Impact on Life Expectancy of Withdrawing Thiopurines in Patients with Crohn's Disease in Sustained Clinical Remission: A Lifetime Risk-Benefit Analysis

Objective

Long-term treatment with thiopurines is associated with a decreased risk of Crohn’s disease (CD) flare but an increased risk of various cancers depending on gender, age, and presence of extensive colitis. We evaluated risks and benefits of withdrawing thiopurines in patients with CD in prolonged remission.

Methods

We developed a Markov model assessing risks and benefits of withdrawing thiopurines compared to continuing thiopurines in a lifetime horizon. The model was stratified by age (35 and 65 years old at thiopurine withdrawal), gender and presence of extensive colitis. Parameter estimates were taken from French cohorts and hospital databases, cancer and death national registries and published literature. Life expectancy, rates of relapse, serious adverse events, and causes-of-death were evaluated.

Results

In patients without extensive colitis, continuing thiopurines increased life expectancy up to 0.03 years for 35 year-old men and women but decreased life expectancy down to 0.07 years for 65 year-old men and women. Withdrawal strategy became the preferred strategy at 40.6 years for men, and 45.7 years for women without extensive colitis. In patients with extensive colitis, continuation strategy was the preferred strategy regardless of age. Risk-benefit analysis was not modified by duration of CD activity.

Conclusions

Factors determining life expectancy associated with withdrawal or continuation of thiopurines in patients with CD and in sustained clinical remission vary substantially according to gender, age and presence of extensive colitis. Individual decisions to continue or withdraw thiopurines in patients with CD in sustained remission should take into account these parameters.

Smoking, cessation, and cessation counseling in patients with cancer: A population-based analysis

BACKGROUND

Smoking is known to be carcinogenic and an important factor in the outcome of cancer treatment. However, to the authors' knowledge, smoking habits and smoking cessation counseling in patients with cancer have been poorly studied. The authors sought to analyze smoking habits among Americans diagnosed with cancer in a nationally representative dataset.

METHODS

The cancer supplement of the National Health Interview Survey (NHIS) in 2010 was used to obtain information regarding self-reported smoking behavior in a representative sample of the US population. Cancer history, smoking history, quitting behavior, cessation counseling, cessation approaches, and sociodemographic variables were analyzed.

RESULTS

A total of 27,157 individuals were interviewed for the NHIS in 2010, representing 216,052,891 individuals, 7,058,135 of whom had ever smoked and 13,188,875 of whom had been told that they had cancer. Approximately 51.7% of individuals diagnosed with cancer and who were active smokers reported being counseled to quit smoking by a health professional within the previous 12 months. Cancer survivors were no more likely to quit smoking than individuals in the general population. Those diagnosed with a tobacco-related cancer were found to be no more likely to report quitting smoking than those with other types of cancers. Rates of quitting did not appear to vary based on the type of smoking cessation method used (P = .50).

CONCLUSIONS

Patients with cancer, including those diagnosed with a tobacco-related cancer, do not appear to be more likely to quit smoking than the general population. Only approximately one-half of patients with cancer who smoke are counseled to quit. Smoking cessation in patients with cancer is an important area for intervention and investigation.

Gender and Race in the Timing of Requests for Ethics Consultations: A Single-Center Study

BACKGROUND

Clinical ethics consultants are expected to "reduce disparities, discrimination, and inequities when providing consultations," but few studies about inequities in ethics consultation exist.1 The objectives of this study were (1) to determine if there were racial or gender differences in the timing of requests for ethics consultations related to limiting treatment, and (2) if such differences were found, to identify factors associated with that difference and the role, if any, of ethics consultants in mitigating them.

METHODS

The study was a mixed methods retrospective study of consultation summaries and hospital and ethics center data on 56 age-and gender-matched Caucasian and African American Medicare patients who received ethics consultations related to issues around limiting medical treatment in the period 2011 to 2014. The average age of patients was 70.9.

