PC-FACS

Abstract

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at [email protected] Boutron I, Altman DG, Hopewell S, et al. Impact of spin in the abstracts of articles reporting results of randomized controlled trials in the field of cancer: the SPIIN randomized controlled trial. J Clin Oncol 2014;23:4120-4126. Boerebach BC, Scheepers RA, Van der Leeuw RM, et al. The impact of clinicians' personality and their interpersonal behaviors on the quality of patient care: a systematic review. Int J Qual Health Care 2014;26:426-481. Obermeryer Z, Makar M, Abujaber S, et al. Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA 2014;312:1888-1896. Kerr AM, Haas SM. Parental uncertainty in illness: managing uncertainty surrounding an “orphan” illness. J Pediatr Nurs 2014;29:393-400. Sautter JM, Tulsky JA, Johnson KS, et al. Caregiver experience during advanced chronic illness and last year of life. J Am Geriatr Soc 2014;62:1082-1090. Flanders SA, Greene MT, Grant P, et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med 2014;174:1577-1584. Spin, misrepresentation of study findings to positively influence interpretation of statistically nonsignificant randomized controlled trials (RCTs), is a common phenomenon.1,2 What is the effect of spin on clinicians' interpretation of study results? This was a French, two-arm, Web-based, blinded, parallel-group RCT evaluating the impact of spin on clinicians' interpretation of oncology clinical trials. Thirty abstracts of articles describing RCTs with statistically nonsignificant primary outcomes that were reported with spin were systematically rewritten without spin. Eligible participants, all clinicians, included corresponding authors of published trial manuscripts, principal investigators of trials registered in CancerTrials.gov, and grant reviewers for the French National Institute for Cancer Research. Participants were randomized to evaluate one abstract that either did or did not include spin. Primary outcome was clinician interpretation of the beneficial treatment impact, as rated on a 0-10 scale. Participants (N = 300) were mean age 48 years (SD, 10), 78% male, 56% European, 55% in practice more than 15 years, and 49% involved in more than 10 RCTs. Experimental treatments reported by abstracts with spin were rated as more beneficial than the same abstract without spin, with a mean difference of 0.7 (95% CI, 0.1-1.4; P = 0.03), corresponding to an effect size of 0.25. Trials reported with spin were rated as less rigorous (mean difference, -0.6; 95% CI, -1.1 to -0.1; P = 0.03), and clinicians were more interested in reading the full-text of trials with spin (mean difference, 0.8; 95% CI, 0.1-1.5; P = 0.03). These findings are unsurprising. Focusing on the positive results leads even sophisticated researchers to overestimate a drug's beneficial effects. It is interesting that even though the subjects found the trials less rigorous, they were more interested in reading the full-text “spun” trials. I wish the researchers had asked the subjects whether they would have been more likely to use the drug or accept the paper for publication. One wonders if journals should be responsible for writing structured, completely neutral abstracts for such papers. Abstracts that focus on secondary outcomes and do not clearly report the negative primary outcomes lead experienced researchers to overestimate a drug's benefit, a point that should be emphasized when teaching learners how to critically review evidence-based medicine. Robert M. Arnold, MD, FAAHPM, University of Pittsburgh Palliative and Supportive Institute, UPMC Health System, Pittsburgh, PA. Boutron I, Altman DG, Hopewell S, et al. Impact of spin in the abstracts of articles reporting results of randomized controlled trials in the field of cancer: the SPIIN randomized controlled trial. J Clin Oncol 2014;23:4120-4126. 1.Boutron I, Dutton S, Ravaud P, et al. Reporting and interpretation of randomized controlled trials with statistically nonsignificant results for primary outcomes. JAMA 2010;303: 2058-2064.2.Vera-Badillo FE, Shapiro R, Ocana A, et al. Bias in reporting of end points of efficacy and toxicity in randomized, clinical trials for women with breast cancer. Ann Oncol 2013;24:1238-1244. Clinicians' interpersonal behaviors are thought to impact patients' quality-of-care indicators but have not been studied in a comprehensive fashion.1,2 What is the impact of clinicians' personalities and observed interpersonal behaviors on the quality of patient care? This systematic review searched MEDLINE, EMBASE, and PsycINFO through January 2014, supplemented by hand searches, for studies evaluating the impact of clinicians' personalities and observed interpersonal behaviors