Kinwah Fung

Palliation of bone metastases: a survey of patterns of practice among Canadian radiation oncologists☆

BACKGROUND Palliative radiotherapy constitutes nearly 50% of the workload in radiotherapy. Surveys on the patterns of practice in radiotherapy have been published from North America and Europe. Our objective was to determine the current pattern of practice of radiation oncologists in Canada for the palliation of bone metastases. METHOD A survey was sent to 300 practicing radiation oncologists in Canada. Five case scenarios were presented. The first three were patients with a single symptomatic site: breast cancer patient with pelvic metastasis, lung cancer male with metastasis to L3 and L1, respectively. The last two were breast and prostate cancer patients with multiple symptomatic bone metastases. RESULTS A total of 172 questionnaires were returned (57%) for a total of 860 responses. For the three cases with a single painful bone metastasis, over 98% would prescribe radiotherapy. The doses ranged from a single 8 to 30 Gy in ten fractions. Of the 172 respondents, 117 (68%) would use the same dose fractionation for all three cases, suggesting that they had a standard dose fractionation for palliative radiotherapy. The most common dose fractionation was 20 Gy in five fractions used by 84/117 (72%), and 8 Gy in one fraction by 19/117 (16%). In all five case scenarios, 81% would use a short course of radiotherapy (single 8 Gy, 17%; 20 Gy in five fractions, 64%), while 10% would prescribe 30 Gy in ten fractions. For the two cases with diffuse symptomatic bone metastases, half body irradiation (HBI) and radionuclides were recommended more frequently in prostate cancer than in breast cancer (46/172 vs. 4/172, P<0. 0001; and 93/172 vs. 10/172, P<0.0001, respectively). Strontium was the most commonly recommended radionuclide (98/103=95%). Since systemic radionuclides are not readily available in our health care system, 41/98 (42%) of radiation oncologists who would recommend strontium were not familiar with the dose. Bisphosphonates were recommended more frequently in breast cancer than in prostate cancer 13/172 (8%) vs. 1/172 (0.6%), P=0.001. CONCLUSION Local field external radiotherapy remains the mainstay of therapy, and the most common fractionation for bone metastases in Canada is 20 Gy in five fractions compared with 30 Gy in ten fractions in the US. Despite randomized trials showing similar results for single compared with fractionated radiotherapy, the majority of us still advocate five fractions. The frequency of employing a single fractionation has not changed since the last national survey in 1992. Nearly 70% use a standard dose fractionation to palliate localized painful metastasis by radiotherapy, independent of the site of involvement or tumor type. The pattern of practice of palliative radiotherapy for bone metastases in Canada is different to that reported previously from the US. The reasons why the results of randomized studies on bone metastases have no impact on the patterns of practice are worth exploring.

A predictive model for survival in metastatic cancer patients attending an outpatient palliative radiotherapy clinic

PURPOSE To develop a predictive model for survival from the time of presentation in an outpatient palliative radiotherapy clinic. METHODS AND MATERIALS Sixteen factors were analyzed prospectively in 395 patients seen in a dedicated palliative radiotherapy clinic in a large tertiary cancer center using Coxs proportional hazards regression model. RESULTS Six prognostic factors had a statistically significant impact on survival, as follows: primary cancer site, site of metastases, Karnofsky performance score (KPS), and fatigue, appetite, and shortness of breath scores from the modified Edmonton Symptom Assessment Scale. Risk group stratification was performed (1) by assigning weights to the prognostic factors based on their levels of significance, and (2) by the number of risk factors present. The weighting method provided a Survival Prediction Score (SPS), ranging from 0 to 32. The survival probability at 3, 6, and 12 months was 83%, 70%, and 51%, respectively, for patients with SPS <or=13 (n = 133); 67%, 41%, and 20% for patients with SPS 14-19 (n = 129); and 36%, 18%, and 4% for patients with SPS >or=20 (n = 133) (p < 0.0001). Corresponding survival probabilities based on number of risk factors were as follows: 85%, 72%, and 52% (<or=3 risk factors)(n = 98); 68%, 47%, and 24% (4 risk factors)(n = 117); and 46%, 24%, and 11% (>or=5 factors)(n = 180)(p < 0.0001). CONCLUSION Clinical prognostic factors can be used to predict prognosis among patients attending a palliative radiotherapy clinic. If validated in an independent series of patients, the model can be used to guide clinical decisions, plan supportive services, and allocate resource use.

