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1.
Cancer Nurs ; 2020 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-32022778

RESUMO

BACKGROUND: Lung cancer survivors are at risk of accelerated declines in physical functioning attributed to cancer treatment. However, it is unknown whether patients experience the same rate of functional decline and how symptoms may contribute to different trajectories. OBJECTIVES: The aims of this study were to identify interindividual differences in the pattern and rate of change in self-reported functioning in lung cancer survivors and examine whether and how symptoms are related to physical functioning over time. METHODS: This was a secondary data analysis in 72 lung cancer survivors. Multilevel modeling was used to estimate trajectories of self-reported physical functioning over 1 year and assess the relation between functioning, fatigue, depressive symptoms, and pain severity across time. RESULTS: Within the sample, average physical functioning did not significantly decrease (coefficient, -0.46; 95% confidence interval [CI] = -2.85 to 0.94) over time. However, among individual lung cancer survivors, baseline physical functioning varied significantly (SD, 20.76; 95% CI, 16.84-25.59) and changed at significantly different rates over 1 year (SD, 3.50; 95% CI, 2.13-5.68). Fatigue, assessed over 1 year, was the only significant symptom predictor of physical functioning changes over time (coefficient = 1.03; 95% CI, 0.79-1.27). CONCLUSIONS: In this sample of lung cancer survivors, not all survivors experienced the same rate of self-reported functional decline and those with lower levels of fatigue reported better physical functioning. IMPLICATIONS FOR PRACTICE: Nurses should recognize that some lung cancer survivors may have faster rates of functional declines than others, which may be related to fatigue severity. Early identification and management of fatigue could help avoid or delay future disability.

2.
JAMA ; 2020 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-32062674

RESUMO

Importance: Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. Objectives: To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. Design, Setting, and Participants: Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. Exposures: POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. Main Outcomes and Measures: The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. Results: Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Conclusions and Relevance: Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31968182

RESUMO

RATIONALE: Gender gaps exist in academic leadership positions in critical care. Peer-reviewed publications are crucial to career advancement, yet little is known regarding gender differences in authorship of critical care research. OBJECTIVES: To evaluate gender differences in authorship of critical care literature. METHODS: We used a validated database of author gender to analyze authorship of critical care articles indexed in PubMed between 2008-2018 in 40 frequently-cited journals. High-impact journals were defined as those in the top 5% of all journals. We used mixed-effects logistic regression to evaluate the association of senior author gender with first and middle author gender, and first author gender with journal impact factor. RESULTS: Among 18,483 studies, 30.8% had female first authors and 19.5% had female senior authors. Female authorship rose slightly over the last decade (average annual increase of 0.44% (p<0.01) and 0.51% (p<0.01) for female first and senior authors, respectively). When the senior author was female, the odds of female co-authorship rose substantially (first author aOR1.93, 95%CI:1.71-2.17; middle author aOR1.48, 95%CI:1.29-1.69). Female first authors had higher odds of publishing in lower-impact journals than men (aOR1.30, 95%CI:1.16-1.45). CONCLUSIONS: Women comprise less than one-third of first authors and one-quarter of senior authors of critical care research, with minimal increase over the past decade. When the senior author was female, the odds of female co-authorship rose substantially. However, female first authors tend to publish in lower-impact journals. These findings may help explain the underrepresentation of women in critical care academic leadership positions and identify targets for improvement.

5.
Ann Emerg Med ; 75(2): 171-180, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31248675

RESUMO

STUDY OBJECTIVE: Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS: This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS: A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION: Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