on the quality of patient care, specifically processes of care and patient outcomes. Eligible studies obtained personality data with validated personality questionnaires. Methodological quality of included studies was assessed by the Medical Education Research Studies Quality Instrument (MERSQI).3 Interpersonal behaviors were categorized as instrumental or affective verbal behavior or as nonverbal behavior. Dimensions of personality were categorized as extraversion, neuroticism, agreeableness, conscientiousness, and openness to experience.4 Eighty-seven articles (88 studies) were included; 46 (53%) were conducted in primary care and 46 (53%) in the United States. Overall, methodological quality was fair to good. Eighty-three studies evaluated interpersonal behavior, 4 evaluated personality; quality of processes of care was an outcome in 70 studies and patient health outcomes in 36 studies. Most studies found no effect of clinicians' personalities or interpersonal behaviors, which included “friendliness,” “dominance,” “empathetic behavior,” “agreeableness,” “extraversion,” and manner of “questioning” on quality of patient care. Some studies found effects for “nervousness,” “nonverbal attention,” and more time spent questioning patients. Inconsistent results were found for “open to experience,” “neuroticism,” and “conscientiousness.” This well-done systematic review showed no consistent effect between physician personality or behaviors and quality process assessments or patient outcomes. Few studies on personality were available for inclusion. Heterogeneity among studies may have limited the ability to ascertain positive associations, especially for behaviors for which there were a small number of studies. Naturally “absence of evidence of effect need not imply evidence of absence of effect.”5 The complexity of providing quality care for patients as individuals may require a variety of clinician behavioral responses. Perhaps this is how team-based structure improves patient outcomes.6 Two additional areas seem important to explore: how individual personality or behavioral traits contribute to team dynamics and success7 and understanding physician behavioral flexibility in response to patient circumstance. There is a lack of compelling evidence linking distinct clinician personality traits or behaviors with improved quality of patient care. Renee Gravois, MD, Palliative Medicine Fellow, and David Nowels, MD, MPH, University of Colorado School of Medicine, Aurora, CO. Boerebach BC, Scheepers RA, Van der Leeuw RM, et al. The impact of clinicians' personality and their interpersonal behaviors on the quality of patient care: a systematic review. Int J Qual Health Care 2014;26:426-481. 1.Lelorain S, Bredart A, Dolbeault S, et al. A systematic review of the associations between empathy measures and patient outcomes in cancer care. Psychooncology 2012;21:1255-1264.2.Venetis MK, Robinson JD, Turkiewicz KL, et al. An evidence base for patient-centered cancer care: a meta-analysis of studies of observed communication between cancer specialists and their patients. Patient Educ Couns 2009;77:379-383.3.Reed DA, Cook DA, Beckman TJ, et al. Association between funding and quality of published medical education research. JAMA 2007;298:1002-1009.4.Barrick MR, Mount MK, Judge TA. Personality and performance at the beginning of the new millennium: what do we know and where do we go next? Int J Select Assess 2001;9:9-30.5.Boerebach BC, Scheepers RA, Van der Leeuw RM, et al. The impact of clinicians' personality and their interpersonal behaviors on the quality of patient care: a systematic review. Int J Qual Health Care 2014;26:426-481.6.Ouwens M, Wollersheim H, Hermann R, et al. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 2005;17:141-146.7.Klarare A, Hagelin CL, Furst CJ, Fossum B. Team interactions in specialized palliative care teams: a qualitative study. J Palliat Med 2013;16:1062-1069. It is unclear how increasing hospice use at the end of life affects health care utilization and costs.1,2 How do resource utilization and cost compare among patients with poor-prognosis cancers who die while enrolled in hospice care versus those who do not? This was a matched cohort study of patients drawn from a nationally representative 20% sample of Medicare fee-for-service beneficiaries with poor-prognosis cancers. Decedents who enrolled in hospice prior to death were matched to similar decedents who did not. The exposure period was the period between hospice enrollment and death for hospice patients and the equivalent period before death for non-hospice patients. Outcome measures included health care utilization and costs during exposure periods. Patient participants (N = 