Functional Status After Colon Cancer Surgery in Elderly Nursing Home Residents

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/91352/1/jgs3915.pd

Quality-of-Life Outcomes of Treatments for Cutaneous Basal Cell Carcinoma and Squamous Cell Carcinoma

Quality of life is an important treatment outcome for conditions that are rarely fatal, such as cutaneous basal cell carcinoma and squamous cell carcinoma (typically called nonmelanoma skin cancer (NMSC)). The purpose of this study was to compare quality-of-life outcomes of treatments for NMSC. We performed a prospective cohort study of 633 consecutive patients with NMSC diagnosed in 1999 and 2000 and followed for 2 years after treatment at a university-based private practice or a Veterans Affairs clinic. The main outcome was tumor-related quality of life 1 to 2 years after therapy, measured with the 16-item version of Skindex, a validated measure. Skindex scores vary from 0 (best) to 100 (worst) in three domains: Symptoms, Emotions, and Function. Treatments were electrodessication and curettage (ED&C) in 21%, surgical excision in 40%, and Mohs surgery in 39%. Five hundred and eight patients (80%) responded after treatment. Patients treated with excision or Mohs surgery improved in all quality-of-life domains, but quality of life did not improve after ED&C. There was no difference in the amount of improvement after excision or Mohs surgery. For example, mean Skindex Symptom scores improved 9.7 (95% CI: 6.9, 12.5) after excision, 10.2 (7.4, 12.9) after Mohs surgery, and 3.4 (−0.9, 7.6) after ED&C. We conclude that, for NMSC, quality-of-life outcomes were similar after excision and Mohs surgery, and both therapies had better outcomes than ED&C

Screening for Gynecologic Conditions With Pelvic Examination US Preventive Services Task Force Recommendation Statement

IMPORTANCE Many conditions that can affect women\u27s health are often evaluated through pelvic examination. Although the pelvic examination is a common part of the physical examination, it is unclear whether performing screening pelvic examinations in asymptomatic women has a significant effect on disease morbidity and mortality. OBJECTIVE To issue a new US Preventive Services Task Force(USPSTF) recommendation on screening for gynecologic conditions with pelvic examination for conditions other than cervical cancer, gonorrhea, and chlamydia, for which the USPSTF has already made specific recommendations. EVIDENCE REVIEW The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women 18 years and older who are not at increased risk for any specific gynecologic condition. FINDINGS Overall, the USPSTF found inadequate evidence on screening pelvic examinations for the early detection and treatment of a range of gynecologic conditions in asymptomatic, nonpregnant adult women. CONCLUSIONS AND RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women. (I statement) This statement does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Papanicolaou smear, screening for gonorrhea and chlamydia)

What’s in a Name? Use of Brand versus Generic Drug Names in United States Outpatient Practice

BACKGROUND: The use of brand rather than generic names for medications can increase health care costs. However, little is known at a national level about how often physicians refer to drugs using their brand or generic names. OBJECTIVE: To evaluate how often physicians refer to drugs using brand or generic terminology. DESIGN AND PARTICIPANTS: We used data from the 2003 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of 25,288 community-based outpatient visits in the United States. After each visit, patient medications were recorded on a survey encounter form by the treating physician or transcribed from office notes. MEASUREMENTS: Our main outcome measure was the frequency with which medications were recorded on the encounter form using their brand or generic names. RESULTS: For 20 commonly used drugs, the median frequency of brand name use was 98% (interquartile range, 81–100%). Among 12 medications with no generic competition at the time of the survey, the median frequency of brand name use was 100% (range 92–100%). Among 8 medications with generic competition at the time of the survey (“multisource” drugs), the median frequency of brand name use was 79% (range 0–98%; P < .001 for difference between drugs with and without generic competition). CONCLUSIONS: Physicians refer to most medications by their brand names, including drugs with generic formulations. This may lead to higher health care costs by promoting the use of brand-name products when generic alternatives are available

Screening for Syphilis Infection in Nonpregnant Adults and Adolescents: US Preventive Services Task Force Recommendation Statement

