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Carney MT, Kwiatek S, Burns EA. Transforming health care: A large health organizations' journey to become an age-friendly health system (AFHS) and beyond. J Am Geriatr Soc 2024; 72:579-588. [PMID: 37927247 DOI: 10.1111/jgs.18646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/27/2023] [Accepted: 09/28/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In 2017, the John A. Hartford Foundation partnered with the Institute for Health Care Improvement, American Hospital Association, and Catholic Health Care Organization to define the 4Ms framework to improve quality of care and health outcomes for older adults. The senior leadership of one of the largest integrated healthcare organizations (HCO) in the country recognized the relevance of these recommendations to the aging demographic of the United States. The health system provides care to over 2,000,000 unique patients annually, about 20% of whom are aged ≥65. We describe how commitment to becoming an Age-Friendly Health System (AFHS) has taken this HCO beyond the targets set by the initiative. METHODS Steps guiding evolution of the AFHS model of care are as follows: Initiation, assessment, planning, implementation, sustainability. An AFHS leadership team including geriatrics and quality improvement expertise oversees the initiative. Plan-Do-Study-Act cycles are utilized at multiple stages to develop structures for data collection and reporting outcomes. RESULTS Initiation and assessment stages identified key champions and existing efforts and programs that were leveraged to implement 4Ms best practices. Working committees with relevant expertise for each M selected evidence-based quality measures and designed/adapted training materials. The EHR is used to integrate quality measures and gather outcome data to inform changes in care. Dashboards capturing quality measures for each M have been implemented and pilot-tested at a community-based hospital and these processes are being adapted and disseminated to other settings. Leadership and stakeholders convene regularly to review lessons learned and next steps. CONCLUSIONS On the health system level, partnering with quality management leaders has led to development of processes that feed into organizational level data used to track longitudinal improvements in patient outcomes. Outcome data in each of the 4M domains are presented. Learning points are shared to help others take a systems-approach to age-friendly change.
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Affiliation(s)
- Maria Torroella Carney
- Geriatrics and Palliative Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
- Geriatrics and Palliative Medicine, Northwell Health, Manhasset, New York, USA
| | - Susan Kwiatek
- Geriatrics and Palliative Medicine, Northwell Health, Manhasset, New York, USA
| | - Edith A Burns
- Geriatrics and Palliative Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
- Geriatrics and Palliative Medicine, Northwell Health, Manhasset, New York, USA
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Zupanc SN, Lakin JR, Volandes AE, Paasche-Orlow MK, Moseley ET, Gundersen DA, Das S, Penumarthy A, Martins-Welch D, Burns EA, Carney MT, Itty JE, Emmert K, Tulsky JA, Lindvall C. Forms or Free-Text? Measuring Advance Care Planning Activity Using Electronic Health Records. J Pain Symptom Manage 2023; 66:e615-e624. [PMID: 37536523 PMCID: PMC10592170 DOI: 10.1016/j.jpainsymman.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
Advance care planning (ACP) discussions seek to guide future serious illness care. These discussions may be recorded in the electronic health record by documentation in clinical notes, structured forms and directives, and physician orders. Yet, most studies of ACP prevalence have only examined structured electronic health record elements and ignored data existing in notes. We sought to investigate the relative comprehensiveness and accuracy of ACP documentation from structured and unstructured electronic health record data sources. We evaluated structured and unstructured ACP documentation present in the electronic health records of 435 patients with cancer drawn from three separate healthcare systems. We extracted structured ACP documentation by manually annotating written documents and forms scanned into the electronic health record. We coded unstructured ACP documentation using a rule-based natural language processing software that identified ACP keywords within clinical notes and was subsequently reviewed for accuracy. The unstructured approach identified more instances of ACP documentation (238, 54.7% of patients) than the structured ACP approach (187, 42.9% of patients). Additionally, 16.6% of all patients with structured ACP documentation only had documents that were judged as misclassified, incomplete, blank, unavailable, or a duplicate of a previously entered erroneous document. ACP documents scanned into electronic health records represent a limited view of ACP activity. Research and measures of clinical practice with ACP should incorporate information from unstructured data.
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Affiliation(s)
- Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Angelo E Volandes
- Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (A.E.V.), Massachusetts General Hospital, Boston, Massachusetts; ACP Decisions (A.E.V.), Waban, Massachusetts
| | | | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Computer Science (E.T.M.), School of Engineering, Tufts University, Medford, Massachusetts
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core (D.A.G.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Social and Behavioral Sciences (D.A.G.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Akhila Penumarthy
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Diana Martins-Welch
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Edith A Burns
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Maria T Carney
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Jennifer E Itty
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - Kaitlin Emmert
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts.
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Volandes AE, Zupanc SN, Lakin JR, Cabral HJ, Burns EA, Carney MT, Lopez S, Itty J, Emmert K, Martin NJ, Cole T, Dobie A, Cucinotta T, Joel M, Caruso LB, Henault L, Dugas JN, Astone K, Winter M, Wang N, Davis AD, Garde C, Rodriguez PM, El-Jawahri A, Moseley ET, Das S, Sciacca K, Ramirez AM, Gromova V, Lambert S, Sanghani S, Lindvall C, Paasche-Orlow MK. Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332556. [PMID: 37695586 PMCID: PMC10495866 DOI: 10.1001/jamanetworkopen.2023.32556] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/27/2023] [Indexed: 09/12/2023] Open
Abstract
Importance Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians. Objective To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation. Design, Setting, and Participants This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022. Intervention The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care. Main Outcome and Measures The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing. Results A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool. Trial Registration ClinicalTrials.gov Identifier: NCT04857060.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Waban, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Howard J. Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Edith A. Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Santiago Lopez
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Jennifer Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Kaitlin Emmert
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Narda J. Martin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Therese Cole
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Alexandra Dobie
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Traci Cucinotta
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Milton Joel
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Lisa B. Caruso
- Department of Medicine, Section of Geriatrics, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Lori Henault
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Julianne N. Dugas
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Kristina Astone
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | | | | | - Perla Macip Rodriguez
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edward T. Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ana Maria Ramirez
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Valeria Gromova
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Sherene Lambert
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Shreya Sanghani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts
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Lakin JR, Zupanc SN, Lindvall C, Moseley ET, Das S, Sciacca K, Cabral HJ, Burns EA, Carney MT, Itty J, Lopez S, Emmert K, Martin NJ, Lambert S, Polo J, Sanghani S, Dugas JN, Gomez M, Winter MR, Wang N, Gabry-Kalikow S, Dobie A, Amshoff M, Cucinotta T, Joel M, Caruso LB, Ramirez AM, Salerno K, Ogunneye Q, Henault L, Davis AD, Volandes A, Paasche-Orlow MK. Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital. BMJ Open 2022; 12:e065236. [PMID: 35879001 PMCID: PMC9328081 DOI: 10.1136/bmjopen-2022-065236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age. METHODS AND ANALYSIS The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included. ETHICS AND DISSEMINATION The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT04857060; ClinicalTrials.gov.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Edith A Burns
