Faculty Bibliography

Purpose To analyze the cost effectiveness of the American Society for Gastrointestinal Endoscopy (ASGE) risk stratification guidelines versus magnetic resonance (MR) cholangiopancreatography-based treatment of patients with possible choledocholithiasis. Materials and Methods A decision-analytic model was constructed to compare cost and effectiveness of three diagnostic strategies for gallstone disease with possible choledocholithiasis: noncontrast MR cholangiopancreatography, contrast material-enhanced MR imaging/MR cholangiopancreatography, and ASGE risk stratification guidelines for diagnostic evaluation recommending endoscopy (high risk), MR cholangiopancreatography (intermediate risk), or no test (low risk). Analysis was performed from a U.S. health system perspective over 1-year and lifetime horizons. The model accounted for benign and malignant causes of biliary obstruction and procedural complications. Cost information was based on Medicare reimbursements. Sensitivity analysis assessed the impact of parameter variability on model results. Results Noncontrast MR cholangiopancreatography was most cost-effective in 45-55-year-old patients (less than $100 000 per quality-adjusted life-year [QALY] gained), while contrast-enhanced MR imaging was favored in younger adults. Risk-stratified testing was less costly than MR cholangiopancreatography, with long-term savings of $1870 and $2068 versus noncontrast and contrast-enhanced MR cholangiopancreatography, respectively, but was also less effective (-0.1814, -0.1831 QALY, respectively). The lifetime incremental cost per QALY for noncontrast MR cholangiopancreatography was $10 311. Contrast-enhanced MR imaging was favored with pretest probabilities of biliary stricture or malignancy 0%-73% for patients aged 20-44 years. For patients older than 55 years, ASGE guidelines maximized QALYs at the lowest cost. Conclusion Although adults older than 55 years of age are optimally evaluated by using ASGE guidelines, younger patients suspected of having acute biliary obstruction likely benefit from MR cholangiopancreatography rather than risk-stratified diagnostic imaging because of improved detection of choledocholithiasis and alternative causes of biliary obstruction. (c) RSNA, 2017 Online supplemental material is available for this article.

BACKGROUND:Optimism and cynical hostility independently predict morbidity and mortality in Women's Health Initiative (WHI) participants and are associated with current smoking. However, their association with smoking cessation in older women is unknown. PURPOSE/OBJECTIVE:The purpose of this study is to test whether optimism (positive future expectations) or cynical hostility (mistrust of others) predicts smoking cessation in older women. METHODS:Self-reported smoking status was assessed at years 1, 3, and 6 after study entry for WHI baseline smokers who were not missing optimism or cynical hostility scores (n = 10,242). Questionnaires at study entry assessed optimism (Life Orientation Test-Revised) and cynical hostility (Cook-Medley, cynical hostility subscale). Generalized linear mixed models adjusted for sociodemographics, lifestyle factors, and medical and psychosocial characteristics including depressive symptoms. RESULTS:After full covariate adjustment, optimism was not related to smoking cessation. Each 1-point increase in baseline cynical hostility score was associated with 5% lower odds of cessation over 6 years (OR = 0.95, CI = 0.92-0.98, p = 0.0017). CONCLUSIONS:In aging postmenopausal women, greater cynical hostility predicts lower smoking cessation over time. Future studies should examine whether individuals with this trait may benefit from more intensive cessation resources or whether attempting to mitigate cynical hostility itself may aid smoking cessation.

Hearing loss is remarkably prevalent in the geriatric population: one-quarter of adults aged 60-69 and 80% of adults aged 80 years and older have bilateral disabling loss. Only about one in five adults with hearing loss wears a hearing aid, leaving many vulnerable to poor communication with healthcare providers. We quantified the extent to which hearing loss is mentioned in studies of physician-patient communication with older patients, and the degree to which hearing loss is incorporated into analyses and findings. We conducted a structured literature search within PubMed for original studies of physician-patient communication with older patients that were published since 2000, using the natural language phrase "older patient physician communication." We identified 409 papers in the initial search, and included 67 in this systematic review. Of the 67 papers, only 16 studies (23.9%) included any mention of hearing loss. In six of the 16 studies, hearing loss was mentioned only; in four studies, hearing loss was used as an exclusion criterion; and in two studies, the extent of hearing loss was measured and reported for the sample, with no further analysis. Three studies examined or reported on an association between hearing loss and the quality of physician-patient communication. One study included an intervention to temporarily mitigate hearing loss to improve communication. Less than one-quarter of studies of physician-elderly patient communication even mention that hearing loss may affect communication. Methodologically, this means that many studies may have omitted an important potential confounder. Perhaps more importantly, research in this field has largely overlooked a highly prevalent, important, and remediable influence on the quality of communication.

Contrary to the "model minority" myth, Asian American children, especially those from low-income immigrant families, are at risk for both behavioral and emotional problems early in life. Little is known, however, about the underlying developmental mechanisms placing Asian American children at risk, including the role of cultural adaptation and parenting. This study examined cultural adaptation, parenting practices and culture related parenting values and child mental health in a sample of 157 English speaking Asian American immigrant families of children enrolled in early childhood education programs in low-income, urban neighborhoods. Overall, cultural adaptation and parenting cultural values and behaviors were related to aspects of child mental health in meaningful ways. Parents' cultural value of independence appears to be especially salient (e.g., negatively related to behavior problems and positively related to adaptive behavior) and significantly mediates the link between cultural adaptation and adaptive behavior. Study findings have implications for supporting Asian American immigrant families to promote their young children's mental health.

