Impact of age and comorbidity on non-small-cell lung cancer treatment in older veterans.

PURPOSE: Because comorbidity affects cancer treatment outcomes, guidelines recommend considering comorbidity when making treatment decisions in older patients with lung cancer. Yet, it is unclear whether treatment is targeted to healthier older adults who might reasonably benefit. PATIENTS AND METHODS: Receipt of first-line guideline-recommended treatment was assessed for 20,511 veterans age ≥ 65 years with non-small-cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry from 2003 to 2008. Patients were stratified by age (65 to 74, 75 to 84, ≥ 85 years), Charlson comorbidity index score (0, 1 to 3, ≥ 4), and American Joint Committee on Cancer stage (I to II, IIIA to IIIB, IIIB with malignant effusion to IV). Comorbidity and patient characteristics were obtained from VA claims and registry data. Multivariate analysis identified predictors of receipt of guideline-recommended treatment. RESULTS: In all, 51% of patients with local, 35% with regional, and 27% with metastatic disease received guideline-recommended treatment. Treatment rates decreased more with advancing age than with worsening comorbidity for all stages, such that older patients with no comorbidity had lower rates than younger patients with severe comorbidity. For example, 50% of patients with local disease age 75 to 84 years with no comorbidity received surgery compared with 57% of patients age 65 to 74 years with severe comorbidity (P < .001). In multivariate analysis, age and histology remained strong negative predictors of treatment for all stages, whereas comorbidity and nonclinical factors had a minor effect. CONCLUSION: Advancing age is a much stronger negative predictor of treatment receipt among older veterans with NSCLC than comorbidity. Individualized decisions that go beyond age and include comorbidity are needed to better target NSCLC treatments to older patients who may reasonably benefit.

Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downstream of CPOE alerts.

OBJECTIVE: To categorize the appropriateness of provider and pharmacist responses to warfarin critical drug-drug interaction (cDDI) alerts, assess responses and actions to the cDDI, and determine the occurrence of warfarin adverse drug events (ADE) after alerts. DESIGN: An 18-month, retrospective study of acute care admissions at a single Veterans Affairs medical center using computerized provider order entry (CPOE). MEASUREMENTS: Patients included had at least one warfarin cDDI alert. Chart reviews included baseline laboratory values and demographics, provider actions, patient outcomes, and associated factors, including other interacting medications and number of simultaneously processed alerts. RESULTS: 137 admissions were included (133 unique patients). Amiodarone, vitamin E in a multivitamin, sulfamethoxazole, and levothyroxine accounted for 75% of warfarin cDDI. Provider responses were clinically appropriate in 19.7% of admissions and pharmacist responses were appropriate in 9.5% of admissions. There were 50 ADE (36.6% of admissions) with warfarin; 80% were rated as having no or mild clinical effect. An increased number of non-critical alerts at the time of the reference cDDI alert was the only variable associated with an inappropriate provider response (p=0.01). LIMITATIONS: This study was limited by being a retrospective review and the possibility of confounding variables, such as other interacting medications. CONCLUSION: The large number of CPOE alerts may lead to inappropriate responses by providers and pharmacists. The high rate of ADE suggests a need for improved medication management systems for patients on warfarin. This study highlights the possibility of alert fatigue contributing to the high prevalence of inappropriate alert over-ride text responses.

Periprocedural complications by Child-Pugh class in patients undergoing transcatheter arterial embolization or chemoembolization to treat unresectable hepatocellular carcinoma at a VA medical center.

BACKGROUND: For patients with compensated cirrhosis, transcatheter arterial embolization with and without additive chemotherapy has been shown to improve survival. The aim of this study was to compare periprocedural complications in a population with hepatitis C virus-related hepatocellular carcinoma to evaluate for differences in complications by severity of liver disease. METHODS: Patients with unresectable hepatocellular carcinoma treated by transcatheter arterial embolization with or without additive chemotherapy procedures from 2003 to 2006 were retrospectively reviewed and compared by Child-Pugh (CP) class. A total of 141 embolizations were done in 76 patients. RESULTS: Complication rates were seen in 27% of CP class A and 17% of CP class B patients. There was no significant difference in the grade of complications between the 2 groups or between procedure types. Survival rate was dependent on the degree of liver dysfunction (3-year CP class A, 49%; CP class B, 13%; P = .0048). CONCLUSION: Embolization procedures to treat hepatitis C virus-related hepatocellular carcinoma can be performed safely with low morbidity and mortality rates, even in patients with a compromised hepatic reserve.

Implementation of a multidisciplinary treatment team for hepatocellular cancer at a Veterans Affairs Medical Center improves survival.

Several methods of treatment for hepatocellular carcinoma (HCC) are often used in combination for either palliation or cure. We established a multidisciplinary treatment team (MDTT) at the San Francisco Veterans Affairs Medical Center in November 2003 and assessed whether aggressive multimodality treatment strategies may affect survival. A prospective database was established and follow-up information from patients with presumed HCC was collected up to November 2006. Information from the American College of Surgeons (ACS) cancer registry from January 2000 to November 2003 identified patients with HCC that were evaluated at the same institution prior to the establishment of the MDTT. The establishment of a MDTT resulted in the doubling of patient referrals for treatment. Significantly more patients were evaluated at earlier stages of disease and received either palliative or curative therapies. The overall survival (p<0.0001) and length of follow-up (p<0.05) were significantly improved after the establishment of the MDTT. Stage-by-stage comparisons indicate that aggressive multimodality therapy conferred significant survival advantage to patients with American Joint Commission on Cancer (AJCC) stage II HCC (odds ratio 15.50, p<0.001). Multidisciplinary collaboration and multimodality treatment approaches are important in the management of hepatocellular carcinoma and improves patient survival.

An electronic medical record intervention increased nursing home advance directive orders and documentation.

OBJECTIVES: To develop an electronic medical record intervention to improve documentation of patient preferences about life-sustaining care, detail of resuscitation and treatment-limiting orders, and concordance between these orders and patient preferences. DESIGN: Prospective before-after intervention trial. SETTING: Veterans Affairs nursing home with an electronic medical record for all clinical information, including clinician orders. PARTICIPANTS: All 224 nursing home admissions from May 1 to October 31, 2004. MEASUREMENTS: Completion of an advance directive discussion note by the primary clinician, clinician orders about resuscitation and other life-sustaining treatments, and concordance between these orders and documented patient preferences. INTERVENTION: The electronic medical record was modified so that an admission order would specify resuscitation status. Additionally, the intervention alerted the primary clinician to complete a templated advance directive discussion note for documentation of life-sustaining treatment preferences. RESULTS: Primary clinicians completed an advance directive discussion note for five of 117 (4%) admissions pre-intervention and 67 of 107 (63%) admissions post-intervention (P<.001). In multivariate analysis, the intervention was independently associated with advance directive discussion note completion (odds ratio=42, 95% confidence interval=15-120). Of patients who preferred do-not-resuscitate (DNR) status, a DNR order was written for 86% pre-intervention versus 98% post-intervention (P=.07); orders to limit other life-sustaining treatments were written for 16% and 40%, respectively (P=.01). CONCLUSIONS: A targeted electronic medical record intervention increased completion of advance directive discussion notes in seriously ill patients. For patients who preferred DNR status, the intervention also increased the frequency of DNR orders and of orders to limit other life-sustaining treatments.