RESULTS

Consultation requests for females were made significantly earlier in their stays in the hospital (6.57 days) than were consultation requests made for males (16.07 days). For African American patients, the differences in admission-to-request intervals for female patients (5.93 days) and male patients (18.64 days) were greater than for Caucasian male and female patients. Differences in the timing of a consultation were not significantly correlated with the presence of an advance directive, the specialty of the attending physician, or the reasons for the consult request. Ethics consultants may have mitigated problems that developed during the lag in request times for African American males by spending more time, on average, on those consultations (316 minutes), especially more time, on average, than on consultations with Caucasian females (195 minutes). Most consultations (40 of 56) did result in movement toward limiting treatment, but no statistically significant differences were found among the groups studied in the movement toward limiting treatment. The average number of days from consult to discharge or death were strongly correlated with the intervals between admission to the hospital and request for an ethics consultation.

CONCLUSION

Our findings suggest race and gender disparities in the timing of ethics consultations that consultants may have partially mitigated.

Long-term outcomes of tyrosine kinase inhibitor discontinuation in patients with metastatic renal cell carcinoma

PURPOSE

The purpose of the current study was to evaluate the clinical outcomes of patients with metastatic renal cell carcinoma (mRCC) who interrupted vascular endothelial growth factor receptor tyrosine kinase inhibitor (VEGFR-TKI) therapy.

METHODS

A retrospective analysis of medical records was performed on all patients with mRCC treated with VEGFR-TKIs between January 2008 and July 2014 (n = 505). Patients who achieved stable disease (SD) or a better response under TKI and later discontinued TKI treatment for any reason with the exception of disease progression were included in the analysis.

RESULTS

We identified 32 patients (sunitinib = 20, sorafenib = 7, and pazopanib = 5). The responses to VEGFR-TKIs were complete response (CR, n = 4), partial response (PR, n = 11), SD (n = 15), and controlled but nonmeasurable response (n = 2). Median time to TKI discontinuation from the initiation of VEGFR-TKI therapy was 16.6 months (95 % CI 12.8-20.3), and the main cause of VEGFR-TKI discontinuation was toxicity (n = 19, 59.4 %). At the time of analysis, 16 patients had disease progression and one patient died. With a median follow-up duration of 51.7 months (range 11.5-87.6), median progression-free survival (PFS) after TKI discontinuation was 20.2 months (95 % CI 6.4-34.0). In multivariate analysis, the duration of TKI therapy (<1 year) before TKI discontinuation was an independent significant prognostic factor of poor PFS (p = 0.045). Among 11 patients who were retreated with the same TKI, two patients (18.2 %) achieved PR and nine achieved SD (81.8 %).

CONCLUSIONS

VEGFR-TKI could be interrupted at least temporarily when clinically warranted in patients with mRCC sufficiently controlled by TKIs.

End-of-life decisions for children under 1 year of age in the Netherlands: decreased frequency of administration of drugs to deliberately hasten death

OBJECTIVE

To assess whether the frequency of end-of-life decisions for children under 1 year of age in the Netherlands has changed since ultrasound examination around 20 weeks of gestation became routine in 2007 and after a legal provision for deliberately ending the life of a newborn was set up that same year.

METHODOLOGY

This was a recurrent nationwide cross-sectional study in the Netherlands. In 2010, a sample of death certificates from children under 1 year of age was derived from the central death registry. All 223 deaths that occurred in a 4-month study period were included. Physicians who had reported a non-sudden death (n=206) were sent a questionnaire on the end-of-life decisions made. 160 questionnaires were returned (response 78%).

FINDINGS

In 2010, 63% of all deaths of children under 1 year of age were preceded by an end-of-life decision-a percentage comparable to other times when this study was conducted (1995, 2001, 2005). These end-of-life decisions were mainly decisions to withdraw or withhold potentially life-sustaining treatment. In 2010, the percentage of cases in which drugs were administered with the explicit intention to hasten death was 1%, while in 1995 and 2001, this was 9% and in 2005, this was 8%.

