Sex Differences in Cardiovascular Outcomes in Patients With Kidney Failure

BACKGROUND

Cardiovascular disease is the leading cause of mortality in patients with kidney failure, and their risk of cardiovascular events is 10 to 20 times higher as compared with the general population.

METHODS AND RESULTS

We evaluated 508 822 patients who initiated dialysis between January 1, 2005 and December 31, 2014 using the United States Renal Data System with linked Medicare claims. We determined hospitalization rates for cardiovascular events, defined by acute coronary syndrome, heart failure, and stroke. We examined the association of sex with outcome of cardiovascular events, cardiovascular death, and all-cause death using adjusted time-to-event models. The mean age was 70±12 years and 44.7% were women. The cardiovascular event rate was 232 per thousand person-years (95% CI, 231-233), with a higher rate in women than in men (248 per thousand person-years [95% CI, 247-250] versus 219 per thousand person-years [95% CI, 217-220]). Women had a 14% higher risk of cardiovascular events than men (hazard ratio [HR], 1.14 [95% CI, 1.13-1.16]). Women had a 16% higher risk of heart failure (HR, 1.16 [95% CI, 1.15-1.18]), a 31% higher risk of stroke (HR, 1.31 [95% CI, 1.28-1.34]), and no difference in risk of acute coronary syndrome (HR, 1.01 [95% CI, 0.99-1.03]). Women had a lower risk of cardiovascular death (HR, 0.89 [95% CI, 0.88-0.90]) and a lower risk of all-cause death than men (HR, 0.96 [95% CI, 0.95-0.97]).

CONCLUSIONS

Among patients undergoing dialysis, women have a higher risk of cardiovascular events of heart failure and stroke than men. Women have a lower adjusted risk of cardiovascular mortality and all-cause mortality.

A clinical score to predict recovery in end-stage kidney disease due to acute kidney injury

Background

Acute kidney injury (AKI) is a major contributor to end-stage kidney disease (ESKD). About one-third of patients with ESKD due to AKI recover kidney function. However, the inability to accurately predict recovery leads to improper triage of clinical monitoring and impacts the quality of care in ESKD.

Methods

Using data from the United States Renal Data System from 2005 to 2014 (n = 22 922), we developed a clinical score to predict kidney recovery within 90 days and within 12 months after dialysis initiation in patients with ESKD due to AKI. Multivariable logistic regressions were used to examine the effect of various covariates on the primary outcome of kidney recovery to develop the scoring system. The resulting logistic parameter estimates were transformed into integer point totals by doubling and rounding the estimates. Internal validation was performed.

Results

Twenty-four percent and 34% of patients with ESKD due to AKI recovered kidney function within 90 days and 12 months, respectively. Factors contributing to points in the two scoring systems were similar but not identical, and included age, race/ethnicity, body mass index, congestive heart failure, cancer, amputation, functional status, hemoglobin and prior nephrology care. Three score categories of increasing recovery were formed: low score (0-6), medium score (7-9) and high score (10-12), which exhibited 90-day recovery rates of 12%, 26% and 57%. For the 12-month scores, the low, medium and high groups consisted of scores 0-5, 6-8 and 9-11, with 12-month recovery rates of 16%, 33% and 62%, respectively. The internal validation assessment showed no overfitting of the models.

Conclusion

A clinical score derived from information available at incident dialysis predicts renal recovery at 90 days and 12 months in patients with presumed ESKD due to AKI. The score can help triage appropriate monitoring to facilitate recovery and begin planning long-term dialysis care for others.

Can a best practice advisory improve anticoagulation prescribing to reduce stroke risk in patients with atrial fibrillation?

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac rhythm disorder and a risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce strokes in AF patients. Yet, widespread underutilization of this therapy continues. To address this practice gap, we designed a study to implement and evaluate the effectiveness of a best practice advisory (BPA) for an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record.

METHODS

Our intervention is provider-facing, focused on decision support. Clinical setting is ambulatory patients being seen by primary care physicians. We prospectively enrolled 608 patients in our health system who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST and randomized them to one of two arms - 1) usual care, in which the AFDST is available for use; or 2) addition of a BPA to the AFDST notifying clinicians that their patient stands to gain significant benefit from a change in current therapy. Primary outcome was effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post-enrollment. Secondary endpoints included Reach and Adoption from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, & Maintenance) framework for implementation studies.

RESULTS

Among 562 patients with a minimum follow-up of 3 months, addition of a BPA to the AFDST resulted in significant improvement in anticoagulation therapy, 5 % (12/248) versus 11 % (33/314) p = 0.02, odds ratio 2.31 (95 % CI, 1.17-4.87).

CONCLUSIONS

A BPA added to an AF decision support tool improved anticoagulation therapy among AF patients in a primary care academic health system setting.

Pregnancies in Women With Kidney Failure on Home Dialysis in the United States

Introduction

Women with kidney failure have impaired fertility and are at a higher risk of maternal and fetal morbidity and mortality. Little is known about pregnancies in women receiving maintenance home dialysis in the United States.

Methods

Using data from the United States Renal Data System (USRDS), a cohort of 26,387 women aged 15 to 49 years with kidney failure receiving maintenance home dialysis from 2005 to 2018 was examined. We calculated pregnancy rates and identified factors, including the modality associated with pregnancy receiving home dialysis.

Results

Overall, 437 pregnancies were identified in 26,837 women on home dialysis. The unadjusted pregnancy rate was 8.6 per 1000 person-years (PTPY). The unadjusted pregnancy rate was higher on home hemodialysis (16.0 vs. 7.5 PTPY) than on peritoneal dialysis. Women receiving home hemodialysis had a higher adjusted likelihood of pregnancy than women receiving peritoneal dialysis (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.79-3.05). Compared with women aged 20 to 24 years, the likelihood of pregnancy was lower in women aged 30 to 34 years (HR, 0.64; 95% CI, 0.43-0.96), 35 to 39 years (HR, 0.53; 95% CI, 0.35-0.79), 40 to 44 years (HR, 0.32; 95% CI, 0.21-0.49), and 45 to 49 years (HR, 0.21; 95% CI, 0.13-0.33). Whereas Black women had a higher likelihood of pregnancy (HR, 1.40; 95% CI, 1.07-1.83), there was no difference in likelihood of pregnancy in Asian, Hispanic, and Native Americans as compared to Whites. Body mass index, cause of kidney failure, socioeconomic status, rurality, predialysis nephrology care, or dialysis vintage were not significantly associated with pregnancy on home dialysis.

Conclusion

The pregnancy rate in women with kidney failure undergoing home dialysis is higher with home hemodialysis than with peritoneal dialysis. Younger age and Black race or ethnicity are associated with a higher likelihood of pregnancy among women receiving home dialysis. This information can guide clinicians in preconception counselling and making informed treatment decisions for pregnant women on home dialysis.

Cardiovascular Outcomes in Patients on Home Hemodialysis and Peritoneal Dialysis

Key Points

Home hemodialysis is associated with decreased risk of stroke and acute coronary syndrome relative to peritoneal dialysis. Home hemodialysis is associated with decreased risk of cardiovascular death and all-cause death relative to peritoneal dialysis.

Background

Cardiovascular disease is the leading cause of morbidity and mortality in patients with ESKD. Little is known about differences in cardiovascular outcomes between home hemodialysis (HHD) and peritoneal dialysis (PD).

Methods

We evaluated 68,645 patients who initiated home dialysis between January 1, 2005, and December 31, 2018, using the United States Renal Data System with linked Medicare claims. Rates for incident cardiovascular events of acute coronary syndrome, heart failure, and stroke hospitalizations were determined. Using adjusted time-to-event models, the associations of type of home dialysis modality with the outcomes of incident cardiovascular events, cardiovascular death, and all-cause death were examined.

Results

Mean age of patients in the study cohort was 64±15 years, and 42.3% were women. The mean time of follow-up was 1.8±1.6 years. The unadjusted cardiovascular event rate was 95.1 per thousand person-years (PTPY) (95% confidence interval [CI], 93.6 to 96.8), with a higher rate in patients on HHD than on PD (127.8 PTPY; 95% CI, 118.9 to 137.2 versus 93.3 PTPY; 95% CI, 91.5 to 95.1). However, HHD was associated with a slightly lower adjusted risk of cardiovascular events than PD (hazard ratio [HR], 0.92; 95% CI, 0.85 to 0.997). Compared with patients on PD, patients on HHD had 42% lower adjusted risk of stroke (HR, 0.58; 95% CI, 0.48 to 0.71), 17% lower adjusted risk of acute coronary syndrome (HR, 0.83; 95% CI, 0.72 to 0.95), and no difference in risk of heart failure (HR, 1.05; 95% CI, 0.94 to 1.16). HHD was associated with 22% lower adjusted risk of cardiovascular death (HR, 0.78; 95% CI, 0.71 to 0.86) and 8% lower adjusted risk of all-cause death (HR, 0.92; 95% CI, 0.87 to 0.97) as compared with PD.

Conclusions

Relative to PD, HHD is associated with decreased risk of stroke, acute coronary syndrome, cardiovascular death, and all-cause death. Further studies are needed to better understand the factors associated with differences in cardiovascular outcomes by type of home dialysis modality in patients with kidney failure.

Sex and Racial/Ethnic Differences in Home Hemodialysis Mortality

Key Points

Women on home hemodialysis have higher 1-year mortality than men, and women and men have comparable survival on long-term follow-up. Compared with White patients on home hemodialysis, there was no difference in all-cause mortality for Black patients, Hispanics, or Native Americans. Among patients undergoing home hemodialysis, Asians had a lower risk of all-cause mortality than White patients.

Background

Women and minorities constitute substantial portions of the prevalent population of patients with kidney failure. Little is known about sex and racial/ethnic differences in mortality among patients with kidney failure on home hemodialysis in the United States.

Methods

Using the United States Renal Data System, we retrospectively evaluated a cohort of 42,849 patients who started home hemodialysis between January 1, 2005, and December 31, 2015. We examined the association of sex and race/ethnicity with the outcome of all-cause mortality using adjusted Cox proportional hazard models and logistic regression models.

