The Real-World Effect of Early Screening for Palliative Care Criteria in a Medical ICU: An Instrumental Variable Analysis.

RATIONALE: Early identification of ICU patients likely to benefit from specialist palliative care could reduce the time such patients spend in the ICU receiving care inconsistent with their goals. OBJECTIVE: To evaluate the real-world effects of early screening for palliative care criteria in a medical ICU. METHODS: We performed a retrospective cohort study in adults admitted to the ICU using a causal inference approach with instrumental variable analysis. The intervention consisted of screening ICU admissions for palliative care trigger conditions, and if present, offering specialist palliative care consultation which could be accepted/declined by the ICU. We evaluated specialist palliative care use in pre- and post-implementation cohorts from the year before/after screening implementation began (October 2022). In the post-implementation cohort, we compared use of specialist palliative care in those who received early screening versus not. We then estimated the effect of early screening on the primary outcome of days to do-not-resuscitate (DNR) code status or ICU discharge, with death without a DNR order placed at the 99th percentile of the days to DNR or ICU discharge distribution. Secondary outcomes included: DNR order, ICU/hospital lengths of stay, hospice discharge, and mortality metrics. To address unmeasured confounding, we used two-stage least-squares instrumental variables analysis. The instrument, which predicts early screening, comprised weekend vs. weekday admission and number of patients meeting palliative care criteria on a patient's ICU days 1 and 2. RESULTS: Amongst 1282 post-implementation admissions, 626 (45%) received early screening, and 398 (28%) received specialty palliative consultation. Early receipt of specialist palliative care was higher in patients who received early screening vs. not (17% vs 1% , p<0.001), and overall use of specialty palliative care was higher post- vs. pre-screening implementation (28 vs. 15%, p<0.001). In the post-implementation cohort, there were no statistically significant effects of early screening on the primary outcome of days to DNR or ICU discharge (15% relative increase, 95% CI [-11% to +48%]) or other secondary outcomes. CONCLUSIONS: Despite significantly increased specialty palliative care consultation there was no evidence that early screening for palliative care criteria affected time to DNR/ICU discharge or other secondary outcomes.

Outpatient Embedded Palliative Care for Patients with Advanced Thoracic Malignancy: A Retrospective Cohort Study.

Although cancer care is often contextualized in terms of survival, there are other important cancer care outcomes, such as quality of life and cost of care. The ASCO Value Framework assesses the value of cancer therapies not only in terms of survival but also with consideration of quality of life and financial cost. Early palliative care for patients with advanced cancer is associated with improved quality of life, mood, symptoms, and overall survival for patients, as well as cost savings. While palliative care has been shown to have numerous benefits, the impact of real-world implementation of outpatient embedded palliative care on value-based metrics is not fully understood. We sought to describe the association between outpatient embedded palliative care in a multidisciplinary thoracic oncology clinic and inpatient value-based metrics. We performed a retrospective cohort study of 215 patients being treated for advanced thoracic malignancies with non-curative intent. We evaluated the association between outpatient embedded palliative care and inpatient clinical outcomes including emergency room visits, hospitalizations, intensive care unit admissions, hospital charges, as well as hospital quality metrics including 30-day readmissions, admissions within 30 days of death, inpatient mortality, and inpatient hospital charges. Outpatient embedded palliative care was associated with lower hospital charges per day (USD 3807 vs. USD 4695, p = 0.024). Furthermore, patients who received outpatient embedded palliative care had lower hospital admissions within 30 days of death (O.R. 0.45; 95% CI 0.29, 0.68; p < 0.001) and a lower inpatient mortality rate (IRR 0.67; 95% CI 0.48, 0.95; p = 0.024). Our study further supports that outpatient palliative care is a high-value intervention and alternative models of palliative care, including one embedded into a multidisciplinary thoracic oncology clinic, is associated with improved value-based metrics.

Coping strategies and anxiety in young breast cancer survivors.

