Underuse of surgical resection for localized, non-small cell lung cancer among whites and African Americans in South Carolina.

BACKGROUND: Early studies using Medicare data reported racial disparities in surgical treatment of localized, non-small cell lung cancer. We analyzed the independent effect of race on use of surgical resection in a recent, population-based sample of patients with localized non-small cell lung cancer, controlling for comorbidity and socioeconomic status. METHODS: All cases of localized non-small cell lung cancer reported to our state Cancer Registry between 1996 and 2002 were identified and linked to the Inpatient/Outpatient Surgery Files and 2000 Census. Comorbidity (Romano-Charlson index) was calculated using administrative data codes. Educational level and income were estimated using census data. Characteristics of white and African American patients were compared using chi(2) tests. Odds ratios of resection and 95% confidence intervals were calculated using logistic regression. RESULTS: We identified 2,506 white and 550 African American patients. African Americans were more likely to be younger, male, not married, less educated, poor, and uninsured or covered by Medicaid (all p < 0.0001), and to reside in rural communities (p = 0.0005). Use of surgical resection across races was lower than previously reported, and African Americans were significantly less likely to undergo surgery compared with whites (44.7% versus 63.4%; p < 0.0001). Even after controlling for sociodemographics, comorbidity, and tumor factors, the adjusted odds ratio for resection for African Americans was 0.43 (95% confidence interval, 0.34 to 0.55). CONCLUSIONS: Underuse of surgical resection for localized, non-small cell lung cancer is a persistent problem, particularly among African Americans. Further studies are urgently needed to identify the patient-, physician-, and health system-related factors underlying these observations and optimize resection rates for non-small cell lung cancer.

Advanced heart failure: prognosis, uncertainty, and decision making.

Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care.

Off-pump coronary artery bypass grafting does not decrease the incidence of atrial fibrillation.

BACKGROUND: Postoperative atrial fibrillation remains a significant source of morbidity after coronary artery bypass grafting. We reviewed the data on 2,569 patients to determine if the absence of cardiopulmonary bypass resulted in a lower incidence of atrial fibrillation. METHODS: All patients undergoing coronary artery bypass grafting without cardiopulmonary bypass from January 1, 1997 through June 30, 2001 were evaluated for postoperative atrial fibrillation. The data of 252 patients with no cardiopulmonary bypass (group 1) were reviewed and compared with three other patient groups. Group 2 consisted of 1,470 patients using cardiopulmonary bypass during the same study period. Group 3 consisted of 841 patients with a similar number of grafts as the study group but using cardiopulmonary bypass. Group 4 consisted of historical data for 847 patients operated on using cardiopulmonary bypass collected from January 1995 through December 1996. Prophylactic beta-blockade was instituted in January 1997. Groups 1 to 3 received this treatment, but group 4 did not. RESULTS: Group 1 had an incidence of atrial fibrillation of 8.8%. Groups 2, 3, and 4 had incidences of atrial fibrillation of 11.6%, 9.4%, and 28.0%, respectively. When compared with group 1, the incidence of atrial fibrillation in group 4 was statistically different (p <. 0001). CONCLUSIONS: Avoiding cardiopulmonary bypass did not aid the reduction of atrial fibrillation at our institution.