Large discordance between creatinine-based and cystatin C-based estimated glomerular filtration rates is associated with falls, hospitalizations, and death in older adults.

BACKGROUND: Estimated glomerular filtration rate (eGFR) calculated using creatinine and cystatin C often differ in older adults. We hypothesized that older adults with cystatin-based eGFR (eGFRcys) values significantly lower than creatinine-based eGFR (eGFRcr) values may have higher risk for aging-related adverse outcomes, independent of kidney function. METHODS: We conducted a longitudinal cohort study of adults ≥65 years old from the Health and Retirement Study, a cohort of older American adults, to determine the relationship between eGFR discordance and aging-related adverse outcomes. We calculated eGFRcr and eGFRcys using baseline creatinine and cystatin C measurements. A large eGFR discordance was defined as eGFRcys >30% lower than eGFRcr. We assessed four aging-related adverse outcomes over a two-year follow-up: falls, hip fractures, hospitalizations, and death. We fit separate multivariable regression models to determine the association between having a large eGFR discordance and each outcome adjusting for confounders including kidney function. RESULTS: Of 5574 older adults, 1683 (30%) had a large eGFR discordance. Those with a large eGFR discordance were more likely to be older, female, and White. The prevalence of a large eGFR discordance increased with age, from 20% among those 65-69 years to 44% among those 80 years and older. Over a two-year follow-up, there were 305 deaths (5.5%), 2013 falls (39.2%), 69 hip fractures (1.3%), and 1649 hospitalizations (32.2%). In adjusted analyses, large eGFR discordance was associated with a higher hazard ratio for death (HR 1.43, 95% CI 1.12-1.82) and significantly higher odds of falls (odds ratio [OR] 1.32, 95% CI 1.16-1.51) and hospitalizations (OR 1.32, 95% CI 1.15-1.51). A large eGFR discordance was not associated with hip fractures. CONCLUSION: In a large, nationally representative cohort of older adults, prevalence of eGFR discordance increased with age and was associated with higher risk of falls, hospitalization, and death, independent of kidney function.

Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results.

BACKGROUND: Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving. OBJECTIVE: Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results. DESIGN: A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response. PARTICIPANTS: Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts. MAIN MEASURES: Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines. KEY RESULTS: In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer. CONCLUSIONS: Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.

Assessing Management of Abnormal Cervical Cancer Screening Results and Concordance with Guideline Recommendations in Three US Healthcare Settings.

BACKGROUND: Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up. METHODS: We identified the index screening abnormality (positive human papillomavirus test or atypical squamous cells of undetermined significance or more severe cytology) among women of ages 25 to 65 years at three US healthcare systems during 2010 to 2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines. RESULTS: Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with atypical squamous cells of undetermined significance/human papillomavirus-negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia I and 90% for patients with cervical intraepithelial neoplasia II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%, respectively. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese body mass index, and specific types of public payor coverage or being uninsured. CONCLUSIONS: Adherence to the recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, although suboptimal, for more severe abnormalities. IMPACT: There remain gaps in the cervical cancer screening process in clinical practice. Further study is needed to understand the barriers to the appropriate management of cervical abnormalities.

Characteristics of Clinicians Caring for Transgender Men and Nonbinary Individuals and Guideline Concordance of Clinicians' Cervical Cancer Screening Counseling for Cisgender Individuals Versus Transgender Men and Nonbinary Individuals with a Cervix.

Purpose: We examined characteristics of clinicians caring for transgender men and nonbinary (TMNB) individuals and guideline concordance of clinicians' cervical cancer screening recommendations. Methods: Using a survey of clinicians who performed ≥10 cervical cancer screenings in 2019, we studied characteristics of clinicians who do versus do not report caring for TMNB individuals and guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women. Results: In our sample (N = 492), 49.2% reported caring for TMNB individuals, and 25.4% reported performing cervical cancer screening for TMNB individuals with a cervix. Differences in guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women (45.8% vs. 50% concordant) were not statistically significant. Conclusion: Sizable proportions of clinicians cared for and performed cervical cancer screening for TMNB individuals. Research is needed to better understand clinicians' identified knowledge deficits to develop interventions (e.g., clinician trainings) to improve gender-affirming cervical cancer prevention.

Attention to body mass index by child psychiatry providers when prescribing second-generation antipsychotic medication to children: a survey study using a clinical vignette.

AIM: We sought to determine whether weight and body mass index measurement were taken into consideration when prescribing second-generation antipsychotic (SGA) medication to a child. METHODS: Two hundred clinicians were surveyed using a hypothetical clinical case vignette at a child psychopharmacology, postgraduate medical education course. The vignette described an overweight 10-year-old boy who was about to be prescribed an SGA medication to control psychotic symptoms. The reference to the patient's being 'overweight' was purposefully included to determine if providers would assess the patient's risk of morbidity from the metabolic side effects of the SGAs at the time of prescribing. RESULTS: Only 7.0% of prescribers listed either 'body mass index' or a combination of 'height' and 'weight' as part of their next treatment steps for an overweight child before prescribing an SGA. CONCLUSIONS: These results suggest the need for education as to the importance of body mass index monitoring when prescribing second-generation antipsychotic medications to children.