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Shahnaz Sultan,1–4 Melissa R Partin,1,2 Phalgoon Shah,5 Jennifer LeLaurin,4 Ivette Magaly Freytes,4 Chandylen L Nightingale,6 Susan F Fesperman,4 Barbara A Curbow,7 Rebecca J Beyth3,4,8 1Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, 2Department of Medicine, University of Minnesota, Minneapolis, MN, 3Department of Medicine, University of Florida College of Medicine, Gainesville, FL, 4Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL, 5Department of Medicine, Tripler Army Medical Center, Honolulu, HI, 6Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem NC, 7Department of Community and Behavioral Health, University of Maryland, College Park, MD, 8Geriatric Research, Education and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA Background: A recommendation to undergo a colonoscopy, an invasive procedure that requires commitment and motivation, planning (scheduling and finding a driver) and preparation (diet restriction and laxative consumption), may be uniquely challenging for individuals with multiple chronic conditions (MCCs). This qualitative study aimed to describe the barriers and facilitators to colonoscopy experienced by such patients.Materials and methods: Semistructured focus groups were conducted with male Veterans who were scheduled for outpatient colonoscopy and either failed to complete the procedure or completed the examination. Focus group recordings were transcribed and analyzed by an inductive grounded approach using constant comparative analysis.Results: Forty-four individuals aged 51–83 years participated in this study (23 adherent and 21 nonadherent). Participants had an average of 7.4 chronic conditions (range 2–14). The five most common chronic conditions were hypertension (75%), hyperlipidemia (75%), osteoarthritis/degenerative joint disease (59%), atherosclerotic heart disease (48%), and diabetes mellitus (36%). We identified four unique themes that influenced motivation to undergo a colonoscopy: competing medical priorities, low perceived benefit, a prior negative colonoscopy experience, and pre-existing medical conditions. Additionally, we identified four themes that influenced individuals’ ability to complete the examination: difficulty with bowel cleansing, difficulty with travel, worry about exacerbation of pre-existing conditions, and heightened concerns about potential complications.Conclusion: MCCs are common in individuals referred for colonoscopy and generate unique barriers to colonoscopy completion related to medication, dietary changes, transportation, preparation processes, symptoms exacerbation, and complication concerns. Future research should examine whether tailored interventions that include education and support in addressing the unique barriers can enhance colonoscopy completion. Keywords: adherence, colonoscopy barriers, multiple chronic conditions, Veterans

Molly W Mandernach,1 Rebecca J Beyth,1,2 Anita Rajasekhar11Division of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, FL, USA; 2North Florida/South Georgia Veterans Health System (NF/SGVHS), Geriatric Research, Education and Clinical Center (GRECC), Gainesville, Florida Abstract: Venous thromboembolism (VTE) results in significant morbidity and mortality. The prevention and treatment of VTE is managed with anticoagulant therapy, historically parenteral anticoagulants such as unfractionated heparin, low molecular weight heparin, and fondaparinux, and oral vitamin K antagonists such as warfarin. In the last few years, several target-specific oral anticoagulants have been developed, including the direct thrombin inhibitor dabigatran and anti-Xa inhibitors rivaroxaban, apixaban, and edoxaban. The target-specific oral anticoagulants have proven to be noninferior to vitamin K antagonists and heparins in the prevention and treatment of VTE. This review will focus on the pharmacology, clinical trial data, and laboratory assessment of apixaban. Moreover, perioperative management, use in special populations, and management of bleeding complications in patients taking apixaban for the prevention and treatment of VTE will also be discussed. Keywords: venous thromboembolism, apixaban, new oral anticoagulant, target-specific oral anticoagulant, thromboprophylaxis

Background: Recent guidelines emphasize the need to assess and treat overall risk for cardiovascular disease through the concomitant management of multiple risk factors. We sought to ascertain treatment patterns and attainment of therapeutic goals in patients with isolated and concomitant hypertension and dyslipidemia, both with and without diabetes mellitus (DM) and symptomatic cardiovascular disease.Methods: Inception cohorts of more than 41,000 newly diagnosed hypertension and dyslipidemia patients from 6 medical centers of the south-central Veterans Affairs health care system were evaluated. Treatment patterns and goal attainment for low-density lipoprotein cholesterol (LDL-C; Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults guidelines: <160, <130, or Results: Treatment rates in patients with and without DM and symptomatic disease ranged from 46.6% to 71.3% in patients with hypertension only, from 31.5% to 64.1% in patients with dyslipidemia only, and from 64.3% to 91.3% in patients with both conditions. Among asymptomatic patients, 40.6% of nondiabetics and 20.6% of patients with DM with isolated hypertension reached BP targets. Attainment of LDL-C goals was slightly higher and reached 52.8% among patients with DM with concomitant hypertension. Among symptomatic patients, attainment of all goals was <40% for all groups. The proportion of asymptomatic patients with concomitant disease reaching goal for both BP and LDL-C was 24.4% among nondiabetics and 15.4% among patients with DM; these proportions decreased to 13.6% and 13.4% respectively, among patients with symptomatic cardiovascular disease.Conclusions: The majority of patients were receiving pharmacological treatment of hypertension and dyslipidemia, yet attainment of therapeutic goals was generally <50%. Further work is needed to determine factors related to improvement in management and outcomes of patients with multiple cardiovascular risk factors. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) tube placement is a widely used method for long-term enteral feeding of demented patients unable to take sufficient food by mouth. National time trends in PEG tube use over the last decade have not been previously reported. The objective of this study was to determine whether use of PEG tubes for patients with dementia has changed over time and by race. DESIGN: Retrospective cohort study. SETTING: All Veterans Affairs hospitals. PARTICIPANTS: Using an administrative database of the Veterans Health Administration, all veterans with dementia and all veterans who received a PEG tube were identified between fiscal years 1990-2001. MEASUREMENTS: Proportion of PEG tube placement for dementia patients over time and by race. RESULTS: Four hundred thirteen thousand six hundred twenty-seven dementia patients aged 60 and older were identified, of whom 6,464 (1.6%) received a PEG tube. Use of PEG tubes for dementia patients increased during the first half of the decade but subsequently decreased almost to baseline after peaking in 1996 (1990: 1.2%, 1996: 1.8%, 2001: 1.3%). Time trends in the use of PEG tube feeding for dementia patients varied by race. Specifically, the relative risk for PEG tube placement in African-American dementia patients increased from 1.65 (95% confidence interval (CI)=1.25-2.17, FY 1990) to 1.97 (95% CI=1.62-2.4, FY 2001). CONCLUSION: Although the overall use of PEG tube feeding for dementia patients decreased over time, rates in use and changes in use over time varied significantly by race. Reasons for the differential use of this procedure should be explored. [ABSTRACT FROM AUTHOR]