DISCUSSION AND CONCLUSION

There has been a reduction of infant deaths that followed administration of drugs with the explicit intention to hasten death. One explanation for this reduction relates to the introduction of routine ultrasound examination around 20 weeks of gestation. In addition, the introduction of legal criteria and a review process for deliberately ending the life of a newborn may have left Dutch physicians with less room to hasten death.

Interventions for dialysis patients with hepatitis C virus (HCV) infection

BACKGROUND

Hepatitis C virus (HCV) infection is common in chronic kidney disease (CKD) patients on dialysis, causes chronic liver disease, increases mortality and impacts kidney transplant outcomes. Sustained response to the preferred treatment with standard or pegylated (PEG) interferon is seen in 39% with side effects necessitating treatment discontinuation in 20%. We collated evidence for treatment response and harms of interventions for HCV infection in dialysis.

OBJECTIVES

We aimed to look at the benefits and harms of various interventions for HCV infection in CKD patients on HD or peritoneal dialysis, specifically on mortality, disease relapse, response to treatment, treatment discontinuation, time to recovery, quality of life, cost effectiveness,adverse effects, and other outcomes. We aimed to study comparisons of available interventions with a placebo or control group, combinations of interventions with placebo or control group, interventions with each other singly and in combination, available standard interventions with newer treatment modalities.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Specialised Register to 24 March 2015 through contact with the Trials' Search Co-ordinator. We also checked references of reviews, studies and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs, first period of randomised cross-over studies on interventions for HCV in CKD on dialysis were considered.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration and also collected adverse effects data listed in included RCTs.

MAIN RESULTS

Ten RCTs (361 participants) met our inclusion criteria. Five RCTs (152 participants, 134 analysed) with low to moderate quality of evidence compared standard recombinant interferon with placebo or control. There was no significant difference for mortality (5 studies (134 participants): RR 0.89, 95% CI 0.06 to 13.23), relapses (1 study (36 participants): RR 0.72, 95% CI 0.28 to 1.88), sustained virological response (4 studies (98 participants): RR 3.25, 95% CI 0.81 to 13.07), treatment discontinuation (4 studies (116 participants): RR 4.59, 95% CI 0.49 to 42.69) and number with adverse events (5 studies (143 participants): RR 3.56, 95% CI 0.98 to 13.01). End of treatment response was significantly more for standard interferon (5 studies (132 participants): RR 8.62, 95% CI 3.03 to 24.55). There was overall low to unclear risk of bias and no significant heterogeneity.One RCT (50 participants) with moderate quality of evidence compared PEG interferon and standard interferon. There was no significant difference in mortality (RR 0.33, 95% CI 0.01 to 7.81), relapses (RR 0.72, 95% CI 0.41 to 1.25), sustained virological response (RR 2.40, 95% CI 0.99 to 5.81), treatment discontinuation (RR 0.11, 95% CI 0.01 to 1.96) and number with major adverse events (RR 0.11, 95% CI 0.01 to 1.96). End of treatment response was significantly more for PEG interferon (RR 1.53, 95% CI 1.09 to 2.15). There was overall low risk of bias.Two RCTs (97 participants) with moderate quality of evidence compared two doses of two different preparations of PEG interferon. Subgroup analysis comparing high and low doses of PEG interferon alpha-2a (135 µg/week versus 90 µg/week) and PEG interferon alpha-2b (1 µg/kg versus 0.5 µg/kg body weight/week) found no significant difference in mortality (2 studies (97 participants): RR 4.30, 95% CI 0.76 to 24.33), relapses (1 study (81 participants): RR 1.11, 95% CI 0.45 to 2.77), end of treatment response (2 studies (97 participants): RR 1.42, 95% CI 0.51 to 3.90), sustained virological response (2 studies (97 participants): RR 1.19, 95% CI 0.68 to 2.07), treatment discontinuation (2 studies (97 participants): RR 1.20, 95% CI 0.63 to 2.28), patients with adverse events (2 studies (97 participants): RR 1.05, 95% CI 0.61 to 1.83) or serious adverse events (2 studies (97 participants): RR 1.24, 95% CI 0.72 to 2.14). Both had overall low risk of bias and no significant subgroup differences.Two RCTs (62 participants) with moderate quality of evidence compared standard or PEG interferon alone or in combination with ribavirin. The only reported outcome in both was treatment discontinuation which was significantly more with ribavirin in the one study (RR 0.34, 95% CI 0.14 to 0.84) and pooled 7/10 in the second.No RCTs had data on time to recovery, cost-effectiveness, quality of life, and other outcomes and in peritoneal dialysis.