36,330) were mean age 80 years (standard difference, 0), 52% female, 90% solid tumor, and median time from diagnosis to exposure start (interquartile range [IQR]) 166 days (24-757) and 165 days (25-758) for nonhospice and hospice patients, respectively. Median duration exposure start to death was 11 days (IQR, 4-35) for both groups. During the last year of life, more nonhospice than hospice beneficiaries were hospitalized (65%; 95% CI, 64-66 vs. 42%; 95% CI, 42-43) and had higher rates of intensive care admission (36%; 95% CI, 35-37 vs. 15%; 95% CI, 14-15), invasive procedures (51%; 95% CI, 50-52 vs. 27%; 95% CI, 26-27), and institutional death (74%; 95% CI, 74-75 vs. 14%; 95% CI, 14-15). Mean difference for costs in last year of life was $8,697 (95% CI, 7,560-9,835). This is an important study that builds evidence supporting the cost effectiveness of hospice care. For this group of poor-prognosis cancer patients in well-matched cohorts with identical survival, hospice patients had fewer invasive procedures, including CPR; fewer acute admissions for nonterminal illness diagnoses; and fewer deaths in facilities. This translated into cost savings, optimally at 5-8 weeks of care, but even for the 38% of beneficiaries under care for less than one week. This is important evidence, and the study should prompt further evaluation of other terminally ill cohorts, such as patients with noncancer diagnoses, especially cardiac disease and dementia. Similar findings could shape policy decisions on the need for and usefulness of frank goals-of-care discussions and hospice referral. Hospice can avoid nonbeneficial interventions and save costs for poor-prognosis cancer patients. Evaluation of noncancer diagnoses should be the next step to determine if this holds true for other terminally ill patients. Joel S. Policzer, MD, FACP, FAAHPM, VITAS Healthcare, Ft. Lauderdale, FL. Obermeryer Z, Makar M, Abujaber S, et al. Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA 2014;312:1888-1896. 1.Kelley AS, Deb P, Du Q, Aldridge Carlson MD, Morrison RS. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff (Millwood) 2013;32:552-561.2.Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med 2007;65:1466-1478. Parents of children with chronic illnesses experience heightened uncertainty1 associated with decreased sense of control and optimism and higher stress.2 How do parents of children with “orphan” illnesses, receiving care from multiple disciplines, experience and manage uncertainty? This mixed methods study incorporated parent questionnaires, participant observation, and parent discussion. Eligible participants were parents of children with vascular anomalies presenting to a vascular anomaly clinic at a large Midwestern children's hospital. Participants completed the questionnaire, which included open-ended items, before seeing the physician. A subset of parent-child-physician interactions were observed, after which discussions with the researcher (who also has a vascular anomaly) occurred. Open-ended responses and field notes were triangulated and analyzed qualitatively using constant comparison analysis. Parents were 84% female, mean (SD) age 33 (7) years; and 35% new to the clinic. Children were 71% female, mean (SD) age 4 (5) years. Five themes capturing parents' uncertainty experience and management emerged: normalization uncertainty (impact on child's ability to be “normal”); information uncertainty (uncertainty about treatment options stemming from perceived insufficient or conflicting information); orphan-illness uncertainty (uncertainty regarding multisystem or complex health risks); parental proxy uncertainty (assessing symptoms and making decisions on behalf of their child); and social stigma uncertainty (how their child will experience others' reactions). This study illustrates multiple types of parental uncertainty attributed to the complexity of the child's condition and resulting medical care. Parents of children with other complex, serious conditions have similar needs; they may well experience similar uncertainties. Parent uncertainty reflects their need for high-quality information about rare conditions and unpredictable outcomes that adequately addresses their concerns without heightening their sense of uncertainty. Study findings also highlight the many facets of uncertainty experienced by parents. Physicians often focus only on the technical aspects of a diagnosis, framing prognosis in terms of numbers alone or treatment decisions and lists of therapeutic options. Parents, however, need opportunities to discuss their lived illness experience and how the care team can support them in managing and adapting to illness uncertainty. The nature of parent uncertainty is multifaceted and may be best met by an interdisciplinary approach that extends beyond the medical or technical aspects of illness Christina K. Ullrich, MD. MPH. FAAHPM, Dana-Farber Cancer Institute, Boston, MA. Kerr AM, Haas SM. Parental uncertainty in illness: managing uncertainty surrounding an “orphan” illness. J Pediatr Nurs 2014;29:393-400. 