6.
JAMA Oncol ; 2019 Sep 19.
Artigo em Inglês | MEDLINE | ID: mdl-31536133

RESUMO

Importance: Palliative care is a patient-centered approach associated with improvements in quality of life; however, results regarding its association with a survival benefit have been mixed, which may be a factor in its underuse. Objective: To assess whether early palliative care is associated with a survival benefit among patients with advanced lung cancer. Design, Setting, and Participants: This retrospective population-based cohort study was conducted among patients with lung cancer who were diagnosed with cancer between January 1, 2007, and December 31, 2013, with follow-up until January 23, 2017. Participants comprised 23 154 patients with advanced lung cancer (stage IIIB and stage IV) who received care in the Veterans Affairs health care system. Data were analyzed from February 15, 2019, to April 28, 2019. Exposure: Palliative care defined as a specialist-delivered palliative care encounter received after lung cancer diagnosis. Main Outcomes and Measures: The primary outcome was survival. The association between palliative care and place of death was also examined. Propensity score and time-varying covariate methods were used to calculate Cox proportional hazards and to perform regression modeling. Results: Of the 23 154 patients enrolled in the study, 57% received palliative care. The mean (SD) age of participants was 68 (9.5) years, and 98% of participants were men. An examination of the timing of palliative care receipt relative to cancer diagnosis found that palliative care received 0 to 30 days after diagnosis was associated with decreases in survival (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.97-2.30), palliative care received 31 to 365 days after diagnosis was associated with increases in survival (aHR, 0.47; 95% CI, 0.45-0.49), and palliative care received more than 365 days after diagnosis was associated with no difference in survival (aHR, 1.00; 95% CI, 0.94-1.07) compared with nonreceipt of palliative care. Receipt of palliative care was also associated with a reduced risk of death in an acute care setting (adjusted odds ratio, 0.57; 95% CI, 0.52-0.64) compared with nonreceipt of palliative care. Conclusions and Relevance: The results suggest that palliative care was associated with a survival benefit among patients with advanced lung cancer. Palliative care should be considered a complementary approach to disease-modifying therapy in patients with advanced lung cancer.

7.
Lung Cancer ; 131: 47-57, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31027697

RESUMO

INTRODUCTION: With advances in treatments among patients with lung cancer, it is increasingly important to understand patients' values and preferences to facilitate shared decision making. METHODS: Prospective, multicenter study of patients with treated stage I lung cancer. At the time of study participation, participants were 4-6 months posttreatment. Value clarification and discrete choice methods were used to elicit participants' values and treatment preferences regarding stereotactic body radiation therapy (SBRT) and surgical resection using only treatment attributes. RESULTS: Among 114 participants, mean age was 70 years (Standard Deviation = 7.9), 65% were male, 68 (60%) received SBRT and 46 (40%) received surgery. More participants valued independence and quality of life (QOL) as "most important" compared to survival or cancer recurrence. Most participants (83%) were willing to accept lung cancer treatment with a 2% chance of periprocedural death for only one additional year of life. Participants also valued independence more than additional years of life as most (86%) were unwilling to accept either permanent placement in a nursing home or being limited to a bed/chair for four additional years of life. Surprisingly, treatment discordance was common as 49% of participants preferred the alternative lung cancer treatment than what they received. CONCLUSIONS: Among participants with early stage lung cancer, maintaining independence and QOL were more highly valued than survival or cancer recurrence. Participants were willing to accept high periprocedural mortality, but not severe deficits affecting QOL when considering treatment. Treatment discordance was common among participants who received SBRT or surgery. Understanding patients' values and preferences regarding treatment decisions is essential to foster shared decision making and ensure treatment plans are consistent with patients' goals. Clinicians need more resources to engage in high quality communication during lung cancer treatment discussions.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Tomada de Decisão Clínica/métodos , Neoplasias Pulmonares/epidemiologia , Preferência do Paciente/estatística & dados numéricos , Pneumonectomia , Radiocirurgia , Idoso , Carcinoma Pulmonar de Células não Pequenas/terapia , Feminino , Humanos , Neoplasias Pulmonares/terapia , Masculino , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Participação do Paciente , Estudos Prospectivos , Qualidade de Vida
8.
Am J Hosp Palliat Care ; 36(7): 564-570, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30700127