AUTHORS' CONCLUSIONS

Our review demonstrated that in CKD patients on haemodialysis with HCV infection treatment with standard interferon brings about an end of treatment but not a sustained virological response and is relatively well tolerated. PEG interferon is more effective than standard interferon for end of treatment response but not for sustained response; both were equally tolerated. Increasing doses of PEG interferon did not improve responses but high and low doses are equally tolerated. Addition of ribavirin results in more treatment discontinuation.

How long is long enough, and have we done everything we should?--Ethics of calling codes

'Calling' a code can be an ambiguous undertaking. Despite guidelines and the medical literature outlining when it is acceptable to stop resuscitation, code cessation and deciding what not to do during a code, in practice, is an art form. Familiarity with classic evidence suggesting most codes are unsuccessful may influence decisions about when to terminate resuscitative efforts, in effect enacting self-fulfilling prophesies. Code interventions and duration may be influenced by patient demographics, gender or a concern about the stewardship of scarce resources. Yet, recent evidence links longer code duration with improved outcomes, and advances in resuscitation techniques complicate attempts to standardise both resuscitation length and the application of advanced interventions. In this context of increasing clinical and moral uncertainty, discussions between patients, families and medical providers about resuscitation plans take on an increased degree of importance. For some patients, a 'bespoke' resuscitation plan may be in order.

Effectiveness and Safety of Immunomodulators With Anti-Tumor Necrosis Factor Therapy in Crohn's Disease

BACKGROUND & AIMS

The benefit of continuing immunomodulators when "stepping up" to anti-tumor necrosis factor (anti-TNF) therapy for Crohn's disease (CD) is uncertain. This study assessed the effectiveness and safety of immunomodulators with anti-TNF therapy in CD.

METHODS

We conducted a retrospective cohort study of new users of anti-TNF therapy for CD in Medicare. Users of anti-TNF combination therapy with immunomodulators were matched to up to 3 users of anti-TNF monotherapy via propensity score and compared by using 3 metrics of effectiveness-surgery, hospitalization, and discontinuation of anti-TNF therapy or surgery-and 2 metrics of safety-serious infection and non-Candida opportunistic infection. Cox regression was used for all analyses.

RESULTS

Among new users of infliximab, we matched 381 users of combination therapy to 912 users of monotherapy; among new users of adalimumab, we matched 196 users of combination therapy to 505 users of monotherapy. Combination therapy occurred predominantly as "step up" after thiopurine therapy. The rates of surgery (hazard ratio [HR], 1.20; 95% confidence interval, 0.73-1.96), hospitalization (HR, 0.82; 0.57-1.19), discontinuation of anti-TNF therapy or surgery (HR, 1.09; 0.88-1.34), and serious infection (HR, 0.93; 0.88-1.34) did not differ between users of anti-TNF combination therapy and monotherapy. However, the risks of opportunistic infection (HR, 2.64; 1.21-5.73) and herpes zoster (HR, 3.16; 1.25-7.97) were increased with combination therapy.

CONCLUSIONS

We found that continuation of immunomodulators after "stepping up" to anti-TNF therapy did not improve outcomes but was associated with an increased risk of opportunistic infection.