Despite the high costs of treatment of people with kidney disease and associated comorbid conditions, the amount of reliable information available to guide the care of such patients is very limited. Some treatments have been assessed in randomized trials, but most such trials have been too small to detect treatment effects of a magnitude that would be realistic to achieve with a single intervention. Therefore, KDIGO convened an international, multidisciplinary controversies conference titled "Challenges in the Conduct of Clinical Trials in Nephrology" to identify the key barriers to conducting trials in patients with kidney disease. The conference began with plenary talks focusing on the key areas of discussion that included appropriate trial design (covering identification and evaluation of kidney and nonkidney disease outcomes) and sensible trial execution (with particular emphasis on streamlining both design and conduct). Break out group discussions followed in which the key areas of agreement and remaining controversy were identified. Here we summarize the main findings from the conference and set out a range of potential solutions. If followed, these solutions could ensure future trials among people with kidney disease are sufficiently robust to provide reliable answers and are not constrained by inappropriate complexities in design or conduct.

BACKGROUND: According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs. PURPOSE: The aims of this systematic review and meta-analysis were to (1) synthesize the findings of studies addressing cancer care coordination, (2) describe study outcomes across the cancer continuum, and (3) obtain a quantitative estimate of the effect of interventions in cancer care coordination on service system processes and patient health outcomes. METHODS: Of 1241 abstracts identified through MEDLINE, EMBASE, CINAHL, and the Cochrane Library, 52 studies met the inclusion criteria. Each study had US or Canadian participants, comparison or control groups, measures, times, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and online coding program to each study. Eleven studies met the additional criteria for the meta-analysis; a random effects estimation model was used for data analysis. RESULTS: Cancer care coordination approaches led to improvements in 81 % of outcomes, including screening, measures of patient experience with care, and quality of end-of-life care. Across the continuum of cancer care, patient navigation was the most frequent care coordination intervention, followed by home telehealth; nurse case management was third in frequency. The meta-analysis of a subset of the reviewed studies showed that the odds of appropriate health care utilization in cancer care coordination interventions were almost twice (OR = 1.9, 95 % CI = 1.5-3.5) that of comparison interventions. CONCLUSIONS: This review offers promising findings on the impact of cancer care coordination on increasing value and reducing healthcare costs in the USA.

This paper is the first in a planned series of papers studying the effectiveness of psychotherapy and counselling in Nairobi. It describes a method for checking the effectiveness of psychotherapy and improving service quality in a Kenyan context. Rather than prematurely imposing psychotherapy protocols developed in Western countries in another cultural context, we believe that first studying psychological interventions as they are practised may generate understanding of which psychological problems are common, what interventions therapists use, and what seems to be effective in reducing psychiatric problems. The initial step is to assess outcome of psychological treatments as they are conducted. This is followed by statistical analyses aimed at identifying patient groups who are not improving at acceptable rates. Therapists will then be trained in a 'best practice' approach, and controlled trials are used in a final step, testing new interventions specifically targeted at patient groups with sub-optimal outcomes.

This study assesses individual- and area-level predictors of racial/ethnic disparities in mental health care episodes for adults with psychiatric illness. Multilevel regression models are estimated using data from the Medical Expenditure Panel Surveys linked to area-level data sets. Compared with Whites, Blacks and Latinos live in neighborhoods with higher minority density, lower average education, and greater specialist mental health provider density, all of which predict lesser mental health care initiation. Neighborhood-level variables do not have differential effects on mental health care by race/ethnicity. Racial/ethnic disparities arise because minorities are more likely to live in neighborhoods where treatment initiation is low, rather than because of a differential influence of neighborhood disadvantage on treatment initiation for minorities compared with Whites. Low rates of initiation in neighborhoods with a high density of specialists suggest that interventions to increase mental health care specialists, without a focus on treating racial/ethnic minorities, may not reduce access disparities.

BACKGROUND: There is a pressing workforce shortage and leadership scarcity in palliative care to adequately meet the demands of individuals with serious illness and their families. To address this gap, the Cambia Health Foundation launched its Sojourns Scholars Leadership Program in 2014, an initiative designed to identify, cultivate, and advance the next generation of palliative care leaders. This report intends to summarize the second cohort of Sojourns Scholars' projects and their reflection on their leadership needs. OBJECTIVE: This report summarizes the second cohort of sojourns scholars' project and their reflection on leadership needs. METHODS: After providing a written reflection on their own projects, the second cohort participated in a group interview (fireside chat) to elicit their perspectives on barriers and facilitators in providing palliative care, issues facing leadership in palliative care in the United States, and lessons from personal and professional growth as leaders in palliative care. They analyzed the transcript of the group interview using qualitative content analysis methodology. RESULTS: Three themes emerged from descriptions of the scholars' project experience: challenges in palliative care practice, leadership strategies in palliative care, and three lessons learned to be a leader were identified. Challenges included perceptions of palliative care, payment and policy, and workforce development. Educating and collaborating with other clinicians and influencing policy change are important strategies used to advance palliative care. Time management, leading team effort, and inspiring others are important skills that promote effectiveness as a leader. DISCUSSION: Emerging leaders have a unique view of conceptualizing contemporary palliative care and shaping the future. CONCLUSIONS: Providing comprehensive, coordinated care that is high quality, patient and family centered, and readily available depends on strong leadership in palliative care. The Cambia Scholars Program represents a unique opportunity.