RESUMO

INTRODUCTION: The Oregon Physicians Orders for Life-Sustaining Treatment (POLST) Program allows patients with advanced illness to document end-of-life (EOL) care preferences. We examined the characteristics and associated EOL care among Veterans with and without a registered POLST. METHODS: Retrospective, cohort study of advanced-stage (IIIB and IV) patients with lung cancer who were diagnosed between 2008 and 2013 as recorded in the VA Central Cancer Registry. We examined a subgroup of 346 Oregon residents. We obtained clinical and sociodemographic variables from the VA Corporate Data Warehouse and EOL preferences from the Oregon POLST Registry. We compared hospice enrollment and place of death between those with and without a registered POLST. RESULTS: Twenty-two (n = 77) percent of our cohort had registered POLST forms. Compared to those without a registered POLST, Veterans with a POLST had a higher income ($51 456 vs $48 882) and longer time between diagnosis and death (223 days vs 119 days). Those with a registered POLST were more likely to be enrolled in hospice (adjusted odds ratio [aOR] = 2.37, 95% confidence interval [CI]: 1.01-5.54) and less likely to die in a VA facility (aOR = 0.27, 95% CI: 0.12-0.59). CONCLUSION: There was low submission to the POLST Registry among Veterans who received care in Veterans' Health Administration. Veterans who had a registered POLST were more likely to be enrolled in hospice and less likely to die in a VA care setting. The POLST may improve metrics of high-quality EOL care; however, opportunities for improvement in submission and implementation within the VA exist.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Neoplasias Pulmonares/psicologia , Neoplasias Pulmonares/terapia , Assistência Terminal/psicologia , Veteranos/psicologia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oregon , Estudos Retrospectivos , Fatores Socioeconômicos
9.
J Thorac Oncol ; 14(2): 176-183, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30336324

RESUMO

INTRODUCTION: Patients with advanced lung cancer have a poor prognosis, but both chemotherapy and early palliative care (EPC) have been shown to improve survival and quality of life (QOL). The relationship between palliative care and receipt of chemotherapy receipt is understudied. We sought to determine if EPC is associated with chemotherapy receipt and intensity among patients with advanced stage lung cancer. METHODS: Retrospective cohort study of patients in the national Veterans Health Administration (VA) with stage IIIB or IV lung cancer diagnosed between January 2007- December 2013. EPC was defined as a specialist-delivered palliative care received within 90 days of cancer diagnosis. Outcomes included any chemotherapy receipt and high-intensity chemotherapy receipt defined as: i) more than 4 cycles of a platinum-based doublet, ii) ≥3 lines of chemotherapy, iii) Bevacizumab/Cetuximab triplet therapy, iv) Erlotinib use prior to 2011, and v) chemotherapy in the last days of life. Logistic regression was used to determine the association between EPC and chemotherapy receipt after adjustment for patient and tumor characteristics. RESULTS: Among the entire cohort (N=23,566), 37% received EPC and 45% received any chemotherapy. Among those with EPC, 34% received chemotherapy compared to 51% among those without EPC (Adjusted Odds Ratio (AOR=0.55, 95% CI: 0.51-0.58). Patients who received EPC had reduced receipt of high-intensity chemotherapy including >4 cycles of platinum-based doublet (AOR=0.68, 95% CI: 0.60-0.77), ≥ 3 lines of chemotherapy (AOR=0.61, 95% CI: 0.53-0.71), triplet therapy (AOR=0.68, 95% CI: 0.56-0.82) and use of erlotinib prior to 2011 (AOR=0.66, 95% CI: 0.55-0.79). Patients with EPC were more likely to receive chemotherapy in the last 14 (AOR=1.65, 95% CI: 1.44-1.87) and 30 days (AOR=1.67, 95% CI: 1.51-1.85) of life compared to those without EPC. CONCLUSIONS: EPC was associated with reduced receipt of both any chemotherapy and high-intensity chemotherapy. However, receipt of chemotherapy at the very end-of-life was increased among patients with EPC compared to those without EPC. Among patients with advanced lung cancer, EPC may optimize patient selection for chemotherapy receipt leading to reduced use of high-intensity therapy by focusing on quality of life in accordance with patients' performance, preferences and goals of care.