Differences in ADHD medication usage patterns in children and adolescents from different cultural backgrounds in the Netherlands

PURPOSE

Differences in incidence and prevalence of ADHD medication use between ethnic groups have been reported. Goal of this study was to determine whether there are also differences in usage patterns of ADHD medication among native Dutch children and adolescents and those with a Moroccan, Turkish and Surinam cultural background in the Netherlands between 1999 and 2010.

METHODS

In a cohort of ADHD patients <19 years (N = 817) incident use and discontinuation of ADHD medication were measured for ethnicity and adjusted for age, gender and socio-economic status.

RESULTS

A significant higher proportion of ADHD-diagnosed patients from Moroccan (32 %) and Turkish (42 %) cultural background never used ADHD medication compared to Dutch natives (21 %). One-fifth of native Dutch and Turkish patients already used ADHD medication before the ADHD diagnosis date. Discontinuation of ADHD medication within 5 years was significantly higher in Moroccan [HR 2.4 (95 % CI 1.8-3.1)] and Turkish [HR 1.7 (95 % CI 1.1-2.6)] patients. A sensitivity analysis with a zip code-matched comparison between Dutch natives and non-natives showed similar results, suggesting this effect is probably not explained by socio-economic status (SES).

CONCLUSION

Differences are found in prescribing and use of ADHD medication between patients with a different cultural background. Native Dutch and Turkish patients start more frequently with ADHD medication before the ADHD diagnose date, which can be an indication of differences in either referral patterns and/or access to care. A higher percentage of patients with a Moroccan and Turkish cultural background never start using ADHD medication at all and discontinuation rate is higher compared to Dutch natives and Surinamese.

Ethnic Differences in Withdrawal of Life Support After Intracerebral Hemorrhage

Minorities are less likely to decide on withdrawal of life support (WOLS) after acute severe illness. However, the decision-making process for WOLS after intracerebral hemorrhage (ICH) among Native Hawaiians and other Pacific Islanders (NHOPI) has not been described. To address this gap in the literature, a retrospective study was conducted on consecutive spontaneous ICH patients admitted to a tertiary center in Honolulu between 2006 and 2010. The occurrence of WOLS and time-to-WOLS were the outcome measures. Unadjusted and multivariable logistic regression models were performed to determine associations between NHOPI ethnicity and WOLS. This study assessed 396 patients (18% NHOPI, 63% Asians, 15% non-Hispanic whites [NHW], 4% others) with ICH. NHOPI was associated with lower rate of WOLS than NHW in the univariate analysis (OR 0.35, 95% CI: 0.15, 0.80). However, NHOPI ethnicity was no longer significant when adjusted for age (OR 0.59, 95% CI: 0.25, 1.43) and in the fully adjusted model (OR 0.68, 95% CI: 0.20, 2.39). Although NHOPI with ICH were initially perceived to have less WOLS compared to NHW, this observed difference was largely driven by the younger age of NHOPI rather than from underlying cultural differences that are inherent to their ethnicity.

Discontinuation of hypomethylating agent therapy in patients with myelodysplastic syndromes or acute myelogenous leukemia in complete remission or partial response: retrospective analysis of survival after long-term follow-up

Hypomethylating agents (HMA), such as 5-azacitidine or decitabine, are currently used to treat patients with myelodysplastic syndromes (MDS) or acute myeloid leukemia (AML) until treatment failure. However, the outcomes for patients who discontinue therapy after achieving partial response (PR) or complete remission (CR) but before treatment failure have not been reported. We present a series of 16 patients with higher-risk MDS (n=5; 31%) or AML (n=11; 69%) who achieved PR (n=1) or CR (n=15) and stopped HMA therapy while in response in the context of clinical trials. They received a median of 12 courses (range 1-24) and achieved response after a median of 1 course of therapy (1-4). Loss of response after discontinuation of therapy was rapid, with a median progression-free survival of 4 months (95% CI: 2-6). Median overall survival (OS) from the time of therapy discontinuation was 15 months (95% CI: 6-24). Patients who received 12 cycles of therapy or more had significantly better OS (median: 20 months [95% CI: 12-27]) than those who received fewer than 12 cycles (median: 4 months [95% CI: 1-8]) (p=0.043). Poor-risk cytogenetics were also associated with lower 1-year OS (33% versus 69%; p=0.046). According to these results and considering the poor prognosis after HMA failure, HMA interruption should be avoided once a sustained response has been achieved.