Background: Warfarin is effective in the treatment and prevention of many venous thromboembolic disorders, but it often leads to bleeding.Objective: To develop a multicomponent program of management of warfarin therapy and to determine its effect on the frequency of warfarin-related major bleeding in older patients.Design: Randomized, controlled trial.Setting: University hospital in Cleveland, Ohio.Patients: 325 patients 65 years of age or older who started warfarin therapy during hospitalization.Interventions: Patients were stratified according to baseline risk for major bleeding and were randomly assigned to receive the intervention (n = 163) or usual care (n = 162) by their primary physicians for 6 months. The intervention consisted of patient education about warfarin, training to increase patient participation, self-monitoring of prothrombin time, and guideline-based management of warfarin dosing.Measurements: Major bleeding, death, recurrent venous thromboembolism, and therapeutic control of anticoagulant therapy at 6 months.Results: In an intention-to-treat analysis, major bleeding was more common at 6 months in the usual care group than in the intervention group (cumulative incidence, 12% vs. 5.6%; P = 0.0498, log-rank test). The most frequent site of major bleeding in both groups was the gastrointestinal tract. Death and recurrent venous thromboembolism occurred with similar frequency in both groups at 6 months. Throughout 6 months, the proportion of total treatment time during which the international normalized ratio was within the therapeutic range was higher in the intervention group than in the usual care group (56% vs. 32%; P < 0.001). After 6 months, major bleeding occurred with similar frequencies in the intervention and usual care groups.Conclusions: A multicomponent comprehensive program of warfarin management reduced the frequency of major bleeding in older patients. Although the generalizability and cost-effectiveness of this program remain to be demonstrated, these findings support the premise that efforts to reduce the likelihood of major bleeding will lead to safe and effective use of warfarin therapy in older patients. [ABSTRACT FROM AUTHOR]

This chapter about hemorrhagic complications of anticoagulant treatment is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Bleeding is the major complication of anticoagulant therapy. The criteria for defining the severity of bleeding varies considerably between studies, accounting in part for the variation in the rates of bleeding reported. The major determinants of vitamin K antagonist-induced bleeding are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. There is good evidence that vitamin K antagonist therapy, targeted international normalized ratio (INR) of 2.5 (range, 2.0 to 3.0), is associated with a lower risk of bleeding than therapy targeted at an INR > 3.0. The risk of bleeding associated with IV unfractionated heparin (UFH) in patients with acute venous thromboembolism (VTE) is < 3% in recent trials. This bleeding risk may increase with increasing heparin dosages and age (> 70 years). Low molecular weight heparin (LMWH) is associated with less major bleeding compared with UFH in acute VTE. UFH and LMWH are not associated with an increase in major bleeding in ischemic coronary syndromes, but are associated with an increase in major bleeding in ischemic stroke. Information on bleeding associated with the newer generation of antithrombotic agents has begun to emerge. In terms of treatment decision making for anticoagulant therapy, bleeding risk cannot be considered alone, ie, the potential decrease in thromboembolism must be balanced against the potential increased bleeding risk. [ABSTRACT FROM AUTHOR]

Objective: Previous studies have shown racial/ethnic differences in preferences for end-of-life (EOL) care. We aimed to describe values and beliefs guiding physicians' EOL decision-making and explore the relationship between physicians' race/ethnicity and their decision-making.Methods: Seven focus groups (3 Caucasian, 2 African American, 2 Hispanic) with internists and subspecialists (n=26) were conducted. Investigators independently analyzed transcripts, assigned codes, compared findings, reconciled differences, and developed themes.Results: Four themes appeared to transcend physicians' race/ethnicity: (1) strong support for the physician's role; (2) responding to "unreasonable" requests; (3) organizational factors; and (4) physician training and comfort with discussing EOL care. Five themes physicians seemed to manage differently based on race/ethnicity: (1) preventing and reducing the burden of surrogate decision-making; (2) responding to requests for "doing everything;" (3) influence of physician-patient racial/ethnic concordance/discordance; (4) cultural differences concerning truth-telling; and (5) spirituality and religious beliefs.Conclusions: Physicians in our multi-racial/ethnic sample emphasized their commitment to their professional role in EOL decision-making. Implicitly invoking the professional virtue of self-effacement, they were able to identify racially/ethnically common and diverse ethical challenges of EOL decision-making.Practice Implications: Physicians should use professional virtues to tailor the EOL decision-making process in response to patients' race/ethnicity, based on patients' preferences. [ABSTRACT FROM AUTHOR]

Objectives: Medical errors attributable to inattentional blindness (IAB) may contribute to adverse patient outcomes. IAB has not been studied in the context of reviewing written radiological reports. This cross-sectional, deception-controlled study measures IAB of physicians towards an unexpected stimulus while interpreting written radiological reports., Methods: Physicians and residents from multiple fields were asked to interpret four radiology text reports. Embedded in one was an unexpected stimulus (either an abnormally placed medical exam finding or a non-medical quote from the popular television show Doctor Who ). Primary outcomes were differences in detection rates for the two stimuli. Secondary outcomes were differences in detection rates based on level of training and specialty., Results: The unexpected stimulus was detected by 47.8% ( n = 43) of participants; the non-medical stimulus was detected more often than the medical stimulus (75.0% vs  21.7%, odds ratio 10.8, 95% confidence interval 4.1-28.7; p < 0.0001). No differences in outcomes were observed between training levels or specialties., Conclusion: Only a minority of physicians successfully detected an unexpected stimulus while interpreting written radiological reports. They were more likely to detect an abnormal non-medical stimulus than a medical stimulus. Findings were independent of the level of training or field of medical practice., Advances in Knowledge: This study is the first to show that IAB is indeed present among internal medicine, family medicine, and emergency medicine providers when interpreting written radiology reports., (© 2021 The Authors. Published by the British Institute of Radiology.)

Background and Aims: Data on colorectal EMR (C-EMR) training are lacking. We aimed to evaluate C-EMR training among advanced endoscopy fellows (AEFs) by using a standardized assessment tool (STAT)., Methods: This multicenter prospective study used a STAT to grade AEF training in C-EMR during their 12-month fellowship. Cumulative sum analysis was used to establish learning curves and competence for cognitive and technical components of C-EMR and overall performance. Sensitivity analysis was performed by varying failure rates. AEFs completed a self-assessment questionnaire to assess their comfort level with performing C-EMR at the completion of their fellowship., Results: Six AEFs (189 C-EMRs; mean per AEF, 31.5 ± 18.5) were included. Mean polyp size was 24.3 ± 12.6 mm, and mean procedure time was 22.6 ± 16.1 minutes. Learning curve analyses revealed that less than 50% of AEFs achieved competence for key cognitive and technical C-EMR endpoints. All 6 AEFs reported feeling comfortable performing C-EMR independently at the end of their training, although only 2 of them achieved competence in their overall performance. The minimum threshold to achieve competence in these 2 AEFs was 25 C-EMRs., Conclusions: A relatively low proportion of AEFs achieved competence on key cognitive and technical aspects of C-EMR during their 12-month fellowship. The relatively low number of C-EMRs performed by AEFs may be insufficient to achieve competence, in spite of their self-reported readiness for independent practice. These pilot data serve as an initial framework for competence threshold, and suggest the need for validated tools for formal C-EMR training assessment., (Copyright © 2021. Published by Elsevier Inc.)

Background: The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically., Objective: The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient's transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions., Methods: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers' Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers' burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors' functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel., Results: Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021., Conclusions: This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke., Trial Registration: ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131., International Registered Report Identifier (irrid): DERR1-10.2196/21799., (©Jennifer H LeLaurin, Avi H Lamba, Nathaniel D Eliazar-Macke, Magda K Schmitzberger, I Magaly Freytes, Stuti Dang, W Bruce Vogel, Charles E Levy, S Angelina Klanchar, Rebecca J Beyth, Ronald I Shorr, Constance R Uphold. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 11.11.2020.)