Results

In the study cohort, 40.4% were women, and 57.4% were White. Women on home hemodialysis had higher unadjusted death rates (26.9 versus 22.4 per 100 person-years) compared with men. There was no difference in adjusted all-cause mortality between men and women, but women had an 8% higher adjusted risk of all-cause mortality at 1 year after initiating home hemodialysis (odds ratio 1.08, 95% confidence interval [CI], 1.01 to 1.15). Regarding race/ethnicity, Hispanic, White, and Black patients had higher unadjusted death rates compared with Asians and Native Americans (25.1 versus 24.8 versus 23.2 versus 17.4 versus 16.6 per 100 person-years). There was no difference in adjusted all-cause mortality in Black, Hispanic, and Native Americans compared with White patients, while Asians had a lower risk of all-cause mortality than did White patients (hazard ratio, 0.81; 95% CI, 0.72 to 0.92). There was no difference in adjusted 1-year mortality for Asian, Black, Hispanic, and Native American patients compared with White patients.

Conclusions

Among patients undergoing home hemodialysis, women have higher 1-year mortality than men, and women and men have comparable survival on long-term follow-up after adjusting for other covariates. Compared with White patients, there was no difference in adjusted survival on long-term follow-up for Black patients, Hispanics, or Native Americans, while Asians had better survival. Our results suggest the need for population-wide strategies to overcome differences in home hemodialysis care.

Racial and sex differences in optimizing anticoagulation therapy for patients with atrial fibrillation

Study objective

Atrial fibrillation (AF) is the most common cardiac rhythm disorder, responsible for 15 % of strokes in the United States. Studies continue to document underuse of anticoagulation therapy in minority populations and women. Our objective was to compare the proportion of AF patients by race and sex who were receiving non-optimal anticoagulation as determined by an Atrial Fibrillation Decision Support Tool (AFDST).

Design setting and participants

Retrospective cohort study including 14,942 patients within University of Cincinnati Health Care system. Data were analyzed between November 18, 2020, and November 20, 2021.

Main outcomes and measures

Discordance between current therapy and that recommended by the AFDST.

Results

In our two-category analysis 6107 (41 %) received non-optimal anticoagulation therapy, defined as current treatment category ≠ AFDST-recommended treatment category. Non-optimal therapy was highest in Black (42 % [n = 712]) and women (42 % [n = 2668]) and lower in White (39 % [n = 4748]) and male (40 % [n = 3439]) patients. Compared with White patients, unadjusted and adjusted odds ratios of receiving non-optimal anticoagulant therapy for Black patients were 1.13; 95 % CI, 1.02-1.30, p = 0.02; and 1.17; 95%CI, 1.04-1.31, p = 0.01; respectively, and 1.10; 95 % CI 1.03-1.18, p = 0.005; and 1.36; 95 % CI, 1.25-1.47, p < 0.001; for females compared with males.

Conclusions and relevance

In patients with atrial fibrillation in the University of Cincinnati Health system, Black race and female sex were independently associated with an increased odds of receiving non-optimal anticoagulant therapy.

Electronic health record-embedded decision support to reduce stroke risk in patients with atrial fibrillation - Study protocol

BACKGROUND

Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful common risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce the risk of stroke in patients with AF. Yet, there continues to be widespread underutilization of this therapy. To address this practice gap locally and improve efforts to reduce the risk of stroke for patients with AF in our health system, we have designed a study to implement and evaluate the effectiveness of an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record.

METHODS

Our intervention is provider-facing and focused on decision support. The clinical setting is ambulatory patients being seen by primary care physicians. Patients include those with both incident and prevalent AF. This randomized, prospective trial will enroll 800 patients in our University of Cincinnati Health System who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST. Patients will be randomized to one of two arms - 1) usual care, in which the AFDST is available for use; 2) addition of a best practice advisory (BPA) to the AFDST notifying the clinician that their patient stands to gain a significant benefit from a change in their current thromboprophylactic therapy.

RESULTS

The primary outcome is effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post randomization. Secondary endpoints include Reach and Adoption, from the RE-AIM framework for implementation studies. Sample size is based upon an improvement from inappropriate to appropriate anticoagulation therapy estimated at 4% in the usual care arm and ≥10% in the experimental arm.

CONCLUSION

Our goal is to examine whether addition of a BPA to an AFDST focused on primary care physicians in an ambulatory care setting will improve "appropriate thromboprophylaxis" compared with usual care. Results will be examined at 3 months post randomization and at the end of the study to evaluate durability of changes. We expect to complete patient enrollment by the end of June 2022.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04099485.

Contraceptive Use Among Women With End-Stage Kidney Disease on Dialysis in the United States

Rationale & Objective

Although end-stage kidney disease (ESKD) adversely affects fertility, pregnancies can occur among women receiving dialysis. ESKD increases the risk for adverse pregnancy outcomes and little is known about contraceptive use in women undergoing dialysis.

Study Design

Retrospective cohort study.

Setting & Participants

Using the US Renal Data System covering January 1, 2005, through December 31, 2014, we evaluated for each calendar year women who for the entire year were aged 15 to 44 years, receiving dialysis, and with Medicare as the primary payer.

Predictors

Age, race/ethnicity, and calendar year of prevalent ESKD.

Outcome

Contraceptive use.

Analytic Approach

We determined rates of contraceptive use and used multivariable logistic regression to identify factors associated with contraceptive use.

Results

The study cohort included 35,732 women and represented 115,713 person-years. The rate of contraceptive use was 5.30% of person-years (95% CI, 5.17%-5.42%). Overall, contraceptive use increased from 2005 to 2014 (4.21%; 95% CI, 3.84%-4.59% vs 6.54%, 95% CI, 6.10%-6.99%). Compared with women aged 25 to 29 years, contraceptive use was higher in women aged 15 to 24 years (OR, 1.30; 95% CI, 1.18-1.43) and lower in women aged 30 to 34 years (OR, 0.74; 95% CI, 0.68-0.81), 35 to 39 years (OR, 0.46; 95% CI, 0.42-0.50), and 40 to 44 years (OR, 0.30; 95% CI, 0.27-0.34). Compared with White women, contraceptive use was higher in Black (OR, 1.12; 95% CI, 1.02-1.24) and Native American women (OR, 1.60; 95% CI, 1.25-2.05). Women with ESKD due to glomerulonephritis had a higher likelihood of contraceptive use than women with ESKD due to diabetes (OR, 1.22; 95% CI, 1.06-1.42). Women receiving peritoneal dialysis had a lower likelihood of contraceptive use than women receiving hemodialysis (OR, 0.85; 95% CI, 0.78-0.93). Compared with women without predialysis nephrology care, contraceptive use was higher in women who received predialysis nephrology care for 12 or fewer months (OR, 1.22; 95% CI, 1.09-1.37) and more than 12 months (OR, 1.33; 95% CI, 1.20-1.47).

Limitations

Retrospective design and use of administrative data.

Conclusions

Among women with ESKD undergoing dialysis, contraceptive use remains low at 5.30%. Younger age, Native American and Black race/ethnicity, ESKD due to glomerulonephritis, hemodialysis, and predialysis nephrology care are associated with a higher likelihood of contraceptive use. The study highlights the importance of prepregnancy counseling for contraceptive use in women receiving dialysis.

Mortality and Recovery Associated with Kidney Failure due to Acute Kidney Injury

BACKGROUND AND OBJECTIVES

AKI requiring dialysis is a contributor to the growing burden of kidney failure, yet little is known about the frequency and patterns of recovery of AKI and its effect on outcomes in patients on incident dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the US Renal Data System, we evaluated a cohort of 1,045,540 patients on incident dialysis from January 1, 2005 to December 31, 2014, retrospectively. We examined the association of kidney failure due to AKI with the outcome of all-cause mortality and the associations of sex and race with kidney recovery.

RESULTS

Mean age was 63±15 years, and 32,598 (3%) patients on incident dialysis had kidney failure due to AKI. Compared with kidney failure due to diabetes mellitus, kidney failure attributed to AKI was associated with a higher mortality in the first 0-3 months following dialysis initiation (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24 to 1.32) and 3-6 months (adjusted hazard ratio, 1.16; 95% confidence interval, 1.11 to 1.20). Of the patients with kidney failure due to AKI, 11,498 (35%) eventually recovered their kidney function, 95% of those within 12 months. Women had a lower likelihood of kidney recovery than men (adjusted hazard ratio, 0.86; 95% confidence interval, 0.83 to 0.90). Compared with whites, blacks (adjusted hazard ratio, 0.68; 95% confidence interval, 0.64 to 0.72), Asians (adjusted hazard ratio, 0.82; 95% confidence interval, 0.69 to 0.96), Hispanics (adjusted hazard ratio, 0.82; 95% confidence interval, 0.76 to 0.89), and Native Americans (adjusted hazard ratio, 0.72; 95% confidence interval, 0.54 to 0.95) had lower likelihoods of kidney recovery.

CONCLUSIONS

Kidney failure due to AKI confers a higher risk of mortality in the first 6 months compared with kidney failure due to diabetes or other causes. Recovery within 12 months is common, although less so among women than men and among black, Asian, Hispanic, and Native American patients than white patients.

Pregnancy-Related Acute Kidney Injury in the United States: Clinical Outcomes and Health Care Utilization

BACKGROUND

Acute kidney injury (AKI) during pregnancy is a public health problem and is associated with maternal and fetal morbidity and mortality. Clinical outcomes and health care utilization in pregnancy-related AKI, especially in women with diabetes, are not well studied.

METHODS

Using data from the 2006 to 2015 Nationwide Inpatient Sample, we identified 42,190,790 pregnancy-related hospitalizations in women aged 15-49 years. We determined factors associated with AKI, including race/ethnicity, and associations between AKI and inpatient mortality, and between AKI and cardiovascular (CV) events, during pregnancy-related hospitalizations. We calculated health care expenditures from pregnancy-related AKI hospitalizations.