Historical cohort analysis of treatment patterns for patients with type 2 diabetes initiating metformin monotherapy

OBJECTIVE

To describe treatment regimen changes of patients with type 2 diabetes mellitus (T2DM) initiating metformin monotherapy, and assess factors associated with those changes 12 months post-initiation.

METHODS

Retrospective cohort analysis of medical, pharmacy and laboratory claims of 17,527 Medicare Advantage (MAPD) Humana members aged 18-89, who had ≥1 medical claim with primary diagnosis or ≥2 medical claims with secondary diagnosis of T2DM (ICD-9-CM code 250.x0 or 250.x2) who filled an initial prescription for metformin (GPI code 2725) between 1 January 2008 and 30 September 2011. The main outcome measure was change in metformin monotherapy during the 12 months following initiation. Factors associated with treatment changes during follow-up were examined using Cox proportional hazards regression models.

RESULTS

Fifty-nine percent of patients (mean age 69.6 years) remained on metformin monotherapy with no changes. Discontinuation was the most common treatment change (33%), followed by addition (5%), and switching (2%) to other antidiabetics. Of patients who discontinued treatment (median time to discontinuation = 90 days), 61% did not reinitiate any diabetic treatment during the follow-up period. Among patients who added or switched to other antidiabetics, sulfonylureas were the most common addition or replacement agent. Predictors of discontinuation were being female, Black or Hispanic, low-income subsidy eligible, having higher initial out-of-pocket metformin costs, or a diagnosis of depression. Discontinuation was less likely during follow-up if patients had higher pre-index pill burdens or records of a pre-index A1C screening test. A higher risk of discontinuation was observed for patients with low baseline A1C. One study limitation was that exact discontinuation dates could not be determined using claims.

CONCLUSIONS

The findings suggest that gender, race, ethnicity, depression, and low income status were contributory factors to metformin discontinuation. More intensive monitoring and treatment adjustments may be warranted for patients newly initiated on metformin. This could ultimately improve morbidity, mortality, and costs associated with poor glycemic control.

Epidemiology of death in the PICU at five U.S. teaching hospitals*

OBJECTIVE

To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States.

DESIGN

Prospective case series.

SETTING

Five U.S. teaching hospitals.

SUBJECTS

We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The overall mortality rate was 2.39% (range, 1.85-3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death.

CONCLUSIONS

The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.

Patient barriers to and enablers of deprescribing: a systematic review

BACKGROUND

Inappropriate medication use is common in the elderly and the risks associated with their use are well known. The term deprescribing has been utilised to describe the complex process that is required for the safe and effective cessation of inappropriate medications. Given the primacy of the consumer in health care, their views must be central in the development of any deprescribing process.

OBJECTIVES

The aim of this study was to identify barriers and enablers that may influence a patient's decision to cease a medication.

DATA SOURCES

A systematic search of MEDLINE, International Pharmaceutical Abstracts, EMBASE, CINAHL, Informit and Scopus was conducted and augmented with a manual search. Numerous search terms relating to withdrawal of medications and consumers' beliefs were utilised.

STUDY ELIGIBILITY CRITERIA

Articles were included if the barriers or enablers were directly patient/carer reported and related to long-term medication(s) that they were currently taking or had recently ceased.