PURPOSE: We sought to describe coping strategies reported by young breast cancer survivors and evaluate the relationship between utilization of specific coping strategies and anxiety in survivorship. METHODS: Participants enrolled in The Young Women's Breast Cancer Study, a multi-center, cohort of women diagnosed with breast cancer at age ≤ 40 years, completed surveys that assessed demographics, coping strategies (reported at 6-month post-enrollment and 18-month post-diagnosis), and anxiety (2 years post-diagnosis). We used univariable and multivariable logistic regression to examine the relationship between coping strategies and anxiety. RESULTS: A total of 833 women with stage 0-3 breast cancer were included in the analysis; median age at diagnosis was 37 (range: 17-40) years. Social supports were the most commonly reported coping strategies, with the majority reporting moderate or greater use of emotional support from a partner (90%), parents (78%), other family (79%), and reliance on friends (88%) at both 6 and 18 months. In multivariable analyses, those with moderate or greater reliance on emotional support from other family (odds ratio (OR): 0.37, 95% confidence ratio (CI): 0.22-0.63) at 18 months were less likely to have anxiety at 2 years, while those with moderate or greater reliance on alcohol/drug use (OR: 1.83, 95%CI: 1.12-3.00) and taking care of others (OR: 1.90, 95%CI: 1.04-3.45) to cope were more likely to have anxiety. CONCLUSION: Young breast cancer survivors rely heavily on support from family and friends. Our findings underscore the importance of considering patients' social networks when developing interventions targeting coping in survivorship. CLINICAL TRIAL REGISTRATION NUMBER: NCT01468246 (first posted November 9, 2011).

Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India.

BACKGROUND: Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality. METHODS: Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality. FINDINGS: Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality. INTERPRETATION: Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex. FUNDING: Bill & Melinda Gates Foundation. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Integration of the Opportunity-Ability-Motivation behavior change framework into a coaching-based WHO Safe Childbirth Checklist program in India.

OBJECTIVE: To evaluate whether integration of the Opportunity-Ability-Motivation plus Supplies (OAMS) framework into coaching improved the delivery of essential birth practices in a low-resource setting. METHODS: This prospective mixed-methods study used routine coaching visit data obtained from the first eight intervention facilities of the BetterBirth trial in Uttar Pradesh, India, between December 19, 2014, and October 21, 2015. The 8-month intervention was peer coaching that integrated the OAMS framework to support uptake of the WHO Safe Childbirth Checklist. Descriptive statistics were used to measure nonadherence to essential birth practices. The frequency and accuracy of coaches' coding of barriers and the appropriateness of chosen resolution strategies to measure feasibility, acceptability, and fidelity of using OAMS, were assessed. RESULTS: Coaches observed 666 deliveries, including 12 602 practices. Overall, essential practice nonadherence decreased from 15.6% (262/1675 practices observed) to 4.5% (4/88 practices) (P<0.001). Of the 1048 barriers identified, opportunity (556 [53.1%]) and motivation (287 [27.4%]) were the most frequently reported categories; the frequency of both decreased over time (P=0.003 and P<0.001, respectively). The coaches appropriately categorized 930 (99.8%) of 932 barriers and provided an appropriate strategy for 800 (85.8%). The commonest reason for unaddressed barriers was lack of coaching opportunities. CONCLUSION: Successful integration of OAMS framework into delivery attendant coaching enabled coaches to rapidly diagnose barriers to practice adherence and develop responsive strategies. CLINICALTRIALS.GOV: NCT2148952 (WHO Universal Trial Number: U11111-1315-647).

A Randomized Multicenter Phase II Study of Docosahexaenoic Acid in Patients with a History of Breast Cancer, Premalignant Lesions, or Benign Breast Disease.

Obesity, a cause of subclinical inflammation, is a risk factor for the development of postmenopausal breast cancer and is associated with poorer cancer outcomes. Docosahexaenoic acid (DHA), an omega-3 fatty acid, possesses anti-inflammatory properties. We hypothesized that treatment with DHA would reduce the expression of proinflammatory genes and aromatase, the rate-limiting enzyme for estrogen biosynthesis, in benign breast tissue of overweight/obese women. A randomized, placebo-controlled, double-blind phase II study of DHA given for 12 weeks to overweight/obese women with a history of stage I-III breast cancer, DCIS/LCIS, Paget's disease, or proliferative benign breast disease was carried out. In this placebo controlled trial, the primary objective was to determine whether DHA (1,000 mg by mouth twice daily) reduced breast tissue levels of TNFα. Secondary objectives included evaluation of the effect of DHA on breast tissue levels of COX-2, IL1ß, aromatase, white adipose tissue inflammation, and gene expression by RNA-seq. Red blood cell fatty acid levels were measured to assess compliance. From July 2013 to November 2015, 64 participants were randomized and treated on trial (32 women per arm). Increased levels of omega-3 fatty acids in red blood cells were detected following treatment with DHA (P < 0.001) but not placebo. Treatment with DHA did not alter levels of TNFα (P = 0.71), or other biomarkers including the transcriptome in breast samples. Treatment with DHA was overall well-tolerated. Although compliance was confirmed, we did not observe changes in the levels of prespecified biomarkers in the breast after treatment with DHA when compared with placebo. Cancer Prev Res; 11(4); 203-14. ©2018 AACRSee related editorial by Fabian and Kimler, p. 187.