READMIT: A clinical risk index to predict 30-day readmission after discharge from acute psychiatric units

Our aim was to create a clinically useful risk index, administered prior to discharge, for determining the probability of psychiatric readmission within 30 days of hospital discharge for general psychiatric inpatients. We used population-level sociodemographic and health administrative data to develop a predictive model for 30-day readmission among adults discharged from an acute psychiatric unit in Ontario, Canada (2008-2011), and converted the final model into a risk index system. We derived the predictive model in one-half of the sample (n = 32,749) and validated it in the other half of the sample (n = 32,750). Variables independently associated with 30-day readmission (forming the mnemonic READMIT) were: (R) Repeat admissions; (E) Emergent admissions (i.e. harm to self/others); (D) Diagnoses (psychosis, bipolar and/or personality disorder), and unplanned Discharge; (M) Medical comorbidity; (I) prior service use Intensity; and (T) Time in hospital. Each 1-point increase in READMIT score (range 0-41) increased the odds of 30-day readmission by 11% (odds ratio 1.11, 95% CI 1.10-1.12). The index had moderate discriminative capacity in both derivation (C-statistic = 0.631) and validation (C-statistic = 0.630) datasets. Determining risk of psychiatric readmission for individual patients is a critical step in efforts to address the potentially avoidable high rate of this negative outcome. The READMIT index provides a framework for identifying patients at high risk of 30-day readmission prior to discharge, and for the development, evaluation and delivery of interventions that can assist with optimizing the transition to community care for patients following psychiatric discharge.

Anticholinergic Drug Burden in Persons with Dementia Taking a Cholinesterase Inhibitor: The Effect of Multiple Physicians

To explore the association between the number of physicians providing care and anticholinergic drug burden in older persons newly initiated on cholinesterase inhibitor therapy for the management of dementia.

Use of the CAGE questionnaire for screening problem drinking in an out-patient palliative radiotherapy clinic.

To determine the positive rate of the CAGE questionnaire in an outpatient palliative radiotherapy clinic and to examine the association between problem drinking, pain control, and analgesic consumption, patients referred for palliative radiotherapy were screened with the CAGE questionnaire and asked to rate their symptom distress using the modified Edmonton Symptom Assessment System (ESAS). The latter instrument uses 11-point numeric scales (0 = best, 10 = worst). Their daily analgesic consumption in oral morphine equivalent was recorded. A total of 128 patients participated in the study. Only 9 patients answered one of the four CAGE questions affirmatively (positive group). All the rest answered negatively (negative group). The mean pain intensity at index site/overall pain was 4.97 +/- 3.31/3.27 +/- 2.76 for the negative group and 6.29 +/- 4.42/2.89 +/- 3.37 for the positive group. The mean total daily oral morphine equivalent for the negative and positive group were 112.35 +/- 233.58 mg and 36.82 +/- 58.85 mg, respectively. There was no significant difference found in other symptoms in the modified ESAS between these two groups. The positive rate of the CAGE in patients with advanced cancer attending an out-patient radiotherapy clinic was only 7%, and analyses were limited by the small sample size of those with a positive CAGE. Whether our observed low positive rate of CAGE represents the true prevalence of problem drinking or the CAGE questionnaire is an insensitive tool for screening problem drinking in an outpatient palliative radiotherapy clinic requires further investigation. We did not find a statistically significant worse pain intensity nor higher analgesic consumption in patients who screened positive for CAGE questionnaire.

Within-Hospital Readmission: An Indicator of Readmission after Discharge from Psychiatric Hospitalization

Objective: Readmission after psychiatric hospitalization is widely used as a quality of care indicator by government funding agencies, policy-makers, and hospitals deciding on clinical priorities. Readmission rates are calculated accurately to allow these varied groups to correctly translate the knowledge into appropriate, tangible outcomes. We aimed to assess how well hospital readmission rates, calculated using only readmissions to the discharging institution, can approximate actual readmission rates. Method: We used administrative data sources to identify patients with a mental health discharge in the province of Ontario (2008–2011). We identified mental health readmissions within 30 and 90 days of discharge occurring to the hospital from which the patient was discharged (within-hospital readmissions), and compared readmission rates using only within-hospital admissions with actual readmission rates. Results: The percentage of readmissions occurring to the discharging institution ranged from 39% to 89% (median 73%) and from 37% to 86% (median 70%) for 30- and 90-day readmissions, respectively. Using only within-hospital readmissions to rank hospitals by their readmission rates, only 56% of hospitals for 30-day readmissions and 50% for 90-day readmissions were ranked in the same quartile as when actual readmission rates were used. Conclusions: These findings highlight the importance of measuring psychiatric readmissions at the system level, particularly for hospitals with lower discharge volumes. As well, the high likelihood that multiple hospitals are involved in the hospital-based care of people who require readmission requires consideration at clinical and policy levels.

Use of Medications of Questionable Benefit at the End of Life in Nursing Home Residents with Advanced Dementia

To determine the prevalence of and resident characteristics associated with the prescription of medications of questionable benefit (MQBs) near the end of life in older adults with advanced dementia in nursing homes.

