Faculty Bibliography

OBJECTIVES: We examined tobacco use screening and treatment by US psychiatrists before and after release of the 1996 American Psychiatric Association (APA) nicotine dependence treatment guidelines. METHODS: We used data from the National Ambulatory Medical Care Survey to identify rates of tobacco screening and treatment by psychiatrists before the release of the guidelines (1993-1996) and during 2 postguidelines periods: 2001-2005 and 2006-2010. Multiple logistic regression was used to compare preguidelines and postguidelines rates. RESULTS: Psychiatrists screened for tobacco use during 77% of visits from 1993 to 1996, 69% of visits from 2001 to 2005 (odds ratio [OR] = 0.69; 95% confidence interval [CI] = 0.64, 0.75), and 60% of visits from 2006 to 2010 (OR = 0.46; 95% CI = 0.43, 0.50). Psychiatrists provided cessation counseling to 12% of smokers from 1993 to 1996, 11% from 2001 to 2005 (OR = 0.97; 95% CI = 0.74, 1.26), and 23% from 2006 to 2010 (OR = 2.23; 95% CI = 1.74, 2.86). Psychiatrists prescribed nicotine replacement therapy to fewer than 1% of smokers during all 3 time periods. CONCLUSIONS: Psychiatrists are screening for tobacco use at declining rates, and the proportion of smokers provided with treatment remains low.

BACKGROUND: Given that 4 million individuals in the United States have atrial fibrillation, understanding the epidemiology of this disease is crucial. We sought to identify and characterize the impact of age on national atrial fibrillation hospitalization patterns. METHODS: The study sample was drawn from the 2009-2010 Nationwide Inpatient Sample. Patients hospitalized with a principal International Classification of Diseases, 9th Revision discharge diagnosis of atrial fibrillation were included. Patients were categorized as "older" (>/=65 years) or "younger" (<65 years) for the purposes of analysis. The outcomes measured included hospitalization rate, length of stay, in-hospital mortality, and discharge status. RESULTS: We identified 192,846 atrial fibrillation hospitalizations. There was significant geographic variation in hospitalizations for both younger and older age groups. States with high hospitalizations differed from those states known to have high stroke mortality. Younger patients (33% of the sample) were more likely to be obese (21% vs 8%, P < .001) and to use alcohol (8% vs 2%, P < .001). Older patients were more likely to have kidney disease (14% vs 7%, P < .001). Both age groups had high rates of hypertension and diabetes. Older patients had higher in-hospital mortality and were more likely to be discharged to a nursing or intermediate care facility. CONCLUSIONS: Younger patients account for a substantial minority of atrial fibrillation hospitalizations in contemporary practice. Younger patients are healthier, with a different distribution of risk factors, than older patients who have higher associated morbidity and mortality.

BACKGROUND: Almost half of adult men in Viet Nam are current smokers, a smoking prevalence that is the second highest among South East Asian countries (SEAC). Although Viet Nam has a strong public health delivery system, according to the 2010 Global Adult Tobacco Survey, services to treat tobacco dependence are not readily available to smokers. The purpose of this study was to characterize current tobacco use treatment patterns among Vietnamese health care providers and factors influencing adherence to guideline recommended tobacco use screening and cessation interventions. METHODS: A cross sectional survey of 134 health care providers including physicians, nurses, midwives, physician assistants and pharmacists working in 23 community health centers in Viet Nam. RESULTS: 23% of providers reported screening patients for tobacco use, 33% offered advice to quit and less than 10% offered assistance to half or more of their patients in the past three months. Older age, attitudes, self-efficacy and normative beliefs were associated with screening for tobacco use. Normative beliefs were associated with offering advice to quit. However in the logistic regression analysis only normative beliefs remained significant for both screening and offering advice to quit. Over 90% of providers reported having never received training related to tobacco use treatment. Major barriers to treating tobacco use included lack of training, lack of referral resources and staff to support counseling, and lack of patient interest. CONCLUSIONS: Despite ratifying the FCTC, Viet Nam has not made progress in implementing policies and systems to ensure that smokers are receiving evidence-based treatment. This study suggests a need to change organizational norms through changes in national policies, training and local system-level changes that facilitate treatment.

BACKGROUND: Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on utilization of the electronic health record (EHR) was associated with patient-level outcomes. METHODS: We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed "EHR interactions." Hospitalizations were categorized based on the mean difference in EHR interactions between the first Friday and Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates. RESULTS: EHR interactions decreased from Friday to Saturday in 77% of the 9,051 hospitalizations included in the study. As compared to hospitalizations with no change in Friday to Saturday EHR interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in EHR interactions were 1.05 (95% CI 1.00-1.10), 1.11 (95% CI 1.05-1.17), and 1.25 (95% CI 1.15-1.35), respectively. Although a large decrease in EHR interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI 0.93-3.25). CONCLUSIONS: Intensity of inpatient care, measured by EHR interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity.