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Maria T Carney
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jennifer Itty
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Santiago Lopez
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Kaitlin Emmert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Narda J Martin
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Sherene Lambert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Jennifer Polo
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Shreya Sanghani
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Julianne N Dugas
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michele Gomez
- Commonwealth Care Alliance, Boston, Massachusetts, USA
| | - Michael R Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Alexandra Dobie
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Meredith Amshoff
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Traci Cucinotta
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Milton Joel
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lisa B Caruso
- Boston University School of Medicine, Department of Medicine, Section of Geriatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Ana Maria Ramirez
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Kathleen Salerno
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Qausarat Ogunneye
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions, Waban, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
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5
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Volandes AE, Zupanc SN, Paasche-Orlow MK, Lakin JR, Chang Y, Burns EA, LaVine NA, Carney MT, Martins-Welch D, Emmert K, Itty JE, Moseley ET, Davis AD, El-Jawahri A, Gundersen DA, Fix GM, Yacoub AM, Schwartz P, Gabry-Kalikow S, Garde C, Fischer J, Henault L, Burgess L, Goldman J, Kwok A, Singh N, Alvarez Suarez AL, Gromova V, Jacome S, Tulsky JA, Lindvall C. Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial. JAMA Netw Open 2022; 5:e220354. [PMID: 35201306 PMCID: PMC8874350 DOI: 10.1001/jamanetworkopen.2022.0354] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. OBJECTIVE To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. DESIGN, SETTING, AND PARTICIPANTS The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included. MAIN OUTCOMES AND MEASURES The primary outcome was ACP documentation. RESULTS A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001). CONCLUSIONS AND RELEVANCE This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Boston, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edith A. Burns
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Nancy A. LaVine
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Diana Martins-Welch
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Kaitlin Emmert
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Jennifer E. Itty
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Edward T. Moseley
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Daniel A. Gundersen
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gemmae M. Fix
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
| | - Andrea M. Yacoub
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | | | | | | | - Jonathan Fischer
- Department of Community Health and Family Medicine, Hospice and Palliative Care, Duke University Health System, Durham, North Carolina
| | - Lori Henault
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leah Burgess
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Julie Goldman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anne Kwok
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nimisha Singh
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Armando L. Alvarez Suarez
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Valeria Gromova
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sonia Jacome
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A. Tulsky
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Graham LA, Hawn MT, Dasinger EA, Baker SJ, Oriel BS, Wahl TS, Richman JS, Copeland LA, Itani KM, Burns EA, Whittle J, Morris MS. Psychosocial Determinants of Readmission After Surgery. Med Care 2021; 59:864-871. [PMID: 34149017 PMCID: PMC8425630 DOI: 10.1097/mlr.0000000000001600] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood. OBJECTIVE We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population. RESEARCH DESIGN This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital. SUBJECTS We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015-June 30, 2017). MEASURES We assessed unplanned readmission to any medical facility within 30 days of hospital discharge. RESULTS A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score <31 as the most important psychosocial determinant of readmission after surgery. CONCLUSIONS Mental health concerns, inadequate health literacy, and lower social support after hospital discharge are significant predictors of increased unplanned readmissions after major general, vascular, or thoracic surgery. These elements should be incorporated into routinely collected electronic health record data. Also, discharge plans should accommodate varying levels of health literacy and consider how the patient's mental health and social support needs will affect recovery.
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Affiliation(s)
- Laura A. Graham
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System
- Department of Surgery, Stanford-Surgery Policy, Improvement Research, and Education (S-SPIRE) Center, Stanford University School of Medicine, Palo Alto, CA
| | - Mary T. Hawn
- Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System
- Department of Surgery, Stanford-Surgery Policy, Improvement Research, and Education (S-SPIRE) Center, Stanford University School of Medicine, Palo Alto, CA
| | - Elise A. Dasinger
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Samantha J. Baker
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Brad S. Oriel
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston
| | - Tyler S. Wahl
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Joshua S. Richman
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Laurel A. Copeland
- VA Central Western Massachusetts Healthcare System, Leeds
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Kamal M.F. Itani
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston
- Department of Medicine, Harvard University School of Medicine, Boston, MA
| | - Edith A. Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI
- Zucker School of Medicine at Hofstra Northwell, Manhasset, NY
| | - Jeffrey Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Melanie S. Morris
- Health Services Research and Development Unit, Birmingham VA Medical Center
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
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Demyan L, Wu G, Moumin D, Blumenthaler AN, Deutsch GB, Nealon W, Herman JM, Weiss MJ, Burns EA, DePeralta DK. Advance care planning in patients undergoing surgery to resect pancreatic adenocarcinoma: Underlying tension between balancing hope and realism. Surgery 2021; 171:459-466. [PMID: 34563351 DOI: 10.1016/j.surg.2021.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/01/2021] [Accepted: 08/16/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The timing and the dose of Advanced Care Planning in patients with pancreatic ductal adenocarcinoma undergoing curative-intent resection are generally dictated by the surgeon performing the operation. METHODS A qualitative investigation using 1:1 interviews with 40 open-ended questions was conducted with a convenience sample of 10 high-volume pancreatic surgeons from across the country. The grounded theory approach was used for data analysis. RESULTS A total of 10 interviews were conducted with expert pancreatic surgeons-6 males and 4 females. During preoperative counseling, all surgeons attempt to motivate patients by emphasizing hope, optimism, and the fact that surgery offers the only opportunity for cure. All surgeons discuss the possibility of recurrence as well as postoperative complications; however, a majority perceived that patients do not fully appreciate the likelihood of recurrence or postoperative complications. All surgeons acknowledged the importance of end-of-life conversations when death is imminent. Seventy percent of surgeons had mixed opinions regarding benefits of preoperative Advanced Care Planning in the preoperative setting, while 20% felt it was definitely beneficial, particularly that delivery of care aligned with patient goals. All surgeons emphasized that Advanced Care Planning should be led by a physician who both knows the patient well and understands the nuances of pancreatic ductal adenocarcinoma management. Most common barriers to in-depth Advanced Care Planning discussion reported by surgeons include taking away hope, lack of time, and concern for sending "mixed messages." CONCLUSION We identified that surgeons experience a fundamental tension between promoting realistic long-term goals and expectations versus focusing on hope and enabling an overly optimistic perception of prognosis.
