Faculty Bibliography

CONTEXT: Measuring What Matters identified quality indicators to examine the percentage of patients with documentation of a surrogate decision maker and preferences for life-sustaining treatments. OBJECTIVES: To determine the rate of advance care planning in older adults presenting to the Emergency Department (ED) and translation into medical directives in the electronic medical record (EMR). METHODS: A convenience sample of adults 65 years old or older were recruited from a large, urban ED beginning in January 2012. We administered a baseline interview and survey in English or Spanish, including questions about whether patients had a documented health care proxy or living will. For patients admitted to the hospital who had a health care proxy or living will, chart abstraction was performed to determine whether their advance care preferences were documented in the EMR. RESULTS: From February 2012 to May 2013, 53.8% (367/682) of older adults who completed the survey in the ED reported having a health care proxy and 40.2% (274/682) had a living will. Of those admitted to the hospital, only 4% (4/94) of patients that said they had a living will had medical directives documented in the EMR. Similarly, only 4% (5/115) of patients who had a health care proxy had the person's name or contact information documented in their medical record. CONCLUSION: About half of patients 65 years of age or older arriving in the ED have done significant advance care planning, but the majority of plans are not recorded in the EMR.

OBJECTIVE: Risk stratification models support clinical decision making in acute myocardial infarction (AMI) care. Existing models were developed using data from younger populations, potentially limiting accuracy and relevance in older adults. We describe physician-perceived risk factors, views of existing models, and preferences for future model development in older adults. METHOD: Qualitative study using semi-structured telephone interviews and the constant comparative method. RESULTS: Twenty-two physicians from 14 institutions completed the interviews. Median age was 37, and median years of clinical experience was 11.5. Perceived predictors included cardiovascular, comorbid, functional, and social risk factors. Physicians viewed models as easy to use, yet neither inclusive of risk factors nor predictive of non-mortality outcomes germane to clinical decision making in older adults. Ideal models included multidimensional risk domains and operational requirements. DISCUSSION: Physicians reported limitations of available risk models when applied to older adults with AMI. New models are needed to guide AMI treatment in this population.

BACKGROUND: Epidemiological studies in humans that have evaluated the association between fine particulate matter (PM2.5) and atherosclerosis have yielded mixed results. DESIGN: In order to further investigate this relationship, we conducted a comprehensive search for studies published through May 2014 and performed a meta-analysis of all available observational studies that investigated the association between PM2.5 and three noninvasive measures of clinical and subclinical atherosclerosis: carotid intima media thickness, arterial calcification, and ankle-brachial index. METHODS AND RESULTS: Five reviewers selected studies based on predefined inclusion criteria. Pooled mean change estimates and 95% confidence intervals were calculated using random-effects models. Assessment of between-study heterogeneity was performed where the number of studies was adequate. Our pooled sample included 11,947 subjects for carotid intima media thickness estimates, 10,750 for arterial calcification estimates, and 6497 for ankle-brachial index estimates. Per 10 microg/m(3) increase in PM2.5 exposure, carotid intima media thickness increased by 22.52 microm but this did not reach statistical significance (p = 0.06). We did not find similar associations for arterial calcification (p = 0.44) or ankle-brachial index (p = 0.85). CONCLUSION: Our meta-analysis supports a relationship between PM2.5 and subclinical atherosclerosis measured by carotid intima media thickness. We did not find a similar relationship between PM2.5 and arterial calcification or ankle-brachial index, although the number of studies was small.

BACKGROUND: Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression. METHODS: We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting. RESULTS: We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices. CONCLUSION: Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.