1.Cohen MH. The unknown and the unknowable: managing sustained uncertainty. West J Nurs Res 1993;15:77-96.2.Madeo AC, O'Brien KE, Bernhardt BA, Biesecker BB. Factors associated with perceived uncertainty among parents of children with undiagnosed medical conditions. Am J Med Genet A 2012; 158A:1877-1884. Informal caregiving is prevalent in the United States; evidence suggests that emotional and lifestyle burden on caregivers is significant.1,2 What are the experiences of those providing informal care for individuals with late-stage illness? This was a longitudinal cohort study of caregivers for individuals facing late-stage chronic illness. Caregivers participated in the Pathways Study, a study of individuals living with serious illness. Caregivers consisted of two groups: those caring for patients with advanced chronic illness (a) before the last year of life and (b) during the last year of life. Caregivers completed the Caregiver Reaction Assessment (CRA) every 4 weeks for 2 to 6 years. The CRA measures caregiver esteem, family, health, financial, and schedule burden. Covariables included demographics, patient activities of daily living, functional health, and disease severity. Caregiver demographics (n = 124) were 76% female, mean age 58 years, and 61% working. Care receivers (n = 124) were mean age 67 years, 45% suffering from cancer, and 32% high disease severity. Schedule burden was the most commonly reported caregiver experience and the only experience that varied between the two groups (58% in end-of-life care vs. 32% in chronic illness, P = 0.01). Other burdens were stable and similar between groups. Few demographic factors were associated with caregiver outcomes; caregivers who reported higher levels of anxious preoccupation and fatalistic coping styles had greater odds of schedule burden (OR, 3.0; 99% CI, 1.1-8.6 and OR, 4.3; 99% CI, 1.0-18.0, respectively). The most important findings from this study are that caregiver esteem and burden did not vary with the needs of the care recipient, did not significantly change over a one-year period of time, and did not change between chronic illness and the end of life, except for that of schedule burden (a measure of the extent to which caregiving interrupts or eliminates usual daily activities and interferes with relaxation time). Although there are limitations to this study, these findings emphasize the importance of exploring potential problems a caregiver might be experiencing and extending support to caregivers in need, including that of integrated palliative care models, earlier in the disease course and not just at the end of life. Individuals having difficulty with caring for a patient at the end of life are likely to have similar difficulties earlier on in the disease course. Interventions to support caregivers should therefore be aimed throughout the course of a chronic illness. Eric Widera, MD, University of California, San Francisco, San Francisco, CA. Sautter JM, Tulsky JA, Johnson KS, et al. Caregiver experience during advanced chronic illness and last year of life. J Am Geriatr Soc 2014;62:1082-1090. 1.Stajduhar K, Funk L, Toye C, et al. Part 1: Home-based family caregiving at the end of life: a comprehensive review of published quantitative research (1998-2008). Palliat Med 2010;24:573-593.2.Schulz R, Beach SR. Caregiving is a risk factor for mortality: the Caregiver Health Effects Study. JAMA 1999; 282:2215-2219. Pharmacologic prophylaxis for venous thromboembolism (VTE) in at-risk individuals is a quality indicator and may be important in value-based medical reimbursement.1 What is the effect of prophylaxis on outcomes in medically at-risk patients? This was a retrospective, multicenter cohort study of the association between pharmacologic prophylaxis and hospital-associated VTE at 35 Michigan hospitals from January 2011 to September 2012. Eligible patients included those admitted to a medicine service for at least 2 days; those admitted or transferred to an intensive care unit or palliative care service were excluded. Primary outcomes included use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission. Participants were stratified based on their location in high-performance (n = 5514), moderate-performance (n = 7897), or low-performance (n = 7383) hospitals. Patient participants (n = 20,794) were 57% female, mean age 66 years, and