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Affiliation(s)
- Lyudmyla Demyan
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.
| | - Grace Wu
- Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Dina Moumin
- Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | | | - Gary B Deutsch
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - William Nealon
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Joseph M Herman
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Matthew J Weiss
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Edith A Burns
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Department of Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Danielle K DePeralta
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
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8
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Lopez S, Finuf KD, Marziliano A, Sinvani L, Burns EA. Palliative Care Consultation in Hospitalized Patients With COVID-19: A Retrospective Study of Characteristics, Outcomes, and Unmet Needs. J Pain Symptom Manage 2021; 62:267-276. [PMID: 33359040 PMCID: PMC7844404 DOI: 10.1016/j.jpainsymman.2020.12.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/23/2022]
Abstract
CONTEXT Few studies have described the characteristics and palliative care needs in hospitalized patients with coronavirus disease 2019 (COVID-19). OBJECTIVES Describing characteristics, consultation demands, patients' needs, and outcomes of hospitalized patients with COVID-19 who received a palliative care evaluation. METHODS Retrospective chart review of patients (aged 18+ years) with COVID-19 admitted to an academic quaternary center and seen by the geriatrics and palliative medicine team from March 1st to May 11th, 2020. Socio-demographics, operational metrics, severity of illness, goals of care-advanced care planning documentation, and outcomes were analyzed. RESULTS Three hundred seventy-six (17.6%) out of 2138 COVID-19 admissions were seen by the consultation team. Compared with prepandemic situation (September 1st, 2019, to February 29th, 2020), overall new consults (205 vs. 371, P < 0.001) significantly increased, particularly in the intensive care unit (ICU; 9.5% vs. 36.9%, P < 0.001). For the COVID-19 population, median age was 78 years (interquartile range, 70-87; range, 36-102); 56% were male. LACE score, D-dimer, and C-reactive protein suggested severe disease and increased risk of mortality. Seventy-five percent of consults were for goals of care-advanced care planning, and 9.6% for symptoms. During the index admission, 7.1% had documented advanced directives, and 69.7% became do not resuscitate. Of all deaths, 55.5% were in the ICU, and 87.2% were aged ≥65 years. Underserved minority patients had a disproportionate mortality. Overall consultation mortality (38.3% vs. 70.4%, P < 0.001) and ICU mortality (55.2% vs. 78.1%, P < 0.001) significantly increased compared with those before COVID-19. CONCLUSION During this pandemic, understanding inpatient specialized palliative care needs and the vulnerable populations driving these causes may encourage health-care agencies and local, state, and federal governments to support the dedicated palliative care workforce.
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Affiliation(s)
- Santiago Lopez
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA.
| | - Kayla D Finuf
- The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Allison Marziliano
- The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Liron Sinvani
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA; The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
| | - Edith A Burns
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA; The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
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9
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Dasinger EA, Graham LA, Wahl TS, Richman JS, Baker SJ, Hawn MT, Hernandez-Boussard T, Rosen AK, Mull HJ, Copeland LA, Whittle JC, Burns EA, Morris MS. Preoperative opioid use and postoperative pain associated with surgical readmissions. Am J Surg 2019; 218:828-835. [PMID: 30879796 DOI: 10.1016/j.amjsurg.2019.02.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The extent of preoperative opioid utilization and the relationship with pain-related readmissions are not well understood. METHODS VA Surgical Quality Improvement Program data on general, vascular, and orthopedic surgeries (2007-2014) were merged with pharmacy data to evaluate preoperative opioid use and pain-related readmissions. Opioid use in the 6-month preoperative period was categorized as none, infrequent, frequent, and daily. RESULTS In the six-month preoperative period, 65.7% had no opioid use, 16.7% had infrequent use, 6.3% frequent use, and 11.4% were daily opioid users. Adjusted odds of pain-related readmission were higher for opioid-exposed groups vs the opioid-naïve group: infrequent (OR 1.17; 95% CI:1.04-1.31), frequent (OR 1.28; 95% CI:1.08-1.52), and daily (OR 1.49; 95% CI:1.27-1.74). Among preoperative opioid users, those with a pain-related readmission had higher daily preoperative oral morphine equivalents (mean 44.5 vs. 36.1, p < 0.001). CONCLUSIONS Patients using opioids preoperatively experienced higher rates of pain-related readmissions, which increased with frequency and dosage of opioid exposure.
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Affiliation(s)
- Elise A Dasinger
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Laura A Graham
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, CA, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tyler S Wahl
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua S Richman
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Samantha J Baker
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary T Hawn
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, CA, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA; University of Massachusetts Medical School, Worcester, MA, USA
| | - Jeffrey C Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Edith A Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melanie S Morris
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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10
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Wahl TS, Graham LA, Morris MS, Richman JS, Hollis RH, Jones CE, Itani KM, Wagner TH, Mull HJ, Whittle JC, Telford GL, Rosen AK, Copeland LA, Burns EA, Hawn MT. Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission. JAMA Surg 2018; 153:e182009. [PMID: 29971429 DOI: 10.1001/jamasurg.2018.2009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission. Objective To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes. Design, Setting, and Participants A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded. Exposures Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL). Main Outcomes and Measures Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome. Results Of 346 676 surgeries, 153 767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR. Conclusions and Relevance Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.
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Affiliation(s)
- Tyler S Wahl
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Laura A Graham
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Melanie S Morris
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Joshua S Richman
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Robert H Hollis
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Caroline E Jones
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Kamal M Itani
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,School of Medicine, Harvard University, Boston, Massachusetts
| | - Todd H Wagner
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.,Department of Surgery, Stanford University, Stanford, California
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey C Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin.,Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Gordon L Telford
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Laurel A Copeland
- Veterans Affairs Central Western Massachusetts Health Care System, Leeds.,Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas.,Department of Medicine, Texas A&M Health Science Center, Temple
| | - Edith A Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin.,Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Mary T Hawn
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.,Department of Surgery, Stanford University, Stanford, California
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11
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Jones CE, Graham LA, Morris MS, Richman JS, Hollis RH, Wahl TS, Copeland LA, Burns EA, Itani KMF, Hawn MT. Association Between Preoperative Hemoglobin A1c Levels, Postoperative Hyperglycemia, and Readmissions Following Gastrointestinal Surgery. JAMA Surg 2017; 152:1031-1038. [PMID: 28746706 DOI: 10.1001/jamasurg.2017.2350] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Preoperative hyperglycemia is associated with adverse postoperative outcomes among patients who undergo surgery. Whether preoperative hemoglobin A1c (HbA1c) or postoperative glucose levels are more useful in predicting adverse events following surgery is uncertain in the current literature. Objective To examine the use of preoperative HbA1c and early postoperative glucose levels for predicting postoperative complications and readmission. Design, Setting, and Participants In this observational cohort study, inpatient gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to 2014 were identified, and cases of known infection within 3 days before surgery were excluded. Preoperative HbA1c levels were examined as a continuous and categorical variable (<5.7%, 5.7%-6.5%, and >6.5%). A logistic regression modeled postoperative complications and readmissions with the closest preoperative HbA1c within 90 days and the highest postoperative glucose levels within 48 hours of undergoing surgery. Main Outcomes and Measures Postoperative complications and 30-day unplanned readmission following discharge. Results Of 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7 (10.6) years. The cohort included 23 094 operations with measurements of preoperative HbA1c levels and postoperative glucose levels. The complication and 30-day readmission rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA1c, postoperative glucose levels, postoperative insulin use, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), and other patient and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). By contrast, a preoperative HbA1c of more than 6.5% was associated with decreased 30-day readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA1c increased, the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an HbA1c <5.7%, 5.7%-6.4%, and >6.5%, respectively; P < .001). Patients with a preoperative HbA1c of more than 6.5% had lower thresholds for postoperative insulin use. Conclusions and Relevance Early postoperative hyperglycemia was associated with increased readmission, but elevated preoperative HbA1c was not. A higher preoperative HbA1c was associated with increased postoperative glucose level checks and insulin use, suggesting that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may explain this finding.