Medical comorbidity, acute medical care use in late-life bipolar disorder: a comparison of lithium, valproate, and other pharmacotherapies

OBJECTIVE Bipolar disorder is associated with high rates of medical comorbidity, particularly in late life. Little is known about medical health service utilization and potential effects of bipolar pharmacotherapy. We hypothesized that lithium use would not be associated with higher rates of medical hospitalization. METHODS Population-based retrospective cohort study of 1388 bipolar disorder patients aged ≥66years discharged from a psychiatric hospitalization in Ontario, Canada, between 2006 and 2012. Patients were divided into lithium users, valproate users, and non-lithium/non-valproate users. The main outcome was acute non-psychiatric, medical/surgical hospitalization during 1-year follow-up. RESULTS The rate of medical hospitalizations was 0.22 per patient-year. Time-to-medical hospitalization did not differ among lithium, valproate, and non-lithium/non-valproate users after adjusting for age, sex, past medical hospitalization, and antipsychotic use. Lithium, valproate, and non-lithium/non-valproate users did not differ markedly in terms of reason for medical hospitalization, 1-year acute medical health utilization outcomes, and medical comorbidity rates. CONCLUSION There were high rates of health service use for medical conditions among older adults with bipolar disorder, but this did not appear to be associated with lithium use, compared to valproate and other medication use (e.g., antipsychotics). A proactive collaborative care approach may prevent medical service utilization in severe late-life bipolar disorder.

Hospitalizations and emergency department visits for psychiatric illness during and after pregnancy among women with schizophrenia.

BACKGROUND Almost 50% of women with schizophrenia become pregnant. Little is known about their psychiatric service use patterns during or shortly after pregnancy. METHODS Using health administrative data, we identified 1,433 women in Ontario, Canada, with schizophrenia (ICD-9, ICD-10, or DSM-IV-TR) who had a live birth delivery from January 2003 through March 2011 and described their use of acute psychiatric care services including hospitalizations, emergency department visits not requiring hospitalization, and self-harm-related emergency department visits during pregnancy and in the first year postpartum. Incidence rates of psychiatric hospitalization during pregnancy, and also within 1 year postpartum, were each compared to the incidence rate of psychiatric hospitalization in the 1-year period before conception. Results are presented as incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Similar comparisons were made for psychiatric emergency department visits not requiring hospitalization, as well as for self-harm-related emergency department visits. RESULTS About 12% of the women had at least 1 psychiatric hospitalization during pregnancy, and 19% in the first year postpartum. About 10% had at least 1 psychiatric emergency department visit without hospitalization during pregnancy, and 16% had at least 1 emergency department visit postpartum. Self-harm-related emergency department visits were rarer, affecting only about 1% of the women in each time period. Relative to that in the 1-year period before conception (50 per 100 person-years), the incidence rate of psychiatric hospitalizations was lower during pregnancy (25 per 100 person-years), which is equivalent to an IRR of 0.50 (95% CI, 0.43-0.60). While the IRR of psychiatric hospitalizations was lower over the entire 1-year period postpartum (0.66; 95% CI, 0.57-0.76), it was transiently higher in the first 9 days postpartum (3.59; 95% CI, 2.74-4.69) and then waned by days 10 to 29 postpartum (0.87; 95% CI, 0.56-1.24). Emergency department visits for psychiatric and self-harm reasons were consistently lower during pregnancy and postpartum compared to the year before conception. CONCLUSIONS Psychiatric hospitalizations and emergency department visits are not uncommon for women with schizophrenia during pregnancy and the postpartum period. However, except for a brief period after delivery, women with schizophrenia are at relatively lower risk of requiring acute psychiatric inpatient and emergency care during and 1 year after pregnancy compared to the 1-year period prior to conception. This is key prognostic information for women with schizophrenia, their families, and providers who counsel them regarding pregnancy, motherhood, and management of schizophrenia. Identifying women at risk of requiring acute psychiatric services in the perinatal period warrants further investigation.

A Population-Based Study of Postpartum Mental Health Service Use by Immigrant Women in Ontario, Canada:

Objective: Postpartum mental disorders are twice as common among immigrant women compared to nonimmigrant women in developed countries. Immigrant women may experience barriers to access and use of postpartum mental health services, but little is known about their service use on a population level. We described postpartum mental health service use of immigrant mothers living in Ontario, Canada, comparing to a referent group of mothers who were either born in Canada or had lived in Ontario or another Canadian province since 1985. Method: Among all women in Ontario, Canada, delivering a live infant from 2008 to 2012 (n = 450,622), we described mental health service use within 1 year postpartum, including mental health physician visits, psychiatric emergency department visits, and psychiatric hospitalization. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) comparing immigrant women to the referent group were adjusted for maternal age, parity, income, rurality, mental health services in prior 2 years, and maternal and newborn health. Results: Immigrant women (n = 123,231; 27%) were less likely to use mental health services than women in the referent group (14.1% vs. 21.4%; aOR, 0.59; 95% CI, 0.58 to 0.61), including for physician-based (13.9% vs. 21.1%; aOR, 0.59; 95% CI, 0.58 to 0.61) and emergency department (0.6% vs. 1.3%; aOR, 0.63; 95% CI, 0.57 to 0.68) services. Hospitalization risk was lower among immigrants (0.20% vs. 0.33%) but became similar after covariate adjustment (aOR, 0.92; 95% CI, 0.79 to 1.06). Conclusions: Underuse of postpartum mental health services may be contributing to the high burden of postpartum mental disorders among immigrant women.