Menopause is a determinant of breast adipose inflammation.

Chronic inflammation is recognized as a risk factor for the development of several malignancies. Local white adipose tissue (WAT) inflammation, defined by the presence of dead or dying adipocytes encircled by macrophages that form crown-like structures (CLS), occurs in the breasts (CLS-B) of most overweight and obese women. Previously, we showed that the presence of CLS-B is associated with elevated tissue levels of proinflammatory mediators and aromatase, the rate-limiting enzyme for estrogen biosynthesis. The associated increased levels of aromatase in the breast provide a plausible mechanistic link between WAT inflammation and estrogen-dependent breast cancers. Thus, breast WAT inflammation could be relevant for explaining the high incidence of estrogen-dependent tumors with aging despite diminished circulating estrogen levels after menopause. To explore this possibility, we determined whether menopause in addition to body mass index (BMI) is associated with breast WAT inflammation among 237 prospectively enrolled women. The presence of CLS-B and its severity (CLS-B/cm(2)) as indicators of WAT inflammation correlated with menopausal status (P = 0.008 and P < 0.001) and BMI (P < 0.001 for both). In multivariable analyses adjusted for BMI, the postmenopausal state was independently associated with the presence (P = 0.03) and severity of breast WAT inflammation (P = 0.01). Mean adipocyte size increased in association with CLS-B (P < 0.001). Our findings demonstrate that breast WAT inflammation, which is associated with elevated aromatase levels, is increased in association with the postmenopausal state independent of BMI. Breast WAT inflammation, a process that can potentially be targeted, may help to explain the high incidence of estrogen-dependent tumors in postmenopausal women.

Determining venous thromboembolic risk assessment for patients with trauma: the Trauma Embolic Scoring System.

BACKGROUND: This study aimed to determine the relative "weight" of risk factors known to be associated with venous thromboembolism (VTE) for patients with trauma based on injuries and comorbidities. METHODS: A retrospective review of 16,608 consecutive admissions to a trauma center was performed. Patients were separated into those who developed VTE (n = 141) versus those who did not (16,467). Univariate analysis was performed for each risk factor reported in the trauma literature. Risk factors that were shown to be significant (p < 0.05) by univariate analysis underwent multivariate analysis to develop odds ratios for VTE. The Trauma Embolic Scoring System (TESS) was derived from the multivariate coefficients. The resulting TESS was compared with a data set from the National Trauma Data Bank (2002-2006) to determine its ability to predict VTE. RESULTS: The multivariate analysis demonstrated that age, Injury Severity Score, obesity, ventilator use for more than 3 days, and lower-extremity trauma were significant predictors of VTE in our patient population. The TESS was from 0 to 14, with the best prediction for those patients with a score of more than 6 (sensitivity, 81.6%; specificity, 84%). Overall, the model had excellent discrimination in predicting VTE with a receiver operating characteristic curve of 0.89. The VTE rates for TESS in the National Trauma Data Bank data set were similar for all integers except for 3 and 4, in which the VTE rates were significantly higher (3, 0.2% vs. 0.6%; 4, 0.4% vs. 1.0%). CONCLUSION: The TESS provides an objective measure of classifying VTE risk for patients with trauma. The TESS could allow informed decision making regarding prophylaxis strategies in patients with trauma.

Has TRISS become an anachronism? A comparison of mortality between the National Trauma Data Bank and Major Trauma Outcome Study databases.

BACKGROUND: The Trauma and Injury Severity Score (TRISS) has been the approach to trauma outcome prediction during the past 20 years and has been adopted by many commercial registries. Unfortunately, its survival predictions are based upon coefficients that were derived from a data set collected in the 1980s and updated only once using a data set collected in the early 1990s. We hypothesized that the improvements in trauma care during the past 20 years would lead to improved survival in a large database, thus making the TRISS biased. METHODS: The TRISSs from the Pennsylvania statewide trauma registry (Collector, Digital Innovations) for the years 1990 to 2010. Observed-to-expected mortality ratios for each year of the study were calculated by taking the ratio of actual deaths (observed deaths, O) to the summation of the probability of mortality predicted by the TRISS taken over all patients (expected deaths, E). For reference, O/E ratio should approach 1 if the TRISS is well calibrated (i.e., has predictive accuracy). RESULTS: There were 408,489 patients with complete data sufficient to calculate the TRISSs. There was a significant trend toward improved outcome (i.e., decreasing O/E ratio; nonparametric test of trend, p < 0.001) over time in both the total population and the blunt trauma subpopulation. In the penetrating trauma population, there was a trend toward improved outcome (decreasing O/E ratio), but it did not quite reach significance (nonparametric test of trend p = 0.073). CONCLUSION: There is a steady trend toward improved O/E survival in the Pennsylvania database with each passing year, suggesting that the TRISS is drifting out of calibration. It is likely that improvements in care account for these changes. For the TRISS to remain an accurate outcome prediction model, new coefficients would need to be calculated periodically to keep up with trends in trauma care. This requirement for occasional updating is likely to be a requirement of any trauma prediction model, but because many other deficiencies in the TRISS have been reported, we think that rather than updating the TRISS, it would be more productive to replace the TRISS with a modern statistical model.