Clock gene dysregulation has been shown to underlie various sleep disorders and may lead to negative cardio-metabolic outcomes. However, the association between sleep apnea (SA) and core clock gene expression is unclear. We performed a cross-sectional analysis of 49 Veterans enrolled in a study of SA outcomes in veterans with chronic kidney disease, not selected for SA or sleep complaints. All participants underwent full polysomnography and next morning whole blood collection for clock gene expression. We defined SA as an apnea-hypopnea index ≥15 events/h; nocturnal hypoxemia(NH) was defined as ≥10% of total sleep time spent at <90% oxygen saturation. We used quantitative real-time PCR to compare the relative gene expression of clock genes between those with and without SA or NH. Clock genes studied were Bmal1, Ck1δ, Ck1ε, Clock, Cry1, Cry2, NPAS2, Per1, Per2, Per3, Rev-Erb-α, RORα, and Timeless. Our cohort was 90% male, mean age was 71 yr (SD 11), mean body mass index was 30 kg/m 2 (SD 5); 41% had SA, and 27% had NH. Compared with those without SA, Per3 expression was reduced by 35% in SA ( P = 0.027). Compared with those without NH, NPAS2, Per1, and Rev-Erb-α expression was reduced in NH (50.4%, P = 0.027; 28.7%, P = 0.014; 31%, P = 0.040, respectively). There was no statistical difference in expression of the remaining clock genes by SA or NH status. Our findings suggest that SA or related NH and clock gene expression may be interrelated. Future study of 24 h clock gene expression in SA is needed to establish the role of clock gene regulation on the pathway between SA and cardio-metabolic outcomes.

Background: Despite efforts by professional societies to reduce low value care, many reports indicate that unnecessary tests, such as nuclear myocardial perfusion imaging (MPI), are commonly used in contemporary practice. The degree to which lack of awareness and professional liability concerns drive these behaviors warrants further study. We sought to investigate patient and provider perceptions about MPI in asymptomatic patients, the Choosing Wisely (CW) campaign, and professional liability concerns., Methods: We administered an anonymous, paper-based survey with both discrete and open-response queries to subjects in multiple outpatient settings at our facilities. The survey was completed by 456 respondents including 342 patients and 114 physicians and advanced practice providers between May and August 2014. Our outcome was to compare patient and provider perceptions about MPI in asymptomatic patients and related factors., Results: Patients were more likely than providers to report that MPI was justified for asymptomatic patients (e.g. asymptomatic with family history of heart disease 75% versus 9.2%, p < 0.0001). In free responses to the question "What would be an inappropriate reason for MPI?" many responses echoed the goals of CW (for example, "If you don't have symptoms", "If the test is too risky", "For screening or in asymptomatic patients"). A minority of providers were aware of CW while even fewer patients were aware (37.2% versus 2.7%, p < 0.0001). Over one third of providers (38.9%) admitted to ordering MPI out of concern for professional liability including 48.3% of VA affiliated providers., Conclusions: While some patients and providers are aware of the low value of MPI in patients without symptoms, others are enthusiastic to use it for a variety of scenarios. Concerns about professional liability likely contribute, even in the VA setting. Awareness of the Choosing Wisely campaign is low in both groups.

Background: Osteoporotic fractures are associated with high morbidity, mortality, and cost., Methods: We performed a post hoc analysis of the Women's Health Initiative (WHI) clinical trials data to assess osteoporosis treatment and identify participant characteristics associated with utilization of osteoporosis medication(s) after new diagnoses of osteoporosis or fracture. Information from visits prior to and immediately subsequent to the first fracture event or osteoporosis diagnosis were evaluated for medication use. A full logistic regression model was used to identify factors predictive of osteoporosis medication use after a fracture or a diagnosis of osteoporosis., Results: The median length of follow-up from enrollment to the last WHI clinic visit for the study cohort was 13.9 years. Among the 13,990 women who reported new diagnoses of osteoporosis or fracture between enrollment and their final WHI visit, and also had medication data available, 21.6% reported taking an osteoporosis medication other than estrogen. Higher daily calcium intake, diagnosis of osteoporosis alone or both osteoporosis and fracture (compared with diagnosis of fracture alone), Asian or Pacific Islander race/ethnicity (compared with White/Caucasian), higher income, and hormone therapy use (past or present) were associated with significantly higher likelihood of osteoporosis pharmacotherapy. Women with Black/African American race/ethnicity (compared with White/Caucasian), body mass index ≥30 (compared with body mass index of 18.5-24.9), current tobacco use (compared with past use or lifetime nonusers), and history of arthritis were less likely to use osteoporosis treatment., Conclusion: Despite well-established treatment guidelines in postmenopausal women with osteoporosis or history of fractures, pharmacotherapy use was suboptimal in this study. Initiation of osteoporosis treatment after fragility fracture may represent an opportunity to improve later outcomes in these high-risk women. Specific attention needs to be paid to increasing treatment among women with fragility fractures, obesity, current tobacco use, history of arthritis, or of Black race/ethnicity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI., Methods: We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention., Results: A total of 889 MPI were evaluated (n=287 pre, n=313 post, n=289 late-post), 95.3% were men. Chest pain was the most common symptom (n=530, 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% in the late-post cohort (p<0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p≤0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI., Conclusions: In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered., Competing Interests: Competing interests: None declared.

Background: The World Wide Web and social media provide the public with access to medical information unlike any other time in human history. However, the quality of content related to cardiac stress testing is not well understood., Objective: The aim of our study was to evaluate the quality of content on the Internet relating to the use of cardiac nuclear stress testing and the Choosing Wisely campaign., Methods: We searched the World Wide Web, Google Video (including YouTube), and Twitter for information relating to these two topics. Searches were performed using English language terms from a computer in the United States not logged into any personal user accounts. Search results were reviewed for discussion of specific topics including radiation risk, accuracy of testing, alternative testing options, and discouragement of inappropriate test use., Results: We evaluated a total of 348 items of content from our searches. Relevant search results for Choosing Wisely were fewer than for other search terms (45 vs 303). We did not find any content which encouraged inappropriate testing (ie, screening in low risk individuals or testing prior to low risk operations). Content related to Choosing Wisely was more likely to discourage inappropriate testing than search results for other terms (29/45, 64% vs 12/303, 4.0%, odds ratio 43.95, 95% CI 17.6-112.2, P<.001)., Conclusions: The Internet content on nuclear stress tests consistently discouraged inappropriate testing. The Choosing Wisely content was more likely to discourage inappropriate testing, less relevant content was available. Generating authoritative content on the Internet relating to judicious use of medical interventions may be an important role for the Choosing Wisely campaign., (©David E Winchester, Diana Baxter, Merry J Markham, Rebecca J Beyth. Originally published in the Interactive Journal of Medical Research (http://www.i-jmr.org/), 04.05.2017.)

Smoking is a potential risk factor for age-related cognitive decline. To date, no study has examined the association between smoking and cognitive decline in men living with human immunodeficiency virus (HIV). The aim of this present study is to examine whether smoking status and severity in midlife is associated with a rate of decline in cognitive processing speed among older HIV-seropositive and HIV-seronegative men who have sex with men. Data from 591 older HIV-seropositive and HIV-seronegative men who have sex with men from the Multicenter AIDS Cohort Study were examined. All participants had information on smoking history collected before age 50 years and at least 5 years of follow-up after age 50. Smoking history was categorized as never smoker, former smoker, and current smoker and cumulative pack years was calculated. The raw scores of three neuropsychological tests (Trail Making A, Trail Making B, and Symbol Digit Modalities tests) were log transformed (Trail Making A and B) and used in linear mixed models to determine associations between smoking history and at least subsequent 5-year decline in cognitive processing speed. There were no significant differences in the rates of neurological decline among never smokers, former smokers, and current smokers. Findings were similar among HIV-seropositive participants. However, an increase of 5 pack-years was statistically significantly associated with a greater rate of decline in the Trail Making Test B score and Composite Score (β -0.0250 [95% CI, -0.0095 to -0.0006] and -0.0077 [95% CI, -0.0153 to -0.0002], respectively). We found no significant association between smoking treated as a categorical variable (never smoked, former smoker, or current smoker) and a small change in every increase of 5 pack-years on measures of psychomotor speed and cognitive flexibility. To optimize healthy aging, interventions for smoking cessation should be tailored to men who have sex with men.