Clinical Review & Education US Preventive Services Task Force | RECOMMENDATION STATEMENT Screening for Syphilis Infection in Nonpregnant Adults and Adolescents US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force (USPSTF) Editorial page 2281 IMPORTANCE In 2014, 19 999 cases of syphilis were reported in the United States. Left untreated, syphilis can progress to late-stage disease in about 15% of persons who are infected. Late-stage syphilis can lead to development of inflammatory lesions throughout the body, which can lead to cardiovascular or organ dysfunction. Syphilis infection also increases the risk for acquiring or transmitting HIV infection. OBJECTIVE To update the 2004 US Preventive Services Task Force (USPSTF) recommendation on screening for syphilis infection in nonpregnant adults. Screening for syphilis in pregnant women was updated in a separate recommendation statement in 2009 (A recommendation). EVIDENCE REVIEW The USPSTF reviewed the evidence on screening for syphilis infection in asymptomatic, nonpregnant adults and adolescents, including patients coinfected with other sexually transmitted infections (such as HIV). Author Audio Interview at jama.com Related article page 2328 and JAMA Patient Page page 2367 CME Quiz at jamanetworkcme.com and CME Questions page 2342 Related articles at jamadermatology.com, jamaneurology.com, jamapediatrics.com FINDINGS The USPSTF found convincing evidence that screening for syphilis infection in asymptomatic, nonpregnant persons at increased risk for infection provides substantial benefit. Accurate screening tests are available to identify syphilis infection in populations at increased risk. Effective treatment with antibiotics can prevent progression to late-stage disease, with small associated harms, providing an overall substantial health benefit. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. (A recommendation) Authors/Group Information: The USPSTF members are listed at the end of the article. JAMA. 2016;315(21):2321-2327. doi:10.1001/jama.2016.5824 Corresponding Author: Kirsten Bibbins-Domingo, PhD, MD, MAS ([email protected]). T he US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the bal- ance. The USPSTF does not consider the costs of providing a ser- vice in this assessment. The USPSTF recognizes that clinical decisions involve more con- siderations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clini- cal benefits and harms. Summary of Recommendation and Evidence The USPSTF recommends screening for syphilis infection in per- sons who are at increased risk for infection. (A recommendation) (Figure 1) jama.com See the Clinical Considerations section later in this article for in- formation on risk factors for infection. Rationale Importance The number of cases of primary and secondary syphilis have been in- creasing since 2000. In 2014, 19 999 cases (6.3 cases per 100 000 persons)ofprimaryandsecondarysyphiliswerereportedintheUnited States. 1 Left untreated, syphilis can progress to late-stage disease in approximately 15% of persons who are infected. 2 Consequences of late-stage syphilis include development of inflammatory lesions throughout the body (eg, aortitis, gummatous lesions, and osteitis), which can lead to cardiovascular or organ dysfunction. Syphilis in- fection of the central nervous system (neurosyphilis) can occur at any stage of disease and can result in blindness, paresis, tabes dor- salis, and dementia. Syphilis infection also increases the risk for ac- quiring or transmitting HIV infection. The USPSTF addresses screening for syphilis in pregnant women in a separate recommendation statement. 3 (Reprinted) JAMA June 7, 2016 Volume 315, Number 21 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by a University of California - Los Angeles User on 09/21/201

Characteristics and Impact of Drug Detailing for Gabapentin

BACKGROUND: Sales visits by pharmaceutical representatives (“drug detailing”) are common, but little is known about the content of these visits or about the impact of visit characteristics on prescribing behavior. In this study, we evaluated the content and impact of detail visits for gabapentin by analyzing market research forms completed by physicians after receiving a detail visit for this drug. METHODS AND FINDINGS: Market research forms that describe detail visits for gabapentin became available through litigation that alleged that gabapentin was promoted for “off-label” uses. Forms were available for 97 physicians reporting on 116 detail visits between 1995 and 1999. Three-quarters of recorded visits (91/116) occurred in 1996. Two-thirds of visits (72/107) were 5 minutes or less in duration, 65% (73/113) were rated of high informational value, and 39% (42/107) were accompanied by the delivery or promise of samples. During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the “main message” of the visit involved at least one off-label use. After receiving the detail visit, 46% (50/108) of physicians reported the intention to increase their prescribing or recommending of gabapentin in the future. In multivariable analysis, intent to increase future use or recommendation of gabapentin was associated with receiving the detail in a small group (versus one-on-one) setting and with low or absent baseline use of the drug, but not with other factors such as visit duration, discussion of “on-label” versus “off-label” content, and the perceived informational value of the presentation. CONCLUSIONS: Detail visits for gabapentin were of high perceived informational value and often involved messages about unapproved uses. Despite their short duration, detail visits were frequently followed by physician intentions to increase their future recommending or prescribing of the drug