High-risk geriatric protocol: improving mortality in the elderly.

BACKGROUND: Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury. We have developed the high-risk geriatric protocol (GP) that seeks to identify high-risk geriatric patients. We hypothesized that a high-risk GP would improve outcome in this select group of patients. METHODS: Patients from 2000 to 2010 were included. Patients 65 years or older who met high-risk GP based on comorbidities and/or physiologic parameters were compared with those patients who had not received GP before its implementation as well as other non-GP patients. This protocol includes a geriatric consultation, as well as a lactate levels, arterial blood gas levels, and echo test to assess for occult shock. Age, trauma activation, preexisting conditions, Injury Severity Score, Revised Trauma Score, and mortality were reviewed. Univariate and multivariate analyses were conducted to identify factors predictive of mortality. RESULTS: A total of 3,902 patients were evaluated. Patients receiving GP were less likely to die (odds ratio, 0.63 [0.39-0.99], p = 0.046). For all patients, there was a dramatic increase in mortality for those patients older than 75 years. CONCLUSION: The GP, adjusted for other covariates, significantly reduced mortality in our patient population. Thus, this study confirms the overall effectiveness of our GP, which is hallmarked by prompt identification of those patients with occult shock and a multidisciplinary care of the aged population.

Acute care and trauma surgeons: we can't get no satisfaction--what do satisfaction surveys measure?

Patient satisfaction surveys are increasingly being used as a measure of physician performance in a hospital setting. We sought to determine what role the clinical condition the physician is treating has on overall patient satisfaction scores. Patient satisfaction scores were calculated for elective and emergent general surgery and trauma patients for eight surgeons taking care of all three types of patients. Both physician satisfaction (PP) and hospital satisfaction (GP) scores were calculated. Mean scores (± standard deviation) between groups were compared with P < 0.05 significance. Of 1521 trauma patients and 3779 general surgery patients, there was 14.8 and 15.1 per cent response rate, respectively, to the survey. Trauma patients had a significantly lower PP than general surgery patients (81.0 ± 19.4 vs 85.7 ± 16.4; P < 0.001). However, the GP between trauma and general surgery was not significant (84.0 ± 13 vs 84.0 ± 12.3; nonsignificant) When general surgery patients were divided into emergent versus elective, the PP was significantly higher for elective than emergent (87.9 ± 14.6 vs 82.7 ± 18; P < 0.001). A patient's underlying clinical condition may influence response to patient satisfaction surveys. Further research needs to be performed before patient satisfaction surveys can be adopted as a overall measure of physician competency.

Old and undertriaged: a lethal combination.

The geriatric trauma patient poses unique challenges to the trauma surgeon due to occult injuries and occult hypoperfusion. We hypothesized that those elderly patients with significant injuries, who were not initially evaluated via trauma activation, would suffer worse outcomes. All cases of elderly (age ≥ 65) admitted to the trauma service from the years 2000 to 2010 were included. Our trauma activation system encompasses anatomic, physiologic, and mechanism of injury criteria. We defined patients as undertriaged (UT) if they had an ISS > 15 and did not undergo a trauma team activation, but had a regular workup by an emergency department physician and trauma team consultation. Factors that contributed to being UT in the emergency department were investigated by univariate and multivariate analysis. A total of 4534 elderly patients constitute this analysis, of which 15.1 per cent were UT. The UT patients were more likely to die, when adjusted for Revised Trauma Score, Glasgow Coma score, the occurrence of ≥1 complication, and whether the patient was on Coumadin. UT has a high risk of death in elderly patients. Trauma triage guidelines need to be better tailored to identify the high-risk geriatric trauma patient.