10.
Ann Am Thorac Soc ; 15(9): 1005-1015, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30168741

RESUMO

Patient-centered outcomes research (PCOR) represents a paradigm shift in research methods aimed to create the body of evidence that supports clinical practice and informs health care decisions. PCOR integrates patients and other key stakeholders including family members, policy makers, clinicians, and patient advocates and advocacy groups as research partners throughout all stages of the research process. The importance of PCOR has received increased recognition, yet there is little evidence available to help guide researchers interested in the design and conduct of PCOR. In May 2014, we convened a workshop to identify key issues related to designing, conducting, and disseminating findings from PCOR studies. Workshop participants included a diverse group of patients, patient advocates, clinicians (physicians, nurses, psychologists, and advanced practice providers), researchers, administrators, and funders within and beyond the pulmonary, critical care, and sleep medicine communities. Participants identified important issues and considerations to address when undertaking PCOR. In this report, we summarize the results of this workshop to inform members of the pulmonary, sleep, and critical care community interested in participating in PCOR. Key findings include the following: 1) requirements for research to be considered PCOR; 2) the potential significant impact of PCOR on patients, clinicians, and researchers; 3) guiding principles and practical strategies to form successful patient-centered research partnerships, conduct PCOR, and disseminate study results to a broad audience of stakeholders; 4) benefits and challenges of PCOR for researchers; and 5) resources available within the American Thoracic Society to help with the conduct of PCOR.


Assuntos
Cuidados Críticos , Avaliação de Resultados da Assistência ao Paciente , Pneumologia , Medicina do Sono , Educação , Humanos , Sociedades Médicas
12.
Mil Med ; 183(11-12): e402-e408, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29788494

RESUMO

Introduction: Given the high prevalence of smoking among Veterans and the economic, social, and clinical implications, it is important to understand the factors that contribute to smoking in order to focus efforts to mitigate these factors and improve smoking cessation efforts among Veterans. The availability of research on smoking in Veterans compared with civilians is limited given the military-specific differences in their life course. We aimed to identify military-specific factors combined with sociodemographic factors for ever smoking and current smoking among Veterans to inform future interventions. Materials and Methods: We used data from the 2010 National Survey of Veterans, the most current, to analyze the association of sociodemographic and military-specific factors with ever versus never smoking, and current versus past smoking using multiple variable logistic regression models (IRB#4125). Results: Among 8,618 respondents, the proportions of current, past, and never smokers were 17%, 48%, and 34%, respectively. Sociodemographic factors associated with ever smoking were female gender, educational attainment of less than a bachelor's degree, and being divorced/separated/widowed. Military-specific factors associated with ever smoking were exposure to dead/dying/wounded soldiers during service, and past, current, and unsure enrollment in Veterans Affairs healthcare. Never smoking was associated with Hispanic ethnicity, income over $75,000, and reporting fair or poor health. Military factors associated with never smoking were presence of a service-connected disability and military service July 1964 or earlier (i.e., pre-Vietnam). Among 5,652 ever smokers, sociodemographic factors associated with current smoking were age less than 65, being non-Hispanic black, educational attainment of less than a bachelor's degree, being divorced/separated/widowed, never married, and having no insurance. Factors associated with reduced likelihood of current smoking compared with past smoking included income >$41,000 and reporting fair or poor health. Military-specific variables associated with reduced likelihood of current smoking were service era of May 1975 or later (i.e., post-Vietnam) and 5 or more years of service. Conclusion: Military-specific variables are associated with smoking behaviors among Veterans. Findings from this study that exposure to dead/dying/wounded soldiers, service era, duration of service, service-connected disability status, and enrollment in VA care all influence smoking in Veterans, can inform prevention and cessation efforts in part by encouraging alternative healthy habits or cessation techniques in subgroups of Veterans with particular military backgrounds. By assessing risk factors in this unique population future research can leverage these findings to determine mechanisms that help explain these associations. Identifying factors associated with smoking offers insights for smoking cessation and prevention interventions given the military experiences and increased smoking incidence among Veterans.


Assuntos
Fumar/psicologia , Veteranos/psicologia , Adulto , Idoso , Grupos de Populações Continentais/estatística & dados numéricos , Feminino , Humanos , Incidência , Renda/estatística & dados numéricos , Masculino , Estado Civil/estatística & dados numéricos , Pessoa de Meia-Idade , Prevalência , Fumar/epidemiologia , Fumar/fisiopatologia , Inquéritos e Questionários , Estados Unidos/epidemiologia , Veteranos/estatística & dados numéricos
13.
Cancer ; 124(2): 426-433, 2018 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-29023648

RESUMO

BACKGROUND: Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems. METHODS: This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used. RESULTS: From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment. CONCLUSIONS: Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care. Cancer 2018;124:426-33. © 2017 American Cancer Society.