Background: The prevalence of ischemia on nuclear myocardial perfusion imaging (MPI) has been decreasing. Recent research has questioned the benefit of invasive revascularization for patients with moderate to severe ischemia. We hypothesized that patients with moderate to severe ischemia could routinely undergo successful revascularization., Methods: We analyzed data from 544 patients who underwent an MPI at a single academic Veterans Affairs Medical Center. Patients with moderate to severe ischemia, defined as a summed difference score (SDS) 8 or greater, were compared to the rest of the cohort., Results: Of the total cohort ( n  = 544), 39 patients had MPI studies with resultant moderate to severe ischemia. Patients with ischemia were more likely to develop coronary artery disease (74.4% versus 38.8%, P  < 0.0001) and have successful revascularization (38.5% versus 4.0%, P  < 0.0001) during the following year. Revascularization was attempted in 31 patients with moderate to severe ischemia, though only 15 (47%) of these attempts were successful. Ischemia was predictive of myocardial infarction (5.1% versus 0.8%, P  = 0.01) within 1 year., Conclusion: Moderate to severe ischemia is an uncommon finding in a contemporary nuclear laboratory. Among patients with ischemia, revascularization is typically attempted but is frequently unsuccessful., Trial Registration: This trial does not appear on a registry as it is neither randomized nor prospective.

Background . The Berlin Initiative Study (BIS) eGFR equations were developed specifically for aged populations, but their predictive validity compared to standard formulae is unknown in older women. Methods . In a prospective study of 1289 community-dwelling older women (mean age 79.5 years), we compared the performance of the BIS1 SCr-based equation to the CKD-EPI cr and the BIS2 SCr- and Scysc-based equation to the CKD-EPI cr,cysc to predict cardiovascular and all-cause mortality. Results . Prevalence of specific eGFR category (i.e., ≥75, 60-74, 45-59, and <45) according to eGFR equation was 12.3%, 38.4%, 37.3%, and 12.0% for BIS1; 48.3%, 27.8%, 16.2%, and 7.8% for CKD-EPI cr ; 14.1%, 38.6%, 37.6%, and 9.6% for BIS2; and 33.5%, 33.4%, 22.0%, and 11.1% for CKD-EPI cr,cysc , respectively. Over 9 ± 4 years, 667 (51.8%) women died. For each equation, women with eGFR <45 were at increased risk of mortality compared to eGFR ≥75 [adjusted HR (95% CI): BIS1, 1.5 (1.1-2.0); CKD-EPI cr , 1.7 (1.3-2.2); BIS2, 2.0 (1.4-2.8); CKD-EPI cr,cysc , 1.8 (1.4-2.3); p -trend <0.01]. Net reclassification analyses found no material difference in discriminant ability between the BIS and CKD-EPI equations. Results were similar for cardiovascular death. Conclusions . Compared to CKD-EPI, BIS equations identified a greater proportion of older women as having CKD but performed similarly to predict mortality risk. Thus, the BIS equations should not replace CKD-EPI equations to predict risk of death in older women.

Objective: We examined the utility of a brief values inventory as a discussion aid to elicit patients' values and goals for end-of-life (EoL) care during audiotaped outpatient physician-patient encounters., Method: Participants were seriously ill male outpatients (n = 120) at a large urban Veterans Affairs medical center. We conducted a pilot randomized controlled trial, randomizing 60 patients to either the intervention (with the values inventory) or usual care. We used descriptive statistics and qualitative methods to analyze the data. We coded any EoL discussions and recorded the length of such discussions., Results: A total of 8 patients (13%) in the control group and 13 (23%) in the intervention group had EoL discussions with a physician (p = 0.77). All EoL discussions in the control group were initiated by the physician, compared with only five (38%) in the intervention group. Because most EoL discussions took place toward the end of the encounter, discussions were usually brief., Significance of Results: The outpatient setting has been promoted as a better place for discussing EoL care than a hospital during an acute hospitalization for a chronic serious illness. However, the low effectiveness of our intervention calls into question the feasibility of discussing EoL care during a single outpatient visit. Allowing extra time or an extra visit for EoL discussions might increase the efficacy of advance care planning.

To examine the association between demographic characteristics and long-term smoking trajectory group membership among HIV-seropositive and HIV-seronegative men who have sex with men (MSM). A cohort of 6552 MSM from the Multicenter AIDS Cohort Study were asked detailed information about their smoking history since their last follow-up. Group-based trajectory modeling was used to examine smoking behavior and identify trajectory group membership. Because participants enrolled after 2001 were more likely to be younger, HIV-seronegative, non-Hispanic black, and have a high school diploma or less, we also assessed time of enrollment in our analysis. Participants were grouped into 4 distinct smoking trajectory groups: persistent nonsmoker (n = 3737 [55.9 %]), persistent light smoker (n = 663 [11.0 %]), heavy smoker to nonsmoker (n = 531 [10.0 %]), and persistent heavy smoker (n = 1604 [23.1 %]). Compared with persistent nonsmokers, persistent heavy smokers were associated with being enrolled in 2001 and later (adjusted odds ratio [aOR] 2.35; 95 % CI 2.12-2.58), having a high school diploma or less (aOR 3.22; 95 % CI 3.05-3.39), and being HIV-seropositive (aOR 1.17; 95 % CI 1.01-1.34). These associations were statistically significant across all trajectory groups for time of enrollment and education but not for HIV serostatus. The overall decrease of smoking as shown by our trajectory groups is consistent with the national trend. Characteristics associated with smoking group trajectory membership should be considered in the development of targeted smoking cessation interventions among MSM and people living with HIV.

Objective: Training in quality improvement (QI) is a pillar of the next accreditation system of the Accreditation Committee on Graduate Medical Education and a growing expectation of physicians for maintenance of certification. Despite this, many postgraduate medical trainees are not receiving training in QI methods. We created the Fellows Applied Quality Training (FAQT) curriculum for cardiology fellows using both didactic and applied components with the goal of increasing confidence to participate in future QI projects., Methods and Results: Fellows completed didactic training from the Institute for Healthcare Improvement's Open School and then designed and completed a project to improve quality of care or patient safety. Self-assessments were completed by the fellows before, during, and after the first year of the curriculum. The primary outcome for our curriculum was the median score reported by the fellows regarding their self-confidence to complete QI activities. Self-assessments were completed by 23 fellows. The majority of fellows (15 of 23, 65.2%) reported no prior formal QI training. Median score on baseline self-assessment was 3.0 (range, 1.85-4), which was significantly increased to 3.27 (range, 2.23-4; P = 0.004) on the final assessment. The distribution of scores reported by the fellows indicates that 30% were slightly confident at conducting QI activities on their own, which was reduced to 5% after completing the FAQT curriculum. An interim assessment was conducted after the fellows completed didactic training only; median scores were not different from the baseline (mean, 3.0; P = 0.51)., Conclusion: After completion of the FAQT, cardiology fellows reported higher self-confidence to complete QI activities. The increase in self-confidence seemed to be limited to the applied component of the curriculum, with no significant change after the didactic component.

