Traci E. Yamashita

Symptom Burden, Depression, and Spiritual Well-Being: A Comparison of Heart Failure and Advanced Cancer Patients

ABSTRACTBACKGROUNDA lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer.OBJECTIVEWe examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients.DESIGNThis was a cross-sectional study.PARTICIPANTSSixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer.MEASUREMENTSSymptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being scale).MAIN RESULTSOverall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction ≤30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer.CONCLUSIONSPatients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.

Predictors of persistent burnout in internal medicine residents: a prospective cohort study.

Purpose Resident burnout continues to be a major problem despite work hours restrictions. The authors conducted a longitudinal study to determine whether burnout in internal medicine residents is persistent and what factors predispose residents to persistent burnout. Method The authors mailed a survey to internal medicine residents at the University of Colorado Denver Health Science Center each May, from 2003 through 2008. The survey measures included the Maslach Burnout Inventory organized into three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment. The authors defined burned-out residents as having a high EE or DP score and persistent burnout as being burned out during all three years of residency. Results Of the 179 eligible residents, 86 (48%) responded to the survey during all three years of their residency. Sixty-seven residents (78%) were burned out at least once: 58 residents (67%) were burned out during their internship, 58 (67%) during their second year, and 50 (58%) during their third year (P < .08). Of the 58 burned-out interns, 42 (72%) continued to be burned out through their three years of training. Persistent burnout was more likely to occur in men (OR = 3.31, P < .01) and was associated with screening positive for depression as an intern (OR = 4.4, P < .002). Conclusions Once present, burnout tends to persist through residency. Men and residents who screened positive for depression as interns are at the highest risk for persistent burnout. Interventions to prevent burnout during internship may significantly decrease burnout throughout residency.

Opioid Prescribing at Hospital Discharge Contributes to Chronic Opioid Use.

ABSTRACTBACKGROUNDChronic opioid therapy for chronic pain treatment has increased. Hospital physicians, including hospitalists and medical/surgical resident physicians, care for many hospitalized patients, yet little is known about opioid prescribing at hospital discharge and future chronic opioid use.OBJECTIVEWe aimed to characterize opioid prescribing at hospital discharge among ‘opioid naïve’ patients. Opioid naïve patients had not filled an opioid prescription at an affiliated pharmacy 1 year preceding their hospital discharge. We also set out to quantify the risk of chronic opioid use and opioid refills 1 year post discharge among opioid naïve patients with and without opioid receipt at discharge.DESIGNThis was a retrospective cohort study.PARTICIPANTSFrom 1 January 2011 to 31 December 2011, 6,689 opioid naïve patients were discharged from a safety-net hospital.MAIN MEASUREChronic opioid use 1 year post discharge.KEY RESULTSTwenty-five percent of opioid naïve patients (n = 1,688) had opioid receipt within 72 hours of discharge. Patients with opioid receipt were more likely to have diagnoses including neoplasm (6.3 % versus 3.5 %, p < 0.001), acute pain (2.7 % versus 1.0 %, p < 0.001), chronic pain at admission (12.1 % versus 3.3 %, p < 0.001) or surgery during their hospitalization (65.1 % versus 18.4 %, p < 0.001) compared to patients without opioid receipt. Patients with opioid receipt were less likely to have alcohol use disorders (15.7 % versus 20.7 %, p < 0.001) and mental health disorders (23.9 % versus 31.4 %, p < 0.001) compared to patients without opioid receipt. Chronic opioid use 1 year post discharge was more common among patients with opioid receipt (4.1 % versus 1.3 %, p < 0.0001) compared to patients without opioid receipt. Opioid receipt was associated with increased odds of chronic opioid use (AOR = 4.90, 95 % CI 3.22-7.45) and greater subsequent opioid refills (AOR = 2.67, 95 % CI 2.29-3.13) 1 year post discharge compared to no opioid receipt.CONCLUSIONOpioid receipt at hospital discharge among opioid naïve patients increased future chronic opioid use. Physicians should inform patients of this risk prior to prescribing opioids at discharge.

A comparison of two spirituality instruments and their relationship with depression and quality of life in chronic heart failure.