RESULTS

Overall, the rate of AKI during pregnancy-related hospitalizations was 0.08%. In the adjusted regression analysis, a higher likelihood of AKI during pregnancy-related hospitalizations was seen in 2015 (OR 2.20; 95% CI 1.89-2.55) than in 2006; in older women aged 36-40 years (OR 1.49; 95% CI 1.36-1.64) and 41-49 years (OR 2.12; 95% CI 1.84-2.45) than in women aged 20-25 years; in blacks (OR 1.52; 95% CI 1.40-1.65) and Native Americans (OR 1.45; 95% CI 1.10-1.91) than in whites, and in diabetic women (OR 4.43; 95% CI 4.04-4.86) than in those without diabetes. Pregnancy-related hospitalizations with AKI were associated with a higher likelihood of inpatient mortality (OR 13.50; 95% CI 10.47-17.42) and CV events (OR 9.74; 95% CI 9.08-10.46) than were hospitalizations with no AKI. The median cost was higher for a delivery hospitalization with AKI than without AKI (USD 18,072 vs. 4,447).

CONCLUSION

The rates of pregnancy-related AKI hospitalizations have increased during the last decade. Factors associated with a higher likelihood of AKI during pregnancy included older age, black and Native American race/ethnicity, and diabetes. Hospitalizations with pregnancy-related AKI have an increased risk of inpatient mortality and CV events, and a higher health care utilization than do those without AKI.

Racial Differences and Factors Associated with Pregnancy in ESKD Patients on Dialysis in the United States

BACKGROUND

Pregnancy in women with ESKD undergoing dialysis is uncommon due to impaired fertility. Data on pregnancy in women on dialysis in the United States is scarce.

METHODS

We evaluated a retrospective cohort of 47,555 women aged 15-44 years on dialysis between January 1, 2005 and December 31, 2013 using data from the United States Renal Data System with Medicare as primary payer. We calculated pregnancy rates and identified factors associated with pregnancy.

RESULTS

In 47,555 women on dialysis, 2352 pregnancies were identified. Pregnancy rate was 17.8 per thousand person years (PTPY) with the highest rate in women aged 20-24 (40.9 PTPY). In the adjusted time-to-event analysis, a higher likelihood of pregnancy was seen in Native American (HR, 1.77; 95% CI, 1.33 to 2.36), Hispanic (HR, 1.51; 95% CI, 1.32 to 1.73), and black (HR, 1.33; 95% CI, 1.18 to 1.49) women than in white women. A higher rate of pregnancy was seen in women with ESKD due to malignancy (HR, 1.64; 95% CI, 1.27 to 2.12), GN (HR, 1.38; 95% CI, 1.21 to 1.58), hypertension (HR, 1.32; 95% CI, 1.16 to 1.51), and secondary GN/vasculitis (HR, 1.18; 95% CI, 1.02 to 1.37) than ESKD due to diabetes. A lower likelihood of pregnancy was seen among women on peritoneal dialysis than on hemodialysis (HR, 0.47; 95% CI, 0.41 to 0.55).

CONCLUSIONS

The pregnancy rate is higher in women on dialysis than previous reports indicate. A higher likelihood of pregnancy was associated with race/ethnicity, ESKD cause, and dialysis modality.

Temporal Trends in Incident Mortality in Dialysis Patients: Focus on Sex and Racial Disparities

BACKGROUND

Racial minorities and women constitute substantial portions of the incident and prevalent end-stage renal disease (ESRD) population in the United States. Although ESRD is characterized by high mortality, temporal trends, and race and sex differences in mortality have not been studied.

METHODS

We evaluated 944,650 adult patients who initiated dialysis between January 1, 2005 and December 31, 2014, using the United States Renal Data System, for sex-related and race-related trends in mortality. Logistic regression models adjusted for pre-dialysis health status were used to examine associations among the predictors' sex, race, and year of incident dialysis, and the outcome all-cause mortality at 1-year post ESRD.

RESULTS

The mean age was 65 ± 14 years. The 1-year crude mortality rates in incident ESRD patients decreased by 28% from 2004 to 2015. Risk-adjusted 1-year mortality decreased by 3% for each later year of incident ESRD (p < 0.001). In general, from 2005 to 2014, mortality rates decreased across both sexes, and all races. White patients experienced the lowest reduction in adjusted 1-year mortality rates (16%). While women experienced a survival advantage over men in 2005, by 2014 it was reversed to survival advantage for men. Combining all years, the adjusted risk of dying at 1-year after initiating dialysis was lower in women than men (OR 0.98; 95% CI 0.97-0.99), and as compared to whites, was lower in blacks (OR 0.73; 95% CI -0.72-0.74), Hispanics (OR 0.64; 95% CI 0.63-0.65), Asians (OR 0.55; 95% CI 0.53-0.56), and Native Americans (OR 0.67; 95% CI 0.63-0.71).

CONCLUSION

The 1-year mortality rates among patients with ESRD have decreased steadily during a recent 10-year period across both men and women, and in all 5 races. Women have only a 2% lower risk of dying at 1-year after dialysis initiation than men. White patients had higher mortality as compared to other races. Our results suggest the need for sex, and race-specific treatment strategies in ESRD care.

Pre-dialysis acute care hospitalizations and clinical outcomes in dialysis patients

BACKGROUND

Patients with chronic kidney disease (CKD), a precursor of end stage renal disease (ESRD), face an increasing burden of hospitalizations. Although mortality on dialysis is highest during the first year, the impact of pre-dialysis acute hospitalizations on clinical outcomes in dialysis patients remains unknown.

METHODS

We evaluated 170,897 adult patients who initiated dialysis between 1/1/2010 and 12/31/2014 with linked Medicare claims from the United States Renal Data System. Using logistic regression models, we examined the association of 2-year pre-dialysis hospitalization on the primary outcome of 1-year all-cause mortality. Secondary outcomes included 90-day mortality, type of initial dialysis modality and type of vascular access at hemodialysis initiation.

RESULTS

Mean age was 72.7 ± 11.0 years. In the study sample, 76.0% of patients had at least one pre-dialysis hospitalization. Compared to patients with no pre-dialysis hospitalization, the adjusted 1-year mortality was higher with pre-dialysis cardiovascular related hospitalization (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57-1.68), infection related hospitalization (OR, 1.51; CI, 1.45-1.57), both cardiovascular and infection hospitalization (OR, 1.91; CI, 1.83-1.99), and neither-cardiovascular nor-infection hospitalization (OR, 1.23; CI, 1.19-1.27). Additionally, the adjusted odds of hemodialysis vs. peritoneal dialysis as the initial dialysis modality were higher, whereas adjusted odds to initiate hemodialysis with an arteriovenous access vs. central venous catheter were lower in patients with any type of hospitalization.

CONCLUSION

Pre-dialysis hospitalization is an independent predictor of 1-year mortality in dialysis patients. Reducing the risk of pre-dialysis hospitalization may provide opportunities to improve quality of care in ESRD.

Gender and Racial Disparities in Initial Hemodialysis Access and Outcomes in Incident End-Stage Renal Disease Patients

BACKGROUND

Arteriovenous (AV) access confers survival benefits over central venous catheters (CVC) in hemodialysis patients. Although chronic kidney disease disproportionately affects women and racial minorities, disparities in the -utilization of hemodialysis access across Asians, Native Americans, Hispanics, blacks, and whites among males and females after accounting for pre-dialysis health are not well studied.

METHODS

We evaluated 885,699 patients with end-stage renal disease who initiated hemodialysis between January 1, 2004 and December 31, 2014 using the US Renal Data System. Multivariable logistic regression models -adjusted for pre-dialysis health were used to test the associations between gender and race on type of vascular access (AV access vs. CVC, and AV fistula vs. AV graft) at hemodialysis initiation as primary outcome, and on 1-year mortality as a secondary outcome.

RESULTS

Mean age was 65 ± 14 years. Females were less likely to use AV access for hemodialysis initiation than were males (OR 0.85; 95% CI 0.84-0.86). Compared to whites, adjusted odds of AV access for hemodialysis initiation were higher in blacks (OR 1.08; 95% CI 1.07-1.70), Asians (OR 1.11; 95% CI 1.07-1.14); and lower in Hispanics (OR 0.89; 95% CI 0.87-0.90). There was no -significant difference in mortality between males and females. Compared to whites, 1-year adjusted mortality was lower in Asians (OR 0.55; 95% CI 0.53-0.56), blacks (OR 0.67; 95% CI 0.66-0.68), Hispanics (OR 0.62; 95% CI 0.61-0.63), and Native Americans (OR 0.62; 95% CI 0.58-0.66).

CONCLUSION

Females had lower odds of using AV access than do males for hemodialysis initiation. As compared to whites, blacks and Asians were more likely, and Hispanics were less likely to use AV access for first outpatient hemodialysis. Further investigation of biological and process of care factors may help in developing ways to reduce these disparities.

Acute Kidney Injury before Dialysis Initiation Predicts Adverse Outcomes in Hemodialysis Patients

BACKGROUND

Acute kidney injury (AKI) is associated with increased morbidity and mortality. Mortality in end-stage renal disease (ESRD) patients is highest during the first year of dialysis. The impact of pre-ESRD AKI events on long-term outcomes in incident ESRD patients remains unknown.

METHODS

We evaluated a retrospective cohort of 47,341 incident hemodialysis patients from the United States Renal Data System with linked Medicare data for at least 2 years prior to hemodialysis initiation. We examined the impact of pre-ESRD AKI events in the 2-year pre-ESRD period on the type of vascular access used at hemodialysis initiation (central venous catheter (CVC) versus arteriovenous access), and 1-year all-cause mortality after initiating hemodialysis.

RESULTS

The mean age was 72 ± 11 years. Of the study cohort, 18% initiated hemodialysis with arteriovenous access, and 54% of patients had at least one pre-ESRD AKI event. One-year, all-cause mortality was 32%. Compared to 75% for patients without a pre-ESRD AKI event, 89% of patients with a pre-ESRD AKI event initiated hemodialysis with CVC than arteriovenous access (p < 0.001). A pre-ESRD AKI event was associated with lower adjusted odds of starting hemodialysis with an arteriovenous access (OR 0.47; 95% CI 0.44-0.50, p < 0.001), and higher adjusted odds of 1-year mortality (OR 1.36; 95% CI 1.30-1.42, p < 0.001).