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Affiliation(s)
- Caroline E Jones
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Laura A Graham
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Melanie S Morris
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Joshua S Richman
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Robert H Hollis
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | - Tyler S Wahl
- University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham
| | | | - Edith A Burns
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Kamal M F Itani
- Veteran Affairs Boston Health Care System and Tufts University School of Medicine, Department of Surgery, Boston, Massachusetts
| | - Mary T Hawn
- Stanford University, Department of Surgery; Veteran Affairs Palo Alto Health Care System, Palo Alto, California
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12
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Wahl TS, Graham LA, Hawn MT, Richman J, Hollis RH, Jones CE, Copeland LA, Burns EA, Itani KM, Morris MS. Association of the Modified Frailty Index With 30-Day Surgical Readmission. JAMA Surg 2017; 152:749-757. [PMID: 28467535 DOI: 10.1001/jamasurg.2017.1025] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Frail patients are known to have poor perioperative outcomes. There is a paucity of literature investigating how the Modified Frailty Index (mFI), a validated measure of frailty, is associated with unplanned readmission among military veterans following surgery. Objective To understand the association between frailty and 30-day postoperative unplanned readmission. Design, Setting, and Participants A retrospective cohort study was conducted among adult patients who underwent surgery and were discharged alive from Veterans Affairs hospitals for orthopedic, general, and vascular conditions between October 1, 2007, and September 30, 2014, with a postoperative length of stay between 2 and 30 days. Exposure Frailty, as calculated by the 11 variables on the mFI. Main Outcomes and Measures The primary outcome of interest is 30-day unplanned readmission. Secondary outcomes included any 30-day predischarge or postdischarge complication, 30-day postdischarge mortality, and 30-day emergency department visit. Results The study sample included 236 957 surgical procedures (among 223 877 men and 13 080 women; mean [SD] age, 64.0 [11.3] years) from high-volume surgical specialties: 101 348 procedures (42.8%) in orthopedic surgery, 92 808 procedures (39.2%) in general surgery, and 42 801 procedures (18.1%) in vascular surgery. The mFI was associated with readmission (odds ratio [OR], 1.11; 95% CI, 1.10-1.12; R2 = 10.3%; C statistic, 0.71). Unadjusted rates of overall 30-day readmission (26 262 [11.1%]), postdischarge emergency department visit (34 204 [14.4%]), any predischarge (13 855 [5.9%]) or postdischarge (14 836 [6.3%]) complication, and postdischarge mortality (1985 [0.8%]) varied by frailty in a dose-dependent fashion. In analysis by individual mFI components using Harrell ranking, impaired functional status, identified as nonindependent functional status (OR, 1.16; 95% CI, 1.11-1.21; P < .01) or having a residual deficit from a prior cerebrovascular accident (OR, 1.17; 95% CI, 1.11-1.22; P < .01), contributed most to the ability of the mFI to anticipate readmission compared with the other components. Acutely impaired sensorium (OR, 1.12; 95% CI, 0.99-1.27; P = .08) and history of a myocardial infarction within 6 months (OR, 0.93; 95% CI, 0.81-1.06; P = .28) were not significantly associated with readmission. Conclusions and Relevance The mFI is associated with poor surgical outcomes, including readmission, primarily due to impaired functional status. Targeting potentially modifiable aspects of frailty preoperatively, such as improving functional status, may improve perioperative outcomes and decrease readmissions.
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Affiliation(s)
- Tyler S Wahl
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Laura A Graham
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Mary T Hawn
- Department of Surgery, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.,Department of Surgery, Stanford University, Stanford, California
| | - Joshua Richman
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Robert H Hollis
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Caroline E Jones
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Laurel A Copeland
- Veterans Affairs Central Western Massachusetts Health Care System, Leeds.,Center for Applied Health Research, Baylor Scott & White Health, Temple, Texas.,Department of Medicine, Texas A&M Health Science Center, Temple
| | - Edith A Burns
- Department of Surgery, Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin.,Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kamal M Itani
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,School of Medicine, Harvard University, Boston, Massachusetts
| | - Melanie S Morris
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
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Copeland LA, Graham LA, Richman JS, Rosen AK, Mull HJ, Burns EA, Whittle J, Itani KMF, Hawn MT. A study to reduce readmissions after surgery in the Veterans Health Administration: design and methodology. BMC Health Serv Res 2017; 17:198. [PMID: 28288681 PMCID: PMC5348767 DOI: 10.1186/s12913-017-2134-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/04/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Hospital readmissions are associated with higher resource utilization and worse patient outcomes. Causes of unplanned readmission to the hospital are multiple with some being better targets for intervention than others. To understand risk factors for surgical readmission and their incremental contribution to current Veterans Health Administration (VA) surgical quality assessment, the study, Improving Surgical Quality: Readmission (ISQ-R), is being conducted to develop a readmission risk prediction tool, explore predisposing and enabling factors, and identify and rank reasons for readmission in terms of salience and mutability. METHODS Harnessing the rich VA enterprise data, predictive readmission models are being developed in data from patients who underwent surgical procedures within the VA 2007-2012. Prospective assessment of psychosocial determinants of readmission including patient self-efficacy, cognitive, affective and caregiver status are being obtained from a cohort having colorectal, thoracic or vascular procedures at four VA hospitals in 2015-2017. Using these two data sources, ISQ-R will develop readmission categories and validate the readmission risk prediction model. A modified Delphi process will convene surgeons, non-surgeon clinicians and quality improvement nurses to rank proposed readmission categories vis-à-vis potential preventability. DISCUSSION ISQ-R will identify promising avenues for interventions to facilitate improvements in surgical quality, informing specifications for surgical workflow managers seeking to improve care and reduce cost. ISQ-R will work with Veterans Affairs Surgical Quality Improvement Program (VASQIP) to recommend potential new elements VASQIP might collect to monitor surgical complications and readmissions which might be preventable and ultimately improve surgical care.