Assuntos
Prestação Integrada de Cuidados de Saúde , Cuidados Paliativos na Terminalidade da Vida , Neoplasias Pulmonares/terapia , Idoso , Feminino , Humanos , Masculino , Estudos Retrospectivos
14.
Ann Am Thorac Soc ; 14(11): 1690-1696, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28489453

RESUMO

RATIONALE: Patient participation in medical decision-making is widely advocated, but outcomes are inconsistent. OBJECTIVES: We examined the associations between medical decision-making roles, and patients' perceptions of their care and knowledge while undergoing pulmonary nodule surveillance. METHODS: The study setting was an academically affiliated Veterans Affairs hospital network in which 121 participants had 319 decision-making encounters. The Control Preferences Scale was used to assess patients' decision-making roles. Associations between decision-making, including role concordance (i.e., agreement between patients' preferred and actual roles), shared decision-making (SDM), and perceptions of care and knowledge, were assessed using logistic regression and generalized estimating equations. RESULTS: Participants had a preferred role in 98% of encounters, and most desired an active role (shared or patient controlled). For some encounters (36%), patients did not report their actual decision-making role, because they did not know what their role was. Role concordance and SDM occurred in 56% and 26% of encounters, respectively. Role concordance was associated with greater satisfaction with medical care (adjusted odds ratio [Adj-OR], 5.39; 95% confidence interval [CI], 1.68-17.26), higher quality of patient-reported care (Adj-OR, 2.86; 95% CI, 1.31-6.27), and more disagreement that care could be better (Adj-OR, 2.16; 95% CI, 1.12-4.16). Role concordance was not associated with improved pulmonary nodule knowledge with respect to lung cancer risk (Adj-OR, 1.12; 95% CI, 0.63-2.00) or nodule information received (Adj-OR, 1.13; 95% CI, 0.31-4.13). SDM was not associated with perceptions of care or knowledge. CONCLUSIONS: Among patients undergoing longitudinal nodule surveillance, a majority had a preference for having active roles in decision-making. Interestingly, during some encounters, patients did not know what their role was or that a decision was being made. Role concordance was associated with greater patient-reported satisfaction and quality of medical care, but not with improved knowledge. Patient participation in decision-making may influence perceptions of care; however, clinicians may need to focus on other communication strategies or domains to improve patient knowledge and health outcomes.


Assuntos
Comunicação , Tomada de Decisões , Conhecimentos, Atitudes e Prática em Saúde , Participação do Paciente , Satisfação do Paciente , Nódulo Pulmonar Solitário/diagnóstico , Idoso , Feminino , Humanos , Modelos Logísticos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/terapia , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Estudos Prospectivos , Medição de Risco , Nódulo Pulmonar Solitário/terapia
15.
Psychooncology ; 26(11): 1763-1769, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27429350

RESUMO

OBJECTIVE: To determine the effectiveness of methylphenidate for depression treatment in patients with advanced cancer. DESIGN: An 18-day randomized, double-blind, placebo-controlled clinical trial of methylphenidate for treatment of depression in selective serotonin reuptake inhibitor-treated patients with advanced cancer in hospice or receiving palliative care. The primary outcome was depression remission, defined as a ≥50% reduction in score on the Montgomery-Asberg Depression Rating Scale. RESULTS: Among 47 enrolled participants, 34 were randomized. At study day 18, 85% of the methylphenidate and 60% of the placebo group were in depression remission (P = .22). Mean time to depression remission was 10.3 days [standard error (SE) 1.8] in the methylphenidate and 8.1 (SE 1.3) in the placebo group (P = .48). The mean baseline score for the Hospital Anxiety and Depression Scale (HADS) was 10.4 in each group and decreased by 3.6 (SE 1.1) in the methylphenidate and 2.3 (SE 1.2) in the placebo group (P = .51) by day 18. Once in remission, 1 methylphenidate and 5 placebo participants relapsed to depression (P = .18). There was no difference in mortality between the groups during the trial. Trial results were limited by small sample size attributed to difficulties in recruiting terminally ill patients. CONCLUSIONS: This trial failed to demonstrate that methylphenidate treatment in selective serotonin reuptake inhibitor-treated patients had a significant effect on depression remission in patients with advanced cancer. This study underscores the difficulties in conducting trials for symptom management in patients with shortened life expectancy.


