Faculty Bibliography

INTRODUCTION: Little is known about the pattern of electronic cigarette (e-cigarette) use over time or among smokers with medical comorbidity. METHODS: We assessed current cigarette smokers' use of e-cigarettes during the 30 days before admission to 9 hospitals in 5 geographically dispersed US cities: Birmingham, AL; Boston, MA; Kansas City, KS; New York, NY; and Portland, OR. Each hospital was conducting a randomized controlled trial as part of the NIH-sponsored Consortium of Hospitals Advancing Research on Tobacco (CHART). We conducted a pooled analysis using multiple logistic regression to examine changes in e-cigarette use over time and to identify correlates of e-cigarette use. RESULTS: Among 4,660 smokers hospitalized between July 2010 and December 2013 (mean age 57 years, 57% male, 71% white, 56% some college, average 14 cigarettes/day), 14% reported using an e-cigarette during the 30 days before admission. The prevalence of e-cigarette use increased from 1.1% in 2010 to 10.3% in 2011, 10.2% in 2012, and 18.4% in 2013; the increase was statistically significant (p < .0001) after adjustment for age, sex, education, and CHART study. Younger, better educated, and heavier smokers were more likely to use e-cigarettes. Smokers who were Hispanic, non-Hispanic black, and who had Medicaid or no insurance were less likely to use e-cigarettes. E-cigarette use also varied by CHART project and by geographic region. CONCLUSIONS: E-cigarette use increased substantially from 2010 to 2013 among a large sample of hospitalized adult cigarette smokers. E-cigarette use was more common among heavier smokers and among those who were younger, white, and who had higher socioeconomic status.

BACKGROUND: The American College of Emergency Physicians and the American Society of Clinical Oncology recommend early palliative care consultation for patients with advanced, life-limiting illnesses, such as metastatic cancer. OBJECTIVES: The objectives were to assess the process of early referral from the emergency department (ED) to palliative care for patients with advanced, incurable cancer as part of a randomized controlled trial and to compare the proportion and timing of consultation to a care as usual group. METHODS: A single-blind randomized controlled trial (ClinicalTrials.gov ID NCT01358110) compared early, ED-based referrals to palliative care for patients admitted with advanced, incurable cancer to physician-driven consultation (i.e., care as usual). Participants had to speak English or Spanish and have no history of palliative care consultation. They were randomized via balanced block randomization to the intervention or control group. Each intervention subject was referred by a research staff member to the palliative care team for consultation. The usual care group received palliative care only if requested by the admitting physician. Analysis was based on intention to treat. A chart review was performed to assess proportion and timing of palliative care consults during the index admission, defined as: 1) completed palliative care consult documented in the chart and 2) days from admission to palliative care consult. RESULTS: A total of 134 participants were enrolled and randomized. For patients in the intervention group, 88% (60 of 68) had documented palliative care consultations during their index admissions (95% confidence interval [CI] = 80.5 to 95.5), compared to 18% (12 of 66) in the control group (95% CI = 8.8 to 27.5; p < 0.01). The 60 intervention patients received palliative care consultations on average 1.48 days from admission (95% CI = 1.19 to 1.76), compared to 2.9 days from admission in the 12 control patients (95% CI = 1.03 to 4.79; p = 0.15). CONCLUSIONS: This study documented a low baseline rate of palliative care involvement as part of usual care in patients with advanced cancer being admitted from the ED. Early referral to palliative care in the context of a research study significantly increased the likelihood that patients received a consult, thus meriting further investigation of how to generalize this approach.

BACKGROUND: Mortality rates after aortic valve replacement have declined, but little is known about the risk of hospitalization among survivors and how that has changed with time. METHODS: Among Medicare patients who underwent aortic valve replacement from 1999 to 2010 and survived to 1 year, we assessed trends in 1-year hospitalization rates, mean cumulative length of stay (average number of hospitalization days per patient in the entire year), and adjusted annual Medicare payments per patient toward hospitalizations. We characterized hospitalizations by principal diagnosis and mean length of stay. RESULTS: Among 1-year survivors of aortic valve replacement, 43% of patients were hospitalized within that year, of whom 44.5% were hospitalized within 30 days (19.2% for overall cohort). Hospitalization rates were higher for older (50.3% for >85 years), female (45.1%), and black (48.9%) patients. One-year hospitalization rate decreased from 44.2% (95% confidence interval, 43.5 to 44.8) in 1999 to 40.9% (95% confidence interval, 40.3 to 41.4) in 2010. Mean cumulative length of stay decreased from 4.8 days to 4.0 days (p < 0.05 for trend); annual Medicare payments per patient were unchanged ($5,709 to $5,737; p = 0.32 for trend). The three most common principal diagnoses in hospitalizations were heart failure (12.7%), arrhythmia (7.9%), and postoperative complications (4.4%). Mean length of stay declined from 6.0 days to 5.3 days (p < 0.05 for trend). CONCLUSIONS: Among Medicare beneficiaries who survived 1 year after aortic valve replacement, 3 in 5 remained free of hospitalization; however, certain subgroups had higher rates of hospitalization. After the 30-day period, the hospitalization rate was similar to that of the general Medicare population. Hospitalization rates and cumulative days spent in hospital decreased with time.

BACKGROUND: Active surveillance (AS) is an important yet underutilized strategy to reduce prostate cancer (PCa) overtreatment. OBJECTIVE: To examine the 5-yr outcomes of AS in a population-based setting. DESIGN, SETTING, AND PARTICIPANTS: From the National Prostate Cancer Register of Sweden, we identified 11 726 men