Clinical Care in the Aging Century-Announcing "Care of the Aging Patient: From Evidence to Action"

The aging of the global population will be a hallmark of the 21st century, when average lifespan may reach 100 years in some countries, at least for women.1 Worldwide, the proportion of the population aged 60 years or older is expected to increase from 10% worldwide in 2005 to 22% in 2050, with the steepest rise in the next 25 years.2 Individuals aged 85 years or older are the most rapidly increasing segment of many populations. By 2100, more than half of the population of Japan will be aged 60 years or older, as will more than one-third of individuals in every region except sub-Saharan Africa.2 Aging will shape societies, economies, the lives of patients, and the practice of medicine. In the \u93aging century,\u94 life in the 10th decade will be a new frontier for medicine and society\u97a part of life about which medicine now knows relatively ..

Acute Care for Elders Units: Practical Considerations for Optimizing Health Outcomes

Older patients often experience a loss of independent physical functioning during the course of an acute illness that requires hospitalization. Although functional outcomes are not usually the focus of care in the hospital, they may be critical determinants of the quality of life, physical independence, cost of care, and prognosis among older patients. Based on a conceptual model of the dysfunctional syndrome (functional decline associated with hospitalization) we developed, implemented and evaluated a multi-component intervention termed Acute Care for Elders (ACE), in hospital medical units of two urban hospitals. ACE is a model of care that combines the principles of geriatric assessment and quality improvement. The ACE intervention includes a prepared environment (environmental modification), patient-centered care (interdisciplinary assessment), interdisciplinary team rounds and planning for home, and medical care review. Results of randomized clinical trials support the effectiveness of ACE to improve outcomes of hospitalization for older patients. Improved functional status, lower risk of nursing home placement and higher levels of patient and professional satisfaction with care are achievable with ACE. The challenges of establishing an ACE unit in community hospitals can be met through a systematic process of implementation and evaluation. ACE is a multi-component intervention that is potentially transportable to other hospital units, with benefits for patients, health professionals and hospital administrators.Disease-management-programmes, Elderly

Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? No

Obtaining definitive evidence on the effects of large scale interventions can be difficult. Bernard Crump (doi: 10.1136/bmj.a145) believes that implementation with careful monitoring is justified but Seth Landefeld and colleagues argue that acting without proof is both costly and potentially damaging to healt

Discussion of medical errors in morbidity and mortality conferences.

CONTEXT: Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal. OBJECTIVE: To determine the frequency at which morbidity and mortality conference case presentations include adverse events and errors and whether the errors are discussed and attributed to a particular cause. DESIGN, SETTING, AND PARTICIPANTS: Prospective survey conducted by trained physician observers from July 2000 through April 2001 on 332 morbidity and mortality conference case presentations and discussions in internal medicine (n = 100) and surgery (n = 232) at 4 US academic hospitals. MAIN OUTCOME MEASURES: Frequencies of presentation of adverse events and errors, discussion of errors, and attribution of errors. RESULTS: In internal medicine morbidity and mortality conferences, case presentations and discussions were 3 times longer than in surgery conferences (34.1 minutes vs 11.7 minutes; P =.001), more time was spent listening to invited speakers (43.1% vs 0%; PCONCLUSIONS: Our findings call into question whether adverse events and errors are routinely discussed in internal medicine training programs. Although adverse events and errors were discussed frequently in surgery cases, teachers in both surgery and internal medicine missed opportunities to model recognition of error and to use explicit language in error discussion by acknowledging their personal experiences with error