Assuntos
Estimulantes do Sistema Nervoso Central/uso terapêutico , Depressão/complicações , Depressão/tratamento farmacológico , Metilfenidato/uso terapêutico , Neoplasias/complicações , Neoplasias/psicologia , Cuidados Paliativos/métodos , Adulto , Idoso , Depressão/diagnóstico , Método Duplo-Cego , Feminino , Cuidados Paliativos na Terminalidade da Vida/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Efeito Placebo , Inibidores de Captação de Serotonina/uso terapêutico , Resultado do Tratamento
16.
Oncol Nurs Forum ; 44(1): 108-115, 2017 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-27991611

RESUMO

PURPOSE/OBJECTIVES: To use dyadic analyses to identify determinants of patients' and family members' perceptions of the positive and negative aspects of the decision-making process in families living with lung cancer. 
. DESIGN: Cross-sectional study. 
. SETTING: Community setting in Greater Portland, Oregon.
. SAMPLE: 109 family care dyads (patient and family member) recruited from a statewide cancer registry. 
. METHODS: Surveys were completed in-person, separately, and privately by each member of the family care dyad. Secondary analysis was completed using multilevel modeling. 
. MAIN RESEARCH VARIABLES: Negative and positive aspects of the decision process. 
. FINDINGS: Level 1 data revealed significant variability across care dyads' positive or negative perceptions of the decision-making process. Level 2 results for negative perceptions of decision making indicated that patient and family member perceptions were significantly associated with their own depressive symptoms and feelings of not being listened to by others. Level 2 results for positive perceptions of decision making indicated that patient and family member perceptions were significantly inversely associated with their own feelings of not being listened to and being in nonspousal relationships. In addition, family members' perceptions were more positive when the patients were older. 
. CONCLUSIONS: This study highlighted the complexity of the decision-making process in families with lung cancer, and underscored the importance of the care dyad feeling listened to by family members in the context of life-threatening illnesses. 
. IMPLICATIONS FOR NURSING: Nurses assisting families with decisions about lung cancer should be aware of the dynamics of the care dyad and how the decision process is perceived by patients and their family members.


Assuntos
Adaptação Psicológica , Tomada de Decisões , Família/psicologia , Neoplasias Pulmonares/psicologia , Pacientes/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude Frente a Morte , Atitude Frente a Saúde , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oregon , Inquéritos e Questionários
17.
J Clin Oncol ; 34(33): 3984-3991, 2016 11 20.
Artigo em Inglês | MEDLINE | ID: mdl-27996350

RESUMO

Purpose Depression symptoms are common among patients with lung cancer; however, longitudinal changes and their impact on survival are understudied. Methods This was a prospective, observational study from the Cancer Care Outcomes Research and Surveillance Consortium from five US geographically defined regions from September 2003 through December 2005. Patients enrolled within 3 months of their lung cancer diagnosis were eligible. The eight-item Center for Epidemiologic Studies Depression scale was administered at diagnosis and 12 months' follow-up. The main outcome was survival, which was evaluated using Kaplan-Meyer curves and adjusted Cox proportional hazards modeling. Results Among 1,790 participants, 681 (38%) had depression symptoms at baseline and an additional 105 (14%) developed new-onset depression symptoms during treatment. At baseline, depression symptoms were associated with increased mortality (hazard ratio [HR], 1.17; 95% CI, 1.03 to 1.32; P = .01). Participants were classified into the following four groups based on longitudinal changes in depression symptoms from baseline to follow-up: never depression symptoms (n = 640), new-onset depression symptoms (n = 105), depression symptom remission (n = 156), and persistent depression symptoms (n = 254) and HRs were calculated. Using the never-depression symptoms group as a reference group, HRs were as follows: new-onset depression symptoms, 1.50 (95% CI, 1.12 to 2.01; P = .006); depression symptom remission, 1.02 (95% CI, 0.79 to 1.31; P = .89), and persistent depression symptoms, 1.42 (95% CI, 1.15 to 1.75; P = .001). At baseline, depression symptoms were associated with increased mortality among participants with early-stage disease (stages I and II; HR, 1.61; 95% CI, 1.26 to 2.04), but not late-stage disease (stages III and IV; HR, 1.05; 95% CI, 0.91 to 1.22). At follow-up, depression symptoms were associated with increased mortality among participants with early-stage disease (HR, 1.71; 95% CI, 1.27 to 2.31) and those with late-stage disease (HR, 1.32; 95% CI, 1.04 to 1.69). Conclusion Among patients with lung cancer, longitudinal changes in depression symptoms are associated with differences in mortality, particularly among patients with early-stage disease. Symptom remission is associated with a similar mortality rate as never having had depression.