CONCLUSION

An AKI event prior to initiating hemodialysis independently increases the risk of CVC use and predicts 1-year mortality. Improving processes of care after AKI events may improve dialysis outcomes in patients who progress to ESRD.

Functional status, pre-dialysis health and clinical outcomes among elderly dialysis patients

Background

Elderly patients comprise the fastest growing population initiating dialysis in United States. The impact of poor functional status and pre-dialysis health status on clinical outcomes in elderly dialysis patients is not well studied.

Methods

We studied a retrospective cohort of 49,645 incident end stage renal disease patients that initiated dialysis between January 1, 2008 and December 31, 2008 from the United States Renal Data System with linked Medicare data covering at least 2 years prior to dialysis initiation. Using logistic regression models adjusted for pre-dialysis health status and other cofounders, we examined the impact of poor functional status as defined from form 2728 on 1-year all-cause mortality as primary outcome, type of dialysis modality (hemodialysis vs. peritoneal dialysis), and type of initial vascular access (arteriovenous access vs. central venous catheter) among hemodialysis patients as secondary outcomes.

Results

Mean age was 72 ± 11 years. At dialysis initiation, 18.7% reported poor functional status, 88.9% had at least 1 pre-dialysis hospitalization, and 27.8% did not receive pre-dialysis nephrology care. In adjusted analyses, 1-year mortality was higher in patients with poor functional status (OR, 1.48; 95% CI, 1.40–1.57). Adjusted odds of being initiated on hemodialysis than peritoneal dialysis (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.16–1.66) were higher in patients with poor functional status. Poor functional status decreased the adjusted odds of starting hemodialysis with arteriovenous access as compared to central venous catheter (OR, 0.79; 95% CI, 0.72–0.86).

Conclusion

Poor functional status in elderly patients with end stage renal disease is associated with higher odds of initiating hemodialysis; increases the risk of central venous catheter use, and is an independent predictor of 1-year mortality.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0898-1) contains supplementary material, which is available to authorized users.

Atrial fibrillation decision support tool: Population perspective

BACKGROUND

Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients.

METHODS

This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs.

RESULTS

When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST.

CONCLUSIONS

Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.

Association Between Weight Loss and the Risk of Cancer after Bariatric Surgery

OBJECTIVE

The goal of this study was to determine whether the reduction in cancer risk after bariatric surgery is due to weight loss.

METHODS

A retrospective matched cohort study of patients undergoing bariatric surgery was conducted using data from a large integrated health insurance and care delivery system with five sites in four states. The study included 18,355 bariatric surgery subjects and 40,524 nonsurgical subjects matched on age, sex, BMI, site, and Elixhauser comorbidity index. Multivariable Cox proportional hazards models examined the relationship between weight loss at 1 year and incident cancer during up to 10 years of follow-up.

RESULTS

The study identified 1,196 cases of incident cancer. The average 1-year postsurgical weight loss was 27% among patients undergoing bariatric surgery versus 1% in matched nonsurgical patients. Percent weight loss at 1 year was significantly associated with a reduced risk of any cancer in adjusted models (HR 0.897, 95% CI: 0.832-0.968, P = 0.005 for every 10% weight loss) while bariatric surgery was not a significant independent predictor of cancer incidence.

CONCLUSIONS

Weight loss after bariatric surgery was associated with a lower risk of incident cancer. There was no apparent independent effect of the bariatric surgery itself on cancer risk that was independent of weight loss.

Contrast-Induced Nephropathy in Renal Transplant Recipients: A Single Center Experience

BACKGROUND

Contrast-induced nephropathy (CIN) in native kidneys is associated with a significant increase in mortality and morbidity. Data regarding CIN in renal allografts are limited, however. We retrospectively studied CIN in renal allografts at our institution: its incidence, risk factors, and effect on long-term outcomes including allograft loss and death.

METHODS

One hundred thirty-five renal transplant recipients undergoing 161 contrast-enhanced computed tomography (CT) scans or coronary angiograms (Cath) between years 2000 and 2014 were identified. Contrast agents were iso- or low osmolar. CIN was defined as a rise in serum creatinine (SCr) by >0.3 mg/dl or 25% from baseline within 4 days of contrast exposure. After excluding 85 contrast exposures where patients had no SCr within 4 days of contrast administration, 76 exposures (CT: n = 45; Cath: n = 31) in 50 eligible patients were analyzed. Risk factors assessed included demographics, comorbid conditions, type/volume of contrast agent used, IV fluids, N-acetylcysteine administration, and calcineurin inhibitor use. Bivariate and multivariable analyses were used to assess the risk of CIN.

RESULTS

Incidence of CIN was 13% following both, CT (6 out of 45) and Cath (4 out of 31). Significant bivariate predictors of CIN were IV fluid administration (p = 0.05), lower hemoglobin (p = 0.03), and lower albumin (p = 0.02). In a multivariable model, CIN was predicted by N-acetylcysteine (p = 0.03) and lower hemoglobin (p = 0.01). Calcineurin inhibitor use was not associated with CIN. At last follow-up, CIN did not affect allograft or patient survival.

CONCLUSION

CIN is common in kidney transplant recipients, and there is room for quality improvement with regards to careful renal function monitoring post-contrast exposure. In our study, N-acetylcysteine exposure and lower hemoglobin were associated with CIN. Calcineurin inhibitor use was not associated with CIN. Our sample size is small, however, and larger prospective studies of CIN in renal allografts are needed.

Modified Constraint-Induced Therapy in Acute Stroke: A Randomized Controlled Pilot Study

To determine modified constraint-induced therapy (mCIT) feasibility and compare its efficacy to traditional rehabilitation (TR) in acute stroke patients exhibiting upper limb hemiparesis. Method. Before-after, multiple baseline, randomized controlled pilot study. Setting. Rehabilitation hospital. Patients. Ten stroke patients < 14 d poststroke and exhibiting upper limb hemiparesis and affected limb nonuse. Interventions. Five patients were administered mCIT, consisting of structured therapy emphasizing more affected arm use in valued activities 3 d/week for 10 weeks and less affected arm restraint 5 d/week for 5 h. Five other patients received 1/2 sessions of traditional motor rehabilitation for the affected arm, which included affected limb manual dexterity exercises and stretching, as well as compensatory strategies with the unaffected limb. The TR regimens occurred 3 d/week for 10 weeks. Main Outcome Measures. The Fugl-Meyer Assessment of Motor Recovery (Fugl-Meyer), Action Research Arm Test (ARA), and Motor Activity Log (MAL). Results. Before intervention, all patients exhibited stable motor deficits and more affected arm nonuse. After intervention, mCIT patients displayed increased affected arm use (+ 2.43 on the MAL amount of use scale), uniformly exhibited increases on the Fugl-Meyer and ARA (mean change scores = + 18.7 and + 21.7, respectively), and were able to again perform valued activities. TR patients exhibited nominal change in affected limb use (+ 0.07 on the MAL amount of use scale) and modest changes on the Fugl-Meyer and ARA (+ 4.4 and + 4.8, respectively). Fugl-Meyer and ARA changes were significant for the mCIT group only (P < 0.01). Conclusions. mCIT is a promising regimen for improving more affected limb use and function in acute cerebrovascular accident. However, larger confirmatory studies need to be performed.

Impact of an Atrial Fibrillation Decision Support Tool on thromboprophylaxis for atrial fibrillation

BACKGROUND

Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge.

METHODS

We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation.

RESULTS

Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance.

CONCLUSIONS

Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.

Multidimensional assessment of spirituality/religion in patients with HIV: conceptual framework and empirical refinement

A decade ago, an expert panel developed a framework for measuring spirituality/religion in health research (Brief Multidimensional Measure of Religiousness/Spirituality), but empirical testing of this framework has been limited. The purpose of this study was to determine whether responses to items across multiple measures assessing spirituality/religion by 450 patients with HIV replicate this model. We hypothesized a six-factor model underlying a collective of 56 items, but results of confirmatory factor analyses suggested eight dimensions: Meaning/Peace, Tangible Connection to the Divine, Positive Religious Coping, Love/Appreciation, Negative Religious Coping, Positive Congregational Support, Negative Congregational Support, and Cultural Practices. This study corroborates parts of the factor structure underlying the Brief Multidimensional Measure of Religiousness/Spirituality and some recent refinements of the original framework.

Complementary and alternative medicine use and psychosocial outcomes among urban adolescents with asthma

Objective. Many adolescents with asthma use complementary and alternative medicine (CAM) for asthma symptom management. The purpose of this study was to investigate cross-sectional and longitudinal differences in psychosocial health outcomes between high and low CAM users among urban adolescents with asthma. Methods. Adolescents (Time 1: N = 151, Time 2: N = 131) completed self-report measures regarding the use of 10 CAM modalities, mental health, and health-related quality of life (HRQoL) following two clinic visits 1 year apart as part of a larger observational study. Multivariable regression analyses using backward elimination examined relationships between CAM use at Time 1 and outcomes at Time 1 and Time 2, controlling for key covariates and, in longitudinal analyses, Time 1 functioning. Results. Participants (M(age) = 15.8, SD = 1.85) were primarily African-American (n = 129 [85%]) and female (n = 91 [60%]) adolescents with asthma. High and low CAM users differed significantly in terms of several psychosocial health outcomes, both cross-sectionally and longitudinally. In cross-sectional multivariable analyses, greater frequency of praying was associated with better psychosocial HRQoL (R(2) = 0.22). No longitudinal relationships remained significant in multivariable analyses. Conclusions. Specific CAM techniques are differentially associated with psychosocial outcomes, indicating the importance of examining CAM modalities individually. Greater frequency of praying was cross-sectionally associated with better psychosocial HRQoL. When controlling for key covariates, CAM use was not associated with psychosocial outcomes over time. Further research should examine the effects of CAM use in controlled research settings.

Impact of health literacy on outcomes and effectiveness of an educational intervention in patients with chronic diseases

OBJECTIVE

Study impact of health literacy on educational intervention for patients "Living with Coronary Artery Disease."

