The rise of concurrent care for veterans with advanced cancer at the end of life.

BACKGROUND: Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy. METHODS: This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment. RESULTS: The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012). CONCLUSIONS: Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2016;122:782-790. © 2015 American Cancer Society.

The use of bone morphogenetic protein in thoracolumbar spine procedures: analysis of the MarketScan longitudinal database.

BACKGROUND CONTEXT: The use of recombinant human bone morphogenetic protein (BMP) in the thoracolumbar spine remains controversial, with many questioning the risks and benefits of this new biologic. PURPOSE: To describe national trends, incidence of complications, and revision rates associated with BMP use in thoracolumbar spine procedures. STUDY DESIGN/SETTING: Administrative database study. PATIENT SAMPLE: A matched cohort of 52,259 patients undergoing thoracolumbar fusion surgery from 2006 to 2010 were identified in the MarketScan database. Patients without BMP treatment were matched 2:1 to patients receiving intraoperative BMP. OUTCOME MEASURES: Revision rates and postoperative complications. METHODS: The MarketScan database was used to select patients undergoing thoracolumbar fusion procedures, with and without intraoperative BMP. We ascertained outcome measures using either International Classification of Disease, ninth revision, or Current Procedural Terminology coding, and matched groups were evaluated using a bivariate and multivariate analyses. Kaplan-Meier estimates of fusions failure rates were also calculated. RESULTS: Patients receiving intraoperative BMP underwent fewer refusions, decompressions, posterior and anterior revisions, or any revision procedure (single level 4.53% vs. 5.85%, p<.0001; multilevel 5.02% vs. 6.83%, p<.0001; overall cohort 4.73% vs. 6.09%, p<.0001). After adjusting for comorbidities, demographics, and levels of procedure, BMP was not associated with the postoperative development of cancer (odds ratio 0.92). Bone morphogenetic protein use was associated with an increase in any complication at 30 days (15.8% vs. 14.9%, p=.0065), which is only statistically significant among multilevel procedures (19.74% vs. 18.02%, p=.0013). Thirty-day complications in multilevel procedures associated with BMP use included new dysrhythmia (4.68% vs. 4.01%, p=.0161) and delirium (1.08% vs. 0.69%, p=.0024). A new diagnosis of chronic pain was associated with BMP use in both single-level (2.74% vs. 2.15%, p=.0019) and multilevel (3.7% vs. 2.52%, p<.0001) procedures. Bone morphogenetic protein was negatively associated with infection in single-level procedures (2.12% vs. 2.64%, p=.0067) and wound dehiscence in multilevel procedures (0.84% vs. 1.18%, p=.0167). CONCLUSIONS: In national data analysis of thoracolumbar procedures, we found that BMP was associated with decreased incidence of revision spinal surgery and with a slight increased risk of overall complications at 30 days. Although no BMP-associated increased risk of malignancy was found, lack of long-term follow-up precludes detection of between-group differences in malignancies and other rare events that may not appear until later.

A provider participatory implementation model for HIV testing in an ED.

BACKGROUND: The Centers for Disease Control and Prevention recommends routine HIV screening for adults. OBJECTIVES: Community-based participatory research incorporates subjects in the design and conduct of research. We included nurses and physicians in the implementation of HIV rapid test use in the emergency department (ED). We explored the process, facilitators, and barriers. METHODS: We identified clinical champions and trained staff. Physicians obtained consent and ordered HIV testing; nurses performed rapid testing. Testing rates were tracked by electronic medical record. We conducted regular meetings between staff and researchers. Semistructured qualitative interviews with providers were conducted at 3 months. RESULTS: By week 15, we administered 121 tests. After the eligibility protocol evolved to incorporate ED nursing concerns regarding staffing limitations from a random sampling model to one focused on testing during nonpeak hours, the weekly number of tests increased. Eighteen percent of providers favored nontargeted HIV screening, 27% favored the current model of testing at nonpeak hours, 32% supported diagnostic testing, and 18% favored no testing or "other." Barriers include written consent, electronic documentation, time constraints, and belief that screening is not a core ED duty. Facilitators include ease of test administration, belief that ED patients are at higher risk, and flexibility to tailor screening efforts according to patient volume. CONCLUSIONS: The ED-based HIV testing is feasible within a Veterans Hospital Administration setting. Involvement of nursing in a community-based participatory research implementation model may facilitate staff acceptance of nontargeted HIV screening and be a mechanism to initiate administration of clinical preventive services to ED patients with limited primary care contact.