BACKGROUND: Children referred to child welfare (CW) due to suspected maltreatment are vulnerable and need many services, particularly minority children. OBJECTIVE: To assess whether service use has improved over the past decade and whether racial-ethnic disparities in service use have decreased. METHODS: We used two national data sets (the National Survey of Child and Adolescent Well-Being I and II) collected a decade apart to assess changes over time in health, education, mental health (MH), dental services and overall service use. RESULTS: In NSCAW II, more children were young, had lower child behavior checklist (CBCL) scores, and were Hispanic. We found significant increases in dental services, a decrease in special education services and a decrease in MH services on the bivariate level (all p<.01). A large proportion of the change in MH services occurred in school settings, but the pattern continued when examining only those services delivered outside of school. The greatest decrease occurred for children with CBCL scores <64. However, in multivariate analyses, older children, white non-Hispanic children and children placed out of the home were significantly more likely to receive MH services. Rates of MH services controlling for CBCL scores showed no improvement over the decade, nor was there a decrease in racial and ethnic disparities CONCLUSION: These data show no change in MH services over time for children referred for CW evaluation, but improvement in dental services. Racial and ethnic disparities persist. MH services decrease occurred predominantly among children whose MH symptoms are below the clinical range.

Case-control designs are commonly employed in genetic association studies. In addition to the case-control status, data on secondary traits are often collected. Directly regressing secondary traits on genetic variants from a case-control sample often leads to biased estimation. Several statistical methods have been proposed to address this issue. The inverse probability weighting (IPW) approach and the semiparametric maximum-likelihood (SPML) approach are the most commonly used. A new weighted estimating equation (WEE) approach is proposed to provide unbiased estimation of genetic associations with secondary traits, by combining observed and counterfactual outcomes. Compared to the existing approaches, WEE is more robust against biased sampling and disease model misspecification. We conducted simulations to evaluate the performance of the WEE under various models and sampling schemes. The WEE demonstrated robustness in all scenarios investigated, had appropriate type I error, and was as powerful or more powerful than the IPW and SPML approaches. We applied the WEE to an asthma case-control study to estimate the associations between the thymic stromal lymphopoietin gene and two secondary traits: overweight status and serum IgE level. The WEE identified two SNPs associated with overweight in logistic regression, three SNPs associated with serum IgE levels in linear regression, and an additional four SNPs that were missed in linear regression to be associated with the 75th quantile of IgE in quantile regression. The WEE approach provides a general and robust secondary analysis framework, which complements the existing approaches and should serve as a valuable tool for identifying new associations with secondary traits.

IMPORTANCE: Androgen-deprivation therapy (ADT) through surgical castration is equally effective as medical castration in controlling prostate cancer (PCa). However, the adverse effect profiles of both ADT groups have never been compared. OBJECTIVE: To provide a comparative effectiveness analysis of the adverse effects of gonadotropin-releasing hormone agonists (GnRHa) vs bilateral orchiectomy in a homogeneous population. DESIGN, SETTING, AND PARTICIPANTS: A population-based cohort of 3295 men with metastatic PCa between January 1995 and December 2009 66 years or older was selected from the Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database. EXPOSURES: Orchiectomy or GnRHa. MAIN OUTCOMES AND MEASURES: Any fractures, peripheral arterial disease, venous thromboembolism, cardiac-related complications, diabetes mellitus, and cognitive disorders. To minimize treatment group biases, the inverse probability of treatment was weighted using the propensity score. Multivariable competing risk regression models were performed with the adjustment of all-cause mortality. Secondary analyses examined the effect of increasing duration of GnRHa treatment. Multivariable logistic regression models examined expenditures. RESULTS: Overall, 3295 men with a primary diagnosis of metastatic PCa treated with GnRHa or orchiectomy were identified between years 1995 and 2009, and in adjusted analyses, patients who received a bilateral orchiectomy had significantly lower risks of experiencing any fractures (hazard ratio [HR], 0.77; 95% CI, 0.62-0.94; P = .01), peripheral arterial disease (HR, 0.65; 95% CI, 0.49-0.87; P = .004), and cardiac-related complications (HR, 0.74; 0.58-0.94; P = .01) compared with those treated with GnRHa. No statistically significant difference was noted between orchiectomy and GnRHa for diabetes and cognitive disorders. In individuals treated with GnRHa for 35 months or more, the increased risk for GnRHa compared with orchiectomy was noted for fractures (HR, 1.80), peripheral arterial disease (HR, 2.25), venous thromboembolism (HR, 1.52), cardiac-related complications (HR, 1.69), and diabetes mellitus (HR, 1.88) (P