STUDY APPRAISAL AND SYNTHESIS METHODS

Determination of relevance and data extraction was performed independently by two reviewers. Content analysis with coding was utilised for synthesis of results.

RESULTS

Twenty-one articles met the criteria and were included in the review. Three themes, disagreement/agreement with 'appropriateness' of cessation, absence/presence of a 'process' for cessation, and negative/positive 'influences' to cease medication, were identified as both potential barriers and enablers, with 'fear' of cessation and 'dislike' of medications as a fourth barrier and enabler, respectively. The most common barrier/enabler identified was 'appropriateness' of cessation, with 15 studies identifying this as a barrier and 18 as an enabler.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The decision to stop a medication by an individual is influenced by multiple competing barriers and enablers. Knowledge of these will aid in the development of a deprescribing process, particularly in approaching the topic of cessation with the patient and what process should be utilised. However, further research is required to determine if the proposed patient-centred deprescribing process will result in improved patient outcomes.

Rate of use and determinants of withdrawal of care among patients with subarachnoid hemorrhage in the United States

BACKGROUND

The use of "withdrawal of care" and impact upon outcomes among patients with subarachnoid hemorrhage (SAH) is not well studied.

OBJECTIVE

To identify the rate and determinants of "withdrawal of care" among SAH patients.

METHODS

We determined the frequency of "withdrawal of care" and compared the demographic, clinical characteristics, and in-hospital outcomes among patients with SAH stratified by use of "withdrawal of care."

RESULTS

"Withdrawal of care" during hospitalization was instituted in 8912 (3.4%) of the 266,067 patients with SAH. In the stepwise logistic regression, age >65 (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 3.3-6.1), women (OR 1.2, 95% CI 1.0-1.3), African American (OR 0.7, 95% CI 0.5-0.8), Hispanic ethnicity (OR 0.4, 95% CI 0.3-0.6), renal failure (OR 1.6, 95% CI 1.2-1.9), intracerebral hemorrhage (OR 2.0, 95% CI 1.7-2.4, All Patient Refined Diagnosis-Related Groups severity score of extreme loss of function (OR 40.1, 95% CI 6.0-270.7), All Patient Refined Diagnosis-Related Groups severity score of severe loss of function (OR 15.0, 95% CI 2.1-103.8), insurance status of private health maintenance organization (OR 0.7, 95% CI 0.5-0.9), and hospital region south United States (OR 0.7, 95% CI 0.5-0.8), were significant predictors of "withdrawal of care" among patients with SAH. In-hospital mortality was significantly greater, but mean hospitalization charges and length of stay were significantly lower among those with "withdrawal of care."

CONCLUSIONS

Although "withdrawal of care" was effective in limiting hospital charges and resource use, caution is needed to avoid disproportionately high mortality. The prominent relationship between race/ethnicity, insurance status, and hospital location with "withdrawal of care" raises concerns that factors other than severity of disease influence decision making.

Forgoing artificial nutrition or hydration at the end of life: a large cross-sectional survey in Belgium

OBJECTIVES

To examine the frequency and characteristics of decisions to forgo artificial nutrition and/or hydration (ANH) at the end of life.

DESIGN

Postal questionnaire survey regarding end-of-life decisions (including ANH) to physicians certifying a large representative sample (n=6927) of Belgian death certificates in 2007.

SETTING

Flanders, Belgium, 2007.

PARTICIPANTS

Treating physicians of deceased patients.

RESULTS

Response rate was 58.4%. A decision to forgoANH occurred in 6.6% of all deaths (4.2% withheld,3.0% withdrawn). Being female, dying in a care home or hospital and suffering from nervous system diseases(including dementia) or malignancies were the most important patient-related factors positively associated with a decision to forgo ANH. Physicians indicated that the decision to forgo ANH had had some life-shortening effects in 77% of cases. There had been no consultation with the patient in 81%, mostly due to incapacity (coma or dementia). The family, colleague physicians and nurses were involved in decision making in 76%,41% and 62%, respectively.

