When to refer patients with chronic kidney disease for vascular access surgery: should age be a consideration?

To determine whether age should inform our approach toward permanent vascular access placement in patients with chronic kidney disease, we conducted a retrospective cohort study among 11 290 non-dialysis patients with an estimated glomerular filtration rate (eGFR) <25 ml/min/1.73 m(2) based on 2000-2001 outpatient creatinine measurements in the Department of Veterans Affairs. For each age group, we examined the percentage of patients that had and had not received a permanent access by 1 year after cohort entry, and the percentage in each of these groups that died, started dialysis, or survived without dialysis. We also modeled the number of unnecessary procedures that would have occurred in theoretical scenarios based on existing vascular access guidelines. The mean eGFR was 17.7 ml/min/1.73 m(2) at cohort entry. Twenty-five percent (n=2870) of patients initiated dialysis within a year of cohort entry. Among these, only 39% (n=1104) had undergone surgery to place a permanent access beforehand. As compared with younger patients, older patients were less likely to undergo permanent access surgery, but also less likely to start dialysis. In all theoretical scenarios examined, older patients would have been more likely than younger patients to receive unnecessary procedures. If all patients had been referred for permanent access surgery at cohort entry, the ratio of unnecessary to necessary procedures after 2 years of follow-up would have been 5:1 for patients aged 85-100 years but only 0.5:1 for those aged 18-44 years. Currently recommended approaches to permanent access placement based on a single threshold level of renal function for patients of all ages are not appropriate.

Screening mammography for frail older women: what are the burdens?

OBJECTIVE: The potential benefits and harms of screening mammography in frail older women are unknown. Therefore, we studied the outcomes of a screening mammography policy that was instituted in a population of community-living nursing home-eligible women as a result of requirements of state auditors. We focused on the potential burdens that may be experienced. METHODS: Between January 1995 and December 1997, we identified 216 consecutive women who underwent screening mammography after enrolling in a program designed to provide comprehensive care to nursing home-eligible patients who wished to stay at home. Mammograms were performed at 4 radiology centers. From computerized medical records, we tracked each woman through September 1999 for performance and results of mammography, additional breast imaging and biopsies, documentation of psychological reactions to screening, as well as vital status. Mean follow-up was 2.6 years. RESULTS: The mean age of the 216 women was 81 years. Sixty-three percent were Asian, 91% were dependent in at least 1 activity of daily living, 49% had cognitive impairment, and 11% died within 2 years. Thirty-eight women (18%) had abnormal mammograms requiring further work-up. Of these women, 6 refused work-up, 28 were found to have false-positive mammograms after further evaluation, 1 was diagnosed with ductal carcinoma in situ (DCIS), and 3 were diagnosed with local breast cancer. The woman diagnosed with DCIS and 1 woman diagnosed with breast cancer were classified as not having benefited, because screening identified clinically insignificant disease that would not have caused symptoms in the women's lifetimes, since these women died of unrelated causes within 2 years of diagnosis. Therefore, 36 women (17%; 95% confidence interval [CI], 12 to 22) experienced burden from screening mammography (28 underwent work-up for false-positive mammograms, 6 refused further work-up of an abnormal mammogram, and 2 had clinically insignificant cancers identified and treated). Forty-two percent of these women had chart-documented pain or psychological distress as a result of screening. Two women (0.9%; 95% CI, 0 to 2) may have received benefit from screening mammography. CONCLUSION: We conclude that screening mammography in frail older women frequently necessitates work-up that does not result in benefit, raising questions about policies that use the rate of screening mammograms as an indicator of the quality of care in this population. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.

Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics.