METHODS

187 patients were randomized to: VHS/DVD plus printed booklet; or booklet alone prior to scheduled visit. Main outcome measures included CAD knowledge assessment, clinical outcomes (weigh and blood pressure) and health behaviors (diet, exercise, and smoking); while functional health literacy was assessed as a possible predictor variable.

RESULTS

Knowledge scores and health behaviors improved following both interventions. Those receiving the booklet and video also had a significant improvement in exercise, and weight loss. There was a trend (p=0.07) towards greater improvement in test scores among those receiving the booklet plus video. Patients with lower health literacy benefited as much as higher literacy patients.

CONCLUSIONS

Incorporation of an educational program into clinical visits for patients with chronic disease improved disease-specific knowledge and prompted patients to become activated and involved in their care, improving health behaviors and outcomes. Lower health literacy was not a barrier to this beneficial effect.

PRACTICE IMPLICATIONS

Patients with lower health literacy may also benefit from educational, shared decision-making interventions.

Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study

Objective

Inadequate participant recruitment is a major problem facing clinical research. Recent studies have demonstrated that electronic health record (EHR)-based, point-of-care, clinical trial alerts (CTA) can improve participant recruitment to certain clinical research studies. Despite their promise, much remains to be learned about the use of CTAs. Our objective was to study whether repeated exposure to such alerts leads to declining user responsiveness and to characterize its extent if present to better inform future CTA deployments.

Methods

During a 36-week study period, we systematically documented the response patterns of 178 physician users randomized to receive CTAs for an ongoing clinical trial. Data were collected on: (1) response rates to the CTA; and (2) referral rates per physician, per time unit. Variables of interest were offset by the log of the total number of alerts received by that physician during that time period, in a Poisson regression.

Results

Response rates demonstrated a significant downward trend across time, with response rates decreasing by 2.7% for each advancing time period, significantly different from zero (flat) (p<0.0001). Even after 36 weeks, response rates remained in the 30%–40% range. Subgroup analyses revealed differences between community-based versus university-based physicians (p=0.0489).

Discussion

CTA responsiveness declined gradually over prolonged exposure, although it remained reasonably high even after 36 weeks of exposure. There were also notable differences between community-based versus university-based users.

Conclusions

These findings add to the limited literature on this form of EHR-based alert fatigue and should help inform future tailoring, deployment, and further study of CTAs.

Acute kidney injury episodes and chronic kidney disease risk in diabetes mellitus

BACKGROUND AND OBJECTIVES

Prior studies have examined long-term outcomes of a single acute kidney injury (AKI) event in hospitalized patients. We examined the effects of AKI episodes during multiple hospitalizations on the risk of chronic kidney disease (CKD) in a cohort with diabetes mellitus (DM).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A total of 4082 diabetics were followed from January 1999 until December 2008. The primary outcome was reaching stage 4 CKD (GFR of <30 ml/min per 1.73 m(2)). AKI during hospitalization was defined as >0.3 mg/dl or a 1.5-fold increase in creatinine relative to admission. Cox survival models examined the effect of first AKI episode and up to three episodes as time-dependent covariates, on the risk of stage 4 CKD. Covariates included demographic variables, baseline creatinine, and diagnoses of comorbidities including proteinuria.

RESULTS

Of the 3679 patients who met eligibility criteria (mean age = 61.7 years [SD, 11.2]; mean baseline creatinine = 1.10 mg/dl [SD, 0.3]), 1822 required at least one hospitalization during the time under observation (mean = 61.2 months [SD, 25]). Five hundred thirty of 1822 patients experienced one AKI episode; 157 of 530 experienced ≥2 AKI episodes. In multivariable Cox proportional hazards models, any AKI versus no AKI was a risk factor for stage 4 CKD (hazard ratio [HR], 3.56; 95% confidence interval [CI], 2.76, 4.61); each AKI episode doubled that risk (HR, 2.02; 95% CI, 1.78, 2.30).

CONCLUSIONS

AKI episodes are associated with a cumulative risk for developing advanced CKD in diabetes mellitus, independent of other major risk factors of progression.

Paul B. Beeson career development awards in aging research and U.S. medical schools aging and geriatric medicine programs

Established in 1995, the Paul B. Beeson Career Development program provides faculty development awards to outstanding junior and midcareer faculty committed to academic careers in aging-related research, training, and practice. This study evaluated the effect of 134 Beeson Scholars on their medical schools' aging and geriatric medicine programs and on the field of aging research from 1995 to 2007. Quantitative and qualitative survey data from multiple sources, including the American Geriatrics Society/Association of Directors of Geriatric Academic Programs' Geriatrics Workforce Policy Studies Center, National Institutes of Health (NIH) rankings of research funding, and other governmental databases were used to compare 36 medical schools with Beeson Scholars with 34 similar medical schools without Beeson scholars and to examine the influence of Beeson Scholars on the field of geriatrics and aging. Most Beeson Scholars remained at the institution where they trained during their Beeson award, and 89% are still practicing or conducting research in the field of geriatrics and aging. Twenty-six (19.4%) of the scholars have led institutional research mentoring awards, 51 (39%) report leadership roles in institutional program project grants, and 13 (10%) report leadership roles in the Clinical and Translational Science Award programs at their institutions. Beeson Scholars are more likely than a matched sample of non-Beeson NIH K awardees to study important geriatric syndromes such as falls, cognitive impairment, adverse drug events, osteoporosis, and functional recovery from illness. Total Beeson Impact Years (the total number of years all Beeson Scholars have worked at each school) is positively correlated with more geriatrics research faculty, after controlling for NIH funding rank (P=.02). Beeson Scholars have made positive contributions to the development of academic geriatrics research programs at U.S. medical schools.

Adherence to the HPV vaccine dosing intervals and factors associated with completion of 3 doses

OBJECTIVE

The objectives of this study were to determine (1) adherence to the immunization schedule for the human papillomavirus quadrivalent vaccine and (2) factors associated with completion of the 3-dose series.

METHODS

This was a retrospective review of health information records from an academic medical center. The sample included all 9- to 26-year-old female patients who initiated vaccination within 2 years after quadrivalent vaccine availability. Multivariable logistic regression models were estimated to determine associations with completion of the 3-dose series within 7 and 12 months.

RESULTS

Among the 3297 female patients who initiated vaccination with human papillomavirus quadrivalent vaccine, 67% self-identified as black and 29% self-identified as white. Fewer than 3% of vaccine doses were received earlier than recommended, but >50% of doses were received late. Completion rates were 14% by 7 months and 28% by 12 months. Independent predictors of completion by 7 months included white versus black race (odds ratio [OR]: 2.04 [95% confidence interval (CI): 1.64-2.56]; P < .001), use of contraception that required intramuscular injections every 3 months (OR: 1.53 [95% CI: 1.12-1.95]; P < .001), and private versus public insurance (OR: 1.31 [95% CI: 1.06-1.63]; P < .05). Age and clinic type were not independent predictors of completion.

CONCLUSIONS

Adherence to recommended intervals and completion of the vaccine series were low. Lower rates of completion in black patients compared with white patients raises concern that disparities in vaccine completion could exacerbate existing disparities in cervical cancer.

Understanding preferences for disclosure of individual biomarker results among participants in a longitudinal birth cohort

BACKGROUND

To describe the preferences for disclosure of individual biomarker results among mothers participating in a longitudinal birth cohort.

METHODS

We surveyed 343 mothers that participated in the Health Outcomes and Measures of the Environment Study about their biomarker disclosure preferences. Participants were told that the study was measuring pesticide metabolites in their biological specimens, and that the health effects of these low levels of exposure are unknown. Participants were asked whether they wanted to receive their results and their child's results. In addition, they were asked about their preferred method (letter vs in person) and format (more complex vs less complex) for disclosure of results.

RESULTS

Almost all of the study participants wanted to receive their individual results (340/343) as well as their child's results (342/343). However, preferences for receiving results differed by education level. Mothers with less than a college degree preferred in-person disclosure of results more often than mothers with some college education or a college degree (34.3% vs 17.4% vs 7.9%, p<0.001). Similarly, mothers with less than a college education preferred a less complex disclosure format than mothers with some college education or a college degree (59.7% vs 79.1% vs 86.3%, p<0.0001).

CONCLUSION

While almost all study participants preferred to receive results of their individual biomarker tests, level of education was a key factor in predicting preferences for disclosure of biomarker results. To ensure effective communication of this information, disclosure of biomarker results should be tailored to the education level of the study participants.

Valuation of scleroderma and psoriatic arthritis health states by the general public

Objective

Psoriatic arthritis (PsA) and scleroderma (SSc) are chronic rheumatic disorders with detrimental effects on health-related quality of life. Our objective was to assess health values (utilities) from the general public for health states common to people with PsA and SSc for economic evaluations.

Methods

Adult subjects from the general population in a Midwestern city (N = 218) completed the SF-12 Health Survey and computer-assisted 0-100 rating scale (RS), time trade-off (TTO, range: 0.0-1.0) and standard gamble (SG, range: 0.0-1.0) utility assessments for several hypothetical PsA and SSc health states.

Results

Subjects included 135 (62%) females, 143 (66%) Caucasians, and 62 (28%) African-Americans. The mean (SD) scores for the SF-12 Physical Component Summary scale were 52.9 (8.3) and for the SF-12 Mental Component Summary scale were 49.0 (9.1), close to population norms. The mean RS, TTO, and SG scores for PsA health states varied with severity, ranging from 20.2 to 63.7 (14.4-20.3) for the RS 0.29 to 0.78 (0.24-0.31) for the TTO, and 0.48 to 0.82 (0.24-0.34) for the SG. The mean RS, TTO, and SG scores for SSc health states were 25.3-69.7 (15.2-16.3) for the RS, 0.36-0.80 (0.25-0.31) for the TTO, and 0.50-0.81 (0.26-0.32) for the SG, depending on disease severity.

Conclusion

Health utilities for PsA and SSc health states as assessed from the general public reflect the severity of the diseases. These descriptive findings could have implications regarding comparative effectiveness research for tests and treatments for PsA and SSc.