Importance: Appropriate use criteria (AUC) assist health care professionals in making decisions about procedures and diagnostic testing. In some cases, multiple AUC exist for a single procedure or test. To date, the extent of agreement between multiple AUC has not been evaluated., Objective: To measure discordance between the American College of Cardiology Foundation (ACCF) AUC and the American College of Radiology (ACR) Appropriateness Criteria for gauging the appropriateness of nuclear myocardial perfusion imaging., Design, Setting, and Participants: Retrospective cohort study at an academically affiliated Veterans Affairs medical center. Participants were Veteran patients who underwent nuclear myocardial perfusion imaging between December 2010 and July 2011 with rating of appropriateness by the ACCF and ACR criteria. Analysis was performed in March 2015., Main Outcomes and Measures: The primary outcome was the agreement of appropriateness category as measured by κ statistic. The secondary outcome was a comparison of nuclear myocardial perfusion imaging results and frequency of ischemia across appropriateness categories for the 2 rating methods., Results: Of 67 indications in the ACCF AUC, 35 (52.2%) could not be matched to an ACR rating, 18 (26.9%) had the same appropriateness category, and 14 (20.9%) disagreed on appropriateness. The study cohort comprised 592 individuals. Their mean (SD) age was 62.6 (9.4) years, and 570 of 592 (96.2%) were male. When applied to the patient cohort, 111 patients (18.8%) could not be matched to an ACR rating, 349 patients (59.0%) had the same appropriateness category for the ACR and ACCF methods, and 132 patients (22.3%) were discordant. Overall, the agreement of appropriateness between the 2 methods was poor (κ = 0.34, P < .001). Ischemia was rare among patients rated as "inappropriate" by the ACCF AUC (1 of 39 patients [2.6%]), while ischemia was more common among patients rated as "usually not appropriate" by the ACR Appropriateness Criteria (14 of 80 patients [17.5%])., Conclusions and Relevance: Substantial discordance may exist between methods for assessing the appropriateness of advanced imaging tests. Discordance in methods may translate into differences in clinically relevant outcomes, such as the detection of myocardial ischemia.

We measured the trend of cigarette smoking among HIV-seropositive and seronegative men over time from 1984 to 2012. Additionally, we examined the demographic correlates of smoking and smoking consumption. Six thousand and five hundred and seventy seven men who have sex with men (MSM) from the Multicenter AIDS Cohort Study (MACS) were asked detailed information about their smoking history since their visit. Prevalence of smoking and quantity smoked was calculated yearly from 1984 to 2012. Poisson regression with robust error variance was used to estimate prevalence ratios of smoking in univariate and multivariate models. In 2012, 11.8 and 36.9 % of men who were enrolled in the MACS before 2001 or during or after 2001 smoked cigarettes, respectively. In the multivariate analysis, black, non-Hispanic, lower education, enrollment wave, alcohol use, and marijuana use were positively associated with current smoking in MSM. HIV serostatus was not significant in the multivariate analysis. However, HIV variables, such as detectable viral load, were positively associated. Though cigarette smoking has declined over time, the prevalence still remains high among subgroups. There is still a need for tailored smoking cessation programs to decrease the risk of smoking in HIV-seropositive MSM.

Background: Recently, the first estimated glomerular filtration rate (eGFR) formula specifically developed for community-dwelling older adults, the Berlin Initiative Study Equation 2 (BIS2), was reported. To date, however, no study has examined the performance of the BIS2 to predict death in older adults as compared to equations used clinically and in research., Methods: We prospectively followed 2,994 community-dwelling men (age 76.4 ± 5.6) enrolled in the MrOS Sleep Study. We calculated baseline eGFR from serum creatinine and cystatin-C using the BIS2, Chronic Kidney Disease Epidemiology (CKD-EPIcr,cysc), CKD-EPIcysc and CKD-EPIcr equations. Analyses included Cox-proportional hazards regression and net reclassification improvement (NRI) for the outcomes of all-cause and cardiovascular death., Results: Follow-up time was 7.3 ± 1.9 years. By BIS2, 42 and 11% had eGFR <60 and <45, respectively, compared to CKD-EPIcr (23 and 6%), CKD-EPIcysc (36 and 13%) and CKD-EPIcr,cysc (28 and 8%). BIS2 eGFR <45 was associated with twofold higher rate of all-cause mortality when compared to eGFR ≥75 after multivariate adjustment (HR 2.1, 95% CI 1.5-2.8). Results were similar for CKD-EPIcr,cysc <45 (HR 2.1, 95% CI 1.6-2.7) and CKD-EPIcysc <45 (HR 2.1, 95% CI 1.7-2.7) and weaker for CKD-EPIcr <45 (HR 1.5, 95% CI 1.2-2.0). In NRI analyses, when compared to CKD-EPIcr,cysc, both BIS2 and CKD-EPIcr equations more often misclassified participants with respect to mortality. We found similar results for cardiovascular death., Conclusion: The BIS2 did not outperform and the CKD-EPIcr was inferior to the cystatin C-based CKD-EPI equations to predict death in this cohort of older men. Thus, the cystatin C-based CKD-EPI equations are the formulae of choice to predict death in community-dwelling older men., (© 2016 S. Karger AG, Basel.)

Myocardial perfusion imaging (MPI) is commonly used to detect ischemia. Concerns about silent ischemia may encourage orders for MPI in asymptomatic patients. Factors contributing to this practice are poorly described and the clinical utility is questionable.We conducted a single center retrospective cohort investigation on Veterans who underwent MPI between December 2010 and July 2011. We gathered data on symptoms, baseline characteristics, results of MPI, and cardiovascular events within 1 year. MPI were categorized using 2009 appropriate use criteria (AUC).Of 592 patients, 127 (21.5%) had no symptoms at the time of MPI. Comparing symptomatic and asymptomatic patients, no differences were observed in baseline characteristics except abnormal ECG, more common in asymptomatic patients (n = 86, 67.7% vs. n = 232, 49.9% for symptomatic patients, P < 0.0001). Asymptomatic MPI were more commonly inappropriate (n = 26, 21.5% vs. n = 31, 6.7% for appropriate/uncertain, P < 0.0001). Detection of ischemia between patients with and without symptoms was not different (P = 0.86); however, among asymptomatic MPI that also demonstrated ischemia, none were inappropriate (n = 10 appropriate, n = 7 uncertain). In multivariate regression, 2 factors were associated with asymptomatic status, abnormal ECG (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.5-3.49) and age over the median (OR 0.63, 95% CI: 0.41-0.95).A substantial portion of MPI tests are ordered for patients without symptoms. When compared to symptomatic patients, MPI for asymptomatic patient were more commonly inappropriate; however, the prevalence of ischemia was similar. MPI may be clinically relevant in some asymptomatic patients and decisions to test should be based on the AUC.

Background: Approximately 10% to 20% of myocardial perfusion imaging (MPI) tests are inappropriate based on professional-society recommendations. The correlation between inappropriate MPI and quality care metrics is not known., Hypothesis: Inappropriate MPI will be associated with low achievement of quality care metrics., Methods: We conducted a retrospective cross-sectional investigation at a single Veterans Affairs medical center. Myocardial perfusion imaging tests ordered by primary-care clinicians between December 2010 and July 2011 were assessed for appropriateness (by 2009 criteria). Using documentation of the clinical encounter where MPI was ordered, we determined how often quality care metrics were achieved., Results: Among 516 MPI patients, 52 (10.1%) were inappropriate and 464 (89.9%) were not inappropriate (either appropriate or uncertain). Hypertension (82.2%), diabetes mellitus (41.3%), and coronary artery disease (41.1%) were common. Glycated hemoglobin levels were lower in the inappropriate MPI cohort (6.6% vs 7.5%; P = 0.04). No difference was observed in the proportion with goal hemoglobin (62.5% vs 46.3% for appropriate/uncertain; P = 0.258). Systolic blood pressure was not different (132 mm Hg vs 135 mm Hg; P = 0.34). Achievement of several other categorical quality metrics was low in both cohorts and no differences were observed. More than 90% of clinicians documented a plan to achieve most metrics., Conclusions: Inappropriate MPI is not associated with performance on metrics of quality care. If an association exists, it may be between inappropriate MPI and overly aggressive care. Most clinicians document a plan of care to address failure of quality metrics, suggesting awareness of the problem., (© 2015 Wiley Periodicals, Inc.)