CONCLUSIONS

A substantial number of deaths are preceded by a decision to forgo ANH in Belgium. These decisions, ethically laden and involving a considerable chance of life shortening, are mostly not preceded by discussion with the patient despite existing patient rights legislation. It is recommended that physicians and patients and their families alike dedicate ample time to the discussion of treatment options and communication about the possibility of forgoing ANH and that this discussion takes place earlier as part of overall end-of life care planning rather than at the very end of life.

Current situation and associated factors of withdrawing or withholding life support to patients in an intensive care unit of cancer center in China

OBJECTIVES

To investigate the current situation and analyze the associated factors of withdrawing or withholding life support in the intensive care unit (ICU) of our cancer center.

METHODS

Three hundred and twenty-two cancer patients in critical status were admitted to our ICU in 2010 and 2011. They were included in the study and were classified into two groups: withdrawing or withholding life support (WWLS), and full life support (FLS). Demographic information and clinical data were collected and compared between the two groups. Factors associated with withdrawing or withholding life support were analyzed with univariate and multivariate logistic regression analysis.

RESULTS

Eighty-two of the 322 cases (25.5% of all) made the decisions to withdraw or withhold life support. Emergency or critical condition at hospital admission, higher scores of Acute Physiology and Chronic Health Evaluation II (APACHE II) in 12 hours after ICU admission, financial difficulties and humanistic care requirements are important factors associated with withdrawing or withholding life support.

CONCLUSIONS

Withdrawing or withholding life support is not uncommon in critically ill cancer patients in China. Characteristics and associated factors of the decision-making are related to the current medical system, medical resources and traditional culture of the country.

Discontinuation of antiretroviral therapy among adults receiving HIV care in the United States

BACKGROUND

Continuous antiretroviral therapy (ART) is important for maintaining viral suppression. This analysis estimates prevalence of and reason for ART discontinuation.

METHODS

Three-stage sampling was used to obtain a nationally representative, cross-sectional sample of HIV-infected adults receiving HIV care. Face-to-face interviews and medical record abstractions were collected from June 2009 to May 2010. Data were weighted based on known probabilities of selection and adjusted for nonresponse. Patient characteristics of ART discontinuation, defined as not currently taking ART, stratified by provider-initiated versus non-provider-initiated discontinuation, were examined. Weighted logistic regression models predicted factors associated with ART discontinuation.

RESULTS

Of adults receiving HIV care in the United States who reported ever initiating ART, 5.6% discontinued treatment. Half of those who discontinued treatment reported provider-initiated discontinuation. Provider-initiated ART discontinuation patients were more likely to have a nadir CD4 ≥ 200 cells per cubic millimeter. Non-provider-initiated ART discontinuation patients were more likely to have unmet need for supportive services and to have not received HIV care in the past 3 months. Among all patients who discontinued, younger age, female gender, not having continuous health insurance, incarceration, injection drug use, nadir CD4 count ≥ 2 00 cells per cubic millimeter, unmet need for supportive services, no care in the past 3 months and HIV diagnosis ≥ 5 years before interview were independently associated with ART discontinuation.

CONCLUSIONS

These findings inform development of interventions to increase ART persistence by identifying groups at increased risk of ART discontinuation. Evidence-based interventions targeting vulnerable populations are needed and are increasingly important as recent HIV treatment guidelines have recommended universal ART.

DNR directives are established early in mechanically ventilated intensive care unit patients

PURPOSE

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

METHODS

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

RESULTS

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> or = 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5-3.4], 65 to 74 yr (HR 1.8, 1.2-2.7), 50 to 64 yr (HR 1.4, 1.0-2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3-2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4-2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7-33.6)], 10 to 40% [(HR 5.0, 2.3-11.2), 41 to 60% (HR 4.0, 1.8-9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6-9.4) or partial advanced life support (HR 3.2, 2.2-4.6) compared to full measures].

CONCLUSION

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.