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Affiliation(s)
- Laurel A Copeland
- Veterans Affairs: VA Central Western Massachusetts Healthcare System, Leeds, MA, USA. .,Texas A & M Health Science Center, College of Medicine, Temple, TX, USA. .,Department of Psychiatry, UT Health Science Center San Antonio, San Antonio, TX, USA.
| | | | | | - Amy K Rosen
- Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.,Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Hillary J Mull
- Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.,Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Edith A Burns
- Veterans Affairs, Milwaukee VAMC, Milwaukee, WI, USA
| | - Jeff Whittle
- Veterans Affairs, Milwaukee VAMC, Milwaukee, WI, USA
| | - Kamal M F Itani
- Department of Surgery, Boston University School of Medicine, Boston, MA, USA.,VA Boston Healthcare System, Boston, MA, USA.,Harvard School of Medicine, Cambridge, MA, USA
| | - Mary T Hawn
- Veterans Affairs, Palo Alto VAMC, Palo Alto, CA, USA.,Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Phillips LA, Leventhal H, Burns EA. Choose (and use) your tools wisely: "Validated" measures and advanced analyses can provide invalid evidence for/against a theory. J Behav Med 2016; 40:373-376. [PMID: 27757769 DOI: 10.1007/s10865-016-9807-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/12/2016] [Indexed: 10/20/2022]
Affiliation(s)
- L Alison Phillips
- Department of Psychology, Iowa State University, Ames, IA, 50011, USA.
| | - Howard Leventhal
- Department of Psychology, Institute for Health, Rutgers University, 112 Paterson St, New Brunswick, NJ, 08901, USA
| | - Edith A Burns
- Division of Geriatrics, Medical College of Wisconsin, Milwaukee, WI, 53295, USA
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Jones CE, Graham LA, Richman J, Hollis RH, Wahl TS, Copeland LA, Morris MS, Burns EA, Itani K, Hawn MT. Association Between Preoperative Hemoglobin A1c, Postoperative Hyperglycemia, and Readmissions after Gastrointestinal Surgery. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Aging is associated with declines in immune system function, or 'immunosenescence', leading to progressive deterioration in both innate and adaptive immunity. These changes contribute to the decreased response to vaccines seen in many older adults, and morbidity and mortality from infection. Infections (e.g., influenza, pneumonia and septicemia) appear among the top ten most-common causes of death in adults in the USA aged 55 years and older. As immunosenescence has gathered more attention in the scientific and healthcare communities, investigators have demonstrated more links between immunosenescent changes and morbidity and mortality related to infections and declining vaccine responses. This review summarizes the recent literature on age-dependent defects in adaptive and innate immunity, data linking these defects to poor vaccine response and morbidity and mortality, current recommendations for vaccinations and potential strategies to improve vaccine efficacy in older adults.
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Affiliation(s)
- Rajesh Kumar
- Medical College of Wisconsin, 5000 W National Avenue, CC-G, Milwaukee, WI 53295, USA.
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Burns EA, Fleming R, Wagstaff DA, Goodwin JS, Hirschman R, Greenberg JJ. Affective and Behavioral Stress Outcomes in Alzheimer's Caregivers. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1751-9861.2002.tb00077.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- Richard S Kane
- Section Geriatrics, Department of Medicine, University of Wisconsin Medical School, Milwaukee Clinical Campus, Milwaukee, WI 53233, USA.
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19
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Burns EA. Effects of aging on immune function. J Nutr Health Aging 2004; 8:9-18. [PMID: 14730363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
A variety of changes are observed in the immune system in both animals and humans with increasing age. There is a decline in the functional capacity of the cell populations that mount generalized and focused immune responses, and decreasing production and response of these cells to regulatory signals and proteins. These changes translate into less effective innate and adaptive immune responses, increased reactivity against self-antigens in vivo, and an increased incidence of infection. There may also be an increased risk of mortality. The mechanisms underlying age-related changes in immune function are not fully understood, but are likely to be multifactorial, including environmental and behavioral factors that affect over-all immune function from the molecular level to that of the entire organism.
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Affiliation(s)
- E A Burns
- Zablocki VA Medical Center, CC-G, 5000 W. National Avenue Milwaukee, WI 53295, USA.
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20
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Raff H, Homar PJ, Burns EA. Comparison of two methods for measuring salivary cortisol. Clin Chem 2002; 48:207-8. [PMID: 11751565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Affiliation(s)
- Hershel Raff
- Endocrine Research Laboratory, St. Luke’s Medical Center, Milwaukee, WI 53215
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Peter J Homar
- Endocrine Research Laboratory, St. Luke’s Medical Center, Milwaukee, WI 53215
| | - Edith A Burns
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226
- Clement J. Zablocki, VA Medical Center, Milwaukee, WI 53295
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Hjertstedt J, Burns EA, Fleming R, Raff H, Rudman I, Duthie EH, Wilson CR. Mandibular and palatal tori, bone mineral density, and salivary cortisol in community-dwelling elderly men and women. J Gerontol A Biol Sci Med Sci 2001; 56:M731-5. [PMID: 11682583 DOI: 10.1093/gerona/56.11.m731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This investigation evaluated the relationship between the presence of tori and bone mineral density (BMD) and salivary cortisol levels. METHODS A total of 230 healthy, community-dwelling elderly men (n = 129) and women (n = 101) aged 60 and older participated in this study. Forty-three women were on hormone replacement therapy (HRT). This was a component of a 5-year longitudinal study measuring subjects' body composition, hormone levels, physical activity, and diet every 6 months. Subjects were examined for the presence of tori by visual inspection and digital palpation. BMD at six sites was measured by dual-energy X-ray absorptiometry. Salivary cortisol levels were measured by radioimmunoassay. RESULTS Twenty-three percent of all subjects had mandibular tori, 13% had palatal tori, and 12% had both mandibular and palatal tori. Mandibular tori were more common in men, and palatal tori were more common in women. The presence of mandibular tori was significantly correlated with BMD of the lumbar spine, femoral neck, trochanter, and Ward's triangle for all subjects, and with the femoral neck and trochanter of women not on HRT. Men with palatal tori had lower levels of salivary cortisol in the evening. CONCLUSIONS This study documented the high prevalence of mandibular and palatal tori in a group of 230 elderly, community-dwelling subjects. Women not on HRT and all subjects taken as a group with mandibular tori had higher BMD. The presence of tori at young adulthood may be a marker of higher BMD in the future and of a lower risk for developing osteoporosis.