Background: Appropriate use criteria for myocardial perfusion imaging (MPI) were developed to categorize scenarios where MPI might be beneficial (appropriate) or not (inappropriate). Few investigations have evaluated the clinical utility of this categorization strategy, particularly with positron emission tomography (PET) MPI., Methods and Results: We conducted this retrospective cohort investigation in a Veterans Affairs (VA) medical center, on predominantly male subjects who underwent PET-MPI. We correlated appropriateness to test result and cardiovascular events. Of 521 subjects, 414 (79.5%) were appropriate, 54 (10.4%) were uncertain, and 53 (10.2%) were inappropriate. PET-MPI was abnormal more often when appropriate or uncertain (28% and 34.6%, respectively, vs 7.7% for inappropriate, P = .003). Among abnormal inappropriate tests, none detected occult ischemia. By Cox regression, summed difference score ≥5 (HR 5.06, 95% CI 2.72-9.44) and an abnormal test result (HR 4.48, 95% CI 2.19-9.14) were associated with higher likelihood of catheterization. Log-rank analysis demonstrated similar likelihood of catheterization when comparing abnormal vs normal test result (P < .0001) and between appropriate, uncertain, and inappropriate tests (P = .024)., Conclusions: Inappropriate PET-MPI was rarely abnormal, associated with low catheterization rates, and failed to detect occult ischemia for any subjects. The clinical utility of inappropriate PET-MPI is negligible.

Background: Inappropriate use of myocardial perfusion imaging (MPI) may vary depending on the training, specialty, or practice location of the clinician., Methods: We conducted a cross-sectional investigation of consecutive patients who underwent MPI at our Veterans Affairs medical center between December 2010 and July 2011. Characteristics of the MPI ordering clinicians were extracted to investigate any associations with inappropriate use., Results: 582 patients were included, 9.8% were inappropriate. No difference in inappropriate use was observed between cardiology and non-cardiology clinicians (n = 21, 9.5% vs n = 36, 10.0%, P = .83); no difference was noted between nurse practitioners/physician assistants, attending physicians, and housestaff (7.5% vs 11.2% vs 1.8%, P = .06). Comparing inpatient, emergency department and outpatient clinician groups, the difference was null (8.6% vs 6.3% vs 10.1%, P = .75). For most clinician groups, the most common inappropriate indication was an asymptomatic scenario; however, some groups were different: definite acute coronary syndrome for inpatient clinicians and low risk syncope for emergency medicine clinicians., Conclusions: Clinician groups appear to order inappropriate MPI at similar rates, regardless of their training, specialty, or practice location. Differences in the most common type of inappropriate testing suggest that interventions to reduce inappropriate use should be tailored to specific clinician types.

Objective: To describe self-reported decision-making styles and associated pathways through end-of-life (EOL) decision-making for African-American, Caucasian, and Hispanic seriously ill male Veterans, and to examine potential relationships of race/ethnicity on these styles., Methods: Forty-four African American, White, and Hispanic male Veterans with advanced serious illnesses participated in 8 racially/ethnically homogenous focus groups. Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the racial/ethnic groups., Results: Patients described two main decision-making styles, deciding for oneself and letting others decide, leading to five variants that we labeled Autonomists, Altruists, Authorizers, Absolute Trusters, and Avoiders. These variants, with exception of avoiders (not found among White patients), were found across all racial/ethnic groups. The variants suggested different 'implementation strategies', i.e., how clear patients made decisions and whether or not they then effectively communicated them., Conclusion: These identified decision-making styles and variants generate strategies for clinicians to better address individualized advance care planning., Practice Implications: Physicians should elicit seriously ill patients' decision-making styles and consider potential implementation strategies these styles may generate, thus tailoring individualized recommendations to assist patients in their advance care planning. Patient-centered EOL decision-making can ensure that patient preferences are upheld., (Published by Elsevier Ireland Ltd.)

Purpose: We critically assessed the methodological and reporting quality of published studies of ablative techniques for small renal masses., Materials and Methods: We performed a systematic PubMed® and EMBASE® literature search from January 1966 to March 2010 to identify all full text, original research publications on ablative therapy for renal masses. Six reviewers working independently in 3 teams performed duplicate data abstraction using Strengthening the Reporting of Observational Studies in Epidemiology criteria, which were pilot tested in a separate sample., Results: A total of 117 original research publications published in a 15-year period (1995 to 2009) met eligibility criteria. No randomized, controlled trials were identified. All studies were observational and 88.9% had 1 arm with no comparison group. Median sample size was 18 patients (IQR 5.5, 40.0) and 53.8% of studies included 20 or fewer patients. Median followup was 14.0 months (IQR 8.0, 23.8) and only 19.7% of studies had an average followup of greater than 24 months. Of the studies 20.5% mentioned the number of operators involved and only 6.0% provided information on their experience level. Of the studies 66.7% addressed the recurrence rate. Disease specific and overall survival was reported in only 15.4% and 16.2% of studies, respectively., Conclusions: The published literature on the therapeutic efficacy of ablative therapy for renal masses is largely limited to uncontrolled, 1-arm observational studies. In the absence of higher quality evidence ablative therapy outside research studies should be limited to select patients who are not candidates for surgical intervention., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Post-stroke depression (PSD) occurs in at least one-third of stroke survivors, is associated with worse functional outcomes and increased mortality, and is frequently underdiagnosed and undertreated., Objective: To evaluate the effectiveness of an electronic medical record-based system intervention to improve the proportion of veterans screened and treated for PSD., Design: Quasi-experimental study comparing PSD screening and treatment among veterans receiving post-stroke outpatient care one year prior to the intervention (the control group) to those receiving outpatient care during the intervention period (the intervention group); contemporaneous data from non-study sites included to assess temporal trends in depression diagnosis and treatment., Participants: Veterans hospitalized for ischemic stroke and/or receiving primary care (PC) or neurology outpatient follow-up within six months post-stroke at two (Veterans Affairs) VA Medical Centers., Interventions: We formed clinical improvement teams at both sites. Teams developed PSD screening and treatment reminders and designed tailored implementation strategies for reminder use in PC and neurology clinics., Main Measures: Proportion screened for PSD within 6 months post-stroke; proportion screening positive for PSD who received an appropriate treatment action within 6 months post-stroke., Key Results: In unadjusted analyses, PSD screening was performed within 6 months for 85% of intervention (N = 278) vs. 50% of control (N = 374) patients (OR 6.2 , p < 0.001), and treatment action was received by 83% of intervention vs. 73% of control patients who screened positive (OR 1.8 p = 0.13). After adjusting for intervention, site and number of follow-up visits, intervention patients were more likely to be screened (OR 4.8, p < 0.001) and to receive a treatment action if screened positive (OR 2.45, p = 0.05). Analyses of temporal trends in non-study sites revealed no trend toward general increase in PSD detection or treatment., Conclusions: Automated depression screening in primary and specialty care can improve detection and treatment of PSD.

