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Background. Among advanced-stage cancer patients, age is an important determinant of decision making about medical care. We examined age-related differences in patient well-being, care perspectives, and preferences, and the relationship between these patient characteristics and subsequent care practices including care communication, pain management, and acute care utilization during the early treatment phase of late-stage cancer. Methods. Patient demographics, well-being, and care perspectives were assessed during patient and physician baseline interviews. Care practices were measured using outpatient and inpatient records for the 30-day period after baseline assessment. Multivariate regression models were used to examine the patterns of association of age and other patient characteristics with care practices. Results. A total of 174 middle-aged and 149 older patients with recently diagnosed late-stage cancer were included. Older patients had more comorbidities but lower levels of depression, anxiety, and symptom distress. Older patients preferred pain relief/comfort as a treatment goal, but received fewer prescriptions for opioids. Whereas provider-initiated communication with patients/families was positively associated with severity of illness, patient/family-initiated communication was associated with patient psychosocial attributes and care perspectives. Satisfaction with care was inversely associated with reports of pain. Symptom distress was positively associated with subsequent opioid prescriptions and hospitalizations. Conclusions. Our results help to explain the role of patients' psychosocial attributes, care perspectives, and preferences in subsequent care practices during the early treatment phase for late-stage cancer. Age-related differences in patient wellbeing and care perspectives suggest a role for age-sensitive interventions in the treatment of advanced cancer patients. Key Words: Late-stage cancer--Age--Well-being--are practices.

Keywords: health state valuation; utilities; dementia; cognitive impairment; computer-based techniques; reliability. (Med Decis Making 2008;28:220--232) 220 Health State Valuation in Mild to Moderate Cognitive Impairment: Feasibility of Computer-Based, Direct Patient [...]

Purpose: There is a growing consensus that quality of care for frail elders should include family and be evaluated in terms of patient-centered, family-focused care (PCFFC). Family caregivers are in a unique and sometimes sole position to evaluate such care. In the context of caring for physically frail elders, this study examined the extent to which objective burden was associated with caregiver perceptions of PCFFC and the extent to which it mediated the influence of other variables on perceptions of PCFFC. Design and Methods: In a study of frail elderly veterans receiving care in U.S. Department of Veterans Affairs ambulatory primary care clinics, informal caregivers assessed quality of care with 13 questions. Factor analysis of these items revealed an eight-item scale that specifically assessed PCFFC ([alpha] = .90). Regression analysis identified variables associated with caregiver (N = 210) assessments of PCFFC and the potential mediating effect of objective burden. Results: Caregiver assessments of PCFFC were positively associated with care recipient instrumental activity of daily living limitations (p = .04) and perspectives on the quality of their own patient care (p < .001). Greater objective burden was negatively associated with caregiver assessments of PCFFC (p < .001) and mediated (i.e., reduced) the relationship between care recipient perceptions of the quality of their own patient care and caregiver assessments of PCFFC ([DELTA][R.sup.2] = .06). Implications: These findings support recommendations for conducting caregiver assessments as part of routine care and highlight the importance of measuring objective burden and expectations for PCFFC in assisting physically frail elders. Primary care providers will require additional training in order to effectively implement and translate such caregiver assessments into clinical practice improvement. Key Words: Family-focused care, Caregiver burden, Quality of elder care