BACKGROUND: Without family caregivers, many frail elders who live at home would require nursing home care. However, providing care to frail elders requires a large time commitment that may interfere with the caregiver's ability to work. Our goal was to determine the patient and caregiver characteristics associated with the reduction of employment hours in caregivers of frail elders. METHODS: This was a cross-sectional study of 2806 patients (mean age 78, 73% women, 29% African American, 12% Hispanic, 54% with dementia) with at least one potentially working caregiver (defined as one who is either currently employed or who would have been employed if they had not been providing care) and their 4592 potentially working caregivers. Patients were enrollees at 11 sites of the Program of All-Inclusive Care for the Elderly (PACE). Social workers interviewed patients and caregivers at the time of PACE enrollment. Caregivers were asked if they had reduced the hours they worked or had stopped working to care for the patient. Nurses interviewed patients and caregivers to assess independence in activities of daily living (ADLs) and the presence of behavioral disturbances. Comorbid conditions were assessed by physicians during enrollment examinations. RESULTS: A total of 604 (22%) of the 2806 patients had at least one caregiver who either reduced the number of hours they worked or quit working to care for the patient. Patient characteristics independently associated with a caregiver reducing hours or quitting work were ethnicity, 95% confidence interval [CI] 1.14-1.78 for African American;, 95% CI 1.43-2.52 for Hispanic), ADL function below the median (, 95% CI 1.44-2.15), a diagnosis of dementia (, 95% -2.17 if associated with a behavioral disturbance;, 95% CI 1.06-1.63 if not associated with a behavioral disturbance), or a history of stroke (OR = 1.42, 95% CI 1.16-1.73). After controlling for these patient characteristics, caregiver characteristics associated with reducing work hours included being the daughter or daughter-in-law of the patient (OR = 1.69, 95% CI 1.37-2.08) and living with the patient (OR = 4.66, 95% CI 3.65-5.95 if no other caregiver lived at home, OR = 2.53, 95% CI 2.03-3.14 if another caregiver lived at home). CONCLUSIONS: Many caregivers reduce the number of hours they work to care for frail elderly relatives. The burden of reduced employment is more likely to be incurred by the families of ethnic minorities and of patients with specific clinical characteristics. Daughters and caregivers who live with the patient are more likely to reduce work hours than other caregivers. Future research should examine the impact of lost caregiver employment on patients' families and the ways in which the societal responsibility of caring for frail elders can be equitably shared.

Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization.

CONTEXT: For many elderly patients, an acute medical illness requiring hospitalization is followed by a progressive decline, resulting in high rates of mortality in this population during the year following discharge. However, few prognostic indices have focused on predicting posthospital mortality in older adults. OBJECTIVE: To develop and validate a prognostic index for 1 year mortality of older adults after hospital discharge using information readily available at discharge. DESIGN: Data analyses derived from 2 prospective studies with 1-year of follow-up, conducted in 1993 through 1997. SETTING AND PATIENTS: We developed the prognostic index in 1495 patients aged at least 70 years who were discharged from a general medical service at a tertiary care hospital (mean age, 81 years; 67% female) and validated it in 1427 patients discharged from a separate community teaching hospital (mean age, 79 years; 61% female). MAIN OUTCOME MEASURE: Prediction of 1-year mortality using risk factors such as demographic characteristics, activities of daily living (ADL) dependency, comorbid conditions, length of hospital stay, and laboratory measurements. RESULTS: In the derivation cohort, 6 independent risk factors for mortality were identified and weighted using logistic regression: male sex (1 point); number of dependent ADLs at discharge (1-4 ADLs, 2 points; all 5 ADLs, 5 points); congestive heart failure (2 points); cancer (solitary, 3 points; metastatic, 8 points); creatinine level higher than 3.0 mg/dL (265 micromol/L) (2 points); and low albumin level (3.0-3.4 g/dL, 1 point; <3.0 g/dL, 2 points). Several variables associated with 1-year mortality in bivariable analyses, such as age and dementia, were not independently associated with mortality after adjustment for functional status. We calculated risk scores for patients by adding the points of each independent risk factor present. In the derivation cohort, 1-year mortality was 13% in the lowest-risk group (0-1 point), 20% in the group with 2 or 3 points, 37% in the group with 4 to 6 points, and 68% in the highest-risk group (>6 points). In the validation cohort, 1-year mortality was 4% in the lowest-risk group, 19% in the group with 2 or 3 points, 34% in the group with 4 to 6 points, and 64% in the highest-risk group. The area under the receiver operating characteristic curve for the point system was 0.75 in the derivation cohort and 0.79 in the validation cohort. CONCLUSIONS: Our prognostic index, which used 6 risk factors known at discharge and a simple additive point system to stratify medical patients 70 years or older according to 1-year mortality after hospitalization, had good discrimination and calibration and generalized well in an independent sample of patients at a different site. These characteristics suggest that our index may be useful for clinical care and risk adjustment.