BACKGROUND: The extent of damage in New York City following Hurricane Sandy in October 2012 was unprecedented. Bellevue Hospital Center (BHC), a tertiary public hospital, was evacuated and temporarily closed as a result of hurricane-related damages. BHC's large primary care office-based buprenorphine clinic was relocated to an affiliate public hospital for three weeks. The extent of environmental damage and ensuing service disruption effects on rates of illicit drug, tobacco, and alcohol misuse, buprenorphine medication supply disruptions, or direct resource losses among office-based buprenorphine patients is to date unknown. METHODS: A quantitative and qualitative semi-structured survey was administered to patients in BHC's primary care buprenorphine program starting one month after the hurricane. Survey domains included: housing and employment disruptions; social and economic support; treatment outcomes (buprenorphine adherence and ability to get care), and tobacco, alcohol, and drug use. Open-ended questions probed general patient experiences related to the storm, coping strategies, and associated disruptions. RESULTS: There were 132 patients enrolled in the clinic at the time of the storm; of those, 91 patients were recruited to the survey, and 89 completed (98% of those invited). Illicit opioid misuse was rare, with 7 respondents reporting increased heroin or illicit prescription opioid use following Sandy. Roughly half of respondents reported disruption of their buprenorphine-naloxone medication supply post-event, and self-lowering of daily doses to prolong supply was common. Additional buprenorphine was obtained through unscheduled telephone or written refills from relocated Bellevue providers, informally from friends and family, and, more rarely, from drug dealers. CONCLUSIONS: The findings highlight the relative adaptability of public sector office-based buprenorphine treatment during and after a significant natural disaster. Only minimal increases in self-reported substance use were reported despite many disruptions to regular buprenorphine supplies and previous daily doses. Informal supplies of substitute buprenorphine from family and friends was common. Remote telephone refill support and a temporary back-up location that provided written prescription refills and medication dispensing for uninsured patients enabled some patients to maintain an adequate medication supply. Such adaptive strategies to ensure medication maintenance continuity pre/post natural disasters likely minimize poor treatment outcomes.

CONTEXT: Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. OBJECTIVE: To review primary data on PCa overdiagnosis and overtreatment. EVIDENCE ACQUISITION: Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. EVIDENCE SYNTHESIS: The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. CONCLUSIONS: Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. PATIENT SUMMARY: Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

PURPOSE: Patients with breast cancer who need adjuvant treatments often fail to receive them. High-quality, community-based patient-assistance programs are an underused, inexpensive resource to help patients with cancer obtain needed therapy. We sought to determine whether connecting women to patient-assistance programs would reduce underuse of adjuvant therapies. METHODS: We conducted a randomized trial of 374 women (190 assigned intervention [INT], 184 to usual care [UC]) with early-stage breast cancer who underwent surgery between October 2006 and August 2009. After initial needs assessment, individualized action plans were created to connect INT patients with targeted patient-assistance programs; UC patients received an informational pamphlet. Main outcome measures were receiving adjuvant treatment and obtaining help. RESULTS: High rates of INT and UC patients received treatment: 87% INT versus 91% UC women who underwent lumpectomy received radiotherapy (P = .39); 93% INT versus 86% UC women with estrogen receptor (ER) -negative tumors >/= 1 cm received chemotherapy (P = .42); 92% INT versus 93% UC women with ER-positive tumors >/= 1 cm received hormonal therapy (P = .80). Many women reported needs: 63% had informational; 55%, psychosocial; and 53%, practical needs. High rates of INT patients with needs connected with a program within 2 weeks (92%). At 6 months, INT and UC women used patient-assistance programs at similar rates (75% v 76%; P = .54). Women with informational or psychosocial needs were more likely to receive help (relative risk [RR], 1.77; 95% CI, 1.51 to 1.90 and RR, 1.37; 95% CI, 1.06 to 1.61, respectively). CONCLUSION: INT and UC patients received high rates of adjuvant treatment regardless of trial assignment. Patients with breast cancer who connect to relevant patient assistance programs receive useful informational and psychosocial but not practical help.

OBJECTIVES: The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes. BACKGROUND: Performance measures for heart failure target patients with a principal diagnosis of heart failure. However, patients with heart failure are commonly hospitalized for other causes and may benefit from treatments such as angiotensin-converting enzyme (ACE) inhibitors for left ventricular (LV) systolic dysfunction. METHODS: We assessed rates of compliance with care measures for patients hospitalized with acute or chronic heart failure in the ARIC (Atherosclerosis Risk In Communities) study surveillance catchment area from 2005 to 2009. Rates of compliance were compared between patients with a principal discharge diagnosis of heart failure and those with another principal discharge diagnosis. RESULTS: Of 4,345 hospitalizations of heart failure patients, 39.6% carried a principal diagnosis of heart failure. Patients with a principal heart failure diagnosis had higher rates of LV function assessment (89.1% vs. 82.5%; adjusted prevalence ratio [aPR]: 1.07; 95% confidence interval [CI]: 1.04 to 1.10) and discharge ACE inhibitor/angiotensin receptor blocker (ARB) in LV dysfunction (64.1% vs. 56.3%; aPR: 1.11; 95% CI: 1.03 to 1.20) as compared to patients hospitalized for another cause. LV assessment and ACE inhibitor/ARB use were associated with reductions in 1-year post-discharge mortality (adjusted odds ratio: 0.66, 95% CI: 0.51 to 0.85; adjusted odds ratio: 0.72, 95% CI: 0.54 to 0.96, respectively) that did not differ for patients with versus without a principal heart failure diagnosis. CONCLUSIONS: Compared with individuals hospitalized with a principal diagnosis of heart failure, heart failure patients hospitalized for other causes were less likely to receive guideline recommended care. Quality initiatives may improve care by targeting hospitalizations with either principal or secondary heart failure diagnoses.

BACKGROUND: Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening. METHODS: A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. RESULTS: Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11). CONCLUSIONS: Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis. Cancer 2014;120:96-102. (c) 2013 American Cancer Society.