Objective: To examine the evidence on the benefits and harms of screening for prostate cancer., Design: Systematic review and meta-analysis of randomised controlled trials., Data Sources: Electronic databases including Medline, Embase, CENTRAL, abstract proceedings, and reference lists up to July 2010. Review methods Included studies were randomised controlled trials comparing screening by prostate specific antigen with or without digital rectal examination versus no screening. Data abstraction and assessment of methodological quality with the GRADE approach was assessed by two independent reviewers and verified by the primary investigator. Mantel-Haenszel and inverse variance estimates were calculated and pooled under a random effects model expressing data as relative risks and 95% confidence intervals., Results: Six randomised controlled trials with a total of 387 286 participants that met inclusion criteria were analysed. Screening was associated with an increased probability of receiving a diagnosis of prostate cancer (relative risk 1.46, 95% confidence interval 1.21 to 1.77; P<0.001) and stage I prostate cancer (1.95, 1.22 to 3.13; P=0.005). There was no significant effect of screening on death from prostate cancer (0.88, 0.71 to 1.09; P=0.25) or overall mortality (0.99, 0.97 to 1.01; P=0.44). All trials had one or more substantial methodological limitations. None provided data on the effects of screening on participants' quality of life. Little information was provided about potential harms associated with screening., Conclusions: The existing evidence from randomised controlled trials does not support the routine use of screening for prostate cancer with prostate specific antigen with or without digital rectal examination.

This article describes medical students' evaluation of a geriatric clerkship in postacute rehabilitative care settings. This was a cross-sectional study of fourth-year medical students who completed a mandatory 2-week rotation at a postacute care facility. Students were provided with three instructional methods: Web-based interactive learning modules; small-group sessions with geriatric faculty; and Geriatric Interdisciplinary Care Summary (GICS), a grid that students used to formulate comprehensive interdisciplinary care plans for their own patients. After the rotation, students evaluated the overall clerkship, patient care activities, and usefulness of the three instructional methods using a 5-point Likert scale (1=poor to 5=excellent) and listed their area of future specialty. Of 156 students who completed the rotation, 117 (75%) completed the evaluation. Thirty (26%) chose specialties providing chronic disease management such as family, internal medicine, and psychiatry; 34 (29%) chose specialties providing primarily procedural services such as surgery, radiology, anesthesiology, pathology, and radiation oncology. Students rated the usefulness of the GICS as good to very good (mean+/-standard deviation 3.3+/-1.0). Similarly, they rated overall clerkship as good to excellent (3.8+/-1.0). Analysis of variance revealed no significant group difference in any of the responses from students with the overall clerkship (F(112, 4)=1.7, P=.20). Students rated the geriatric clerkship favorably and found the multimodal instruction to be useful. Even for students whose career choice was not primary care, geriatrics was a good model for interdisciplinary care training and could serve as a model for other disciplines.

Background: No national data exist regarding racial/ethnic differences in the use of interventions for patients at the end of life., Objectives: To test whether among 3 cohorts of hospitalized seriously ill veterans with cancer, noncancer or dementia the use of common life-sustaining treatments differed significantly by race/ethnicity., Design: Retrospective cohort study during fiscal years 1991-2002., Patients: Hospitalized veterans >55 years, defined clinically as at high-risk for 6-month mortality, not by decedent data., Measurements: Utilization patterns by race/ethnicity for 5 life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans and Hispanics, controlling for age, disease severity and clustering of patients within Veterans Affairs (VA) medical centers., Results: Among 166,059 veterans, both differences and commonalities across diagnostic cohorts were found. African Americans received more or the same amount of end-of-life treatments across disease cohorts, except for less resuscitation [OR = 0.84 (0.77-0.92), p = 0.002] and mechanical ventilation [OR = 0.89 (0.85-0.94), p < or = 0.0001] in noncancer patients. Hispanics were 36% (cancer) to 55% (noncancer) to 88% (dementia) more likely to receive transfusions than Caucasians (p < 0.0001). They received similar rates as Caucasians for all other interventions in all other groups, except for 161% higher likelihood for mechanical ventilation in patients with dementia. Increased end-of-life treatments for both minority groups were most pronounced in the dementia cohort. Differences demonstrated a strong interaction with the disease cohort., Conclusions: Differences in level of end-of-life treatments were disease specific and bidirectional for African Americans. In the absence of generally accepted, evidence-based standards for end-of-life care, these differences may or may not constitute disparities.

This article about hemorrhagic complications of anticoagulant and thrombolytic treatment is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Bleeding is the major complication of anticoagulant and fibrinolytic therapy. The criteria for defining the severity of bleeding vary considerably between studies, accounting in part for the variation in the rates of bleeding reported. The major determinants of vitamin K antagonist (VKA)-induced bleeding are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. There is good evidence that VKA therapy, targeted international normalized ratio (INR) of 2.5 (range, 2.0-3.0), is associated with a lower risk of bleeding than therapy targeted at an INR > 3.0. The risk of bleeding associated with IV unfractionated heparin (UFH) in patients with acute venous thromboembolism is < 3% in recent trials. This bleeding risk may increase with increasing heparin dosages and age (> 70 years). Low-molecular-weight heparin (LMWH) is associated with less major bleeding compared with UFH in acute venous thromboembolism. Higher doses of UFH and LMWH are associated with important increases in major bleeding in ischemic stroke. In ST-segment elevation myocardial infarction, addition of LMWH, hirudin, or its derivatives to thrombolytic therapy is associated with a small increase in the risk of major bleeding, whereas treatment with fondaparinux or UFH is associated with a lower risk of bleeding. Thrombolytic therapy increases the risk of major bleeding 1.5-fold to threefold in patients with acute venous thromboembolism, ischemic stroke, or ST-elevation myocardial infarction.

Background: End-of-life decisions are frequently made by patients' surrogates. Race and ethnicity may affect such decision making. Few studies have described how different racial/ethnic groups experience end-of-life surrogate decision making., Objectives: To describe the self-reported experience the self-reported experience of African-American, Caucasian, and Hispanic surrogate decision makers of seriously ill patients and to examine the relationship of race, ethnicity, and culture to that experience., Design: Purposive sample to include racial/ethnic minorities in a qualitative study using focus group interviews., Participants: The participants of the study were 44 experienced, mostly female, surrogate decision makers for older veterans., Approach: Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the three groups., Results: The experience of burden of end-of-life decision making was similar in all three groups. This burden in its medical, personal, and familial dimensions is compounded by uncertainty about prognosis and the patient's preferences. Racial/ethnic variations of responses to this burden concerned the physician-family relationship, religion and faith, and past experiences with race/ethnicity concordant versus non-concordant physicians., Conclusions: Regardless of race/ethnicity, surrogates for seriously ill patients appeared to experience increased significant, multidimensional burdens of decision making under conditions of uncertainty about a patient's preferences. This aspect of the burden of surrogate decision making may not be fully appreciated by physicians. Physicians should identify and be especially attentive to strategies used by surrogates, which may vary by race/ethnicity, to reduce the uncertainty about a patient's preferences and thus the burden of surrogate decision making to assist them in this difficult process.