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Affiliation(s)
- J Hjertstedt
- Division of Oral Medicine and Diagnostic Sciences, Marquette University School of Dentistry, Milwaukee, Wisconsin 53201-1881, USA.
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Abstract
BACKGROUND The prime function of the immune system is to protect the entire organism from a variety of insults and illnesses, including the development of cancer. The question of how age-related declines in immune function contribute to an increasing incidence of malignancies continues to be a focus of discussion and speculation. METHODS The recent literature from the National Library of Medicine database (1990 through the present) was searched for articles using the medical subject headings (MeSH terms) of aging, immunity, cancer, senescence, and apoptosis. Bibliographies of articles retrieved were also scanned. RESULTS Data from in vitro and in vivo animal and human studies demonstrate clear age-related alterations in both the cellular and humoral components of the immune system, but there is little evidence supporting direct causal links between immune senescence and most malignancies. CONCLUSIONS Senescent decline in immune surveillance leads to the accumulation of cellular and DNA mutations that could be a significant factor in the development of malignancy and programmed cell death or apoptosis observed in the elderly.
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Affiliation(s)
- E A Burns
- Section of Geriatrics, the Department of Medicine, Medical College of Wisconsin, Milwaukee 53295, USA
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24
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Burns EA. Exploring the vision of family medicine: research, technology, and practice. Fam Med 1999; 31:382-3. [PMID: 10367198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- E A Burns
- Department of Family Medicine, University of Illinois at Chicago, USA.
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25
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Abstract
Aging is associated with declines in multiple areas of immune function, but to date no single mechanism has emerged as being responsible for all the observed changes. Many changes occur at different rates within individuals as well as between individuals. With advancing age there is a concomitant increase in the incidence of many infections and cancers. It is being increasingly acknowledged that autoimmune processes play a proinflammatory role in the development of many pathological conditions, such as atherosclerosis. However, direct causal relationships between specific changes in immunity and the occurrence of specific diseases are rare. There is accumulating epidemiological, in vivo and in vitro evidence to support many such direct relationships in both animals and humans. It is likely that the mechanisms underlying age-related changes in immunity are multifactorial, with both genetic and environmental factors playing a significant role. Despite the current lack of unifying theories, much active and exciting work is proceeding in the area of immune stimulation. Studies describing age-related changes in immunity, as well as the testing of interventions to reverse these changes, will continue to fill the gaps in our knowledge, leading to a more comprehensive understanding of immunosenescence.
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Affiliation(s)
- E A Burns
- Department of Medicine, University of Wisconsin Medical School, Milwaukee, USA.
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Abstract
OBJECTIVES To describe CPR policies and the procedures for discussing CPR policies of Wisconsin long-term care facilities. DESIGN Mail survey and telephone interview. MEASUREMENTS Information about CPR policy, how policy is disclosed to residents and by whom, emergency medical technician team (EMT) response time, and number of CPR attempts during 1993. RESULTS The 1994 survey response rate was 85% (346/ 404 facilities). Four percent of responding facilities maintain a policy of never initiating CPR. Another 23% never initiate CPR but would call an EMT. Lack of efficacy was the usual basis for policies never initiating CPR. About 15% of facilities would initiate CPR only on residents who had previously indicated a preference. On individuals who had not made an advanced directive decision, 57% of facilities would initiate CPR in the event of an arrest. Almost 30% of facilities offering CPR would initiate CPR on unwitnessed arrests. Approximately 51% of all facilities assigned a social worker alone to discuss CPR policy and preference, whereas 12.5% assigned a physician alone or as part of a team. During 1993, an estimated 118 attempts at CPR were reported for 172 facilities with a total of 19,596 licensed beds, for a frequency of one CPR attempt per 166 beds per year. CONCLUSIONS Poor efficacy in this population was the main reason given for policies of never initiating CPR. Specific factors relating to CPR efficacy, such as EMT response time and ease of maintaining trained staff, were not major influences. Almost 30% of facilities offering CPR would perform it in unwitnessed situations, despite unlikely success. Many decisions about CPR may not be fully informed as nurses and physicians are not often assigned to discuss advance directives with residents or surrogates. Utilization of CPR in nursing homes offering resuscitation is low.
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Affiliation(s)
- R S Kane
- Department of Medicine, University of Wisconsin, Milwaukee, USA
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Kane RS, Burns EA, Goodwin JS. Minimal trauma fractures in older nursing home residents: the interaction of functional status, trauma, and site of fracture. J Am Geriatr Soc 1995; 43:156-9. [PMID: 7836640 DOI: 10.1111/j.1532-5415.1995.tb06381.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE This study was conducted to determine the incidence of long bone fractures in institutionalized older persons and to describe preceding traumatic events and the functional status of individuals sustaining fractures. DESIGN A 1-year, prospective, cumulative incidence survey. SETTING Eleven skilled nursing care facilities in the state of Wisconsin. PATIENTS All residents of the 11 facilities. MEASUREMENTS All incident reports of long bone fractures, description of events preceding the fractures, and functional status of the fracture cases. In addition, demographic and medical information was collected on fracture cases and the general nursing home population. MAIN RESULTS Overall long bone fracture incidence was 3.52 per 100 subjects per year. Minimal trauma fracture incidence was 0.84 per 100 subjects per year. Fracture location was significantly related to type of trauma. Functional status was significantly related to fracture location and to the type of trauma preceding the fracture. Minimal trauma fractures occurred in individuals who were less mobile and more likely to be bed-bound, and the location was more likely to be the lower extremity below the hip. CONCLUSION This is the first prospective survey of long bone and spontaneous fracture incidence rates in multiple nursing home facilities. Minimal trauma fractures are common in the nursing home, and most have no clear precipitating factors other than severely impaired mobility.
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Affiliation(s)
- R S Kane
- Department of Medicine, University of Wisconsin, Milwaukee
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28
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Burns EA, L'Hommedieu GD, Cunning JL, Goodwin JS. Effects of interleukin-4 on antigen-specific antibody synthesis by lymphocytes from old and young adults. Lymphokine Cytokine Res 1994; 13:227-31. [PMID: 7999922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The current series of experiments were designed to explore the role of the B cell growth factor, interleukin-4 (IL-4), in the age-related decrease in production of antitetanus toxoid antibody in vitro. Exogenous recombinant IL-4 led to significant suppression of antitetanus toxoid antibody synthesis and numbers of antitetanus toxoid antibody-secreting B cells in cultures from healthy old subjects and healthy young subjects. These effects were most pronounced when IL-4 was present during the early phase of culture. Lymphocytes from old subjects were less sensitive to these effects and produced significantly less IL-4 than did lymphocytes from young controls. The addition of exogenous IL-4 may be inhibiting early activation signals that normally stimulate proliferation of B cells. A decreased sensitivity to the growth-promoting effects of IL-4 may be one of the mechanisms underlying defective specific antibody synthesis in aging.