Assuntos
Depressão/etiologia , Neoplasias Pulmonares/psicologia , Idoso , Depressão/psicologia , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Estudos Longitudinais , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos
19.
NPJ Prim Care Respir Med ; 25: 15028, 2015 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-26028564

RESUMO

BACKGROUND: Hundreds of thousands of incidental pulmonary nodules are detected annually in the United States, and this number will increase with the implementation of lung cancer screening. The lengthy period for active pulmonary nodule surveillance, often several years, is unique among cancer regimens. The psychosocial impact of longitudinal incidental nodule follow-up, however, has not been described. AIMS: We sought to evaluate the psychosocial impact of longitudinal follow-up of incidental nodule detection on patients. METHODS: Veterans who participated in our previous study had yearly follow-up qualitative interviews coinciding with repeat chest imaging. We used conventional content analysis to explore their knowledge of nodules and the follow-up plan, and their distress. RESULTS: Seventeen and six veterans completed the year one and year two interviews, respectively. Over time, most patients continued to have inadequate knowledge of pulmonary nodules and the nodule follow-up plan. They desired and appreciated more information directly from their primary care provider, particularly about their lung cancer risk. Distress diminished over time for most patients, but it increased around the time of follow-up imaging for some, and a small number reported severe distress. CONCLUSIONS: In settings in which pulmonary nodules are commonly detected, including lung cancer screening programmes, resources to optimise patient-centred communication strategies that improve patients' knowledge and reduce distress should be developed.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Neoplasias Pulmonares/diagnóstico , Nódulo Pulmonar Solitário/diagnóstico , Idoso , Feminino , Humanos , Achados Incidentais , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Estresse Psicológico/psicologia , Veteranos
20.
J Thorac Oncol ; 9(7): 927-34, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24922011

RESUMO

INTRODUCTION: Lung cancer screening using low-dose computed tomography (LDCT) is now widely recommended for adults who are current or former heavy smokers. It is important to evaluate the impact of screening on patient-centered outcomes. Among current and former smokers eligible for lung cancer screening, we sought to determine the consequences of screening with LDCT, and subsequent results, on patient-centered outcomes such as quality of life, distress, and anxiety. METHODS: We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth Quarter 2012), MEDLINE (2000 to May 31, 2013), reference lists of articles, and Scopus for relevant English-language studies and systematic reviews. To evaluate the effect of LDCT screening on patient-centered outcomes, we included only randomized controlled trials (RCTs) involving asymptomatic adults. To evaluate the association of particular results and/or recommendations from a screening LDCT with patient-centered outcomes, we included results from RCTs as well as from cohort studies. RESULTS: A total of 8215 abstracts were reviewed. Five publications from two European RCTs and one publication from a cohort study conducted in the United States met inclusion criteria. The process of LDCT lung cancer screening was associated with short-term psychologic discomfort in many people but did not affect distress, worry, or health-related quality of life. False-positive results were associated with short-term increases in distress that returned to levels that were similar to those among people with negative results. Negative results were associated with short-term decreases in distress. CONCLUSIONS: As lung cancer screening is implemented in the general population, it will be important to evaluate its association with patient-centered outcomes. People considering lung cancer screening should be aware of the possibility of distress caused by false-positive results. Clinicians may want to consider tailoring communication strategies that can decrease the distress associated with these results.


Assuntos
Ansiedade/etiologia , Detecção Precoce de Câncer/psicologia , Neoplasias Pulmonares/psicologia , Qualidade de Vida/psicologia , Detecção Precoce de Câncer/métodos , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Assistência Centrada no Paciente , Doses de Radiação , Estresse Psicológico/etiologia , Tomografia Computadorizada por Raios X
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