Many elderly hospitalized patients may not necessarily desire to live a shorter life in better health and many family members may not be aware of this health value. Of 414 hospitalized patients 80 years or older, almost 70% were unwilling to trade a long life for better health even though only 30% rated their quality of life as good or excellent. However, family members and other surrogate decision-makers often believed just the opposite. This illustrates the necessity of asking patients directly about their health values., Context. -- Health values (utilities or preferences for health states) are often incorporated into clinical decisions and health care policy when issues of quality vs length of life arise, but little is known about health values of the very old. Objective. -- To assess health values of older hospitalized patients, compare their values with those of their surrogate decision makers, investigate possible determinants of health values, and determine whether health values change overtime. Design. -- A prospective, longitudinal, multicenter cohort study. Setting. -- Four academic medical centers. Participants. -- Four hundred fourteen hospitalized patients aged 80 years or older and their surrogate decision makers who were interviewed and understood the task. Main Outcome Measures. -- time -- trade-off utilities, reflecting preferences for current health relative to a shorter but healthy life. Results. -- On average, patients equated living 1 year in their current state of health with living 9.7 months in excellent health (mean [SD] utility, 0.81 [0.28]). Although only 126 patients (30.7%) rated their current quality of life as excellent or very good, 284 (68.6%) were willing to give up at most 1 month of 12 in exchange for excellent health (utility [greater than or equal to] 0.92). At the other extreme, 25 (6.0%) were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility [less than or equal to] -0.04). Patients were willing to trade significantly less time for a healthy life than their surrogates assumed they would (mean difference, 0.05; P=.007); 61 surrogates (20.3%) underestimated the patient&apos;s time -- trade-off score by 0.25 (3 months of 12) or more. Patients willing to trade less time for better health were more likely to want resuscitation and other measures to extend life. Time -- trade-off score correlated only modestly with quality-of-life rating (r=0.28) and inversely with depression score (r=-0.27), but there were few other clinical or demographic predictors of health values. When patients who survived were asked the time -- trade-off question again at 1 year, they were willing to trade less time for better health than at baseline (mean difference, 0.04; P=.04). Conclusion. -- very old hospitalized patients who could be interviewed were able, in most cases, to have their health values assessed using the time -- trade-off technique. Most patients were unwilling to trade much time for excellent health, but preferences varied greatly. Because proxies and multivariable analyses cannot gauge health values of elderly hospitalized patients accurately, health values of the very old should be elicited directly from the patient. JAMA. 1998;279:371-375

Cardiac catheterization using a Swan-Ganz catheter may actually be detrimental to most critically ill patients. Cardiac catheterization is often used in these patients to monitor heart function. Researchers studied the use of cardiac catheterization in 5,735 critically ill patients between 1989 and 1994. Patients who were catheterized had a slightly higher 30-day mortality rate. They also used more resources and stayed in the ICU longer. This outcome remained even when the data were adjusted for other risk factors for mortality., Objective.-To examine the association between the use of right heart catheterization (RHC) during the first 24 hours of care in the intensive care unit (ICU)and subsequent survival, length of stay, intensity of care, and cost of care. Design.--Prospective cohort study. Setting.--Five US teaching hospitals between 1989 and 1994. Subjects.--A total of 5735 critically ill adult patients receiving care in an ICU for 1 of 9 prespecified disease categories. Main Outcome Measures.-Survival time, cost of care, intensity of care, and length of stay in the ICU and hospital, determined from the clinical record and from the National Death Index. A propensity score for RHC was constructed using multivariable logistic regression. Case-matching and multivariable regression modeling techniques were used to estimate the association of RHC with specific outcomes after adjusting for treatment selection using the propensity score. Sensitivity analysis was used to estimate the potential effect of an unidentified or missing covariate on the results. Results.--By case-matching analysis, patients with RHC had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03-1.49). The mean cost (25th, 50th, 75th percentiles) per hospital stay was $49 300 ($17000, $30 500, $56 600) with RHC and $35 700 ($11 300, $20 600, $39 200) without RHC. Mean length of stay in the ICU was 14.8 (5, 9, 17) days with RHC and 13.0 (4, 7, 14) days without RHC. These findings were all confirmed by multivariable modeling techniques. Subgroup analysis did not reveal any patient group or site for which RHC was associated with improved outcomes. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death following RHC. Sensitivity analysis suggested that a missing covariate would have to increase the risk of death 6-fold and the risk of RHC 6-fold for a true beneficial effect of RHC to be misrepresented as harmful. Conclusion.--In this observational study of critically ill patients, after adjustment for treatment selection bias, RHC was associated with increased mortality and increased utilization of resources. The cause of this apparent lack of benefit is unclear. The results of this analysis should be confirmed in other observational studies. These findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study. JAMA. 1996;276:889-897