median length of stay 4 days. The overall incidence of VTE was 1.28 per 10,000 patient days. Risk increased with length of stay ≥ 5 days (hazard ratio [HR], 2.1; 95% CI, 1.6-2.7); history of cancer (HR, 1.5; 95% CI, 1.1-2.0); and central venous catheters (HR, 2.9; 95% CI, 2.1-3.9). Pharmacologic prophylaxis on admission had no effect on VTE hazard (HR, 1.1; 95% CI, .8-1.5). Risk of VTE was not adversely influenced by poor hospital performance as assessed by HRs, risk-adjusted hazard ratios, or Kaplan-Meier survival estimates. The rate of VTE pharmacologic prophylaxis (VTE ptx) in the hospital is a well-recognized quality measure hospitals scramble to meet. Does conformance to this quality measure lead to improved VTE outcomes? Unfortunately no. Increases in performance on this quality measure (i.e., improved health care processes that ensure patients at risk get VTE ptx) do not lead to improved VTE outcomes. In other words, improving your score on the quality measure doesn't translate to better patient outcomes. A few words of caution: palliative care patients were excluded, and blunt quality measures like these don't inform optimal care of individual patients. Most VTEs occur after hospitalization; the study may have missed significant events. Clearly we must understand relationships between quality measures and patient-level outcomes before widescale implementation. This needs to happen for every quality measure, including those applicable to palliative care. VTE pharmacologic prophylaxis in the hospital may not improve patient outcomes. Amy P. Abernethy, MD, PhD, FAAHPM, Duke University School of Medicine, Durham, NC. Flanders SA, Greene MT, Grant P, et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med 2014;174:1577-1584. 1.Lyman GH, Bohlke K, Khorana AA, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update 2014. J Clin Oncol. 2015 Jan 20. [Epub ahead of print]. PC-FACS Feedback We appreciate your feedback. Help us help you—send your comments to [email protected] PC-FACS was created in 2005 by Founding Editor-in-Chief Amy P. Abernethy, MD, PhD, FACP, FAAHPM. The Academy is deeply grateful to Dr. Abernethy for creating this important publication and for her many contributions to the field of hospice and palliative medicine. PC-FACS is edited by Editor-in-Chief, Donna S. Zhukovsky, MD, FACP, FAAHPM, of the University of Texas M. D. Anderson Cancer Center, and Associate Editor-in-Chief, Mellar P. Davis, MD, FCCP, FAAHPM, of the Taussig Cancer Institute at Cleveland Clinic. All critical summaries are written by Moses Sandrof and Jane Wheeler, MPH. AAHPM thanks the following PC-FACS Editorial Board members for their review of the critical summaries and preparation of the commentaries: Basic Science Egidio Del Fabbro, MD, Senior Section Editor Fidel Davila, MD, MSMM Rony Dev, DO, MS Khurram J. Khan, MD Eric Prommer, MD, FAAHPM Bioethics, Humanities, and Spirituality Francine Rainone, DO, PhD, MS, FAAHPM, Senior Section Editor Robert M. Arnold, MD, FAAHPM Ira Byock, MD, FAAHPM Valencia Clay, MD Hunter Groninger, MD, FAAHPM Jessica A. Moore, DHCE, MA Alan J. Nixon, MB, BCh, BAO, CCFP(C), FAAHPM Gordon Wood, MD, MSci, FAAHPM Geriatrics and Care Transitions Paul Tatum, MD, MSPH, AGSF, CMD, FAAHPM, Senior Section Editor David B. Brecher, MD, FAAFP, FAAHPM Laura C. Hanson, MD, MPH, FAAHPM Sandra Sanchez-Reilly, MD, MSc, AGSF, FAAHPM Eric Widera, MD Hospice, Hospice and Palliative Medicine Interface, and Regulatory Issues Tommie W. Farrell, MD, Senior Section Editor Janet H. Bull, MD, FAAHPM Charles S. Mills, MD, FACP J. Cameron Muir, MD, FAAHPM Joel S. Policzer, MD, FACP, FAAHPM Pediatrics Christina Ullrich, MD, MPH, Senior Section Editor Rene D. Boss, MD, MHS Marcia Levetown, MD, FAAP, FAAHPM Robert C. Macauley, MD, FAAHPM Psychosocial Thomas B. Strouse, MD, Senior Section Editor Steven J. Baumrucker, MD, FAAFP, FAAHPM Myra Glajchen, DSW Stephanie M. Harman, MD, FACP Jane E. Loitman, MD, MBA, FAAHPM David Nowels, MD, MPH Symptom Assessment and Management Stephen J. Bekanich, MD, Senior Section Editor Amy P. Abernethy, MD, FACP, FAAHPM Michael A. Ashburn, MD, MBA, MPH James T. D'Olimpio, MD, FACP, FAAHPM Daniel L. Handel, MD Dana Lustbader, MD, FCCM, FCCP, FAAHPM Aaron Olden, MD, MS Eric Roeland, MD Ad Hoc Reviewers Mary Braun, MD Jeanne-Marie Maher, MD, FACP Lisa E. Thompson, MD Denise G. Waugh, MD, FACEP, FAAHPM PC-FACS is partially supported through an unrestricted educational grant from Purdue Pharma, LP. The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and / or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 8735 W. Higgins Road, Suite 300 Chicago, IL 60631, USA Phone: 847-375-4712 Fax: 877-734-8671 E-mail: Website: www.aahpm.org