Human papillomavirus concordance in heterosexual couples

PURPOSE

Few studies have examined the relationships between sexual or hygienic behaviors and human papillomavirus (HPV) transmission. Our objectives were to (1) describe HPV concordance between the anogenital, oral, and palmar areas of monogamous heterosexual couples; and (2) determine sexual behaviors, hygienic practices, sexual histories, and subject characteristics associated with HPV anogenital concordance.

METHODS

Couples were recruited from women who developed an incident HPV infection while being enrolled in a longitudinal HPV natural history study that recruited from two family-planning clinics. Men were their monogamous partners of at least 3 months. Samples were tested for HPV-DNA of 37 high- and low-risk genotypes. Questionnaires completed privately assessed health, sexual, hygienic history, and behaviors.

RESULTS

A total of 25 couples enrolled between February 2006 and July 2007; none had received HPV vaccine. The average age was 25 years (SD, 6) for men and 23 years (SD, 3) for women. HPV-84 was the most commonly shared HPV type in the anogenital and palmar areas. HPV-16 was the only shared oral-HPV type. Sixty-eight percent of couples had type-specific anogenital concordance. Receiving finger-anal sex (p = .05), sharing towels (p = .04), longer time since last intercourse (women: p = .03, men: p = .02 men), and men washing their genitals after sex (p = .03) were associated with decreased likelihood of concordance. Persistence of incident HPV types in women was associated with HPV in men (p = .002).

CONCLUSIONS

Our findings show that certain hygienic and sexual behaviors are associated with anogenital concordance between healthy, monogamous, heterosexual couples. Future studies are needed to see whether these detections reflect contamination, transient, or established infections.

Health care utilization history, GOLD guidelines, and respiratory medication prescriptions in patients with COPD

BACKGROUND

The relationship between prior health care utilization and respiratory medication prescriptions in an unselected population of patients with COPD is not known.

METHODS

We determined the prescribed respiratory medications and respiratory and nonrespiratory health care encounters in 523 Veterans with COPD at the Cincinnati Veterans Affairs Medical Center between 2000 and 2005. Prescribed treatments were compared with the GOLD guidelines and each patient was classified as receiving less medications than recommended in the guidelines (<G), medications according to the guidelines (=G), or more medications than recommended (>G).

RESULTS

Respiratory medications were <G for 54%, =G in 33%, and >G for 14% of the patients studied. For GOLD stages 1 and 2, <G patients had the fewest and >G patients the most prior respiratory encounters during a 12 month period (0.31 +/- 0.073 (0.21, 0.47), 0.75 +/- 0.5 (0.37, 1.5), 1.1 +/- 0.27 (0.74, 1.6) visits/person/year, <G, =G, >G, respectively, mean + standard error of mean (SEM) (95% confidence limits) 2 degrees of freedom (df) ANOVA P < 0.001 for prescription effect). For GOLD stages 3 and 4, <G was associated with significantly fewer prior respiratory visits than was =G (0.78 +/- 0.11 (0.6, 1.0) and 2.4 +/- 0.47 (1.9, 3.1) visits/person/year, respectively, P < 0.001). There were no differences in nonrespiratory health care visits for GOLD stages 1 and 2 by prescription level (3.1 +/- 0.24 (2.6, 3.5), 3.1 +/- 0.46 (2.1, 4.6) and 4.1 +/- 0.55 (3.3, 5.1) visits/person/year, <G, =G, >G respectively, 2 df ANOVA P = 0.096) or for GOLD stages 3 and 4 (3.6 +/- 0.25 (3.2, 4.1) and 4.0 +/- 0.44 (3.3, 4.9) visits/person/year, <G and =G, respectively, P = 0.36).

CONCLUSIONS

Respiratory medications prescribed for an unselected population with a broad range of COPD severity complied poorly with the GOLD pharmacologic treatment guidelines but correlated with the number of prior respiratory health care visits.

Religious coping and physiological, psychological, social, and spiritual outcomes in patients with HIV/AIDS: cross-sectional and longitudinal findings

The present study investigated the relationships between positive religious coping (e.g., seeking spiritual support) and spiritual struggle (e.g., anger at God) versus viral load, CD4 count, quality of life, HIV symptoms, depression, self-esteem, social support, and spiritual well-being in 429 patients with HIV/AIDS. Data were collected through patient interview and chart review at baseline and 12-18 months later from four clinical sites. At baseline, positive religious coping was associated with positive outcomes while spiritual struggle was associated with negative outcomes. In addition, high levels of positive religious coping and low levels of spiritual struggle were associated with small but significant improvements over time. These results have implications for assessing religious coping and designing interventions targeting spiritual struggle in patients with HIV/AIDS.

Outcomes of hemodialysis patients in a long-term care hospital setting: a single-center study

BACKGROUND

Long-term care hospitals (LTCHs) provide intermediary care after an acute-care hospitalization and usually furnish care to patients with complex medical problems. Outcomes of hemodialysis patients admitted to LTCHs, which includes patients with either end-stage renal disease (ESRD) or acute kidney injury (AKI) requiring dialysis therapy, are not known.

STUDY DESIGN

Observational study.

SETTING & PARTICIPANTS

All consecutive hemodialysis patients admitted to an LTCH.

PREDICTORS

Demographic characteristics, comorbid and laboratory variables, ESRD, and AKI status during LTCH stay.

OUTCOMES

Disposition from LTCHs was classified as discharge to home, nursing home, death in LTCH or hospice care, and re-admission to the hospital. In patients with AKI, renal recovery was defined as discontinuation of dialysis therapy before meeting disposition outcomes.

RESULTS

96 of 206 (46.6%) patients had ESRD, whereas 110 of 206 (53.3%) developed AKI requiring dialysis therapy during the acute-care hospitalization. 63 of 206 (31%) were discharged to home, 11 of 206 (5.4%) died or transferred to hospice, 81 of 206 (40%) went to a nursing home, and 49 of 206 (24%) were re-admitted to a hospital; mortality after re-admission was 32%. Older age (OR, 0.96; 95% CI, 0.93-0.98), diabetes mellitus (OR, 0.45; 95% CI, 0.23-0.94), number of re-admissions to the hospital (OR, 0.38; 95% CI, 0.18-0.78), aminoglycoside use (OR, 0.16; 95% CI, 0.04-0.64), and duration of hospitalization before LTCH admission (OR, 0.96; 95% CI, 0.94-0.99) were associated with lower odds of discharge to home. Of 110 patients with AKI requiring dialysis therapy, 30% (33 patients) discontinued dialysis therapy, whereas 70% were deemed to have ESRD on discharge.

LIMITATIONS

Retrospective observational study.

CONCLUSIONS

Most dialysis patients at LTCHs are either re-admitted to acute-care hospitals or require nursing home placement. Only 30% of patients with AKI recover sufficiently to discontinue dialysis therapy, whereas 70% are deemed to have ESRD.

Change in quality of life after being diagnosed with HIV: a multicenter longitudinal study

The objective of this study was to assess in patients with HIV perceptions of life pre-HIV versus post-HIV diagnosis and examine whether such perceptions change over time. We conducted interviews and chart reviews of 347 outpatients with HIV from three cities in 2002-2004. In two interviews 12-18 months apart, patients compared their life now with their life before HIV was diagnosed. Independent variables included demographic and clinical characteristics; HIV-specific health status, symptoms, and concerns; spirituality/religion; social support; self-perception; and optimism. The patients' mean (standard deviation [SD]) age was 44.8 (8.3) years; half were minorities; and 269 (78%) were taking antiretroviral therapy. Comparing life at time 1 versus before diagnosis, 109 (31%) patients said their life was better at time 1, 98 (28%) said it was worse, and the rest said it was about the same or did not know. By time 2, approximately one fifth of the patients changed their answers to indicate life improvement and one sixth changed them to indicate life deterioration. In multivariable analysis, change in perception for the better between time 1 and time 2 (versus prediagnosis) was positively associated with time 1 positive religious coping scores, whereas change in perception for the worse was associated with study site, heterosexual orientation, a detectable viral load, shorter duration of HIV, lower spirituality scores, and lower positive religious coping scores. We conclude that many patients with HIV feel that their life is better than it was before their diagnosis, although results of such comparisons often change over time.

A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: a pilot study

The prevalence of adult tobacco users who utilize the emergency department as patients or parents is disproportionately higher than the national average rates of tobacco use. Thus, it is advised that the emergency department be utilized as a venue for providing tobacco cessation counseling to adult tobacco users. Using a randomized control trial design, this pilot study evaluated the effect of a brief tobacco cessation intervention for tobacco using parents of children brought to a pediatric emergency department. Participants received either usual care or a brief tobacco cessation intervention based on the first 2 of the 5A's of the Clinical Practice Guidelines and fax referral to the Quitline. The primary outcome was self-reported repeated point prevalence of tobacco use at 6 weeks and 3 months following the intervention. Secondary aims included number of quit attempts, increases in readiness to quit, comparisons of participants who were successfully retained, and contact rates by Quitline counselors. At 3-month follow-up, compared to the Usual Care Control group, intervention participants were more likely to have made at least one quit attempt (59% vs. 34%; p<.01), be seriously thinking about quitting (68% vs. 37%; p<.001), and have higher Ladder scores (6.2 vs. 5.3; p<.05). Study personnel were able to contact 68% and 52%, respectively, of participants at 6-week and 3-month follow-up. Quitline counselors were unable to reach 54% of participants. Our results reveal increased intentions to quit and trends toward quitting, however we experienced difficulties with participant retention. Suggestions for improvements in point prevalence and retention are given.

Patient-specific decision modeling to guide the use of drotrecogin alpha (activated) in patients with severe sepsis

PURPOSE

The expected benefit of treating severe sepsis with drotrecogin alpha (activated) for an individual patient may depend upon several clinical factors including disease severity. Our objective was to create a decision support tool incorporating patient-specific inputs to estimate the balance between treatment risks and benefits for individual patients with severe sepsis.

MATERIALS AND METHODS

Logistic regression models were developed to calculate patient-specific mortality risk with and without treatment, which were then used as inputs into a 75-state Markov model. Patient-specific inputs included patient age, sex, and 12 readily available clinical characteristics.