Cancer screening in elderly patients: a framework for individualized decision making.

Considerable uncertainty exists about the use of cancer screening tests in older people, as illustrated by the different age cutoffs recommended by various guideline panels. We suggest that a framework to guide individualized cancer screening decisions in older patients may be more useful to the practicing clinician than age guidelines. Like many medical decisions, cancer screening decisions require weighing quantitative information, such as risk of cancer death and likelihood of beneficial and adverse screening outcomes, as well as qualitative factors, such as individual patients' values and preferences. Our framework first anchors decisions through quantitative estimates of life expectancy, risk of cancer death, and screening outcomes based on published data. Potential benefits of screening are presented as the number needed to screen to prevent 1 cancer-specific death, based on the estimated life expectancy during which a patient will be screened. Estimates reveal substantial variability in the likelihood of benefit for patients of similar ages with varying life expectancies. In fact, patients with life expectancies of less than 5 years are unlikely to derive any survival benefit from cancer screening. We also consider the likelihood of potential harm from screening according to patient factors and test characteristics. Some of the greatest harms of screening occur by detecting cancers that would never have become clinically significant. This becomes more likely as life expectancy decreases. Finally, since many cancer screening decisions in older adults cannot be answered solely by quantitative estimates of benefits and harms, considering the estimated outcomes according to the patient's own values and preferences is the final step for making informed screening decisions.

Functional status before hospitalization in acutely ill older adults: validity and clinical importance of retrospective reports.

OBJECTIVES: Retrospective reports of patients' functional status before hospital admission are often used in longitudinal studies and by clinicians caring for hospitalized patients. However, the validity of these reports has not been established. Our aim was to examine the validity of retrospective reports by testing hypotheses about the relationships these measures would have with other clinical measures if they were valid. DESIGN: A prospective cohort study. PARTICIPANTS AND SETTING: A total of 2877 older patients (mean age 81, 36% women) hospitalized on the general medical service at two hospitals. For 1953 of the subjects, the patient was the primary respondent, whereas for 924 subjects, a surrogate was the primary respondent. MEASUREMENTS: Shortly after hospital admission, patients or surrogates reported whether the patient was independent in each of five activities of daily living (ADLs) on admission and at baseline 2 weeks before admission. Outcome measures included reported independence in each ADL 3 months after the hospitalization and survival to 1 year. RESULTS: Patients' retrospective reports of their ADL function 2 weeks before admission had a clinically plausible relationship with ADL function at the time of admission, in that patients independent in an ADL on admission rarely reported they were dependent in that ADL 2 weeks before admission (range 2-6%). Surrogates were somewhat more likely than patients to report that patients independent on admission were dependent 2 weeks before admission (range 5-14%). Retrospective reports of prehospitalization ADL function demonstrated strong evidence of predictive validity for both patients' and surrogates' reports. For example, among patients dependent in bathing on admission, patients who were reported as independent 2 weeks before admission were much more likely than those reported as dependent 2 weeks before admission to be independent 3 months after hospitalization (68% vs 20%, P < .001 for patient respondents; 30% vs 5%, P < .001 for surrogate respondents). Similarly, among patients dependent in bathing on hospital admission, survival 1 year after hospitalization was much higher in patients who were independent in bathing 2 weeks before admission than patients who were dependent 2 weeks before admission (76% vs 59%, P < .001 for patient respondents; 60% vs 45%, P < .001 for surrogate respondents). Results were similar for each of the other four ADLs. In a logistic regression model controlling for the number of ADLs reported as dependent on admission, the number of ADLs reported as dependent 2 weeks before admission was significantly associated with 1-year mortality among both patient (odds ratio (OR) = 1.39 per dependent ADL, 95% confidence interval (CI) - 1.26-1.54) and surrogate (OR = 1.14, 95% CI = 1.06-1.24) respondents. CONCLUSIONS: Hospitalized patients' assessments of their ability to perform ADLs before their hospitalization have evidence of face and predictive validity. These measures are strong predictors of important health outcomes such as functioning and survival. In particular, among patients dependent in ADL function on hospital admission, these results highlight the prognostic importance of inquiring about the patient's functional status before the onset of the acute illness.