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Affiliation(s)
- E A Burns
- Department of Medicine, University of Wisconsin School of Medicine, Milwaukee
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29
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Abstract
The etiology of Crohn's disease is still unknown. The present study served to test the hypothesis that baker's yeast (Saccharomyces cerevisiae) plays a role in Crohn's disease. Blood samples were obtained from 12 patients and 15 healthy controls. Peripheral blood leukocytes were isolated and incubated alone or with different concentrations of baker's yeast. After 3 days, the cultures were pulsed with tritiated thymidine. None of the lymphocyte cultures from healthy controls, including 3 bakers, proliferated in response to yeast. In striking contrast, all 9 patients with Crohn's disease in remission, on no medication, showed a threefold increase in their lymphocyte proliferation rate. Lymphocytes from 3 patients on 1.5 g of olsalazine maintenance therapy failed to respond. These results are consistent with previous findings that showed increased titers of IgG and IgA antibodies to baker's yeast in patients with Crohn's disease as compared to healthy controls. They confirm the suspicion that baker's yeast itself or a related antigen play a role in Crohn's disease and suggest that anti-inflammatory agents may act, in part, by inhibiting lymphocyte proliferation.
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Affiliation(s)
- C A Young
- Division of Gastroenterology, VA Medical Center, Milwaukee, Wisc. 53295
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30
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Abstract
Vaccinations are often unsuccessful in preventing infection among elderly populations because of generally poor humoral immune responses. We have used tetanus toxoid (TT) antigen to stimulate in vitro anti-tetanus toxoid antibody (anti-TT) synthesis and have found that lymphocytes from many healthy elderly individuals have a reduced production of anti-TT in vitro compared to young adults. This is associated with decreased numbers of B cells secreting anti-TT IgG and a decrease in the mean amount of anti-TT IgG produced per TT-specific B cell. In the present study we report that immunization results in a significant increase in serum titers in young adults for up to one year, whereas levels in old adults fall to baseline by 6 months. The number of B cells that secrete anti-TT IgG increases after immunizations in both young and old subjects, although the number in old subjects is significantly lower than in young subjects at all times except 6 months after. The mean amount of anti-TT produced per B cell (B-cell potency) is significantly lower for the old adults both before and at 6 and 12 months after booster. Immunization does not significantly change the mean amount of anti-TT produced per B cell for either age group. The decreased response to immunization with aging is associated with decreased numbers of specific Ab-secreting B cells and usually decreased potency of those B cells.
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Affiliation(s)
- E A Burns
- Department of Medicine, University of Wisconsin School of Medicine, Milwaukee
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31
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Abstract
PURPOSE Therapy with anticonvulsants such as phenytoin, phenobarbital, and carbamazepine can be complicated by severe hypersensitivity reactions. Previous work has suggested that the predisposition to such reactions is based on an inherited abnormality in the detoxification of reactive metabolites of the drugs. However, there are no reports of familial occurrence of the reactions in the literature. In the current study, we examined a family in which three siblings developed hypersensitivity reactions to phenytoin, confirming the inheritance of a predisposition to the reactions. Detoxification of reactive metabolites of the anticonvulsants was studied in cells from the patients and their siblings. PATIENTS AND METHODS Three siblings from a family of 12 siblings developed hypersensitivity reactions to phenytoin characterized by fever, rash, lymphadenopathy, and anicteric hepatitis. All recovered completely after discontinuation of treatment. One sibling tolerated phenobarbital without toxic sequelae. Peripheral blood mononuclear cells from the three patients and five additional siblings who had never taken anticonvulsants were exposed to oxidative metabolites of phenytoin, phenobarbital, and carbamazepine generated by a hepatic microsomal drug-metabolizing system in vitro. The toxicity of metabolites in the cells from the siblings was compared with that in cells from control subjects. RESULTS Cells from each of the patients who had experienced a hypersensitivity reaction exhibited increased toxicity from metabolites of phenytoin and carbamazepine, while the cellular response to metabolites of phenobarbital was within normal limits. Cells from four of the other siblings showed an abnormal response to phenytoin metabolites, while cells from the final sibling detoxified phenytoin metabolites normally. CONCLUSION Our observations on the patients confirm the inherited nature of phenytoin hypersensitivity reactions in vivo. In vitro studies demonstrated abnormal metabolite detoxification in the patients and several of their siblings. The detoxification defect included metabolites of phenytoin and carbamazepine but not of phenobarbital. A family history of a drug hypersensitivity reaction should alert physicians to the probability of a markedly increased risk of an adverse reaction in family members. In vitro assays to confirm adverse reaction risks may ultimately be able to provide individualized risk assessment for patients who must take anticonvulsants.
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Affiliation(s)
- M A Gennis
- Department of Medicine, University of Wisconsin School of Medicine, Milwaukee
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32
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Burns EA, Lum LG, Seigneuret MC, Giddings BR, Goodwin JS. Decreased specific antibody synthesis in old adults: decreased potency of antigen-specific B cells with aging. Mech Ageing Dev 1990; 53:229-41. [PMID: 2376983 DOI: 10.1016/0047-6374(90)90041-d] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The rise in rates of infection in adults over the age of 60 is accompanied by a decreased ability of older adults to make specific immune responses after immunization with a variety of specific antigens (Ag). This investigation delineates age-related changes in Ag-specific humoral immunity, comparing adults over age 60 to young adults aged 18-40, using tetanus toxoid (TT) as an immunologic probe. A culture system which does not require TT booster immunizations of study subjects was used to induce in vitro specific antibody responses. The amount of anti-TT antibody (Ab) produced in serum and in culture was measured by a TT-specific enzyme-linked immunosorbent assay (ELISA). The numbers of anti-TT Ab-secreting B cells were measured by a TT-specific ELISA-plaque assay. The TT-specific responses of old subjects were significantly less than that seen for young control subjects in the following measures: (1) serum anti-TT Ab titers (mean +/- S.E. log 2 titer = 3.3 +/- 1.1 vs. 9.5 +/- 1.4, P less than 0.01); (2) anti-TT Ab produced by peripheral blood lymphocytes (PBL) in cultures stimulated with TT (6 +/- 2.1 ng/ml vs. 22 +/- 8.4 ng/ml, P less than 0.01); (3) numbers of anti-TT Ab secreting B cells per million cells cultured (6.7 +/- 3.4 vs. 26.6 +/- 7.6, P less than 0.001) and (4) mean ng Ab secreted per anti-TT Ab-secreting B cell (0.6 +/- 0.4 ng vs. 12.7 +/- 7.8 ng, P less than 0.01). This study shows that both decreased numbers of Ag-specific immune B cells and decreased potency on a per cell basis contribute to the impaired immune responses to immunizations in older adults.
