates.nnnCONCLUSIONSnUnconscious bias related to physicians gender is not associated with differential use of information in clinical vignettes. Any possible bias may arise from face-to-face interactions with patients. Research into physicians and patients gender differences during such interactions is warranted.

Improving medical and pharmacy student confidence in medication management and attitudes about interprofessional collaboration by utilizing an interprofessional module

ABSTRACT Adverse drug events are common and often preventable. Educating the interprofessional workforce to appropriately manage medications as part of a team is a priority. An interprofessional medication management module for graduating medical and pharmacy students was developed. The module was case-based and co-led by physicians and pharmacists. Students completed pre- and post-module surveys regarding their attitudes about interprofessional collaboration, confidence in managing medications, and self-reported ability to perform the tasks laid out in the minimum geriatrics competencies as a result of the module. Eighteen medical and 13 pharmacy students participated over a two-year period. There was statistically significant improvement in students’ attitudes about interprofessional collaboration with regards to understanding their role and the role of others on the interprofessional team, and about teamwork between medical and pharmacy students. There was also statistically significant improvement in confidence with regards to the 3 medication management competencies after completion of the module. The vast majority of students agreed that the module improved their self-reported ability to manage medications. An interprofessional medication management module is an effective way to improve medical and pharmacy students’ attitudes about interprofessional collaboration and confidence in medication management.

Geriatrics training for nurses in a skilled nursing facility: a GWEP feasibility study

ABSTRACT Geriatrics knowledge and expertise is critical to the care of older adults in skilled nursing facilities. However, opportunities for ongoing geriatrics training for nurses working in skilled nursing facilities are often scarce or nonexistent. This feasibility study describes a mixed‐methods analysis of nurses educational needs and barriers to continuing education in a for‐profit skilled nursing facility in an underserved, urban environment. Potential mechanisms to overcome barriers are proposed.

Primary Care for the Older Adult Patient: Common Geriatric Issues and Syndromes

Older adults are the fastest growing segment of the US population and the majority of older adults are women. Primary care for the older adult patient requires a wide variety of skills, reflecting the complexity and heterogeneity of this patient population. Individualizing care through consideration of patients goals, medical conditions, and prognosis is paramount. Quality care for the older adult patient requires familiarity with common geriatric syndromes, such as dementia, falls, and polypharmacy. In addition, developing the knowledge and communication skills necessary for complex care and end-of-life care planning is essential.