RESULTS

The expected benefit from drotrecogin alpha (activated) treatment was most dependent upon the underlying disease severity. For example, for a 56-year-old white man with severe sepsis and a 28-day mortality risk of 29%, the model predicted a treatment-related gain of 1.2 quality-adjusted life years (17.3 vs 16.1). Probabilistic sensitivity analyses demonstrated that this patient would benefit from therapy 85% of the time.

CONCLUSIONS

A customizable decision model using patient-specific inputs can be used to inform the treatment decision when considering the use of drotrecogin alpha (activated) therapy by weighing the risks vs the benefits of therapy in the treatment of severe sepsis.

A randomized study of scleroderma health state values: a picture is worth a thousand words, and quite a few utiles. [corrected]

OBJECTIVE

Assigning utilities to hypothetical health states requires that the health states be described in adequate detail, but there is no agreement on exactly how health states should be described. We assess utilities from the general public for health states common in scleroderma (SSc) by describing the health states in writing alone v. with photographs of patients with SSc.

METHODS

Subjects rated several SSc health states on a 0 to 100 rating scale (RS) and completed computer-assisted time tradeoff (TTO; range, 0.0-1.0) and standard gamble (SG; range, 0.0-1.0) assessments. Half of the subjects were assigned to be shown photographs of patients with SSc health states in addition to written health state descriptions, whereas the other half were given only the written descriptions.

RESULTS

Of the 213 participants, 133 (62%) were female, 138 (65%) were Caucasian, and 62 (29%) were African American. Median RS, TTO, and SG scores for 5 SSc health states ranged from 20 to 70, 0.28 to 0.94, and 0.50 to 0.90, respectively. In bivariate analyses, showing pictures was associated with lower RS scores for 2 of 5 health states and lower SG values for all 5 health states (P < 0:05 for comparison of pictures v. no pictures), but with no difference in TTO values. Multivariable analyses revealed negative associations between pictures and SG valuations for the 3 most severe SSc health states (R(2) range, 0.04-0.08).

CONCLUSION

Adding pictures of people with SSc to written health state descriptions can affect valuations of SSc health states, although the effect differs by valuation measurement method and by health state severity.

Effect of race and HIV co-infection upon treatment prescription for hepatitis C virus

BACKGROUND

Treatment rates for hepatitis C virus (HCV) have not been compared directly between HCV mono-infected and HCV-HIV co-infected patients in academic center settings.

METHODS

We prospectively enrolled consecutive mono-infected and co-infected subjects at three academic centers in the USA. Clinical and laboratory data were gathered through interviews and medical records. Logistic regression analysis was used to determine the factors associated with treatment prescription for HCV.

RESULTS

The 241 HCV mono-infected and 158 HCV-HIV co-infected subjects were similar in age, but there were more blacks (58.9% vs. 30.7%, p < 0.001) and males (81.6% vs. 58.5%, p < 0.001) in the latter group. The co-infected subjects were less likely to have a liver biopsy (43.7% vs. 71.4%, p < 0.001) or ever receive treatment for HCV (32.3% vs. 62.2%, p < 0.001). In bivariate analysis, subjects not prescribed treatment for HCV were more likely to be black, have HIV co-infection, and have ongoing alcohol abuse. In multivariate analysis, black race (odds ratio (OR) 0.44, 95% confidence interval (CI) 0.28-0.70) and HIV co-infection (OR 0.33, 95% CI 0.21-0.53) were independently associated with non-prescription of treatment.

CONCLUSIONS

Black race and HIV co-infection are associated with a lower likelihood of treatment for HCV. Addressing comorbidities in these populations may help to reduce such treatment disparities.

Ontogeny of salivary epidermal growth factor and necrotizing enterocolitis

OBJECTIVE

To examine the ontogeny of salivary epidermal growth factor (sEGF) in premature infants and to determine the relation of sEGF to the development of necrotizing enterocolitis (NEC).

STUDY DESIGN

Salivary EGF was prospectively measured in 327 infants with gestational ages from 23 weeks to term. Infants of < or = 32 weeks' gestation (n = 261) were followed with weekly sEGF measurements through 3 weeks of life. Multivariable regression analyses were used to determine variables significantly related to sEGF levels and to identify predictors of NEC.

RESULTS

Over the first 3 weeks of life, sEGF increased across gestational age and postnatal age categories. In multivariable models, gestational age was a significant predictor of sEGF levels (P < .009). In a cohort of 27 infants who had NEC, gestational age, race, and changes in sEGF levels between weeks of life 1 and 2 were predictive of the development of NEC. These infants had lower sEGF at week 1 and greater increases from week 1 to week 2 compared with infants without NEC.

CONCLUSIONS

There is a positive relation between sEGF levels and gestational age. Patterns of sEGF levels over the first 2 weeks of life were significantly related to development of NEC in very low birth weight infants.

Acute kidney injury after gastric bypass surgery

Gastric bypass surgery is a common treatment for morbid obesity. The presence of comorbid conditions and drugs that are used to treat them can adversely influence kidney function. Risk factors and outcomes of acute kidney injury (AKI) after gastric bypass surgery are not well understood, however. A total of 504 patients underwent gastric bypass between January 2003 and 2005. Primary outcome was AKI, defined as a > or =50% increase in serum creatinine relative to baseline or requirement of dialysis. Secondary outcomes were duration of hospitalization, all-cause hospital mortality, and readmissions within 30 d after surgery. Demographic, comorbid, and laboratory variables and preoperative medication use were examined as potential risk factors for AKI. A total of 42 (8.5%) patients developed postoperative AKI. Hyperlipidemia, preoperative use of angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB), intraoperative hypotension, and higher body mass index were associated with increased frequency of AKI. By multivariable analyses, the independent risk factors for AKI were body mass index (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.00 to 1.06), hyperlipidemia (OR 2.53; 95% CI 1.21 to 5.28), and preoperative use of ACE-I or ARB (OR 2.06; 95% CI 1.05 to 4.04). The postoperative mortality was 0.45% (n = 2), both of whom had AKI. Duration of hospitalization was greater in patients with AKI versus no AKI (4.0 versus 2.7 d; P = 0.0003). Postoperative AKI is not infrequent after gastric bypass surgery. Certain comorbid conditions and their commonly prescribed treatments, ACE-I or ARB, are independently associated with increased risk for postoperative AKI.

Factors associated with a provider's recommendation of carotid endarterectomy: implications for understanding disparities in the use of invasive procedures

OBJECTIVE

This study assessed the relative importance of clinical and nonclinical factors in a provider's decision to recommend carotid endarterectomy (CEA) for a patient, with emphasis on the role of the patient's race in the provider's assessment of the risks and benefits of the procedure.

METHODS

The study was a secondary analysis of data on the use of CEA conducted in a patient sample of 355 white and black patients who were referred for evaluation for CEA and were adjudicated preoperatively as appropriate candidates for the procedure by objective criteria. The patients were from five VA medical centers nationally. The primary outcome was the provider's recommendation that the patient receive CEA. Patient factors included age, race, the degree of carotid artery stenosis, clinical status, trust in the provider, and aversion to surgery. Provider factors were assessment of the patient's risks and benefits from CEA, including perceived efficacy of the surgery, perceived risk of stroke < or =1 year without the surgery, and perceived risk of stroke < or =30 days from the surgery.

RESULTS

The primary factor associated with a provider's decision to recommend CEA was his or her assessment of the patient's risk of stroke without the surgery. The patient's race was not associated with the provider's assessments of the patient's risks or benefits from CEA.

CONCLUSION

A major determinant of a provider's recommendation for a patient to receive CEA endarterectomy is the assessment of the patient's likely future risk of stroke, regardless of the patient's race.

Modeling the effects of spirituality/religion on patients' perceptions of living with HIV/AIDS

BACKGROUND

Spirituality/religion is an important factor in health and illness, but more work is needed to determine its link to quality of life in patients with HIV/AIDS.

OBJECTIVE

To estimate the direct and indirect effects of spirituality/religion on patients' perceptions of living with HIV/AIDS.

DESIGN

In 2002 and 2003, as part of a multicenter longitudinal study of patients with HIV/AIDS, we collected extensive demographic, clinical, and behavioral data from chart review and patient interviews. We used logistic regression and path analysis combining logistic and ordinary least squares regression.

SUBJECTS

Four hundred and fifty outpatients with HIV/AIDS from 4 sites in 3 cities.

MEASURES

The dependent variable was whether patients felt that life had improved since being diagnosed with HIV/AIDS. Spirituality/religion was assessed by using the Duke Religion Index, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being-Expanded, and Brief RCOPE measures. Mediating factors included social support, self-esteem, healthy beliefs, and health status/health concerns.

RESULTS

Approximately one-third of the patients felt that their life was better now than it was before being diagnosed with HIV/AIDS. A 1-SD increase in spirituality/religion was associated with a 68.50% increase in odds of feeling that life has improved--29.97% due to a direct effect, and 38.54% due to indirect effects through healthy beliefs (29.15%) and health status/health concerns (9.39%). Healthy beliefs had the largest effect on feeling that life had improved; a 1-SD increase in healthy beliefs resulted in a 109.75% improvement in feeling that life changed.

CONCLUSIONS

In patients with HIV/AIDS, the level of spirituality/religion is associated, both directly and indirectly, with feeling that life is better now than previously. Future research should validate our new conceptual model using other samples and longitudinal studies. Clinical education interventions should focus on raising awareness among clinicians about the importance of spirituality/religion in HIV/AIDS.

Changes in religiousness and spirituality attributed to HIV/AIDS: are there sex and race differences?

BACKGROUND/OBJECTIVE

Having a serious illness such as HIV/AIDS raises existential issues, which are potentially manifested as changes in religiousness and spirituality. The objective of this study was (1) to describe changes in religiousness and spirituality of people with HIV/AIDS, and (2) to determine if these changes differed by sex and race.

METHODS

Three-hundred and forty-seven adults with HIV/AIDS from 4 sites were asked demographic, clinical, and religious/spiritual questions. Six religious/spiritual questions assessed personal and social domains of religiousness and spirituality.