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Affiliation(s)
- E A Burns
- Department of Medicine, University of Wisconsin School of Medicine, Milwaukee
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Abstract
Cases of profound hypoglycemia after the initiation of tricyclic antidepressant therapy in two patients taking sulfonylureas are described. To the authors' knowledge, this is the first report of a potential drug interaction between tricyclic antidepressants and sulfonylureas.
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Burns EA, House JD, Ankenbauer MR. Sibling grief in reaction to sudden infant death syndrome. Pediatrics 1986; 78:485-7. [PMID: 3748684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Much of the literature that exists regarding psychologic outcomes of sudden infant death syndrome (SIDS) has focused on parental grief or family response; at least two studies suggest that a SIDS death also affected siblings. It is believed that children who experience the death of a sibling due to SIDS do grieve. Factors related to bereavement are the child's age at the time of the sibling's death, special circumstances of the SIDS death, and explanations and grieving response of the parents. However, no information currently exists that characterizes the course of the grief response of these children. Studies have indicated that about 1 year is a normal grieving period for adults. This study was conducted to evaluate the time frame of children's grief response to the death of a sibling from SIDS. A questionnaire was designed that incorporated child grieving behaviors from several sources; 151 questionnaires were distributed to families in which a SIDS death had occurred in the past 16 years in Iowa and Illinois. Information was obtained from 43 families for 50 children who were older than 2 years of age at the time of the sibling's death. With respect to the length of children's grief response, 54% were reported to have grieved longer than 1 year and only 40% were reported to have grieved less than 6 months. Thus, it appears that the length of the grieving response for these children is similar to that described for adults.
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Burns EA, House JD, Hartunian DL. Relationships between attitudes and use of adult-learning teaching activities by medical faculty. Fam Med 1985; 17:274-5. [PMID: 3870799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This study examined teaching behaviors of medical faculty and their attitudes toward adult learners. A number of studies have examined characteristics of adult learners and found that certain teaching activities produce more effective learning in adults. Adult learners tend to be more self-directed and bring a variety of experiences to the educational setting; they also profit more from collaborative curriculum planning, learning activities, and evaluation of progress.
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Affiliation(s)
- E A Burns
- Department of Family Practice, University of Iowa, Iowa City 52242
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36
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Abstract
The benefits and risks of both the vaccine for pertussis and the disease itself are reviewed in this article. Unlike with the smallpox vaccine, it seems unlikely that a vaccine will be developed to eradicate pertussis completely, since most confer only a short-term immunity. A longitudinal study was undertaken to compare the mortality and morbidity rates of pertussis with the adverse reaction rate of the vaccination program. Risks of the vaccination, such as erythema, drowsiness, and vomiting are well known. However, the issue of neurologic difficulties has surfaced and disagreement exists. Some association does seem to exist between the vaccine and neurologic problems; however, the morbidity and mortality of whooping cough is of a greater health consequence than these rare neurologic reactions.
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Abstract
Premenstrual syndrome (PMS) is a diagnostic enigma that causes significant morbidity in many woman. Numerous theories have been proposed in an attempt to explain the varied symptoms that occur cyclically in women with PMS. Suggested etiologic theories of PMS include psychological abnormalities, nutritional deficiencies, aberrations in the renin-angiotensin-aldosterone axis, altered prostaglandin activity, hormonal imbalances, and changes in endogenous opioid peptide activity. Because of the lack of standardized diagnostic criteria, clinical drug trials for PMS have been severely compromised. For every proposed cause of PMS, there exists a drug or drug class that has been investigated for treatment of the associated symptoms. Many clinical studies are uncontrolled, a significant deficiency in study design for a disorder that is associated with a high placebo response rate. At the present time, no definitive treatment for PMS exists and therapy must be individualized according to clinical response. This review article defines PMS, describes one of the current approaches to the diagnostic work-up, discusses the proposed etiologies of PMS, and reviews the various proposed treatment modalities.
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Carter BL, Helling DK, Burns EA, Johnson RE, Danielson SL. Association between appropriateness of prescribing and prescription documentation. Am J Hosp Pharm 1983; 40:1513-5. [PMID: 6624753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The association between the quality of physician prescribing and the degree of prescription documentation in the medical record was studied in four family-practice offices. Carbon-copy prescriptions were collected for five months at each office, and 438 were randomly selected for evaluation. For each prescription, a case abstract was prepared from the medical record. The abstract summarized the patient's previous care related to the problem for which the prescription was issued. The abstracts were blinded and randomly assigned for review by a panel of physicians and pharmacists working in family practice, resulting in a total of 1866 evaluations. Each panelist evaluated appropriateness of drug choice, potential benefit, and degree of prescription documentation. Actual prescription documentation of drug name, strength, quantity, directions, and refills was determined by comparing the carbon-copy prescription with the medical record. Multiple regression analysis revealed a significant correlation between panel evaluations for drug choice and actual documentation of drug name, strength, and directions. Likewise, the mean rating of potential benefit was significantly associated with actual documentation of drug name, strength, directions, and refills. The mean rating of appropriateness of documentation was significantly associated with all five independent documentation variables. Drug name, strength, and directions were recorded in 94%, 60%, and 75% of the medical records, respectively. These data demonstrate a positive association between the quality of prescribing and actual prescription documentation in the medical record.
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Brown JM, Helling DK, Burns EA, Burmeister LF, Rakel RE. Patient care telephone calls received in family practice offices. J Fam Pract 1982; 14:527-532. [PMID: 7061959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The majority of patients care calls referred to practitioners at each of two family practice office study sites were related to medications. However, there were significant differences in the proportion of patient care calls managed by staff physicians, family practice residents, and clinical pharmacists which involved discussion of medication. There were also significant differences in the callers and types of medication related calls managed by each practitioner group. Calls initiated by patients and those classified as refill requests accounted for the largest proportion of calls managed by staff physicians, residents, and clinical pharmacists. The majority of calls received by each practitioner group were managed without consultation. A follow-up office visit was recommended in approximately one half of all medication related calls. The findings of this study may be useful in determining the personnel required to manage medication related telephone calls and in identifying potential areas for education and training of personnel in family practice.
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Burns EA. [Not Available]. Hist Med Vet 1982; 7:12-9. [PMID: 11637134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
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