Introduction: Stroke is a leading cause of disability and death around the world., Methods: We conducted a systematic review of peer reviewed articles published since 1999 on the topics of public education and policy for stroke prevention. A research librarian conducted the search using Pubmed and the International Pharmacy Abstracts (IPA). We reviewed the abstracts from the search results to determine if they met the inclusion criteria. Then we abstracted the relevant data from the articles using an evaluation criteria and data abstraction instrument., Results: The searches of Pubmed and the IPA returned 446 articles, of which 36 were included in the review. Thirty-two were educational programs and four were policies. Twenty-two of the programs were directed at patients, four at providers, and seven at both. Seven of the educational programs were judged successful using the evaluation criteria. They included two large scale programs and five narrowly targeted programs. The policies included two articles presenting guidelines for treatment for stroke prevention in specific patient populations and two articles presenting recommendations for changes in systems of care for stroke prevention and treatment., Conclusions: Future efforts to evaluate these programs will require global efforts with a special emphasis on testing and validating with international patient populations. Barriers remain for translating stroke prevention policies into clinical practice. "This material is based upon work supported by the North Florida/South Georgia Veterans Health System, the Office of Research and Development, Rehabilitation R&D Service, and Health Services R&D Service, Department of Veteran Affairs."

Background: We investigated the association of process of care measures with adverse limb and systemic events in patients with peripheral arterial disease (PAD)., Methods: We conducted a retrospective cohort study of patients with PAD, as defined by an ankle-brachial index (ABI) <0.9. The index date was defined as the date, during 1995 to 1998, when the patient was seen in the Michael E. DeBakey VA Medical Center noninvasive vascular laboratory and found to have PAD. We conducted a chart review for process of care variables starting 3 years before the index date and ending at the time of the first event or the final visit (December 31, 2001), whichever occurred first. We examined the association between PAD process of care measures, including risk factor control, and prescribing of medication, with time of the patient's first major limb event or death., Results: Of the 796 patients (mean age, 65 +/- 9.9 years), 230 (28.9% experienced an adverse limb event (136 lower-extremity bypass, 94 lower-extremity amputation), and 354 (44.5%) died. Of the patients who died, 247 died without a preceding limb event. Glucose control was protective against death or a limb event with a hazard ratio (HR) of 0.74 (95% confidence limits [CL] 0.60, 0.91, P = 0.004). African Americans were at 2.8 (95% CL 1.7, 4.5) times the risk of Whites or Hispanics for an adverse limb event. However, this risk was no longer significant if their glucose was controlled. For process measures, the dispensing of PAD specific medication (HR 1.4, 95% CL 1.1, 1.7) was associated an increased risk for an adverse outcome., Conclusions: Our data suggest that glucose control is key to reducing the risk for adverse outcomes, particularly limb events in African Americans. Certain process of care measures, as markers of disease severity and disease management, are associated with poor outcomes in patients with PAD. Further work is needed to determine the role of early disease intervention to reduce poor outcomes in patients with PAD.

Background: Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-based intervention aimed at increasing the use of thiazide-based antihypertensive regimens., Methods: This quasi-experimental study was carried out in general medicine ambulatory practices of a large, academically-affiliated Veterans Affairs hospital. The intervention group consisted of the practitioners (13 staff and 215 trainees), nurses, and patients (3,502) of the teaching practice; non-randomized concurrent controls were the practitioners (31 providers) and patients (18,292) of the non-teaching practices. Design of the implementation intervention was based on Rogers' Diffusion of Innovations model. Over 10.5 months, intervention teams met weekly or biweekly and developed and disseminated informational materials among themselves and to trainees, patients, and administrators. These teams also reviewed summary electronic-medical-record data on thiazide use and blood pressure (BP) goal attainment. Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen, and the proportion of hypertensive patients attaining BP goals regardless of regimen. Thirty-three months of time-series data were available; statistical process control charts, change point analyses, and before-after analyses were used to estimate the intervention's effects., Results: Baseline use of thiazides and rates of BP control were higher in the intervention group than controls. During the intervention, thiazide use and BP control increased in both groups, but changes occurred earlier in the intervention group, and primary change points were observed only in the intervention group. Overall, the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients (0.091 vs. 0.058; p = 0.0092), as was the proportion achieving BP goals (0.092 vs. 0.044; p = 0.0005). At the end of the implementation period, 41.4% of intervention patients were prescribed thiazides vs. 30.6% of controls (p < 0.001); 51.6% of intervention patients had achieved BP goals vs. 44.3% of controls (p < 0.001)., Conclusion: This multi-faceted intervention appears to have resulted in modest improvements in thiazide prescribing and BP control. The study also demonstrates the value of electronic medical records for implementation research, how Rogers' model can be used to design and launch an implementation strategy, and how all members of a clinical microsystem can be involved in an implementation effort.

We examined the cost-effectiveness of a care coordination/home telehealth (CCHT) programme for veterans with diabetes. We conducted a retrospective, pre-post study which compared data for a cohort of veterans (n=370) before and after the introduction of the CCHT programme for two periods of 12 months. To assess the cost-effectiveness, we converted the patients' health-related quality of life data into Quality Adjusted Life Year (QALY) utility scores and used costs to construct incremental cost-effectiveness ratios (ICERs). The overall mean ICER for the programme at one-year was $60,941, a value within the commonly-cited range of cost-effectiveness of $50,000-100,000. The programme was cost-effective for one-third of the participants. Characteristics that contributed to cost-effectiveness were marital status, location and clinically relevant co-morbidities. By targeting the intervention differently in future work, it may become cost-effective for a greater proportion of patients.

Objectives: To assess healthcare use among veterans with diabetes mellitus (DM) enrolled in a Department of Veterans Affairs (VA) Care Coordination Home Telehealth (CCHT) program during 24 months and to contrast this utilization with the service use of a comparison group of veterans with DM not enrolled in the program., Study Design: Two-year, retrospective, concurrent matched cohort study design., Methods: The VA CCHT program included older veterans with type 2 DM at high risk for multiple VA inpatient and outpatient visits. Healthcare utilization (hospitalizations, length of stay, and outpatient visits by type) was assessed at baseline and at 24 months after intervention for the treatment (n = 400) and comparison (n = 400) groups. Propensity scores were used to improve the balance between the treatment and comparison groups. A difference-in-differences approach was used to control for selection bias and for intervening time factors., Results: Two years after enrollment, the treatment group exhibited a statistically significant reduction in the likelihood of all-cause and DM-related hospitalizations. In a subgroup analysis in which we controlled for patients' baseline glycosylated hemoglobin levels, the treatment group had a lower likelihood of having any care coordinator-initiated primary care clinic visits (in which the care coordinator initiated referral to primary care based on health information received from patients' CCHT technology)., Conclusion: After controlling for selection bias and for intervening time factors, the VA CCHT program reduced avoidable healthcare services for DM (such as hospitalizations) and reduced care coordinator-initiated primary care clinic visits.

Objectives: To estimate the prevalence of concurrent hypertension and dyslipidemia among a general veteran population and separately among patients with diabetes mellitus, and to compare the prevalence of cardiovascular disease among groups with isolated versus concurrent hypertension and dyslipidemia., Study Design: Retrospective cohort study., Patients and Methods: This study was conducted in 6 medical centers of the Department of Veterans Affairs and included 371221 patients seen for any reason from October 1, 1998, to September 30, 2001. The proportion of patients with isolated or concurrent hypertension and dyslipidemia was estimated based on diagnostic, pharmacy, laboratory, and vital sign information, and the age-adjusted proportions of individuals with cardiovascular disease were compared between groups., Results: We found that 57.8% of all patients had hypertension or dyslipidemia; 30.7% had both. Sixteen percent of all patients had diabetes mellitus, and 66.3% of these patients had concomitant hypertension and dyslipidemia. The prevalence of coronary artery disease was often more than doubled among patients with concomitant conditions compared with patients with either condition alone. The prevalence of stroke and peripheral arterial disease similarly increased among patients with both conditions. The prevalence of these cardiovascular diseases was highest among patients with diabetes mellitus., Conclusion: The prevalence of cardiovascular disease was high among this population of older, predominately male US veterans.