Factors influencing older adults to complete advance directives.

OBJECTIVE: The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults. METHOD: Direct interviews of hospitalized and community-dwelling cognitively intact patients > 65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables. RESULTS: Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3, p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2, p < 0.0001), having undergone major surgery (OR 6.3, p < 0.0017), female gender (OR 11.1, p < 0.0001) and increasing age (76-85 vs. 59-75: OR 3.4, p < 0.0543; < 85 vs. 59-75: OR 6.3, p < 0.0263). SIGNIFICANCE OF RESULTS: This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Patient noncompliance before surgery.

OBJECTIVE: To assess patient compliance with preoperative instructions and to determine causes and factors of noncompliance, as noncompliance might affect surgical outcome and has potential medicolegal implications. PATIENTS AND METHODS: One surgeon counselled 101 consecutive patients before undergoing laparoscopic renal surgery. Deliberate discussions instructed patients to bring their radiograph films on the day of surgery and complete a preoperative bowel preparation. Noncompliance was defined as failure to bring films and/or complete bowel preparation. Patient demographics, socio-economic and clinical variables were analysed, and reasons for failure to comply with instructions were also recorded. RESULTS: Twenty-four of the 101 (24%) patients were not compliant, 13 with films only, seven with bowel preparation only, and four with both sets of instructions. Univariate analysis showed that language and race were factors for noncompliance. Multivariate analysis showed that non-Caucasians had 17 times the risk of noncompliance (P < 0.001); long distance from home to the site of care had five times the risk of noncompliance (P = 0.041), and each day between the initial consultation and the date of surgery had 1.05 times the risk of noncompliance (P < 0.001). The most common reason given by patients for noncompliance was that they were never given the preoperative instructions. CONCLUSIONS: Noncompliance with preoperative surgical instructions is a significant issue and is increased in non-Caucasian patients, those travelling long distances, and those whose surgery date is long after their preoperative consultation. A systems-based approach is needed to address this significant issue.

Can antidepressants be used to treat the schizophrenia prodrome? Results of a prospective, naturalistic treatment study of adolescents.

OBJECTIVE: This study reports the results of a prospective, naturalistic treatment study of adolescents considered to be in the prodromal (i.e., prepsychotic) phase of schizophrenia. METHOD: Forty-eight adolescents (mean age = 15.8 years) participating in the initial phase of the Recognition and Prevention (RAP) program (1998-2005) were included in the current report. Individuals were selected from the overall sample (N = 152) if they had: (1) displayed attenuated positive symptoms, (2) been treated pharmacologically for at least 8 weeks, and (3) been followed up for at least 6 months (mean follow-up = 30.5 months). RESULTS: Two types of medication were naturalistically prescribed: antidepressants (N = 20) or second-generation antipsychotics (N = 28), with polypharmacy common. The 2 treatment groups did not differ in baseline symptom profiles, with the exception of disorganized thinking, which was more severe in second-generation antipsychotic-treated adolescents. Twelve of the 48 adolescents (25%) developed a psychotic disorder, with all converters having been prescribed second-generation antipsychotics. There were no conversions among antidepressant-treated adolescents (log-rank chi(2) = 7.36, df = 1, p = .007). Treatment outcome, however, was confounded, since 11 of the 12 converters were nonadherent. Adolescents, in general, were more likely to be nonadherent to second-generation antipsychotics (61%, 17/28) than to antidepressants (20%, 4/20; chi(2) = 7.86, p = .005). Improvement in 3 of 5 positive symptoms over time was significant (p < .001) and similar for both medications. Disorganized thought, however, did not improve regardless of treatment. CONCLUSIONS: Nonrandom assignment limits comparisons between antidepressants and anti-psychotics in this study. However, with follow-up, a number of adolescents meeting criteria for prodromal schizophrenia were successfully treated with antidepressants. At present, a substantial number of false positives among the antidepressant-treated subgroup cannot be ruled out. However, the findings suggest that, in some cases, it might be preferable to begin treatment with antidepressants and progress to antipsychotics once symptoms intensify, since adherence to the latter is difficult to maintain.

U.S. board-certified pain physician practices: uniformity and census data of their locations.

UNLABELLED: We determined the profiles of the board-certified pain physician workforce and the profiles of those residing near medical pain practices. Data from a mail survey of U.S. pain specialists were compared with U.S. Census data, and different settings and types of practices were contrasted. The 750 respondents (32.1%) were similar to the entire board-certified group in age, geographic distribution, and primary specialty. Although pain practices were underrepresented in rural areas, their prevalence was unrelated to other demographic data. Ninety-six percent of pain physicians treated chronic pain; 84% followed patients longitudinally; 31% worked in an academic environment; 50% had an interdisciplinary practice; and 29% focused on a single modality. Academics were more likely to be neurologists (P < .05) and to have had a pain fellowship (P < or = .0001). Modality-oriented practitioners were more likely to be anesthesiologists (P < or = .0001) and were less likely to follow patients with chronic pain longitudinally (P < or = .0001), provide training to fellows, prescribe controlled substances (P < or = .0001, respectively), or require an opioid contract (P < or = .01). Although boarded specialists learn from similar curricula and must pass a certifying examination, their practices vary considerably. Data are needed to further clarify the nature of workforce variation, its impact on patient care, and the role of other pain management clinicians. PERSPECTIVE: A survey of board-certified pain specialists reveals considerable variation in practice and a total number of specialists that is probably insufficient to meet the needs of the population with chronic pain. The location of pain management practices largely corresponds to census data, with the exception of underrepresentation in rural areas.