Spirituality is a multifaceted construct related to health outcomes that remains ill defined and difficult to measure. Spirituality in patients with advanced chronic illnesses, such as chronic heart failure, has received limited attention. We compared two widely used spirituality instruments, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) and the Ironson-Woods Spirituality/Religiousness Index (IW), to better understand what they measure in 60 outpatients with chronic heart failure. We examined how these instruments related to each other and to measures of depression and quality of life using correlations and principal component analyses. The FACIT-Sp measured aspects of spirituality related to feelings of peace and coping, whereas the IW measured beliefs, coping, and relational aspects of spirituality. Only the FACIT-Sp Meaning/Peace subscale consistently correlated with depression (r=-0.50, P<0.0001) and quality of life (r=0.41, P=0.001). Three items from the depression measure loaded onto the same factor as the FACIT-Sp Meaning/Peace subscale (r=0.43, -0.43, and 0.71), whereas the remaining 12 items formed a separate factor (Cronbachs alpha=0.82) when combined with the spirituality instruments in a principal component analysis. The results demonstrate several clinically useful constructs of spirituality in patients with heart failure and suggest that psychological and spiritual well-being, despite some overlap, remain distinct phenomena.

Development of a Primary Care-Based Clinic to Support Adults With a History of Childhood Cancer: The Tactic Clinic.

PURPOSE Describe the development and evolution of a primary-care-based, multidisciplinary clinic to support the ongoing care of adult survivors of childhood cancer. METHODS A consultative clinic for adult survivors of childhood cancer has been developed that is located in an adult, academic internal medicine setting and is based on a long-term follow-up clinic model available at Childrens Hospital Colorado. RESULTS The clinic opened in July 2008. One hundred thirty-five patients have been seen as of April 2014. Referrals and clinic capacity have gradually increased over time, and a template has been developed in the electronic medical record to help facilitate completion of individualized care plan letters. CONCLUSIONS A primary care-based, multidisciplinary consultative clinic for adults with a history of childhood cancer survivor is feasible and actively engages adult primary care resources to provide risk-based care for long-term pediatric cancer survivors. This model of care planning can help support adult survivors of pediatric cancer and their primary care providers in non-academic, community settings as well.

Inconsistencies in Opioid Equianalgesic Ratios: Clinical and Research Implications

Cancer pain is common, occurring in up to 60% of patients and opioid conversion may be required for effective pain management. Conversion from one opioid to another can be problematic due to differences in equianalgesic ratios found in established resources. This study explores the implications of using various published equianalgesic ratios when converting to a common opioid unit. This secondary analysis includes 105 advanced cancer patients who reported use of transdermal fentanyl, long-acting oxycodone, or oral methadone. Common clinically used equianalgesic ratios were identified and utilized to calculate a parenteral morphine equivalent for each of the selected agents. When the equianalgesic ratios were applied to each drug, there were substantial differences in the calculated morphine equivalent for transdermal fentanyl (2-fold difference) and methadone (100-fold difference). The calculated difference for oxycodone was lower, with a 1.5-fold difference. This study demonstrates large variability in opioid conversions based on the use of common equianalgesic ratios for transdermal fentanyl, long-acting oxycodone, and methadone. These findings have important clinical and research implications. First, this study substantiates the use of these ratios as only guidelines for treatment. Second, it supports the need for well-designed, rigorous studies to evaluate opioid conversions. Third, this study demonstrates the need for a standard reporting system of opioid equianalgesic ratios employed in clinical trials.

Characteristics and trends of low-dose quetiapine use in two western state Medicaid programs.

Medicaid programs are concerned about inappropriate, potentially hazardous, and costly off‐label use of second‐generation antipsychotics (SGAs). Several states are exploring policies aimed at managing low‐dose quetiapine, commonly prescribed for off‐label conditions. This study aimed to characterize longitudinal trends and patient characteristics associated with low‐dose quetiapine in two state Medicaid programs. We further aimed to quantify changes in the use of quetiapine associated with a legal settlement that curtailed off‐label promotion of this product.

Characteristics associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospice.

BACKGROUND Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness, while achieving hospital cost savings. However, studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay (LOS) who may benefit from palliative care consultation. OBJECTIVE Identify characteristics associated with higher cost per day or longer LOS in hospitalized patients at the end of life--those likely to benefit from palliative care consultation. DESIGN Observational study. SETTING Academic medical center. PATIENTS Adult inpatients who died during the hospitalization or were discharged to hospice. INTERVENTION None. MEASUREMENTS We hypothesized that several patient characteristics would be associated with higher cost per day and/or longer LOS. Using administrative data, we developed univariate and multivariate models to evaluate association between these patient characteristics and cost per day and LOS. RESULTS Patients cared for on the cardiothoracic surgery service had significantly higher cost per day (

Erratum: Spiritual well-being and depression in patients with heart failure (Journal of General Internal Medicine (2007) 22, (470-477) DOI: 10.1007/s11606-006-0044-9)

12,937; P < 0.0001) and LOS (7.0 days; P = 0.001). Neurosurgery patients also had higher cost per day (

Positive predictive value of medical student specialty choices

2255; P = 0.03), and surgical oncology patients had a longer length of stay (5.3 days; P = 0.003). Patients 65 years and older had a significantly lower cost per day (-