RESULTS

Eighty-eight participants (25%) reported being "more religious" and 142 (41%) reported being "more spiritual" since being diagnosed with HIV/AIDS. Approximately 1 in 4 participants also reported that they felt more alienated by a religious group since their HIV/AIDS diagnosis and approximately 1 in 10 reported changing their place of religious worship because of HIV/AIDS. A total of 174 participants (50%) believed that their religiousness/spirituality helped them live longer. Fewer Caucasians than African Americans reported becoming more spiritual since their HIV/AIDS diagnosis (37% vs 52%, respectively; P<.015), more Caucasians than African Americans felt alienated from religious communities (44% vs 21%, respectively; P<.001), and fewer Caucasians than African Americans believed that their religiousness/spirituality helped them live longer (41% vs 68% respectively; P<.001). There were no significantly different reported changes in religious and spiritual experiences by sex.

CONCLUSIONS

Many participants report having become more spiritual or religious since contracting HIV/AIDS, though many have felt alienated by a religious group-some to the point of changing their place of worship. Clinicians conducting spiritual assessments should be aware that changes in religious and spiritual experiences attributed to HIV/AIDS might differ between Caucasian and African Americans.

Spirituality and religion in patients with HIV/AIDS

BACKGROUND

Spirituality and religion are often central issues for patients dealing with chronic illness. The purpose of this study is to characterize spirituality/religion in a large and diverse sample of patients with HIV/AIDS by using several measures of spirituality/religion, to examine associations between spirituality/religion and a number of demographic, clinical, and psychosocial variables, and to assess changes in levels of spirituality over 12 to 18 months.

METHODS

We interviewed 450 patients from 4 clinical sites. Spirituality/religion was assessed by using 8 measures: the Functional Assessment of Chronic Illness Therapy-Spirituality-Expanded scale (meaning/peace, faith, and overall spirituality); the Duke Religion Index (organized and nonorganized religious activities, and intrinsic religiosity); and the Brief RCOPE scale (positive and negative religious coping). Covariates included demographics and clinical characteristics, HIV symptoms, health status, social support, self-esteem, optimism, and depressive symptoms.

RESULTS

The patients' mean (SD) age was 43.3 (8.4) years; 387 (86%) were male; 246 (55%) were minorities; and 358 (80%) indicated a specific religious preference. Ninety-five (23%) participants attended religious services weekly, and 143 (32%) engaged in prayer or meditation at least daily. Three hundred thirty-nine (75%) patients said that their illness had strengthened their faith at least a little, and patients used positive religious coping strategies (e.g., sought God's love and care) more often than negative ones (e.g., wondered whether God has abandoned me; P<.0001). In 8 multivariable models, factors associated with most facets of spirituality/religion included ethnic and racial minority status, greater optimism, less alcohol use, having a religion, greater self-esteem, greater life satisfaction, and lower overall functioning (R2=.16 to .74). Mean levels of spirituality did not change significantly over 12 to 18 months.

CONCLUSIONS

Most patients with HIV/AIDS belonged to an organized religion and use their religion to cope with their illness. Patients with greater optimism, greater self-esteem, greater life satisfaction, minorities, and patients who drink less alcohol tend to be both more spiritual and religious. Spirituality levels remain stable over 12 to 18 months.

Patterns of responses on health-related quality of life questionnaires among patients with HIV/AIDS

BACKGROUND

Health-related quality of life (HRQoL) has become an important facet of HIV/AIDS research. Typically, the unit of analysis is either the total instrument score or subscale score. Developing a typology of responses across various HRQoL measures, however, may advance understating of patients' perspectives.

METHODS

In a multicenter study, we categorized 443 patients' responses on utility measures (time-tradeoff, standard gamble, and rating scale) and the HIV/AIDS-Targeted Quality of Life (HAT-QoL) scale by using latent profile analysis to empirically derive classes of respondents. We then used linear regressions to identify whether class membership is associated with clinical measures (viral load, CD4, time since diagnosis, highly active antiretroviral therapy [HAART]) and psychosocial function (depressed mood, alcohol use, religious coping).

RESULTS

Six classes were identified. Responses across the HAT-QoL subscales tended to fall into 3 groupings--high functioning (Class 1), moderate functioning (Classes 2 and 3), and low functioning (Classes 4 to 6); utility measures further distinguished individuals among classes. Regression analyses comparing those in Class 1 with those in the other 5 found significantly more symptoms of depression, negative religious coping strategies, and lower CD4 counts among subjects in Class 1. Those in Class 5 had been diagnosed with HIV longer, and members of Class 6 reported significantly less alcohol consumption, had higher viral loads, and were more likely to receive HAART.

CONCLUSION

Patients with HIV respond differentially to various types of HRQoL measures. Health status and utility measures are thus complementary approaches to measuring HRQoL in patients with HIV.

Health-related quality of life in veterans and nonveterans with HIV/AIDS

PURPOSE

To compare health-related quality of life (HRQoL) between patients receiving care in Veterans Administration (VA) settings (veterans) and non-VA settings (nonveterans), and to explore determinants of HRQoL and change in HRQoL over time in subjects living with HIV/AIDS.

SUBJECTS

One hundred veterans and 350 nonveterans with HIV/AIDS from 2 VA and 2 university-based sites in 3 cities interviewed in 2002 to 2003 and again 12 to 18 months later.

METHODS

We assessed health status (functional status and symptom bother), health ratings, and health values (time tradeoff [TTO] and standard gamble [SG] utilities). We also explored bivariate and multivariable associations of HRQoL measures with a number of demographic, clinical, spiritual/religious, and psychosocial characteristics.

RESULTS

Compared with nonveterans, the veteran population was older (47.7 vs 42.0 years) and consisted of a higher proportion of males (97% vs 83%), of participants with a history of injection drug use (23% vs 15%), and of subjects with unstable housing situations (14% vs 6%; P<.05 for all comparisons). On scales ranging from 0 (worst) to 100 (best), veterans reported significantly poorer overall function (mean [SD]; 65.9 [17.2] vs 71.9 [16.8]); lower rating scale scores (67.6 [21.7] vs 73.5 [21.0]), lower TTO values (75.7 [37.4] vs 89.0 [23.2]), and lower SG values (75.0 [35.8] vs 83.2 [28.3]) than nonveterans (P<.05 for all comparisons); however, in multivariable models, veteran status was only a significant determinant of SG and TTO values at baseline. Among other determinants that were associated with multiple HRQoL outcomes in baseline and follow-up multivariable analyses were: symptom bother, overall function, religiosity/spirituality, depressive symptoms, and financial worries.

CONCLUSIONS

Veterans reported significantly poorer HRQoL than nonveterans, but when controlling for other factors, veteran status was only a significant determinant of TTO and SG health values at baseline. Correlates of HRQoL such as symptom bother, spirituality/religiosity, and depressive symptoms could be fruitful potential targets for interventions to improve HRQoL in patients with HIV/AIDS.

Health values of patients coinfected with HIV/hepatitis C: are two viruses worse than one?

OBJECTIVES

We sought to assess health values of patients coinfected with HIV/hepatitis C (HCV) and compare them with those of patients singly infected with HIV or HCV and to characterize and assess the relationship of clinical and nonhealth-related factors with health values.

SUBJECTS

We studied a total of 203 subjects infected with HIV, HCV, or both.

MEASURES

We assessed rating scale (RS), time tradeoff (TTO), and standard gamble (SG) values, and we explored associations of health values with the Mental Component Summary (MCS) and Physical Component Summary (PCS) of the SF-12; number of bothersome symptoms from the HIV Symptoms Index; spirituality, as assessed by the Functional Assessment of Chronic Illness Therapy, Spiritual Well-being scale; as well as with a number of demographic, clinical, and psychosocial characteristics.

RESULTS

Of the 203 subjects, 59 (29%) had HIV monoinfection, 69 (34%) had HCV monoinfection, and 75 (37%) were coinfected. The mean (SD) health values for the cohort were: RS = 0.69 (0.23), TTO= 0.88 (0.24), and SG = 0.78 (0.30). Infection type was related, albeit differently, to TTO values (mean values for patients with coinfection = 0.82; HIV = 0.91; and HCV = 0.91 [P < 0.05]) and SG values (coinfection = 0.77; HIV = 0.70; and HCV = 0.87; P < 0.05). In multivariable models, RS scores were significantly associated with sexual orientation, PCS scores, MCS scores, symptoms, and spirituality (adjusted R = 0.61); TTO with symptoms and spirituality (adjusted R = 0.23); and SG with infection type, PCS scores, and symptoms (adjusted R = 0.24).

CONCLUSIONS

Health values and their correlates varied by method of assessment. Health values appear to be driven more by symptoms, health status, and spirituality than by number of viral infections.

Mentorship in academic general internal medicine. Results of a survey of mentors

BACKGROUND

Effective mentorship is crucial to career development. Strategies to improve the availability of mentors include mentoring multiple mentees at once, compensating mentors, comentoring, and long-distance mentoring.

OBJECTIVE

To describe current trends in mentorship in general Internal Medicine (GIM).

METHODS

We conducted a national cross-sectional web-based survey of GIM mentors, GIM fellowship directors, and GIM National Institutes of Health K24 grant awardees to capture their experiences with mentoring, including compensation for mentorship, multiple mentees, comentorship, and long-distance mentorship. We compared experiences by mentorship funding status, faculty type, academic rank, and sex.

RESULTS

We collected data from 111 mentors (77% male, 54% full professors, and 68% clinician-investigators). Fifty-two (47%) received funding for mentorship. Mentors supervised a median (25th percentile, 75th percentile) of 5 (3, 8) mentees each, and would be willing to supervise a maximum of 6 (4, 10) mentees at once. Compared with mentors without funding, mentors with funding had more current mentees (mean of 8.3 vs 5.1, respectively; P<.001). Full professors had more current mentees than associate or assistant professors (8.0 vs 5.9 vs 2.4, respectively; P=.005). Ninety-four (85%) mentors had experience comentoring, and two-thirds of mentors had experience mentoring from a distance. Although most mentors found long-distance mentoring to be less demanding, most also said it is less effective for the mentee and is personally less fulfilling.

CONCLUSIONS

Mentors in GIM appear to be close to their mentorship capacity, and the majority lack funding for mentorship. Comentoring and long-distance mentoring are common.